Aditi U Joshi of Panda Health: 5 Things We Must Do To Improve the US Healthcare System

An Interview With Luke Kervin

Leave policies: We have seen the burden of people being sick at work firsthand during the pandemic. This was the first time we were all required to stay home when sick to avoid making others ill. Why did it take a pandemic for us to realize that those who are sick need rest? I contracted COVID very early in the pandemic in March of 2020 and it took weeks for me to recover but the shortness of breath and fatigue took much longer. Like most doctors, I was not used to sick days and called out only once in my career before that. However, I was forced to rest, and I realized that my body required it. Had I not it would have taken much more time to improve. I am grateful I recovered fully but it made me realize that our culture of hustling/doing/going/never stopping has contributed to making us more ill.

As a part of our interview series called “5 Things We Must Do To Improve the US Healthcare System”, I had the pleasure to interview Aditi U. Joshi.

Dr. Aditi U Joshi is an emergency physician and digital health consultant who began a career in telehealth at a DTC startup and then as telehealth medical director at an academic medical center. She has a diverse experience in these roles working in operations, quality assurance, provider training, medical education and implementing new programs and use cases. She ran a Telehealth fellowship aimed at training future physician leaders interested in furthering virtual care. She currently works as a consultant to health systems and startups working on bridging the gap between diverse stakeholders in digital health. Nationally, she chairs the telehealth section for the American College of Emergency Physicians working on how digital technologies will affect the workforce, policy, and future practice models in the specialty.

Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us a story about what brought you to this specific career path?

Thank you for having me! I always knew I wanted to be a physician even as a child. I always thought I’d become a surgeon but found emergency medicine (EM) in medical school and decided it was much more my speed and have never regretted that choice. While I love EM as a practice and field, it is tough — we hear about the burnout of frontline workers in the news now, but it has existed for much longer and I had some of those symptoms in 2012. I wanted a change and began looking around for something new and found that Doctor on Demand was looking for doctors. I applied, joined in 2013, and went full time with them in 2014. It was new at the time so much of what we did revolved around figuring out how to work in this emerging technology: we created clinical pathways, QA processes, had to demonstrate what exactly telehealth was and, of course, saw patients.

In 2015, I was recruited by Thomas Jefferson University in Philadelphia which had begun a multi department telehealth program that year and were looking for a Medical Director with telehealth experience. I started there in 2016 and stayed there for 5 years. In that time, I worked on several different aspects of telehealth since we were a small and emerging technology and had to ‘prove’ that this modality was something useful. We were lucky that the CEO of the hospital had committed to innovation, and we were able to try out different programs and use cases. Over those years, I worked in operations, created education and training for all levels of learners from students to attendings, created quality assurance programs, performance improvement, led a fellowship and worked on telehealth in EM clinical practice. When 2019 and the pandemic hit, our already existing program, in numerous departments, allowed us to scale and use virtual care swiftly and effectively. It felt like all the previous work had finally come to demonstrate how much use telehealth could have, and we were able to help much of the city with screening, treatment, and testing coordination.

Currently, I work as a consultant to digital health startups and health systems. One of my current projects is evaluating the digital health space and categorizing it to get a cohesive picture for those looking to buy solutions for their health system. It has been an interesting and informative project as I note how much the market has changed. I have enjoyed being able to bring these disparate experiences together to evaluate the space at a larger level.

I’m fortunate in many ways when I look at my career so far. Much of how I got here was being curious and interested in how things were practiced and trying to pull information from other parts of the world. For example, I knew a ton of people working in tech so when I first joined a startup, I had information about how they work. I also made sure to say yes to new opportunities to try out how an emerging tech could work in ways outside its initial use case.

Can you share the most interesting story that happened to you since you began your career?

Hmmm, well emergency physicians generally have many interesting stories! I’ll say instead that I could not have predicted that telehealth would become so crucial. I started in telehealth because I was interested in tech and believed it would one day be a normal part of our healthcare options, replacing some types of clinic visits for example. Those first years, I spent much of my time discussing why it was needed, why it was safe, how to do it, why it helped, who could do it etc. Still, a number of people asked me why I was tanking my career and when I’d go back to be a ‘real’ doctor. While I expected telehealth to be part of healthcare eventually, I could not have predicted it became necessary almost overnight in 2020. Now I don’t need to explain what it is and can work toward real implementation into healthcare practice. I find it interesting because it is one of those life events you cannot predict nor really plan for — true for all of us during the pandemic, overall.

Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?

Working in healthcare it’s hard to say something is funny since the consequences can be dire, however I do laugh at how naïve I was about certain topics that physicians are supposed to ‘know’ and give advice about. Patients are much more comfortable sharing than I was expecting at the age of 22 so there were funny moments from that as I do not have a poker face. Of course, you learn by experience, asking questions, and being genuinely curious. I learnt that it is okay to not know something but always with the intention of being open and learning about it in the future. And to not be judgmental about it.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

Amid being burnt out in emergency medicine around 2012, I was frustrated with the burdens that patients and clinicians had to take on because the health system fails at so many levels and the ER is where people come when they need care and there is nowhere else. While that is a good thing and makes me proud of EM as a field, the day-to-day shifts are difficult.

I remember my mother listening to another set of frustrations and finally telling me that if ‘I wasn’t dedicating myself to fixing the underlying issue of that particular healthcare failure, then concentrate at the task in front of you and take care of that patient.’ That helped me to realize to stay focused on the person in front of me rather than getting overwhelmed by how the health system fails so many vulnerable people. It was a constant practice to internalize that while at work, of course, but I still try to think this way anytime I feel overwhelmed. Instead of spiraling I try to ask myself ‘what is the one thing I can do right now to help’. This practice helped tremendously during the pandemic when our patient volume changed dramatically overnight.

How would you define an “excellent healthcare provider”?

Health isn’t relegated to our clinics or hospitals — every part of our lives contributes to our overall picture including our circumstances, daily choices, and world around us. The best clinicians are those who recognize that and can be able to be that bridge between a patient’s actual life and their health goals. Everyone does not and cannot have the same health picture even with similar treatments — that is one of the biggest misconceptions and difficulties in practicing medicine. However, what we as providers can do is understand what our patient’s goals are, find out what and how to get there practically, and redefine those goals if that is not possible.

We also need to be clear when we don’t know the answer — scientific discoveries are happening all the time and we don’t know everything about the human body. Of course, we all should stay abreast of research, updated guidelines, and apply it to clinical practice but it is constantly evolving. That is okay but our patients need to know our limits so they can be part of the decision-making process in their healthcare.

We also must be comfortable with the concept and discussion of death. I do not mean to be morbid, but it is a fact of life and being able to have those discussions when warranted allows for better idea of what a patient wants, needs, and can accomplish before that inevitability.

In general, it is realizing that we are all humans, and it is a privilege for someone to trust you with their healthcare and taking that responsibility with compassion, empathy and knowledge.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

I’m partial to reading as I’m a visual learner and my attention span doesn’t pay attention well enough to podcasts! I was a Literature major in college, so I still read an occasional fictional novel for pleasure, but I tend to read more nonfiction. I read mostly topics on behavioral economics, psychology, science, history, and technology and try to read at least one book a week. Inspiration comes from curiosity, and I have gotten ideas about healthcare from subjects completely unrelated to medicine. Scientific and human discoveries don’t exist in silos; they reflect societal changes in all aspects of life. For that reason, I read anything that interests me to get a better understanding about myself, other innovations, human existence, and its future potential.

Are you working on any exciting new projects now? How do you think that will help people?

I’ve recently gotten interested in the capabilities of decentralized data and the next iteration of the web in applications to healthcare. Unlike the transition to web 2.0 when other parts of our life such as banking and shopping transitioned to technical solutions, healthcare did not initially join that evolution. However, digital health is now a huge space and there is opportunity for being thoughtful about how having access to our own data and transparency will affect these tech solutions. It has always bothered me that telehealth had such promises for equitable access, but we did not see it play out in that manner. Will this next step of technology finally be able to do so? How do we make it sound practical rather than science fiction? I find this whole idea fascinating and am working on an article to demystify it at a high level.

Ok, thank you for that. Let’s now jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?

I’ll give you one reason — the underlying premise that our entire system is based upon. When you consider how people view healthcare, it is one of two options: whether or not healthcare is considered a human right and should be provided by the government or society under which you live. If you look at other high-income nations, as you mention, their society believes it is a human right and their healthcare system reflects that allowing for care to all and valuing prevention. Ours, overall, does not and our policies reflect this.

I write this as the underlying reason because all other parts and failures are going to be because of this: the lack of healthcare for those who cannot afford it, lack of incentives for preventive care, medication pricing based on the market forces, individuals going bankrupt because of healthcare costs, political maneuvering that allows for vulnerable populations to suffer etc.

This is especially poignant in the emergency department. I mentioned earlier that the ED functions as the catchall for health system failures and every one of us who has worked there can give you examples of people delaying care or not wanting to stay in the hospital even if necessary due to the fear of the costs. It is heartbreaking.

As a “healthcare insider”, If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.

I mentioned that our society’s premise for healthcare is the main factor, however, I am a practical person and realize that changing that zeitgeist is not an easy feat. Instead, I try to stress practical changes.

1. Expanding our definition of what is health: From my telehealth clinical practice, I became aware that our health extends well past the borders of the clinic as I was caring for patients in their homes and able to get a larger picture of who they were. We must invest time in looking at all the individual and systemic factors that affect care — this is why the social determinants of health (SDOH) are so important. We need more preventive health and health at home which can extend outside of simply medications. I see a large opening for care coordination from diverse team clinical teams that can lead to this.
   Personally, I am gratified that connectivity has been added to the SDOH. This recognizes that having access to devices and internet is important to avoid further increasing health disparities as we use more technology.
2. Having access to health data: It is frustrating for everyone that patients and clinicians cannot get a comprehensive view of their health picture due to health records existing in different places. This not only affects the individual, who may have repeated or unnecessary tests, but affects health system costs, community productivity and population health. Without having deidentified data from the population in an aggregated way, we cannot affect changes at a wider scale.
   While the solution currently would be a centralized accessible health record, if we do realize changes to web3, this would allow patients to own and keep their data likely bypassing the need for a central database. It will be interesting to see which of these come first.
3. Health and Digital Literacy: There is still a disconnect between what patients need to know and how effective clinicians think they are communicating. Patient may get a diagnosis and be given several resources. However, it may not be the right information or said in a way that is understandable. Since we are also using more digital technologies, patients who would benefit from these services need to understand how to use them effectively. We also need to consider language, literacy, and other factors that might be affecting a patient and create individualized solutions. This burden is not just on physicians, but we have to do better — our new technologies are allowing for patients to have more say in their care. However, they also need the right tools to understand that care.
4. Costs: This is the biggest issue. Healthcare is expensive, not only for the care received but its effect on communities. I understand that. However, we have insurance and pharma companies that make money due to incentives that favor the market rather than patient care. We have shifted costs to individuals in a system that is not transparent. Our pricing of medications and care is astronomical and can change without anyone knowing until they try to refill their prescriptions. While I worked in the ED, I had no idea what patients were being charged to see me — I was shocked to find out how much as it was certainly not even a fraction of what I was paid for it. Our costs routinely bankrupt people. Is it any wonder than that uninsured or underinsured patients delay care due to the fear of costs? Delaying care only leads to higher costs in the future as the needed care is more complicated and expensive. So in this scenario, everyone loses. The result is that we have the highest costs of any high-income country’s healthcare system with the worst outcomes.
   This problem, again, is due to the underlying premise of our system that healthcare is not a right and that those who cannot buy it don’t ‘deserve’ it. However, this is a complete fallacy. Any clinician will tell you that health outcomes are not always predictable and controllable. We also cannot control for accidents or being diagnosed with a cancer that is not hereditary. This can happen to anyone. It is cruel then that only some of us should be able to get care without stressing over going bankrupt.
   Some solutions are to make one centralized payor similar to other countries. This has been floated before and seems unlikely in the short term. I’ll suggest instead to make preventive care free. If we consider that COVID vaccines are a form of free preventive care, it is clear we can do it if we so choose. Prices should be transparent. The way insurance reimburses should be easy to navigate. Medication pricing should have a cap. It is criminal that insulin is unaffordable for patients as diabetics cannot live without it. I cannot stress this failure enough. We need to find a better way to pay and deliver healthcare so everyone can access it. It is an ethical and rational solution.
5. Leave policies: We have seen the burden of people being sick at work firsthand during the pandemic. This was the first time we were all required to stay home when sick to avoid making others ill. Why did it take a pandemic for us to realize that those who are sick need rest? I contracted COVID very early in the pandemic in March of 2020 and it took weeks for me to recover but the shortness of breath and fatigue took much longer. Like most doctors, I was not used to sick days and called out only once in my career before that. However, I was forced to rest, and I realized that my body required it. Had I not it would have taken much more time to improve. I am grateful I recovered fully but it made me realize that our culture of hustling/doing/going/never stopping has contributed to making us more ill.

I recognize some of this is due to economics as not all of us can leave work, maternity leave gives no time for recovery, mental health is not considered at all, and if we do rest, we are not sure we will have a job when returning. We need better policies to ensure we have rest — both for individuals to be protected but also companies to recoup losses when it happens. This will allow for more empathy and compassion for ourselves and others. We must remember that our human bodies are not machines and will shut down in some manner if we do not take care of them. It is also practical for us to rest — several books and research supports that when we rest, we are more creative and productive when we return.

What concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

That’s a great question. Because healthcare, or at least health, touches all aspects of life it can be changed at all these levels.

It’s an interesting time at the individual level — we have more access to information and our own health data. We can speak to a clinician at the click of a button. So, we all need to take more responsibility for our own health — gone are the days of a paternalistic system telling us what to do without explanation. This is great but it does mean we have to be cognizant of our own choices. I do want to be clear that it is difficult to improve your health if you are worried about everyday needs and survival and we may not have the full spectrum of choices, but we can all learn more about our health. On a more general note, we are learning more about the stigmas and inequities both in society and the system. I also want individuals to have more empathy for those who are struggling with health — the stigma around mental health, substance use disorder and disability only leads to worsening health outcomes. This we can change as individuals with more understanding, research, and compassion to our fellow humans.

At a corporate or business level, that can mean many things. Companies should consider their leave policies, how insurance premiums or the insurance they offer affects their employees as well as their business. The corporations tied to medicine including insurance, contract management groups etc should take a hard look at whether they are using their considerable profits to aid the system. I cannot and won’t argue for altruism as it is unlikely to happen. However, a healthy population leads to further human development and more productivity.

I am not optimistic that these needed changes will be made at a corporation level so that is where leaders and federal policies can help. We already have changes to insurance and leave policies — they are not enough but they demonstrate that there can be federal investment. There has been a serious loss of trust in our leadership and governing parties which I understand. However, sometimes that is the only way to change things. I think of the example of France — the president decided to make it mandatory last summer to be vaccinated to eat at restaurants, attend shows or to have a social life. It was not universally popular especially by those who did not want to get vaccinated. It did, however, get some people to change their mind so they can participate in social events. I think about this as an example of the federal government making a hard, unpopular but ultimately right decision at the time. We must decide whether we all believe in taking care of our population or not, whether we believe in investing in long term health or not. The answer of course may be no, and we continue onto an inevitable failure and continued separation of society. I am hoping not.

Communities have stepped in sometimes when policies have failed both at individual, corporate or government level. There are examples of groups rallying to help raise money for those needing health care. During the pandemic, when telehealth was the prime way of healthcare, there were rural communities that did not have devices or internet to access healthcare. To help, some communities setup kiosks in libraries and community centers. Communities are an undervalued resource for health data and support. There are always political pundits reminding us that our local politicians affect us more than federal ones and this is true for our health systems. As far as asking how they can help, it would be an extension of the answer for individuals: to understand their local community with population research and serve in those capacities. Now that we have larger cohorts of data, we can soon be able to target community health as well as individual health. I would like to see better sharing of data and research, which could lead to more personalized programs for local communities and targeted resources for better health. Saying that, communities are not built to take in the failures of insurance, or policy and I won’t suggest that it can or should.

The COVID-19 pandemic has put intense pressure on the American healthcare system, leaving some hospital systems at a complete loss as to how to handle this crisis. Can you share with us examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these issues moving forward?

Our lack of investment in preventive or value-based care became evident during this pandemic. We saw a huge volume of patients during this pandemic. Let me define that when I say patients during this pandemic, I mean everyone since we all had to participate in public health measures to decrease exposure. So now we have the entire population as patients from needing information at the very least all the way to patients needing critical care. We then saw what happens when we did not have enough primary care, lack of preventive care and screening workflows. We saw our already overburdened emergency departments get overwhelmed and the result of not having enough critical care beds. There was also the mentioned issues with burnout in the workforce. To some degree, part of it is inevitable — we cannot plan for such a mass of patients overnight. However, now we have some idea of the breaking points of the system when taxed. Aside from costs which I’ve mentioned, we need preventive and primary care so that patients have basic healthcare to screen and treat before things get worse. We need more options for acute and urgent care that is not the emergency department; emergency departments were never designed to see this volume of patients and we see delays of care to detrimental effects on patients and staff.

We are also seeing the inequities in our system. There has been much more discussion about race, gender, disabilities, and other groups of patients who do not receive the same standard of care. Much of it is historical and without its recognition and changes, it remains systemic. This is a hard thing to fix because it is not specific to healthcare; this is a societal problem, and we need to fix it in all parts of ourselves to help. As mentioned, there are those trained to do this; experts that should be listened to and given the power to change things.

How do you think we can address the problem of physician shortages?

This is a complicated issue. Even prior to the pandemic burnout or moral injury were already a growing issue. The pandemic did not create this problem — it made them more obvious because it caused more strain on the system. While there are a number of issues that contribute, the main problem is that doctors have and have had almost no decision-making capacity in policy decisions at both a local and federal level, however they take the blame much of the time when things go wrong. It is no wonder that clinical practice, documentation, patient volume, and the general expectation put on physicians has burnt them out. We need to listen to what is happening to on the ground physicians.

As an example, I remember early in my career when I was working a very busy telehealth shift and told the director to consider creating max patient volumes for the health of the clinical staff. They did not understand why that was necessary believing that since it was telehealth it should be ‘easier to do than when in clinic’. They then worked a shift themselves and then called me to tell me I was right — after a certain volume it was burdensome and overwhelming. I do not tell this story to blame anyone, and this scenario is not certainly specific to that company or person. I tell this story because it exemplifies the disconnect. Many decisions on how to practice and what is considered ‘safe’ for doctors to do are being dictated by those who no longer practice. We need to bridge that gap and listen.

There have been instances of doctors silenced or fired for speaking up when things are not going well. It’s no surprise that those that have other career options are taking them. In even sadder cases, there have been increasing numbers of physicians dying by suicide leading to a recognition that we need better mental health services as well. The stigma around mental health exists everywhere but it sometimes prevents physicians from being hired as we must report it on our licensing documents. There has been a huge effort to change and recognize this problem. The Dr. Lorna Breen Heroes Foundation has made strides on this issue and I suggest for those interested in this topic to look into their work.

Physicians need to be more in charge of the clinical practice of medicine which includes what is considered clinically relevant, how they are paid, how they train and simply what they need. Let’s be more compassionate. We have trained an entire cadre of experts to do this work — let us do our job and help us when we need it. I cannot promise it will help with physician shortages, but it will help. The lives of our colleagues depend on it.

How do you think we can address the issue of physician diversity?

The way we increase diversity anywhere is recognizing that there are barriers to entry. Medicine is no exception — whether it’s due to geography, economics, systemic and institutionalized barriers, we see a lack of diversity in our workforce. Even if we have increased those numbers in some capacity, there is still a lack of diverse leadership such as chairs of departments and hospital administration. Recognition is the first step, having a plan for DEI is the second. The right team must be assembled and paid for their time, by which I mean actual DEI experts not clinicians from marginalized communities who may not have the training or the bandwidth. Those teams need the resources to evaluate the issues and create solutions. Lastly, they must be allowed to carry out their recommendations and be accountable to their employees, patients, and communities by making it happen. It is going to be hard because it takes looking at the root causes of these gaps which are not pretty. I’m not an expert in this but have seen some attempts with little success due to lack of tough decisions at the implementation stage. However, all large-scale changes are painful in the short term. But this must happen because lack of diversity hurts patients and communities. Students and would be future physicians need to see themselves represented — we all do — to realize the full potential of opportunities available to us.

I’m interested in the interplay between the general healthcare system and the mental health system. Right now, we have two parallel tracks, mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?

This dichotomy has always been false; psychiatrists have been and are my colleagues in medical school and in hospitals, so they are clearly considered part of healthcare by definition. We also know much more about the link between mental and ‘general’ health, as you say, to doubt that it is a part of health. However, that has not been true historically due to the long history of stigma surrounding anything to do with mental health. I’m optimistic as there has been widespread acceptance and openness about seeing mental health providers. When I was in college/med school there was little talk about therapy. Certainly no one was open about it. Now, I’ve heard medical students openly talk about their therapists and struggles with mental health and it is trickling upward as the realities and risks of physician burnout affect the workforce. We are slowly seeing the change at a cultural level. Our emotional health and stress affects our bodies, affects chronic disease and how we engage with keeping ourselves healthy so it’s in everyone’s interest to support mental health.

One way to improve this is to train more mental health providers and include a therapy session as a yearly preventive care visit. We get a yearly physical scheduled already. This can be part of that and allows for screening of those who have more needs just like any other health complaint. The more we make it the norm, the more we all will treat it like the norm.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

I wish I had understood the concept of empathy and not taking things personally earlier in my career. There is incredible value in listening to others and hearing their experience without dismissing or making it personal to yourself. There are many times I learnt something from unlikely sources. Healthcare relies on the workforce to practice like this but without it being allowed or taught. This is why we need diversity in thought and teams. I’d like to see this continue to change.

How can our readers further follow your work online?

Thanks for asking. I can be followed on Twitter at @draditijoshi or LinkedIn at dr-aditi-joshi. My website is draditiujoshi.com

Thank you so much for these insights! This was very inspirational, and we wish you continued success in your great work.

Thank you for having me!