The Future of Emergency Medicine w/ Dr. Boykin Robinson

Episode Information

July 2, 2021

Emergency Medicine Physician Dr. Boykin Robinson talks about his early interest in medicine, the inefficiencies of the emergency department and his ideas to change them, his company and its goals, and more.

Topics Include:

• His initial interest in psychology and how it evolved into emergency medicine
• Why emergency medicine appeals to him
• Clearing up misconceptions about ER doctors
• The many challenges he faces and inefficiencies he sees in emergency medicine
• What he values most in the doctor-patient relationship
• The company he founded and its aims
• His plans for Doctorpedia’s Emergency Medicine channel
• What he does to stay healthy

Highlights

• “The idea that there were these neurochemicals that caused everything to happen, and just thinking about the amazing ways the brain works and how you can kind of objectively look at this chemical moves over here and does this, and it causes this to happen in your body. It was just fascinating to me.”
• “Medicine is somewhat inexact science. We don’t understand everything about the human body, and human bodies don’t always follow the rules. We joke in medicine that the patient in room six clearly didn’t read the textbook, because the way they presented doesn’t make any sense for what they have.”
• “The horror stories are, “I signed in and then I had to wait an hour and a half and that’s when my stroke completed,” or “My chest pain got worse and then I had a heart attack.” So in an ideal world, everybody can come in, sign in, get seen, and at least have some clinician hear their story, even if it’s quick.”
• “If you look at a family practitioner or an internist, or even a pediatrician, someone who has a long-term relationship with a patient, it’s easier to build up that doctor-patient trust over 18 years, maybe with a pediatrician, or over 30 or 40 years, with an internist or a family practitioner. The challenge in the emergency department is, we have to build that trust in about five minutes.”
• “We call ourselves a physician services company, because what we do once we have the contract with the hospital, so yes, we are then going out, recruiting physicians, PAs, and NPs, to come in and staff that emergency department. But what we’re also doing is getting in there and understanding the flow.”
• “[In the emergency department], whether we’re seeing an ankle sprain or whether we’re seeing someone in cardiac arrest, we want to make sure that we have the right people in the right place to see that person and get their care efficiently.”
• “What I like about Doctorpedia is it allows physicians to take bite sized pieces of information, talk about them in terms people can understand, and people who have a question can go on and listen to a doctor explain it without having to go see that physician.”

Relevant Links

• Doctor Profile
• Doctorpedia Spotlight Interview
• Emergency Medicine Channel
• Core Clinical Partners

Episode Transcript

Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

Daniel Lobell: (00:17)
Hello, and welcome to the Doctorpedia podcast. I am your host, Daniel Lobell and today I’m joined by Dr. Boykin Robinson. It’s an honor to have you on the line, doctor. Thanks for joining!

Dr. Boykin Robinson: (00:37)
Thank you for having me.

Daniel Lobell: (00:39)
My pleasure. I have many questions for you, and I’m curious about the specific work that you’re doing, but I want to start at the very beginning and go back to your origin story, and find out where you grew up and what were the influences that wound up leading you into a life in medicine.

Dr. Boykin Robinson: (00:56)
Yeah, absolutely. I grew up in South Carolina, and attended University of North Carolina in Chapel Hill for undergrad and had really no thought of becoming a physician. It wasn’t really on my radar. I was a psychology major. And —

Daniel Lobell: (01:15)
Let me pause you right there. Why did you want to go into psychology? This is kind of interesting. Let me psychoanalyze you.

Dr. Boykin Robinson: (01:23)
I took an intro to psychology class my freshman year, thought it was very interesting, wasn’t really sure what I’d do with it, but I was 18, 19, no real thought of what I wanted to do, and so I was taking the classes that seemed the most interesting, headed down that psychology path and then took a bio psychology class. It was all about the way the brain works.

Daniel Lobell: (01:53)
That sounds really fascinating.

Dr. Boykin Robinson: (01:53)
Yeah, it was. And that led to a research project in OR with some brain monitoring equipment, and that led me kind of into the hospital. And it was, I guess, not until my junior year that I thought, “Hey, maybe I should go to medical school.” And at that point I was really behind, I hadn’t taken any of the required classes. So I had to kind of double up and take a lot of classes really fast. But that led me to medical school, where I ended up back in South Carolina, University of South Carolina for medical school.

Daniel Lobell: (02:34)
So the common theme here is that you wanted to help people, whether it was helping them from the analyst’s chair or in a surgery room. That’s obvious that that was the motivation. Where do you think that comes from?

Dr. Boykin Robinson: (02:49)
I think that’s right. I was always interested in learning about people and helping people. I actually have a sister who became a pediatrician, and then I’m married to another physician, her sister’s a physician. So it’s certainly — it didn’t run in the family prior to us, but certainly in the family now.

Daniel Lobell: (03:13)
What did your parents do?

Dr. Boykin Robinson: (03:16)
Stockbroker and a school principal.

Daniel Lobell: (03:21)
Oh, wow. I’m guessing your mom, the principal, am I correct?

Dr. Boykin Robinson: (03:26)
Yes. Yes.

Daniel Lobell: (03:28)
I mean, wow. Being a kid of the school principal, was it the school you went to?

Dr. Boykin Robinson: (03:34)
[Both chuckle] No, she became a principal after I was — she was a teacher at the time. Became a principal later. That would have been tough. You’re right.

Daniel Lobell: (03:41)
[Daniel laughs] You get sent to the principal’s office and…. You know what, it might not be as tough because they don’t need to call your parents. [Both chuckle] I remember, it’s funny because I was just telling this story over because it was Holocaust Remembrance Day, I’m Jewish. And, I remember when I first found out about the Holocaust, I was just talking about this yesterday. I was in, I think, third grade and they assigned us to draw a picture of what we thought we might look like when we were 30. And I thought, my dad’s friend Amos, who was my godfather, looked pretty cool, and he had a mustache. So I drew myself with a mustache and the mustache was a little too small. And the next thing I knew I was at the principal’s office and they called my parents and they came in and they thought — they said, your son drew himself as Hitler. [Both laugh] And I was like, who? I didn’t even know there was a Hitler. So it was like doubly disappointing, because then I had to find out about the Holocaust at the same time. [Both chuckle] But was your mom pretty tough being a principal, growing up? What was that like? I mean, I know she was a teacher when you were younger, but I mean the personality type that becomes a principal. Was that…

Dr. Boykin Robinson: (04:55)
No, I don’t think I would’ve guessed she was going to become a principal and it was pretty normal mom stuff.

Daniel Lobell: (05:04)
Was it a big family?

Dr. Boykin Robinson: (05:05)
One sister, one brother. I was the oldest.

Daniel Lobell: (05:08)
And you mentioned your sister’s a pediatrician. Your brother didn’t go into medicine, I assume, or you would’ve mentioned that.

Dr. Boykin Robinson: (05:14)
Correct. He’s actually a school teacher.

Daniel Lobell: (05:16)
[Daniel chuckles] All right. So he stayed with the family business.

Dr. Boykin Robinson: (05:19)
That’s right.

Daniel Lobell: (05:21)
What was the thing in bio-psychology that stuck with you that inspired your interests to go into medicine? If there was one.

Dr. Boykin Robinson: (05:32)
I thought, just the idea that there were these neurochemicals that caused everything to happen, and just thinking about the way that you were… Just the amazing ways the brain works and how you can kind of objectively look at this chemical moves over here and does this, and it causes this to happen in your body. It was just fascinating to me.

Daniel Lobell: (06:03)
Fascinating to me as well. I wonder if in that field, they’re figuring out anything with regards to Alzheimer’s disease and with those chemicals playing a part.

Dr. Boykin Robinson: (06:14)
Yeah. I know there’s lots of research going on. Hopefully they will.

Daniel Lobell: (06:20)
I find that all very, very interesting. I think if I was somebody who was going to become a doctor, I’d want to study the brain because I think it’s just such an uncharted territory, I guess.

Dr. Boykin Robinson: (06:31)
Yep. Absolutely. I actually had thoughts — from getting introduced to medicine in that way, I had thoughts of going into some sort of neurosurgery or something brain related. But then once I got to medical school, found myself much more drawn to emergency medicine.

Daniel Lobell: (06:50)
So we’re getting to emergency medicine now, which is cool. You’re the second doctor I’ve had on the program whose specialty was emergency, or is emergency medicine. And I know you went on to do more than emergency medicine and we’ll get to that as well. But what was it? Was it the adrenaline rush? For you, what was it about emergency medicine that made it so appealing?

Dr. Boykin Robinson: (07:14)
I mean, that’s certainly part of it, I think for most ER docs, you can’t deny the adrenaline rush, but I found myself in third — so the way it works in medical school, the first two years, you mostly just sit in classrooms. And then in the third year you start doing clinical rotations, but at least from where I went to school at the time, emergency medicine wasn’t one of them, it was more standard internal medicine, pediatrics surgery, OB. And on each of those rotations, you would end up in the ER for something. You get a new patient, you admit them from the ER. And I just found myself drawn to that chaos. It was just organized chaos. And so I’d be down there admitting my patient for internal medicine, but I’d be looking around at the trauma that came in. Kind of sneaking into the trauma room to see what they were doing, and just found myself more and more interested in what they were doing and less and less interested in what rotation I was supposed to be on.

Dr. Boykin Robinson: (08:17)
And so, by the beginning of my fourth year, I decided definitely to do emergency medicine, and then mashed into the program at Emory in Atlanta and did my emergency medicine residency there.

Daniel Lobell: (08:33)
What are some common misconceptions people have about emergency room doctors?

Dr. Boykin Robinson: (08:39)
So I think the most common misperception is this idea that because we have to do a little bit of everything, that ER docs are sort of a jack of all trades, master of none, and that’s not accurate. What is true about emergency medicine is that ER docs are expert at the first hour or two of care in whatever field it is. So sick kid comes in, ER doc’s the right person. Somebody who needs to be evaluated to see if they need surgery comes in, ER, doc is the right person. And then if we decide they need surgery, call a surgeon. Same with trauma, the ER doc can take care of a lot of trauma themselves, but if it needs to go to the operating room, they’ll call the right person to do that. And so you really become an expert. You become expert at the first hour or two, and you learn a pretty fair bit about all different aspects of medicine, which is different than some specialties where, for instance, a neurosurgeon knows a lot about the brain and how to operate on it, and knows a lot less about the foot. ER docs need to understand all the possibilities that might walk into the ER that day.

Daniel Lobell: (10:05)
So how quick are you guys to send somebody for a surgery, for instance? Is it like something you try to avoid, or… I imagine you don’t have too much time to make that call, right?

Dr. Boykin Robinson: (10:18)
Well, it depends on what you’re talking about. So, somebody comes in from an automobile accident and needs urgent surgery, you need to figure it out quickly and get them up there. Somebody comes in with appendicitis, you might have hours to run tests, to figure out if they really have it or not. And the hard thing about emergency medicine is you don’t know when they walk in, — well, most of the time — you don’t know when they walk in what they have. And so once you figure it out, it’s easy to say, “appendicitis needs to go to the operating room.” But we didn’t know it was appendicitis four hours ago. It could have been 17 other things and probably wasn’t appendicitis, but after a bunch of tests, we figured out it was, now they need to go to the operating room.

Dr. Boykin Robinson: (11:08)
And so it’s the hardest part of emergency medicine, but it’s also, I think what keeps most of us interested. It’s that you just don’t know. Every patient is a new mystery. Every patient is a new challenge to figure out from the clues you have. And the other thing is you don’t know what tests to run. So you’re basically listening to the patient, taking a history, examining the patient. And then you decide what sorts of tests will get you to the right answer or get you closer to the right answer. And then maybe a second layer of tests if you need that. And then the big decision, is can that patient go home or does that patient need to stay in the hospital?

Daniel Lobell: (11:51)
And those beds are super valuable, right? There’s not usually that many beds available. I don’t know, not usually, but I know from my own experience that sometimes you’ve had to wait for a bed for a long time and the beds need to be turned over as quickly as possible because people are waiting for them.

Dr. Boykin Robinson: (12:14)
That’s right. Often the hospitals are full. And so yes, beds upstairs are valuable. You’re not going to change the patient’s care based on the number of beds, but yes, what that means is all of this, unraveling this mystery, is also happening in a very chaotic, very intense environment where you need to move every patient as efficiently as you can. And so there’s ED metrics. Many of the metrics we measure in the emergency department are timed. What was the time from the time the patient arrived until they got to triage? How long from triage to the room? How long from the room till a physician came in to see them? How long from the time the physician’s on until the time the physician decided they could either go or stay? We look at these sub cycle times in the emergency department and it makes sense, we need to run it more efficiently, but it is kind of crazy when you step back from it, that we are looking very intently at these time intervals.

Dr. Boykin Robinson: (13:32)
And we’re timing people making these very complex decisions about patients and what tests they need and whether they need to be admitted or not, sometimes life and death decisions. And there’s a timer, a stopwatch going at all times.

Daniel Lobell: (13:47)
Yeah. I wonder if they should have you guys play Clue competitively in medical school just to like prepare you. [Both chuckle]

Dr. Boykin Robinson: (13:58)
I would sign up for that class.

Daniel Lobell: (14:02)
Competitive Clue. You mentioned that there are these inefficiencies in the process. Let’s say I gave you full autonomy over the entire profession. And I said I’m giving you the power to make a change, one change to how emergency medicine is run. What would that be?

Dr. Boykin Robinson: (14:29)
Oh, wow. It’s so layered, and multi-sectoral, it’s really hard to say what the one change would be. I think that, given the nursing shortage we have right now, and having more people does not solve process or flow problems, but since you’re only giving me one magic wand to wave, I would say that I’d want to have enough nurses at all times to take care of all of the patients in the department.

Daniel Lobell: (15:07)
So it’s basically, there’s a shortage of nurses is what you’re saying.

Dr. Boykin Robinson: (15:12)
I mean, there is a shortage of nurses. Now, again, that’s one of a hundred potential inefficiencies in the department. I’d also want lab tests that come back in less than 10 minutes and CAT scans that are read in less than 20 minutes. There are a lot of things that I would like to see. I’d like to see all admitted patients move upstairs. Way too often in ERs all over the country, there are half or 75% sometimes of the emergency department beds are occupied by people who should be upstairs. But they’re not because there aren’t beds upstairs or there aren’t beds — and sometimes there aren’t beds upstairs because there aren’t enough nurses. So it’s all, again, very multi-factorial as to what creates the inefficiencies. But it is unfortunately not uncommon that half of your department is people who ideally would be upstairs in a bed.

Daniel Lobell: (16:17)
That’s a shocking statistic.

Dr. Boykin Robinson: (16:17)
And that’s an off the cuff. That’s certainly not an actual statistic.

Daniel Lobell: (16:27)
But still, I’m surprised to hear that. It’s very interesting to me. What about with regards to getting people into triage when you’re in that waiting room? I’ve heard horror stories of people who have been in emergency room waiting rooms and had only they gotten in sooner. Is there something that you think could be done better or differently there?

Dr. Boykin Robinson: (16:49)
Yes. And there are a lot of different things that can be done. And so one of the things that we do when we walk into a new emergency department to evaluate how we can improve flow, we have to look at the geography, look at the footprint. Sometimes there’s a lot of wasted space up front for registration booths and various things. And so the ideal way to handle that is to make sure that patients, as soon as they walk in, they can sign in with, name and some identifier and get to a clinician immediately, ideally a nurse — either a nurse and then some sort of, either a physician or a PA or nurse practitioner, or sometimes a team, but make sure that clinicians see that person as soon as they walk in. If it’s busy, this might be very quick, it might be vital signs and a few questions to make sure that patient isn’t having some sort of life or limb threatening emergency.

Dr. Boykin Robinson: (18:01)
Because that you’re right. The horror stories are, “I signed in and then I had to wait an hour and a half and that’s when my stroke completed,” or “My chest pain got worse and then I had a heart attack.” So in an ideal world, everybody can come in, sign in, get seen, and at least have some clinician hear their story, even if it’s quick. The reality is, if the department is full, whether it’s full from people who should be upstairs or whether it’s full of emergency patients, there may not be rooms to put them in. And so then you get into, well, okay, how much can we do out in the waiting room? Can the clinician who sees them say, “Hey, this person might have appendicitis.”

Dr. Boykin Robinson: (18:55)
They’re stable. They’re not going to decompensate in the waiting room, but let’s go ahead and order their workup for them while they’re in the waiting room, let’s put them over in this room here, draw their blood, and then sit them back in the waiting room and knowing that now their workup has started, so now we’re kind of parallel processing. That’s in a really busy emergency department where patients are waiting. I never like patients to be waiting in the waiting room, but if they’re gonna wait, if I can look at the tracking board and say, “Okay, there are 20 patients in the waiting room and 18 of them have tests running,” effectively we’ve just doubled the size of our ER. Because I got 20 patients in the back and they’ve all got tests running and I’ve got 20 patients in the waiting room, they’ve all got tests running. So at least everybody is in process versus just waiting.

Daniel Lobell: (19:49)
Then you’re gonna need a waiting room just to get into the waiting room. That’ll happen.

Dr. Boykin Robinson: (19:54)
[Daniel chuckles] Exactly. And there are all sorts of very interesting things that we’ve done in the last 15, 20 years on emergency department flow. With results pending areas. So that’s another thought, is, well, if you get to the room in the back and we order all your stuff, and let’s say it’s going to take two hours to get your labs and CAT scan back, do you really need to be in that room the whole time? Maybe we can put you in another room. A results pending room, where we can kind of gather more patients who are stable, but waiting for results. And then we can use the actual ER rooms for the next sick person who comes in or the next person who we don’t know if they’re sick or not, and we need to figure it out.

Daniel Lobell: (20:41)
Yeah. You’re familiar with those things you walk through in the airport that do a full body X-ray? I would imagine some possibility for that when you walk into the ER, something that scans your whole body and puts you into like a red, yellow, or green category of how quickly you need to be seen.

Dr. Boykin Robinson: (20:59)
Yeah. That’s still very Star Trek. [Daniel chuckles] And the problem is you think, well, if we put everybody through a full body CAT scan, if they walked through, we would learn a lot about them. The problem is we would create a lot of cancers from the radiation, and we would find a lot of things that don’t matter, they didn’t have to get worked up. And that’s one of the problems with imaging, whether it’s CAT scan or x-ray or MRI. They’re needed when they’re needed, but when they’re not needed, you really don’t want to do it because a lot of us have something that looks abnormal on an imaging study. So maybe I have a cyst in my kidney that I’m never going to know about, and it’s never going to affect me in any way, but on the CAT scan, it’s hard to tell it’s a cyst.

Dr. Boykin Robinson: (21:57)
It might be a mass. And so now I gotta go get a biopsy. And I gotta take the risk of having a needle stuck into my kidney to biopsy this thing that really would have never caused me any problems. And so that’s when you get into these statistics where if you full body CAT scan everybody who walked in, you would pick up some early cancers and you’d save some people, but you’d create some cancers that were never there by the radiation. And you would cause untold number of people to have other tests, to evaluate things that didn’t need to be evaluated. And you have the risk of those tests. And so it’s kind of fascinating when you look at it from a population health standpoint, when you look at number needed to treat and various statistics around testing and whether the testing is going to help more people than it hurts or vice versa. And usually it comes back to you need a well-trained clinician to decide if this test is necessary. If that’s not the case, you shouldn’t do the test. But that’s at a population level. And so that’s very different for the individual who comes in. Sometimes it’s a different decision for that individual versus the population as a whole.

Daniel Lobell: (23:22)
You just reminded me of an old Janeane Garofalo joke about how she didn’t go to the doctor. She’d say “I never go to the doctor, because I know as soon as I go to the doctor for one thing, they’re going to be like, ‘Oh, this is an interesting mole on your back.’ And the next thing I know I’ve got cancer, but if I only never would have gone, I would have been fine.”

Dr. Boykin Robinson: (23:42)
Exactly.

Daniel Lobell: (23:43)
It’s very much like what you’re saying, that you can find all these things that it would be unnecessary to find and actually could cause you harm to find, in the process of trying to help you. Which to me raises the question, how are we going to get to that place where we know what we need to look for specifically, and we can eliminate what we don’t need. I mean, it seems almost so shocking to me that we’re still not able to decipher between what’s medically necessary and what isn’t. Whereas so many people’s cancers, as you mentioned, could be preventable if they got those CAT scans. But I guess the numbers come to the point where more people would suffer than would benefit. Is there anything happening on that front to progress that problem? Some solution on the horizon?

Dr. Boykin Robinson: (24:43)
Yes, absolutely. Everyone’s always looking for the test that doesn’t cause any harm, that will pick up something bad. And so research continues on that, but this brings up one of the things that the public doesn’t always understand about medicine, is that medicine is somewhat inexact science. We don’t understand everything about the human body, and human bodies don’t always follow the rules. We joke in medicine that the patient in room six clearly didn’t read the textbook, because the way they presented doesn’t make any sense for what they have. And so we get surprised by things, because some of it is people feel things in different ways, people can convey what’s going on in their body in different ways. And so you’ve got to use a lot of — and that’s where I think my psychology background comes in a little bit.

Dr. Boykin Robinson: (25:44)
I can try to understand what the patient’s trying to tell me, even if those aren’t the words they’re using. But we’re always, in emergency medicine, at least, we’re always trying to hone in on the right test order. We have a lot of tests at our disposal, but we need to order the right ones and not a bunch of wrong ones and not a bunch of unnecessary ones. And there is no magic bullet on that and I don’t know when there will be. I think certainly the public would love to see medicine be more exact. I think we saw this play out with COVID, where doctors and scientists were learning about COVID in real time. And so, because they were learning about it in real time, they sometimes had to go back and say, “Hey, what we said a month ago, I’m not so sure that’s right.” And that drove the public crazy because, well, they’re doctors and scientists, we need to trust them. Well, yeah, but the doctors and scientists were learning about the disease in real time, and didn’t know everything about it when it started, still don’t know everything about it. And so I think to those of us in medicine, we looked at it and say, “Yep, that’s the way the scientific method works.” They have a hypothesis, they’re trying this, they’re seeing if it works. But I think that in general, people think, “Oh, well, science, we understand science.” So we shouldn’t have any unknowns. And we do. Probably will continue to have unknowns, especially when new things, like COVID, come up, that are novel. We just, by definition, can’t know everything about them because it didn’t exist a couple of years ago.

Daniel Lobell: (27:33)
And basically, what you’re saying is, the American public, and I guess the public of the world at large, our innocence was ruined. We all had this belief that the doctors knew and understood everything. It’s kind of like when I learned about the Holocaust when I was a kid and I drew myself as Hitler, it was very shocking to believe that, “Wait, what? You guys don’t quite know?”

Dr. Boykin Robinson: (27:59)
[Both laugh] Right. Exactly. And I think it’s a source of frustration for patients in the emergency department. Often people will come in with some sort of — say, abdominal pain that they’ve had for months. And so we run some tests and we say, “Look, I don’t see anything life threatening. I think you’re going to be okay, you need to continue to follow up with this specialist or that specialist, but I don’t know what’s causing your pain.” And that is incredibly frustrating to patients because they think, “Well, I came to see the doctor, you’re supposed to figure this out.” And the reality is that we only have a certain number of tests and sometimes they’re all negative. And so, I mean, thousands of times in my career, I’ve said, “Hey, great news. I don’t know what’s going on with you today.” [Daniel laughs] “But I don’t think it’s anything bad.” “I think you’re going to be okay, but I don’t know what caused this symptom you were having.” And that’s okay. And that’s good. Because if I found it, with the only five things I was looking for, they were all really bad. I’m glad you don’t have them.

Daniel Lobell: (29:10)
Yeah. It’s good we don’t know those things also. I don’t think we’d want to know what you’re looking for. [Boykin laughs] And I thought it was funny when you said that you use your psychology, your knowledge of psychology when the patient comes in, because I was imagining somebody coming in and saying, you know, “Doctor, I have chest pain,” and you say, “Well, let’s talk about your mother,” [Both laugh] But on a serious note, I think it’s probably a very good skill to have that. And it brings me to talking about the doctor-patient relationship. What do you think are the most important facets of that relationship and how do you see that playing on a basis with regards to your work?

Dr. Boykin Robinson: (29:59)
Yeah, absolutely. I think that trust, it really comes down to the most important factor in the doctor-patient relationship is trust because the doctor needs to trust that what the patient is saying is accurate. And then if they say, “Hey, I tried this and it didn’t work,” but they really did try this because the doctor’s next decision is based on knowing, oh, they tried this and it didn’t work. And at the same time, the patient has to trust the doctor to do what the doctor is suggesting. And this is something we see, if you look at a family practitioner or an internist, or even a pediatrician, someone who has a long-term relationship with a patient, it’s easier, not always easy, but easier, to build up trust, that doctor-patient trust over 18 years, maybe with a pediatrician, or over 30 or 40 years, with an internist or a family practitioner. The challenge in the emergency department is, we have to build that trust in about five minutes. We have a few minutes with the patient initially, we run some tests, we come back later, we have a few more minutes. And that’s it. They’ve never seen us before. They’ll never see us again, probably. But we’ve got to build up enough rapport with that patient that they’re going to trust what we say and take our recommendations. And that is a real challenge in emergency medicine, and something that I think we all challenge ourselves to do. And I think we all get better at it over the course of our career, but it is definitely difficult to create that level of trust in the doctor-patient relationship when you don’t have a relationship.

Daniel Lobell: (31:47)
Just made me think, I bet you there’s a much higher rate of mortality amongst pathological liars, because…

Dr. Boykin Robinson: (31:56)
You’re probably right.

Daniel Lobell: (31:58)
Are there special doctors that specialize in dealing with them? “Did you do this? Yeah, I did it.” Well, he’s a pathological liar, so he probably didn’t do it. But he’s good enough, then he thinks that you’re a liar, and he says that he didn’t do it, but… anyway, but he says he did do it because he thinks you didn’t do it, but he did do it. [Boykin chuckles] But that’s an interesting thing when you talk about trust, I always thought about it in terms of trusting the doctor. I never really thought about it from the perspective that you just presented, which is trusting the patient, that the patient’s telling you they truly did do what the doctor recommended. How often do you find that that is the case, that patients aren’t following what you’re asking them to do?

Dr. Boykin Robinson: (32:39)
Oh, I think it happens a lot. And it happens for a variety of reasons. Sometimes it happens because they didn’t trust the original recommendations from the doctor. Sometimes it happens because, well, sometimes they can’t follow the recommendations because they couldn’t afford the medication or couldn’t get a follow-up appointment. There are various reasons that are not the patient’s fault. They couldn’t couldn’t do what the doctor recommended. But I think sometimes it’s hard. Sometimes it’s… I mean, for instance, me, I’ve got kind of a chronic knee problem that I know I need to do physical therapy and various things. And if I did them every day for a month, my knee would get better, but it’s hard. It’s hard to find the time to do that and remember that. And I think that I’m a typical patient in that regard.

Daniel Lobell: (33:38)
I heard that doctors make the worst patients. I’ve heard that before.

Dr. Boykin Robinson: (33:40)
They do. I think that’s true. I know I’m not a great patient.

Daniel Lobell: (33:46)
But why do you think it is? Do you think it’s because you’re like, “Yeah, I know what to do. I’ll get around to it.” Whereas other people, they don’t know, and they’re like, “I better get on it right away when the doctor tells me.”

Dr. Boykin Robinson: (33:54)
I think that’s part of it. I think part of it is that doctors probably tend to self-diagnose and decide that this is just heartburn. When a non-physician might’ve said, “Hmm, this feels like chest pain. I better go get checked out.” But yeah, I’ve definitely heard that, and I think also, for some physicians it’s kind of a busy-ness factor too. Life gets very busy, and so you don’t have time to do that physical therapy or go in for that. I think also going in for your annual visit with your physician, when you’re around medicine all the time, you just don’t think to do that as much because you’re kind of always in it, but then you forget that you’re not taking care of you.

Daniel Lobell: (34:50)
Right. That makes a lot of sense. I want to shift gears for a second to talk about, I know, as I mentioned earlier, I said, you’re an emergency physician, but you’re also other things amongst them, a medical director and an onsite medical director. Is that correct?

Dr. Boykin Robinson: (35:06)
Well, I’ve been an onsite medical director at several different facilities in the past, and then sort of moved from that into running a region for a company that’s staffed emergency departments. And then a few years back I actually left that role and started a new company. And so my company works with hospitals all over the country to both staff and manage emergency physicians and their hospital medicine physicians.

Daniel Lobell: (35:39)
Is that Core?

Dr. Boykin Robinson: (35:40)
Core Clinical Partners. Exactly.

Daniel Lobell: (35:45)
So please, I didn’t mean to interrupt you when I asked that. Can you please go into that a little more about what you guys do there?

Dr. Boykin Robinson: (35:53)
Yeah, sure. So some people don’t even realize that what I do is a space because most emergency departments, or sorry, most hospitals, most non-academic hospitals outsource their emergency medicine physicians, PAs and NPs to companies who specialize in doing that. So companies who specialize in managing emergency physicians, of course, companies who specialize in managing hospitalists physicians tend to do a more efficient job than the hospital does of hiring those physicians of making the ED work well, of decreasing problems with flow, getting patients out of the hospital faster. So companies like mine exist and contract with the hospital to provide those services. Most of the time, the patient, they just kind of assume that the doctor is with the hospital. And we certainly act with other hospitals specialists and some hospital specialists might work for the hospital.

Dr. Boykin Robinson: (37:03)
Some might not. Some might be independent practitioners. And so anyway, my company staffs emergency departments and hospital medicine teams in about 13 states across the country.

Daniel Lobell: (37:16)
So you’re essentially an employment agency, in a way.

Dr. Boykin Robinson: (37:20)
We’re a lot more than that. We call ourselves a physician services company, because what we do once we have the contract with the hospital, so yes, we are then going out, recruiting physicians, PAs, and NPs, to come in and staff that emergency department. But what we’re also doing is getting in there and understanding the flow. We have clinical operators, we have a guy who has a nursing background and he got his master’s in healthcare administration who is lean certified and has spent years doing nothing, but looking at what are the best ways for ERs to work going in and fixing flow.

Dr. Boykin Robinson: (38:06)
And so we go in and spend a lot of time saying, “Hey, what if we moved this over here?” And it’s the patient flow, again, instead of going this way, they go this way. We’re going to have them see a triage nurse here and then move… Things I talked about earlier with the results pending areas and clinicians in triage to get things started. All of those kinds of things are what we spend, actually the majority of our time on. Yes, we also staff the physicians and schedule them and pay them and bill patients and all that. But where we really add value to our hospital partners is in getting in and fixing these slow problems so that patients can be seen more efficiently. We can decrease the — every ER at some level has a number of patients who leave before they’re seen. And it might be 0.3% of their patients, or it might be 7% of their patients, depending on the ER.

Dr. Boykin Robinson: (39:06)
And so we bring that number down. We bring the average length of stay in the ER down because we can do things more efficiently. And if you bring that length of stay down, you have the capacity to take care of more patients. You can create higher quality care and you can also create a better experience for the patient because they weren’t waiting. So we look at all of that, the patient experience, the physician experience, and try to improve on that in the emergency department. And then again, kind of similar, but different things up in the inpatient units for our hospitalists, where we do various different things to decrease the length of time patients are in the hospital and also increase the quality of their stay.

Daniel Lobell: (39:58)
A recent interview I did for this podcast was with Dr. Madeleine Biondolillo, and she does quality medicine. It sounds an awful lot like what you’re saying. Would you classify what you’re doing as quality medicine?

Dr. Boykin Robinson: (40:17)
I mean, certainly we spend a lot of time thinking about quality of care and quality of care metrics. I don’t refer to it as quality medicine, I have not heard that podcast so I’m not sure, but we are looking at — like we talked earlier, there are a bunch of timed metrics in emergency medicine. So we’re looking at those, we’re looking at quality metrics. We’re really looking at the entire experience in the emergency department and on the inpatient ward, and ensuring that our physicians are representing Core in the way we want them to, making sure we have a great team of…

Daniel Lobell: (41:00)
They have to have the good core values.

Dr. Boykin Robinson: (41:04)
Exactly. We can’t… You have to have, first of all, you have to have good physicians and other clinicians, they have to be smart and compassionate, caring. But then you also have to give them the right environment to work in, and make sure that they can have an efficient process to get patients seen and get patients through the process, because in the emergency department, we’re sometimes, depending on the size of the ED, we might be putting 200 patients a day through a limited number of beds. And so we’ve got to keep things moving so the weights don’t get higher.

Daniel Lobell: (41:48)
Yeah. So I guess some of the questions I asked you earlier in the interview were really right up your alley with regards to efficiency in the emergency room.

Dr. Boykin Robinson: (41:57)
Yes. Those were exactly right up my alley and things that we’re thinking about all the time.

Daniel Lobell: (42:06)
I didn’t even know it.

Dr. Boykin Robinson: (42:06)
I thought you were just giving me softballs.

Daniel Lobell: (42:06)
What are some of the ones that I missed? What are some of the tougher questions?

Dr. Boykin Robinson: (42:13)
About emergency medicine? I think you’ve asked a couple of them, like ways to fix medicine in general and even ways to fix emergency medicine. It’s just so hard to look at it and say, “If only we had this, we’d be okay.” There’s a lot we need. And then there are the questions of healthcare at large, are there better ways we could be taking care of some of these patients? I mean, the emergency department is open 24/7, 365 with physicians ready to see anything that walks in the door. Nothing else in medicine can provide that. And so it is something that can’t be replaced and it’s something where… I don’t like to hear that it’s the wrong place for care. It’s not the wrong place for care for, say somebody with sniffles, or an ankle sprain. Sometimes it’s the only place that they have available. And so we want to make sure that whether we’re seeing an ankle sprain or whether we’re seeing someone in cardiac arrest, we want to make sure that we have the right people in the right place to see that person and get their care efficiently.

Daniel Lobell: (43:37)
So essentially, you’re not just a staffing agency, as I said, and you’re not just looking at the quality of medicine inefficiency, but you’re also a talent agent. You’re out there trying to figure out who the talent is that’s needed for a specific hospital.

Dr. Boykin Robinson: (43:53)
Oh, absolutely. Absolutely.

Daniel Lobell: (43:57)
Are you sitting in the rafters during surgery, like watching somebody might a comedian in the back of a nightclub trying to be like, “This guy’s good!”

Dr. Boykin Robinson: (44:09)
[Boykin chuckles] Yeah, we are out there talking to physicians all the time… We’re at the specialty trade shows, we’re at residency dinners… Out there talking and finding the right fit for our facilities. A lot of it comes — the first thing people are looking for is geography. A lot of times it’s, I have a tie to this area, my wife’s family or my husband’s family is from this area, and we want to get back to this area. And then it’s, do you want to be in a 20,000 volume ER, or a 100,000 volume ER? Do you want really high acuity or not so high acuity? And so certainly over the years, I’ve developed all the right questions to ask to find out what’s going to be the right fit for this physician.

Dr. Boykin Robinson: (45:03)
And then make sure that they’re the right fit for the hospital. And in emergency medicine, you really need this interesting mix of, they gotta be smart, they gotta be nice, because we’re dealing with a lot of different personalities through the ER, but then they also gotta be able to do all of that efficiently. And so it’s an interesting type of person you’re looking for, when you’re thinking about a really good emergency physician, we used to say, “You want them smart, fast, nice, not dumb, slow, mean,” and you really need some combination of all three of those things in a busy emergency department to make it all work well,

Daniel Lobell: (45:53)
That’s pretty interesting. And probably pretty exciting when you find these people. It’s almost like scouting a team for baseball more than it is…

Dr. Boykin Robinson: (46:04)
Yeah, that’s right. And then you’ve got leadership, medical leadership, the director of that emergency department. And you’ve got to make sure that that team, that director, is on the same team as the nursing director. And the hospitalist director and various other key stakeholders in the hospital. And so that’s fun to make sure that you have good teamwork across the hospital, because the emergency department does not exist in a vacuum. It’s very much a part of the hospital, and we’ve got to work with other people throughout the facility to make sure that the emergency department works but also that the rest of the hospital team does. We are the front door of the hospital. Most hospitals, about 70 or 80% of their admissions come through the emergency department. So we are truly the front door, and we’ve got to make sure that the patients have a great experience coming through that front door.

Daniel Lobell: (47:06)
I love it. I know that you’ve recently gotten involved with Doctorpedia, for whom we’re doing this great podcast. Can you talk a little bit about your role at Doctorpedia, what involvement you have, and what excited you about the company?

Dr. Boykin Robinson: (47:23)
Yeah, absolutely. So yeah, I’m recently the chief medical officer for the Emergency Medicine channel at Doctorpedia and just kind of getting started with that, excited to see where we can take it. I think that there’s clearly the online health and wellness, there’s a lot of it online, often referred to as Dr. Google. And what I find, and I use it too, right? I might type something in, something I don’t know much about. What I always noticed though, if I’m Googling something, something in medicine, is that I know which — I’ll scroll through and know exactly which links I want to click on, because I know it’s reputable. I know it’s likely to be accurate. But I know that because of my background. And I often think, man, the average person might click on this first one or click on this one here that I don’t think is going to get them the right information.

Dr. Boykin Robinson: (48:24)
And so there’s plenty of quantity of health and wellness. There’s not as much quality of health and wellness out there. And deciding which is quality and which is not, I think is really hard. So what I like about Doctorpedia is it allows physicians to take bite sized pieces of information, talk about them in terms people can understand, and patients or people who aren’t patients yet, who have a question, can go on and listen to a doctor explain it without having to go see that physician, right? And maybe you’re just interested in… You want to know about something because you don’t think you have it, but you want to make sure, and you can listen to an ear nose and throat specialist talk about some particular thing you were worried about. You can’t get that anywhere else. And so I think it’s a fascinating idea, to have thousands and thousands and thousands of physician videos explaining things and let people search up and hear exactly the snippets they want to hear about the things they’re interested in, coming directly from an expert in the field.

Daniel Lobell: (49:38)
So going back to your role as the chief medical officer of the Emergency channel, what kind of things can we hope to see from you at Doctorpedia?

Dr. Boykin Robinson: (49:48)
Yeah, so it’ll be interesting as we build this out, because Doctorpedia has been more specialty driven, emergency medicine, as we have discussed, is a little bit of everything. And so I think we’ll start with some of the common diagnoses people get discharged from the emergency department for. If you’re being admitted from the emergency department, then you have some disease process that will be addressed elsewhere, but if you’re being discharged from the emergency department with, say, abdominal pain, that means we didn’t know exactly what’s going on and there are certain instructions that you need and things you need to think about if you have abdominal pain without a diagnosis. And there are hundreds of thousands of people with undiagnosed abdominal pain out there. And so, we will look at the top 50, or start with the top 50 or so emergency department diagnoses.

Dr. Boykin Robinson: (50:52)
And talk about what you should do before you get to the emergency department with these kinds of things, or if you’re thinking about going, and then what you should do, if you were discharged from the emergency department with these kinds of symptoms. And I think from there, get into the types of symptoms people have that they’re thinking about going to the emergency department for. So you start to help people to triage. What should I do if I have X? Is this something that is best suited for a telemed visit? An urgent care? Or an emergency department? And I do find that that’s something that people — and it makes sense. The general public doesn’t know what resources an urgent care has versus an emergency department. And so it makes sense that people, should I — I was actually talking to a family member the other day who had had a medical issue and said, “Should I just go to the minute clinic for this?” And I said, “No, the minute clinic is not the right place. You need to go to at least the urgent care, maybe the ER,” but there was no way for her to know what resources would be at each of those three. And so I think that that’s something we can do on the emergency medicine channel, is help people understand where the right place for care for their symptom is, and, and how to decide how to get help.

Daniel Lobell: (52:21)
That’s so critical for people. I think it’s a great resource and I’m really looking forward to seeing what you do with the channel. I feel like I could keep talking to you. There’s so much, I think we’ve only just scratched the surface here, but our hour is nearly up. And I’ve enjoyed the conversation, I hope you have too, I’m going to ask you the same question that I round off all these interviews with. And that is, what is it that you personally do to keep healthy?

Dr. Boykin Robinson: (52:49)
So in the last couple of years, a couple of years ago, I invested in the Peloton. And so I bike to keep healthy and I found that to be a great thing that I don’t — once it’s here, I don’t need it to go anywhere. I don’t need other equipment. I can just throw on the shoes and bike. And so it gets me moving, most days a week.

Daniel Lobell: (53:15)
That’s great. I have one too. I haven’t been using it too much, I’ll be honest. I haven’t gotten used to the seat. It hurts, but I’ve…

Dr. Boykin Robinson: (53:26)
[Both laugh] It can be uncomfortable. I agree.

Daniel Lobell: (53:28)
Yeah. Does it get better? [Daniel laughs]

Dr. Boykin Robinson: (53:32)
Not really.

Daniel Lobell: (53:32)
Somewhere to improve there, maybe. We’ll have to look at the efficiencies, go in and make it better as you do with the work you do.

Dr. Boykin Robinson: (53:43)
Get some padded bicycle shorts.

Daniel Lobell: (53:47)
I did get them. I haven’t tried them yet. They’ve just arrived. All right, well I guess I’ll see you on the Peloton app at some point and hopefully we’ll get healthy together. What do you think of that?

Dr. Boykin Robinson: (53:59)
That sounds great. Thanks very much.

Daniel Lobell: (54:01)
It’s a plan. Thank you so much for your time and for sharing with me, Dr. Robinson, I appreciate it.

Dr. Boykin Robinson: (54:07)
Absolutely.

Daniel Lobell: (54:10)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.