In a healthcare environment defined by rapid change, building resilient systems and cultivating collaborative leadership have never been more essential. As electronic health records evolve alongside the growing influence of artificial intelligence, healthcare professionals are challenged to rethink how technology, ethics, and communication intersect. This episode offers practical insights into system design, ethical decision-making, and the strategic use of communication tools, all aimed at improving patient outcomes and fostering trust across diverse care settings.
On today’s episode of In Network's Designing for Health podcast, Nordic Chief Medical Officer Craig Joseph, MD, talks with Matthew Denenberg, MD, Chief of Pediatrics at Corewell Health East. They discuss the transformation brought by electronic health records, the challenges of adolescent access, and the shift from punitive peer review to organizational learning. They also discussed how thoughtful design and leadership can improve care delivery, provider experience, and patient outcomes.
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Want to learn more from Dr. Joseph? Order a copy of his book, Designing for Health.
Show Notes:
[00:00] Intros
[01:15] Alaska to administration
[02:23] Climbing the leadership and educational ladder
[04:32] Defining “systemness” in healthcare
[06:01] Designing health systems that work
[10:20] Data overload and AI solutions
[17:25] Managing disruptive providers
[20:53] EHR access
[28:50] Matthew’s favorite well-designed things
[31:19] Outros
Transcript:
Dr. Craig Joseph: Doctor Matthew Denenberg. Where do we find you this morning, sir?
Dr. Matthew Denenberg: I am in my office here in Royal Oak at William Beaumont University Hospital in Michigan.
Dr. Craig Joseph: And that used to be William Beaumont Hospital, I believe.
Dr. Matthew Denenberg: Used to be William Beaumont Hospital when I was born here in the 60s.
Dr. Craig Joseph: I was going to try to one up that, I was not born at that hospital, but I did get some sutures in my head when something fell on my head when I was, like, 4 or 5 years old at that hospital. So, I do feel a connection to you and to that hospital system. Well, I should welcome you to our podcast, and I'm going to ask you to kind of give us a little introduction to yourself where, how did you get into this position that you're in now?
Dr. Matthew Denenberg: Yeah. It's, you know, it's funny, the residents and students that I mentor asked me that all the time because everybody believes they want to get into a hospital administration. Right. So, I have a pretty, pretty traditional pathway. I started in college and went to medical school, and then I did my residency at Bellevue, spent a year in New York at Bellevue, and then did a combined pediatric emergency medicine and emergency medicine program at Detroit Medical Center at a children's hospital in Michigan, where you and I met as residents.
Dr. Craig Joseph: That's right.
Dr. Matthew Denenberg: Finished school and was ready to go out and save the world. And so, I took a job as a pediatric ER physician in a general ER physician in Fairbanks, Alaska. We went off to the Great White North, where it was 40 below in the winter and 60 and sunny in the summer. And after two years of that, my fiancée, my wife now of almost 25 years said, I'm not going to Alaska. It's 40 below and dark. So, we came back to Michigan, and I took a job at Helen DeVos Children's Hospital, which wasn't heaven on top of the time, but in early 2000’s and as pediatric emergency physician just started clinically and then got asked to do things right. You want to work on guidelines. Do you want to work on protocols?
Do you want to work on making triage better for kids? Do you want to develop a department? Hey, by the way, we're going to build this 13-story hospital. Do you want to design a trauma center? You want to be the first CMO and you know where this goes, right? So, this slowly through time took on bigger roles as a physician leader. And now I have crossed over to the state as we merged with Beaumont and Spectrum Health three years ago. I'm now the chief of pediatrics here at Coral Health East, which was Beaumont Hospital in the past.
Dr. Craig Joseph: All of this is impressive, but even more so given the fact, and I believe you will agree with me that we both graduated from residency about 5 or 6 years ago. And so that's my story, and I hope you support it. That's a long process. So, it sounds like mostly you were given a task, and you succeeded at that task. And they said, well, if you can do that, let's try something else.
Dr. Matthew Denenberg: Yeah. It's interesting. You know, you have two ways for some folks to get into leadership nowadays. They get their MBA, or they get their degree. And right out of school they get into leadership. And the others just kind of kept asking to do things. And when you're able to just get stuff done, people keep asking you to do bigger and bigger things. And that's kind of how my 22 years in leadership are. Progress is just continuing to do bigger and bigger things and getting more done and being asked to take on bigger roles. I have a very different approach as a lifetime learner. I didn't go on to get my master's in ethics or my math. My AA or my master's in quality and safety.
The CV ought to have more letters by my name. I did it up, usually at points in my career where I wanted to continue to learn and learn things that I could use every day. So, you know, I took on a master's in ethics at Michigan State University at a time when we were just getting started on our ethics committee work and some of the work I was doing in pediatrics and pediatric consent and some other things, and so rather than the traditional, you know, go to a course, go to a podcast or doing a podcast back then get CME, I decided I'm going to spend the time and effort to read a couple dozen books, and I might as well write some papers and talk to some college professors and get a degree out of it. And so that's kind of how I look at my advanced degrees. Is there a way to advance my career and my understanding of medicine and pediatrics and how to take better care of our health system?
Dr. Craig Joseph: Let me play off those last words you just said, health systems. One of the things that seems to be a defining part of your career is this kind of building system, this taking a bunch of disparate, either departments or organizations and bringing them together. So, you know, tell us, what have you done in that area and how do you kind of think of systemness and what are the benefits?
Dr. Matthew Denenberg: I've been lucky, right? Because if you look at when you and I started, we didn't have the big systems, we had hospitals. And I think that some of the success you see in the building system is that I had systems built around me. Right? We started as 1 or 2 hospitals, and then we started growing as systems. And so, the idea of bringing folks along, right, bringing folks into understanding the system is, isn't same, right? We want to unify how we take care of patients. We want to unify how we take care of that. Yeah. The community, one of the reasons for hospitals coming together as systems is to provide higher quality, more affordable care across a region.
And with our system it's disparate and it's choppy. And so systemness to me is bringing and bringing really good folks together, nurses, doctors, administrators, everybody together to provide better care for everybody across the system. And I'll use a cliche, we want folks to understand, you know, to have the same kind of care whichever door of the system they come into, whether it's in the northern rural system or in the urban part of the system. And I think that to me, that's systemness it's not sameness. It's unifying how we care for patients, the community.
Dr. Craig Joseph: How do you design that? You know, we like to talk about design on this podcast series. Is that something that you think about from the beginning, or is it move along as you as you are adding groups and trying to put things together in a way that they, you know, the, the whole is greater than the sum of the parts.
Dr. Matthew Denenberg: There's two ways. And the second one is more successful than health systems, two systems, one is they come in, and they say, here's the structure, here's the policies, here's how we're going to do it. Everybody adapts. So, you know you have to do it. That never works. If it works, it takes a decade. The other way is you really must have some governance structure, culture and really some incentives behind getting people to do the work together. So, if you just standardize across hospitals without engagement, it's not going to work. And so, to me and I said the support system is not sameness. You really do need to get folks working together. And it's layered on trust. Right. Remember hospitals are our traditional systems of ways of doing things. You have to convince people that doing it together is better.
Dr. Matthew Denenberg: And to your point, it is better. You just can't force it. And you can't force really smart people and really dedicated people to do stuff. And so, the best way to do it is to bring them on and that's how we did it, right? We failed the first time. Don't get me wrong, we failed the first time because we tried to force systems, and then we took a step back and said, all right, let's get everybody in a room together, stakeholders together, and let's get a common goal.
Dr. Craig Joseph: When you're doctors and nurses and therapists can see the benefits of, you know, if they now have access to resources, they didn't have access to before, technology that they didn't have before it, their jobs become easier. And what they're usually looking to do in the clinical side is care for people and, and for kids. And so, yeah, that makes sense. I've always tried the first method, which is just telling people what to do. Well, so some of your experience has been as you build this system, this is around technology.
Dr. Matthew Denenberg: There's been two times in my career where technology has been more than just a tool, and I and I were involved, they were transformational. One is the EHR, there's no question. And I can say the EHR. And for those positions on the line, they're listening to this. They're probably throwing things at me. But the EHR was one of them, because I remember as a student in the E.R. in Chicago doing records on triplicate. And then I remember when I started at spectrum, having charts stacked as high as the desk to try and find an EKG for a patient that was in the middle of having an MRI in our head, and then having a dumb waiter bring me. And I'm not I'm not a person, a dumb waiter from the basement. Bring me, bring me charts.
And so, bringing Cerner or Epic online or bringing epic across a system or bringing a bridge forward, all of these new technologies, they added to that platform. So, the EHR has been transformed. So, my involvement as a physician leader has been to bring people along, right? To convince them of the need for the change, to help them understand why we're doing it, and then to help them with the technology. Right. I was part of those teams that helped bring the EHR forward. From paper to the EHR. You and I did that together in Detroit Medical Center when we were younger. But then from, you know, various formations over the last 20 years. And then the second piece, again, is another tool transformation, another transformation or foundational pieces, clinical communication. If we can't talk to each other, if we can't have in-the-moment real-time conversations, especially when we're taking care of acutely ill patients or staff members that are having a an acute issue with security or whatever the issue is, if you can't communicate in real time or effectively, it dies. So, I've been very involved as we brought clinical communication tools forward so team members can talk.
And when I say team members, I mean everywhere from environmental services and food services all the way up to the CEO of the hospital is engaged in these systems. And so, the ability you know, the first system I helped bring online was a communication tool called Voalte, where I think we were doing 10 million messages a month or a year, 10 million, that's a year. And so that's a lot of communication. And if you don't have the tool and technology to get that right, it's a mess. And so those are the two big projects that I'm most proud of and other things along the way, obviously. But those are my those are day one.
Dr. Craig Joseph: Yeah. Well, you are certainly not going to get any disagreement from me about the transformation of the EHR. And I agree, many physicians, they'll tell you they're unhappy and then when, but you always can go to them and say, well, are you should we go back to paper. And, and the answer is invariably, no. All I want you to do is fix this aspect or fix that aspect of it for me. And, and we've come a long way and from the, from the days 15 years ago or so where we were just kind of just throwing these things in and hoping for the best to know there's implementation science. And, who knew that it could be science? I just thought it was, we turn on the application and hope for the best. So, we've gone from too little information. I remember as a resident you are going down to medical records and trying to find you right in the middle of the night. It was 3 a.m., and if we didn't have a medical student, we went down ourselves to try to find old records so that we could. And then it was it was sometimes huge amounts of records to try to get through. Now we have the opposite problem often is too much information.
Dr. Matthew Denenberg: Well, and I'm not sure that's completely an issue. Is that the data that's the data that we concentrated on as physicians and caregivers, because we live that every day. But I got to tell you, my email is full of data that I'm not interested in, my social media stuff full of data that I'm not. So, it's for me to get through my email now, my personal email takes me an extra half hour every 2 or 3 days because of all the data and junk that's thrown at me. So, I'm not sure it's just the EHR. We are getting there this year. The data science that you guys are implementing, the experts that are at this, are making a difference. But it's everywhere. It's not just the air. It's everything and everything that uses data now. It's just too much. If a non er physician wants to spend more time dictating or writing a super long note, first of all, I want to teach them not to do that because we don't need these long notes with everything pulled in.
But if they want to do that, as in Air Doc, I'm hoping to use A.I. to just go through their bloated chart and just give me the information I need to take care of that patient at the moment, and hopefully they'll stop doing that someday. But at least there's a fix for that with AI, because some people, you won't be able to stop doing that. But I got to tell you, as an air doc, I don't need to read a ten-page note to get to what I need. I need AI to tell me: Here's five things you need to know about me that's in front of you to take care of his shunt in the moment.
Dr. Craig Joseph: You know we write notes. Well, I'm not even sure we're going to continue to write notes, but we write notes for many audiences. One, of course, ourselves, our future self and for our colleagues and for, our defense attorneys and our QA people and our billing folks. There are lots of different reasons to write those notes. I remember practicing in Michigan. This is, long before I had an electronic health record, but I would get from my EMT friends when I sent patients. Hey, should this patient maybe have tubes, and I would get a three-page letter? Very nicely typed. And I just, I instantly, I think, like, every primary care physician would just go to the final page and where it said, assessment and plan.
That's all I cared about, which is one of those, you know, changing from a Soap note to an app. So no, putting the assessment plan at the top, especially with electronic health records, just makes complete sense because most of the time that's what we care about. There are absolutely times where you are interested in their physical exam finding or something. But, you know, 90% of the time, if I'm asking you for your opinion, is I'm interested in what's the bottom line? And what are you going to do about it or what do you need me to do about it?
Dr. Matthew Denenberg: I think this helps our coders and builders, because rather than having to search through all of our writing or all of our dictations, they are going to be able to say, what code should this be? And they are going to figure it out because they're going to search for every and the same thing with the payers. I think the players are going to win because the players are telling us we're going to get rid of your authorization. No, you're not, you're just going to use AI due to the same level of scrutiny. You're just going to say, should we approve this or not? And I am going to decide, because you're not going to be searching for the entire record. And so, I think patients will win eventually because things will be quicker. But I think that the ability to search through data quicker and get to the same or better answer is where we're all going to win.
Dr. Craig Joseph: Let's pivot a little bit at the organizations that you've been at. You've had responsibility for quality or peer review, making sure that physicians practice the way that they should. Is that being something that that you, you relished or was that foisted upon you? If it were me and someone said, I need you to, judge some of your peer physicians and tell them if they're not doing a good job, that would be, not high on my list of stuff to do.
Dr. Matthew Denenberg: I would say as a physician leader, it's all of our job to make sure that our peers and our colleagues and those that we're responsible for are not only practicing in a way that's safe, high quality and good experience for the patients, but more importantly, that we're helping them have a successful career. And that's really my peer review of the period we've done is one of my proudest moments. You know, we both grew up in an era where peer review and Eminem were seen how let's see how much we can shame this provider. Let's see if we can find everything they did wrong as a Monday morning quarterback. And then and if they can, if they can leave the room without crying, maybe it's okay. But if they cry, that's probably okay too.
And so that sort of shame and blame culture has been pervasive. And so, we took an approach to really start working on that organizational learning aspect. We wanted peer review to be an opportunity for our peers, our friends, and our peers to improve. So, if somebody does something, God forbid, that causes harm or does something that's not according to policy or does something that's not exactly best practice, most of the time they're not doing it on purpose. They're not doing it to be harmful.
So, we have to find a way to help them and more importantly, they're probably doing something where somebody else is in the same position. But what more, more than likely are likely to do the same thing? So, we took an approach where we developed an organization like Peer Review, where we all learn from all of the cases. Now, don't get me wrong, if someone does something totally out of scope, they have no business to do or are totally against policy. They're there are actions for that. But what I found in doing this for 5 or 6 years now is most of the things that most physicians do, a lot of us look back and be like, oh, in the same circumstances, I could see how I would have done the same thing. You know, Monday morning I can say I wouldn't have. And so, we took an approach where we wanted that person to learn if close to the event. So, they don't do it again. We want everybody else to learn so they don't do it for the first time, and then we want the system to learn why we set them up for failure, because we didn't have these five things in place and so it's the organizational learning for the person and the system, learning for the system. And I think we've made some really good strides and sepsis care. We've made some strides. Physicians that in the old days would have waited for 5 or 6 bad cases and they would have been in trouble. So, we kept them with the first case, and then we all learned from it.
Dr. Craig Joseph: I love the idea of, hey, how do we make it not only easy to do the right thing, right? The first thing we have to do is define what the right thing is and then create systems in it and to make it easy to do that. But also, how do we make it if we can? We can't often, but if we can't, how do we make it impossible to do the wrong thing? Kind of an adjacent topic. Looking through your CV, you list disruptive provider resolution as an area of expertise, part of your leadership. So, we talked about the kind of quality and making sure that patients are safe and trying to improve the care that we give. And oftentimes that ends up improving the care that not just that another doctor gave, but that I'm going to do tomorrow.
I want to make sure I do it right. Disruptive doctors, I recall as a as a medical student at your institution, doctor tending bird, watching a surgeon throw a tray of instruments at the wall kind of screamed at the resident, you're killing the patient. You're killing the patient. Now, he was not killing the patient, but it wasn't really accepted even back then. But nothing happened to that doctor that I knew of. And I think nowadays something that that behavior would have resulted in potentially coming across your desk. And so, is that still a problem, by the way? Or if we kind of matured beyond that.
Dr. Matthew Denenberg: It's still a problem. And I'm really careful. And I've have done this before. You know, obviously, we like to use the surgeon analogy, but I got to tell you over doing this for 20 some years, pediatricians are just as disruptive, the surgeons are disruptive, hospice care doctors, everybody. I have learned a ton from some experts in the field. There are 2 or 3 different kinds of disruptive physicians. There's a kind that you describe where there's a red line, there are some red line issues. You cannot throw a scalpel. You cannot yell and scream and swear at a patient and a nurse and a tack because you're angry that they didn't, you know, do exactly what you wanted. Those are just human decencies that we have to and have not done a very good job traditionally and are getting better at it.
But then there's the piece of disruption that that I think we needed to start in medical school. I'm on the Spark committee, which is for disruptive medical for students with behavior issues. And I got to tell you, we got to start with early intervention in early coaching because we are highly educated, highly competitive professionals that are in high acuity business. And I don't think we give ourselves enough credit early on in our careers to prevent disruptive behavior. So, I think one of the things that I think that I've become pretty good at, and I've helped our teams become good at, is there are all kinds of reasons why people are being disruptive. And I think we have got to find a way to help them through that. Right. I'm not saying people get ten chances, but, you know, I've had providers, I've had substance abuse issues that we've been able to successfully get back into their careers. I've had providers have been going through family issues. We've had providers that have had, you know, medical issues that they weren't sharing. There are all kinds of reasons why physicians are disruptive.
And it's on us as peers and as professionals and as leaders to figure out ways to prevent that, if we can. There will always be times when we just have to take action. The medical staff, I get that, but that's few and far between the number of providers we've had to terminate or kick off staff. I can count on the one hand the number of providers we've helped through with coaching. I can count on many, many.
Dr. Craig Joseph: As you mentioned, you did residency, and in pediatrics and emergency medicine. From the emergency medicine perspective, you've done some work as a medical director for FEMA and worked on pandemics. What have you learned about that aspect? Most of us when I, when I think about you, your pediatric hat, that's far from stuff that most primary care pediatricians for sure would have to deal with. What about that kind of work excites you or piques your interest?
Dr. Matthew Denenberg: I'll start off by saying it's pretty clear, and the evidence supports that we are not in this country. And I think Covid showed us this. We are not ready for a significant disaster, and our major events are health care, adult and pediatrics. There's no I mean, we're getting better, but we just don't have the interconnectivity among highly competitive health systems, even though health systems are getting bigger. And so, if you take that that non-readiness and emergency preparedness for health care magnify that by ten for pediatrics. We just have not for decades been as prepared. And we know that right. We did our first survey in 2016. Pretty clear. We aren't ready. We did another survey a couple of years ago. Better but still not ready.
And so, I've been very involved with a couple of grants, one through HRSa and one through Asper with Children's Hospice around the country. As we start to prepare a preparedness network, you know, preparedness protocols and ideas and language around how children's hospitals and health systems that our children's hospital prepare for a surge or a disaster. And so that's been a lot of that's been a lot of fun. But we've got a long way to go. We're making progress. We are definitely making progress. But this is the first time I feel optimistic. There's two major networks right now that bring about 20 or 25 of the children's hospitals from Puerto Rico all the way up to Seattle, Washington, that are finally creating these networks of readiness. And I think if the federal government and the state governments continue to support that work, I think we're moving in the right direction.
Dr. Craig Joseph: I'm hearing that you don't believe that children are just small adults.
Dr. Matthew Denenberg: No. And I'll tell you that. Funny. When I was in one of my previous roles with my background in emergency medicine, I used to also give a lecture for the pediatric residents that adults aren't just big children. There are, you know, when you work in a pediatric emergency room, grandma has a stroke in front of you, all of the PDR docs get nervous. The whole 911 got them over to the adult hospital. So those of us that are adult trained, I'm like, wait a minute, will first of all, stabilize. And I'm kind of kidding, but I'm not. So yes. And especially in pediatrics, they are not just small adults. Physiologies, different medicines are different, their development different. One of the things that we believe that we were ready for pediatric disasters is, oh, we'll just we'll just bring in all the equipment, and we'll just take care of them, and we'll bandage them up or we'll take care of the eyes.
I'm like, okay, but don't forget the developmental needs of those kids that a 12-year-old, a ten-year-old, a six-year-old are not the same as a 24-year-old. And don't forget the family reunification piece. What are you going to do with all those kids that have been separated from their families? It's, you know, a 19-year-old can figure their way out. A six-year-old can't. And so, I think they're not just small adults.
Dr. Craig Joseph: Now, you've been involved in figuring out how adolescents can access technologies such as electronic health records. How does that work, how adolescents have let me I don't know if you're sitting down. They're difficult. You might want to sit down for that comment. How have you been successful in dealing with adolescents' access to technology, like the EHR?
Dr. Matthew Denenberg: So, if any of my detractors from this work are listening to me, you're going to love this statement. When we started doing this work, my 19-year-old college student and my 17 soon to be 18-year-old daughter, we're not adolescents. And so, I was doing this out of my knowledge as a pediatrician in my research work in adolescent ethics. But I got to tell you, the hardest part about figuring out how to give adolescents or allow adolescents appropriate access to their health care records into their health care in general, is it's there's 3 or 4 things that are that complicated. One is the family dynamic. You know, there is this dynamic between the parents and the adolescent. They are struggling with trying to figure out how my child is going to become an adult during adolescence, parents have different views.
Some believe that their kids, their adolescents, should have full access to their medical records and be able to make decisions. And others are until you're out of my house or until you're 18, I make all decisions. I need to know everything. So, you have those and it's different in different parts of the country, right? The other pieces, the legal aspects, every state has slightly different law. Some adolescents get a little more right at 13, some get it at 12, some get it at 14, some don't get it till whenever. So, you have got to deal with the legal and compliance piece of it. And then there's that. There's the public piece of this. Right. What does the public want you to do? And then the last piece is the players.
Even if we make it so that adolescents will access the record and the parents don't have access, the payers still send a bill to the parents for that pregnancy test. That and that 15-year-old. And so, we had to take all of that math that nobody really needed to deal with the paper records because it was a little easier. You didn't write in the record what you need to. Parents had to get a copy. The electronic record is more difficult. So, we set up a system. We worked with Epic, we worked with the Epic builders, and we built a system where at the edges of legality in Michigan, we were able to turn on the adolescents' access to their own chart. We were able to give parents the appropriate limited access to help them make appointments and stuff. But if it was a child with complex medical needs or some reason why the primary care pediatrician felt the parent needed full access or the child agreed to the counseling, we do it we gave that can actually develop three ways, three kinds of access.
And you know, it was hard at first, but Epic really did a nice job of helping us sort that out. So, we did that live on the west side of the state. And then we brought it to the east side of the state when we switched to one version of Epic last year. So of course you can imagine that, you know, I then, the parent concerns, I got about what do you mean my child has access? What do you mean I don't have access? But in the end, it's the right thing to do, right? Our kids need to become adults to all that was. And I will and I will give Epic some kudos on this is they really helped us fine tune what we were doing in the state of Michigan, who's got some very specific laws and rules around this. But then when we presented it at GM, we had other states reach out to us to adopt the technology, the methodology behind it. So, like a lot of what we do in pediatrics, especially adolescents, it's a leadership issue I needed to know. And I had the support of my leaders, that when they got a call from parents yelling and screaming, or they got a call from Congressman Y that they were going to support, that we were doing the right thing.
Dr. Craig Joseph: Absolutely. Without that leadership support, you're useless. And from a designing perspective, I think that's a really important point, right, to kind of help leaders saying like, hey, it's not a possibility that someone's going to call and complain to you. It's definitely going to happen. And so, let's think about what you tell me, what you're going to say to that parent or to that Congressman. This was an amazing conversation. Doctor Denenberg, we like to always end these talks, asking you a design question and the design question is this, is there something in your personal life or work life that's so well designed that you, it makes you happy every time you interact with?
Dr. Matthew Denenberg: My wife would say that my work life balance design is terrible, but again, she's been very supportive all over. Do I? I'm going to tie this all together with one thing that I do. If I chose to retire tomorrow, the one piece of work that I've been involved in in the last ten years that I'm most proud of is us as our help chain work. And it really was a modernization of the chain of command, which is a term I don't particularly like. And if you look at some of the stuff that we talked about this last 45 minutes, the foundational pieces of clinical communication, of organizational learning, right, getting providers to work together to solve problems for patients. The idea that we want to flatten the hierarchy and not have these gradients of authority. We created a health chain which uses all of these tools and effort, and a nurse or environmental services or a physician is having an issue in the moment with patient care or a patient safety or provider or team member safety. If it's urgent. We use our normal code blue. Wrap whatever you want to call. If it's something that clearly can wait till tomorrow, you know that the parking lot needs to be repainted.
Fine, but if it's a patient that needs pain medication or needs something urgent for their care and a second example, nurses having a hard time getting hold of the physician, we wanted to make sure that we had a health chain so that after 20 minutes of trying to get hold of the first person in line used to help change. So, the next escalation is a manager and if not the third escalation, why is that help chain is the physician executive on call. So, we had a group of 4 or 5 of us that promised we would be nice, no matter what time of day. We promised we would help find a solution. We didn't have all the answers, but we knew to your point how to get ahold of who is around the system.
And so, there was always somebody at a level to help that person take care of a patient. So, we universalize that on the west side of the state. And now it's to help change universal across the system. And that's my proudest piece of work, because it allows nurses and team members to have immediate access to somebody to help them get something done when they feel they weren't. So, I got tired of hearing in the morning, boy, we tried to get a hold of doctor X for seven hours for pain medicine and they never answered. And so, I think that's my proudest speech. I think that is the design that I think is the thing I'm most proud of.
Dr. Craig Joseph: I love it, it's simple and straightforward, yet incredibly effective.
Dr. Matthew Denenberg: Simple, straightforward, effective. You know what, we want things that are simple and elegant, but it's not complicated, right?
Dr. Craig Joseph: Doctor Denenberg, thank you so much. This has been a great conversation. I certainly learned a bunch. So, thank you, sir.
Dr. Matthew Denenberg: Awesome. Thank you.
READ THE TRANSCRIPT
Show Notes:
[00:00] Intros
[00:09] Marina’s background and her book: The Vagina Business
[01:29] Gender data gaps
[02:52] The emergence of Femtech
[04:00] Innovation and obstacles in birth care
[05:30] Title controversy and pushback
[13:02] Femtech vs. Scamtech
[14:09] The pink tax in healthcare and global innovations
[27:03] Marina’s favorite well-designed thing
[28:52] Outros
Transcript:
Dr. Craig Joseph: Marina Gerner. Welcome to the podcast. Where do we find you today?
Marina Gerner: Thank you so much for having me. I'm sitting on my chair in London in the UK.
Dr. Craig Joseph: We are talking today because someone connected us about your book. And so, you put out a book recently, The Vagina Business.
Marina Gerner: That's right. And the subtitle is The Innovative Breakthroughs that Could Change Everything in Women's Health.
Dr. Craig Joseph: So, give us the backstory. Why don't you kind of give us a little introduction as to how you got to where you are and how you got to write a book that's called The Vagina Business.
Marina Gerner: My background is that I'm a journalist, and I also have a side hustle as an adjunct professor at the NYU Stern School of Business, and I've always been interested in the stories of women, whether that's in, you know, technology or health or business. So that's been my focus for a while. And then a few years ago, I learned that if you ask most people to imagine a person who's having a heart attack, most people tend to picture an old white man and the symptoms they think of is pressure on the chest and then pain radiating down the left-hand side.
And I learned that those symptoms are typical for men, but they're not typical for women. And I thought that was so shocking. You know, and as a result of that, women are 50% more likely to be misdiagnosed after having a heart attack. We also wait longer to seek help. Our symptoms are considered atypical. They're more likely to include things like jaw pain and long-term fatigue, for instance.
And women also experience that pain and the pressure on the chest but were more likely to describe it as discomfort. And so, I learned there was this issue. And I also met the founder of a company called Bloomer Tech, and the founder is called Alicia Chong Rodriguez. And what her company has created is what I thought is the coolest thing. It's a smart bra that can help women who are at risk monitor their heart health. And I thought, this is wonderful. You know, not only is there this huge problem, but there are also people who are creating new things that might be part of the solution, and that might help us fill that particular gender data gap. And I approached her about an interview.
I messaged all of my editors about this story of the smart bras, and then I kept looking at my inbox and there was just tumbleweed. Nobody was interested. And there it was this. Yeah, it was really surprising because I've written for lots of different places. You know, I've been a journalist for 15 years, and there was the sense that the topic was a bit niche. That made me wonder, how can something that could potentially help over 50% of the population, how can that be considered niche? And then I held on to this story. Even though I didn't manage to place it. The story stayed with me, which doesn't happen with many other stories in journalism, you know. But this story stayed with me. And then the pandemic happened. And I think that changed a few things, because power dynamics shifted between the doctor's office and the patient's home, because we trusted people to test themselves for Covid. And, initially, when you think back to the start of Covid, men had worse symptoms than women. So, if you wanted to be cynical, you could say we started to pay attention to sex differences in health because men were more affected by Covid.
And that's when I finally managed to place the story. But the smart bras came out in the Guardian. It did really well, and I was invited as a result of that, to chair a panel at one of the first ever conferences focused on Femtech, which is female technology. So that's technology focused on female bodies. And I was completely blown away by this conference. I was drawn into this space. I was in my early 30s at the time. I'm in my mid-30s now and I have a child now, but at the time I knew that I wanted to have children soon. So, I was preparing for this, and I knew that the vast majority of first-time mothers experienced birth injuries, unfortunately.
So, I wanted to prevent that. And I was looking for solutions. And I found a company in California called Maternal Medical that's creating a preventative device for birth injuries. And I thought that was so fascinating. I spoke to the CEO, Tracy McNeil, and she told me that the last big innovation in the standard of care at birth, mostly epidural, which was popularized in the 1950s, and that was that just blew my mind because I was thinking, there's no other area of society or technology where we bring something out from the 1950s and we say to people, hey, look, this is the best we got. Look at this cutting-edge floppy disk over here. But in birth, that's exactly what we do. And I thought that was shocking. And the more I looked into the space of what I describe as vagina-centric innovation, the more I realized that one of the biggest or perhaps the biggest obstacle is that most investors are male, and they don't want to invest in these companies because there's so much stigma around these topics.
And I have a quote from one investor who says in the book, “I don't want to talk about vaginas at my Monday morning partner meeting.” And that's the kind of attitude that stands in the way of innovation focused on female bodies. And that just made me so angry. Yeah, I wrote an article called “We Need to Talk about Investors Problem with Vaginas”, and that went viral, came out in Wired magazine. And then I took this as my what they call a proof of concept in the business world, to then write a book and look at this movement and, you know, tell the story of the Femtech movement.
Dr. Craig Joseph: So, I love everything about that. What I wonder about is what is the right response to that. That partner who said, I don't want to talk about vaginas at my Monday morning partners meeting, right? It would seem to me in hindsight, the best response is, you know, would you like to talk about money?
Marina Gerner: Yes. Would you like to talk about the unmet need? Would you like to talk about the total addressable market? Would you like to talk about why these matters? And you know, if you don't want to talk about vaginas, maybe all the others also don't want to talk about vaginas. So, wouldn't you have an advantage if you were the odd one out?
Dr. Craig Joseph: Yeah, that makes sense. Is that message being received now because of some of these conversations, because of some of the female founders that you're referencing?
Marina Gerner: I sure hope so. I mean, my goal with the book is to change that conversation and to normalize that conversation, and that's why it was so important for me to have the word vagina on the cover, because I could have called this book lots of other things. And I actually, you know, faced lots of obstacles with that particular title, and I had to come up with 16 alternative titles at one point. All of those titles were tested on a target audience in A/B testing by my publisher. And then The Vagina Business won. So ultimately, this title won in the market research. But there's been a lot of resistance to it. But the point of the book is to destigmatize the conversation. So, I figured if I put the word vagina right next to the word business, you know, and the book can sometimes be found in the business section, sometimes it's in the social sciences section. It depends on the bookstore, but it stands out wherever it is.
Dr. Craig Joseph: I love it. And did you get pushbacks from someone other than the publisher?
Marina Gerner: Oh, yes. Yeah. So, the publisher also had feedback from independent bookstores who said that they wouldn't display it, and they wouldn't promote it. I had pushbacks from when I was reaching out to other authors to write endorsements for the book. One author said to me the title is too much for her, so she wouldn't write me a blurb. I had a venue turn me down when I wanted to have a book launch there, just purely based on the title. Some people who've written reviews for the book on Amazon have used the word vagina in the review, and then that was flagged as violating community guidelines. So, they've sent me screenshots of their reviews being censored. And I think there's a lot of censorship that happens behind the scenes where people wouldn't necessarily tell me, you know, nah, I think your book titles are too much for us, but they simply don't reply.
Dr. Craig Joseph: Wow. I'm just honestly shocked.
Marina Gerner: Yeah. No, this book was published a few months ago and it continues to be an obstacle. So, the book has already won two awards, which is amazing. And one of them was supposed to be announced in Dubai. So that didn't happen because they couldn't have mentioned the title on the stage of this big conference. And you know, that continues to be back. It keeps happening and it is shocking, but it's not too surprising because all of the founders I've interviewed in this space, whether that's menopause-related, UTI-focused, sex education, all these companies and nonprofits experienced censorship online. All of them.
Dr. Craig Joseph: Wow. I'm at a loss for words, and that's not typical for me. So.
Marina Gerner: I can believe that. Yeah.
Dr. Craig Joseph: It's just I get it in certain areas of the world maybe or but boy, widespread.
Marina Gerner: Yeah. Including things like lactation cookies, you know really things where you just wouldn't expect it.
Dr. Craig Joseph: You said that you were a professor at Stern as well. How did that come about?
Marina Gerner: So, I have these, some people call it what, my multi-hyphenate or, you know, portfolio career. I have these two tracks in my career. I've been a journalist from the age of 19, I think that is when I published my first article in a vague newspaper, and I also did a PhD in my early 20s. And so, I just continued doing those two things at the same time. I left academia for about five years to be in journalism full time as a staff writer. I returned to academia with this. It's an adjunct professor role, so it's part time. Yeah. It's wonderful. I teach a course called Commerce and Culture, which is very unusual because it combines, you know, business and society, business and culture.
And it's also what I'm doing with the book because I think women's health innovation is the perfect case study for that, because if you only looked at it from a business perspective, you'd think, hang on. This is our $1 trillion market opportunity, you know? Yeah. And you wouldn't understand the stigma and the cultural side of things if you only looked at it from the cultural side of things. You wouldn't understand the financial underpinning of everything. So, I think with a topic like that, my very idiosyncratic choice of subjects has come together in a way that's really helpful.
Dr. Craig Joseph: Some of the female founders that you talked about in the Femtech area, they all seem to be female.
Marina Gerner: Not all of them aren't.
Dr. Craig Joseph: Yeah. I was going to say, tell me about that.
Marina Gerner: About 80% are estimated to be female. But then there's a, you know, a fair amount of both founders and researchers and investors who are men. And I've included plenty of them in the book as well, because I think everybody needs to be on board with this subject. And it's an opportunity for everyone, really. Where it gets a bit complicated is when you look at the data on how much money different teams raise and unfortunately, most money, even in the Femtech space, is raised by all male teams. And that's where it becomes a structural issue because there's a company over here called Flo Health, which is a period tracker, and they've become the first European Femtech unicorn. And they were founded by a group of men. And so, when they became a unicorn, people were asking, you know, is it what do you make of it?
Is it a problem that it was set up by guys or is it a victory for all of us because they've raised all this money and they've achieved this unicorn status? And it's complicated in and of itself as a case study or as a one-off example. It is a good thing for the Femtech industry to have such an example, such an example of success. But if you look at the structural side of things and you realize, well, if it was led by a group of women, they wouldn't have raised that money. And so that's where it becomes difficult.
Dr. Craig Joseph: Tell me about that. We like to talk about design. The stat part of the part of the podcast designing and healthcare. And so Femtech design, are there any kind of overarching concepts that people just generally get wrong when designing for Femtech from? Not just the product itself necessarily, but maybe the, the, the conceptualizing of it and marketing of it and financing of it. Are there design flaws that you've seen that are common?
Marina Gerner: Yes. Let me just pull up a certain chapter in my book. What I do is I distinguish between Femtech and scam tech, and so Femtech is technology focused on female bodies, everything from periods to menopause, but also going beyond like cardiovascular health and bone health. And then you have scam tech, which is technology that monetizes insecurities and that, you know, mis-sells things. And so that's where we get to the insidious side of things. So, for instance, vagina steaming devices, you know, are harmful devices and those still exist. They're not banned. But we know that they can lead to all sorts of damage. There's also a range of intimate wash products that are potentially quite harmful. And then I've also found that there is a new version of the pink tax in health care.
So, you know, when we think of the pink tax, traditionally we would think of razors. And so pink razors that are marketed to women are more expensive than blue razors that are sold to men. And in healthcare we have generic drugs like ibuprofen being repackaged, put into pink packaging, and they're being called feminine acts or Midol. And those are then sold at a premium or period pain relief. So those are three categories. Kind of the actively damaging, the useless, potentially damaging and a new version, of the pink tax. And so, the questions I recommend asking are, does this product monetize shame in any way? So, does it imply that your body is dirty? Does it sell?
But is it painful? You know that that old idea? Does it provide a full sense of safety? Is it under regulate it for what it is? What data does it collect? You know, what claims does it make? What's the evidence and what emotions does it trigger? Because in the fertility space we sort of messaging that sounds, like you're running out of eggs, you know, quick, quick, quick. You're running out of eggs. You're almost 35. Your fertility is about to fall off a cliff. And so, whenever you have something that triggers your emotions so strongly, it's kind of worth pausing and asking, you know, what? Am I being sold here?
Dr. Craig Joseph: I'd say I've never heard of the pink tax, but it totally resonates.
Marina Gerner: Yeah, it applies. So, I usually use the example of razors. But you could also look at haircuts. You know, haircuts for women are so much more expensive or rain jacket all sorts of things. Once you start looking into them, you'll see the pink tax in them.
Dr. Craig Joseph: That is fascinating. How do you draw attention? You know, you've said some of the media of which you are somewhat a part of the media is not helping, right? Sometimes even in trying to advertise your or market your book.
Marina Gerner: Yeah, absolutely.
Dr. Craig Joseph: How do we get the folks in the media to be more comfortable, or is it just part of the overall culture of the area that they live in?
Marina Gerner: I think it's about shifting the conversation, and not just by making people more comfortable with certain terms, but also by just using certain terms, without using euphemisms, for example, because, you know, if people don't want to use vagina at a doctor's office and there are some surveys that show that I don't remember the exact percentage, but a really large percentage of young women don't want to use the word vagina at the doctor's office, and that has really terrible consequences further down the line.
How do we get people to use those words, and how do we get people to use words like perimenopause or endometriosis? And I think because if you don't know that something might happen to you or your friends or your family members, how are you supposed to address it? And there are still lots of people who think, okay, menopause is when your period stops one day and they're not really aware of perimenopause and the various symptoms, the 34 odd symptoms that can come with that. And the same goes for endometriosis. 10% of women are estimated to have endometriosis, but historically we've normalized female pain. Right? So, women were always told, oh, you've got period pain. Extreme period pain. Well, that's normal. And in reality, there could be an underlying issue there like endometriosis.
Dr. Craig Joseph: You're going back to your first example of heart attacks with women too. This has real world implications as you know, even if the signs of a certain disease are slightly different, it's on the healthcare side of being able to think about some of these things. And yeah, you're right. The average female having a heart attack doesn't have the same symptoms as the average man. And yet we only assume all heart, we kind of, most of us assume all heart attacks are, you know, chest pain feels like an elephant standing on my chest, that sort of thing. And that shows in the morbidity and mortality results of cardiac problems in women. Let me pivot a little to the concept of Femtech that term.
Some folks have a problem with that in saying that. Well, why does it? Why is it Femtech? Isn't it just tech?
Marina Gerner: Yeah.
Dr. Craig Joseph: Femtech, why does it need its own category?
Marina Gerner: I have lots of thoughts on this. I think the first funny thing is with term Femtech is whenever you use it, people hear fintech, financial technology. So, you know, oftentimes people think you talk about online banking when obviously that's not what we're talking about here. The term was coined by Ida Tin, the founder of CLU, in 2016, to bring together all these different kinds of companies that are innovating in women's health.
And so, what's special about it is that 80% of founders are female, and it's estimated to be a $1 trillion market opportunity. Obviously, I hope that Femtech will only be called tech one day, just like health tech, but will simply be health, right? Because tech will be a normal component of health care. And I think with Femtech, some people prefer to use the term women's health innovation. But I think the success of the movement does not really depend on what term we use exactly. And I think the term might evolve in the future as well. But right now, it's really helpful because people find each other by using that term as a hashtag on LinkedIn, on Instagram, there are conferences that are organized that are specifically called Femtech conferences, Femtech webinars, Femtech accelerators.
So, it's a term that has energized people and that has brought people together. And I think for that, it's really helpful. And a parallel example is, you know, feminism, you could say, well, isn't it simply equality or human rights? But we still have feminism for a certain reason, and hopefully we won't need feminism one day. And the same way I would say, hopefully we won't need the term Femtech one day it will all be tech because tech will serve us all equally.
Dr. Craig Joseph: So, are there any good examples or particularly interesting founders or companies that you've encountered in the writing of the book that you think deserve highlighting?
Marina Gerner: Absolutely. I could give you so many examples. It really depends on what part of women's health you're interested in. But there's for instance, in Copenhagen, there's a new form of contraception that's being developed called V, and it looks like a laundry capsule. It's transparent. And so, it's something you dissolve in the vagina, and it works together with the cervical mucus to keep sperm out. So, it's a non-hormonal form of contraception. And I think in the future we will have more non-hormonal choices. There's also contour line, which is a long-term contraceptive for men. It's a reversible vasectomy that uses hydrogel and that's being developed at the moment. So, I think there's a lot that will happen in the non-hormonal contraceptive space. Then there's also a device that's just come to the market in Ireland, which is a smart nipple shield.
So, you know, nipple shields are usually used when you're breastfeeding to either help with a latch of the baby or to protect the nipple. And historically, they've been made out of lots of different materials, like glass and pewter and plants even. I think this one is different because it has a sensor in it that can measure the amount of milk a baby is getting. And that could potentially be really helpful if you have babies with a low birth weight or, you know, if you have mothers who would like to breastfeed, but they're too worried about how much milk the baby's getting, you can also then use that information for research purposes. And that's the case with a lot of Femtech companies, is that they collect so much data we've never had before, that if you partner with researchers, you can get some incredible insights into how somebody's milk supply correlates with other aspects of their health.
Dr. Craig Joseph: That's amazing. As a pediatrician, all we could do was measure the number of minutes the baby was nursing and then the output. Right. We you could never really know what the baby was getting. So that would be incredibly helpful, especially for kids who are somewhat sick. And we really need to know about their fluid intake.
Marina Gerner: So that one's called the Coro. That device. Yeah.
Dr. Craig Joseph: That's awesome. So those are just a few of the kind of examples that are.
Marina Gerner: Yeah, I've interviewed over 100 people in the book. So, you'll find many, many, many more examples there. And I've interviewed people across 15 different countries because I wanted to show people the range of innovation there is.
Dr. Craig Joseph: If you could wave a magic wand and change just one thing about women's health care, how it's designed, how it's delivered, what would that be?
Marina Gerner: Oh, yes. I think there's something really universal, which is the normalization of female pain. I think if we reverse that, that would be a huge and revolutionary thing to do, because right now we still say to women, you know, extreme period pain, oh, that's normal pain with breastfeeding. That's normal. Oh, you're giving birth. Well, there's no birth without pain. IUD insertion. Well, you can't possibly expect pain relief, although that's slowly changing. But I think if we completely reverse that attitude across the world, that would be revolutionary.
Dr. Craig Joseph: Is there any specific advice that you'd give to aspiring entrepreneurs who are looking to break into Femtech? What can they learn? Besides reading the book for sure, what can they learn, to either avoid or make sure that they do?
Marina Gerner: Well, of course I was also going to say, read the book. All of my wisdom, all my treasures, contained in the book. And, you know, I'm giving them to the world. I think it's really important to if you're not a researcher, if you're not a medical professional, to assemble a team that you know, includes medical professionals, that includes researchers, and to make sure that whatever you're doing is evidence based. I think we see a lot of snake oil. Unfortunately, there are a lot of things that are not evidence based, especially in the area of supplements or apps or, you know, things that aren't regulated to a high standard. Always make sure that what you're doing addresses an actual problem, because I see companies that are addressing issues that aren't actually issues as well.
So, I've seen apps that will analyze your menstrual cycle and tell you if you're supposed to have a meeting or if you're particularly creative on that day. And that's just reductive. And it's just unhelpful. It's not constructive. So, make sure that you're addressing an actual problem that you find a, you know, solid unmet need. Make sure that there's a business model for your venture, that it can exist in a commercial frame, because not everything can exist in a commercial frame, even if it's a good idea, even if it addresses an unmet need. Put together a good team and think about how it will get funded. And you know, venture capital is not right for every company. And in fact, I think we need many, many other sources of funding in women's health.
Dr. Craig Joseph: Excellent. Well, we always like to end with the same question and the of all of the folks that we interview. And the question is this, is there something in your life that is so well designed that it brings you joy whenever you interact with it?
Marina Gerner: I would say my hands free and smart breast pump. So, I have a baby. I'm breastfeeding, and I also launched a book at the end of last year. So, I've had speaking engagements all over the world, and I always travel for the shortest possible amount of time. You know, a day and a half, maybe two days and one night. And I'm traveling with this breast pump that is quite small that I've used on the plane that you simply pop into your bra, and it doesn't have any wires that are, you know, attached to anything. It's relatively quiet. It's convenient. And on these trips, I always find myself thinking, wow, I'm so dependent on this device because, you know, without it I would risk having a clogged milk duct.
I could risk having mastitis, I could risk my milk supply going down and so on. But with this device, I've got the freedom to be away for a day or so. I used a breast pump on the plane, and I asked the flight attendant on the way back from San Francisco, I said to them, have you ever seen anyone else using a breast pump on the plane? And they said to me, oh yeah, actually, there was a woman there on Friday who used a breast pump. And I said, yep, that was me, because I was flying on the same schedule as the flight attendants. So, it's still quite rare, I guess. And there are certain suggestions I have on how they could improve that design. But I think compared to all the breast pumps, it's a much more convenient tool right now.
Dr. Craig Joseph: That's amazing. Doctor Marina Gerner, thank you so much for educating us about Femtech. And I would encourage everyone to check out your book, The Vagina Business, and to prominently display it in their front window.
Marina Gerner: Yes, that would be great. And please post about it on LinkedIn or on Instagram and feel free to tag me and I will reshare your posts.
Dr. Craig Joseph: Excellent. Well thank you again. I really appreciated the conversation.
Marina Gerner: Thank you so much for having me. It was great talking to you.