Andrew Shirk of CityPT: In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System

An Interview With Luke Kervin

To improve health outcomes of African Americans and other minorities, we need them to trust their physicians and providers so they are comfortable asking them questions and taking their recommendations without suspicion. This might sound easy to do, but it is not. There are well understood reasons for the distrust between minorities and the healthcare system, which is probably why some studies have shown that African Americans treated by African American physicians have better health outcomes. Telehealth can be used to facilitate the presence of minority providers in areas where patients express a desire for their care and where they might have the greatest impact.

The COVID-19 Pandemic taught all of us many things. One of the sectors that the pandemic put a spotlight on was the healthcare industry. The pandemic showed the resilience of the US healthcare system, but it also pointed out some important areas in need of improvement.

In our interview series called “In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System”, we are interviewing doctors, hospital administrators, nursing home administrators, and healthcare leaders who can share lessons they learned from the pandemic about how we need to improve the US Healthcare System.

As a part of this series, I had the pleasure to interview Andrew Shirk.

Andrew Shirk is a Software Engineer, Application Architect, and Digital Health Entrepreneur living in Durham, NC. He is the Founder of CityPT Inc. a leader in frontline care for musculoskeletal health, nutrition, and improving the patient experience through technology, engagement, and access. Before founding CityPT, Andrew developed software systems for clinical research and Patient-Reported Outcomes at the UNC Lineberger Comprehensive Cancer Center in Chapel Hill, NC.

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

Thanks for including my perspective in your series, Luke. I first want to point out that I am not a physician or a healthcare provider. My views on the state of the US healthcare system come from three aspects of my life:

First, there’s my occupation. My initial job out of graduate school was as a software developer for a medical information startup company. Right away, I learned of the byzantine nature of healthcare insurance plans, extreme drug pricing, and the importance of obtaining expert medical care in a timely manner. More recently, I dedicated years to learning about the mechanics of the healthcare system by implementing clinical trials alongside researchers and physicians who are leaders in their field at the UNC School of Medicine. And now, I’ve taken it upon myself to start a clinical practice and software company aimed at solving many of the problems that cause people untold frustration and pain.

Second, there’s my extensive first-hand experience as a patient and consumer navigating the US healthcare system. It’s one thing to learn about the challenges and shortcomings of the healthcare system in an abstract way as a healthy person. It’s a whole other ballgame when you’re faced with a series of quickly evolving or potentially life-threatening problems that require immediate attention and analysis. It doesn’t take long to start bumping up against the enormity and complexity of the crisis we’re facing.

Third, my fiancée is a nurse practitioner at a clinic that primarily treats an underserved population. I’ve learned a tremendous amount from her regarding not only the challenges and inequities her patients must deal with, but also the reality and challenges of what it’s like to be a provider grinding it out day after day on the frontlines, combating acute and an increasing number of chronic diseases on extremely limited resources. She’s a true inspiration to me and the work we’re doing at CityPT to deliver personalized, integrative care for musculoskeletal health.

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

There is one story that is particularly relevant to my personal relationship with the healthcare system and how it caused me to become my own patient advocate early in adulthood.

I was in my early 20’s and I had been experiencing terrible chest congestion in the aftermath of a bad cold. Despite feeling very unwell, I ventured out to get groceries and a movie. While at the video store, standing in front of the wall of new releases, my breathing became labored; I felt lightheaded and collapsed. After a staff member helped me up, I slowly drove myself to the hospital emergency department.

Once at the emergency department, after the typically long wait into the wee hours, I finally got my x-ray results. I was told my lung had collapsed and I needed immediate surgery. I was informed a surgeon had been called in and would be there shortly.

Once the surgeon arrived, he confirmed the x-ray results, but relayed that he had done very few of these types of operations. I told the surgeon I wanted a second opinion from a specialist. Understandably, the surgeon was put off, and the head ED physician was upset. To the hospital’s credit, they respected my decision and called in a thoracic surgeon who arrived promptly, talked with me, looked at the x-ray and, in a moment of incredible relief, told me my lung was not collapsed and I did not need surgery. It was pneumonia, he said, combined with an abnormality on my lung. I was given antibiotics and sent home, told to return in a year for another x-ray.

I believe my story to be an outlier. But as an American, this experience was the perfect health-system-life-lesson: Your care is often in your own hands. You must educate yourself and ask questions until you are ready to make the final decision about your care. Healthcare providers are human, fallible, and are under a lot of pressure. Their experience and knowledge should be respected but you have an active role to play as a patient.

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

When I first began speaking on some of the ideas that we’re including in our software, I had taken several days off to prepare all the content for a new talk. I had been working very hard for days, fleshing out the messaging and creating fancy new information graphics.

Public speaking is quite nerve wracking to me, but I felt like I had taken the time I needed to deliver a presentation that would effectively communicate my ideas. The host started the meeting, introduced me, then turned control of the meeting and camera over to me. I got all situated in my chair, and then we were off. About 10 minutes into my initial comments, I realized that I had been projecting the wrong screen to the audience the whole time. I was mortified!

Despite that mistake, everyone was polite, and nobody mentioned the random notes and garbage I had on my screen. The talk resulted in some interesting questions and valuable follow-up from the audience. The lesson I learned is that, even when you make mistakes, if you’ve really poured your heart into something, some people will still pay attention and benefit from your efforts.

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

Oh man. I’m inspired, motivated, and influenced by the life lessons of all the usual suspects in my field. I’m also guided by the writings of pioneers and new voices in computer science, art, design, business, linguistics; it really runs the gamut. I’m just not sure I can honestly pinpoint a favorite. Each of them can be used as a tool to view the challenges of life from a different perspective. They’re metaphors and conceptual models that can be used to drive those valuable “Aha!” moments.

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

CityPT is hands down my biggest and most exciting project ever. As with any startup company, it contains many subprojects that are designed to further our mission of enabling fast and effective musculoskeletal care, as well as improving the fragmented patient experience found in conventional care.

CityPT is both a clinical practice as well as a software company. I’m going to great lengths to recruit like-minded clinicians that are not only interested in practicing at the highest level as therapists, but also interested in non-clinical roles that tap into their creative and technical sides. Together, we are creating processes and software that are designed to reduce the friction and heavy documentation burden commonly experienced by healthcare providers in all roles, as well as software that facilitates our objectives for personalized care and engaged patients.

Musculoskeletal (MSK) concerns are among the top reasons patients visit a primary care provider despite the fact that primary care providers are generalists and there are direct access specialists — physical therapists — readily available in many states. With the rise of Telehealth, there is research data that show, when carried out by physical therapists with special training, virtual physical therapy is as effective as in-person care for many conditions. Virtual physical therapy can also change the patient/provider dynamic in such a way that patients are more empowered to take an active role in their own care.

How would you define an “excellent healthcare provider”?

I’d say this depends on the type of healthcare provider you’re referring to. I’ve interacted with a wide range of providers over my lifetime, particularly the last few years, and I’ve learned the nuanced ways to spot the ones that will provide the best care for me.

For example, when I meet a surgeon, I’m not particularly concerned in their bedside manner. We’re not going to be friends. I’m probably never going to see them again after the surgery and a follow-up. I’m more interested in the depth of their knowledge, the number of procedures like mine that they’ve performed, and their mortality rate. In other words, I want to know their performance statistics. A polite dispassion gives me confidence if it’s coming from someone who has performed thousands of successful surgeries. Also, I want to know about any odd complications they’ve seen in patients during or following surgery and how they’ve dealt with it.

Now, I have completely different expectations from a primary care provider. With them, I’m looking to build a long-term relationship. I expect a willingness to learn about me as a person and my health history. So, I look for signs they are patient, a good listener, and exhibit genuine empathy. Next, I want to know they are a good troubleshooter. When I first meet them, I may ask how they would approach solving a hypothetical health problem. How they answer tells me a lot about their flexibility and style of care. I’m not looking for someone to have all the answers. Rather, I want a primary care provider who is a collaborator, someone who asserts their knowledge and expertise, but who is non-judgmental, curious, and open-minded to personal experiences that may conflict with what they have learned.

Perhaps the most important characteristic of an excellent healthcare provider, however, is the willingness to become your advocate. When a provider does this, it often means they’ve put themselves on the line for you a little bit. They have challenged the insurance company, or they’ve bent the healthcare system’s rules somewhat to help you out. The documentation alone for something like this can take a lot of time, so if a provider does this for you, it’s a strong sign of excellence.

Can you share with our readers a few examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these specific issues moving forward?

The pandemic highlighted how far the U.S. healthcare system has fallen behind other industries when it comes to technologies for customer engagement and experience. Try navigating nearly any facet of most health systems you’ll be met with frustrating obstacles and delays.

Something as simple as selecting a primary care provider takes so much time you end up just accepting the default assigned by the insurance company. The industry did not evolve with customer experience as a priority. I don’t think this is entirely the fault of hospitals or health systems, but I think they are at risk because of it.

For example, the main reason many health systems were caught flat-footed when the pandemic hit regarding technology and Telehealth is that, prior to the pandemic, insurance refused to reimburse for it on par with in-person services, so they hadn’t invested very much in planning, testing, and rolling out solutions. This is just one of the myriad ways health systems are steered by the directives of insurance companies.

Many people don’t realize that health systems pay their bills and make a profit from elective surgeries and hospital stays, not from keeping people healthy through preventive care. I don’t believe there are evil masterminds at the heart of all this. I think it’s more the result of a culture that’s afraid and unable to take risks because of regulatory forces, litigation risk, and consumer demand for quick fixes.

The good news is that when the pandemic hit, necessity kicked in and many regulations were temporarily repealed. The pandemic has provided this rare window of opportunity for an incredible amount of technology and process innovation to take place in a very short period. It’s allowed companies like CityPT Inc. to emerge and build things that have a fighting chance of being used and adopted by patients. In 20 years, I think we’ll look back on the pandemic as an avoidable tragedy, but one that had an ultimately positive impact on the way the US healthcare system operates.

Of course the story was not entirely negative. Healthcare professionals were true heroes on the front lines of the crisis. The COVID vaccines are saving millions of lives. Can you share a few ways that our healthcare system really did well? If you can, please share a story or example.

Hospitals, health departments and clinics really stepped up and did they best they could with very little guidance up stream, and very little national support. Some institutions took risks by spearheading small patient engagement projects for contact tracing or patient triage. I was a part of an expedited effort at UNC Health to develop a Covid-19 self-assessment tool that was used until just recently to help thousands of patients determine if they should seek further care for their symptoms. These efforts should be recognized and commended because they were expensive at a time of plummeting revenue and widespread uncertainty.

Additionally, there were also many accounts of grassroots efforts to supply 3-D printed or custom fabricated PPE to health systems and hospitals. My fiancée’s sister, for example, was part of a self-initiated program to manufacture and deliver hundreds of face masks to frontline providers. It was really inspiring to see all these little assembly lines of lifesaving equipment on social media.

Here is the primary question of our discussion. As a healthcare leader can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.

First, to enable the most dramatic change, fiber internet connections should be made available everywhere in America, including rural areas. The pandemic has permanently reshaped not only how we obtain healthcare, but also how we work. Unfortunately, employers are still the main source of healthcare in America. Thus, without access to high-speed internet, disadvantaged and underserved populations will not be able to access as many good jobs that provide good healthcare benefits. Not everyone will work in information technology roles, but everyone should have access to the basic utilities needed to educate themselves and obtain a healthier life for their family.

Second, we need to move toward licensing healthcare providers at the federal level. Today, it happens at the state level. This results in all kinds of wasteful bureaucracy, increases costs for healthcare companies, and maintains barriers to access for patients. It also limits economic opportunities for providers which may discourage them from relocating to a different area that could benefit from their presence and care. The more freely healthcare resources can travel around the country the more efficiently the load can be distributed.

Third, we need to accelerate the shift away from the standard fee-for-service healthcare business model. This keeps health systems locked into focusing on services that are at odds with proactive and preventive care programs. Most primary care providers are under absurd productivity demands these days because health systems are paid by the number of office visits, not by the quality of the care. Fifteen minutes for an office visit, which is the standard, is a fraction of the amount of time required to effectively treat chronic and difficult-to-diagnose conditions. So, people continue getting sicker.

Fourth, a federal law is needed that requires interoperability between electronic medical records so that patient health data can be conveniently moved from one system to another. Although the Affordable Care Act lit a fire underneath health systems and private practices to move their patient records from paper to electronic systems, the law made no mention of data portability. As a result, patient data sit in silos that, ironically, aren’t that much better than paper when it comes to helping patients choose the best provider for their current needs. It’s still difficult and time consuming to change healthcare providers and bring your full health record with you.

Fifth, the healthcare industry should fully recognize and utilize physical therapists as primary care providers that are trained and able to provide preventive as well as rehabilitative care. Physical therapists are musculoskeletal health specialists, and musculoskeletal disorders are among the most common reasons patients visit their primary care provider for care. Back pain, for example, is an extremely common cause of a visit to the doctor. All too often, these visits result in unnecessary tests and failed surgeries instead of effective care that treats the actual problem: we are not moving enough, and our bodies are breaking because of it. With an aging population and provider shortages, the situation is bound to get worse without this action.

Let’s zoom in on this a bit deeper. How do you think we can address the problem of physician shortages?

The short answer is that we need to get creative. Given any supply shortage, you can increase the supply, or you can look for ways to decrease the demand. We need to do both.

In terms of increasing the supply, the reality is we do not have enough time to train the number of physicians required to meet demand across the board. We must prioritize where they are needed most and improve their distribution using Telehealth and other digital health innovations. For example, in my geographic region, I don’t feel there is much of a shortage, which sits in stark contrast to rural areas not far away.

Also, we need to honestly assess in which roles, specialties, or scenarios physicians are absolutely required, and then tune the distribution models to get them there virtually and physically. In roles such as primary care where a medical doctor (MD) is not always needed, there are other viable healthcare providers that are underutilized or go unmentioned altogether.

For example, in my own care, I used to insist on an MD as my primary care provider, believing their training and experience would yield better care. But the best primary care I have received in the last five years has come from nurse practitioners and physical therapists, both of which can be trained faster than MDs.

Nurse practitioners (and physician assistants) seem more apt or equipped by training to truly listen and consider unique health histories and symptoms. Physical therapists, who many people don’t realize are Doctoral level healthcare providers, are also great candidates because so many conditions that patients bring to primary care encounters these days are musculoskeletal related, which is where PTs focus.

In terms of decreasing the demand, when clinicians are given the training and time to provide personalized, holistic care, a more comprehensive approach can be taken to better understand what’s going on with the patient. A patient is more likely to change their behavior long-term if their provider has taken the time to really understand what is going on and build the required trust. This is not a quick fix, but over time the population will get healthier, and demand will drop.

So, the need for physicians will always be present, but better utilizing all types of healthcare providers along with advancements in technology and Telehealth may get us where we need to go in a shorter amount of time.

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

Any underrepresented minority that wants to be a physician, or other type of healthcare provider, should be encouraged and supported in any way possible to help them achieve their goal. This is yet another reason why we must supply fiber internet infrastructure to all communities, not just affluent ones. At a minimum, young minds need access to the fresh ideas and vast educational resources that are available on the internet to give them the basic tools they need to become effective and inspirational clinicians, leaders, and role models.

Despite the flawed and failed attempts to recruit underrepresented minorities into the healthcare workforce, I think there are reasons to be hopeful about improved physician diversity, and diversity in all healthcare provider roles, especially if the industry fully embraces Telehealth. The “5 changes needed” I discussed above mainly address big technology infrastructure or policy changes that would reduce the friction between the demand for care and the supply of providers. Just like the supply of physicians isn’t evenly distributed, the supply of minority providers isn’t evenly distributed either; urban centers are more diverse than rural areas.

To improve health outcomes of African Americans and other minorities, we need them to trust their physicians and providers so they are comfortable asking them questions and taking their recommendations without suspicion. This might sound easy to do, but it is not. There are well understood reasons for the distrust between minorities and the healthcare system, which is probably why some studies have shown that African Americans treated by African American physicians have better health outcomes. Telehealth can be used to facilitate the presence of minority providers in areas where patients express a desire for their care and where they might have the greatest impact.

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

Burnout has been a problem long before the pandemic. The pandemic just exacerbated the issue. And, again, it’s not just physicians that are burned out; it’s nurse practitioners, physician assistants, nurses, social workers, pretty much anyone that deals with patient care. Although I’m confident that process and technology inefficiencies could be improved, I think the single greatest factor that causes burnout is the fee-for-service business model that the U.S. healthcare system relies upon.

If we could, hypothetically, eliminate every inefficiency in patient care through process improvements and technology innovations, I’m not convinced that would reduce burnout. Counterintuitively, it might even increase the number of patient encounters providers are expected to conduct thereby increasing the number of insurance reimbursements. This bleak reality leads some clinicians to simply leave conventional care and stop taking insurance.

For example, physical therapists at many outpatient clinics commonly have their schedules double booked to increase the total claims from insurance. This, among other things, is leading to physical therapist burnout and an exodus to private practices where they don’t take insurance and can focus on taking better care of patients.

So, what can be done overall? I’ll just go back to what I said earlier about accelerating the shift towards fee-for-value. The industry has been talking about this for years, but research is still taking place on how we even measure value. Patient-Reported Outcomes, which collect mostly subjective symptoms and quality of life data from patients, are one piece of the puzzle that should see wider-spread adoption for this purpose.

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

As an individual, it’s hard to feel like you’re having an impact on large policy action. Yes, individuals should contact their local and state leaders and make it known they want access to more diverse providers, or that they demand future-proof internet services. But they should also speak with their dollars by taking a step back and assessing the landscape of healthcare options that are emerging. It might be worth dipping a toe in and experimenting a little with some of the products and services that new startups are offering and comparing them with what they get through their employer’s plan. Once they factor in wasted time, frustrating delays, deductibles, co-insurance, co-pays, etc., they may find new services to be a better value. But whether it’s experimenting with alternative services or reading the latest research on conditions that affect you, I think individuals need to start taking a more proactive and collaborative role in their own healthcare. Don’t just choose the cheapest service. Try and determine long-term value.

Regarding corporations, some are already taking matters into their own hands by developing internal healthcare services aimed at preventive care and improved outcomes. These internal services provide employees with more options, but they also serve as testbeds for entirely new products and services to eventually be offered to the public. Amazon and Walmart are already doing this.

Communities must step up and bridge the gap to providing broadband internet access. Cable isn’t enough since it limits upload speeds, which is critically important for future telepresence and internet-of-things applications. Chattanooga, TN, which developed its own municipal fiber internet service, should be used as a model for doing the same across the country. There’s probably no greater return on investment for these smaller communities than fiber internet. The quality of the healthcare in the community is just one of the many things that will improve.

Finally, leaders need to resist the temptation and pressure there will be to go back to the way things were before the pandemic. Let’s harness the power of the momentum that’s started, and reform practice and licensure laws.

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

I’m not sure a movement is a good fit for my objectives. Movements can be short lived or suddenly polluted by some scandal. I’d like to inspire something more like an epiphany so that the motivation for change comes from within and isn’t associated with me or my company. The most lasting and meaningful changes will happen when people realize things on their own. At CityPT, we’re trying to help people connect the dots between pain, movement, healing, food, and knowledge. When clients better conceptualize their body as an intricate system to proactively care for, when they become as concerned about the maintenance of their body as they are about changing the oil in their car every 5000 miles, that’s when we’ll know we’re having an impact.

How can our readers further follow your work online?

You can find me on LinkedIn: https://www.linkedin.com/in/andrew-shirk/

And you can learn more about CityPT Inc. at https://www.citypt.com

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