Scrubcast

Rachel Baker: [00:00:00] Hey everyone, this is Rachel Baker back with another episode of Scrubcast, where we discuss the latest research happening at Stanford University's Department of Surgery. Today we're speaking with Dr. Tom Weiser, a clinical professor in the Division of General Surgery's Trauma and Acute Care section.

Welcome to the show, Dr. Weiser. Thank you, Rachel.

Tom Weiser: I'm really excited to be here.

Rachel Baker: Trauma is incredibly different from its fellow general surgery subspecialties. What drew you to it?

Tom Weiser: I, well, when I was a medical student, obviously I did my surgical rotation and I felt like trauma was the complete surgical experience.

It was immediate, immediately gratifying. It was exciting. It was never the same thing ever. Um, and the, in truth, the people that I admired during my training, during my medical school. We're all the surgeons who are taking trauma call, who are doing good trauma work, and the [00:01:00] senior residents were unbelievably competent.

and confident and skilled, at least to my naive medical school eyes. And I felt like that was somebody that I wanted to be like. I admired their work. I felt it was an incredible need. This was an incredibly underserved population. And, uh, it was incredibly rewarding to see people who literally had life threatening injuries walk out of the hospital several days later when you were able to stop the bleeding, control contamination, and get people on the road to recovery.

Rachel Baker: Awesome. Well, the impetus for me inviting you on the show today was a paper recently published in the American Journal of Preventative Medicine looking at the impact of Medicaid expansion on people's lives. And firearm legislation on the cost of firearm injuries. This is a bit of a sensitive subject Why did you decide to study it?

Tom Weiser: Yeah, so, um, it's interesting. I don't know if I'd use the [00:02:00] word sensitive I would say maybe politically charged and perhaps i'll go back several years ago to Why I got into this type of research in the first place. Um, and it was because of these kind of politically charged issues Obviously, gun issues, gun safety, gun control, gun legislation, gun rights, these are things that, that are debated in the public sphere, and almost anything one does in the research sphere has some sort of political implication.

And so what I try to do in, in evaluating the costs of injury was take a little bit of the political sensitivity out of the equation. Everyone can understand these cost numbers, and I felt like if we come at it, From a financial perspective, just remove the emotional piece and we'll turn it really into a financial economic piece.

Then maybe we can actually shed some light on some of the issues in a way that informs the debate [00:03:00] in a much more, perhaps cold hearted, but in a much more objective, purely financial sense. And so what we, what I first set out to do is just start looking at the, at the cost, the dollars and cents that are implicated.

In our current political climate of gun legislation as it exists in the United States. And so, I actually worked with a medical student from Stanford, Sarah Beth Spitzer, who's currently in her senior years of surgical training at Brigham. But she approached me for a med scholars program and we sat down together to look at this issue of firearm violence and came upon this concept of looking at the financial issue.

So our very first paper was actually looking at the costs of injury, the costs of firearm injury, and there's a lot of ways you can calculate costs, but what we did is really just looked at the hospital costs. And we looked at hospital costs because they're fairly easy to wrap your mind around. They're quite objective.

[00:04:00] Unlike looking at, say, societal costs, or opportunity costs, or lost income, we're really looking at the dollars and cents of the hospitalization due to a firearm injury. And so that was the first area of work, and we found that during an initial hospitalization, for firearm injuries. That, that costs the U.

S. about 735 million a year just treating people during their first admission for a firearm injury. And that's where we started, from there. Yeah, yeah, absolutely. How

Rachel Baker: much of that firearm... Injury related hospitalization is is unintentional energy injury and self harm,

Tom Weiser: right? So this is a great question, right?

Because to be perfectly frank most firearm deaths at least 50 percent or more of firearm deaths are self harm. They're due to suicide So of course in that context Actually, not a high burden is self inflicted because these are highly lethal injuries and [00:05:00] most patients who use firearms to injure themselves Succeed and die before they ever reach a hospital and so those kind of costs are actually those hospital costs are zero because there is No hospitalization for those kind of patients now There obviously are patients who fail to kill themselves during for self inflicted Injury and those account for about a little under 5 percent of all costs and but that represents a very small proportion of the hospital costs or even the hospital admissions.

Rachel Baker: Got it. So what is accounting for that majority section?

Tom Weiser: So it's hard to say specifically because these codes are kind of all over the place. When, when, when patients are admitted with a firearm injury, people try to code on whether it's a unintentional or self inflicted or assault or undetermined or whatever.

The vast majority either has some intent that can't really be coded or is an assault. And so most even those of those intents that can't be coded tend to be things where it's Fortunately, domestic [00:06:00] violence, interpersonal violence, or assault from an unknown assailant. But those really represent the vast majority of injuries that we see, both in terms of numbers as well as overall costs.

Rachel Baker: So, and then one of the things that you also looked at was firearm legislation and, um, you specify, uh, it's, it just says weak. Um, and so I'm sort of like, how do you define what is weak firearm legislation? It's just the number of laws or do certain rules get weighted more heavily, like a midterm paper.

Tom Weiser: Yeah, so, so, um, so this was actually an extension of the original work, because what we were, as we started calculating these firearm costs, or these, these hospital costs for, uh, due to firearms, we started looking at, well, there are policy implications to this, and obviously the expansion of the Affordable Care It presents an opportunity to evaluate how government insurance schemes change the [00:07:00] proportions of who's paying for what.

So just by way of background, when we did our original study, most of the costs of care tended to be borne by, by government payers. So either the federal government or ACA?

This is kind of before and during ACA. So the original studies, we didn't really distinguish before and after ACA. We're just kind of looking at costs per year. And the reason this is important is, right, that's taxpayer money that's being used to cover the cost of hospitalizations for people injured by firearms.

And this was about 40 to 45 percent of all costs. So when I, you know, I talked about this 735 million a year, it actually turns out, if you look at both initial hospitalizations and then readmissions, We're closing on a billion dollars a year in paying for hospitalizations for people who are injured by firearms.

That's

Rachel Baker: a lot of money we could be doing

Tom Weiser: with other things. It's a lot of money that we could absolutely be doing other things with. And if the [00:08:00] government is, is covering, you know, some 50 percent of this, then the government has a vested interest in understanding what the policy implications are. are for this coverage and how they might be able to control those injuries and reduce those injuries everyone wants to reduce the injuries, for sure regardless of where you sit on the political spectrum so if we can reduce the number of injuries And we can apply appropriate policies that has cost implications.

And again, that's why we looked at these costs in, in the first place. So what we basically did is in our most recent paper that you were referring to just at the very outset of the interview was this paper that, where we looked at two things. So one is whether or not a state. Implemented the Affordable Care Act or not, right, so states during ACA expansion could either choose to or not to expand Medicaid coverage for their population.

So there were states that did that and there were states that did not. Okay. And then there were also, there are also states that have different [00:09:00] legislation, state legislation around the strength of their, of their firearms regulations. Yeah, it varies wildly. Right, it varies wildly, you're right. And, and there's no great, Perfect score for it, but probably the best is Gabby Giffords, uh, program, uh, and also the, the Brady program looking at, they basically score states from A to F with respect to their policies regarding the ability to kind of the unfettered ability or access to firearms.

And so states that have an F grade basically have very, very open. Highly accessible guns available to the public, and states that get an A are much, have a, a much more, a much stronger regulatory environment around who can own, can own and purchase firearms when and under what circumstances. And so what we basically did is we just divided states in two.

You either got an F or you didn't get an F. So when we say weak firearms, you got an F on the Gifford score. And if you [00:10:00] are not weak, you are anything that's not an F. Okay. Yeah.

Rachel Baker: Solid. Okay. And so then how did those, I guess, you know, uh, letters, those grades affect how much the government was paying for firearm related injuries

Tom Weiser: and hospitalizations?

So it, so it turns out there's, there's, there's kind of kind of three buckets of states. So they're the states that expanded. They expanded Medicaid and have strong, have strong legislation. There are states that had weak firearm legislation, so in other words the F grade, but also expanded Medicaid through ACA.

And then there are states that had weak firearm legislation and didn't expand Medicaid under the ACA. So it turns out that there are no states with strong firearm legislation that also did not expand Medicaid. So those are the three groups. So. Okay. [00:11:00] Regardless of where you are on gun legislation, when you expand Medicaid, the proportion of patients who are injured by firearms and are covered by government insurance schemes go up.

So it turns out that goes up by about 15 percentage points. So in 2013, about 40 percent of all patients injured by firearms were covered by some federal or state. insurance scheme by 2016, about almost 60%, so like a near, like an almost 20 percentage point increase, um, in 2013 and 2016 between those people who've presented with firearms who were covered by some sort of federal or state insurance scheme.

Okay. In states that didn't... expand Medicaid. They basically shifted the cost of care onto typically the uninsured or the self paid patients. So what you're doing, what you're seeing is you're seeing kind of this very anti poor [00:12:00] policy whereby those who are at most financial risk who are also at risk of assault and interpersonal violence, et cetera, et cetera, are also paying the highest price financially.

For getting injured because they're not actually being covered by the insurance schemes that are supposed to protect. vulnerable patients within the state. And that's particularly true in states with the weakest gun legislation. And the interesting thing, and perhaps the infuriating thing about what we were trying to do or determine with this paper, is in states that have weak legislation and don't cover their population through a Medicaid scheme, basically the states are shifting the cost of care for their own policy On to those patients who are injured by firearms, so they actually don't have a financial incentive to change the regulations because for them, it doesn't matter because the taxpayer is not on the hook for it anyway.[00:13:00]

That's not entirely true because obviously hospitals still need to pay their bills. And there are these kind of payback schemes where counties and state governments will pay back safety net hospitals for indigent care. But you can see how there's this disconnect between what the policies that are being created and then how much a state is on the hook for their own policies that they're creating in terms of their financial obligations.

Rachel Baker: I get it. This is very interesting. Okay, so but now that you've got all of this research and you've seen all of this, you know, the results Where do you go from here? What's the next

Tom Weiser: step? Yeah, so The purpose of all this was really to provide information this kind of information is in constant evolution flux.

These are challenging statistics to capture because they live in these databases that are not the easiest to analyze. It takes a pretty heavy statistical lift to understand what's [00:14:00] happening in these databases, to aggregate these data, to clean them, and then to provide this kind of information. It's actually not overly hard, but it is hard in the academic world because This is all unfunded work.

We do this because we think it's important, but there are very few grants or, or, or funds to do this kind of work, certainly there has been in the past. I think that's, that's changing now. So we're kind of doing it because we believe it's important, but it means you have to allocate resources that are love and, and tears to get this kind of information out there.

What I'd like to see ultimately is that this kind of information filters back to policymakers. It obviously doesn't necessarily filter back. through the peer reviewed literature. So I think there are other opportunities. In the lay press, for example, to illustrate these kinds of issues that resonate with the general population and that help people understand what the implications are of these policies with respect to [00:15:00] general costs for medical coverage, for care of indigent patients, how these policies actually affect real spending, because those are real dollars and those real dollars come from real taxpayers.

And people care about

Rachel Baker: that. Definitely. Let's talk about your team here. And you mentioned that you were working with a medical student who's now, um, I think you said at Brigham?

Tom Weiser: That, yeah. So that, so my, the first medical student I worked with, uh, I said was, uh, Sarah Beth Spitzer. So she's at Brigham. Um, and then, uh, we continue this work with another Stanford medical student who is now a surgical resident out at Inova Fairfax in Virginia.

Her name is Sikhi Kao, and she, uh, she was the lead author on the most recent paper that we were just discussing on these difference between Medicaid expansion and firearm legislation strength, um, and how those differences actually play out with respect to which entities are paying for what kind of coverage.

And this was amazing work by her. She'd done some fantastic statistical work [00:16:00] and did it during a master's program that she was doing as part of her Uh, MD program, so she got a master's during her MD degree, uh, and then has, has since graduated medical school, and now I'm very proud to say that she, too, is a surgical trainee, yeah, on the East Coast.

Rachel Baker: Nice. So you have a pretty good track record here. How do you go about setting up your team? What's, and you know, what's your method for working together?

Tom Weiser: So typically these folks come, the medical students have come through the Med Scholars Program at Stanford, which is an incredible program that allows medical students to explore research or other opportunities.

I've mentored a number of Uh, med scholars in the past doing a variety of different types of work, most often working internationally, but also obviously on local issues and national issues such as, uh, firearm injuries. And so typically the method of working is somebody will approach me with, with interest in some topic, typically around firearm violence [00:17:00] and gun issues.

And so we'll, we'll work out a mechanism for what we want to do, how we want to do it, and then what their specific skill sets are and how they apply their skill sets. to particular types of data. We will frequently have a very structured process for evaluating the data. I work with Lakshika, who is in the Department of Surgery, who is a wonderful data analyst who helps pull data together, clean some of the data, get it set up for analysis.

And then of course, working with other collaborators who, it's always nice to have other folks who put eyes on the program. And think about these kinds of issues, so David Spain and Joe Forrester and other, Christian Stoudemire, others who kind of think differently and then allow, you know, provide some other perspective, because sometimes one loses the forest for the trees.

Rachel Baker: Nice. Well, but you don't just do firearm work. You are also really big in the global engagement

Tom Weiser: space. So that's definitely [00:18:00] one of my primary interests and thrust areas. So yes, I am the director for global engagement for the Department of Surgery and we are really promoting Stanford efforts to engage with the global community with respect to surgery.

This has been a passion and a focus of my career since I was a kid. Uh, an MPH student way back, uh, during my surgical training took a, a few years off first to get my MPH and then to work with Atul Gawande in the WHO to create the Surgical Safety Checklist. And since then, um, a lot of my focus has really been around safety, quality improvement, systemization of care, um, and compliance with best practices.

Rachel Baker: Awesome. Great work. Well, time flies when you're saving lives and we are almost out of time here. So I'd like to move on to a couple of questions that we ask every guest on the show. Who is a surgeon you admire and why?

Tom Weiser: So one [00:19:00] of my heroes is a surgeon named Selwyn Rogers. He's a surgeon at University of Chicago.

He's actually one of my mentors at Brigham, which is where he was trained in Boston. And he was brought to the University of Chicago when they opened their trauma center. And he's a hero because at the time, the University of Chicago, which is situated in the south side, didn't have a trauma center and were not serving their community in the south side of Chicago.

So patients who are injured in this highly violent area, unfortunately, um, those patients were being transported 20, 25 minutes away. to Cook County and other facilities when there was a hospital basically on their back door that didn't have a trauma center. So Selwyn was hired to build that trauma center.

He's done an amazing job. But in addition to building the trauma center, he has done a tremendous amount of community outreach because a trauma center is fine for patients who are injured, but really getting to the root cause and trying to [00:20:00] understand and decouple all of these Environmental and social factors that cause trauma in the first place is a fundamentally important role that a medical center like University of Chicago can play.

And he's done a tremendous amount of work trying to engage community leaders, other community members to break this cycle of violence in Chicago's South Side.

Rachel Baker: Awesome. I'm totally going to go stalk him now. What is the best advice you received in 10 words or less?

Tom Weiser: Yeah, okay. Be kind, work hard, treat everyone with respect.

Oh, I like that one. And, uh, those are words, when I was a trauma fellow up at the University of Washington up at Harborview, there was a guy, Copus, who was a kind of, he was a retired emergency medicine physician and neurologist, and that was his mantra. Be kind, work hard, treat everyone with respect. If you do those things, you will provide good care with a good team all [00:21:00] the time.

Rachel Baker: Well. That is the end of our show for today. Thank you so much for joining me. This was a great chat Um, I want to talk longer, but our episode has to come to an end

Tom Weiser: unfortunately. Well, Rachel Thank you so much for taking the time and for inviting me I'm really honored to be a guest and I look forward to talking with you more in the future

Rachel Baker: And that brings us to the end of another episode If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts.

Scrubcast is a production of Stanford University's Department of Surgery. Today's episode was produced by Rachel Baker. The music is by Midnight Rounds. And our chair is Dr. Mary Hawn.