Good Medicine explores today’s healthcare environment through the lens of one essential attribute. Last time, we discussed the importance of realism with the great Dr. Bob Wachter. And today, we’re going to explore “persuasion” with a physician and digital health leader I deeply admire: Dr. Neel Shah.

Why persuasion? So much of what we do as healers is convincing our patients and convincing each other. For clinicians, that might mean persuading a patient to try a therapy or convincing a health system to invest in a new technology. The ability to persuade is a key skill…perhaps even an essential skill.

I’ll note here that the word “persuasion” is a two sided one. It can mean “encouraging” and “motivating,” which has a positive connotation, but it can also mean cajoling. I’ll be honest with you - there’s aspects of the job that require doing both, which is why I chose the word. So I was thrilled today to sit down with Dr. Shah, an OB-GYN and the Chief Medical Officer at Maven clinic. Neel undoubtedly has the gift of persuasion, one he has shown repeatedly with his academic writings and work with Maven, one of the fastest growing companies in digital health. If you’re unfamiliar, Maven is a virtual women’s health clinic that offers services from preconception care through menopause. It’s also a juggernaut in the digital health space, and Neel has played an essential role in their success.

Neel’s story

As Neel tells it, he was just “an Indian kid from New Jersey” doing the “expected, honorable” thing by going to medical school. (This story resonates with me). His folks also came to the U.S. on H1b visas and won the American dream for themselves through hard work and integration into their new communities. But Neel also grew up with what he describes as a “healthy respect for radical thought” as his grandparents were revolutionaries in India, helping to decolonize the country during the Gandhi era (fun fact, Neel’s great grandfather participated in the Salt March). As we’ll see, maybe this is why Neel can seamlessly blend the pragmatic with the radical. Three cheers for Mendelian inheritance!

I’ve always been struck by the role serendipity plays in shaping our lives. As Neel explained during our conversation, his medical school had a lottery system that determined the order of clinical rotations. And as luck would have it, obstetrics was first. He was struck by the opportunity to mix surgery with primary care, all while helping people build their families (another fun fact: OB is one of those rare specialties that combines primary care and surgery). But in the middle of medical school, he had the somewhat random opportunity to work for the Obama campaign. Neel described it as his first startup, and there he was taken by the innovation possible in campaigning and policymaking. But it was also an incredible window into what it takes to persuade, and hopefully win hearts and minds in the process.

This experience truly emboldened him to choose OB. So much of our national healthcare discussion is focused on our senior Medicare population, but Neel thought those in their reproductive years needed much more attention and care. He rose through the academic ranks, won grants, and published some incredible research showing that C-section rates can vary tenfold depending on the hospital. Given the policy implications of this statistic, he offered solutions and advocated relentlessly for change. People noticed, and then Maven came knocking.

On Maven

It’s hard to wrap your mind around, but Maven today is the world’s largest virtual health clinic for women and families. Started by Kate Ryder in 2014, the virtual care we know of today was in its preconception phase back then.

Ryder understood that legacy healthcare has an access problem. In most metro markets, it takes roughly 30 days to get an appointment with an OB. And this reflects markets where there are lots of physicians… Imagine the access problems faced by patients in less populated areas. Here, Neel makes a convincing case for Maven. What Maven promises is the ability to “connect you to the expert that you need within 30 minutes to an hour, no matter where you are and no matter what time it is.”

As anyone that knows me will attest, access and patient experience are my love language. When it comes to our health, why must it be that we have to wait, sometimes for months, for a medical answer? We live in a time where we can “take the devices that people carry in their pockets and turn them into a portal, into a human [health] service.” At my company Roon, we’ve long believed that people deserve answers to their medical questions anywhere, and anytime and I was heartened to see Neel felt similarly.

There’s also something to be said about having an intense focus. As a consumer, you almost always win when you choose services from companies that focus intensely on one thing (Remember the old adage - the main thing is to keep the main thing the main thing). Maven is a women’s health company, and not, according to Neel, “a “condition-based company.” Instead, he urged us to think about it as a “ ‘phase of life company’ from preconception care through menopause.” To me, this framing shows the intense focus they are bringing to the women’s health space. Health verticals like this can obsess about their customers(to their benefit) and customer obsession is something we need a lot more of in health care.

Neel is also pragmatic. He readily acknowledges that “no app is going to solve health care” and that you “can’t deliver a baby through a screen.” In-person care will always be necessary, inclusive of that pivotal relationship with a local practitioner. But digital health can play an incredible role in synergizing with legacy healthcare. This is because our healthcare system is built across episodes of care, with more attention and resources built around high value events like childbirth. But what about preconception care? What about coaching to improve a mother’s  overall health so she can get pregnant naturally? On the latter, the digital paradigm seems well suited to serve consumer needs most effectively.

I don’t want to sound pollyannaish about digital health broadly. There’s a lot to dislike; think about all the snake oil companies that have popped up to provide unproven anti-aging remedies or “hormonal rebalancing.” And so I asked Neel about the difficulties digital health companies face in demonstrating value to payors. Make no mistake - it is really hard to develop a care model with reliable attribution models that demonstrate improved health or reduced cost or both. But again, mixing the pragmatic and the radical, Neel made the case that we should hold digital health to a much higher standard than we currently do:

As he put it: “It has as much potential to influence people's health as drugs and devices. There's a lot of digital health companies that have gotten shredded and I'm not shedding many tears about that…I think that we should make sure these businesses are built with the right unit economics and have the right underlying products to actually return value to people…so it is very reasonable for a purchaser or a payer to want to see a return on their investment.”

Amen, brother.

Another program Neel has instituted at Maven is their visiting scientist program. Innovation is hard and Maven is bringing top scientists like Rachel Hardeman into the fold. From within, these scientists work to apply their hard won academic insights towards improving care models. In 2024, priority research areas include fertility and menopause, where scientists will work to understand how health disparities can be influenced by virtual platforms. Because this research can use real time outcome data, and because startups can move fast, there is a real opportunity to innovate continuously with care models using this kind of research.

One area which will be fascinating to watch is the new preconception care program. I’ve always thought it’s peculiar how the usual advice when you’re starting a family is to come back in 6 to 12 months if it's not working out. As Neel said, “this is the reason why people are on TikTok trying to figure out how to conceive, because the healthcare system isn't serving their needs.” Shouldn’t there be a lot more proactive counseling to make sure your health is optimized for successful family building? Might that perhaps reduce the need for some to utilize assistive reproductive technologies? It’s tantalizing, and I for one am excited to see the results.

On Medical Misinformation

I’m often gratified by how many physicians recognize and rate medical mis/disinformation as a high-priority problem. They should. This problem is not a benign one. As I discussed with Dr. Wachter in a previous post, medical disinformation harms and kills. For example, the excess death rate among Republican voters was 43 % more relative to Democratic voters after the vaccine rollout. This was both a tragedy and a national shame.

Neel agreed that this is a huge problem in the reproductive healthcare space as well. But as he points out, our “House of Medicine bears some responsibility” for this trust deficit that fuels medical misinformation, “particularly [among] women, particularly people of color, and especially women who happen to also be people of color.” When we don’t offer compelling, educational messages, disinformation artists thrive. In reproductive health care, we’re seeing this with hormonal rebalancing treatments and unindicated testosterone therapies in men. As Neel points out, “the number one intervention for male infertility in our practice is to ask men if they're on testosterone and take them off. Number one, not number two or three, number one!” For that reason, Neel’s time spends a lot of time on TikTok and Reddit analyzing how people interact with reproductive health care information online.

When I asked him how we as doctors could combat this problem, he had a systematic response. “Fundamentally, I think our mandate is to be trustworthy. It's not the job of our patients to trust us. It's our job to be trustworthy. And I think it requires three things that are lacking in the world. One is competence… we need better outcomes than we see…[people] are getting less and less healthy.. So we should be competent, number one. Number two, we have to affirm people, which actually [means] listen to them. And I don't mean just like the act of listening. I mean, attend to what they're actually telling us. And then the third thing is we've got to show up when they need and expect us to.”

I added a 4th to his list, that we as physicians need to be a lot more proactive with our communication rather than reactive in the public sphere. Here, Neel agreed saying

“We as doctors need to stop complaining about TikTok, own our responsibility for why people are seeking it out and then do something about it.”

And it doesn't necessarily mean that we have to occupy the TikTok space..But we have to go back to these fundamentals, and just provide people with what they're missing.”

Of course, I’m biased, but he’s definitely right.

On the Physician Advocate

Speaking of trust, trust in our institutions broadly seems to be at a modern nadir. As Neel said, Trust is a “outcome of a system that's either working or not working…You can’t fix what you can’t see, and you can’t see what you don’t measure.” So whether in healthcare or anything else, treating trust like a composite metric with many parts requires measurement, hypothesis-testing and data-driven decision making.

I was also curious whether Neel thought we were doing a good enough job as physicians on the advocacy side. He thought, broadly speaking, physicians “absolutely go to bat for the patients in front of us…but also, as a coalition, we have a lot of opportunity to be much more effective.” He added for a long time, advocacy was “actually discouraged from the [medical] profession…a doctor going out canvassing? That was not a thing that happened when I was in medical school or encouraged or celebrated.”

Here I totally agree. I wonder whether the professional detachment some of us develop as an emotional shield hobbles us when it comes to advocacy. For a long time, I’ve been surprised at how little health policy advocacy I’ve seen around me, apart from issues related to billing or medical malpractice. That’s not to say there’s not amazing people or organizations doing impactful work in this space. A recent example might be Vivek Murthy’s advocacy around putting warnings on social media apps for teens. But, we can’t delegate all of this to Dr. Murthy. We collectively need to be much more involved.

Take the recent Supreme court decision related to the Idaho abortion law. The ruling preserved emergency abortion access on procedural grounds. But on the substance, the court was silent. Neel told me that the Idaho abortion ban was in “direct opposition with EMTALA, which is a sacrosanct federal mandate that obligates emergency departments to provide stabilizing treatments. In some cases, abortions (or ectopic pregnancy excisions) are necessary to prevent sepsis or hemorrhage(For a good description of the circumstances in Idaho, check this out).  And in Idaho, physicians were literally flying dying, pregnant women to other states to receive the life saving care they needed. These physicians performed heroically in their circumstances but how did we even get here? Can we say that we did everything we could as medical professionals nationally to prevent this from happening in the first place?

All that said, Neel is actually excited by the energy he’s seeing on the legislative front with regards to reducing maternal mortality. What’s impressive is that “community-based organizations are [the ones] fixing it. It's almost exactly parallel to what happened in the HIV AIDS movement in the late 1980s, early 1990s, where it was community-based organizations that held the Reagan administration to account, got AZT passed and dropped mortality by 70%.” The efforts of this activism recently include the Preventing Maternal Deaths Act passed in 2018 and “unprecedented levels of investment in women’s health.” It could be that there's hope after all.

Closing

What I took away from our conversation is that we need new methods for care delivery that are safe and evidence-based. But we also need to be change agents and advocates for the healthcare system that we all deserve. There’s a role for clinicians to be far more vocal, and not just in the mediums that we’re naturally comfortable with. If it takes being on TikTok to rally support for reproductive rights, we should be there.  We need those who are brave enough to persuade and push, and not just to sit within the status quo. Neel Shah, MD, my friend, thank you for speaking with Good Medicine.

Neel’s Book Recommendation

Neel had incredible praise for Abraham Verghese’s The Covenant of Water. Yes, it’s intimidatingly long but Neel says it “pulls you in right away…[it’s such] beautiful writing, how can you not keep at it?” Plus, how can you argue with Oprah?

Most Impactful Mentor

Neel was quick to say he’s had so many great people support him in his career. One that stands out though is Atul Gawande. Dr. Gawande gave Neel the advice to be very intentional with “what you leave in academia, what you bring with you, and what you make space to newly adopt” with respect to his career transition from academic medicine to joining Maven. “I like to think I brought my scientific integrity with me to Maven,” he said. “And I made space to learn how to be a business operator.”

The Thing He Most Wants to Fix in healthcare

“I have so many salty things that I want to say right now, but I would get rid of every entity in the healthcare system that extracts value out of the value chain. [There are no] simple transactions in healthcare between the patient and the doctor. There's always a third party involved somehow. And I would at least, at the very least, try to make what's happening at the point of care more transparent to everybody involved so that you can better align incentives. That's a wonky, not pithy one, but it's like, the one.”

On the day we had this conversation, the NYtimes published quite the expose on PBMs (pharmacy benefit managers). Read it, it will drive you crazy, hopefully in a motivated way. There’s a reason these third parties don’t exist in most other countries around the world.

For Love of Great Writing

“Joy can be as strong as Everclear or as mild as Coors Light, but it’s never not joy: a blossoming in the heart, a yes to the world, a yes to being alive in it.” Jonathan Franzen

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