Ep. 104 - Reclaiming Joy When Medicine Loses Its Meaning with Dr. Alen Voskanian

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I am Meredith Hirsch, and this is working healthcare. The US faces a projected shortage of up to 86,000 physicians in just 10 years. I interviewed Dr. Alan Bosganian, and we talk about his journey from an immigrant with a childhood dream of medicine to a physician executive.

And he reveals how the system burns out the purpose, even in the most dedicated clinicians. He talks about pebbles versus boulders and which ones can be squashed and which ones are more difficult to overcome. His work reframes burnout as a structural issue and outlines how leaders can restore meaning without waiting for massive systemic overhaul. He wrote an amazing book called Reclaiming the Joy of Medicine.

And he talks about how we have to bring the humanistic aspect back into our healthcare system. Oh, yeah. And he's actually hoping that he will someday be a stand-up comic. You will not want to miss this.

Dr. Alan Boscanian, welcome to working healthcare. It's so great to be here. You've said burnout isn't about working too hard.

What actually broke you? You know, it's all the things that uh are not meaningful, that do not add value, that are not aligned with um the reason why I went into healthcare. Um, those are the things that wear me down. Sometimes I call them the pebbles in the shoe, the day-in, day out headaches of being in healthcare.

For example, filling out prior authorization that seems so uh not aligned with the reason why uh most of us went into medical school. You didn't go into medical school to fill out forms to get medication for patients. Let's go back. I know, definitely not.

Let's go back to the beginning. You decided that you wanted to be a doctor when you were eight years old. Tell me that story. Gosh, yeah.

I think um I when I was so I'm eight years old, and um I am told that I can possibly lose my mom from breast cancer. So um really stressed. Uh I'm at the hospital uh waiting in the waiting room for my mom to come out from surgery. And all the feelings and the emotions and questions in my head, and here walks out uh my mom's surgeon and kneels down at my eye level.

I'm short, shorter than everybody else, all the adults, and says, I'm gonna make sure that your mom is okay. And that at that moment I realized that um physicians play it such an important role, not only in taking care of patients, but also also the family members. And subconsciously, I decided to kind of uh wanting to do the same thing. I wanted to be a doctor.

Uh so that's the moment uh for me that it clicked in the back of my head. It just I didn't know how to do it. I didn't have any doctors in the family, and you know, years later, I remember vividly thinking that uh what do medical students look like? Like, who are they?

Like I had this, I didn't know anybody. So I was in my head, I was thinking they're superheroes, they're like extraordinary people. And uh, but that everything started for me at the age of eight. And your journey was not easy.

Anybody listening to this podcast episode may think that you were natively born in America. You actually didn't get over here until you were 19 years old. Walk me through that journey and how you actually got to medical school. Yeah.

Um so I am uh Armenian, um, but I was born in uh the country of Iran, uh, which I think is uh recently has been in the news a lot. Only a little bit. But um Armenians are a Christian minority, you know, they're spread out across uh the world. And um so my great-grandparents had moved there, and I grew up in this really sheltered uh community, uh, but then there was the revolution that happened in Iran, and it became extremely difficult for minorities to uh live in the country, but to thrive, um, and in my case, to go to medical school and get educated.

And for various different reasons, um I had to um kind of leave the country and um ended up in Austria uh in a refugee camp, uh, a religious refugee uh waiting to come to the United States. And um I left home when I was 18. I was in this refugee camp. Um, just had to grow up so fast.

Look, all of a sudden, one minute I'm living at home with my parents. Yes, in a difficult country with difficult circumstances, the next moment I'm in a refugee camp by myself, and um just hoping and praying that uh my application would be accepted and I could come to the United States. Uh I'm so fortunate that I was able to come to US when I was 19. And um so here I am uh in America and realized that uh I need to be able to speak English.

So I signed up um at a community college in uh Glendale, California, and taking ESL classes, and realized that uh the math that I had taken in high school was very advanced. So um I was excelling in all the science classes and math while learning English. And uh also at the same time I'm looking to find a job, and I am so excited when I find my first job, which I think is the best job in the world, at Kmart on San Fernando Road in Los Angeles, and I think it's I feel so lucky.

I'm like, oh my God, this is American Dream. I found my first job and working minimum wage at Kmart Sporting Goods Department and cleaning the store and closing it. And that was really one of the best things that happened to me because the work was so challenging that made me realize that I do not want to work at Kmart for the rest of my life. And you thought medical school would have been less challenging than working at Kmart?

Yeah, I was like, of course. Like I can't work at Kmart, I need to be a doctor. No, I I think I um I was doing well at community college. I once I started um my English started improving.

Um, the science part, the math, the chemistry. I loved those classes and I thought I was doing so well. I actually started tutoring calculus because I'd done calculus in high school. And I also am such a nerd.

Like I love learning. So I was loving community college, and I was doing well and um working at Kmart and still just this dream of being a doctor, but it's so unattainable for me because I don't have anyone who could tell me what it takes to be a doctor. Uh so I remember vividly my um chemistry 102 teacher, my second chemistry class. I heard that he his wife was an endocrinologist.

Uh, and I was actually the TA for his class. And one day in the lab, I asked him, I said, uh, Dr. Gordon, do you think that I would be able to become a doctor? And he looked at me and paused, and then he said, like, are you stupid?

Like, of course you can, but that would be the worst decision. You should become a chemist. And at that moment, like I think, I don't think he realized it, but it it it's all like it gave me so much confidence to feel like yes, I could become a physician. So I applied after two years in community college.

I applied to transfer to various universities, uh, and um I was able to get it accepted to UC Berkeley, went there, and uh I did what I could do, which was in my control, was studying really hard, uh, really getting good grades, and um was able to graduate from Berkeley with honors and with the 4.0 GPA, which in retrospect I'm not recommending because for me, I came from such a place of maybe scarcity. I don't know what it is, but I thought the only way to get to medical school is if I really only get A's.

Uh but I then I had to sacrifice the social life, the all the nights that every all my friends would go out and hang out, I would be studying. Um, but I think that's what I had to do to be able to get into medical school. Um, and then, you know, I think that's where my life changed. I was able to go to medical school at UC Irvine, um, and then did my residency at UCLA.

Your journey is one of such determination and fortitude. It's amazing. I will tell you though, you and I are about the same age, and I went through this process with my brother, who's a couple years younger, and my husband, they're both physicians. And I think back then, students were required to have pretty much a 4.

0 if you're going to get into a great program. But it makes for devout doctors, let me tell you. My husband and I are celebrating almost our 30th wedding anniversary in June, which is insane to me. And my brother and his wife, I think they've been married for about 25 years, which is insane.

So very loyal because they don't know how to play the field because they never got to, because they were so fixated on medical school the whole time. There's your positive. Yeah, it's it's it is. And you didn't go into oncology.

That's not the route you went into, but you also went into a very underserved specialty. You actually got your fellowship in HIV and AIDS. Tell me why you chose that. You know, it's so interesting.

I've been reflecting on this a lot, being kind of getting towards, I can't say I'm getting towards the end of my career, but like that midlife uh reassessment of like what brings me joy. And now, like many years out, I realized that I always gravitated towards communities that um I thought were a little bit underserved or were suffering a lot. And so when I uh was in medical school in late 1990s, of course, the AIDS epidemic was happening, and I saw so many people being disenfranchised from our healthcare system, people being kind of disowned from their families, uh, a lot of folks who were having substance abuse issues, and then on top of all of that, they had to deal with their illness.

And being ill and having HIV and AIDS was so stigmatized that it felt so wrong to me. And um, it really gravitated me towards wanting to give back to that community. So did a fellowship, uh, really enjoyed my fellowship, but when I started practicing, um, that's when I felt uh burnt out. And this at that time we weren't even using the term burnout, but I realized it wasn't the hard work that made me burn out.

It was the sense that no matter, first I'm not doing meaningful work, and no matter how much effort I put in, I still felt like I was failing my patients. My patients had not only health conditions, they had all these opportunistic infections on top of AIDS, but also they had issues with securing housing or food or dealing with substance abuse. And I was being told, I'm not doing enough. I need to see patients faster, I need to see more patients.

And that's when I had to take a pause about three years into my uh into me being a physician, and did a lot of soul searching about what brought me joy and made a pivot at that point to go into palliative care, hospice and palliative care. Um and I think that really saved my um healthcare career. It's really interesting that you say that palliative care and hospice care would have saved your joy for medicine. I know that when my husband was going through the process of selecting a fellowship, he was debating between rheumatology and hematology oncology.

And the reason why he chose rheumatology, one of the big reasons, was because of lifestyle. And he thought it would be too difficult and depressing, and and he would feel as though he wasn't making a big enough impact with patients who are constantly like dying on him. And with rheumatology, 90% of our patients walk in in pain, and then most of them walk out feeling better. You went into the HIV AIDS practice and world, and then you went into hospice and palliative care, which is also, I think, a very somber healthcare specialty, yet you felt joyful.

So you don't think that there's a correlation in the type of specialty that a doctor chooses? I think there is a lot of correlation, and I've been thinking about that a lot. When I went into HV and AIDS, it was a really exciting time because new medications were coming out, and we were actually uh helping people like saving lives, truly. Like it was all about people who thought they were gonna die and with um antiretrovirals, advancing, truly, like people's lives were being saved.

And then all of a sudden, HIV became a chronic condition because there were so many great medications and it wasn't a death sentence anymore. And at that time I realized that yes, that that was bringing me joy, the the saving of lives. But what brought me joy the most was uh being with patients and reassuring them through a challenging part of their healthcare journey. And in HIV and AIDS was that uh, you know, this the uncertainty of the disease and the advanced disease and being able to um help patients through that.

But I also felt that patients at the end of life are often very underserved and feel very abandoned by their doctors and the healthcare system. So it again was an area that is very comfortable for me to walk into when I feel a community, a group of patients are underserved. And I truly believe that end-of-life patients often feel like that because they've had this long-term relationship with their doctor, but now their care is their condition is terminal, and they're often told that their doctors tell them, like, there's nothing I can do for you, which I don't think that's true at all.

There's so much we can do, physicians, especially at the end of life, to keep patients comfortable, to be there, to reassure them, to find um different ways for that person to have joy in their lives. So I think it's that um intimacy, that honor and privilege to be in that sacred space at the end of life, that was really um, you know, very fulfilling to me. It was heavy, and there needs to be coping mechanism to be uh able to sustain oneself in end-of-life care, in hospice, in palliative care.

There's often this team approach to care, which is includes a physician, a nurse, often a chaplain, a social worker. And that team debriefs uh on a regular basis about uh the experience of working with patients uh that are very close to death. And I think that was very self-s uh sustaining, not only for me, but for the whole team members. You wrote a book called Reclaiming the Joy of Medicine.

So you are focused on a joyful life. I want to start out though with the problem first. Yeah. How would you describe burnout?

Burnout is losing the sense of meaning and purpose. I guess joy in our profession, uh feeling like what we do is not good enough, that we're not we're not aligned with our values, uh, with our with our why for being in healthcare. Uh the work becomes meaningless, like the work we do is not fulfilling anymore. Uh but it's really this constantly feeling tired, uh uh overwhelmed, and not feeling like we're making a difference.

Uh, but when you like, I think losing joy to me, that's the way it manifests. When something doesn't make me happy, it's time for me to sit down and say, like, what's going on here? Is it me? Is it the circumstances?

And more importantly, how can I fix it? So you don't think that workload or being overburdened necessarily has to do with burnout? Not for me. Not for me.

I thrive like when I do a lot of different things. I love it. Like I I but I know I'm also like a little bit weird like that, but I love doing a lot of different things. Like I think my friends and my family, they always make fun of me because I'm always like reading three different books.

I'm often uh signed up for a class. Like right now, I'm learning Italian. Um, I'm also um signed up for a stand-up comedy workshop. And that's good.

That would be very interesting to see you do comedy, stand-up comedy with what you um, gosh, with your background. I don't know. A little morbid. Yeah.

Yeah. No, I I love it. I don't think it's it's the hard work. You know, you're like, so if you go back and um uh in terms of looking at physicians and this whole arc of like the way doctors have been practicing, there was a period of time.

I think my generation is right when there were a lot of uh laws passed for how long residents can work in the hospital, so better work-life balance, like how many shifts they can do. I I think I was in the last year where there was really very little regulations. Like we could be on call like a day, two days in a row, there, and then go back the next day. So there's a lot more laws have passed, but the generation of physicians, like before.

Me, uh, they were working really, really hard. But I think the they were getting tired of the work, but they weren't like complaining of burnout. There was this sense of like this is a uh voc, this is like more than a career, this is a calling. And so I don't think it's the hard work.

I think it's just all the all the like stupid stuff that people have to do that burns people out. Describe that stupid stuff for people who uh are not physicians, who people people who don't work in the healthcare administration, which I don't think they'll probably listen to this podcast because most of my listeners are physicians and executives. But what is the burnout? What is the lack of joyful responsibilities that you are required to do?

Yeah, so like there's so many, but I can give you a couple of concrete examples of the headaches, the the those pebbles in the shoes. So you you end up um seeing your patients, you need to click, like just something before even you see your patients, you need to enter your password, um, and you need to change your password all the time, and then you step away from your computer and you come back and you need to enter your password. And let's say you see 30 patients in a day, so you need to now enter your passwords probably 30 to 50 times in a computer.

So, like that over time, day in, day out, like constantly entering a password and logging in. Now you are in your computer, now you need to log into your electronic health record. So, for example, that maybe has an easy solution, which is using a badge. Now you tap your badge, so that removes that one thing, one pebble.

But there's so many examples of that. You finish your um talking to your patient, it's a very meaningful connection, but the whole time you're looking at your computer, you can barely make a uh uh eye contact with your patient because you're entering and you're clicking. If you don't do that while you are work uh talking to your patient, you know that you're gonna spend so much time afterwards documenting. Most doctors spend so much time, especially in primary care, after hours at home on their computer documenting.

There's a term for this, it's called pajama time. It's the time that physicians are using when they sh uh at home, when they should spend time with their families or go to the gym or uh just have them kind of take care of themselves. They're spending it on their computer. So that is not that to me, that's like uh one of the other pebbles.

And you know, let's say a surgeon is ready to go do a surgery in the morning, the patient has not had any food all night, uh, the physician shows up at 6 a.m. and their case doesn't start till 8 a.m.

And then their whole day gets uh pushed back or they're finished with a surgical case, they're ready to go do another surgery, but there's a turnover of the room that takes two hours, they have clinics scheduled in the afternoon, now they're running late for their clinic, so they have to cancel their patients. Those are the little uh annoying things that maybe once, if it happened twice, uh you could overcome it. But when it happens day in, day out, over time they lead to uh burnout or sense of losing the joy in healthcare.

How can these pebbles be crushed? So you wear very like robust boots and you start jumping on them. No. See, that's your that's your comic show.

Yeah, exactly. No, you do uh you need full-on um buy-in from uh operational team and you need physician involvement to first uh talk about what those pebbles are, but partnering with the operational team, this is where I feel that a close collaboration between physicians and administrative team is so helpful because these are pebbles that not only help the doctors, but also help uh the entire team, the healthcare system. So close partnership when possible to say, hey, these are the big pebbles.

I think the reason why it's so difficult with pebbles is that we're not talking about one or two. We're talking about like hundreds of pebbles. So prioritizing and saying, like, okay, this login situation is a nightmare. Let's address that.

Or maybe there is AI scribes, let's focus on that. Uh so I think prioritizing the pebbles, being patient, taking um, you know, tackling one at a time. What is more challenging to crush are more like the boulders. Those are like bigger challenges, and it's uh often it's regulatory, it's harder to address.

But the pebbles, I've seen a lot of really great success in close partnership between positions, operational teams, and then tackling them one at a time. How many pebbles need to be crushed before you can reclaim joy? Yeah. And I'm just thinking about the question you're saying.

Because yeah, it's never going to be 100% crushed, right? So I think it's as long as there's hope, like we're moving in that direction, and then that's where the reality of the personal aspect of joy, wellness comes in. That I think at some point in my life I had to realize like, what are what is realistically um realistic expectation in terms of what can change in healthcare, uh, and what is never gonna change, and how do I still find the joy in healthcare despite all the pebbles?

I appreciate you speaking up about this because I think it is generational. If you look at the baby boomers, they're the ones who are still physicians, they're the ones who are still working. They are still trudging in every single day, and they're like, this is what I was told, this is what I learned, this is what I'm gonna do day after day after day. And then you have the millennials who I think have taught us Gen Xers, because the millennials are like, no, we don't have to put up with this.

We can have our work-life balance. I like calling it work-life integration, and I try to tell the millennials that, but they're like, we can have the balance, we can fight the system because our generation has always been work hard, play hard. Like we will work our asses off all day really hard while you're in the clinic, but then we're gonna play really hard on the backside. And millennials are like, why do you have to play so hard?

And why do you have to work so hard? Can't everything be a little bit more toward the middle? And I'm glad you're taking that perspective as to how can we be joyful so we aren't the baby boomers and have to trudge in every day, day in, day out, like a little time punching card, in and out, in and out. Those boulders, though, how are they crushed?

Yeah, yeah, they're not, they're not, uh sometimes it seems they're not crushable, but I think like chipping at them um and being patient that we know it's not going to be solved overnight, but we're working towards fixing it. And there were some things that I thought we would never, like big boulders that I thought would never be moved. Let's say the use of um virtual health care. Um it seems like our progress was so slow, and then COVID happened, and then like within weeks, everyone is doing virtual visits and things like that.

Uh, there were a lot of regulations that were preventing us from doing virtual care. So um I'm hopeful that some of the big boulders can be changed also, but they're gonna take a long time. It's um it's when you know there's payers involved, insurance companies involved. Um, often you need to follow the money in terms of health care, which is not something as physicians um people get trained on.

Like how's the economic, the business side of healthcare working? And um, sometimes things don't make sense um, like clinically, from a patient perspective, it makes sense to do the right thing. But then you have to jump through hoops. Let's say prior authorizations, there's a reason why there are prior author authorizations to make sure there's appropriate utilization.

But there are times where you're like, oh my God, this patient really needs this procedure, like or needs this medicine right away, yet you still need to jump through so many hoops to get that approved. So um I think have partnership with the right people who are involved in those boulders, trying to tackle them, and then just being patient. In my mind, when you had said, well, we were able to conquer the boulder and crush it during COVID, I'm like, COVID is a once in a century event.

Yeah. Like, what are we waiting for the next COVID? We'll all be dead, and trying to figure out what we're going to do to create change. Would you encourage your children to go to medical school and become doctors?

So I am like, you're asking me a question which is really hidden close to home because my kids are at that age. So I want to be mindful of answering it because they might be listening to this and they'll be like, oh dad, like, why did you say that? So you know, if I want them to have a choice to find what they uh what brings them joy long term, uh, but if they if healthcare being a physician is something that they want to do 100%, I would go back and become a physician. Uh, you know, 100% again, I would do it.

Um, and I think it's one of the best careers. Um, it's so meaningful, so special. It give opens up so many different doors in terms of what you can do with it. So if that's aligned with their long-term goals, yes, 100%.

Besides finding joy by learning Italian or by taking a class to be a stand-up comic, what do you do every day now to reclaim the joy in medicine? Yeah. Yeah, I'm really mindful about it. It's so important to me.

It's such a high priority. I I do I do a couple of different things, and uh it's a little bit maybe um geeky or dorky the way I approach it, but it works for me. So first I truly uh believe in organizing it and being very mindful about uh maintaining that joy. So I have a couple of habits that I do in the morning.

Uh, one is I get up really early, um, around 4:30, try to, and most days I'm able to get up at 4:30, and that's my time to do the things that make my day great. And um, the way I think about it is falls in three main buckets. One is my uh love life or my family life, like how I want to be with my family, and I set an intention for that. Uh, the second one is my work life, uh, which is my professional work, but also some of my creative uh endeavors, if it's about writing or doing comedy.

And then the last one is my well-being or my health. Like those three things I have a goal every day. And like, for example, in my well-being portion, it's really about working out. So um every day, six days a week, I work out.

So it often involves going to the gym, but then I try something new. So uh recently I've started doing this thing uh with this Pilates class, which I know it's um anyway, I'm not gonna Don't say it's girly. My husband, my husband loves Pilates, and he's never felt better than doing yoga one time a week. He even said that this morning.

He's like, it's amazing how much more flexible I've become, and I only do yoga one day a week. So own it, own it. Yeah, I'm owning Pilates, but it was a little bit when I first class I walked into, I was like, how's this gonna be? And I walk in and I'm the only guy in the class, and I was like, oh God, like please, like uh let me get through this class.

And the teacher walked in and was like, Okay, ladies. I was like, oh god, like this is not this is gonna be a long class. But I constantly looked at her. I'm like, please just acknowledge me.

Um but um did she ever acknowledge you? Uh I by calling me girl. Like, yeah, okay, girl. I'm like, okay, let's do it.

No. So yeah, it's uh, but I like I I do that one day a week because it's really helpful. I think as like for core strengthening, um I try to meditate every day. I gamify that using an app that tracks my daily meditation.

And I think those are little things that are so important. If I can make time for that, and then the skip the day starts really early, like let's say at seven or eight. But at least I feel like I had that time in the morning to take care of myself. And then by the time my day is over, it's time for my kids and my family.

So what time do you go to bed at night? How many hours of sleep do you get? I try to go to bed by 9:30. So um I try to avoid looking at the phone.

Um, and I think you and I talked a little bit about the aura ring. I track my sleep. So um, but yeah, I try to go to bed at 9.30.

I try to get seven hours. So that's about what I get, but you are pivoted earlier than I am. Uh, but I think it works because you're on the West Coast, so even dealing with East Coast colleagues, it probably works out really well because when it's 4:30 your time, it's 7.30 on the East Coast.

So it works well. I don't have enough hours in my day to work out six times a week. Like I'm listening to you going, when does he work? When does he do these other things?

Now I will tell you, I feel like I have four jobs, but you do, you wrote a book, you are uh you see patients, you're a professor at uh Berkeley. Like, what else do you do? How do you find time to do all of these activities? And you have two kids.

Yeah. Yeah, it's uh yeah, I yeah, three kids. Three kids, sorry. You have three.

It's yeah, it's a lot. And um, I mean, of course, like I'm not perfect, and you know, certain areas I want to improve, um, like spending time with my kids and my family, that's something uh I'm I really want to do a better job. And you know, because the work is never ending, like uh some days it's back to back, full of meetings, but that doesn't account for my email. Um, and I also still see patients.

So I think there is this sense, and I'm saying it, and I've wrote a book about wellness and burnout, but are there times where I feel so overwhelmed? Yes, of course I do, but I realize that those days are when I need to double down on my routine. Like I need to make sure I get up and I get enough sleep and uh make time. And sometimes it's just uh when I say workout, it's not crazy workout like every day, but sometimes it's just going for a walk, taking my dog uh on a long walk, and um that brings me so much peace.

And often I double uh like do two things at the same time. Like I'm walking and uh listening to a podcast or doing some Italian lessons on Duolingo, or like it's that's the way I think as much as I can I uh double task, but some things you cannot double task. I've realized like I cannot do two Zoom meetings or one Zoom and one Teams meeting at the same time. Yeah, don't do that.

I have tried, it does not work. Well, that's ambitious. I don't think I've ever actually tried to do two at the same time. Do you have hope within our American healthcare system that we can eliminate these pebbles?

That future doctors or the young doctors within our system right now are able to reclaim joy, if it's the pebbles that are impacting their ability to have that joy. Yes, I do have hope, but it's not that we can eliminate pebbles. I think the hope I have is if we bring humanity back to healthcare, if we really focus on that human aspect of healthcare, the care uh that our doctors want to give and the patients want to receive. If we allow for that to happen, you could have so many pebbles.

But if you feel that your work is meaningful, that you truly are caring for your patients, that there's that human moments that sometimes are taken away when you have a bureaucratic system that doesn't allow for that, those things lead to burnout. So I have hope that we could have humanity in healthcare, and I think that's gonna sustain us through the pebbles and the boulders. Who's the one responsible for bringing the humanity back? Yeah, I I think I think everybody, uh everybody, like everybody is uh uh, you know, I I feel like that's my responsibility as a leader, as a physician, but I think everyone could do it.

Like it could you could be the uh person that uh parks the cars in the uh basement that if you see someone who looks fatigued and tired and they're not looking well, to tell them, hey, like let me get you a wheelchair and take you up to the floor. And I think we need to empower everybody in healthcare to be able to make a difference because it matters. It's it could be the medical assistant, it could be the PSR at the front desk. I think it's the human moments can happen.

And I think sometimes people feel they're not empowered to make a difference because they're they're not a doctor or they're not a nurse. But I think the healthcare journey is so complex that as soon as people step up and make it human, you're teaching a lesson to the rest of the team members and people take notice. So I think all of us in healthcare could do it. I do feel a big like burden on my shoulders to make it human as a leader, but I think everyone should focus on that.

That culture shift to me has to be the biggest boulder that I can think of. I have seen the shift. You grew up in Iran, came over, went to Austria, came over to California, you're at UC Berkeley, which is a very liberal institution. And I see both sides.

I've lived around the country, not around the world. And as I said, we're about the same age, and we've seen this shift go on in America where we were inclusive, and now it's become so divisive. Even at UC Berkeley, when you thought it was so inclusive, it's divisive against people who think differently than the majority of the students. And then we have Florida, where I think Californians are like, who the hell would ever live in California?

I don't even think this is a healthcare issue. I think this is a human issue. Oh, yeah, yeah, yeah, 100% agree. I think it's how do we overcome that?

And you know, at the at the end, we're like all humans have very similar goals and aspirations, care about our families, care about our well-being, and this othering that happens is so detrimental everywhere, like I think in general, like you said, but in healthcare, it's like the worst. Like you don't want that to happen in healthcare. Like at the end, like patients are not feeling well, all they care about is their their loved ones, themselves, their health. Like nothing worse in that vulnerable moment to feel that you're being treated poorly because of something that basically you have no control over.

Your your financial status, your race, your ethnicity. Like at that moment, if you're having a heart attack, you just want someone to show up there and treat you, treat your healthcare condition without all that division. So yeah, I think maybe healthcare could set an example for the rest of us. Yeah, it's definitely a big boulder.

So I'm gonna ask you for a pebble and not this huge boulder right now. If you could create one change, one pebble change within our American healthcare system, what would that change be? What would create the biggest impact? I think just going back to the term healthcare, like it has care in it, and often it's void of care in our healthcare system.

So just bringing care back to healthcare, truly, like I know it sounds corny, but to me it it just really focusing on the patients and making sure we're caring for them. Dr. Alan Boscanian, thank you for joining me on Working Healthcare. If this conversation hit home or made you think a little differently, don't keep it to yourself.

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