Dr. Bergein F. Overholt needs no introduction. He founded the Gastrointestinal Associates in Knoxville and led the group for four decades. He is also the past president of the American Society for Gastrointestinal Endoscopy and American Association of Ambulatory Surgery Centers.
Dr. Overholt helped develop the flexible fibersigmoidoscope-colonscope, for which he earned many awards. In 1986, his efforts resulted in the establishment of the nation’s first GI single specialty Ambulatory Surgery Center. Dr. Overholt has also taught many of today’s GI practice leaders how to develop and manage their own GI-ASCs.
In this one-of-a-kind interview, Dr. Overholt walks us through his four-decade-long journey, reflects on the new technologies, private equity, and shares his views on alignment among physicians. And finally, he shares timely and relevant advice for gastroenterologists.
At a time when gastroenterology is at crossroads, Dr. Overholt says what needs to be said. Watch on. Don’t miss the story of how the country’s first GI ASC started.
Do not miss this one (25+ mins).
◘ Dr. Overholt’s journey: “I wanted to be just like my father”
◘ On private equity: “I think the story is still out “
◘ “One of the most important things is that the physicians you associate with will determine a great part of the direction you and your practice will take”
The Transcribed Interview:
Praveen Suthrum: Dr. Bergein Overholt, thank you so much for joining me today and people always refer to you as a legend in GI so it’s a distinct privilege and honor for me to interview you and I first want to welcome you warmly to the Scope Forward Show.
Dr. Bergein Overholt: Well, thank you. The word legend can be interpreted in two ways. It can be positive or negative so, thank you for your comments and I hope they were positive!
Praveen Suthrum: Very much so and you paved the way for the field of GI for not one or two but many decades. And on the clinical side, you’ve received prestigious honors for your work in flexible sigmoidoscopy, and on the business side, you were the first one to start a licensed and accredited GI-ASC. So, that’s quite a span and you’ve always innovated and more importantly, you’ve shared your ideas freely with everybody who was interested to learn. So, when I did some of these interviews people always would refer back to you and that’s what prompted me to you know to reach back. But I want to start all the way you know to the beginning I want to go to the beginning Dr. Overholt and my question is why did you become a doctor and why gastroenterology?
Dr. Bergein Overholt: Both are easy to answer. In the third grade, I was asked to write a little book booklet and it was what do you want to do and why… and I wrote that I wanted to be a doctor and take care of people and help people like my dad did. And my father was a physician he was a beloved individual in the medical community and he was, of course, my father and he led me in all directions and I wanted to be just like him. Later on in medical school in the third year, I was in classes with a very interesting and motivating physician who was actually an internist but he lectured on gastroenterology and that’s that just lit me up. So, I decided in the third year that I wanted to be a gastroenterologist.
Praveen Suthrum: When you reflect back on your career what are some of the big shifts in gastroenterology that you observed?
Dr. Bergein Overholt: The biggest shifts of course have been in the science of medicine, and in gastroenterology, and in technology development. Gastroenterology was in a fortunate position to be able to use both knowledge and technology and we were there at the right time. I started practice in 1969, and that was not many years after the introduction of Medicare and so as I was starting practice most patients began to have insurance that would cover their healthcare. So, economics was not the problem. That was good and there’s, of course, the downside to that but nonetheless, that was a major change back then.
Praveen Suthrum: Now… you have innovated both in clinical on the clinical side of medicine as well as the business side of medicine. How did you manage to do that? It is quite a spread.
Dr. Bergein Overholt: My dad ran his internal medicine practice and I watched him and I became interested in the management side of medicine. And that always carried forward into my practice so when ideas came, I had training on-site to running the practice to move the practice forward into new areas and that’s really how that occurred. You go to national meetings, you talk with other leaders around the country, you see what’s happening, and you get ideas. And then if you have the right kind of background and the right people working with you in the right situation, you can implement new ideas into your practice and that’s basically what we did in Knoxville and it was a wonderful experience. Exciting and challenging, and I was able to take those ideas perfect them to a degree, and then share that with other physicians and you could just see this begin to move around the country. So, it was a unique time and a unique opportunity.
Praveen Suthrum: What triggered the idea of starting an endoscopic ASC in the first place? What is that story? How did it happen and how did you go about it?
Dr. Bergein Overholt: So, we started office endoscopy in the early 80s and we focused on quality and we built some rather nice office endoscopy units. And about that time, across the country, there were maybe half a dozen ambulatory surgery centers. These are general… they were plastics and general surgery and I was involved in some groups that bumped up against those things. And I began to think about it and said why can’t we do that in GI? So, I met all the criteria and I went to our state and said, “I’d like to license this as an endoscopic ambulatory surgery center” and they looked at me and said, “You’re crazy! What are you talking about?” and I said, “I’ve set up endoscopic ambulatory surgery center and I want you to come and license it” He said, “Well we don’t know how to do that and thank you very much.”
And I went through that about three different times over three years. I would do it once a year and in that process, I began to work with a lady who was the head of Medicaid in Tennessee and she and I became friends and I kept sort of telling her about how we were doing endoscopy in the office and that I needed to get licensed. I did not think that she would be able to help me. Well, one day she showed up at my office and she said, “Okay show this to me” and we had a very nice three-room… well three cubicle facility and six recovery areas – staffed and equipped, and so forth. Well, I had just performed an upper endoscopy on a poor, remote county farmer. He had a deep gastric ulcer he was really uncomfortable. And as he was recovering she walks in. I take her over and I said, “Here’s what we’ve done, here’s the picture.” And she looked at me and she said, “Who’s going to pay for this?” And I was startled by the question and I said, “I’m sorry I do not know.” And she looked at the patient and she said, “How are you going to pay for this?” And the patient looked at her and said, “I don’t know, I can’t!”
And she said, “Okay” and she spent a few more minutes with me and then she left. A week later the licensure arrived on my front step. And so she was the Medicaid director and as long as we were providing care, that in this case was free, to the poor people she was going to be on our side. And that’s how that occurred. Very shortly thereafter I began to teach other doctors how to do that and it went from one endoscopic ASC to now there’s well over 800 I’ve been told may be more than that across the country. So, it was an exciting opportunity and exciting time to be able to develop and teach that.
Praveen Suthrum: And that one action has resulted in… yes the number of ASCs, but it’s like an entire mini-industry into its own. The jobs that it has created, the industries that it has spun, and everything else surrounding it… it’s amazing. So, I want to congratulate you on that. How do you feel reflecting on something like that today?
Dr. Bergein Overholt: Well of course, back when we did the first one I had no concept that this would spread across the country like it has. I enjoyed greatly sharing the information with other physicians and it was exciting to see them start up and then come back and say this is one of the best things that we have done in our practice. So, that spread across the country and it really has changed the way endoscopy has been practiced and I’m just very proud of being involved in the early stages of that but there were many others who have contributed equally or more so than I did in that evolution of office endoscopic ASCs. I don’t take the credit.
Praveen Suthrum: But thank you for sharing that story. I want to shift gears and ask about your views on Scope Forward. You read the book, what do you think about the themes that evolved from the book on the future of GI?
Dr. Bergein Overholt: I will go back and say that for gastroenterologists that are coming out one of the decisions that they need to make is – Whom to join? And what kind of a group? And where’s that group going? The groups today seem to be moving into private equity arrangements where they join a larger national group of practices and carry forth them there. I think the story is still out on that. One of the big reasons that we all went into practice was because we wanted to control our future. When somebody buys you and owns even as little as 30% and it’s not little, but it owns 30% of your practice… you lose the opportunity to have absolute control over your future. And to me, that’s a big issue in medicine.
That’s one of the reasons I went into medicine because I could control it… control my future. As a member of a group that owns part of you… you lose a great deal of that control on the other hand joining up with other practices in that way gives you tremendous strength in negotiations. So, that’s a powerful tool and I am not sure yet which is the best way to go – stay independent or to join up. For me, and Knoxville what the group is doing is well… they are becoming… they are locally dominant and if they are dominant why do they need to join a national group which takes revenue and control away from you when you’ve got that under your own control locally. So, I think the story’s still out. I’m favorable for some groups to join into larger groups but for some, they don’t need to. That story is unfolding.
Praveen Suthrum: Got it and I want your comments on the aspects of advanced technology such as stool DNA testing or artificial intelligence in the endoscopy room. So, there’s all these exponential technologies or advanced technologies that are coming to medicine and also to gastroenterology I wanted your thoughts and reflections on that. What do you think about that?
Dr. Bergein Overholt: Well the technology is always going to advance, it’s always going to improve, and it’s always going to impact what we do. And physicians need to adopt and adapt to that new technology. I think it will enhance our ability to take care of patients in terms of diagnosis and treatment but it will further separate us from what physicians need to be about and that is one-on-one with the patient. So, I have concerns that technology is going to isolate us away from patients but on the other hand, it’s going to improve our ability to take care of them. So, it’s a mixed bag. I’ve always been one to move toward new technology at the very first. I’ve always liked it. The challenge, the risk, the advances that you can do it but as long as you put the patient first and you still can work one-on-one with that patient… the adaptation of your practice to new technology is an awesome opportunity.
Praveen Suthrum: So, I want to ask you if you were running a GI group today what would you do? How would you make your bigger decisions?
Dr. Bergein Overholt: One of the ways that helped me when I was active in all this was going to meetings and listening, reading what the literature says, and understanding that, and then assimilating all of that information into where is the future going. You don’t have to be a visionary you can go to the meetings, talk to others, read the literature, and it will tell you what’s going to happen. And then you make the decision whether you want to move in that direction. That’s basically the way and the way I did a lot of that.
Once you make that decision yourself then the work begins because you have to convince X number of other physicians to move in that. And most physicians do not like change. It’s quite difficult to move a group in a direction for something new such as a new building to allow you to provide better care or an endoscopic ASC… “oh my how are we going to pay? But what about insurance? What about the risk? What about the lawyers?” So, you’ve got to have good leadership within the practice. You’ve got to have good leadership within the management staff and they have to be helping you lead the practice in the direction you want to take it. So, it’s a challenge and it takes time but the reward at the end of the day is good in terms of patient care and economics.
Praveen Suthrum: How did you get alignment with other physicians how did you make sure that everybody goes in the direction of the vision of the organization or even beyond and you can ask that question even at an industry level?
Dr. Bergein Overholt: That’s a very difficult thing to do. If you have a group of 10 physicians there’ll be two or maybe three in that group that are willing to move with change and understand that you need to make a change to keep up and stay ahead of the future. You use those physicians. You convince them of the idea and then collectively together you change the rest of them. And it usually comes down to if you have 10… an eight to two vote in favor of change and you drag the others kicking into the change and then about a year later they say, “What a great idea we all had!” That’s a difficult thing to do… to convince physicians and think in a different direction.
Praveen Suthrum: What advice do you have for early-stage gastroenterologists who might be entering the field today?
Dr. Bergein Overholt: I would step back a few years earlier and it’s very important that a doctor gets the very best training that they can. Then you enter into a practice that has physicians and staff that put the patient first. Always put the patient first. Honor your spouse and take time for your family you must do those things… those things are your life and they’ll be with you for your life and you need to be sure that you spend a good time with them.
One of the most important things is when you enter into practice the physicians you associate with will determine great part the direction that you and your practice will take. The second and probably certainly the second most important thing is the quality of the staff. You want to have the very best staff that you can because second to your training and your practice the single most important thing to your success is the quality of your staff. Put the time, and put the money into developing that. Those people… they will make you or break you and you want the best that you can get.
Praveen Suthrum: I want to get to my final question, Dr. Overholt. So, if you reflect back on the time when your father was in medicine and when you entered medicine and look at the healthcare system then and compare it to what we have today. I’m wondering are we better off or worse off and in what ways?
Dr. Bergein Overholt: Praveen, in some ways we’re better off in some ways we’re not. There’s too much attention on making money, there is too much of leaving the decisions up to technology and testing. We used to be able to sit down with the patient and talk to them for a few minutes and listen, truly listen. And 80% of the time you come up with a diagnosis by just listening to the patient. They’ll tell you what their diagnosis is. Now, it’s a few words and order to test and we rely too much on testing. Now, there are a number of reasons for that. Some of it’s the pressure time, for some of us it’s the legal pressure, and some of it is income pressure.
We’re better off in that we can provide a higher level of diagnostic and therapeutic care to patients. So, there are improvements that have occurred. I mean we can do things now that weren’t even thought about back when I started practice but we have tended to lose the one-on-one with the patient. My dad taught me, and I used it my entire career and I think it was the right thing to do. He said, “Wear a positive attitude and walk into that patient’s room with a little smile on your face. Sit down and talk and listen to the patient and while you’re in there, always appropriately, always put your hand on the patient. An encouraging hand on the shoulder, an examination of the abdomen, those are very comforting things to do with patients that they know and they feel that you are focusing on them and taking care of them.” So, to answer your question, there are pluses and minuses. We’re better off in certain areas we can provide more advanced care but we’re not better off in terms of personal care. I think there’s too much reliance on technology.
Praveen Suthrum: Thank you, Dr. Overholt. This was fantastic and thanks for sharing uh the history and your views on where GI practices can go from here both were tremendously insightful. Were there any final thoughts that you wish to share before we close?
Dr. Bergein Overholt: Yes and there are a few for the new physicians and one of the words of advice is always do the right thing and the right thing is what’s best for the patient. That should be right in the front of your mind every time you’re thinking about a decision for a patient. So, thank you for the opportunity. I have been retired for three years I miss the practice of medicine primarily the aspect of dealing with patients one-on-one. I don’t miss the rest of it.
Praveen Suthrum: Thank you so much Dr. Overholt it was very nice talking to you, thank you.
Dr. Bergein Overholt: Alright!
By Praveen Suthrum, President & Co-Founder, NextServices.