In an era when viewers can click off in a million directions, how do you connect with your audience to make your work "stick"? It's a question that's been on my mind as the California Health Care Foundation works to leverage nearly two decades of expertise in health policy to connect more deeply with audiences old and new.
I recently spoke with someone who reaches audiences in a dramatically different way. Dr. Zubin Damania is a former Stanford hospitalist who two years ago was lured to Las Vegas by Tony Hsieh, founder of the online shoe retailer Zappos, to create a more effective, caring model for American primary care. By day he is CEO of Turntable Health in Las Vegas. By night, he morphs into ZDoggMD, a raucous hip-hop video parodist with a medical bent. ZDogg has two g's, he said, because one isn't "gangster enough."
Damania sees his ZDogg character as a "bizarro Atul Gawande." Where Dr. Gawande is earnest and empathetic, ZDogg is brash and self-absorbed, akin to Sasha Baron Cohen's hysterical Ali G. The parallels between Drs. Damania and Gawande don't end there. Both were raised in immigrant Indian-American families in small towns by doctor parents and have a keen knowledge and love of music. And both have managed to maintain an inside-out perspective: Their insider status affords them credibility with other clinicians, while their outsider perspective — perhaps forged by being raised by relatively recent immigrants — enables them to keenly comment on what's not working.
Mad as Hell
Damania told me that ZDoggMD was born in 2010 out of his frustration with the "worst parts of the health care system, the part that turns clinicians and patients against each other" and that ends up "doing stuff to patients instead of for patients." Ten years of internal medicine practice left him burnt out and disconnected from why he became a doctor in the first place. Like so many others who struggle within dysfunctional systems, he felt powerless to change it.
Yet instead of following the lead of Peter Finch in the movie Network and yelling, "I'm mad as hell, and I'm not going to take it anymore," he created ZDoggMD, an alter ego based on one of his favorite artists from the '90s, Snoop Dogg. Damania also credits "Weird Al" Yankovic, who rose to fame with his parody of Michael Jackson's "Beat It," as an influence.
ZDogg allowed Damania to safely channel his alienation — to say things that he couldn't or wouldn't say professionally. Most importantly, it allowed him to get in touch with his wildly creative id. In the serious world of health care, where the stakes can be truly life and death, it's often overlooked that even docs, with apologies to Cyndi Lauper, just want to have fun. And boy, does Damania as ZDoggMD appear to be having fun.
Check out "Readmission," a parody of R. Kelly's R&B song "Ignition." The song deals with hospital readmissions, a serious subject with repercussions for patients and hospital employees up and down the food chain. It doesn't matter whether you are unfamiliar with the original song. The lyrics are specific to life as a hospitalist. And besides, he totally looks the part, sporting a ridiculous white fur coat over his scrubs.
Here's a sample of the darkly funny lyrics:
It's just one more readmission
No love from the Joint Commission
Cause my one-day prednisone taper
Is probably why her colon's now missin'.
Damania works on the videos with Dr. Harry Duh, a longtime friend from UCSF Medical School and Kaiser Redwood City pediatrician, to brainstorm topics like low platelet counts, bad skin, or the merits of the HPV vaccine. Then they get to work writing the often-hysterical lyrics. The videos, which enlist a rotating cast of colleagues as extras, are shot for free in an unidentified Las Vegas hospital. None of this would be possible, he said, without the advent of inexpensive editing software and YouTube.
"Ain't the Way to Die," based on the Eminem/Rihanna hit "Love the Way You Lie," is by far ZDogg's strongest video. It was also my entry point into his work; the video started making the rounds at the foundation about six months ago. Unlike his other videos, he didn't play this one for laughs. Damania said he intended to make it into a parody until he was talked out of it by friends and colleagues arguing that the subject matter demanded he play it straight.
The result is moving and plaintive, aided by the power and emotion of the original Eminem song. Here are ZDogg's lyrics, from the patient's perspective:
I can't tell you what I really want
You can only guess what it feels like
And right now it's a steel knife in my windpipe
I can't breathe but ya still fight 'cause ya can fight
Long as the wrong's done right — protocol's tight
High off of drugs, try to sedate
I'm like a pincushion, I hate it, the more I suffer
Why do "Readmission" and "Ain't the Way to Die," which have nearly 1.3 million and 252,000 views on YouTube, respectively, resonate with clinicians? Damania thinks it's because he channels their frustrations.
Case in point: I showed "Readmission" to my wife, a geriatrician, and she immediately asked me to send it to her so she could share it with all her colleagues. That ability to connect with health care professionals could be why they are now coming from around the country to perform in his videos, many on their vacation time (hey, it's Vegas, baby).
Two Turntables and a Microphone
When he's not playing a hip-hop video artist, Damania has a serious job at Turntable Health. His goal is "relationship-based" care that keeps people healthier by focusing on prevention. Turntable provides unlimited access to primary care to reduce trips to specialists that result in costly, often unnecessary procedures.
Because patients pay a flat monthly fee for care, the clinic has a financial incentive to keep people healthy, as opposed to insurance-based models, where providers have a financial incentive to see more patients, make referrals, and order procedures without regard to outcomes. Should patients require treatment beyond the scope of primary care, clinic staff will help coordinate referrals and specialty care. The secret sauce, he says, is employing health coaches who encourage patients to stick with the program.
According to Damania, Turntable has logged impressive outcomes with its patients. Hypertension, diabetes, smoking cessation, weight loss all improved in the sick population they studied in the course of a year. Prescription drug spending went up, he said, "because people are actually compliant with medication, and they're filling their prescriptions."
The question is whether they can attract enough patients to succeed. The insurance plan Nevada Health Co-op, a source of patients for Turntable, recently announced that it was closing due to insolvency. Even if Turntable is not sustainable, Damania sees it as a workable model for innovative primary care experiments in other states. "This model is going to spread, and that's the wonderful thing about it," he said. "And so even if Vegas goes down in the books as, okay, that was the proving ground for it and we failed, I'll still be thrilled."
Not Afraid to Fail
What I most admire about Damania is his fearlessness, whether to re-imagine a better form of primary care at Turntable, or as his rapping alter ego ZDoggMD. This willingness to take creative risks offers a lesson for organizations that possess credibility with their audiences, but may be reluctant to reach them emotionally. Facts will always remain important, but social change won't occur without a deeper connection.
The California Health Care Foundation is starting to do this with recent projects, such as funding 55 screenings of the PBS Frontline documentary "Being Mortal." In communities across California, each presentation was followed by conversations about end-of-life care decisionmaking.
Damania acknowledges that he wants to reach a much wider public with his work, not just clinicians. Thus far, even his videos with an explicit public health message, like "More Than Warts" about the dangers of HPV, haven't yet broken through to a mass audience. Now he is developing a YouTube show in which he plans to be more Dr. Damania and less ZDogg (think Stephen Colbert on The Late Show versus the old Colbert Report). "It's going to predominantly be Zubin Damania mixed with ZDogg," Damania said. "Because I think ZDogg gets tiring. There's a cheesiness about him that was fun in the beginning, but now we want to try to get a little bit more serious."
Over on the ZDogg side, his latest video project is a sendup of electronic health records. He's got a five-figure production budget from an EHR vendor that's willing to be associated with the slings and arrows of parody because ZDogg reaches its desired audience. Considering how good his previous videos have been on a shoestring budget, I'm looking forward to seeing what he can do with greater resources.
Check out the full range of ZDoggMD videos.