"My belief is that together we can once again make American medicine great again." - Dr. Robert Pearl
Dr. Robert Pearl joins Shireen to discuss physician culture, improvements that can be made to it, and questions to ask your doctor.
Dr. Pearl is a Forbes healthcare contributor, the former CEO of The Permanente Medical Group, a best-selling author, and a Stanford Medical School and Business School professor. He is also the host of two healthcare podcasts: “Fixing Healthcare” and “Coronavirus: The Truth.” His new book “Uncaring: How the Culture of Medicine Kills Doctors & Patients” is available for presale.
Shireen: Podcasting from Dallas, Texas I’m Shireen. And this is the Yumlish podcast. Yumlish is working to empower you to take charge of your health through diet and exercise, and reduce the risk of chronic conditions, like type two diabetes and heart disease. Through amplifying the voices of healthcare professionals, educators, and communities, we hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.
Dr. Robert Pearl is a former CEO of the Permanente medical group. He’s a Forbes, healthcare contributor, bestselling author, Stanford medical school and business school professor, and the host of two healthcare podcasts: Fixing Healthcare and Coronavirus:The Truth. Dr. Pearl’s next book, “Uncaring: How the Culture of Medicine Kills Doctors and Patients” is available for presale now, and all profits for the book go to Doctors Without Borders. Welcome, Dr. Pearl.
Dr. Pearl: Thank you so much for having me today. It’s really a privilege and a pleasure.
Shireen: A pleasure having you on. So I want to, I want to start right out by asking you what really brought you to the medical field?
Dr. Pearl: I went to college to be a university professor. And in my freshmen year, my hero, who is a very excellent professor, went on to become chairman at Reed failed to get tenure. And he didn’t get tenure, not because of his academic excellence, but because of his political views. And it’s so strange in retrospect, having been a CEO and having been so long involved in healthcare, I went into medicine to avoid politics. I decided that this was life and death. I mean how could the healthcare system be anything except scientific and objective? And I went on to Yale medical school then to Stanford for my residency. And I was certain that I had found the perfect perfection – profession, but of course, I did discover that there is a little bit of politics, at least in medicine.
Shireen: Lovely. Can you tell us a little bit more about the physician culture you have experienced? Can you elaborate a little bit?
Dr. Pearl: Let me start for the listeners with the notion of “what is culture?” as the values, the beliefs, the norms. The doctors learn in medical school and residency and carry with them across their entire career. Culture can do amazingly positive things. You know, during the Coronavirus era, you had doctors working 12 and 24 hours a day. Where there’s not protective gowns, they put on garbage sacks. Yeah, plastic garbage containers. When they didn’t have N-95 masks, they put on salad lids. When they had a patient who couldn’t breathe, they passed a tube through the mouth into the lung, knowing that the patient would cough, spewing virus in their face. They did it anyway. When two patients needed a ventilator, there was only one. They figured out how to put two people on one machine: Something that had never been not only not done – never been considered before.
The culture is really a very positive side. And yet what we see is that the culture of medicine is equally problematic. You know, what we saw in, in the Coronavirus here was that 88% of people who died at two or more chronic diseases. And we do a terrible job in the United States of prevention and avoidance of complication of chronic disease. We just don’t value it. You know, when I think about the culture, I go back to 1850, Ignaz Semmelweis is appointed the head of the delivery service at the leading hospital in Vienna, Austria. At the time, the mortality of women is 18% associated with childbirth, and he’s embarrassed that the neighboring facility, one run by nurse midwives, has a mortality that’s two-thirds lower.
Very much like my interest into medicine as serendipity, a colleague of Semmelweis’ nicks his finger, and goes on to develop a course that’s similar to the women that died. It was a common reason that women died, was called puerperal fever, an infection of the uterus that spread to the entire body. And the belief was that it came from miasmas, smelly particles wasting up from the streets, but he thinks about it. Why should the women laboring in the facility run by the nurse, midwives not die as often? And why should his colleague, who nicked his finger, why should he go on to develop the same basic condition?
So, Semmelweis introduces the idea that says something’s being carried from the autopsy room to the delivery room in his academic hospital, and he says it could be the hands of the doctors. So we’ll dip the hands in chlorinated water and it could be the leather aprons that they wear to cover their well-pressed three piece suits. So we’ll change it each time. Lo and behold, mortality drops from 80% to 2%, to 2%. He publishes his data. Guess what happens? Nothing.
No one changes practices. He ends up dying in a psychiatric facility, four years later, alone and isolated. Now the important part for listeners to think about why do these doctors not embrace these approaches that could have saved tens of thousands of lives? Usual explanations we give is “well it’s expensive.” There’s no expense involved. Just putting on a clean apron and dip your hands in chlorinated water, or a lot of time – wasn’t much time either. That’s why I came up with this idea that it had to be something else, something invisible, and that’s the culture of medicine, the physician culture, you see doctors who see themselves as healers, the idea that they could be carrying disease.
That’s not acceptable in the notion that’s there. These leather aprons, the more pus, the more blood, the more experience, the higher, the status of doctors. To give all that up was something that the culture limited the change from happening. Now, I know a lot of listeners are saying, okay, it’s 1850. Why are you telling this story? Because today in 2021, the leading cause of death in American hospitals is hospital-acquired infection. The organism is called Clostridium difficile (C. diff.). And unlike the Coronavirus, it doesn’t travel through the air.
It’s only carried in the hands of people, and yet one in three times when doctors go from one patient room to the next, they don’t wash their hands, no cost with alcohol-based disinfectants, no time. How do we explain this? When we know that this is the leading cause of death, the fourth, most common cause of death amongst all causes in the United States today. It’s the same culture of medicine. It’s a culture that has persisted from the past. It’s a culture that says doctors are healers. We can cut corners. We can’t be the source of disease and, when a patient dies, it’s always in the mind of a physician, someone else. That’s why I call the book “Uncaring: How the Culture of Medicine Kills Doctors and Patients.”
Shireen: What are some of the methods that you pro – that you propose to improve this culture in the medical field?
Dr. Pearl: One of the important parts of the book is the intersection and entwining of culture and systemic issues. The first book that I wrote “Mistreated: Why We Think We’re Getting Good Health Care and Why We’re Usually Wrong,” focused on these systemic issues: the very problematic insurance industry with all of the restrictions that are placed on physicians and other clinicians, the uh, self-centered pharmaceutical world, able to raise prices without adding much value as they either introduce new drugs or bringing ones in from the past, the electronic health record that literally comes between doctors and patients. These are the systemic issues. But when you dive levels deeper and you look at the problems, which you see is that there are other issues that actually come from inside the system of medicine inside the, sorry, inside the culture of medicine, in addition, to inside the system of medicine.
And so, the book is designed to help people see this interplay. You know, if we look at the post Coronavirus era, what’s going to happen in the future? What we see is that coming out of this current time period, the United States will have borrowed about $8 trillion. Uh, it has to repay that money and repay it with interest. The states will have by law have to have a balanced budget. And the states are going to find themselves with higher costs for unemployment, for Medicaid, lower tax revenue, Lusher, a state that has Google and Netflix and Amazon and Apple, uh, the small businesses, which are really the engine of employment, 150 million people being employed by a small and medium-sized business. They will have burned through all of their reserves.
There’s going to be this push to lower the cost of healthcare. We’re there to push, because we had a push for many, many years. It’s now going to become a necessity, because if you can’t afford to pay for something, you simply can’t buy it, no matter how would you might value it. And if you look to ask, how are we going to address the problem? Obviously, what we have to do is move from a FIFA service-type system, one in which if prices come down utilization go up and the cost can become even higher to one, in which the cost, the total dollar spent can be predicted and limited.
There’s only two ways you can do that. You can do that by rationing. Tell people you’re going to be too old to get heart surgery or a total joint replacement. Tell them, the drug you want to use might be better than any other drug, but just simply cost too much. Or if you need a routine problem, get online, get in the queue. Whenever we get to you, we’re going to get you, or we can transform how healthcare is delivered. And if you get transform it, you’re going to start by making a single large payment. We call it “capitation,” technically, but thinking about a group of doctors in a hospital, working together, taking care of a population and be given a certain amount of money with expectations, and that it can be measured around quality, access, and patient satisfaction. When you start to have that model, now that the doctors in the hospitals come together and they ask different questions that they might’ve asked before. And this, to my way of thinking, is how this culture starts to evolve. Number one, you start to focus on prevention. Right now in the culture of medicine, what do we elevate to the top? Intervention.
You know, the doctor who prevents the heart attack, or prevents the heart vessels from blocking off, that person is lower down than the doctor who unblocks it, even though the number of lives that are saved through prevention is going to be so much greater, avoids of complications from chronic disease, from problems like diabetes, investing in lifestyle changes, investing in diets, investing in ways to help patients, uh, better monitor and better measure their health status and be able to do intervention. You start to value those things: patient’s safety, avoiding the need to do amputations of limbs and to unblock car vessels, to the brain, into the heart. All the things that are associated with a disease like diabetes is the type of action that starts to become more valued in the minds of people who were are in a capitated system with the appropriate measurements that are going to be coming out of it. And that’s where the culture starts to change. You collaborate more, you cooperate more.
I mean, it’s remarkable to me, telemedicine, you know, 7 years ago, I published an article in health affairs where I pointed out that 30% of what’s done in doctor’s office offices could be done virtually. I pointed out that in Kaiser Permanente at the time, when I was CEO, 14 million virtual visits of reading done a year, and I expected, probably like Semmelweis, that immediately everyone would embrace this idea and start to use telemedicine and six and a half years later, 1 or 2%. And then the coronavirus comes, and what do we see? Telemedicine starts replacing so much of what we do because the new context is that you have doctors that have to close their office, ‘cause they and their staff don’t want to get sick from this virus, that we don’t understand and don’t have any treatments for.
And so they embraced telemedicine and having embraced it, they start to offer care that is more convenient, care that can be delivered to the patient’s home, care that doesn’t require the patient to come to the doctor’s office, See, in the culture of medicine, at the top of that hierarchy is the doctor’s office. And again, it’s interesting to me to think about the cultural aspects of the language we use.I mean, imagine the fact that we have waiting rooms, these are places designed to make patients wait, what do we call it? Reception areas? But why don’t we call it, uh, some kind of greeting place, orientation or education? No, we call it a waiting area because that’s the culture of the structure that sits in place.
As a consequence of that, what we see, I believe, is that the patients are not treated the way they should be treated. And we’ve seen inside medicine we’ve seen in primary care, which is near the bottom of the hierarchy in medicine, even though the data says that you add 10 primary care physicians to a community, you extend longevity by two and a half times more than if you add 10 specialists. In the culture of medicine, we ignore issues around racism. You know, most physicians will tell you that “I’m not racist. I treat everyone the same.”
And then you look at the data, which you see in early in the Coronavirus pandemic, what you saw is that if two patients came to the “EDue” with identical symptoms, the white patient got tested twice as often as the black patients, and if they had a procedure done, the black patient got 40% less pain medication. And you see three times higher mortality, except when the attending physician is a black physician. We have a culture that makes physicians blind to the things that are happening. It means they lower the importance, the value of patients convenience, the patients time – we talked about the waiting area – and I’m hopeful that in the postcard quarter virus era, that this change is going to happen. It’s not going to be easy.
It’s – Doctors will go through the Kubler-Ross five stages of grief, of loss. You know, first, they’ll get a, they’ll be in denial that it’s necessary, probably where a lot of them are today and they’ll become angry when they have to change. Then they’ll bargain. Okay. I’ll do the prevention on Monday, Wednesday, and Friday, but Tuesday and Thursday I’ll do what’s really valuable to me, really important. Then I’ll get depressed and finally, they’ll get to acceptance. And I’m hoping at that particular time period, that’s when this change in the culture’s going to start to happen. And if they need another motivation around it, I’ll point out to listeners, a company called Amazon.
You know, three years ago, Amazon Berkshire Hathaway, JP Morgan Chase came together to form Haven. At the time, I said to people that although the three CEOs are promising this would be a not-for-profit venture only for their 1 million employees, if you want to believe that you probably think that all Amazon does is sell books. Now, this is going to be an attempt to take over one-sixth of healthcare the same way that Amazon has one-sixth of retail, and I think that that’s going to be the alternative path that’s there. And I’m hopeful that this evolution of both the system of medicine and the culture of medicine will be led by clinicians, encouraged by patients for the greater good of all.
Shireen: Talking about encouraging, uh, you know, by, by patients, what are some questions that patients can ask today from their doctors to make sure that they’re getting the quality of care that they truly deserve?
Dr. Pearl: So in the book “Uncaring: How The Culture of Medicine Kills Doctors and Patients,” I have an entire chapter on the nine questions that patients, like nine-category of questions patients should as, and given the time that we have, let me just mention three of them. So if the patient has what I will call an acute problem and not a serious one, then the kinds of questions should be about convenience. They see the physician. The physician says I need to see you in a week. Can I text or email instead? Can I set up a video visit? What is it that you’re trying to find out? Cause maybe I can provide the information for you in an easier, simpler form. And if the doctor’s not able to give individuals the same convenience and medicine that they would demand in retail and travel in the hotel industry, they may want to consider having a different set of physicians.
The second set of problems is when they have a more serious illness and they need a procedure done. And now the questions really have to be, how many of these did you do last year? If you, or a family member, or a loved one, needed to have this procedure done? What’s the minimum number that you would demand that a physician have done before we let him or her do the procedure on you?
You know, you could fill out an informed consent and list every possible complication. What’s the most serious complication you’ve created? And if it’s operation, does it have a 90% chance of success or a 10% chance of success? Is the chance of a complication 90% or 10%? You deserve the answers before undergoing an operation or procedure that could potentially risk your life.
And then finally, for people who now get, I’ll say towards the terminal end of their life, they might have heart disease, heart failure, that’s required three or four hospitalizations or lung failure that’s required three or four hospitalizations, maybe it’s cancer for which they’ve had chemotherapy, multiple different agents. And now they’ve expended through all the ones that are available. And now, they need to be asking the questions: What are going to be my choices, now that we’re approaching the end of life? How confident should I be that you can control my pain? And maybe the most significant question of all: Is that where the point comes that I decide that I don’t want any more aggressive treatments, will you be there for me or will you desert me?
You know, in my first book “Mistreated,” I talked about my dad who died from medical error. And I talked about the fact that all the systemic reasons could have saved him: A better electronic health record, greater coordination across physicians, a greater focus on making sure that all the pieces were done. It’s also the culture elements: valuing patient safety, valuing prevention, but I speak at the end of the book about my dad’s last days. When he’s in the hospital, he has a bleed into his brain.
My brother and I raced there. My sister’s already at the hospital in Florida, and there’s my dad intubated with a tube through his mouth, into his lung, a tube through his nose into his stomach, a line of doctors out the door. There’s the ENT doctor wants to do the tracheostomy. There’s the – a GI doctor wants to put in a feeding tube, then the neurosurgeon wants to take out a piece of my dad’s skull, so his brain can expand. My brother’s a physician. And I both look at the x-rays. We say, my dad’s not getting better. This is not what he wants. And so we say to them, thank you so much, but we’d prefer that he not get any additional intervention. The two and a half days, we never see another physician. You see, in the physician culture, if you can’t intervene, then the problem is not particularly important, and a family grieving for the upcoming loss of a father just as not that important, it should be. It used to be, it needs to be once again.
Shireen: With that, Dr. Pearl, thank you so much for sharing that. With that, I really want to thank you for your time and for sharing this information, and for putting this book out there again, the name of the book is “Uncaring: How The Culture of Medicine Kills Doctors and Patients.” It is available for pre-sale. All proceeds go to doctors without borders. Thank you so much, Dr. Pearl for your time. Just one last question for you: How can our listeners connect with you and learn more about your work?
Dr. Pearl: Well, thank you so much for hosting this podcast. Anyone who wants more information can go to my website, robertpearlmd.com, and they can find information about the book, but find also a lot of other information. I write for Forbes twice every month. Uh, they can find out information from the podcast that you mentioned that I do, uh. My belief is that together, we can once again, make American medicine great again, uh, make it the best in the world once again, which is not today, it’s too expensive. The quality compared to other countries is not as good. We need to change the system of medicine, and we need to change the culture of medicine. And I’m hoping that people will read the book, understand what needs to happen and that together we can march forward, to make American medicine once again the best in the world. So thank you so much for hosting the show today.
Shireen: Thank you. And to our listeners, we will see you on social media and continue the conversation there. Thank you for joining us today and we’ll see you on the next one. Thank you for listening to the Yumlish podcast. Make sure to follow us on social media: @Yumlish_ on Instagram and Twitter and @Yumlishon Facebook and LinkedIn for tips about managing your diabetes or other chronic conditions. You can also visit our website Yumlish.com for even more information, and to get involved with all of the exciting opportunities Yumlish has to offer.
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