It’s time we stopped ignoring the deadly invisible elephant in the room: our dysfunctional and outdated physician culture.

Dr. Pearl’s new book, Uncaring: How The Culture Of Medicine Kills Doctors And Patients, is a MUST-READ and can be pre-ordered (with special free extras) now here. All proceeds go to Doctors Without Borders.

Here’s our other show with Robbie where we discussed his prior book, Mistreated.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group (1999-2017), the nation’s largest medical group, and former president of The Mid-Atlantic Permanente Medical Group (2009-2017). In these roles he led 10,000 physicians, 38,000 staff and was responsible for the nationally recognized medical care of 5 million Kaiser Permanente members on the west and east coasts. 

Named one of Modern Healthcare’s 50 most influential physician leaders, Pearl is an advocate for the power of integrated, prepaid, technologically advanced and physician-led healthcare delivery.

He serves as a clinical professor of plastic surgery at Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business, where he teaches courses on strategy and leadership, and lectures on information technology and health care policy.

Dr. Pearl hosts the popular podcasts Fixing Healthcare and Coronavirus: The Truth. He publishes a newsletter with over 12,000 subscribers called Monthly Musings on American Healthcare and is a regular contributor to Forbes.

Full Transcript Below

 

Chapters

0:00 Intro
6:33 Medical culture and why it matters
15:00 Medical school begins this culture
19:22 Culture of medicine that looks down on primary and preventative care services
23:29 Status in the culture of medicine
40:35 Small and medium-sized businesses struggle through the Pandemic
44:02 Physicians, watch what Amazon is doing
51:02 Breaking through what has been lost in medicine
58:15 When patients want to stop care, will their doctors stand by them?
1:06 What to ask yourself when working in healthcare
1:10 Summary of show

 

Dr. Z: Hey guys, Dr. Zubin Damania. Welcome to The ZDoggMD Show. Dr. Robbie Pearl is here. Robbie, you’ve been on this show before, just introduce yourself real quick for the homies who don’t know.

Dr. Pearl: I’m a surgeon, went to medical school at Yale, then came out to Stanford where I learned how to fix cleft lip and cleft palate. I then went on to Kaiser Permanente, where I worked taking care of patients until I became the CEO. And then after 18 years as the CEO in Kaiser Permanente, I wrote a book called, Mistreated: Why We Think We’re Getting Good Health Care and Why We’re Usually Wrong. I had the chance to be on your show when you were still in Las Vegas and was a Washington Post best-seller. I got ahead of Condoleezza Rice but didn’t catch President Obama. And now I have another book called, Uncaring: How the Culture of Medicine Kills Doctors and Patients, and I can’t wait to talk with you about it today. I’ve been looking forward to this since we were in Las Vegas together.

Dr. Z: You know, there’s a reason, I let you do your own introduction, ’cause you have such a presence about that, Dr. Robert Pearl, aka Robbie. So look, man, I’ve been looking forward to this since we talked the first time. Your first book, Mistreated, now look, for people who don’t really know, two decades at the helm of the Permanente Medical Group, you know, thousands of doctors, three million-odd patients under your care, and you were a physician leader. All that experience culminated in your first book, Mistreated, which was about how we think we’re getting the best healthcare in the world, and we’re really not, and here’s a prescription of how to make it better. And we talked about that book, and I’ll link to it. But this book that you just wrote that I read, Uncaring, that we’ll link, too. By the way, all the proceeds from your books go to Doctors Without Borders. So you’re not just selling books-

Dr. Pearl: That is correct.

Dr. Z: You’re here selling ideas, selling change, selling introspection in this book. This book, Uncaring, takes the lens of our concern as doctors, oh, we’re always projecting, all these things are pulling us down and we’re morally injured and we’re miserable and burned out and so on, and it turns it back and goes, let’s look at the culture of medicine, where it’s beautiful and where it’s tragic. And when we understand it, we can get through the denial and the weirdness that really has us locked into suffering, not just for us, but for patients. And I read it with the usual skepticism I read when a doctor writes a book, and I came out going, this is absolutely must reading. You may not agree with everything in it. It’s gonna trigger you, especially if you’re a doctor, but it’s absolutely must reading. I mean, well, why did you even decide to write this book after all this time?

Dr. Pearl: I wrote Mistreated because I was very aware of the systemic issues that existed. The reimbursement system, paying in a piecemeal, 19th-century cottage industry kind of way, the fragmentation, technology leftover from the last century. Oh no, no, the century before, ’cause it was the fax machine that was the most common thing that people used, and a complete lack of leadership structure. And then I realized as I went around that there was more, because if that’s all it was, we would have changed.

Dr. Z: Yeah.

Dr. Pearl: And I wanted to know, what else was there? And I did research and I looked at my own experience, and Uncaring: How the Culture of Medicine Kills Doctors and Patients was the outcome. And by the way, for any of your viewers who pre-order the book before May 18th, they’ll get four freebies. They’ll get a signed book plate, they’ll get a discussion guide, they’ll get a reading list, and they’ll get a chance to review and watch and read the introductory chapter, one you’ve read, but they have not read. And then on May 18th, it will be delivered to their home.

Dr. Z: Look at you. This is the other life you live Robbie Pearl, which is faculty at the Stanford School of Business, where you teach as well.

Dr. Pearl: Yes.

Dr. Pearl: Both at the business school and the medical school-

Dr. Z: And the medical school.

Dr. Pearl: But I have studied marketing a little bit, and hopefully, this approach will work. But I also hope that it will lead to discussions. I mean, I created this discussion guide ’cause I’m hoping that book groups will look at this, because, as you know, in the end, ideas are just ideas.

Dr. Z: Yeah.

Dr. Pearl: But what has to happen is people translating them into action, and much of that is by getting a broader audience. It’s why you’re so successful. Your audience is broad and diverse. They engage in conversation, and out of that comes the best, best ideas and best way to move forward and progress happens.

Dr. Z: I love it. You know, and again, I get very philosophical about this book because I read it. And, again, like I said, I’m very resistant to physician books, ’cause generally, they suck. And yours, I read because it came from an interesting duality. It came from somebody who is passionate about medicine as a practitioner. You’re a plastic surgeon, the cleft lips, cleft palates, you’re passionate about global surgery, helping people in underprivileged places to get care. This is one of your passions. Then on top, so you’re a practitioner, you have this philanthropic component, but then you have the leading of one of the largest integrated health systems in this country for two decades, and all that experience being on what the white coats call the dark side. So the leadership, administration, business, also practicing medicine side, and that folds into the book in a way that gives it a kind of a unique perspective and credibility, which I think is very important. Like I wouldn’t be able to talk about the issues I talk about if I hadn’t run a clinic for three years and then failed. I don’t think you could have written this book, had you not had, and because you draw from those stories. And some of them are heartbreaking stories, Robbie. I have to say, don’t read this book if you don’t wanna at least cry twice, because that’s what happened to me. And it takes a lot to make me cry these days because I’m a jaded doctor, but I mean, the stories in there, not just the physicians who suffer, but patients who suffer and, you know, holding the hand of a 10 year old. I mean, that’s what humanizes it, but then the truth is it’s a scathing indictment of something that we as the fish don’t even recognize, which is the very water we swim in in healthcare, which is our culture. Can you talk a little bit about that aspect of it, the medical culture and why it matters?

Dr. Pearl: Let me offer two thoughts. The first one is that I hope readers will come away recognizing that I both praise and point out the gaps in that physician culture. At the end, you may remember reading about my mom and my dad. My dad, who worshiped my mother, she could make not the slightest mistake. To the day he died, he would have traded his arms, his legs for a couple more days with her. And my mother who recognized that my dad wasn’t perfect. And that is how I sort of see my evolution early on. I went into medicine ’cause I was sure it was about human life. I mean, there would be no politics. I literally went in to avoid politics. I mean, if you live or die, I mean, what could be more real, more easy to calculate. And, of course, I discovered a different piece. And so I write about both parts. I write about the positive ones that we saw during COVID-19. And I also write about what I think are the parts that are not being talked about, the invisible pieces. As you know, I start by describing Ignaz Semmelweis.

Dr. Z: The famous Ignaz who-

Dr. Pearl: A physician in Vienna, Austria. He’s appointed the head of the Maternity Unit, and he’s appalled. 18% of the women are dying, but that’s not really what he’s most appalled by. The next hospital over run by nurse midwives…

Dr. Z: Heaven forbid.

Dr. Pearl: Two-thirds lower mortality.

Dr. Z: Uh-oh.

Dr. Pearl: He’s gotta figure this out. As you know, at the time, they didn’t have any infectious disease. Pasteur would not come around for 50 more years. And they thought that the cause of death, which by the way, was puerperal fever, intense infection of the uterus spreading across and around the body was caused by miasmas, smelly particles that wafted up from the underlying streets. Exactly, yes, yeah.

Dr. Z: No comment.

Dr. Pearl: And as you know, in healthcare, we often make advances through serendipity. A colleague nicks his fingers doing an autopsy on a woman who had died from puerperal fever. And lo and behold, he gets a local abscess systemic disease and he dies with what appears to be an identical clinical course. And he hypothesizes, that’s what we do well in medicine, right? We come up with a hypotheses and then we wanna test them. He hypothesizes that somehow the doctors who are doing the autopsy carry something, either on their hands or the leather aprons they wear to protect their well-pressed, three-piece suits into the delivery area. So he requires they change their aprons and dip their hands in chlorinated water. Lo and behold, what happens? Mortality drops 18% down to under 2%. He publishes it. He sends letters to the maternity units around the world, and guess what happens?

[Both] Nothing.

Dr. Z: ‘Cause this is medicine.

Dr. Pearl: Exactly. Because, and that’s the question for the viewers and the listeners, why would you hypothesize that nothing changed?

Dr. Z: Now, I know the punchline to this-

Dr. Pearl: Yeah.

Dr. Z: Because I love this story as an example of how really our culture holds us back. It’s a conditioning and it is a, even just to define culture and my definition of it is, it is an adaptation that a people or a group or a tribe use to their environment that allows them to get by. And in this environment, you have an establishment group of physicians who are at the top of a hierarchy, which they have established saying, wait, why are these midwives and nurses having lower… And they go, oh, I don’t know. It’s not us though, because we get to wear the aprons covered in blood and pus that show that we’ve been doing stuff, that we are awesome experts. And now you’re telling me that it is I that is spreading the disease and killing these women? No. Immediate shutdown, immediate denial, and then project onto Semmelweis, You’re a quack. You’re crazy. How dare you. Get out. And that’s, I think, roughly what happened.

Dr. Pearl: And he ends up four years later in a mental hospital where he dies alone with his theories having been rejected, and tens of thousands of women die as a consequence, because it is the bacteria that would be discovered by Pasteur, obviously, sitting on the blood and pus on the leather aprons, the ones that give them so much prestige, and on the hands of the individuals as they fail to wash them between the autopsy room. And why I think the story is so amazing is that it’s not a story of pre-Pasteur, 1850 Austria.

Dr. Z: It’s a story of now.

Dr. Pearl: It’s a story of now. The number one cause of death in hospitals is hospital-acquired infections. It’s C. difficile. We know it doesn’t travel through the air like coronavirus, it’s carried. And we know that one out of three times, when doctors go from one patient’s room to the next, they don’t wash their hands and they can no more see themselves as capable of causing disease as Semmelweis’ colleagues were at the time. And in both cases, and this is what I want viewers to recognize, there was no financial costs, either today to washing your hands or dipping them in alcohol disinfectant, or back in his time, changing the apron or doing whatever we wanna do today to clean the hands. And, yet, the right thing doesn’t happen because of the culture, the values, the beliefs, the norms that we learn in medical school and residency carry with us across our professional careers. And the information is transmitted, not in textbooks, not in lecture halls, but by the stories we tell, the way we observed those senior to us taking care of patients. And it lasts for decades beyond the time. We are living in the 21st century with a 20th century physician culture, because that is both either when we learned it, or from whom we learned the information that would lead us to have our views on what we should believe, what we should value, and how should we behave.

Dr. Z: And we hardly ever talk about it, because part of the reason that culture persists into the 21st century is that we’ve created a cocoon around ourselves in medicine where we’ve protected ourselves, we’ve resisted through our organizations like AMA, through these sort of sacred cows in medicine. We push back against the change that would change the culture. Even something as simple as washing your hands, we project, “Well, maybe the nurse didn’t do it. Maybe it was the the nutritionist who didn’t wash their hands.”

Dr. Pearl: The housekeeper. It has to be the housekeeper.

Dr. Z: It was the housekeeper. Environmental services didn’t disinfect the room. It’s like, I see you. We’ve done studies. The doctors, like you said, one in three times aren’t washing their hands. It doesn’t take a lot to do, but it’s really ingrained in the culture. And what’s fascinating, the first time I knew medical, so you actually talk in the book a little bit about this. And by the way, I wanna back up onto something you said just to put a point on it, you have the same relationship with medical culture that your mother had with your dad, it sounds like. This love, but then also seeing it and going, oh, but there’s these things that we need to work on, right? And there’s a beautiful passage in the book, a series of passages, where you play the lawyer for medical culture, defending it. And you go, yes, I know this, but look at this. Ladies and gentlemen of the jury, look at this. Look at the beauty and the majesty of what we do. Yes, we don’t wash our hands. And that’s what it is, that’s what it is. That’s how we defend it. We do, well, yeah, but you know, our jobs are hard. We’re always put upon. We don’t make enough money. We’re burned out, the EHR, the administrators, everybody else pushing on us. But then you actually look at it. Now, I remember the first time I read House of God by my now friend, Sam Shem, who wrote the book, Stephen Bergman. That was when I first, I saw the indoctrination of medical culture, like, oh, my gosh. And the way he put it out there, he writes, now, he tells me, this was an act of resistance. I saw this culture, and he was a child of the ’60s. And he’s like, this is terrible. It’s this horrible culture that breaks medical students. Do you think it starts in medical school, how we start to sort of instill the culture?

Dr. Pearl: Absolutely. Absolutely, on the first rotation that exists, we see what people say, what the stories they tell. You know, if you ask primary care physicians about their burnout, particularly, other medicine and primary care physicians, they will talk about the fact that they’re not paid enough, the demands, the bureaucratic demands on them, the EHR, and they’re all true. Every one is true. But walk into a hospital and listen to the specialists talk about primary care and talk about how little they know. Of course they don’t know as much as a specialist, because they have the whole body. I only focused on the left little pinky. Of course, I’m the world’s expert on that, but that’s not the way it happens in our culture. And primary care is looked down upon. Prevention is not considered very important. 88% of the people who died from COVID-19 had two or more chronic diseases.

Dr. Z: That’s a whopping number. Let that settle in. 88% had two or more chronic diseases.

Dr. Pearl: And the number one, hypertension, poorly controlled, which in the United States-

Dr. Z: Preventable.

Dr. Pearl: Is 55 to 60% of the time, except in some medical groups like we had when I was the CEO in Kaiser Permanente, 90%, same doctors, same medication, same almost everything. What’s different? The culture.

Dr. Z: The culture.

Dr. Pearl: The culture.

Dr. Z: The culture.

Dr. Pearl: And the culture ties into this system, because if you’re paid in a capitated way, now you view your value of prevention more, particularly when your members stay for 15 or 17 years on average, right? You avoid complications from chronic disease ’cause they now become a loss leader, not becoming an added source of revenue, right? So when you have that culture, you approach things differently. Patient safety becomes more important. You want to make sure you don’t create a medical error ’cause that also will be problematic. And you start to offer things like telemedicine. You know, I wrote a paper, it’s amazing, six years ago, when we were doing 14 million virtual visits. And I talked about the fact that the rest of medicine was doing 1%. Now, what happens to the COVID-19? It soars 60, 70%. How did that happen? Did telemedicine get better? No. What about all the reasons why it didn’t make sense? All that changed again was the dynamics of what’s happening in the context of that physician culture, because now, keeping patients out of the office, ’cause they may be contagious, became virtuous. And now, instead of the office being the ultimate destination, I’ll do a video visit with you. Let’s see what happens afterwards. Are we going to slide back? And it’s interesting to listen to people talk about it. They talk about telemedicine as though it’s a second rate. well, I can’t get a real visit with you, then I guess I’ll satisfy. No, it’s the opposite. Problems are solved immediately. Care can become the same day. The patient doesn’t have to miss work or school. Now, some problems can’t be, and they’re gonna have to be in the office. But I’ll be fascinated to see what happens. And my prediction is we’re gonna see a farther slide downward that is best for patient care because of that physician culture that will continue to elevate the doctor’s office, rather than the patient’s convenience.

Dr. Z: So it took a pandemic to wake people up to the idea that telehealth was both, it has this triumvirate: quality, cost, and convenience, convenience being key. Convenient not just for the patient, but also actually for the doctor when done correctly with the right technology, which is why the technology actually matters, high-bandwidth connection, maybe sometimes just audio only, because then you de-stress the visual cues. And I’ve talked about this. Now, so telehealth as an emergent of physician culture is a fascinating piece, but I wanna back into what you said earlier, because this was a part of your book that I thought was very important and nobody talks about it openly. The culture of medicine that looks down on primary care and preventative services and how that relates to status, perceived status, reimbursement in a fee for service model. The procedures make the money. My dad, who was a primary care outpatient doctor, all his life, he used to tell me, don’t do what I do. It has a very low status, even though I love my patients and I love what I do. The specialists make money to do things to people. I’m trying to do things for people, but nobody pays me to do that. And so you should go become a specialist. I mean, and that was my own dad telling me that, who’s lived the primary care thing. And this culture in medicine, we see it all the time. The specialists kind of talk about it. Even us hospitalists will be like, oh, you know, primary care, I know I’d hate to do that, 30, 40 patients a day and all these problems and the worried well and ugh, I’m glad I specialized in hospital medicine, which is basically internal medicine in a hospital. So this the sense of hierarchy and status, how does that affect actual outcomes in patient care and our system, in your mind?

Dr. Pearl: We know that burnout is a negative factor when it comes to patient outcomes. That’s been studied many times. It’s been highlighted by people out of Harvard. So it’s bad. Now, the question becomes, can we explain burnout by the factors you just mentioned? And my answer is, no. If you ask physicians, and Medscape has done the studies on them, three things cause burnout: I don’t get paid enough, too many bureaucratic tasks, bad computers.

Dr. Z: Right.

Dr. Pearl: Prior to the pandemic, we can talk about it during the pandemic, when it became critical care physicians and ID doctors. And I just wrote about in the Forbes piece, on my concerned about post-traumatic stress disorder that they are all going to have as a consequence of seeing so much harm happening everyday. I talked to a doctor who lost four patients in one day. I mean, how terrible could that possibly be? I can’t imagine that experience and how many sleepless nights followed that. But let’s go back to the question. Before the pandemic, what was the most burned out specialty? And the answer is urology.

Dr. Z: And you mentioned that in the book and I laughed out loud, ’cause I’m like these guys are rich, they’re surgical. As a internist, how can a urologist complain?

Dr. Pearl: Exactly.

Dr. Z: So tell us what’s up with this-

Dr. Pearl: Yes.

Dr. Z: Because this was shocking.

Dr. Pearl: So this was fascinating to me when I started, again, to research for this book, Uncaring: How the Culture of Medicine Kills Doctors and Patients, because burnout leads to suicide and the possibility of real harm, not just to the patients, but for the doctors sits there as well. So I wanted to understand that they make almost half a million dollars a year, which is double what primary care makes on average. And yet they’re almost 10 points more burned out than internal medicine. So I went back and looked at the data and I asked myself, well, maybe they’re always, maybe it’s the urine that’s causing it or something.

Dr. Z: So it’s a darn urine creatinine, yeah.

Dr. Pearl: Exactly, maybe urea nitrogen, makes them become burned out.

Dr. Z: I know it was BUN-

Dr. Pearl: Exactly.

Dr. Z: Burnout, Urea Nitrogen. That’s what it stands for.

Dr. Pearl: Exactly.

Dr. Z: Right.

Dr. Pearl: So I went back and no, the answer was, around 2010, they were actually very, very low, very similar to orthopedists, very similar to ophthalmologists, the other surgical specialist that were sitting there. And what happened in 2012, the national society that makes recommendations about preventive testing said that you should not be doing PSA testing routinely. They gave it a D at the particular time, they’ve since raised it to a C, but it’s still a very unrecommended area. And number two, people decided that they wanted to do a lot more watchful waiting. So this one operation, prostatectomy-

Dr. Z: With the robot.

Dr. Pearl: With the robot.

Dr. Z: Because who doesn’t wanna .

Dr. Z: Star Wars.

Dr. Z: That’s dope, right.

Dr. Pearl: Exactly, exactly.

Dr. Z: Right.

Dr. Pearl: Now, not only is it dope in terms of the experience of using it, but it’s what gives the specialty its status. And this is what needs to be understood in the culture of medicine, that status, esteem, if your colleagues give that to you, your satisfaction, your fulfillment goes way up. So Michael Marvin, who you obviously have read about, has looked at this in British workers. And the ones that near the bottom of the status level, not necessarily income, but status have a higher frequency of depression, of a lack of fulfillment, dissatisfaction. And the group that goes from high status to low status, they have exactly every single symptom of burnout. And that’s what’s happened in urology as there’s fewer, fewer people desiring to have prostatectomy at all. Robotic prostatectomy has become a limited operation to some centers of excellence and some other individuals and a growing percentage of urologists find themselves not doing this operation. And burnout is the only explanation that I can explain for why they’re feeling the way they feel in the context of having lost that status. ‘Cause their incomes are just as high, and their days are just as filled, and their bureaucratic tasks are no more than the orthopedists and no more than the ophthalmologists and the computers are exactly the same. I can’t find in a traditional explanation, why urology has been at the very, very top. As I say, they only in the past year replaced with critical care and ID in the context of COVID-19.

Dr. Z: Which is a unique situation. But this to me makes a ton of intuitive sense because for those the blind who once could see, the bell tolls for thee. The urologist went into this going, I really want this, and I love this marquee procedure. It’s like the Whipple of our craft. And then to have it taken away, but not only taken away, taken away by what is perceived as these outside forces that heaven forbid, wanna improve patient results and outcomes. So the guidelines that say you know what? This is probably not a good idea. We’re over-treating, we’re causing harm, impotence, incontinence in people that we’re over-operating on, when watchful waiting may be the way. And then that is then internalized as a direct attack on identity. Now, our status as this really unique specialty skill is evaporated, and we’re back to doing the run of the mill stuff. Still making money, still busy, but it doesn’t matter. You told a really powerful story in the book about an emergency doctor who became hooked on narcotics, was diverting narcotics. And, ultimately, you sat down with her. She was one of your doctors. You were the leader in the group. By the way, I do not want your job ever that you had. It sounds like the hardest job in the universe. You sat with her while she was in recovery and said why? And she said, honestly, I was bored. Everyday, it’s the same thing. I’m busy, I’m making money. I shouldn’t complain, but it’s the same routine stuff. There’s no challenge. It’s just monotony. And for that personality, that emergency room adrenaline seeker, it was poison. Can you speak more to that?

Dr. Pearl: Certainly, let’s look at healthcare in the 20th century versus the 21st century, right? We didn’t know very much, at least until the last decade or so, but for most of the second half of the 20th century, we didn’t know what caused, really, cardiovascular disease. We know it caused cancer. We didn’t have the medical knowledge. And so the culture of medicine, what did it value? Intuition, anecdotal experience. It’s almost like the leather aprons of Semmelweis’ day. The more things you’ve seen, that means you saw seven of them. We valued our ability to ponder ideas and make a diagnosis. And now we’re in the 21st century. We have CT and we have MRI and we have evidence-based medicine. And now, I’ve read 60 studies that have all shown how consistently following evidence-based guidelines, you can call them checklists. You can-

Dr. Z: Cookbook medicine, algorithms.

Dr. Pearl: Try and put ’em down. Exactly. Leads to better outcomes. Now, no one believes it because by the way, the same thing has happened in a lot of different specialties besides medicine. But the data shows time and again, if everyone followed the practices of the best consistently, the outcomes would be dramatically better. But what do we still value? The things from the last century. So now when our jobs, are really designed around implementing algorithmic change. And don’t get me wrong, there’s obviously some patients who are so complex, they don’t fit into an algorithm. There’s some people who truly have a diagnosis that can’t be made. But when the biggest contribution you can make, is to follow something that is pretty straightforward, it doesn’t feel exciting. It doesn’t give you status. It doesn’t give you esteem and it leads you to be unhappy and burnout. And you often project it on someone else who is making you do it. I know we talk a lot about moral injury, and I don’t wanna make anyone unclear that I do believe that moral injury exists. The insurance companies are villains that limit good patient care. And I tell the story of my sister’s husband who died in the book-

Dr. Z: Yeah.

Dr. Pearl: And all the challenges they had trying to get the studies that they needed for his health and for their mental wellbeing. But having said that, I also wanna point out how often we do it to ourselves, but the culture helps protect us from recognizing that when we only control hypertension, 55 to 60% of the time, we don’t say to ourselves, oh my gosh, we are somewhat responsible for some of the deaths that have happened. We don’t say that, but culture is a little bit the repression and denial is a little bit like a fine grain sieve, things leak out. We may not be aware of that, but we get just as harmed by the things inside medicine as we do those things that are done to us. Let me give you one other example to me that I’m actually writing about a lot now, ’cause I’m just seeing it more and more and it’s in the context of the current world. You know, as doctors, what do we tell ourselves? We treat every patient the same, but what does the data show? Early in the pandemic, when there were not enough testing kits, and two people came to the hospital with the same set of symptoms, one was a black patient, one was a white patient, we ordered the testing twice as often for the white patient.

Dr. Z: On the white patient. Which is backwards to what the data should say because-

Dr. Pearl: Exactly.

Dr. Z: African-Americans are more likely to get infected.

Dr. Pearl: Yeah, what do we know? 40% less pain medication given to African-American patients, after the same operation with the same neurologic aspects to them and pain sensitivity as in white patients. Although we tell ourselves maybe it’s not true, but that’s the reality that sits there in the medical data.

Dr. Z: Because Robbie, according to medical students that were surveyed, African-Americans have thicker skin-

Dr. Pearl: Oh yeah.

Dr. Z: Fewer nerve endings-

Dr. Pearl: Oh yeah.

Dr. Z: And extra muscle in their leg.

Dr. Pearl: Yeah.

Dr. Z: I’m not making this up. And these are the, but then, you know, the editor of JAMA says, no physician is racist.

Dr. Pearl: Yeah.

Dr. Z: Now, the thing is, I understand his point which is they don’t wanna be called racist because it’s unconscious bias, but they’re not conscious of it. It still has outcome ramifications which is what you’re talking, maternal mortality, yeah.

Dr. Pearl: So let me address this question ’cause I get asked that question all the time is, whether implicit bias is racism. And my answer is straightforward. Implicit bias is not racism, but not recognizing it, and taking action, is incredibly racist.

Dr. Z: Is racist, yeah.

Dr. Pearl: And that’s the issue that exists today because medicine still denies it. You know, it was 15 or 20 years after Jackie Robinson broke into baseball, that the AMA stopped allowing societies to not accept black physicians into their organization. It was a decade, after the US military-

Dr. Z: Integrated.

Dr. Pearl: Integrated before the AMA did. And finally, I think it was like 2010, that the AMA apologized only 50 years late. This is the culture, but I wanna make sure people understand. The culture is what exists, it’s what we’re raised in, and we have to as adults struggle to address that and overcome that rather than continuing it, and medicine does not or has not evolved in the way that it should. And the problems that we see today, whether it’s the burnout, whether it’s the patients dying, whether it’s the lack of chronic disease management, the unacceptable cost, we could go down the whole litany, that is shame on us. It’s not been done to us. We should be leading this chat, this fight to make things better. And as doctors, we’re not.

Dr. Z: You know, the reason I want doctors to read this book and nurses to read this book and healthcare professionals and patients to read this book is that it shines a light on the uncomfortable parts of us that we don’t wanna hear. There were points in the book, Robbie, when I was deeply offended, like just like , and then I introspected a bit. And I’m like, oh, that’s why, because I won’t acknowledge that this is like, when I yell and scream about EHR, like, I think that’s, sometimes I think that’s it. If we just fixed that, everything would be fine, forgetting the fact that without it, we would never be able to acquire enough data to understand whether we’re actually doing good for our patients. There’s unexplained care variation. It’s one thing to have care variation where you kind of you know, customize for each patient within guidelines. Unexplained care variation is where you and I are across the street from each other. We do something entirely different with entirely different outcomes, and we don’t even know it because there’s no integration, no coordination. And so there’s this huge variation where a patient could either live or die, have a good outcome or a bad outcome, and it’s entirely against any evidence that we have. And yet we not only do we allow it, it’s almost like, well, we don’t even wanna expend energy on that because then they’re gonna look at me and measure me and I may not be perfect. And so then our own imposter syndrome comes out. And so that’s why the book is so beautifully triggering. Like you just, you feel it right here. And then you get a little destabilized, which is beautiful for being open to actual change. Now, once reading the book, you go back to your practice, you will never not see the water you’re swimming in again. It becomes apparent and you go, oh, it’s like being awakened with the red pill. You go this is the medical culture. What are we gonna do?

Dr. Pearl: Yeah.

Dr. Z: Yeah. And one thing I wanna go back on because man, and I could talk to you for like four hours on this, because every chapter, if we went chapter by, and by the way, you’ve never sell a book. ’cause we’d just go through the whole book. So we won’t do that. But you know, the Doctors Without Borders are getting no money and no one would read it because I think people have to read it, because they have to go on the journey. This idea that we’ve been, say primary care used to be this intuitive intuition, my dad’s era. That’s what he loved about it. You know, relationships with patients, spending time, knowing them and part of the healing was that knowing that relationship. But then part of it was just, there’s not a lot you could do. And you did what you could and you were just there and witnessed their suffering. And that was enough, that’s all we had. Now, we have more though. We have that piece of it, but then we also have all this data that says, treat hypertension with these medications or these dietary admonitions or exercise prevention. If we coordinated a care across a system that is not very glamorous but incredibly important. If we had EHRs that shared APIs that could share data so we never duplicated or missed stuff. Those kinds of things are low hanging fruit, yet the culture of medicine resists. And then the doctors who’ve now fallen from this status of intuitive gods to algorithmic enforcers in their mind find places to project the grief. For example, I see this conflict between doctors and so-called mid-levels or PAs, nurse practitioners, et cetera. They can’t do what we do, yet they’re being elevated to the status in the name of cost savings. Do you have thoughts on that? It’s a very difficult topic for a lot of doctors.

Dr. Pearl: No question, what you’re describing is very much cultural. The data says that, at least the data that I’ve read, maybe you’ve read different data, that the outcomes are very similar, but we should study it. Is there a difference in outcomes, difference in practice, difference in costs? Because data should be the driver, but that’s not gonna be the driver because of the physician culture, it’s gonna be about the culture, which is going to say how do we elevate physicians and drive down everyone else? And the higher anyone else rises, the more threatening it’s gonna be to us. Yes, there’s an economic issues, sitting back behind there-

Dr. Z: Yeah.

Dr. Pearl: But I don’t think that’s the big driver.

Dr. Z: I think it’s cultural.

Dr. Pearl: I think it’s culture that’s sitting there. And I think that that’s why it’s gonna be very hard to get past until we changed the model. And by the way, we changed the models, it’s gonna happened as fast as telemedicine. Because if you look inside organizations that are integrated where the let’s say, the physician assistant is a tremendous source of support and actually revenue to the orthopedic surgeon, they love the physician assistant who’s there. And when the nurse is helping them to get much better outcomes relative to chronic disease, and is able to help take care of their patients without having a disruption in care when the doctor goes on vacation, and they share practices and overlap, all of a sudden, these are the best people in the entire world. So I think there is an economic factor. And then again, I wanna go back to this, why is this systemic? But it’s a cultural issue that is very much there. And it’s just threatening to the status of doctors who feel already as you know, under attack and feel as though by society, they become second rate to the people in financial banking and Silicon Valley and all the other people who are making more money than they are, and seem to be happier than they are in their medical profession.

Dr. Z: Man, it’s right there this thing. You know, it’s the pain that so many physicians feel, and I hear it when they email me. You need to speak out about mid-levels taking over our… It’s so much and you can just, you can feel the tears welling in their eyes as they’re just contracting into this defense of, this is the straw that’s gonna break the camel’s back. Our reputations slide, patients are now reviewing us online which you talk about in the book. And it’s all about customer service. They aren’t customers, they’re patients. And I know things no one else knows. I went to so much school. This nurse practitioner did an online course, that is a fraction of the hours. And yet the administrators would rather hire she or he, than me and I’m devalued everyday. And you just, you feel it coming out and it is now you can study it and go, well, what are the outcomes and all that. But despite all that, that’s not gonna change the cultural hurt. How do we begin to even address this?

Dr. Pearl: Yeah. So let me go back, that you’re absolutely right. All I was saying is we should study it to make sure there’s nothing there.

Dr. Z: Yeah.

Dr. Pearl: Because if there is something there we should address it, acknowledge it, and the nurse practitioner or the PA should acknowledge the fact that the results are not as good, we could ask how do we get it better? But if it’s not there, that’s the starting point that I’m starting from.

Dr. Z: Right, right, right.

Dr. Pearl: Making the assumption-

Dr. Z: Assumption that it’s not there. Yeah, yeah.

Dr. Pearl: I talk in the book, as you know, about the post-coronavirus era. And the post-coronavirus era, my projection is, we don’t know it hasn’t come yet, that the nation’s gonna face major economic problems. Now, why do I say that? Because we’ve borrowed at the federal level eight trillion dollars, that’s either got to be paid back or the interest on it is gonna have to be paid. So the federal government’s gonna have to have pressure on it. The States by law have to have a balanced budget. And we know is that gonna have more people unemployed, they have to pay for, more Medicaid and revenue is likely to be down in most States, the ones that don’t have a Google and Amazon and Apple and the other places to help support them. And we know that the small and medium sized businesses, these are the ones that actually employ the majority of Americans. You know, we hear about the Netflix and the other companies that have a lot of income and a lot of oomph in the stock market. But in terms of the jobs in this country. they are mainly created by small and medium sized businesses, and they’ve been killed. A third of them says they… The ones who are still left say, they can’t survive the year without government assistance. And it’s all been hidden by the stimulus money.

Dr. Pearl: Yeah.

Dr. Pearl: But as soon as that stimulus money goes away, we’re gonna see problems. And the place people are gonna look is gonna be at medical costs. Now, if you think back, you may remember, in December of 2019, this is two months before at least the coronavirus was reported in China, and maybe three, four months before it came ashore, large enough to be noticed in the United States. The federal government said, healthcare costs are gonna rise five to 6% a year for the next decade. That’s compounded 60, 70%. And did anyone even blink? Did anyone say wow, that’s a huge amount of money. Do we really need 60 to 70% more money? No, that’s not part of the culture that sits there. We said we’re entitled to that much money. And we’ve said now, and I talked in the book about, you know, a group from 1932 that looked at this question-

Dr. Z: Yeah.

Dr. Pearl: And we’ve said, since then-

Dr. Z: It’s remarkable story.

Dr. Pearl: You know, for 90 years we’ve said we must change. We can’t afford it anymore. I think in the post-coronavirus era, we will change because if you can’t afford to buy something, even though you value it, you can’t buy it ’cause you don’t have the money to do that. I think we’re gonna be there as a nation. And if you try to say how can we limit healthcare expenditures? There’s only two ways. You can do it by rationing. You say, basically, you’re too old. You can’t get your heart surgery. You create lines to see the orthopedist and have your total joint replaced, this drug isn’t on the formulary. And there are nations in the world that do it.

Dr. Z: Yeah.

Dr. Pearl: But I think we all know that rationing is worst care.

Dr. Z: Yeah.

Dr. Pearl: And I’m hoping that physicians will find that simply unacceptable.

Dr. Z: So in other words, a two-tier system where if you have a ton of money, you get the procedures. If you don’t-

Dr. Pearl: Sure.

Dr. Z: Yeah, that’s another way to ration.

Dr. Pearl: Yeah.

Dr. Z: Yeah, mhm.

Dr. Pearl: Alternatively, is capitation. And capitation or a single payment to take care of a population of people, measured on quality of service outcomes starts to work. And when that happens, what you see is culture change. Because in that environment, all of a sudden prevention becomes more important. Primary care becomes more important.

Dr. Z: Care coordination becomes more important.

Dr. Pearl: Care coordination. Nurse practitioners, PAs, working with you to help you make sure that your patients have better quality and easier access. That’s something that starts to become valued now, not rejected. You start to say how do we integrate, coordinate, collaborate? Words that we’ve said all along doctors, you know, it’s like herding cats, right? That’s the phrase that you use.

Dr. Z: Yeah, yeah.

Dr. Pearl: What does that mean? You don’t like to coordinate, to collaborate. You wanna work alone, that’s not gonna be acceptable. And technology, technology that makes care more rapid, easier to accomplish and lower costs will start to be embraced. To the physicians who are watching, I wanna warn you, watch what Amazon is doing. If you’re not watching them, you are going to be surprised. Three years ago when Haven was formed, my friend Atul Gawande leading it at the particular time. I said to people, Jeff Bezos is doing this for his million employees between him, Berkshire Hathaway and JPMorgan Chase. It’s a not for profit, and if you believe that that’s his end game, you probably think Amazon only sells books. They do one-sixth of all retail. He wants to do one-sixth of all medicine. And remember, what telemedicine has said is, I don’t have to see the doctor in my local community. I can bring an expert in from anywhere.

Dr. Z: Center of excellence can be anywhere.

Dr. Pearl: Center of excellence can be anywhere, but even more than that. The biggest problem in medicine is what I like to call it in business school, the N of one, which is, you can’t manage variation with only one of you.

Dr. Z: Yeah.

Dr. Pearl: But as soon as you have 50 or 100 people available to be providing expertise anywhere in the United States, and you can put together 50 million or 60 million people, now you can start to provide immediate care. I’m predicting that Amazon prime members, will soon get a certificate that for $10, you can have a doctors visit.

Dr. Z: Oh, hell yeah.

Dr. Pearl: Virtually-

Dr. Z: Delivered by drone.

Dr. Pearl: And then you can have the medication delivered by drone.

Dr. Z: Yeah, yeah.

Dr. Pearl: And by the way, if you happen to live near a site where they have their workers, you can come utilize that facility, but who are the, and I keep talking about Jeff Bezos, even though he’s no longer gonna be CEO, who are his friends? The CEOs of other businesses. And pretty soon he’ll say to them, you know, why don’t I take care of your employees too? And now all of a sudden there’s a critical mass. And if that’s not scary enough to you, look what’s happening with Livongo and Teladoc.

Dr. Z: Yep.

Dr. Pearl: Look, what’s happening with a company that has now done something like 40 million virtual acute visits, merging with a company that manages chronic disease. There’s not a whole lot of material left. And anyone who believes that what these companies are gonna do is to just figure out, how do I pick the best insurance company or how do I have all the docs in my network? Amazon sells only books.

Dr. Z: Okay, okay, okay, okay. All right, oh.

Dr. Pearl: Don’t be afraid, you’ll have a job.

Dr. Z: Hey, this job is going nowhere fast.

Dr. Pearl: Okay.

Dr. Z: Believe me, nowhere fast. Listen, there’s so much that you said that I think points out the main thrust of your book. And this is so important. Oh my God, Robbie, Dr. Robert Pearl, sorry, if you’re nasty. Okay. Where to start with this because it’s so much, all right. First of all, the first point you made is we can’t afford the way it is. The way it is, is what generated the medical culture and is generated by the medical culture, guess what? Can’t pay for it anymore, which means, hey, something’s gonna have to give. Number next, we have structures. Integration, capitation team-based care where you’re no longer fighting with the PA and the nurse practitioner for supremacy. You’re all part of a holarchy where everyone’s practicing at the top of their game together in service of the patient and each other in an integrated platform where everyone’s skin is in the game. You point out in the book and this has been talked about ad nauseam, human happiness and flourishing, depends on largely three things at work. One is a sense of autonomy. The second is a sense of competence or mastery, like you’re actually getting good at something you’re good. you’re really good at this thing. And the third is relationships or relational competency. In other words, connections of being part of something bigger. And when a culture starts to fail those three things, it needs to be replaced with a new culture. So if the new world is for better or for worse, and believe me, and you talk about this in the book that there’s a grieving process that happens for doctors who grew up in one world and are seeing it change. People like myself, people like my parents, who had to go through anger, bargaining, denial, you know, anger, denial, bargaining, depression. When will they get to acceptance? And acceptance is not surrender. Acceptance is saying, this is the new world. We can’t afford the old way. It wasn’t that good anyways. There were parts of it that were beautiful. Take what was good, bring it to the new world. Use technology, make it team-based. Give ourselves a sense of autonomy where we do have latitude but at the same time we have support. Make sure we’re good at what we do even if that isn’t super broad stuff. It may be something very narrow, but we’re so good at it, and we have colleagues to support us through it and provide high level connection that then makes us happy, then we accept that and we change the culture. Does that sound about right?

Dr. Z: It sounds absolutely right. It’s what I hope will happen. You know, I often think of it as like the Roger Banister effect. Everyone thought it was impossible to run a four minute mile until he did. And within three years, 10 more people run it. So I’m hoping that when some physicians lead the way that others will follow, but if not someone else will.

Dr. Pearl: Someone else will do it.

Dr. Z: Whether it’s Amazon or whether it’s just business coalition, or someone else will force it to us. But let me ask you a different question. Let me ask it to you, which is that if you look at presidents, ever since Truman or Roosevelt was very involved in this, you have a Nixon who’s pushing the HMO, a pretty conservative president. You have Clinton pushing a…

Dr. Pearl: Managed competition.

Dr. Z: Accountable competition. You know, you have Trump even pushing for a value-based system. You have Obama, every president is pushing in the same direction towards capitation, towards integration, towards technology, towards leadership. Why do you think it hasn’t happened?

Dr. Pearl: Physician culture, that’s what I learned from your book, and I think you’re right. Now, I know, yeah, I think you’re right. I think that’s really it. Now, as an example, I’m just gonna give a quick example of myself. So I go, you know, I ended up becoming a hospitalist because that’s where my passion was. I knew I wasn’t smart enough to do primary care. I wanted to do acute medicine. I go to Stanford. We’re part of this multi-specialty group. We were salaried. So already the stress of like having to churn through patients was not there. We had lower volumes so we were able to spend more time with the patients. And we had EHR that was read-only, but not write, so we could get data, but we didn’t write. And I had a team of people, the house staff, the residents, the medical students, the sub-Is, my colleagues, all serving each other. And we would do two half days of clinic outpatient to connect with the rest of the people in the org, so we weren’t these isolated satellites. I have never been so happy in my life as I was in those first three to four years of my career doing that. I had a sense of competence. The orthopedic surgeons would tell me, you know, Zubin, I know we generate all this money for the clinic, but we’re happy to give some of it to your salary because you manage our patients’ illnesses, their hypertension, their anemia, all these things that we, and lets us do what we do well. So I felt valued. The house staff were mentorship, connection. And I felt like I could be with my patients when they were at their most vulnerable. When that changed, when Epic came live, but they never gave us the resources to actually optimize it properly. When they started peeling away how staff support made us more like cogs. Now, we’re just doing all the work, but we have no mentorship or teaching or any of that. When we were pulled out of clinic because we thought it was too busy, we lost the connection to our colleagues. We had no doctor’s lounge, no third place as you call it in the book to connect with our colleagues. Now, we’re an isolated cog in a machine that runs on RVUs. And that’s when I’d realized I can’t do this anymore. So in many ways, I went through that grieving process for the loss of this, and I had to break out to find my own thing, but many people don’t have that option. You’re showing an option. There is a better way, and it may not be what you think. It may be an integrated approach that’s team-based. So this is important stuff, man. It really is. And the clinic we built Turntable Health, was predicated on this-

Dr. Pearl: Yeah.

Dr. Z: Prevent disease, team-based, everyone operating at the top of their game. EHR designed to serve patients without billing, ’cause it was capitated. So I know it works. It’s Health 3.0.
Dr. Pearl: I think most people like being on a winning team. There’s some people who wanna be their own, they’re like playing golf or some other event where you’re not dependent upon everyone else. But most of us liked being on a team. We like playing a given a sport, playing in a symphony. It doesn’t matter what the particular era is going to be. We feel good when the team wins, we don’t have to be the MVP and we don’t even want there to necessarily be a… And that’s what I see as being possible. I think that’s gotten lost. You know, as you know, I’ve done a lot of global surgery.

Dr. Z: Yeah.

Dr. Pearl: That’s how I got interested in Doctors Without Borders and fixed children with cleft lips in three or four different continents already. But in the book I talk about the experience that I’ve had with the physicians. I tell a story about after the tsunami in Sri Lanka, the day after Christmas, half the people are on vacation with 10,000 physicians providing care to 5 million people. Half of them were on vacation. I send out an email, it says, there’s been a tsunami in Southeast Asia in Sri Lanka. If any of you wanna volunteer, we’ll find a way with Doctors Without Borders to get you there, but I have to give you an informed consent. There may not be any clean water. There may not be any food at all. There’s been a civil war for 20 years. But if you wanna volunteer, let me know. You know, I figured five doctors maybe, I had over 200 people stepping forward. We sent 10 teams of physicians, actually physicians at first. And then we sent psychologists because there’s a lot of mental health issues. And then we sent a lot of nurses and other folks to help deal with the malaria that would’ve killed 10,000 people. It kills a million people a year around the globe. And when they come back, we’d have a celebratory dinner, and I never saw people as happy. You know, they were working 12 and 14 hours a day. The heat was unbearable. You know, we send people after Katrina and people after the earthquake in Central America. We sent physicians to Liberia. Get this, they have to have IVs going in their arms because it’s so hot inside the suits they wear that they would become dehydrated and pass out if they were not getting fluids in while they administered care to the people with Ebola.

Dr. Z: Wow.

Dr. Pearl: And they came back smiling with the greatest fulfillment and the satisfaction of their life. That’s the purpose of medicine. And I think it got lost, and I think we did it to ourselves in the context of the systemic issues. You can’t take those away, but we also do the same. That’s what I’d say about the Stafford experience you described. The systemic issues were a problematic view in Las Vegas and they closed you down. There was nothing you could have done about that, but I don’t know how many physicians were involved in making those decisions about what you should be doing. And I had someone on my podcast the other day who was telling me about the text message he had gotten from his physician chief telling him to no longer offer telemedicine visits because they were not generating enough revenue. That’s a systemic issue.

Dr. Z: Yeah.

Dr. Pearl: What about patient satisfaction? How do you look a patient in the eye who had to take three buses to get to you and miss a day of work, when you know that in the family they’re having to make decisions about whether to buy new clothes for their kids or buy better food for their children? How do those go together? We can blame everyone else for the problems, but I think we’re better off if we look inside and that’s why I wrote the book and why I’m so happy you’re having me here today. But I’ll warn listeners, you and I had this conversation before we started the interview, that I offer ideas to patients, ways that they can help protect themselves against the culture. There’s nine sets of questions. I’ll only mention three today so that people decide to buy the book and get the freebies to learn the other six. But I talk to people about if you’re coming in for sort of a routine problem, a one-off kind of problem, you should be asking the physician or the nurse practitioner you see. It doesn’t matter who you’re seeing, the clinician you’re seeing. Do I have to come back or can I communicate with secure email? Text message? Can we set up a video visit? I was talking to someone, this is yesterday, and it’s in Marin County, you know, the epicenter-

Dr. Z: Richie Rich.

Dr. Pearl: Of Richie Rich, yeah.

Dr. Z: And anti-vaccine sentiment.

Dr. Pearl: Yeah, talking about how she had sent an email to the physician and the physician didn’t know how to email back and had to make a phone call. I mean, this is what we’re talking about at the cutting edge-

Dr. Z: Culture, culture.

Dr. Pearl: Yeah, yeah. So can I get back more conveniently in a way that I don’t have to miss work or miss school? If you’re gonna have a procedure done, you should ask how many of these did you do last year? And if you were gonna have this done or someone in your family was gonna have it done, what’s the minimum number you would require that the doctor did the year before before you would let him or her do it? And you know in the book, I talk about laparoscopic hysterectomy.

Dr. Z: Right.

Dr. Pearl: But when I asked this question to the chiefs of OBGYN, they all said the same thing, three to four a month, 36 to 48 a year. Half of the OBGYNs in the United States do fewer than 10. We give care that’s less good than the care that we deserve. And then finally, if you have a severe problem, a somewhat terminal illness, heart failure and lung failure, advanced cancer that has now failed chemotherapy. You wanna ask the physician, what are my other options? And maybe most importantly, if I decide I don’t want more care, will you desert me or will you be there in my time of greatest need?

Dr. Z: Oh yeah, you threw the softball questions out, Robbie. Those are the softball questions patients should be asking. By the way that chapter is one of my favorite in the book because it is the most triggering as a doctor. It’s like, I don’t wanna answer those questions. Oh, you better look then ’cause they’re good questions. And that’s what we ought to be, because that means, look, we’re all patients, some of the most powerful stories you tell are about your own family members or yourself. Man, you’ve been through a lot, Robbie, like you’ve had so many ortho injuries. I’ll let people read the book to hear about that. You are a cursed man. You run a lot. You’re very athletic. You ski and you get injured from time to time.

Dr. Pearl: Yeah, I come off cliffs and I’ve got injured, yeah. But I’ve had tremendous orthopedic care and I’m back to running my 30 miles a week, and everything’s working very well. But yeah, that’s the choices we make. But as long as we acknowledge them, that’s okay.

Dr. Z: That’s right.

Dr. Pearl: And I’m happy for all the things that I’ve done physically.

Dr. Z: And you Know, and the story you told about the orthopedic surgeon that took care of your tibial plateau fracture was a wonderful story. It was exactly how the culture can change when our financial structure changes, when our incentives change, when we think about us and we instead of I and me, which is we’re cowboys in the old way of medicine. And it’s hard and we have to be very compassionate which you do in the book, to the current way of thinking because we didn’t ask for this culture, this was a culture that existed.

Dr. Pearl: And we shouldn’t lose it. I mean, one of the questions I ask at the end of the book is how do we manage to evolve the culture without giving up the culture?

Dr. Z: Right.

Dr. Pearl: Because if you look at the COVID-19, and you look at the doctors or the nurses who didn’t have protective equipment and they put garbage bags on, and they didn’t have N95 masks, they put salad lids on their face, and they worked for 12 hour and 24 hour shifts. And they knew that every time a patient couldn’t breathe, and they passed that tube through the vocal cords, the patient would cough spewing virus into their face. And when they couldn’t figure out who should be put on the remaining ventilators, they figured out how to put two patients on a single ventilator, something that hadn’t been thought about or ever done before. I mean, these are the kinds of things that we should be celebrating. It’s a great culture. It’s a magnificent culture that allows physicians to go to other nations and come back so satisfied. And how do we preserve that mission and that purpose, because much that we’ve given up has been we gave it up. We could have kept it, but we chose not to because it was maybe slightly economically more beneficial or slightly more positive for us. But mainly because it would compromise our steam and our position in the hierarchy. And it is that culture that stopped us from doing the things and why I’m convinced that it’s been as harmful to physicians as it has to patients. And for your audience, many of whom are not physicians, I wanna say, I wrote it about physicians, not because I think that physicians are higher in the hierarchy. It’s just what I know.

Dr. Z: Yeah.

Dr. Pearl: I would have felt very awkward…

Dr. Z: Talking about nursing.

Dr. Pearl: Talking about what motivates nurses, ’cause I don’t know in the same way. I mean, I know lots of nurses that I’ve talked to them about it, a nurse should write that book and a PA should write the other book about what motivates them. But be honest, be honest about the wonderful things of all of our professions, but also acknowledge the challenges that are there. As you know, there’s a chapter that has the five Cs.

Dr. Z: Yes. And this is the kind of solutions that we have, yeah.

Dr. Pearl: The solutions, particularly in organized institutions.

Dr. Z: Right.

Dr. Pearl: Confronting the problems that exist. I think we just are in complete denial and repression. You know, no one has come forward to say, oh my gosh, with all these people dying from chronic disease. Where were we? How come we couldn’t have done a better job? Yeah, there were always other problems. But look what we could have done within what we had and we failed to do it, confronting it. And then confronting is not enough unless you commit. Commit to make something be different. Don’t say what they have to do. What can we do? And when you start to do both of those, right? Now, you have to come together.

Dr. Z: Connect.

Dr. Pearl: To connect with people. And having connected with them in multiple specialties and multiple areas and multiple job descriptions, right? You know, how do you then collaborate and coordinate, right? And then finally, how do you make sure that you can experience the contribution? You asked me early about medical school. I think people go to medical school for the right reasons overall. I think they’re very motivated to make a difference for patients, a difference in the world. And yet, what do we see? We see that medical students start burning out, after their first year. They haven’t yet touched a computer-

Dr. Z: No EHR, no insurance authorization-

Dr. Pearl: Exactly.

Dr. Z: No administrators, and they’re burned out by the end of the first year. I got that out of your book and I was like, oh, tell me more, Robbie, why? Why is that?

Dr. Pearl: I think they come in contact with this culture.

Dr. Z: With the culture.

Dr. Pearl: You know, I often talk about the white coat ceremony.

Dr. Z: Yeah.

Dr. Pearl: Which to me is fascinating. I mean, everyone remembers it. You go there on that day, your parents are sitting in the audience. You get to walk on stage, and a faculty member from the institution drapes you in your white coat with one exception. And that is if a parent is a doctor, he or she is able to drape you in your coat. Now think about that. I mean, we just take it for granted, right? ‘Cause that’s what happens. But think about that. Why? You know, are the parents who help their child get through into medical school, by working three jobs-

Dr. Z: Being a migrant farm worker or whatever it is, right?

Dr. Pearl: Are they less entitled to have the pride? It’s not about the parents. This is about the physician culture. This is the family centuries ago taking the bride and having her join the husband’s family and his values. His culture is what is going to be there. This is the permission of the parents and the audience to the faculty to say you can train my child in your culture, not necessarily my culture. And if the parent happens to be a doctor, they already have the culture. They can be trusted to put the coat on ’cause they can be trusted. It is such a strange place. And the medical students experience it and they experience it again. What they think they experience is how boring it is learning the Krebs cycle, all right? They think it’s all of the pressures of that first year of basic science but that is there because of the culture of medicine ’cause that’s what elevates doctors. They spent all these years learning all these arcane facts, so they should be at the top of the hierarchy. And if we give that up, we’re gonna fall down and be just like everyone else. The culture of medicine harms, not just patients but physicians as well.

Dr. Z: Damn Robbie, that was hot fire, man. I love it. That was so good. I got goosebumps, dog. And I got to say, medical students who are watching this, they’re gonna resonate. They’re gonna resonate with this. I remember contacting, I remember coming in contact with that culture for the first time and getting burned, like third degree burns, feeling it and then becoming it. By the end of residency, you’re using words like GOMER, and all the usual cultural train wreck and dump and all the other stuff that gets you through residency. You’re indoctrinated in the culture.

Dr. Pearl: If I could offer one thought that’s not in the book that I just thought about having been around you.

Dr. Z: Free advice.

Dr. Pearl: If I could offer one question that everyone should ask whether they’re a medical student, whether they are a physician or practice. And I’ll say whether you’re a nurse or a PA, I think it’s good for you too, but I’ll let you decide whether it is, if that’s okay.

Dr. Z: Yeah.

Dr. Pearl: Everything you do, ask yourself, if this were a member of my family, is this the way that I would want them to be treated? Not by the system, but by me.

Dr. Z: Me.

Dr. Pearl: And if the answer is yes, the care that I provide is the care that I would expect, then you’re probably doing the best you can, and work hard to change the system. If the answer is no, still work hard to change the system, but also look at yourself, look at your colleagues, have the conversations, and I’ll go back for the people on the line who are critical care physicians like yourself, ICU physicians, hospitalists. COVID-19 has inflicted tremendous harm, and the physician culture has taught us to deny-

Dr. Z: Deny it.

Dr. Pearl: And repress emotion.

Dr. Z: Yep.

Dr. Pearl: What do we say? Don’t become emotionally involved, you’re gonna become a worse physician, you’re gonna make bad judgments if you let emotion cloud your brain. You can’t possibly have the experiences that are going on today. I talked to a resident, he inherited six patients on the first day of his month long rotation. By the 30th day, they were all dead. I talked to a physician who was double-bordered. This is the most resilient woman physician or any physician, she doesn’t have to be a woman, that I know in this world. And she says she can’t go to sleep at night and she wakes up in sweats before sunrise. This is the reality. And if you’re not recognizing it, that’s really a problem. And if you are, I wanna encourage you to talk with your colleagues ’cause they are too, and they may not be able to talk about it, but this is what needs to happen. And I’m encouraging every hospital administrator, every residency director to make available psychological resources. But that’s not enough because the culture of medicine, we deny that we have needs, that we have emotions, that we need help. And right now it is inevitable. And what we know about PTSD, because it’s been looked at in so many different areas, it doesn’t strike, it doesn’t reach consciousness in the moment that’s happening. The adrenaline or the other factors prevent it from impacting us. It happens when it’s all over. And I’m hopeful that with vaccination coming, it will be over soon or at least under control enough that we won’t have to deal with four deaths in a single day. And that’s when I’m most worried, and the time to do something about it is not then, but now, and I’m hoping that people will do it and recognize this is equally part of the culture. As we said earlier, it’s not problematic to be impacted by the culture. It’s problematic to not recognize it and take action to correct it.

Dr. Z: Beautiful words. Agree, 1000% I have referred to it as communalizing our pain. Let’s put it out there and say we’re sharing the suffering, and some of our suffering is personal, and get help, get support, make it normative to do that ’cause this is a kind of witnessing of human suffering that has not happened in memory for us. And to ignore it, to repress it, to deny it, which you talk about in the book leads to no good outcomes, only bad outcomes.

Dr. Pearl: And we had to, to some extent, because if not, patients would have died.

Dr. Z: Exactly.

Dr. Pearl: ‘Cause someone had to be there, and we were the only one who could do it, but we paid a price that we need to recoup.

Dr. Z: Yes, and you mention in the book too that this kind of repression is a tool we need when you’re designing chemotherapy for the first time, and you’re poisoning people to near-death to save a life. They had to turn off their sensitivity to that suffering and repress it in order to be able to do that. But that’s, they’re still humans. We’re emotional, intuitive creatures with a little logic thrown on in the last million years. If we don’t appreciate and accept that, then that’s why we have twice the suicide rate of any other profession.

Dr. Pearl: And to the nurses listening in, I saw a research this week that said, nurses have even a higher rate of suicide. So this is all of us. And again, I can only imagine what it must be like for the nurses in the critical care units, as they take care of the same patient day after day after day until the individual goes on to die. That’s probably, again, a culture that permeates all of our lives. But again, I speak about the physician, ’cause it’s the part that I’ve seen the most closely and know the best.

Dr. Z: Robbie Pearl, what a joy, you’re a gift. I mean, and people can disagree and then come in the comments, but they need to read Uncaring. We’ll put links in. It really was a powerful experience for me and very triggering, which is beautiful. Like that’s what we want. We wanna look, where are my own biases, what’s going on here, what are my blind spots? And coming from someone in our tribe, who’s led our tribe for so many years and is a practicing surgeon, it’s quite powerful. So thank you Robbie, for trekking all the way from the East Coast to come and talk with me. What’s next for you by the way?

Dr. Pearl: Next is going to be trying to get enough people to read the book. No, I’m serious now.

Dr. Z: Yeah.

Dr. Pearl: You know, there’s a lot of studies that are out there that says it takes about 30% of a culture, of a tribe, of a group to start to change before others are able and willing to come along. It’s a critical mass that has to be there. And so I’m hoping that enough people will read this to start having the conversations. They won’t be afraid of them. If they disagree, my website’s RobertPearlMD.com, let me know. I learn from the readers, I learn from the listeners to my podcast, so don’t hesitate to give me your thoughts around all of that. But until we get enough people understanding and seeing it, if I can give a visual image to your viewers, it’s North Carolina, a room full of people smoking cigarettes. You barely can see across the room, and someone from Berkeley, California, walks in there and immediately starts coughing and their eyes water and they can’t imagine how these people are sitting there not seeing it. That’s my hope, that people will see the culture, this invisible force that surrounds us and point it out to others and maybe be able to clear the air and make it a healthier place to receive care and to provide care.

Dr. Z: I think that it’s gonna go a long way to that, and we’re gonna raise heck about it right here, people will get the book. The other thing I gotta say is they got to check out your podcast, Fixing Healthcare and Coronavirus Truth and sign up for your email list, which I’m a member of. I love reading your email summaries. They’re really, really insightful. All your experience and wisdom. Thank you for sharing with us, Robbie. I mean, it’s great. And to put a final point on your tipping point piece about 30%, then you get culture change. This is true across society. When we start getting to what I call an alt-middle perspective, 10% roughly of the population gets there. That’s what happened with civil rights. You had a tipping point where 10% of the population was at this level where they’re like wait a minute. We should be judged on the content of our character. And you get an explosion of change. The same thing can happen in medical culture. The same thing’s gonna happen in our next societal evolution, which is to stop all the political bickering and start seeing everything as true but partial and looking rationally at better ways to serve each other and ourselves.

Dr. Pearl: I know you’ll lead the process. And I thank you on behalf of both healthcare professionals and the patients that we all are for your work.

Dr. Z: What a kind, you know, this is what happened when two podcasters do an interview. We’re both like, and that my friends… I love it. Guys, please share this video. Just share this video, links to the books, get the book, share it with your friends. I love you guys. Robbie, thank you so much.

Dr. Pearl: Thank you, Zubin, appreciate it.

Dr. Z: And we are out. Peace.

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