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This week’s episode is the second part of our conversation with Dr. Robert Pearl. In his book, Uncaring: How the Culture of Medicine Kills Doctors & Patients, Dr. Pearl asserts that doctors are taught how to cure people, but they don’t always know how to care for them. There are many contributing factors, ranging from how doctors are trained, to increasing workloads and lack of resources, a widening disconnect between patients’ and doctors’ values and expectations, and increased risk and death due to the pandemic, all of which are intertwined with systemic and cultural issues. These are people who, with the highest ideals of caring for people, have entered a system rife with misaligned incentives that undermine and contradict their own hopes and expectations, and a culture that shapes them into being unable to care in the way they originally intended. The book examines the elements of physician culture that need to be corrected, the ones that should be preserved, and how to accomplish both.
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. He is the author of Washington Post bestseller “Mistreated: Why We think We’re Getting Good Healthcare—And Why We’re Usually Wrong,” and “Uncaring: How the Culture of Medicine Kills Doctors & Patients” which is scheduled to be published in spring 2021 (all proceeds from the book go to Doctors Without Borders). Dr. Pearl also hosts the popular podcasts Fixing Healthcare and Coronavirus: The Truth.
00:30 The cultural hierarchy in medicine
01:00 Research on effects of concentrated primary and specialty care on life expectancy
03:00 Dr. Pearl explains how primary care was once on top of the cultural hierarchy before technology advancements
04:00 The need for Primary care to adjust to the current world (The Acceptance stage of the Kübler-Ross grief cycle)
05:30 Leading innovation in Primary Care and the success of ChenMed as a primary care model that can lower cost and improve outcomes
06:30 How the current fee-for-service model creates ineffective primary care delivery to ensure population health (e.g. lack of access and availability)
08:00 The use of telemedicine in the primary care setting to improve patient outcomes
09:15 The need for interdisciplinary, technology-enabled primary care teams and the integration of specialty services
10:00 How Kaiser Permanente leveraged telemedicine and other digital tools for clinical integration
11:30 PCP/SCP collaboration to determine evidence-based practices in a consistent, technologically-enabled, efficient way
12:00 Redefining primary care to elevate its value.
12:20 “Primary care shouldn’t just be the gatekeeper for referrals; they should be the facilitators of higher quality care by collaborating with specialists.”
12:40 Inefficient, low-value referrals from primary care for consultations that could be prevented with better integration
14:00 Onsite primary care clinics for Apple employees that are improving collaboration with specialists
14:30 Consumerism and Patient Experience — patients feel disrespected by long wait times, short visits, and poor communication.
17:00 “Culture, to some extent, allows you to avoid the harm you inflict and take privilege in what you desire. Some of that exists within the physician world.”
17:20 Physicians that refuse to value patients’ time as much as their own as seen by long wait times, limited access and availability, and limited consumer-driven technology
18:20 The culture of customer-focused technology and service, exemplified by Amazon, has changed patient expectations
18:50 Patients value empathy, listening, and being available – not a provider’s medical training, publications, degrees, etc.
19:55 “The culture of the consumer will end up winning in healthcare. If the traditional medical system doesn’t offer it, someone else will.”
20:10 Amazon as a force of disruption in healthcare. Anyone who doubts the ability of Amazon to take over healthcare is in denial.
21:30 Dr. Pearl’s Fixing Healthcare podcast episode with a patient diagnosed with advanced breast cancer
23:00 Loss of purpose and mission in medicine as a positive force for physician culture change
23:45 The story of a physician treating an Ebola patient in the most miserable of circumstances but feeling immense happiness due to a connection with purpose
24:50 Physician’s returning from medical missionary trips deeply inspired and fulfilled
25:40 Providing care that is equitable and magnanimous with a deep sense of gratitude helps the physician heal as much as the patient
26:45 The invisible component of physician culture: the gap between what physicians know and what they actually do (e.g. handwashing)
27:15 In-hospital deaths in 1850’s Vienna, Austria blamed on miasmas by physicians, and how Semmelweis’ research on hospital cleanliness was rejected by his colleagues
31:40 The leading cause of death in U.S. hospitals is a hospital-acquired infection, and how 1 in 5 doctors today still fail to wash their hands
33:00 Killing patients with a hospital-caused infection as a source of inspiration for the book’s title “Uncaring”
34:00 The irrefutable public health data shows that U.S. medicine threatens the health of the African American community more than police brutality
34:40 Denial of institutional racism in medicine by physicians and how poor outcomes are instead attributed to external factors or biological falsehoods
36:10 Two-thirds of white physicians have implicit bias against African American patients
37:45 Recognition of the problem of unintentional, implicit bias (physicians are simply not aware that their actions are biased)
40:10 Dr. Pearl’s article on the use of Artificial Intelligence as a means to address racism
41:00 The limitations of using medical claims data for AI models
44:30 Using unbiased AI models and clinical decision support alerts to inform physicians of possibility of biased decisions
47:40 In Buddhism, a bodhisattva refers to anyone who is able to reach nirvana but delays doing so out of compassion in order to save suffering beings. This sacred role, which requires great personal sacrifice, mirrors the virtues of medical practice.
48:00 As healers, doctors have traditionally put the needs of others ahead their own. In the twenty-first century, however, physicians are focused on their own suffering.
50:00 The Five Cs of Cultural Change as an approach to help evolve complex organizations and help people move forward.
50:30 Confront (understanding and confronting reality)
52:11 Commit (making change happen)
53:50 Connect (physicians connecting together in ideation)
55:00 Collaboration (how physicians work together for the greater good)
55:35 Contribution (sense of purpose in the practice of medicine)
57:16 Parting thoughts from Dr. Pearl on the death of his father and why he wrote “Mistreated” and “Uncaring”