Do You Know How to Predict Externalities?

Did you catch the episode of Malcolm Gladwell’s Revisionist History about triplicates—those state-issued prescription pads that produced three copies of every painkiller script written? Many in medicine remember triplicates as a classic example of government overreach. But in 1990s New York, a city beset by a major drug problem, these triplicate pads had an amazing effect: opioid overdoses plummeted when doctors were forced to use them.

In this episode of Fixing Healthcare, hosts Jeremy Corr and Dr. Robert Pearl join ZDoggMD to take an unfiltered look at the impact of triplicates (and regulations in general) on healthcare.

The group also debates Amazon’s $3.9 billion purchase of One Medical and explores the untold lessons of Sesame Street (including: did the Count have an undiagnosed mental health disorder?), and much more.

Welcome to Unfiltered, a show within the Fixing Healthcare family of podcasts that brings together iconic voices in healthcare for an unscripted, hard-hitting half hour (plus) of talk.

For more, press play or peruse the transcript below.

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

UNFILTERED TRANSCRIPT

Jeremy Corr:

Hello, and welcome to Unfiltered, our newest program and our weekly Fixing Healthcare Podcast series. Joining us each month is Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice. Then I’ll pose a question for the two of them as the patient based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Good morning, Zubin.

Zubin Damania:

Hey, top of the morning, Robbie.

Robert Pearl:

You know, for a whole week before we do this show, it feels like I’m about to go to a Michelin starred restaurant and the chef’s going to cook me some new dishes. I don’t know what they’re going to be, but I’m certain they’ll be tasty and well seasoned and I can’t wait for today’s tasting menu. So if it’s okay with you, I’d like to revisit the conversation we had in the last episode, about the value of eliminating regulations and restrictions to address problems, rather than adding new ones to deal with the rules and regulations and restrictions that aren’t working. Like you, I agree, we have far too many. But I had an a-ha moment this week, when I listen to an episode from a different podcast, this one, Malcolm Gladwell’s Revisionist History. And he talked about the impact of triplicates, a topic I had never considered. So let’s start by, for listeners who may not know what a triplicate is, could you describe it for them?

Zubin Damania:

So are we talking about the old school DEA triplicates, where whenever you wrote a narcotic, it was copied three times with carbon paper and you had to send one copy to somebody and it was just this onerous process?

Robert Pearl:

Exactly the one I’m talking about. That’s exactly the one or the one he talked about. And he described some research that came, as you say, it’s the old way, so this was research coming out of, I’ll say 1990s. New York, Massachusetts, and New Jersey have similar populations and in the past they had similar incidents of deaths from overdoses. Then New York puts in place the triplicate process, but the other two states don’t. And suddenly deaths from overdoses come crashing down. This is like a natural experiment. It’s what economists love to find. And I want to know if our goal as doctors is to minimize deaths, how can we figure out which bureaucratic tasks are valuable? Which ones are waste of time? Which one will save lives and which will result in harm to doctors and patients?

Zubin Damania:

Man, this is a wonderful thought experiment because you have the regulation, which was designed to make it more difficult, presumably, to give out narcotics and so it adds a little activation energy to the physician’s workflow. So in a way, what you’ve done, is you’ve made it a little less easy for a physician to give a narcotic. And I remember when I trained in the ’90s, if someone needed a narcotic, I would just have to let out this heavy sigh, because now I got to go back to the little office, grab this thick old pad with the triplicates, do all this whole rigamarole, keep the records safe somewhere where they aren’t going to be stolen for a decade or whatever the requirement was. So any way I could get out of having to do that, you’re kind of looking, “Well, does this patient really need narcotics?” Et cetera.

Zubin Damania:

So in a way, what it was, was in my mind, it was saying, “Okay, did the doctors really need to do this?” Now, so it turns out they probably didn’t. Now the question is you didn’t really study how much excess pain was there, how much suffering was there, et cetera. We don’t know the answer to that, but we do know that overdose deaths plummeted. So the question is, was the regulation a good idea in the sense that, oh, we need that kind of regulation. Or was it a more of a test that says, “Hey, maybe we ought to retrain physicians.” Because at that time the pharmaceutical companies were telling us, you know what, a pain is the fifth or sixth vital and we need to treat it aggressively with narcotics and people don’t get addicted if they have real pain and so on. All of which has been proven to be nonsense and or less sensical than they were saying. And there we are. So it’s a matter of teasing out, do we need that bureaucracy or do we just need more awake medicine that looks at the externalities of everything we do?

Robert Pearl:

What do you think?

Zubin Damania:

I think it’s actually, we need more awake medicine that looks at the externalities of everything we do. And it just happened to take a bureaucratic intrusion at that time to teach us that guess what? This is probably not a good idea, how much opioids we’re giving out. Now the thing is, again, you and I are both also I think, although I may be putting words in your mouth, advocates of good system design, like smart system that, to use Jonathan Hyatt’s metaphor of the elephant and the rider. Our sort of unconscious mind that kind of runs the show in many ways. And the conscious little guy riding on top that really often is more the servant to the elephant. How do you shape the path that they’re walking on to make the default actions more beneficial? And to that degree, systems design is good. So would it be great to make it really easy to prescribe narcotics in the setting of a pharmaceutical industry that’s promoting them? No, probably not. So you would need that kind of systems designed. So it’s always a balance.

Robert Pearl:

I think that’s the argument that people make when they put in place restrictions and regulations, which is that if you shape the path in the direction that either will maximize good or minimize harm, that that’s going to lead to a good outcome, but as you and I both know, often that’s not what occurs. And what occurs is you inflict pain on both the doctor and the patients.

Zubin Damania:

So I, yeah. And the way I think about that increasingly is the way we think about any sort of, even if you study existential risk, like nuclear war or environmental catastrophe or these kind of things, you’re always looking at, okay, here’s an intervention that we do, like say social media with tech algorithms that try to draw our attention. Okay, that’s great. It has this outcome that the companies make a lot of money and we get this experience of social media. What are the externalities, the second, the third, the fourth order effects of that technology? And it’s the same with regulation in the healthcare space. We don’t know what those externalities are until you put it into place. And at that point it may be out of the bag, very hard to unwind and you’ve caused a lot of damage. So we need to get better at predicting externalities or considering them. Factoring them into the cost of any intervention. And it just gets tricky, but it’s not impossible. We ought to make it a priority.

Robert Pearl:

I heard interesting, I’ll say study, I don’t know if it was really a study or just an observation, that Sesame Street, the show for little kids, you think is designed to teach them the alphabet and mathematics. You know what it teaches them? Television is about entertainment. It’s not about learning. So although it is introduced at that point, it becomes an addiction for entertainment rather than for growing one’s mind and confronting difficult questions and challenges.

Zubin Damania:

Now that’s really interesting. So I actually revised my history of Sesame Street years later when I went through medical school, because I realized each of the characters had distinctive psychopathology and physical pathology, like the Count. Do you remember him? He would teach kids purportedly how to count, but really he had a severe case of obsessive compulsive disorder. I mean, he was counting everything. He couldn’t stop. One, two, three, ah, ah, ah. Poor Count. He’s suffering. But yeah, I hear you.

Robert Pearl:

Let me ask you about an associated issue that you and I both think about a lot, which is burnout. And one of the first step in addressing any problem, is always to figure out what’s going on and we know that bureaucratic tasks and the prior authorization imposed by insurers and all the rules and restrictions by hospital administrators. We know that this is making the lives of doctors and patients worse. But now I want to ask you the next step, which is recognizing the problem doesn’t, from my perspective, solve it. What you actually do is have to get someone else to take action. In your mind, how can doctors and nurses force the insurers and hospital administrators, to do the things that we know will reduce burnout without creating secondary problems as a consequence?

Zubin Damania:

Mm, I think in this case, it’s one of those situations where we have this adversarial zero sum relationship. It’s kind of like this game A dynamics, where somebody wins and somebody loses. So the administrators win, the doctors lose. The doctors win, the administrators lose. The insurance companies lose. We really have to align the incentives across the spectrum of that, which means maybe it’s more integration. Maybe it’s the integration of the payers and the caregivers together, that allows the incentives to align. And even then, of course, we’re going to have the politics that go back and forth and the different dynamics, but it would be much better. So I don’t know that anybody’s going to be able to force anybody to do anything.

Zubin Damania:

But even like something like a prior auth. Why are prior auths in place? Because a lot of times physicians will do things that are not evidence based, that are costly, that have second order iatrogenic effects, meaning they cause harm because of over-testing, over diagnosis, overtreatment. And the insurance companies say, “Well, okay, it’s also increasing cost. So let’s put a prior auth, let’s throw that triplicate, the barrier to entry here. Make it higher.” And then what happens is the doctors escalate and say, “Well, now my autonomy is threatened. Now my clinical judgment is questioned and my time is affected.” And that creates this injury that leads to burnout. So how about we actually powwow and say, “Okay, so what are the practices that actually do work? And when can we have the clinical autonomy to override those practices?” Because that’s what doctors do best is that deep intuition to say, “This is where the algorithm actually doesn’t apply or where we can actually make an exception.” And that trust then leads to more alignment, less need for these weird negative incentives to be put in place, I think.

Robert Pearl:

I agree with you completely. It’s a lot of why I think we have to move from a fee-for-service volume based mentality to one that’s capitated. The tremendous work you did when you were in Las Vegas, demonstrating how you can improve quality and lower costs, if you all have the incentives that align with each other, but still the progress to that goal seems to be incredibly slow.

Zubin Damania:

It does. Now, what’s interesting is our partners in that effort in Las Vegas, they merged with One Medical last year and One Medical just got bought by Amazon. So it’ll be interesting to see how that sort of intensive primary care model evolves in that space. It’s going to be interesting. And there’s a lot of headwinds to change, because the payment models haven’t changed. You’re still working in this kind of either fee-for-service or capitated without sort of revenue share or positive externalities when you do really well piece. And so we really need to look at how those payment models affect care models. And it’s tough because there’s so many legacy players. So many people with so much to lose and they’re all oligopolies. So how do you even start to crack that? It’s going to be multifactorial.

Robert Pearl:

Let’s follow up on what you just raised, which was the Amazon purchase of One Medical. For listeners who may not know, One Medical is a primary care first organization, Began in San Francisco. It’s now in 180 offices and 24 different cities. It was just purchased by Amazon for 3.8, I believe, billion dollars. Amazon entered into healthcare very slowly. A couple of years ago, they bought PillPack, which is a pharmacy delivery, that was really important because you have to have licenses in every state and they inherited the 50 licenses needed to distribute pharmaceuticals. Then they built some clinics for their own employees. Then they started online telemedicine. And now with One Medical, particularly because One Medical has acquired a company called Iora, about a year ago, which is in the Medicare space. You’re looking at this massive opportunity for Amazon to come into medicine, the way that it went into retail.

Robert Pearl:

It’s began in the book era. And when everyone was worried about the bookstores, they were already thinking about all of retail and then people were worried about the retail. Now they’re thinking about medicine and on and on in that process. How do you see this acquisition? How big a threat do you think it is? Where’s it going to go? When’s it going to happen? How should doctors think about it? How should they behave differently at this point?

Zubin Damania:

So this is an interesting response to the clear market dynamics with big self-funded employers, like Amazon, that prices keep going up. Care, quality and outcomes are not good. And it’s unsustainable, economically and morally actually, because people go bankrupt because of these medical bills and so on. And it’s a drag on the economy. So Amazon said, “Okay, well now we’ve disrupted these other spaces. Let’s see if we can do medicine.” Now, of course, they failed to do that with their enterprise Haven, with Berkshire Hathaway and JPMorgan Chase. So they know already how difficult this space is and they purchased One Medical. Now what’s interesting about One Medical relative to Iora, like you said, Iora’s focused more in the Medicare space because we use the same Turntable Health model that we used in Vegas at Iora, this sort of team based primary care, health coaches, intensive management of at-risk patients.

Zubin Damania:

Now One Medical actually just charges a yearly membership fee for access. So you get easier access. You have this high touch app and so on that you can schedule easily, but they still charge commercial insurance. And so as a result, they were losing money prior to the acquisition. So in order to make this work, Amazon’s going to have to figure out how to actualize really good preventative team based, relationship driven, primary care, that prevents downstream spending that allows some curation of a network of specialists that are actually doing the right thing, which is very tough in the self-funded space, because then that means employees have restricted choice. And they have to do it in a way that they’re going to have to subsidize, because it’s not going to be profitable initially.

Zubin Damania:

Now, if they can do that, they have the power, the money, the scale, the drive to do it. They could actually produce a kind of care that patients are so compelled by and physicians are so compelled to work in, that it does create that disruption and then the payment models start to change and you have true transformation. So that’s the potential outcome there. The more likely outcome is it’ll all fail, but that’s how I think about it.

Robert Pearl:

I would beg to disagree.

Zubin Damania:

Awesome.

Robert Pearl:

I predict that this will be a major transformation of American medicine. I think Haven failed because the other two CEOs really wanted it to be a not-for-profit for their own employees. And Jeff Bezos wanted it to be a sixth of a $4 trillion industry. He already got what he could get in retail, and now he wanted it to do it in medicine. I think that he will. I think that the word, choice, that we use has two meanings. Choice is, I want Dr. Smith. Choice is, I want my problem taken care of next Thursday. And he’ll be able to offer you the convenience. He will design healthcare the way he designed Amazon, which is to make it so convenient to give you lots of choices. And the fee you described for One Medical, I think that sounds like a Amazon Prime subscription model of which he only has 110 million people paying him for exactly what One Medical does.

Robert Pearl:

I think the big problem that One Medical, Iora and everyone else has had is scale. And what is Amazon really good at? Scaling. And I said back at Haven, is there anyone who thought that Bezos was in this as a not-for-profit for his own employees, probably also thought that all Amazon did, was sell books. I think the same thing here. This is not about improving the American healthcare system. This is about making money for Amazon, but his strategy would be to do in healthcare, what he did in retail, which is to make it very patient focused.

Robert Pearl:

And I believe that unless physicians start to change now, they’re going to get left behind, because I guarantee you, he’s not going to pick the best insurance company. He’s going to be his own insurance company. And he’s not going to pick every doctor in every hospital, but he’s not going to pick them because they’re cheap. He’s going to pick them because he provides high quality, good service in an efficient kind of way. And so I’m betting on them. And it’d be a great one to come back in about five years and see whose prediction ended up being more accurate.

Zubin Damania:

So, listen, I hope to God you’re right Robbie, because this is part of… Look, if they can pull that off, it will truly be the kind of American style healthcare transformation that I’ve been advocating. Rather than just straight single payer and paying for our broken system currently, why don’t we actually try real innovation? And if Bezos can do it’d be wonderful. What’s fascinating is don’t forget Zappos, who’s CEO actually funded our clinic, Turntable Health, is a fully owned subsidiary of Amazon. And they actually worked with us and saw our model at Turntable through Zappos. And so that was their sort of first exposure to this sort of intensive primary care.

Zubin Damania:

If they can bring what we were trying to do to scale, it would be absolutely transformative. And so I’m rooting for them. What I am Robbie is, I’m a little superstitious. If I’m too optimistic, what I find is, it’s like what my mom taught me. She never bragged about her kids, things would go wrong. So I’m hoping you’re absolutely right, but publicly I’m going to be very a circumspect because there’s a hubris in tech too, that often leads to failure.

Robert Pearl:

Now, on the other hand, I am worried about the success they’re going to have, because I can predict what it’s going to mean for doctors and nurses. And I’m not sure that they’re going to be happier under, I’ll say under the thumb or under the employment, I don’t know which way it’s going to go, of Amazon. We certainly know there are a lot of issues with the people who work inside Amazon today.

Zubin Damania:

So that was another point. And when I talk about it with my audience, they express the same concern. They’re a healthcare audience. What I’ll say is this, the hope there is that when Amazon acquired Zappos, Zappos was considered one of the best places to work. It would win these awards every year because of Tony Hsieh’s leadership and the general focus on happiness and work/life balance and so on. If Amazon does the same thing with Iora, One Medical, then we’re in good shape. If they try to turn them into Amazon employees, we should be very concerned, because they will create this attempt at cost, quality and convenience on the backs of overworked and underpaid and under automatized employees. But hopefully that’s not the case. And in fact, I don’t think it’s possible, because without engaged, trusted, and resourced healthcare providers, you can’t have quality, cost and outcomes that work.

Robert Pearl:

Yeah. I don’t think it’s going to be a question of not paying them. They’re going to pay them adequately. I think it’s going to be a question of expectations and that the expectations that Amazon will have, which is going to be a customer first notion, will clash with the culture of medicine, where physicians have, as you said earlier, focused on autonomy, focused on their own office, focused on the freedom to do whatever they wanted. And now there will be expectations about how quickly patients need to get care and how broadly they need to be available. And the types of things you could see coming out of Amazon. I think, again, I’ll flip back the other way, like yourself, the idea that somehow you could order shoes and just return them back and all the other conveniences that Zappos did, made no sense, except that it was so successful, because it was so desired by the customer. And I think that that’s the biggest shift. That I think Amazon will make medicine be customer, patient focused rather than provider focused.

Zubin Damania:

I think you’re right. And so the caregivers better get ready for that. But the other thing is, hey, if they just give them the 25% Amazon employee discount, I think everyone will be perfectly happy don’t you?

Robert Pearl:

Yep. I think it will be true.

Zubin Damania:

Just solve burnout. Just solve burnout. Just order a hand massager from Amazon at 25% off.

Robert Pearl:

So Zubin, I love our listeners and our audience is massive and several of them said they really liked our conversation last time about movies. And they wanted me to ask you, what is your favorite movie of all times?

Zubin Damania:

Oh, it’s really a difficult answer because there’s a few, but I’d say one is The Matrix. And the reason I love The Matrix is because it really encapsulates the deepest sort of Buddhist philosophy or any spiritual philosophy, which is you feel like you’re one thing and it turns out that’s an illusion. And at some point you wake up and then you do battle with your demons and then you transcend. You almost die and are reborn as a much more awake being. And that’s why I love The Matrix. Plus it was just amazing effects and action and all of that, but every single frame of that movie, points to this sort of deeper truth. So I love that. And then one of my other favorite movies is The Big Lebowski. Just because it’s The Big Lebowski. The dude abides.

Zubin Damania:

How about you?

Robert Pearl:

I’ll throw you two in return. A movie that probably 1% of listeners may ever have heard of, but I love, was a movie called Burn. It was Marlon Brando. And it’s the story of Marlon Brando, Sir William Walker in the movie, who’s sent to a Portuguese island in the Caribbean, to incite a revolution, because the British wanted to take over this very high revenue, highly profitable, sugar cane growing island. And he finds a dock worker, Jose Dolores. And he teaches him how to be a rebel and how to incite a revolution and it’s successful. And he leaves. And then in the second part of the movie, he returns seven years later, because now the island is in revolution against the British government. And he’s sent there to shut down the revolution. And the only way he can do that is by burning the entire island, because once the revolution begins, it can’t be stopped. So that is one of the best movies I’ve ever seen that I think of often.

Zubin Damania:

I don’t know how to parse that Robbie. It kind of feels like the hospital, like the clinical administrator’s paradox. You come from that space, you’re like, “Okay, I’m going to fix things.” You go become a leader and then you realize how trapped you are. But that’s great. I’d never heard of that movie. I’ll have to check it out. What’s the other one? Oh, go ahead sir.

Robert Pearl:

I just think the revolutionary spirit to make change is why this whole season I’m focusing on, this idea of rule breakers. And I think rule breakers have to understand that once you break the rules, you don’t control the rules, but they need to be broken and basically the entire model of the colony, which is really what it was, whether it was under Portuguese or British control, just was not appropriate. And ultimately the human spirit would survive. Although I guess in the end, the island was burned down, but you can’t stop it once it starts.

Zubin Damania:

Sometimes you have to start fresh. That’s you know.

Robert Pearl:

The other movie and to me, it’s the three part movie, is The Godfather. What I love about movies is when I learn things and what I loved about the three… The first one is one of the best movies ever made, but it’s beyond that. It’s the triple movie where you have the immigrant coming to the United States, starting with nothing, working his way up. And by the third movie, now you’re on the third generation and the last thing they want is to be in any way associated with the past.

Robert Pearl:

This is just the classic three generation story. It was in my family. It’s probably in your family. We see it all over the place. And it’s just so well shown. Without telling people, you just watch it. Everyone moves in the direction that you can understand. And by the end, you’re in a totally different place than you start and The Godfather is all over. So the other thing I loved about that movie is that my dad, near the end of his life, we had a little thing where for three weeks in a row, every Sunday night, we’d watch one of the three. And I still remember being with him in those last days. And it was a very emotional time for me.

Zubin Damania:

Mm that’s beautiful. Yeah. The immigrant story and the fact that everyone can get something from that. That’s beautiful.

Zubin Damania:

Movies, oh, sorry, one last thing. I mean, movies are so powerful, I think for us, because when we’re watching a movie, if we’re truly absorbed, the sense of self evaporates, it’s just the movie. And we lose ourselves in that. And I think that’s why it’s such a powerful archetype for us that going to the movies, especially going to the movies with others. There’s this weird collective thing that happens. It’s really wonderful. I recently saw a movie, Everything Everywhere All at Once, which is about this sort of multiversal Asian immigrant tale that throws in a multiverse. And some sci-fi and some action, but it’s really about a family story. And you could just feel the energy of the audience, many of whom were Asian American and is a very powerful experience.

Robert Pearl:

Wow. I haven’t heard of that movie. I’ll check that out too.

Zubin Damania:

You might enjoy it.

Robert Pearl:

Is it currently playing?

Zubin Damania:

It might be rereleased. It came out a few months ago, but you can get it on the usual rental channels online.

Robert Pearl:

One last topic coming out of what you mentioned earlier, you mentioned Buddhism and I’m always fascinated by your understanding of it, your practice of it, you’re going towards it. A book that I read at least twice a year is Victor Frankl’s Man’s Search for Meaning. And in this podcast, we’ve covered the gamut already. Issues around suffering and happiness. You’ve pointed out many times about Buddhism and the idea that suffering is, it’s integral part of life. Last episode we talked about on the other hand, that we’ve both had great fortune in our lives to have had pretty good lives and excellent upbringing. Victor Frankl talks about the fact that we can’t control the world around us, but we can control our response to that world. I want to ask you about this whole notion about our attitudes, about happiness and what we should do about that in the context of healthcare today. How do we separate what’s real, which is our ability to gain happiness out of purpose and at a function from what is simply Pollyanna deception.

Zubin Damania:

So, this is interesting and I actually don’t consider myself a Buddhist. I actually look at all these different approaches to self-awareness or awakening or however you want to call it. But I think what many of us in healthcare suffer from and I saw this at the retreat we did, I’m actually tomorrow, I’m leaving for another eight day silent meditation retreat, actually with a anesthesiologist, Angelo DiLulo, who’s been on my show a few times at his home. It’s just a small group of people. And it’s interesting, because a lot of these guys are healthcare people at the last retreat.

Zubin Damania:

And what we find is we are so self-referential, we’re so up in our head, we’re so identified with our thoughts and our emotions and our bodies and we feel like we’re the small thing against the world. And so we’re trying to find happiness as a separate self battling against a world that is opposed to us. And the real revelation starts to come when you realize, that’s just not the case. When you can actually examine your experience in the current moment and find no distinction between self and other and in a sense, it’s all happening and it’s happening perfectly. And that automatically realigns attitude, because attitude is a kind of a thought pattern.

Zubin Damania:

And we then interact with the world in a very different way. The energy we put out is different and our responses are different. And it’s all the cliches you hear, everything is love and this and that and all that. Those are just dumbed down ways of saying the experience that’s available in the present moment is beyond words. And people will reduce it to a Hallmark card, but it’s actually experienceable. So instead of thinking about it, talking about it, theorizing about it, just pay attention to the present moment and see what happens. And often the attitudinal changes and all that can just emerge from that, but it takes persistence, awareness and sometimes a teacher and sometimes some striving, which is paradoxical, but that’s been my experience so far on this sort of journey.

Robert Pearl:

How do you stop that from making the individual, the victim and the source of the problem, when it’s really the context around him or her?

Zubin Damania:

Yeah, it’s a paradox because you’re telling somebody, “Listen, this is really in your control. Meaning there’s no control, but you can wake up to that and you have to look.” And so in a way, you’re giving them this sense of agency and responsibility for themselves, which can create this kind of victim mentality. But in reality, that’s to wake up to the fact that they’re really, this is just this beautiful present moment happening. There’s no past and future. It’s really just this.

Zubin Damania:

And that means that when you actually, it’s not even a knowing, it’s an actualized realization. You embody this understanding. The way that you show up in the world actually is better. It’s better for you in the story sense. It’s better for you in the emotional sense and it’s better for others. And so it’s because so many of us are trapped in the kind of, I’m a victim mentality, or it’s all my circumstance, that’s the problem. And the truth is, there is no problem in the present moment, but that again, and that gets back to The Matrix. He says, “There is no spoon,” to Neo. In the end, when you realize that, then you have all the power paradoxically.

Robert Pearl:

To be continued in the next episode. Let me turn it back to Jeremy to pose the question to you and me.

Jeremy Corr:

I’m curious if there is a person or topic or something that happened in medical history, that if each of you had to choose, that you would make a movie out of that you would feel that would be inspiring to not just medical professionals, but to a mainstream audience as well?

Zubin Damania:

Boy, there are a lot of beautiful evolvements in medicine. I think Osler’s story, some people call him the father of modern medicine would be a great kind of biopic to tell, to kind of show what medicine is at its heart. I think the story of Maurice Hilleman who pioneered and discovered and invented some of the first commercial vaccines is a beautiful story. I think Paul Offit actually was involved in a documentary about him, but doing a fictionalized version would be a beautiful piece. There’s so many of these things that would inspire us to reconnect to the kind of sacred heart of medicine, which is that deep connection with other humans. That then you fold in the science and the technology and the innovation, but really it’s about other people. So I’ll turn it over to you, Robbie. But those are my top of the head thoughts.

Robert Pearl:

I love, whether it’s a novel, whether it’s a movie, the vision of an arc. I think every story has to have an arc of one sort. There are lots of different arcs, but it has to have a connection coming up to either a peak or going down to a valley and coming back up afterwards. And the story that I’m obviously focused a lot on right now, I just did a TED Talk on, was the story of Ignaz Semmelweis and the discovery of how doctors were carrying the bacterium, they didn’t know as a bacterium at the time, from the autopsy room into the delivery room and killing large numbers of women. I could imagine the movie opening with the suffering of women who were coming in for, what should have been a glorious event, delivering a child and dying in the hospital and leaving the new baby and the children back at home without a mother. Semmelweis’s fortuitous experience where a colleague nick’s finger, develops a local infection, goes on to a clinical course, identical to these women who develop the technical term’s puerperal fever.

Robert Pearl:

And he goes on to die. Semmelweis comes up with an idea. He’s a scientist. He tests it. He finds that the mortality drops from 18% to under 2%. We expect, as the audience, oh my gosh, this is terrific. People are going to embrace it. Doctors are going to love it. It’s going to spread rapidly. Only to find out that no, they actually hate it, because it lowers their status. It lowers their prestige. And Semmelweis ultimately gets submitted to a psychiatric mental health facility where he goes on to die a couple of years later.

Robert Pearl:

And it’s the pathos of both the experience, the suffering of the women and the families and the arrogance of the physician at the time. And of course, in the end, the pathos of Semmelweis himself, who won’t get a chance 50 years later, to see Pasteur define infection and be able to identify the bacteria that is responsible for this disease. And therefore allow us to then go on to treat the bacterium. And now that’s a relatively rare complication following delivery. So that’s the arc that I would follow in the story. And I think it would make a far, even a far more beautiful movie, than either book or article.

Zubin Damania:

So basically what I’m hearing is, you’re nixing my inventor of the DaVinci prostate robot story. Is that what you’re saying for Semmelweis? Because I think that story is completely boring and uncompelling.

Zubin Damania:

No, it’s beautiful. The Semmelweis story, because it points right back at us, at the culture of medicine. It’s so uncomfortable to think that we could be complicit in harming and creating, suffering in women. And yet there it is, the culture trumps everything else. And Semmelweis, when you talk about the arc, the hero’s journey, what Joseph Campbell, famous mythology professor talked about this hero’s journey. And by the way, a great thing to listen to if you haven’t, Robbie is The Power of Myth. It’s an audio series with Joseph Campbell and Bill Moyers from, I think it was the ’80s. And they talk about this stuff, the hero’s journey, it’s really, really powerful.

Robert Pearl:

I’ve read Joseph Campbell’s book. I love it. And I’m going to make sure we talk about it as the first thing we discuss in the next episode of Unfiltered. So Zubin, it’s been terrific. Thank you so much. And I can’t wait till we get back online a month from today.

Zubin Damania:

Thank you, Robbie. It’s always a blast.

Jeremy Corr:

We hope you enjoyed this episode and we’ll tell your friends and colleagues about it. Please follow Fixing Healthcare and Apple Podcast, Spotify or your favorite podcast app. If you like the show, please rate it five stars and leave a review. If you want more information on healthcare topics, you can go to Robbie’s website, robertpearlmd.com or visit our website at fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook and Twitter at Fixing HC Podcast. Thank you for listening to Fixing Healthcare’s newest series Unfiltered with Dr. Robert Pearl, Jeremy Corr and Dr. Zubin Damania. Have a great day.

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