FHC #74: The tangled mess of medicine and politics

As a college freshman, Fixing Healthcare cohost Dr. Robert Pearl decided that rather than becoming a university professor as he had planned, he’d go into a field without politics: medicine. He laughs about how naïve he was as a 17-year-old.

“Healthcare is about life and death,” said Pearl, recalling his decision, “How could there be politics entwined inside that esteemed world?” Of course, Pearl soon learned that politics and medicine are a tangled mess.

In this episode of Unfiltered, Pearl and his cohost Jeremy Corr join ZDoggMD to look at the relationship between medicine and politics and if there’s any opportunity for logic to prevail.

To find out, press play or keep reading.

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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 in our weekly 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 to the two of them based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Hey, Zubin, how was your Thanksgiving?

Zubin Damania:

It was thankful. I really enjoyed it. My wife was on call, which meant we didn’t have to go through the full production of the meal. We went to a half meal, which was absolutely great. I had 70% less bloat and 100% more gratitude. How about you?

Robert Pearl:

I had a great time. I was over at my sisters and had a bunch of folks there. Did you do anything special to communicate your gratitude to others?

Zubin Damania:

I texted a lot of people that I had been a little out of touch with, and just to convey how important they are in my whole life and journey.

Robert Pearl:

Excellent. That sounds great. So I don’t know if I ever told you that I became a doctor to avoid politics.

Zubin Damania:

I didn’t know that.

Robert Pearl:

Yeah. So I was in college. I was a philosophy major, and my hero, who was a philosophy professor, quite an excellent one, he went on to become the chairman at Reed College, didn’t get tenure because of his political views, and I decided then that I wanted to do something that would have no politics. I mean, healthcare is about life and death. How could there be politics entwined inside that esteemed world? And so that’s truly why at the age of 17 I decided that I’d become a doctor, and I learned stuff later on. Any thoughts on that observation, and what we can do to minimize the politics in medicine?

Zubin Damania:

Well, you had me at philosophy major. I don’t remember you… You must have told me that, but that’s impressive. If I could go back in time and do it again, I would do philosophy instead of music and molecular biology, although that’s kind of philosophy in a way. Yeah, politics and medicine have been to some degree dance partners for a long time, but I think right now it actually just reflects how politicized everything is, and how everything is so kind of divided. Although, I’ll say this, Robbie, I’m sensing something in the air, and I might have said this at our last conversation, but I really think something is shifting. I feel like people are starting to wake up to the fact that we are really divided over nothing substantial in the sense that we’re all trying to find truth and goodness, and we just have a slightly different spin on it, and medicine maybe will wake up, but as usual, we’re about a decade or two behind the rest of the culture.

Robert Pearl:

Actually, I think that you’re correct, and I think we saw that in the most recent midterms that there was a lot more people I’ll say in the middle rather than the 20%, at both extremes, who were yelling the loudest and typing with all capitals and explanation points, but there’s a lot of people in the middle, and they want to know the truth. And I think in many ways, I’m not talking about the specifics of the outcome, but the election process itself, and, of course, we didn’t even have any attempt except in Nevada to just get rid of the entire voting and somehow have a different method of selecting candidates based upon maybe some sorcery or something else that could go into its place.

Zubin Damania:

Yeah.

Robert Pearl:

But one of the things… Sorry, go on.

Zubin Damania:

No, no, no. I was just going to say in Nevada we have a lot of interesting things like legalized prostitution among other things, so we are a special state.

Robert Pearl:

Oh, excellent. That’s right. You were there. Exactly. Legalized gambling, prostitution, so on. Yeah. One of the things that strikes me as I think about the politics is that you would think that the health status would drive the politics, by which I mean if a lot of people didn’t have coverage, then they would be attracted to a party that would be likely to give them the coverage, and we think about people voting their interests. If there was a lot of opioid addiction in a particular geography, you would think that that would be a very high concern, and yet we see almost the opposite. Tell me where you live, and I’ll tell you your view on a problem. Whether for you it’s a particular medical challenge or not doesn’t seem to be the driver as opposed to where you happen to own a home and in many cases grow up. This seems really strange to me.

Zubin Damania:

Yeah, it does, and again, all things seem strange if you look at humans as rational actors that work in their best interests all the time. And unfortunately I think we’re emotional, intuitive creatures that are the product of our conditioning and our moral sort of taste buds. And I think if your moral taste buds are concerned about say liberty versus oppression or government controlling things, even though you’re desperate for care, and you need it, and it would save your life or your family’s life, I think through that moral lens you’ll see any sort of government “intrusion” into healthcare is something that’s adverse, and you’ll fight tooth and nail.

There’s also a tribal component on all sides of this, like you said, where you grow up, and I think where you grow up is to some degree it conditions how you are, but to another degree you’re kind of attracted to those places that are an expression of your own sort of moral matrix. And so I think it’s a variety of those factors, and so people do not necessarily vote, or act, or think in their best interests always, if you look at their best interests from that standpoint. But if you look at their best interests as a morality play, they almost always do it in that way it seems. Yeah, that’s just my sense of this.

Robert Pearl:

I always love talking to you, because I think about things that I hadn’t contemplated before. About a decade ago, I did some research with a neurologist named George, and George and I looked at brain scans, and we looked at what happens when people get put into situations of great threat or great opportunity, and what we found, George York and myself, was that there’s actually a shift in our brain in terms of perception. In the last show you mentioned the amygdala, the source of great fear, and what you see is that the amygdala first gets stimulated, and then as you mentioned actually in the last show, how the occipital lobes change, and we see things differently, and by see it’s not just a vision. It’s all of our senses.

It’s our perception of the world, and maybe some of these pieces are that there are fears or maybe hopes that people have that actually change their perception. And when you move someplace else where there’s different fears, and different hopes, different views of the world because of circumstances, then you change that perception, and maybe that accounts for some of this great shift in how we relate to each other or fail to do so, and maybe some of it is coming together to recognize that we may share in more common fears and more common hopes than we otherwise might realize.

Zubin Damania:

This is a really interesting insight actually, Robbie, because it made me think of something. You were saying sometimes I’ll prompt you. This prompted me, because there is this idea that part of the reason where… There are many reasons why we’re so divided and politicized nowadays, but one of them might be that your local scenario kind of conditions you and vice versa, but the global village that we have with social media is that now there’s a saying, “Good fences make good neighbors.” When not much about someone else they’re actually all right. The more about them sometimes it’s like, “Hmm, I’m not sure about this.”

And when you take disparate ideas from different geographies that are evolved differently to suit that geography, and you place them adjacent to each other, that’s when the all caps starts happening on Twitter, because somebody that you never would’ve really known that well, and you still don’t know them well, but you know them in a social media way, are hitting you with ideas that seem so antithetical to that moral palette that they do generate that fear. It’s that fear of loss of identity, the fear of loss of self, that this is who I am, right? I’m this liberal, or I’m this conservative, or I’m this libertarian, and suddenly you’re met with somebody who’s giving you totally different ideas, and it becomes instantly a kind of like, “Okay, fight or flight. I must defend this,” sort of identity.

And what may be happening is we’re getting so used to social media now that we might be starting to transcend that initial shock and start to see what you’re pointing out, which is, “Hey, actually we’re all in this game.” And actually when you start to point out how divided we are, people start to wake up and go, “Yeah, we are kind of getting played by this, the news cycle, and social media, and this kind of thing.” So it is really interesting.

Robert Pearl:

So let’s try to meld the politics and the health. One of the areas that I’m increasingly concerned about is the LBGTQ population, and how in this environment they’re going to be able to get good healthcare across the nation in all 50 states. Do you have any thoughts about, first of all, the hatred that’s seems to be often directed particularly at trans individuals, and how will they get their healthcare needs met from an optimal medical perspective?

Zubin Damania:

Yeah. And this is one of those things where… Who said this? It was recently the World Cup, and the Iranian media was questioning American soccer players, and they asked a black soccer player. They said, “What’s it like living in a country where you’re discriminated against?” And obviously this was all politicized because of the whole Iran-US thing. And so this journalist was really trying to provoke this guy to say, “Yeah, we live in a super racist country where people are discriminated against because we keep accusing them of discriminated against women, which they do.” And he said, “Yeah, it is interesting, but I’ll say this, in America, one of the things I’ve noticed is we’re constantly trying to get better. There’s always some feeling that there is a kind of progress, and that makes it much easier to live here and deal with it, and I want to be part of the change.”

And I think with trans, with LGBTQ+, and all of that, I think that’s also what we see. These issues were repressed previously. Now the repression is less, and so we’re seeing them come to the fore, and it’s louder in sort of the culture, and so it’s easy to feel that there’s no progress, but I think that even that the conversations are happening is progress, so it’s a lot of it is ignorance. A lot of it is just lack of knowledge, and reactionism, and that kind of thing, and I think it is going to continue to progress. I mean, just look at the bill now that that’s going through the Senate where they’re going to codify protections on gay marriage say. That would’ve been unheard of a decade ago, and so I’m actually optimistic, but you can’t stop working for it, right? You can’t stop being part of the progress.

Robert Pearl:

Again, another interesting thought that I hadn’t had before about how as soon as you stop pushing forward, you slide back, and that it’s not a question of pushing forward always to make progress. It’s pushing forward even to hold the progress that you have, and I can think of a lot of examples where as soon as people stop pushing, what we see is that everything slides back to where it came from even though I can’t find the rationality for why it started there.

Zubin Damania:

Yeah, I think it takes a collective effort, and you’ll always get resistance and even understanding the resistance is a good thing. If you can see through other people’s eyes and go, “Okay, what is it that… What is this? Is this fear of other? Is this just misunderstanding? Is this a kind of projection where there’s something about them that they feel isn’t as mainstream, and they don’t want… They’re projecting this onto others.” You wrote your book Uncaring about medical culture, and I think what I loved about that book is that you just shined a direct light on things like emotional repression, projection, denial, the things that we do in medicine that we’re conditioned to do, that are really fundamentally quite harmful to progress, and I think it’s true in broader society as well. We have an epidemic, a pandemic of emotional repression, and avoidance, and projection as a result.

Robert Pearl:

Well, for any listeners who might not have read the book, let me point out that a part of why I focused on denial is that denial is what makes the medical culture great. How else do you go into the streets during the plague and take care of people knowing that it’s a contagious disease, even though you have no idea what contagion means, because it hasn’t been yet discovered, or how do you go into ERs and take care of patients early in the pandemic when you don’t have protective gear? You have to deny the risk to yourself in order to put the patient first, but I also note that that tendency towards denial can spill over when there are things that we don’t necessarily want to see, and I thought of that this week. I don’t know if you noticed that the Merriam Webster word of the year is gaslighting. Did you know that?

Zubin Damania:

I didn’t know that, but it doesn’t surprise me.

Robert Pearl:

Yeah, and there’s actually a lot of studies that have come out that said that it’s very frequent, and actually it’s very frequent in the LGBTQ+ population that we talked about, when they go for care. It’s actually very frequent when women go for care. I think many of the groups that have felt as though there’s a certain level of discrimination, the truth is that in the doctor’s office it’s there as well. The complaints are not taken as seriously. Problems that otherwise might be investigated are assumed to be simply psychological, and, of course, in medicine we deny that psychological is as important as physical, and you go on, and on, and on. Your thoughts on what we can do about it?

Zubin Damania:

Yeah, I mean, again, this is our culture. You’re right. I mean, and the gaslighting is an interesting thing because I think a lot of it is unconscious, right? People are doing it not intentionally. It’s a kind of pattern of behavior. You try to make people feel like they’re not right in the head because you’re either projecting or denying something about the nature of their care, and I think it doesn’t happen at a conscious level. So until you bring it into the light of awareness, and you actually make it explicit in a way that doesn’t actually threaten the identity structures of the person you’re talking with. That’s the problem is a full frontal assault, and I think this is why in the culture right now, the full frontal assault of progress on people who are more say conservative, it leads to kind of a psychological reactance, and because, again, we’re going to defend our identity structures on all sides of it.

So there’s a way to do that I think that is much more compassionate and actually effective. So we have to focus on those strategies. Those kind of alt middle strategies that I talk about I think are more effective ways to bring progress that also is inclusive of people that feel they’ve also been left behind.

Robert Pearl:

The reason I like the word denial, although I’ll have to tell you that there’s some readers who didn’t like it, but I like the word because of the point you just made. It’s subconscious. We’re not aware of it. We act in ways without being conscious that this is what we’re doing. We don’t see it, and that makes me think about all the problems that if you read the literature, it’s so clear how important they are, social determinants of health, racial disparities. You know, 10% of Americans are still uninsured. It used to be 16% before the ACA, and I don’t hear a whole lot of conversation about that. Last night, I teach in the Stanford Graduate School of Business, and last night our guest speaker was a guy named Dr. Dr. Devi Shetty, who’s been the podcast, and whom I’ve spoken about before, and it was fascinating.

What he said is that he believes that India will be the first nation in which the healthcare you receive will not be dependent upon the amount of money that you have. In his mind, in a nation of 1.4 billion people. And the podcast he did with me a couple of months ago is just so inspirational. It’s great, and this reflected it. He worries about all 1.4 billion people and asks himself, “How do we provide care to the last of that 1.4 billion that’s as good as we provide to the best?” And in our country we tell ourselves we provide the same care to everyone, but when you look at the data, there’s not a shred of truth about that, and I don’t hear it being talked about in a broader context of people.

I think people look at it very much by what do I and my family get? What do the people that I’m most close with in my community get? And that’s about as far as we look, and we don’t see all the implications. It’s mainly about the system of healthcare, but I think it’s really about the values of the nation.

Zubin Damania:

Yeah, I think what you nailed particularly explicitly there is the values of the nation, and America really was kind of founded in this kind of oppositional way where there’s almost an unwritten social contract that listen, listen, listen, listen, we all hate rich people for being rich and having everything, but secretly we want to be that rich person, and one day we want to have those things, and we want that opportunity to do that, to live at the top of the hierarchy. And I think it’s an unconscious kind of contract that has existed in the strata of American psyche for a long time, and that’s why something as egalitarian as a universal coverage, or everyone being treated equally in healthcare is something in the American psyche that reacts to that, and to be honest, I mean, my parents are from India. It is a vastly hierarchical, horrifically hierarchical.

In fact, when I first visited, I was taken aback by the servant class there that was treated almost akin to slaves. I mean, and part of this is the sort of general caste system, but it’s just all accepted there. And coming from America, it was a shock. It was like, “Wait, wait, you can’t treat other humans like this.” So it’s good to see Devi Shetty actually trying to unwind that, because on some level there’s aspects of Indian culture that are so community focused, and we’re all in this together. And so those things coexist, and so it can be a little schizophrenic at times.

Robert Pearl:

Well, I think that’s very true what you said, because I’ve been there too, and the disparities are massive, but the idea of asking, of starting with the question, “How do we provide excellent care to all,” I think is a fascinating path. It’s the one that he’s on, and interestingly enough, much of his answer is technology. And he says that because in a poor country there’s not enough resources. If I have a sack of rice, and I give half of it to you because you’re hungry, I only have a half sack left. If I have a computer program that allows me to get great care, and I give you a copy, I still have my computer program. And so it’s a resource that you can give away. It’s like gratitude. I can give you all the gratitude in the world, and I haven’t depleted myself at all. In fact, I’ve actually augmented my satisfaction, my happiness, my fulfillment.

Zubin Damania:

I think that’s a beautiful way to put it, and it’s very similar to thinking about compassion as opposed to empathy. Empathy is feeling someone’s pain, affective empathy as your own. That does exhaust you, actually, but compassion, which is love and concern in the face of suffering and an unconditional kind of love, that actually fills you with kind of an elevation, and it’s inexhaustible. And so technology, absolutely, so there was ways to scale what we do in medicine that allow the human relationship at the center to kind of still flourish while scaling, and I think you’re absolutely right. You’re absolutely right. And actually, it’s got to be central to our answer, because we have resource limitation across the globe when it comes to high quality healthcare. So how do you scale it in that kind of way? I like that software analogy. It’s actually a very good one. One piece of software can serve infinite numbers of people.

Robert Pearl:

Absolutely. So let me ask you a slightly tangential question, but it still is this split in society that it’s been bothering me ever since I read the Pew Research study on it about two weeks ago, and I’ve wanted to ask you about it. So in this study, only 41% of people, and this was 12,000 individuals they surveyed, thought that scientific experts are better than others at making policy decisions about scientific issues, and that negative view is held by both Democrats and Republicans. We’ve looked at this question of scientific expertise throughout COVID 19, and we’ve certainly come to the conclusion that those with the scientific backgrounds aren’t necessarily the ones that we should be trusting, and I wonder your thoughts. You’ve been right in the middle of this scrum, if you want to think about it in that way, over this issue of the role of the expert as we look at whether you want to talk about COVID or just healthcare policy in general.

Zubin Damania:

Yeah, this is something that really, like you said, I’ve been kind of in the middle of it, and this is the thing. I have always kind of worked hard, early pre-pandemic especially to defend the role of expertise in healthcare, because it is invaluable. When you’re talking about recommending a type of surgery, having an interaction with a patient where it’s an interpretive dance of their hopes, dreams, and fears, and goals, and your knowledge. The your knowledge component is a very important part of the equation, right? Now, I think what’s happened here though is… And the fact that Democrats and Republicans are both saying this makes you think also of China. So here you have say let’s say a scientific technocracy, autocracy ruling class that says, “You know what? We can actually literally prevent deaths by locking people in their homes, and the number of deaths that result from that will be less than the number of deaths that happen from COVID.”

And to some degree so far they’ve proven themselves correct, because they have the lowest per capita, if you believe their numbers, per capita death rate from COVID, but they’ve had to do these draconian things about policy-wise, and just now people are standing up and saying, “You know what? Enough is enough.” And I think what humans here are saying in America, are saying is, “Yeah, it’s…” or they’re not saying this explicitly, but I think this is the motivation is, “Expertise is great and wonderful, but when it comes to policy, we actually want to determine what our values say in the setting of that knowledge. So it may be that we could prevent all this COVID, but we’re actually more interested in going out to eat, seeing our friends without masks, not having our kids be out of school,” these kind of things.

And so that disjunction between values, which are what politics tries to apply, or policy, and scientific expertise I think has manifested now with people saying, “You know what? I don’t trust these guys to make policy.” And so I think that’s what’s happening. Now, I’m curious what you think, but that’s been my feeling. And the problem is they’re throwing the baby out with the bath water, so now they’re like, “Well I don’t trust these guys to tell me I should vaccinate my children against mumps, because the way they managed COVID I felt was incompatible with my values. What are they telling me about mandates for childhood vaccines?” So it’s really causing all this collateral damage to public health now.

Robert Pearl:

No, I really love that, because as you know, I’ve been focusing a lot the past year on these rules of healthcare that I believe many of which need to be broken, and we have maybe the strongest rule, which is to save a life at any cost, and at any cost means any cost. If kids lose a year of school, that’s a cost to save one life, or two lives, or three lives. Now, we could spend a lot of time debating this issue. It’s certainly been debated by Talmudic scholars across history, but I think at some point we have to accept that death is a reality that we can’t overcome, and we probably need to take a broader view of what that means. What’s the impact to people’s lives of missing a year of education? What’s it going to mean for them and their families? How many people are going to die even though we won’t know exactly who they are as a result of that because of their family’s socioeconomic situations? Those conversations never penetrate into medicine.

Zubin Damania:

Oh, you nailed it, man. And again, it gets to get to that root of what you wrote about in Uncaring. It’s our denial, which again can be an adaptive denial. It’s unconscious about that death is something that is inevitable, and that it’s not necessarily the worst enemy, and it has to do with your values. So Dr. Monica Gandhi, an infectious disease specialist at UCSF, who’s been on my show several times, is coming again on Saturday. Early in the pandemic, we started doing a series of shows where we were really trying to talk people off the ledge a little bit and talk about these issues. And she said to me, and she said this on camera eventually, but initially she told me off camera that she had lost her husband, who was roughly her age, late forties, early fifties to cancer right before the pandemic, and he was a cardiologist, worked super hard.

Who knows if it was radiation exposure or what, but he had a head and neck cancer, and he died, and she has two young sons, and she’s raising them alone now, and the pandemic hits, and she’s watching people, the medical system treating death like it is the worst possible thing in the universe relative to actually living your life. And it became a kind of passion for her to say, “Listen, we all look at risk differently. Here’s how you can look at risk here rather than just save a life at any cost.” And that was part of her motivation. And again, she was woken up by this tragedy that hit her and her family, and sometimes it takes something that horrible to pull the rug out of under your denial, and you shouldn’t have to have that, right? We ought to be cognizant of this as a society and as individuals in healthcare, but it’s not been part of our sort of process.

Robert Pearl:

Let me ask you one last question. It’s one question that I got asked. I was keynoting a large event a couple of weeks ago, and at the end you know you have the Q&A, and an individual stood up, wasn’t a physician, and asked me whether with more and more doctors becoming employees, whether we’re seeing, and he used the phrase, “Loss of motivation to drive change,” whether medicine is just similar to everyone else with quiet quitting, and burnout, and a sense that dedication to work isn’t worth the effort and the energy, or whether the traditional purpose and mission of medicine still persists. You have probably the broadest network of millions of people who follow you and communicate with you. What do you think? How would you answer that question?

Zubin Damania:

That’s a great question, and from the standpoint of say an independent physician, you might ask that question. From a standpoint of an employed physician, you might not know anything differently, but this is my take. Hey, remember when we didn’t have a lot of employed physicians? How much change, progress, innovation, and transformation did we get? Zero. It’s the same thing that they’re all conditioned by their incentives, by their training, by inertia, by fear. And the employed physicians have a different set of conditioning in inertia and fear, but I don’t think it’s vastly different than the old way of doing things in terms of generating innovation. I think if you want to find the roots of our failure to innovate or to feel invested in the change, I think it goes right to medical school, which you’ve talked about.

I mean, we’re basically trained to, we’re conditioned to memorize facts, half of which are eventually shown to be untrue, but they don’t tell you which half, because they don’t know, and then you’re conditioned to obey authority in the second two years, and you’re afraid you’re going to hurt someone, and you don’t want to rock the boat. And so it doesn’t matter. You come out with that conditioning. You’re really trained that way. So employed or not employed, at least if you’re an employed physician, you have this network of support, and you have an organization theoretically that could support you, or it could be seen to be trying to harm you or control you, but a lot of it is our own perspective until we kind of wake up to what we’re repressing, denying, projecting, and so on in our own conditioning, our system is going to be very unlikely to change, because our organizations are epiphenomenon of who we are.

Robert Pearl:

My answer was that, no, what I see is physicians are just as motivated to want to make medicine better, just as motivated to want to do the best for patients. They’re frustrated by the system. They’re frustrated by the inability to make change happen, and sometimes when you’re frustrated you lose the energy needed to try to drive change, but I still believe, and maybe I’m being too optimistic, which is why I asked you, or maybe just too idealistic, that the people who go into medicine are motivated by the right reasons, and that given the opportunity, they would push hard on the block, the cart, whatever you want to be saying it to be, to move it forward, and to make it accelerate at an ever faster rate.

Zubin Damania:

Oh, I think you’re absolutely right given the opportunity, and when they see these little cracks. We all think about our best day in medicine, and it’s always this kind of connectedness. It’s always this kind of autonomy, tools, teams, trust, and the patient. And it just kind of is a flow state, and I think if you give people more opportunities to actualize those flow states, show them bright spots where these things are working, and kind of just point directionally, because we all kind of know where we kind of generally want to be. We just don’t necessarily know how to get there. I think things will start. It’s inevitable. The change is already happening. It’s like what we said earlier in the thing. I sense the shift in the air.

I think the same thing is happening in medicine. There’s huge intractable seeming problems, but it’s always that way before the caterpillar spins the chrysalis and the transformation happens that you could never have predicted. So I think I’m with you on the optimism. I may be less of an idealist in this sense that it’s going to be a lot more brutal I think, and people will feel a certain way about it that’s very negative, but I think it’s inevitably going to go in a good place if we keep on the direction.

Robert Pearl:

I love it, because I’m more of an idealist. I think people have all the right motivation. I’m a little bit less of an optimist, because I think the hurdles are so tall that it’s going to take a massive amount of energy to make change happen, but with that, let’s turn it over to Jeremy for his question to us, and I can’t wait to have the next opportunity to be able to learn from your experience, and to have new views into the world.

Zubin Damania:

Likewise.

Jeremy Corr:

When it comes to politics, many voters on both sides of the aisle seem to think that the elected officials on their side are fighting for them when it comes to healthcare, while believing the other side is making healthcare worse for both them in society, whether it’s the issue of abortion, Medicare, drug pricing, transgender issues, et cetera, and I would say that the hot issue on everyone’s mind right now is freedom of speech versus censoring what some people consider disinformation or hateful speech on social media. What I really want to ask though is for a reality check from both of you. When there is so much money in politics via campaign financing, lobbying, et cetera, coming into both Republicans and Democrats from big pharma, health insurance companies, health tech companies, et cetera, is either side really fighting for the best interests of lower and middle class voters when it comes to healthcare issues, or are they just focusing on keeping these big and influential healthcare companies happy?

Zubin Damania:

Oh, I’d love to defer to Robbie first on this one, because I’m dying of curiosity to hear your take.

Robert Pearl:

I think, Jeremy, you’re raising two separate issues. I think the first issue is relative to the healthcare system, and a professor that I teach with, Robert Burgelman at Stanford, talks about medicine as being a super unmoving industry. Nothing changes over time, and he doesn’t understand why that is the case, and I think you’ve described the reason, which is there’s so many people in it, around it, impacted by it, making money from it for whom change is not what they want, and they have the power, and they have the money to be able to make stability be the example that sits within it. In contrast, I think that within the healthcare itself, that the politics, that the money is not the force that’s restraining change. I think that it’s within the people itself, it’s the difficulty of making that change happen, and I think it’s the amount of time that it takes, and I just think that it’s too much.

And that’s why I’m a big believer that the change will come not through the political process, because I think that will be blocked by the money forces that exist, but it’s going to come actually through the economics, and that’s why I’m a big believer that it’s going to be the retail forces that will drive it, the Amazons of the world and the CVSs of the world, the Walmarts of the world that are going to make the change happen. I think they’re going to drive it not necessarily out of some commitment to improving the health of people. They’re going to drive it out of a profit motive, but I think that it will create a more positive change for the country, at least that’s my optimism, and that I think that once physicians get behind it, and nurses get behind it, and patients get behind it, and they can see an improvement to happen, that there will be what Zubin has talked about, this very major shift suddenly, and what seemed impossible and then seemed possible now will seem inevitable.

Zubin Damania:

Yeah, and I think Upton Sinclair, I think it was, who said, “It’s impossible to make a man believe something if his salary depends on him not believing it.” And I think in medicine for many people, our salaries depend on us not believing, not changing to some degree, and that includes big legacy players like pharma, and insurance companies, and those kind of things, and politics just feeds right into that, and money is all the currency, the lifeblood of that. But once, like Robbie says, once the realities of the economics start to click in, and you do have these sort of disruptive agents like Amazon kind of pushing things like our old Turntable/Iora Health Model that’s now part of Amazon, when those are normalized, and consumers, the patients are able to vote with their feet a little bit, you’ll start to see change, and it will pull in especially the younger generation of healthcare professionals, who have been kind of hungry for this kind of change. They want to do the right thing. They are idealistic, and given an opportunity to practice in that kind of world, they’ll take it.

So it’s actually very, very, very encouraging. I think the shift will happen. Now, the last pitch I’ll give is personal, and I always say this, and I’m sure I can feel this is probably not true, but I can feel Robbie rolling his eyes at me. It is that people have to wake up too to their own transformation. They have to see that this sort of egoic striving that we’ve always been conditioned to do is a bit of an illusion, and once we see past that, we do emerge a world where that is actualized in a way that it’s very hard to predict, but it’ll definitely be better than what we’re going through now.

Jeremy Corr:

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