Ep 43 – How the Culture of Medicine Kills Doctors and Patients (Part 1), with Dr. Robert Pearl

In a year of great need, during the pandemic, Americans saw and celebrated an army of physician heroes. In doing so, they overlooked an uncomfortable reality. Doctors are humans who share a culture that produces both remarkable successes and abysmal failures. As in Robert Louis Stevenson’s gothic novella The Strange Case of Dr. Jekyll and Mr. Hyde, it is possible that one person — or this case, one culture — can be both a virtuous force and a destructive influence. Until now, the negative aspects of physician culture have remained largely invisible. But like a virus, it affects people even if they can’t see it. Physician culture wields tremendous influence over the lives of patients, doctors, and the nation, regardless of whether people acknowledge (or are even aware of) its existence.

This week, we have as your guest Dr. Robert Pearl.  He will be discussing his new book which tells the story of a profession that is both triumphant and dangerously flawed, filled with people who aspire to help others, yet who sometimes act coldly, callously, and indifferent. This book takes you inside the doctor’s world, revealing unique insights about their training, their daily practices, and the culture they share. It is a book about people striving for perfection and about the impossibility of achieving it. It sheds light on the norms, rules, and expectations of doctors, and shows how culture shapes their thoughts and beliefs. It deciphers their evolving language, symbols, and codes. It highlights what brings doctors together and what isolates them from their colleagues and patients. Finally, this book examines the elements of physician culture that need to be corrected, the ones that should be preserved, and how to accomplish both. If we are to win this Race to Value, we must fully understand and reform physician culture so it can be more caring.

Episode Bookmarks:

2:00 “The Strange Case of Dr. Jekyll and Mr. Hyde” – Is it possible that one culture can be both a virtuous force and an equally destructive influence?

2:40 If we are to win this Race to Value, we must fully understand and reform physician culture so it can be more Caring.

3:00 Dr. Robert Pearl’s new book, “Uncaring : how physician culture kills doctors and patients.”

4:45 Physician culture tolerates low value care, inequitable outcomes, excessive profiteering, and perpetuation of institutional racism.

5:40 Despite the clear link between avoidable chronic disease and excessive COVID-19 deaths, physicians are not speaking out on this.

6:45 Dr. Robert Pearl defines what culture really is and how drives physicians to perform but also inflict harm

7:30 The “invisible” nature of physician culture

8:45 The heroism of physicians during COVID-19

10:00 Systemic issues and cultural issues go together – Why Mistreated and Uncaring are perfect companions in solving for healthcare.

10:45 Chronic diseases and the lack of accountability in physician culture

11:30 The focus on Prevention is not elevated in medicine, as illustrated by how we undervalue primary care

11:50 Research study showing that adding PCPs increases life expectancy in communities, while adding specialists does not have a comparable effect.

12:30 Primary care physicians are paid more in large multispecialty medical groups like Mayo Clinic, Kaiser Permanente, and Geisinger

12:50 Pre-Order information for “Uncaring” and all profits go to Doctors Without Borders/Médecins Sans Frontières (MSF)

14:00 How the “Art of Medicine” philosophy in physician culture prevents progress towards evidence-based medicine

15:30 Research showing that as much as one-third of physician services is low value care, offering little to no benefit for patients

16:30 The long lasting and pervasive effects of a physician culture that pre-dated scientific advancements

17:45 “It is not a question of how we maintain the esteem of the past, but how do we create the esteem of the future?”

18:15 The economic fallout of COVID-19 and how that will affect physician satisfaction

20:20 “What we have to understand as accountable physicians is that the care we provide is not affordable and it is not world leading.”

20:45 The entitlement of physicians feeling like they need a 5-10% FFS increase every year despite not delivering good outcomes in population health

20:55 The US is last among the 12 industrialized nations in life expectancy, childhood mortality, and maternal mortality.  Physicians don’t see it as their fault.  Instead they blame they systemic parts around them.

21:30 The role of technology in elevating the medical profession

22:00 The U.S. is last among the 12 industrialized nations in health care outcomes, and physicians don’t see it as their fault.

22:20 Healthcare costs in the post-coronavirus world will get lowered because people won’t have the resources to pay.

22:45 Rationing of care inflicts harm

23:00 Prospective payment is the only way to deliver care that is higher quality, more convenient, and at a lower cost.

23:40 The cultural evolution of the medical profession can give us hope.

24:55 Transformation will not be easy, but seeing physicians thrive in value-based care will enable change.

25:25 Roger Bannister breaking the 4-minute mile is similar to what we will see in physician culture transformation.

28:00 Confronting the truth about clinical outcomes and physician performance through transparent reporting

28:15 Dr. Pearl’s leadership at the Permanente Medical Group in creating a physician culture of transparency and “group excellence”

32:00 Kaiser Permanente went from “middle of the pack” to “number 1” with physician satisfaction that was 20% higher and total cost of care that was 20% lower

33:00 “The mindset of the 20^th century is “Quality, Service, Cost:  Pick any Two.” We need a different mindset that we can achieve all three.”

36:25 Roughly 15 percent of physicians struggle with depression, and 20 percent report having had suicidal thoughts.

36:40 Physician burnout is affecting over half of the physicians in practice, and a recent Harvard report even called burnout “a public health crisis that urgently demands action.”

38:00 Physicians focus primarily on three causes of burnout (compensation, bureaucratic tasks, and technology) but ignore cultural issues within their profession

38:40 Pediatric physicians are paid less than adult medicine physicians, but they are actually more satisfied.

39:00 Urologists earn over half a million dollars annually, but they are extremely dissatisfied (more than twice than other surgical specialties).

41:00 Esteem in medicine is driven by doing the “coolest interventions”

42:20 Fewer prostatectomies in urology caused the rising burnout of the specialty because esteem was tied to that surgical procedure.

43:20 Moral Injury in the medical profession is real, but part of the reason is what physicians actually do to themselves.

44:30 The justification of surprise medical billing in the medical profession as a cause of physician moral injury.

45:40 Institutional racism in healthcare as a cause moral injury.

46:00 Dr. Pearl extensively outlines the racial inequities in our healthcare system and how physicians are not leading with the issue of health equity, racism, and unacceptable mortality.

48:00 Burnout with critical care and ID physicians and “Why Doctors Can’t Cope with Anguish of COVID-19 Casualties”

51:00 “PTSD in combat doesn’t happen in the battlefield but afterwards.  That is why I am really worried about what is going to happen to physicians in critical care and ID.”

52:00 Suicide rates in physicians projected to skyrocket once post-COVID PTSD sets in