Fixing Healthcare Podcast

Welcome back to Unfiltered, a show that features two iconic voices in healthcare for a half hour of unscripted, hard-hitting talk. Dr. Robert Pearl has twice appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who had twice appeared on the Fixing Healthcare podcast with Pearl, alongside cohost Jeremy Corr (see: here and here). This episode (the third in this series so far) covers a lot of ground, starting with questions of censorship and medical misinformation as talks continue around Elon Musk’s pending ownership and overhaul of Twitter. Also in this episode: Financial incentives vs. intrinsic drivers: What motivates doctors? Should we do away with the MCATs and change physician education for good? Why are women physicians more burned-out than male colleagues? And, according to the latest surveys, why is the problem getting worse? To get started, press play or peruse the transcript below. * * * 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: Welcome to Unfiltered our newest program in 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 experts, they’ll apply the lessons they extract to medical practice. I’ll then 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: Hello, Zubin. Zubin Damania: Robbie, always a joy. I look forward to this time. Robert Pearl: This is our third podcast and I wonder, would you feel comfortable with my asking you a personal question? Zubin Damania: It could have been the first podcast. You know I’m a bit of a scary open book. Robert Pearl: Well, I heard, Zubin, a rumor that you just paid $44 billion to buy Twitter. Is that right? Zubin Damania: It is. They say it’s Elon Musk, but when you rip off his latex mask, it’s that old man Damania underneath, just scared of those meddling kids. Robert Pearl: I see. Well, I’m always confusing you with someone else, but you do drive a Tesla, right? Zubin Damania: No. I’m not rich enough to drive a Tesla. I have a Camry hybrid, so I am gas efficient, but also cheap. Robert Pearl: Okay. But seriously, no, let’s put this potential change in a healthcare context for our listeners. I’d like to explore the dividing line between opinion and science. Free speech is a right in the country, but shouting fire in a crowded building is not. You can have an opinion that Putin is the most horrific human being in the world or the savior of Russia, or if you think that swallowing bleach is an effective way to cure COVID-19, telling others to do so is likely to lead to someone’s death. If Mr. Musk called you, wanted your opinion how best to draw that line, what would you tell him? Zubin Damania: This is such a challenge because, yes, there are certain types of disinformation, whether intentional or unintentional, that can lead to havoc. And I think this idea of yelling fire in a crowded theater is a good version of that. Remembering that our right to free speech, that’s government stuff. It does not apply to companies. So companies can do whatever they want to your speech, in theory. What I would tell Elon is, listen, don’t entirely abandon the idea that extremely dangerous and direct disinformation that is clearly outrageously wrong shouldn’t be removed from the platform. There is a certain responsibility, I think, to do that. Where it becomes difficult is where there’s scientific debate or there’s opinion or whatever that is and allowing that to air is very different. And I think who the arbiters are of that truth has become difficult. Dr. Vinay Prasad has looked at who are these sort of filters that some of the companies, the big tech companies, have hired to determine what’s disinformation. And often it’s just the loudest voices on Twitter. So that may stifle scientific debate. You do want to a very vigorous, open debate, especially in a time when we don’t know everything, the time of a pandemic. Robert Pearl: How would you set up the panel, the algorithm, the AI application? How would you set up somebody to make this decision? Zubin Damania: Oh, man. If I knew that … Honestly, because I am much more on the free speech angle of it, I think it’s really … I don’t know, Robbie. What would you do? I don’t know that it can be done well, honestly. Robert Pearl: I think when it comes to healthcare, I tend to be a bit more conservative than I am when it comes to almost any other issue. I’m not so in believing you should censor anyone’s opinion unless there’s an implication for others. I’m worried and bothered by the fact we crossed a million deaths in the United States. I don’t think we should have had anywhere near that number of people perishing from this virus. Yes, in the first year, we didn’t know quite what to do. But the second year, we really should have done a lot better. I don’t know whose responsibility it is, but I know that what whoever’s it was, it’s a failure. Not an easy question, but somehow we had to figure out a better way and be prepared at least the next time to do so. If anyone on Twitter wants to tell the world that you or I or Jeremy or anyone else isn’t very smart, our ideas are wrong, that’s okay. There’s no problem doing that. But I just really worry. When we have a means of being able to advise people positively and the risk is tragedy, not just for themselves, but their family, their kids, their loved ones. I just somehow feel that we need to do a bit more, because it is good public health. And that’s where I separate out medicine from everything else that I can think of. Zubin Damania: So this is interesting. I think actually what we find is when these companies did label these things as disinformation or block them or whatever, whether it’s a Marty Makary op-ed in The Wall Street Journal or something more even very much to the fringe like Robert Malone or Peter McCullough, these sort of anti-vaccine activist physicians. What we found is that this is the internet, so people will go somewhere else where they aren’t censored. And the very act of censorship confirms the conspiracy bias of a segment of the population that’s prone to believe these things for whatever reason. And some of that is just having a sense of control. They don’t understand how this could all be happening to us and so they’re looking for meaning. And when these guys say, “Oh, the government’s doing this or Fauci’s doing that,” they’re very receptive to that because they say, “Oh, well that at least makes sense. It’s this nefarious plot.” Zubin Damania: And my concern is when we start doing those things, we drive people to those other locations and it doesn’t solve the problem. But where I think we can do better as healthcare professionals is we need to step up and say, “Okay, well …” If we think there’s good things like, say, vaccines or certain interventions to prevent the spread of COVID, then we have to be vocal in a way that isn’t judgmental, that isn’t partisan, that isn’t overtly political because the whole thing’s been so politicized. And that would go a long way, I think. Having a louder voice for science and truth and process than for disinformation is one way to drown out the noise without canceling the noise makers that then confirms the bias of the people who are prone to believe it. Jeremy Corr: ZDogg, you bring up a very good point of the whole canceling people from those said platforms. For example, when you saw Trump get removed from Twitter and then he moved over to Truth Social and all these kind of right wing people that get banned from Twitter and then moved over to Truth Social or these other kind of platforms, they’re going to be in these echo chambers of people that only think the exact same way as them and spreading whatever information or misinformation or whatever you want to call it. But when you have Twitter as more of a public square type of thing, for example, when you had the QAnon phenomenon going on. For every person that posted some crazy conspiracy theory, you had 20 people responding, being like, “Look, you’re being dumb. Here’s proof. Look, this doesn’t make any sense. Here’s why.” What are both of your thoughts around that, out of curiosity, about is it better to not censor them and engage with them further versus driving them into those echo chambers? Zubin Damania: So my take on the echo chambers is that it’s an existential threat, actually, to all of us, this idea that we are polarized into chambers that just reflect what we already hear. And those chambers don’t connect. They only connect through virtual violence. In other words, this antagonism. They’re almost these hive mind, group minds that form. And you’re right. Whether it’s a Truth Social hive mind or a Twitter hive mind or a Rumble hive mind or wherever it is, they tend to attract like minds and then echo the sentiment. So making that corpus callosum, those fibers that connect those different hive minds, is actually key, which means a dialogue. That’s why I’m … And I get it, Robbie. I totally get that this is healthcare and people’s lives are at stake, so we as physicians really want to intervene. And so the question then is what’s the best, most effective way to do that? I wish I had a direct answer, but it’s quite nuanced. Robert Pearl: Yeah. I think what you’re hearing from me is just frustration. I can’t stand to see human life wasted, and we wasted human life. And I’m looking for a better answer and that’s why I thought I would ask you about that. But let’s switch maybe to another topic. Zubin, our discussion of the four existential questions in the last podcast, it stimulated lots and lots of great conversation from our listeners. I heard from quite a number of them. And a physician and former student of mine at the Stanford Graduate School of Business asked if you and I could talk about the difference between transactional and transformational leadership. As you know, transactional leadership is quid pro quo. You increase your screening for colon or breast cancer in patients in the recommended age group from 50 to 60%, you get an extra $1,000 a year. You go from 50 to 70, you get $2,000 more. In contrast, transformational leadership, inspires people and attempts to improve medical outcomes by connecting with their inner motivation as people. You led Turntable Health in Las Vegas. What did you learn about the value and role of financial incentives versus intrinsic motivation? Zubin Damania: Ah, what a great question. This is the central piece because how do you motivate people through leadership rather than management, through, like you said, transformation instead of transaction? And what I think, I think the data shows this too, and what I found was that pay for performance just doesn’t really work. Doctors are intrinsically motivated to do the right thing. They’re also a bit competitive. They want to actually do better than their peers on average. They don’t want to be the one that’s the last in their class or whatever it is, or the one that has the lowest scores on whatever. They’ve always been intrinsically motivated. So how do you then lead in that sort of setting? And what it seems is, first of all, you got to just set this culture that we’re trying to do the right thing for patients and for each other. And then you provide the tools, the team, and the trust to actually accomplish that. Zubin Damania: And the tools will be the technology that’s actually there to enable what they’re trying to do to make them feel capable to do it. The teams are the support structures, the human support that allow everybody to do the top of their game and support each other too. And then trust is the key thing, which is where you’re saying, “Listen, I’m not going to nickel and dime you and give you an extra $1,000 for this outcome. I am going to actually give you the autonomy to accomplish what we have as goals here together that are partially intrinsically motivated, and then give you those tools and team to actually accomplish it.” And yeah, we may measure it as an outcome in a big sense, like how are we doing here, and then have the discussion as a group and maybe have a healthy competition around it. But pay for performance just is not going to motivate intrinsically motivated people. Robert Pearl: If that’s the case, and I concur with you, everything you said, why are financial incentives used so often by leaders across the United States? Zubin Damania: I think it’s a currency that they understand, especially non-clinical leadership. And I think they think that humans are motivated by that sort of financial reward. But these are medical professionals. After they reach a certain point, it’s more about that intrinsic motivation. For me, when I was practicing fulltime too, that’s how it felt. It’s like, I wanted to feel valued. I wanted to feel like I was providing value. I wanted to feel like I was part of a team that I felt responsible to, and that felt responsible to me. And I felt that I wanted resources to be able to do my job, meaning technological resources that didn’t suck. And I think when I had those, when everything was firing on all cylinders, giving great care just became the default and you are always striving to be better. But when it became about RVUs and when it became about productivity, when it became about these rewards for clicking the right boxes and getting the things done that way, it really stripped away the intrinsic motivation. And I think it had bad outcomes. But I think our leaders are conditioned that way, many of them, especially non-clinical leaders. Robert Pearl: Maybe a theme from today’s conversation, Zubin, is my frustration in how slow our progress is. And I want to figure out how we can make it happen faster. Earlier today, I spoke at Rochester at a really excellent organization that was there. And there was a dinner last night and we were talking about the fact that four miles from we were sitting, life expectancy was 10 years less than the people who were living in the area where we were. And I asked them, I said, “What’s going on to change that?” We know what many of those factors are. And the answer was in a motivated community, not much was occurring. How do we accelerate this change to get the best health for people? Zubin Damania: So much of it is all healthcare is local. So actually having members of the team from the community you’re trying to serve, who understand that community, having skin in the game, knowing that every community is different, is motivated differently. Not having a one size fits all platform, but maybe having a central thesis like, “These are the goals we want to accomplish. So how do we do it here, versus here, versus here and making it a priority?” We talk a lot about equity and things like that, but when the rubber hits the road, it’s really about financial outcomes or just playing the same old game. And I’m as frustrated as you are, Robbie. It’s very frustrating. Zubin Damania: There’s a female physician at Penn. I’m forgetting her name now, but she was on my show. And she works with health coaches from community areas that are zip codes of tremendously poor outcomes and found that bringing those health coaches that go to homes, that interact with the patients. We did this at Turntable, too. Driving these very empathic, motivated interviewers from the communities they’re going to serve. That was 90% of the battle. And then really tailoring it to how do those patients want to communicate? Maybe they don’t want to do a telehealth thing, but they would love to text. So can we set it up so that they can text us because that’s culturally what they do? Or whatever it is. It’s really being adaptable to the community at hand, and then having the motivation to actually want those disparities to go away. Robert Pearl: So let me be a little bit controversial and look at another area related to this, which is how we select medical students. Malcolm Gladwell popularized the 10,000 hour rule, implicit in the idea is that if you want to become, let’s say, a great guitar player, it takes that level of dedication and commitment. And maybe coincidentally 10,000 hours is about the amount of time a resident’s in a three year program like internal medicine spends. As you know, I think Malcolm is one of the most talented non-fiction writers, and he was a guest on a recent Fixing Healthcare podcast. But I’d like to add a second rule, and that I’ll label the three step rule. And just so listeners aren’t confused, unlike the 10,000 hour rule that has deep research background, my three step rule, it’s completely made up. I don’t have the least bit of scientific data, but it comes from my life. Robert Pearl: And the rule concept is that we all are born with intrinsic ability in each category, how high we can jump, how good looking we are, how well we do mathematics. And let’s just say we have a number between one and 10. With 10,000 hours of practice, we can go up, this is my hypothesis, three spots. I use my life as an example. One of the greatest gifts I ever got was how terrible I am at singing. I was between a one and a two. Had I been a five or six, I might have deceived myself into becoming a rock professional musician. But no matter how hard I worked, I knew the best I could become was five. So if you, at least for the time being, will agree that talent is equally important to dedication and hard work, let me ask you what are the skills we should screen for in medical students? We both know that traditionally we screened from memorization through Step One tests and MCATs and other pieces. But today with the smartphone, memorization is less crucial. Should we be screening for empathy? Should we be screening for communication ability? Should we be screening for ability to motivate? What do you think we should be screening for picking the next generation of doctors? Zubin Damania: Oh, all of those things. All of those things are crucial. And I love that theory. I think that’s fact. I’m going to go further and say for my own life, it’s the same thing. There’s this controversial thing in leadership. It’s like do you work on your weaknesses? Do you spend all this time working on these weaknesses where you’re at a one or a two, try to get it to a three or a four? Or do you really just boost those strengths? And I don’t know. I’m always a fan of boosting the strengths. So if you’re looking in healthcare, the truth is there isn’t a one size fits all because you need surgeons, you need urologists, you need psychiatrists, you need primary care doctors. They all do different things. My neurosurgeon doesn’t necessarily have to be the most empathic person in the world, but they better be a really disciplined technician and highly learned to be able to do what they do. Zubin Damania: So maybe you have some latitude for how you’re screening, but I would say the more we screen for things like communication, bedside manner, empathy, compassion, interesting stories that people have overcome adversity, the idea that they would then have real compassion for people who are struggling, those kind of things are … We always give lip service to it, but we’ve never really screened for it. We screen by, like you said, by the tests. And that’s why it’s interesting. A lot of times you’ll get into a school system like a D.O. School system where they screen maybe a little bit differently, and those doctors are trained differently too. And you wonder like, “Oh.” When you’re sitting in the room with them, it’s a different vibe and often in a good way. So it really … And again, I don’t mean to paint it with a single brush, but it really does speak to how we’re even picking people who go through medical school. Zubin Damania: Now, the other problem is if you screen based on empathy and those kind of things, and you do underemphasize the testing, then you may set up people for failure in a medical school education system that is designed to continue that process of test taking brilliance and not necessarily all those other factors. I’m curious what you think, Robbie. Robert Pearl: Well, I think we need to change not just the acceptance process, but the educational process and the evaluation process. I believe, and I’ve written about it, that rather than banning cell phones from all these exams, you should be required to bring one. We shouldn’t be testing your ability to find the Kreb cycle. For listeners who aren’t doctors, it’s a very famous set of information that’s hard to exactly discern that physicians get tested on in their second year of medical school and never again ever use. So it’s the ultimate metaphor for the problem that we’re talking about. In fact, the entire step one examination is one that’s 16 hours of testing on about 10,000 arcane facts. Medical students spend six to eight weeks, 12 hours a day memorizing all of these, again, 95% of which they’ll never ever use unless they happen to be on the Amazon river somewhere in the jungle encountering some kind of protozoan that they only read about and they, of course, would never have the medication anyway. Robert Pearl: No. We’re in the 21st century. Smartphones are with us all the time. I think we should be evaluating people on their ability to take that information that’s readily available now and apply it to difficult situations, to be able to figure out with access to all of that smartphone what really is going on with this patient and this family and how am I going to impact that person’s life. We really don’t measure the change in the patient’s health. We measure simply the advice the doctor gave. And as you well know, we have major problems with patients getting prescribed maybe the right medication but not taking it, sometimes getting prescribed the wrong medication, but getting prescribed the right medication and not taking it. The opportunity to be able to engage in opportunities to improve and prevent chronic disease and treat chronic disease. Diet, nutrition, relaxation. There’s a whole litany of opportunities that exist and we don’t do a very good job of helping patients. Some is the system of medicine. Some is the society around it. Robert Pearl: But I personally think that the physician skills going forward in a world where increasingly there are patients with multiple chronic diseases, each of which interact with each other, all of which are overwhelming. The ability of the physician of the future, I think, will be very different than the past. I just wonder how you would screen the 50,000 medical student applicants for the 20,000 physicians that exist every year in the United States? Zubin Damania: Yeah. And the screening is one piece, but like you said, how we’re even teaching them medical school is such a … It’s not set up to manage all that chronic disease. It really isn’t. And I almost feel like you should have as part of medical training a week long silent meditation retreat where these students are forced to introspect for a week and come back very sensitive to their environment and very much using nonverbal cues and things like that where they get out of their head and into this space around them with the patient and with each other and with themselves. And I think that would really help open up the motivational aspects of how do you connect with another human being. We don’t teach it very well in medical school. More clinical stuff would be nice, starting very early and really saying, “Hey, this is what it is.” Again, that’s not to lessen if you’re going to be a pathologist or you’re going to do something that’s more research oriented. You want to accommodate for that as well, because that’s important. But man, we’re doing it wrong. Whatever we’re doing now, it’s not right. It’s not working Robert Pearl: Well, that’s also why I asked you about this rule of three steps, because unless you’re convinced that everyone who applies to medical school is a seven or eight in the ability to communicate, the ability to empathize, the ability to understand what an individual from a different background is telling you, then we probably do need to figure out the individuals best able to do that, if those are the skills of the future. But I also would agree with you. I think the classes should involve using that technology to be able to now understand, let’s say, the physiology of the heart or the pharmacology of the medications. Why should you have to memorize the dose of a drug when you can look it up with 100% accuracy rather than relying on your memory? But understanding things about lifestyle that affect the drug, that’s a different set of skills that I think we don’t focus on nearly as much. Zubin Damania: And I think that that speaks again to mechanical intelligence versus human intuitive connective intelligence, relational intelligence. Why don’t we optimize for that since the computers are going to take everything else and do it better than us? So I agree. I agree a hundred thousand percent. Everyone’s using Up To Date now anyways as a source reference for a lot of stuff. We ought to train how do you use that effectively? How do you overcome bias in it? How do you think from the human side taking that data? Absolutely. But we would just memorize stuff. I mean, that was our thing when I trained. Robert Pearl: And the errors in it, not because the science is wrong, but because the application is wrong, as you said, based upon a given population or given set of individuals. So let’s go one more step. I want to talk a little bit with you today about burnout among doctors. I don’t know if you looked at the most recent Medscape survey. It had the information that we would expect. Burnout’s gotten worse in the context of COVID. The two specialties that have been that at the highest level are the two you would predict, ER and critical care. These are the people who have had to deal with the majority of individuals who’ve gone on to die. These are situations where physicians have been overwhelmed by the sense of loss, the inability to change the trajectory of a disease, the frustration of being unable to be effective as doctors. You had the isolation with COVID and families not being there. On and on and on. Robert Pearl: But what struck me as being most interesting was the third specialty on the list. The third most burned out specialty today, it wasn’t true two years ago, is OB/GYN. Now OB/GYN physicians don’t have a lot of patients who had COVID. They didn’t see a huge number of deaths. And why did this specialty soar in burnout rates compared to the other specialties? And as I looked at it, my conclusion was it’s one statistical fact, 85% of physicians in OB/GYN are women. And they took on another job, eight to ten hours more work outside the medical office or the hospital because they bore the brunt of child care. And I haven’t heard a whole lot of physicians talking about, and I’ll call it the two-way flow of the world inside medicine and outside. It’s almost like, as you said, the corpus callosum which connects the two sides of the brain was severed. And our minds are, we either have a work environment or our personal environment, and maybe the work environment negatively affects the personal, but not necessarily that the personal affects the work. Robert Pearl: I wrote a piece for it on Forbes and I expected about a third of the people would say I was right, a third of the people would say I was a total idiot and I had gotten it completely wrong, and a third would’ve said, “Oh yeah. We knew this all along.” But instead I think there was a pretty good resonance, at least amongst the women responding, that this was the reality of the past two years. How do we have a more broad understanding of burnout to recognize what happens in our practices that we don’t control, what happens in our practices that we can control, and what happens in our life outside of medicine that impacts our satisfaction, our job fulfillment and our level of fatigue? Zubin Damania: I read your Forbes piece and I was actually really … I said, “Yeah.” And the thing is, it’s difficult because you and me are mansplaining this thing. But I would say this, I mean, my wife is a female physician and the truth is when you look at burnout, you have to look at it’s not work-life balance. It’s life of which work is an integrated piece and they all resonate together. So for men, they have this, at least in the typical roles that we see, they’re not necessarily always the primary caregiver also of children at home. They’re not caring for elderly loved ones directly. They can be, but it’s not the primary thing. We often see that to be more a female role historically in society. And it’s dragged into current where women are now a huge part of the medical workforce. Zubin Damania: So they go to work, they do all the stuff that we have at work that is hard for us, but then they have the extra element, which this is going to be controversial, but if you look at personality tests, women score higher on agreeableness than men. So when asked to do extra stuff, they tend not to say no as often as men do. Men are jerks on personality tests. Again, just trying to stick with the data here, Robbie. I’m editorializing occasionally. And so they get sucked into stuff at work. Then they go home. They’re the caregiver for the kids. They have all that other stress. And even if they’re part-time, it’s like the equivalent of 1.5 FTE full-time equivalent. Duh, it’s going to be harder for them in many ways. And so it’s not surprising to me that that OB/GYN and maybe pediatrics too, which is more female, higher up on the list of people who self-report burnout. Robert Pearl: Pediatrics was another specialty that went up quite significantly. But why don’t we talk about it? Why don’t we talk about gender inequality in the context of burnout? Why don’t we talk about the parents who are sick or other environment or personal issues? We just keep separating our work experience and our dissatisfaction, and there’s no question the bureaucratic tasks and the computer systems and all of the problems are very real. But these other pieces, when I look at the data, seem to be quite significant as well. And yet at least I don’t hear it. You talk to far more physicians than I do. Are you hearing this type of outside world impinging on our personal professional satisfaction? Are you hearing that discussed very much? Zubin Damania: Absolutely. And when I talk to male physicians who are experiencing high degrees of burnout, often they will report having a child who either has special needs or who is having difficulty through the pandemic and has required a lot more attention from the male parent. And so these things are absolutely intertwined but we reduce it to, well, it’s Epic or it’s an electronic health record problem, or it’s too much insurance interference. All that’s there and that’s been going on, but what is it that really this is about is we try to make doctors try to feel like they’re these invincible, off the grid kind of super humans. And in fact, we codify that in our cultural response to the pandemic and say, “Oh, heroes work here. These are healthcare heroes.” Zubin Damania: And so what is calling somebody a hero says, well, then you’re more than human. So you can take on all this stuff. And the truth is, no, we’re absolutely human. And the hero’s journey is the human going on the journey, right? And coming back and returning with new knowledge, new insight, new awakeness. But we’ve taken away the journey and we’ve said, “Oh no, no, no. You’re just going to do inhuman amounts of work and then suffer at home too with all the responsibilities you have.” And we’re not going to talk about it, Robbie, because you asked that. Why don’t we talk about it? Because it’s stigmatized. People are afraid to talk about it. They’re afraid of getting canceled for saying the wrong thing. They’re afraid of … You call this series Unfiltered. You and I will just say what we think, right? But there’s still that subtle fear, like, “Well, I don’t want to come off like I’m mansplaining about what women are going through.” And so everybody’s just all uptight about it. We just need to have these open conversations. You’re very good at that. Your book about physician culture was … I mean, I was like, “This is it right here. And it’s going to generate anger.” But, man, that’s what we need to do. Jeremy Corr: All right. So I guess my final question for you both is in 2021, 107,000 people died from a drug overdose in the US, roughly a quarter of the number of deaths attributed to COVID during the same time period. The opioid epidemic is something you hear about in the news significantly less, yet I do not think there’s a single person who has not had a friend or family member that’s been impacted by the opioid epidemic, many of them due to fentanyl. There’s also a massive mental health crisis in this nation that’s been very much exacerbated by the pandemic. I didn’t see the 2021 numbers for suicide, but in 2020, there were over 45,000 deaths by suicide in the US. And a couple days ago, the House overwhelmingly voted to send $40 billion in military aid to Ukraine. This is during a time of record inflation, gas prices, baby formula shortages. Jeremy Corr: And I saw one comment on Twitter that I found fascinating that I wanted you both to discuss. I saw someone say that if a member of the House proposed $40 billion to fight the opioid epidemic or mental health crisis here in the United States, they’d be laughed out of the room. I understand that to an extent. This is an apples and oranges comparison. But as healthcare experts, what are your thoughts on this? And why isn’t more being done to address the domestic issues around the mental health crisis and opioid epidemic? Zubin Damania: Jeremy, this is what some friends of mine call COVID myopia, for example. We’re so focused on what’s an obvious pandemic, a million dead and so on, that we’ve always ignored actually a very iatrogenic, medically caused epidemic, the opioid epidemic that, like you say, is a significant fraction of the COVID deaths, but it continues year after year after year and only seems to get worse. And the pandemic does not make it better. And so to some degree, our shortsighted responses to one thing tend to either exacerbate, because it’s all connected. During the pandemic, of course, seems like drug use, mental illness has gotten worse because we’ve destabilized society with some of the response to this, which again, gets back to our original discussion of like, well, do you censor people’s discussions when they disagree with our response? Zubin Damania: And the answer is no, because some of them may be looking at bigger picture stuff. And sending money to Ukraine, we’re printing that money. It’s not like … We’re just deficit spending. So our children are paying for that and they’re going to pay for the opioid crisis that the Sacklers helped create. And it just becomes a very frustrating stew of not being able to see context and the holistic picture of what’s going on. And I think that really has come to a head here with this. Robert Pearl: My take is that in our nation, we do not see all lives the same. And if you are in a group such as someone with mental health illnesses, someone with opioid addiction problems, heroin issues, someone who’s very old with lots of chronic disease, our nation doesn’t value those lives, doesn’t see them as being productive and doesn’t make the investments. Whether they spend the money someplace else, and I personally believe that the war in Ukraine is one that’s vital for our future, because I think the aggression that Russia has shown is only the start. We’ve seen it many times in the past. But that’s my political views. As a physician, my view is that all lives are not the same. I mentioned earlier, the zip code four miles away, people are living. You can run there in 40 minutes. And yet the people dying 10 years earlier are simply not seen as being as important lives worth saving as the people living in the houses surrounding your own home. Robert Pearl: This, I think, is a part of the human existence. In particular, we know this from implicit bias that people who look like you, act like you, talk like you, believe like you are ones whose lives you think are more significant. And I think what you’ve pointed out, Jeremy, is the price that we pay, 107,000 people dying now. It was 60,000. We didn’t notice it back then. It could be 125,000 a year from now. And maybe I’m just an idealistic doctor. I just think that every life that is lost unnecessarily and not from a disease we can’t control, but for a problem we could take care of is simply a tragedy. And we have a growing number of tragedies across our nation. Jeremy Corr: We hope you enjoyed this podcast and will tell your friends and colleagues about it. Please follow Fixing Healthcare on Spotify, Apple Podcast, your favorite podcast platform. If you liked the show, please rate it five stars and leave a review. If you want more information on healthcare topics, please go to Robbie’s website at robertpearlmd.com and 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. Thank you very much, and have a great day. The post FHC #52: The future of medical misinformation, education and motivation appeared first on Fixing Healthcare.

One hard part about interviewing Dr. Eric Topol is knowing where to begin. Topol wears a seemingly infinite array of hats: He is the director of Scripps Research Translational Institute. He’s a professor of molecular medicine. He’s an expert on artificial intelligence, Covid-19, genome editing and precision medicine. He’s a bestselling author, the editor of the popular healthcare publication MedScape, and one of the most followed physicians on Twitter. Thus, another hard part about interview Eric Topol is knowing you’ll always have far more questions than time to ask them. For this interview, the questions of cohosts Jeremy Corr and Dr. Robert Pearl center on rule-breaking in medicine—and, specifically, the unwritten rules doctors follow. Who better to ask than Topol, one of healthcare’s biggest rule breakers?   Interview Highlights On precision medicine “We have a huge number, every year, of serious diagnostic errors. And our treatments are based largely in clinical trials, where maybe 10 people out of 100 in a really good trial might derive benefit. But the 90 people who don’t derive benefit, we give them the same therapy. That’s not exactly an accurate and precise way of delivering care. So, we can do far better, but it involves dealing with lots of data, a tsunami of data. And we aren’t well equipped to do that yet.” On doctors who can’t handle the data “The way things are in medicine, we can’t handle the data. So, we need to acquiesce and we need to say, ‘We need help.’ You’re well aware of the crisis, the global crisis we have of burnout, and disenchantment, and depression. Part of that is non-ability to care for patients because of being overwhelmed. And part of that being overwhelmed … is not being able to get our arms around all the data of any given patient because it takes time. But that’s what machines are really good for.” On using smartphones in medical practice “Part of the unwillingness for cardiologists to accept smartphone ultrasound is that their first reaction says, ‘Well, I don’t want have to do that. That’s what ultra-stenographers are for. I don’t want to have to acquire the images. That takes time and I’m not getting reimbursed for it,’ and every possible excuse. But in reality, every cardiologist should know how to acquire an echo … It takes just a minute or two. It’s so much more effective in time-use than with a stethoscope because you’re seeing everything.” On what patients want “They want to be more autonomous than they are, not so dependent. And we have the tools to do that. Already, we have emerging tools to deal with very common conditions like skin rashes and lesions through a smartphone picture and AI algorithm, ear infections for children, UTIs with an AI kit, heart rhythms through a smart watch. I mean, we have a lot of common diagnoses that are not life threatening that can be screened by patients and that list is just going to keep growing.” On the Covid-19 vaccine-booster fiasco “The biggest thing in my concern about the way the pandemic has been managed actually with the boosters, Robbie. I think this has been a fiasco. I think that we, as a country, are ranked 70th in the world for boosters in our population. We’re only at 30%, whereas most countries that you would consider peer in Europe or Asia are 70, 80%. And most importantly, in people over age 50, where in the US, 1 out of 125 Americans have died over age 50. And that’s for confirmed deaths, not even excess mortality in the COVID era. And we know that booster shots reduce death. They also reduce hospitalizations. They reduce long COVID.” On fighting medical disinformation “I’m very into free speech. However, we need to, in my view, at least draw the lines about when there’s clear, unequivocal, medically harmful disinformation, lies, misinformation, fabrication, because we’re talking about people being hurt or dying from it. And so that’s different than expressing opinions or providing data that’s real instead of just making things up. And there’s been a lot of that. We’re not talking about Galileo here. We’re talking about people who are purposefully, if not unwittingly, trying to hurt a lot of people.” READ: Full transcript with Eric Topol  * * * Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders. Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn. The post FHC #51: Eric Topol on breaking the rules and putting patients in charge   appeared first on Fixing Healthcare.

The biggest Covid-19 news of the last month came out of Florida, where a federal judge struck down the CDC’s mask mandate on planes, trains and in transportation hubs. As Americans jubilantly removed their masks, the Justice Department quickly filed an appeal. Importantly, however, the DOJ did not immediately request a stay on the ruling in Florida. Thus, Americans will be flying mask-free for months before the appellate court can hear and rule on the appeal. What does this mean for Covid-concerned travelers? Are masks as good as gone or could they still make a comeback? Jeremy Corr and Dr. Robert Pearl examine these questions and many others in this episode of Coronavirus: The Truth. You’ll find all the [time stamped] topics from this show below in the notes: [01:18] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean? [02:58] Why are masks no longer required on planes and public transportation? [04:16] What should we know about the new strains of Covid-19? [07:02] If VP Kamala Harris tested positive for Covid-19, but didn’t have any symptoms, does this mean she’s not contagious? [10:55] Survey says: Are Americans worried about Covid-19 anymore? [13:12] What’s the latest science on Covid-19 and young kids? [18:18] How are healthcare workers coping today with the trauma of Covid-19? [22:42] Do patients think about how their actions affect doctors? [23:50] How are teens coping with mental health challenges of the pandemic? [24:56] Why are so many elected officials getting Covid-19? [27:17] What’s good this week? [30:11] What’s the biggest non-Covid story in healthcare? [32:19] Do Americans still believe U.S. healthcare is best in the world? This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms. If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn. *To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest. The post CTT #60: Will mask mandates return to planes and trains? appeared first on Fixing Healthcare.

Welcome back to the Fixing Healthcare series, “Diving Deep,” which features a robust and probing discussion about some of healthcare’s most deep-seated problems. In this episode, Dr. Robert Pearl Jeremy Corr dive deep into the unwritten rules of healthcare, which have long dictated for doctors “the right way to act.” Two examples featured in this show include the doctor’s use of intuition when making medical recommendations and the current rules surrounding hospital care, which lead to high prices but not necessarily better care. For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a discussion guide: When it comes to medical decision-making, where should the science end and gut-feelings take over? What is evidence-based medicine and why does it matter? Why do doctors (and people in other industries) distrust science-based guidelines? What can go wrong with intuitive medical decision-making? When (if ever) is intuition is better than science? Why don’t doctors have time to talk with patient about their hopes, fears and values? How can patients know whether or not a hospital offers good care? * * * Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders. Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn. The post FHC #50: Diving deep into physician intuition and hospital prices appeared first on Fixing Healthcare.

Welcome to Unfiltered, a new show that brings together two iconic voices in healthcare for an unscripted, hard-hitting half hour of talk. Dr. Robert Pearl has twice appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who has twice appeared on the Fixing Healthcare podcast with Pearl, alongside cohost Jeremy Corr (see: here and here). This episode ventures into uncomfortable territory. It starts with “the slap” at the Oscars and asks whether making fun of a medical condition is ever okay. Next up, the two doctors discuss emotion in medicine: should physicians show more of it at work? And finally, four existential questions for healthcare professionals, including: What’s our purpose? To get started, press play or peruse the transcript below. * * * 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: Welcome to Unfiltered, our newest program on our weekly Fixing Healthcare podcast series. Joining us each month as 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 a patient based on what I’ve heard. Robbie, why don’t you kick it off. Robert Pearl: Zubin, I’ve heard great feedback from our listeners about the first show and our willingness to tackle controversial issues. You’re my social media maven. And I have to ask you about the event that garnered twice as many social interactions than Ukraine, and four times as many as the president of the United States. And of course that was the confrontation between Will Smith and Chris Rock at the Oscars. But rather than talking about the slap, Zubin, I’d like to ask you a different question. Why do comedians think it’s okay to make jokes about people’s medical issues? Zubin Damania: Ah, well, boy, there’s so much here. I mean, the truth is comedians, like anybody, their job is to make people laugh or to point out absurdities and that kind of thing. Now, whatever Chris Rock knew or didn’t know about Jada Pinkett Smith’s alopecia, I actually am with Bill Maher on this, where again, there is a free speech protection here where Chris Rock can make jokes all he wants and Will Smith can protest verbally, legally, however he wants to do it. That’s fine. What’s inexcusable is hitting anybody and hitting a comedian for making a joke. Now, whether or not he knew, because Jada Pinkett Smith has been public about her alopecia, there’s a lot to nuance here. It’s more common in African American women. She’s a public figure. So it is traumatic for her. But as Bill Maher said, “If the worst thing you have to deal with is alopecia, I don’t think someone should slap somebody for making a joke about it.” So, I tend to fall on the free speech side on this one myself just being somebody who dabbles in comedy. Robert Pearl: Yeah. I agree with you completely. First of all, we both agree that the violence is inexcusable. So that’s why I didn’t want to talk about that. And I also agree with you on this free speech. He has the right, the legal right, the constitutional right to do so. I guess the question I’m really asking, is it worth the pain that’s inflicted? Zubin Damania: Mm, this is a great question. I mean, look, in comedy, you’re not supposed to punch down. Anytime you make fun of someone with a chronic disease, you’re punching down, kind of by definition, like Putin could suffer from end-stage renal disease. And if you make a joke about him being on dialysis, you’re still punching down because he didn’t choose to have that disease, and it doesn’t do well for other people with the disease, and it’s stigmatizing. So, as a general rule, right, you don’t punch down in comedy. Robert Pearl: Probably because I fixed so many kids with clef lips in the past, and I’ve heard all the jokes and I’ve seen the pain that they experience, I am overly sensitive about this issue. But I guess, as a physician, I would hope that we would keep people’s diseases out of comedy. It may be funny, don’t get me wrong, but I think the pain inflicted on the individual, now, if it’s the president of the United States or it’s Putin or someone, these are very public figures who are at the center of the discussion. If it was about Will Smith, you could say, “Okay, well he’s about to win an Oscar, but” his guest, who happens to be a public figure, but still, to make that be the brunt of the comedy, again, I’m probably overly sensitive, but I’m reacting as a doctor to this. And that’s why I wanted to ask you, because you’re a social media leader. And as you say, you’re quite a funny comedian. Zubin Damania: Well, I mean, that’s a great perspective, Robbie, that you’re bringing because you’re actually seeing the suffering that these diseases can cause. And so you compound the suffering if you’re making jokes about it as a public comedian and so on. This situation is a little murky. It’s just hard to know what Chris Rock knew about… Maybe she, in his mind, she had just chosen to shave her head as a style point, in which case, as a public figure, you’re fair game. Right? But I think your point is very well taken. And again, it’s a question of, are you generating net suffering in the world or are you generating net joy or well-being? And I think that’s a good moral compass for all of us. That’s why comedy, in general, I’ve seen comedy where I’m just like, “Yeah, that was just, not only was it not funny, but it was kind of hurtful.” So it’s kind of like, well, there’s no net benefit. Like I’ll defend your right to make the joke, but it’s just not good comedy. Right? So I think you bring a very valid point here. Robert Pearl: Zubin, your comments about the emotional aspect of this encounter, they make me think about a class that I took at the Stanford Graduate School of Business on politics and public speeches. It was about the relative power of emotion versus logic. My favorite clip was from Oliver North and his testimony to Congress in the Iran-Contra affair. It begins with one of the senators who wasn’t a fan of Colonel North showing a video of the FBI agents storming into his office in Washington, DC, as he sat at his desk, shredding all the incriminating evidence. The senator, certainly no fan of North, believes that he’s made Oliver look like a fool. He says, “What were you doing?” North says, “My job.” The Senator’s flummoxed, this is not what his prep team has predicted. The senator stammers. He asked the colonel, “Why do you think this is your job?” And in this totally unemotional calm face, he says, “If it wasn’t my job to shred documents, then why would the government have given me a shredder? And why would Congress have paid for it?” This complete lack of emotion is powerful. And in contrast, in the same class, the professor showed the 1988 debate between the democratic candidate, Mike Dukakis and the republican candidate, George Bush. The CNN correspondent Bernard Shaw asked Dukakis whether he would support the death penalty if his wife were raped and murdered. His response purely cerebral, “No, sir. I don’t see any evidence it’s a deterrent to deal with violent crime.” The pundits think he may have lost the election because of that one completely unemotional response. So now let me ask you, doctors are taught not to show emotion. Don’t cry, don’t yell. Don’t admit how unfair life can be when it comes to who gets cancer. And yet we’re expected to be authentic. How should we, as physicians, as clinicians, resolve this contradiction? Zubin Damania: Man, this is why I love doing this podcast with you, Robbie. I say no to every podcast invite I get. And Robbie’s like, “No, we’re just going to talk about this kind of thing.” I’m like, “Yeah.” So look, this is central to who we are as human beings. And you said the word authenticity. We’re expected to be authentic. And yet we can’t show what we are, which is largely emotional creatures with a little reason tacked on evolutionarily. We really are, as Jonathan Haidt says, “We’re all elephant with this limbic system that is evolved actually to keep us safe”. Emotions are there for a reason. They’re feelings. They call them feelings because you feel them in the body, they’re an energetic pattern. You ignore them or you repress them at your peril. And the reason, Dukakis lost that thing, the reason we loved Spock is not because he was all logic. It’s because you could feel clearly Spock was half-human. The underlying emotion was there and watching him try to repress it, watching him try to be a good Vulcan and fail very often was what made him human. And that’s why Kirk, at the end of Star Trek II, says, “Of all the souls I’ve encountered in my travel, his was the most human.” And that’s why in medicine, I think it’s important that we’re authentic with our patients. We do need to show some emotion, but we also need to have that kind of cognitive empathy that says, “You know what? Yes, I feel that you’re suffering. I know that you’re suffering and you can feel some of my emotion, but also I’m going to be a source of stability for you. So I’m not going to let it cloud decision-making. I may help with you to use our emotions together to inform what values matter to us.” And I think that’s important when we ignore that. When we ignore our own emotions, we end up with all kinds of problems. And physicians in particular are the masters and mistresses of emotional repression. Yeah. So to me, focusing deeper on understanding our own emotions and unrepressing them and really feeling them and getting rid of this stigma, oh, there are negative emotions and positive emotions. No. There are energetic patterns that we call emotions, e-motion, energy in motion. Let’s feel them because if you don’t, they’re not in motion, they almost become solidified. And then you tell stories about them and then you act unconsciously on them. So, you know what happened with will Smith? Undoubtedly, there was deep emotional repression for years of being a celebrity and having to swallow this stuff and whatever was going on with him and his wife. And then what happens? It comes out in violence. You don’t have to do that if you’re actually in touch with that stuff on a regular basis. Robert Pearl: Let me ask you where the line is. I was talking to a doctor who lost four COVID patients in the same day. This feels to me to be beyond the possible human tolerance. How are we going to address this? And how are we going to deal with the PTSD that invariably is now about to start in even greater force than during the pandemic itself. Zubin Damania: Yeah. You know what’s interesting is I think human tolerances are beyond our imagination. Like we, humans are able to tolerate insults and traumas that would just theoretically break anyone and they seem to do it. And some actually find meaning in it and grow stronger. But the difference is you have to have that, in my opinion, in medicine, what we miss is this communalization of pain. We don’t make it okay to talk about this stuff. We don’t make it okay to say, “You know what? I’m suffering too.” And that way, you could tell people, “Look, we’re all in this together. Yeah, man, four patients that we’ve known forever, and now they’re not here.” That is a trauma. So let’s sit and process that, let’s feel the emotion. It’s okay to have grief. That’s normal. If you’re suppressing grief, that’s what’s not going to be good for you. So providing the tools and resources to actually process that stuff will be important to mental health resources, et cetera, but just changing the culture to say it’s okay to feel these things. This is normal. In fact, if you don’t, maybe that’s the pathological state. And we ought to think about that. So again, I don’t have a magic answer, but I’d say that diving into the pure emotion of loss and grief… One of the things that happens when you go down any sort of self-realization or meditative path is strong emotions start to arise that were repressed by the mind for years and years and years. And they start to unrepress because the mind relaxes and the thought-based structures relax. And one of the things that can happen is you can feel unmitigated sorrow out of the blue, be driving and just burst into tears. And we have no societal container for that. So in medicine, it’s even worse. So we have to start building those containers and those structures to process. Robert Pearl: Well, I want to dive a tiny bit deeper and ask you how. Because I’ve seen the response that people have had to individuals who say, “I need therapy,” or “I’m not able to work to my best today because of the emotional experience I had.” I mean, I’ve seen people, a physician get a diagnosis of cancer in the morning and come back and take care of her patients in the afternoon. I mean, I just keep feeling as though this problem is going to be so hard to burst through. How can we start? Zubin Damania: Oh, my gosh, man. I mean, that stuff is heartbreaking and you’ve seen it so much as leader of the group. I’ve seen it when I was on the front lines with my own team. And people I used to work with still email me and they go, “I’m at my wits end. I don’t know what to do. Do you have any advice?” And I think… Okay, I’m going to give you an answer that is going to be unsettling for some people and they’re not going to like it. But the truth is, I’m just going to tell you what I know. Recently, I did like a six day semi-silent meditation retreat led by another physician. And they were all healthcare professionals, about six or seven or eight doctors, many nurses, physical therapists. And this was just in November. So COVID had been going on. People were traumatized and they came in. Many of them had never meditated and had never had this kind of practice, but they saw my show and they’re like, “You know what? I want to do this thing.” And what we found was people opened up and just torrents of emotion and sharing in the non-silent parts in the evening when we did group activities. And the being with yourself and processing that stuff, that unconscious stuff, in a safe space with other people who do what you do is so powerful, Robbie. When the thing was done, many of them were saying this was the most powerful experience they’d had. And that they went back with renewed sort of resilience to their careers. That doesn’t mean that’s the single answer, but you can see how powerful unrepressing that stuff, having a safe space with your colleagues and doing the deep work of actually introspection. We tend to externalize everything. We project everything we say, “Oh, this is the problem. It’s this guy or that guy.” But when you actually look inside, it’s really all right there, and we create the world. So that’s my really questionable answer to that. Robert Pearl: Your story, Zubin, reminds me of a talk I heard Yo Yo Ma give in Silicon Valley. And for any of our listeners who don’t know his background, he was a child prodigy. He performed from the age of four and a half. At something like five or six, he and his sisters gave a concert for President Kennedy at The White House. He’s recorded 90 albums, 19 Grammy Awards. He’s the best celloist of the time. At the event I attended, first he played a series of some of the most beautiful and moving cello pieces I’ve ever heard in my life. But then he talked about four existential questions that he said he often thinks about. He said that he wonders first, who am I? Second, what am I grateful for? Third, what is my purpose? And fourth, what do I want? Sitting in the audience, Zubin, I wanted to scream at, “Who are you? You’re the greatest living celloist in the world! You’re a musical genius! What do you mean, who are you?” But I didn’t. Fortunately, I didn’t. But it did inspire me, somewhat similar to your six-day event, to ask myself these kinds of questions at various points in my life. So let me ask you, as a profession in the 21st century, as physicians today, first, who are we? Zubin Damania: Oh, these are the easy questions, Robbie. These are the easy questions. They’re very hard. So here, okay. I’ll give you two answers to this question that I’ve struggled with myself. There’s a deep who am I question, which is one of the spiritual questions that we ask, who am I? And when you actually investigate and look for yourself in the present moment, keep looking, keep looking, because you will not find a solid self there. And as you keep looking, you may find something really interesting, the real self. And so that’s answer one. That is a little woo-woo for this talk. Answer two is your authentic self, which is in this present moment, you’re an expression of reality, you are. And what is that? So Yo Yo Ma probably knew from a young age, “Look, this is who I am and being authentically me is standing on stage in front of the Kennedys with my sisters doing this and talking about it,” and so on. Now, many of us in healthcare, we knew authentically. We were drawn to, it’s not something we chose. There was no agency involved in many ways. We were called to do this. And yet, we’re often made to compromise on what it is we know is authentically us. And I think that’s part of that moral injury component that we have to make these compromise. We have to do things we know are antithetical to, maybe not just… Forget about our interests and aptitudes. It’s more just what we fundamentally know we are, and that causes this tension, which you could call… The Buddhist will say is the nature of suffering that you’re diluting yourself by trying to be something you’re not. Now when you really… And that’s why I think that meditation thing was powerful because people could feel in. Like when I did it, what I realized was, I’ve often undervalued my own compassion. I feel like I’m not compassionate enough. I can be a jerk. I’m self-centered, all these other like me, me, me, me, me, beating yourself up type of things. But during meditation, I realized, wow, there’s an infinite well of compassion there. And I do express it. And sometimes you have to forgive yourself. And when you do that, you can then be authentic. You can say sometimes there’s tough love, like being a little bit hard with people is an act of compassion. And again, that’s connecting with your authenticity. So how do we train or create… It’s hard to train, right? You create a space for people to be them. And that means again, giving them tools, resources, and autonomy to be who they are, which some of its systems change. But some of it is working on ourselves. Robert Pearl: Are we healers, experts, teachers, businessmen and businesswomen? As a profession, who are we? Zubin Damania: Yes. All of those things. We could be any and all or none. I mean, we may be something totally different within there. And each person is different. Each person may have aspects of it. As a profession, I think it’s tough to paint us with a single brush. The people that we admire the most may have one or two or three of those aspects that are so powerful and we just really are drawn to it. And that’s why mentorship is so important, right? Because the mentors can show us who we, not only who we are, because that’s our aptitude or our draw, but who we can be. Right? So more mentorship, more openness about that stuff, and then we find out who we are. Robert Pearl: So then as doctors, what should we be grateful for? Zubin Damania: Gratitude is a central practice. It actually is an anchor through all kinds of suffering. Anytime, I was just talking to my mother and she’s now entering our 80s. And my dad is in his 80s and they have their problems. They have health problems. They have problems with their house, the kind of things that happen with your elderly parents. And we were talking about it. And she said, “A year ago, I would’ve really been upset by all these things. And I would’ve stressed and we would’ve been anxious, and so on. But all I have to do is watch the news for five minutes to see people in Ukraine suffering, who didn’t ask for it. And I’m filled with the gratitude that I live here, where I have these first world problems and everything is great. It’s wonderful. It’s beautiful.” So that gratitude practice is so powerful. In healthcare, the gratitude that you can be with people when they’re at their most vulnerable and they open up in a way they don’t do for anybody else, and they let you be with them in that sacred space. That is deep gratitude. The fact that you are, regardless of your loans and all of that, you’re actually doing okay overall in the grand scheme of things. And you get to do a trade that, there’s almost no other profession on the planet where you get this kind of connection with humans and get to help people this way, no matter what aspect of medicine you’re doing. So there’s an immense well of gratitude there that’s available if you choose to be aware, make yourself aware of it. Robert Pearl: If we’re going to deal with burnout, should we be expressing a lot more gratitude about the positive things that we have than I believe we are today? Or is that just too Pollyannish? Zubin Damania: Ooh, burnout is such a… I mean, again, it’s that end stage of the chronic injury. So it has multiple facets. So yeah. Gratitude is a powerful prophylactic against… It’s like taking lisinopril when you have chronic hypertension. It’s going to protect your kidneys a little, protect your blood pressure and your heart a little bit, but it’s not the only answer. It’s a piece of it. You also have to stop eating the salt or stop stressing yourself out, so environment matters. Your own personal framing matters. And gratitude is a powerful piece of that. Some kind of spiritual practice, whether it’s prayer or meditation or looking at the night sky and with awe, whatever it is, that’s a piece of it. But then it’s also asking yourself, am I authentically me in this thing? And sometimes, Robbie, I hate to say this, but you got to stand up and say, “This isn’t me. I got to go do something else in medicine or out of medicine.” And for some people that is the answer and they know it, they know it. I had an OB reach out the other day on Instagram. I was taking a ask me anything thing. And she just said, “Look, I’m an older, morally injured, upset obstetrician. Should I retire?” And I said, “You know the answer if you actually feel into it. You know what the answer is. So why are you asking? You’re really asking for permission to do what you know is right already, whatever that is.” Robert Pearl: So that leads into the question of what’s our purpose? Because I’m thinking about that woman you just described. I’d hate to see her lose the purpose that she entered medicine for at the start of her career, maybe different ways she could express it. But as physicians, as doctors, what’s our purpose? Zubin Damania: Yeah. It’s great. It’s a great framing of it because if she really feels into what her purpose is, she will figure out a way to fulfill it, authentically. My feeling is I really like what writer Jonathan Haidt, the same Elephant and Rider writer wrote about purpose. He says, “The meaning of life, it’s not without, so it’s not outside us. And it’s not even within us. You don’t find meaning within. You find meaning between.” So humans are, we’re relational creatures. We find meaning in the connections between us and others. And so when we feel into our authentic selves and then we express it in the world in a way that connects with other people, that’s all the meaning you need, even if everything is empty void and it means nothing in that sense, it means something in the relational sense right here and now in this second. The universe, man, I showed my daughter a picture of the Andromeda Galaxy taken by Hubble. And as you zoom in at 8K on YouTube, you see every single star in that galaxy of a billion stars. And as you start to see, each of those stars has planets around it. And some of them probably have life. And you’re thinking, “God, I feel so small.” I could see her face start to just shrink in horror at the existential terror of that. What is my purpose when I’m this small? And then I told her, “Your purpose is right here. Look what’s happening right in this minute. You and I are having this connection. That’s a purpose. That’s all that matters. It’s right here right now.” So it’s the same with medicine, really focusing on what is and what our relations are with others. I think that’s where a lot of meaning can be found. Robert Pearl: I believe, and I hope again, that I’m being realistic, that the purpose of medicine is around health and that medicine today is focused on disease. And I think that a lot of the burnout type of experience, the lack of fulfillment, the lack of satisfaction we have, is that we’re focusing on the wrong purpose. Any thoughts? Zubin Damania: Oh, I mean, I think you’re absolutely right. Now, what people would say on the front lines is, “Well, of course, Robbie and Zubin can say that because they’re not having to chart 40 patients a day, and click all these boxes, and to get yelled at for low productivity, and so on and so forth.” And so sometimes it’s tough to see the purpose from the immediate feeling of lack or of overwhelm or of stress. And that’s absolutely valid, but there are solutions to these problems if we work together with people who lead rather than just manage. Right? So I do think reconnecting with what the purpose is means that you use technology to actually enable the purpose instead of using technology to enable an outside purpose of whatever it is, billing or nonsense like that. The technology ought to enable the human relationship that allows us to connect and heal with our patients and help each other. So if people have those tools, resources, and autonomy, then the purpose is the guiding beacon. But I think what we’ve done is we’ve made the purpose too skewed towards one thing or another, whether it be profit for an institution or whether it be quality measures that don’t measure quality, whatever it is, get those things right. And then the purpose shines through. Robert Pearl: We’re in complete agreement. I mean, I think the people who are experiencing these emotions, they’re the victims. There’s no question about that. The question is how to get from here to where we need to get to. And I think that by being able to understand the purpose and exactly what you said, figure out, how do we augment the things that we can do, use the technology to accomplish that, put together the teams to accomplish that? Then that is how we can eliminate our own pain, but more importantly, fulfill our purpose. So what do we want? Zubin Damania: Yeah. You’re the master of this, man. You’ve been doing this for so many years. I would be asking you this. But I’ll just say one thing, which is Garry Kasparov, right? With the chess champion who was defeated by Big Blue, the IBM AI, it was written about this quite a bit. He could have gone into a deep depression and felt a lack of purpose and so on when that computer beat him with mechanical intelligence. But what he said instead was, “No, this is a huge opportunity to use a tool, the AI, with a human, me, and I could beat anybody alive in any computer with that tool.” And that’s what we need in medicine is those tools, that technology that takes all the mechanical intelligence away, that it does it better than us. Let’s just be honest. And so then we get to do what only humans do with our awareness, our comprehension, our emotion, our intuition, our connection, those are the things, and our intelligence, that computers will never have that comprehension. So that’s what we need is those tools and resources that enable us to do the job better. And that means better systems thinking better individual awareness and awakeness, all those things are connected and integrated. That’s why it’s so hard. People say, “Oh, how do you solve this problem? It’s so complicated.” Well, you have to go in all the parts and they add up to bigger than the sum of the whole. So you have to work on everything. Robert Pearl: I love the answers and I hope the listeners learned a lot from it. Jeremy, your question as the patient listening to this conversation. Jeremy Corr: You both talked about grief and being authentic and being human. As patients, we often look up to doctors, especially in times of major crisis, such as early on in the pandemic, or if a loved one just got in a car accident as being almost above human, almost a godlike figure that can, I mean, essentially perform miracles, help us in our time of need and save lives. We expect perfection from doctors and almost stoic brilliance, but we expect human empathy from physicians, but we really do not allow them and maybe cannot allow them to be truly human. Humans get burned out at work, have marriage problems, have loved ones pass away, things that happen in their personal lives that can impact job performance. But we do not, as patients in our minds, view physicians as having the luxury of being human, making mistakes, having bad days. How do physicians deal with that pressure? And should patients look at physicians as being humans who can make mistakes? And is it dangerous to have patients lose that reverence for physicians? What are your thoughts? Zubin Damania: Hmm. This is something that I’ve personally struggled with because there is this aura around the physician that actually has a potential healing piece to it. There’s this therapeutic alliance. Now, what I’ve learned over my years is that the more honest, open, and authentic I can be with patients, the more they actually are able to connect within parameters. You’re not going to behave the way you behave with say your best buddy when you’re at the gym or something, making jokes with a patient. That’s just never going to work, right? So there’s the use of humor. You have to be very careful, and thoughtful, and respectful with patients, but at the same time, some of it is an authentic expression of connection and a rapport. So I think what we, patients are already waking up to the idea that their doctors are not robots or superhuman, and they don’t want that, because a doctor who stares at the computer is not a good doctor in their mind. They want their doctor to make eye contact, to show a little bit of connection, at least probably more than a little. Surgeons, they’re a little more lenient with, but in surgeons, maybe there’s different degrees of this for different professions, but I’ll tell you for internists in general, they want a little bit of that connection in humanity. And I think that’s one of the reasons that whatever I do online is vaguely popular. As I think people are like, “Oh, this guy’s not so uptight like a lot of doctors that I’ve met. Maybe he goes too far, actually, in the other direction.” But it’s a balance that we have to strike. And some of it is modulating patient expectations, which happen when there’s a million doctors on YouTube making videos that are a little bit funnier and more open. Robert Pearl: My answer, Jeremy, is to start with what the data says, which is that paternalism, and now maternalism, doesn’t work. The top-down approaches to work. We know that patients don’t take the medications as effectively as they should, as in terms of their best health. We know that they don’t often follow up on recommendations that will improve their health. The current system doesn’t work and yet we ignore it. And I think physicians don’t recognize the gap between what could be and what is, because they believe that it’s time-inefficient to establish a real relationship with the patient. But I think that that’s what’s necessary. If you don’t have that relationship, and you don’t build the trust, if you don’t build the trust, you don’t develop a level of commitment. And without the level of commitment, the healthcare system doesn’t move forward. And I believe that that’s what we’re seeing today. And so I think it’s essential that physicians be able to be human. Now, the reality is the person who is sick has come to your office and you’re the healer role. You can go to someone else’s office and they become the healer for you. And you should do that as well. But if there is a complete lack of authenticity, to use Zubin’s word, or a complete lack of openness, then I think the patient leaves and feels like maybe they got some information, but they’re not sure that they’re really going to trust it, believe it, or follow up upon it. I think the teachings of the past around the lack of emotion was really a defense by doctors for their complete inability to treat almost every disease. I mean, if you think about it, doctors could repair lacerations for centuries. They could fix, put bones back in place. After anesthesia came along, could do appendectomy. But the kinds of problems that we’re facing today, the kinds of treatments that we have, they are so complex that if we don’t invest the time upfront to educate patients, to make certain that they understand the disease they have, the treatment that will make it most likely to get better, if we don’t have a mutual commitment coming out of that meeting, I think it is going to fail. I think doctors wanted to protect themselves from their inability and their lack of success. They saw their job as telling patients. And I think we need to ask more and engage more. And I know a lot of listeners are going to say, “We don’t have time.” Somehow we find the time when the complications happen to treat the problems that ensue, we need to figure out how we can invest in the front to improve the outcomes of the back end, and minimize the need for rework and treatment of medical issues that could otherwise have been avoided. Jeremy Corr: We hope you enjoyed this podcast and we’ll tell your friends and colleagues about it. Please follow Fixing Healthcare on Apple Podcasts, Spotify, your favorite podcast app. If you liked 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 at robertpearlmd.com, and visit our website, fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter @FixingHCPodcast. Thank you for listening to Fixing Healthcare’s newest series Unfiltered with Dr. Robert Pearl, Jeremy Corr, and Dr. Zubin Damania. Thank you very much for listening and have a great day. The post FHC #49: An unfiltered chat about ‘the slap,’ emotional doctors, and more appeared first on Fixing Healthcare.

Season seven of the Fixing Healthcare podcast focuses on the unwritten and outdated rules of American healthcare—many of which Dr. Marty Makary would badly like to see broken. In this episode, the nationally renowned surgeon, author and educator sets his sights on the outrageous rules of medical education, healthcare spending, the “appropriateness of care” and much more. With cohosts Dr. Robert Pearl and Jeremy Corr, Dr. Makary shares his candid comments on the rules of American medicine that need to be broken. Interview Highlights On the ills of medical education “The AAMC continues to inflict tremendous damage on a generation of young people, who are trying to learn how to be great doctors. They’re forcing them to do all of this rote memorization, and it comes at the exclusion of other important skill sets … The AAMC has too much power. It’s the concentration of power in medicine, it’s not healthy. And by the way, many of these organizations lack diversity. Look at the editorial board of the New England Journal of Medicine and JAMA, I think it was like one African-American out of 50 editors.” On the cost crisis in healthcare “Well, I think the cost crisis in healthcare is really a function of three factors. One is pricing failures in the marketplace that enable price gouging, and they also enable the second factor which is a giant growth of a middleman industry. This is a group of thousands of millionaires that we’ve created who are not patient facing, who are not contributing to patient outcomes … And finally, the third biggest driver of our cost crisis is care coordination.” On the price of medicine “Financial toxicity is a medical complication, and billing quality is medical quality. These are things that are measurable, but up till now, we’ve only been measuring infection rates and readmission rates. We’ve got to start measuring billing quality performance and the price of services.” On end-of-life care “I can point and show you in detail areas of waste in healthcare where anybody, doesn’t matter what political party they have allegiance to, will agree that it’s egregious, it’s corrupt, it should stop, and it is wrong. Now, there’s a lot of those things in healthcare, actually. There’s a lot of area where there’s broad consensus, but reining in inappropriate care at the end of life is one of the most challenging, because it is still and always will be an art form. It’s not something that can be managed with policies or rules.” On the rat race in academic medicine “There was a time in the medical profession where in order to get a medical degree in the English empire, you had to have a degree from Oxford or Cambridge, at a time when neither Oxford nor Cambridge offered pre-medical education. It was just a royal lineage, if you will. It was an oligarchy, and they had all of these rules and we still have these rules in American medicine. And many of them live in this so-called academic promotion process, and that is a major barrier in my opinion to scientific advancement. People playing the game to get promoted, and we see that a lot.” READ: Full transcript with Marty Makary * * * Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders. Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn. The post FHC #48: Marty Makary on breaking the rules of medical education appeared first on Fixing Healthcare.

A group of researchers in the UK examined hundreds of brain scans that were taken both before and after people became infected with the coronavirus. The study, published in Nature, concluded that “there is strong evidence for brain-related abnormalities in Covid-19.” Some of the recorded disease effects included tissue damage, along with reductions in both grey matter and overall brain size, post-infection. This study raises more questions for scientists and medical professionals about the possible long-term consequences of Covid-19. Jeremy Corr and Dr. Robert Pearl examine these questions in this episode of Coronavirus: The Truth. You’ll find all the [time stamped] questions from this show in the notes below: [01:15] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean? [10:23] What’s the latest on Ivermectin, the Covid-19 treatment therapy? [14:41] How can patients distinguish science from pseudoscience? [16:48] Did researchers uncover data that shows brain damage after Covid-19 infection? [18:06] What do we know about “long Covid” now? [21:12] Is the CDC finally agree with the WHO on vaccines? [23:18] What’s good this week? [27:15] Why are medical workers abandoning the profession? [29:55] How do employer vaccine requirements and mask mandates affect local businesses? This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms. If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn. *To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest. The post CTT #59: What does Covid-19 infection do to the brain? appeared first on Fixing Healthcare.

Welcome back to the Fixing Healthcare series, “Diving Deep,” which features a robust and probing discussion about some of healthcare’s most deep-seated problems. In this episode, Dr. Robert Pearl Jeremy Corr talk about two areas of medicine where the existing “rules” seem out of date. The hosts begin with a bizarre norm in healthcare: that technologies must, above anything else, boost the status of the physician. That’s followed by another odd norm: that primary care physicians, the doctors who save the most lives, are among the least-valued in the profession. For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, each episode of this series will feature a time-stamped discussion guide (as follows): [01:07] Why is healthcare the only U.S. industry that has failed to use technology to lower prices or improve quality? [04:26] Why doesn’t medical technology improve life expectancy? [06:51] How are patients affected by the rules of health-tech? [08:58] Which technologies actually benefit patients? [12:36] What’s the difference between episodic and continuous medical care? [14:34] Which technology in medicine is most underutilized and undervalued? [18:37] How do we break the current rule of health-tech? [20:08] Why are primary care physicians undervalued in healthcare? [25:24] Can primary care solve our nation’s chronic disease crisis? [26:26] How do we break the outdated rule of primary care? * * * Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders. Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn. The post FHC #47: Diving deep into primary care & health-tech appeared first on Fixing Healthcare.

Welcome to Unfiltered, a new show that brings together two iconic voices in healthcare for an unscripted, hard-hitting half hour of talk. Twice, Dr. Robert Pearl has appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who hosts of the internet’s No. 1 medical news and entertainment show. And twice before, Damania had appeared the Fixing Healthcare podcast with Pearl and his cohost Jeremy Corr (see: episode 1 and episode 26). In the first episode of their new show Unfiltered, part of the Fixing Healthcare franchise, the duo dives into the differences—and similarities—between generations: from Boomers on up to Gen Z. Along the way, they discuss everything from techno-economic structures of healthcare to cancel culture to rap lyrics. Press play now or peruse the transcript below. * * * 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:  Welcome to Unfiltered, our newest program in our weekly Fixing Healthcare podcast series. Joining us each month will be 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. I’ll then 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: Zubin, welcome back to the Fixing Healthcare show. Zubin Damania: Dang, Robbie, I’m ready to get Unfiltered. I don’t know what that means, but we’re going to do it. Robert Pearl: Okay. Let’s begin in a place you love, Broadway. I had the chance to see a remarkable show called The Lehman Trilogy. It traced the history of the Lehman brothers from when the first generation came to the U.S., middle of the 19th century. And then it ended at the financial collapse in the first part of the 21st. What was most interesting was the continual clash of generation. Three brothers began in the South manufacturing clothes from cotton, but the next generation, it realized that it was more profitable to become transporters of cotton from the South to the industrialized North. Then the next generation recognizes it’s more profitable to be the financiers of industry and they start banking. Then the next generation says, “Why not expand to all businesses?” And they create the stock exchange, or contribute to its founding. Robert Pearl: And, finally, the company no longer at this point led by the family, introduces an array of financial products that ultimately proved to be Lehman’s downfall. What was so powerful to me was watching this inevitable clash. Each generation with the one that follows, one generation holding onto power, the other one coming of age, embracing change, and rejecting the values of their parents. I’d like to start by hearing your thoughts on this issue of the generations battling, whether it’s society overall, or how it plays out in medical practice. What are your thoughts, Zubin? Zubin Damania: Man, I love generational conflict because first of all, it’s entertaining. Second of all, it is an indicator of the natural evolutionary process of everything, like the entire universe unfolds this way. So you have generation one, let’s call them the boomers, for example, who did things a certain way. They were actually the rebels of their time. They pushed the envelope. In the ’60s the emergence of this sort of cultural revolution and the plurality and multiculturalism and postmodernism and all of that. They were the leading edge of that evolutionary chain. And then the generations that followed kind of emerged, and each of them takes a tact of first kind of learning what the previous generation kind of did. And then dis-identifying from it saying, “Oh, this has this many problems, and I don’t really like this, and this is not how I want to live.” And then trying to grab a foothold in something new and saying, “Okay, well, no, this is what we are.” And identifying with that. Zubin Damania: I think where that becomes healthy is where you integrate what the previous generation was able to do and actually say, “Yeah, that was necessary, but it’s partial. We need to keep striving for whatever truth is.” But if you don’t integrate it, if you just reject it and you never integrate it, then you’re in a difficult situation, then you have this kind of conflict. Now I think some of that’s inevitable, but some of it isn’t. Zubin Damania: As I started growing older in medicine and having house staff you could watch this play out. First, you have me, Gen X and then you start having millennials and you see a kind of a contrast in styles and expectations in sort of work ethic in a sense of it’s not that the work ethic isn’t there. It’s just it’s a different balance of what they want. They’re quite clear of saying, “I actually want to learn.” Whereas, we were like, “Well, whatever we need to do, we’ll do to kind of power through.” And so this kind of conflict to me it’s fascinating. I think it’s necessary to some degree, but understanding it allows us to actually transcend to a more integrative evolutionary approach to generational kind of thinking. Robert Pearl: One of the things that’s fascinating to me is how the events of the time so shape a group of individuals. As you mentioned, you have the boomers, they watched a man land on the moon, and President Kennedy talking about getting to space in less than a decade, anything’s possible. And Gen X this is the latchkey generation. They watched the breakup of the family. I’m not so sure anymore that this hard pushing is the best thing for people. Gen Y comes along and there’s 9/11, the world, it could collapse at any moment. And then Gen Z, the people who grew up during the 2008 recession. Now they’re moving back, look a lot more than the boomers. Robert Pearl: My sense is that the underlying motivation of people doesn’t change. It’s not that one generation is more purpose-driven or mission focused. No, it’s how it’s presented out. Is it going to be in the external world? Is it going to be in the family? Is it going to be an accomplishment? Is it going to be individual? And I fear a little bit, and this is overall, but medicine in particular that we personalize it in a negative way. My approach is better rather than understanding how as humans, we’re all shaped by what’s around us. What’s your sense? Zubin Damania: It’s like every disease is biopsychosocial. It has biomedical component. It has psychological component. It has social and technological components and environmental components. Everything in generational thinking is exactly that. For example, for me, Gen X we were shaped by our memories are the Challenger disaster, and the ’80s. And like you said, the sort of slow decline of family, the culture wars, these kind of things kind of shaped us and destabilized us to some degree, but I think that interaction with the system, the environment, the techno-economic structure. Zubin Damania: In healthcare, it becomes really fascinating because you have Gen Z now and Gen Y that have a very different upbringing than we did. They are digital natives. They started with an iPhone in their hand, the Gen Zers. And they’re entering a system where we have fax machines still. We have pagers still. We have this archaic set of payment models and CPT codes, and all this stuff. And they look at it and they cannot understand why this exists, and that pushback that they might feel, or might exhibit can be interpreted through the older generation’s lens as you’re just not paying your dues. You don’t understand, this is how we’ve done it. And we got stuck with this crap and you should too, but I don’t think that’s the right way to look at it. Zubin Damania: What we have to do is understand that both the techno-economic structures of healthcare and everything, and society have to adjust and vibrate along with the generation that’s coming into being, that’s going to be the predominance of the workforce, and all that, instead of us, like a lot of Gen X attendings now are just, “Oh my gosh, these millennials and these Gen Zers they’re impossible to deal with.” I don’t think that’s the right way to look at it at all nor is it for a Gen Z-er. It’s usually millennials looking at boomers going, “Yeah, okay, boomer, you guys wrecked everything. You guys don’t even know what you’re doing. Like, let us handle this.” That’s the wrong way to look at it too. Robert Pearl: I’m just so excited I have to tell you about Gen Z. If I were back in college, I’d study Mandarin, because I’d see that as what the future world is going to be rather than what was in the past. I’d be really interested in this narrowing of the line between humans and robots and seeing a world in which we actually will interact with these technologically created creatures that biologically don’t exist, and yet in so many psychosocial ways do. It’s interesting that I somehow have this view of the future rather than the view of the present and the past. I think it’s true for you too, Zubin. Am I right? Zubin Damania: Yeah, this merging of, so you cannot separate our tools and toys and technologies from us. We are intertwined with that. I recently had a guy named Daniel Schmachtenberger on my show. And we talked about this, that technology and society those structures feed back on the human mind. They feed back on us in ways that evolve us that are beyond our DNA, actually. Although, some of it is our DNA, methylation, and these sort of Lamarckian effects on our DNA, but the truth is even beyond that we are absolutely changed by these structures, so we ought to actually approach the future with kind of a mix of kind of techno optimism, like let’s design systems that actually encourage the kind of outcomes that we want as a people, which right now we haven’t done. Zubin Damania: With social media, we haven’t done that. We’ve encouraged fear of missing out. We’ve encouraged bad body image. We’ve encouraged division and polarity with those structures because they are purely incentivized by money. So we have to change those sort of incentives and structures to understand what you’re saying, right, Robbie? Like to actually respect that so that we can create a world that actually is what we want as opposed to what’s just going to happen to us. Robert Pearl: There’s no way we can stop the progress, and so I agree with you completely. We should be trying to shape it in the best way power and recognize that some of it is beyond our simple control. Zubin, you are a musical genius. At some point on this show I’d love to have you sing for people and rap for people, but let me ask you now just for your perspective on the evolution of music in a generational context. Elvis to hip hop to heavy metal to rap, where are we? What’s coming next? What is exciting to you in the musical world? Zubin Damania: Man, this is, and by the way, I’m a real crappy musician, but the bar in healthcare is quite low. So all I have to do is show up and I’m going to rap over a track, and I’m probably okay, but in the real world I would die instantly. So what I think about this is fascinating. It’s almost like karma, right? Cause and effect, like everything you do kind of ripples out and has effects on everything else. And it’s all a web of interdependency. Zubin Damania: So Elvis was basing his music on black music and blues and jazz, and that evolved into rock and roll, and that evolved into Prog rock, and that evolved into hip hop, and all these things kind of are interdependent. Everything is appropriating from everything else. When you talk to any good musician, the first thing they’ll do is tell you who their influences are. They never say, “Oh, I just made this stuff up from scratch.” No, they go, “No, no. I listen to this. I listen to that. I listen to this.” And they process it through their unconscious and out it comes. They open a hole in the universe. They take all this input and outcome something completely novel that’s actually made of these building blocks. So music is like that. Zubin Damania: So that’s why it’s funny as I get older, Robbie, I listen to new music and I go, “God, this sounds just like this, this sound just like this, this sounds just like this.” Because you start to pick out that karmic influence from all the generations before because you have the age and perspective to see it. Whereas, I think young people they’re just like, “This is my music. This is brand new. This has never happened.” And as they get older, they start to put it into the context of this evolutionary chain of music that’s beautiful. I mean, it goes back to the beginning of art the earliest Gregorian chanting, and before that cave singing, and all that, it all is this uninterrupted line as far as I see it. Robert Pearl: I read that unless you’re exposed to new music early in your life you’re never going to be able to embrace it. That there’s a cerebral neurobiological way that music gets incorporated into your brain, and yet you seem to keep evolving. I mean, I think the Super Bowl halftime show was one of your most favorite musical events. Is this your experience, or are you able to keep taking in the newest forms of music and finding value inside them? Zubin Damania: It’s a real challenge. I think that this window to novelty starts to close in our 30s. There’s been some data around that that if we’re not exposed to something new before we start hitting our 30s that novelty window closes and we’re more resistant. And some of it may just be biological conditioning. Some of it may be some other effects, but my experience is musicians who are the most open-minded they already emotionally personality wise they’re born with a set of tools, high openness to experience these kind of personality traits that allow them to be open to different things. Zubin Damania: And they’ll often say, “Oh, my parents played all kinds of music in the house, or my father was a musician,” or something like that. And that often opened their it’s like learning, like you said, you’d learn Mandarin. Like if you learn a bunch of languages before you’re 10, they’re really easy to learn. Once you get older the window of plasticity starts to close. It doesn’t close entirely. It never does, but it does make it harder. And I think the same is true with music. So some of the best musicians are the ones that had the most musical exposure when they were young. Zubin Damania: For me watching that Super Bowl show was like a take back to 1993. I was elated as a generational thing as Gen X going, “Oh, that was our music.” That was when I was in college. That’s when we were this was the edgiest, craziest music, and now it seems like classic rock it’s so crazy tame. And to watch them do it in the Super Bowl, and really crush it was just a lot of fun really kind of elating to see. Robert Pearl: I’ve heard that 50% of all music is about love either the unrequited love, the fulfilled love, the early love, the late love, the good love, the bad love. Does the music shape our view of relationships, or is that something, again, that we should be leading and directing? Zubin Damania: Ooh, what a lovely question. Man, I haven’t thought about this enough, but I’d say this, that it’s an epiphenomenon of our relationships and it also does shape our relationships. And in some ways it’s unhealthy because the concepts of romantic love often espoused in music are reductionist and a little cliche, and they don’t take into account the broad breadth of how humans are. So in a way romantic love is so interesting to begin with because you can contrast it in a meditative experience, or a spiritual context unconditional love, where you feel absolute acceptance unconditionally for all beings where we’re all one thing. And that kind of love feels very different than romantic love, which is in many ways kind of conditional and kind of dependent, and is dualistic in the sense that it has its highs, and then it has its very much lows, right? So music captures that because music is the emotional human state in a crystallized vibratory form. That’s why it triggers emotions, but it also is created by emotions in a way. So it’s mutually interdependent in my mind. Robert Pearl: I’m going to ask you a question that I would hesitate to ask to almost anyone else, but I’m very interested/really concerned about racism in medicine. I was at a karaoke club, believe it or not, about two weeks ago. And a lot of the songs were rap songs. And if they had come out of individuals who were white they would have been very offensive, I believe. Of course, the singers were black in this particular case. How do you view the language sitting in rap today that sits on this boundary around racism? Zubin Damania: Oh, that’s interesting because you’re talking about the N-word, which is used profusely, I think, in rap music. And it is, it’s not a word that say a Caucasian person, or me as an Indian American can use. It’s not a word that I think we can use. Now, in the music it’s interesting because it is in cadence, in incisiveness, in context of the experience of that community in the rap it is the perfect word in many ways. And so that’s the tension there and that’s art. Art is that kind of tension, the tension between society, between the social structures, between the weight of history, and between that performance in the present moment, right? So I think there’s no single answer to this. And if you asked 20 people they’ll all tell you different things depending on their background, their race, their own lived experience. Zubin Damania: I recently had a doc named Ian Tong on my show who is the chief medical officer of a company called Included Health. And he’s written extensively on race and medicine. He’s a black physician and he talked quite powerfully about his own experience. And I think what we have to do is listen to these perspectives and see how we can incorporate change in a systemic way, but at the same time we have to be careful about the reverse, where we’re starting to attack and marginalize say Caucasian people based on their race. Like we’re just assuming you’re a racist, we’re assuming this. And it just becomes this very self-fulfilling prophecy and a big mess. So I think just being open and authentic and honest in our conversations is 90% of the battle. And trying to really inhabit the other person’s lived experience and position as an empathic sort of exercise is crucial. Robert Pearl: When I was on your incredible podcast I think it’s the best one in all of healthcare. Congratulations on it. Zubin Damania: I’ll give you that honor, Robbie. Actually, my podcast kind of sucks for healthcare. Robert Pearl: You asked me a question about racism. We talked about the fact that early in the pandemic that when there was a shortage of testing kits that physicians under-tested black patients that when two patients came to the ER with the same symptoms, one a white patient, one a black patient, the likelihood was that the white patient got tested twice as often. And we talked about the nature of implicit bias that it’s biological most likely dating back 20,000 years we were cave people. Someone shows up at the door to the cave. We have a nanosecond to decide whether it’s someone we should welcome in and feed or throw a spear at because they’re coming to kill us. And that that biological piece isn’t an excuse for racism. Robert Pearl: And most importantly, that not recognizing it and not putting in place systems to be able to address it and prevent it that was racism. And I see that in medicine today. I see artificial intelligence as possibly being able to say, “Zubin, when you take care of this patient, usually you prescribe ex dose of medication. This patient you’re prescribing half of the pain medication, even though the pain is likely the same, do you want to reconsider?” And I don’t see medicine either acknowledging it. I mean, you can find it in the literature, but acknowledging it in how it’s changing. I don’t see residency building it into place. I don’t see technology coming in. I’m concerned and we’re seeing it in the data, women’s mortality who are black women in labor. We’re seeing this problem continue and actually become worse on what I’ve seen recently. Your thoughts on how we can best address racism in American medicine today? Zubin Damania: I mean, this is a massive topic. One thing you mentioned about AI is interesting because it’s a double-edged sword. AI is only as good as the information you feed it. And actually it can lead to perpetuating systemic bias if it’s fed information that is innately incomplete, or biased, and this has been something that’s been documented in AI in medicine too. And so what I think this is tricky because there are a lot of like sort of like when we point a temperature gun at someone’s head when they’re coming into a restaurant and we call that COVID screening, that’s called hygiene theater, right? It’s not really doing much of anything, but people feel better by having done it. Zubin Damania: I think some of the techniques and things that they’re doing in medicine are along those lines. They make people feel like, well, we’re doing something about race, but it’s really not doing anything. And what we really need to do is what you’re saying, which is look at our systemic structures and see, okay, are these contributing to this situation? And also we have to be careful about reductionist diagnoses of what’s going on because sometimes we’re missing a broader problem that is contributing to an outcome, right? Because we want equality of opportunity everywhere we can. And so any way we can knock down barriers to that equality of opportunity we need to look at systems that do that, but it’s hard, man. It’s really hard. And people don’t even want to talk about it because it makes them uncomfortable. Zubin Damania: Whereas, every time when I would round and we’d have a multiracial team, which was every time, right? I would talk about race all the time because I wanted to put it. And by the end, everyone was like, “This is our culture. This is what we do.” And even just having an open dialogue and people are afraid. I could get away with it because I’m off white, right? So I felt like, oh, I can say this. I don’t feel bad about it. I think a lot of Caucasian people feel bad about doing that. They’re nervous about it. And I think we have to get over that too. And that’s going to take some generations probably. Robert Pearl: I heard an interesting dialogue between two physicians. The first one, this is relative to the issue of change how fast we can make it. One said, “Rome, wasn’t built in a day.” And the other one said, “But it could have been.” Zubin Damania: I like that, could have. That sounds like Gen Y right there. Just get on Instagram and take a selfie of you with Rome, and there it is, it exists, it’s there in the picture. Robert Pearl: How fast can we, and should we evolve the American healthcare system? Zubin Damania: Man, if I could wave a magic wand, I would just start entirely fresh. And that includes medical education. And that includes our concept of what wellness and health actually mean because that’s a cultural and personal context. And, again, biopsychosocial, there’s a whole wave of that. So if I could do it, I would completely reboot it, so I’m in the camp of like, hey, it could have been built in a day, right? Because in a way, trying to undo these legacy systems at some point it just gets to be you’re banging your head against the wall, which we’ve been doing for quite some time. Zubin Damania: At the same time it’s very destabilizing to even talk like that. Markets would collapse if we suddenly did that, although we’d get a lot of our GDP back, probably. So I’m somewhere in the middle on that. I think we need real disruptive change, but at the same time, we’re going to have to work with structures that we have. And we’re going to have to work with a legacy population of healthcare professionals that have been conditioned and cultured in a system that is no longer going to exist if we do things right. Robert Pearl: So I’d like to return one last time to the generational questions. You have a massive following on your podcast. How many people follow your podcast now? Zubin Damania: Well, on Facebook, it’s about 2.5 million. YouTube, about half a million. Instagram, about half a million. Robert Pearl: I’m guessing you have a pretty broad population of generations, ages, et cetera. Zubin Damania: Yeah. Robert Pearl: Do you see, do you hear, do people respond differently based upon the generations, and if so, how is that? Zubin Damania: Yeah, actually they do. And each platform has a different age mix. Instagram skews younger. YouTube skews more male and younger. Facebook skews female and older. And they all respond to different, like, I can put the same piece out on different platforms and the response may be a viral million hits on one, and 5,000 meh with no comments on another. And so different generations do respond to different material quite differently whether it’s a music video from a certain era, or whether it’s just a topic that they’re interested in or not interested in and there are gender differences for sure. So it’s a real cross section of all of healthcare actually are following. Some of it depends, too, on what their profession is. Nurses respond differently than doctors respond differently than physical therapists respond differently than respiratory therapists. So there’s just so much diversity there. It’s almost impossible to know what’s going on so you just try to talk about stuff you care about authentically. Robert Pearl: In the end my conclusion based upon everything I’ve just heard from you is that everyone is motivated to make positive changes happen. It happens across generations. It happens across training and backgrounds. And I think that the separations that we have done personalizing it around your generation is a problem. My generation is right. I think it’s standing in the way and I would encourage you on your show and continuing in our conversation on this show to look at the similarities, to find the ways that the motivation is the same. The driver is the same because as you’ve said, I have had really wonderful experiences in my medical career in training residents and working with colleagues regardless of the particular year they were born. We should understand those influences, but we shouldn’t let them stay in the way. That’s my view of generations. Closing thoughts by you. Zubin Damania: I think that’s spot-on. I think we should embrace these differences as part of the normal evolutionary wave of how humans are and try to really, really put ourselves in each other’s shoes. So if we can really feel what it’s like growing up as I say a Gen Z, you can actually feel a lot of love and compassion for their struggle too, as well as the opportunities that they have. I think we’re in a spot to do that, but I do think that we get calcified as we get older and we’re more resistant to that kind of thing. Whereas, the younger generations, I mean, we ought to just make it a cultural norm that that’s how we behave. Jeremy Corr: ZDogg and Robbie, you guys talked about the generational differences in healthcare. One thing I hear frequently in many industries is that the younger generations are too self-obsessed, self-righteous and arguably fragile, especially on social media. Social media is obviously a blessing and a curse. It gives people the ability to share with the masses in a way they’ve never done before, but also to attack and cancel people for what they believe is wrong things like never before. Jeremy Corr: We see people raising awareness for humanitarian crises all over the globe, but also mobs of people canceling people for things they tweeted, or said back when they were in high school. People feel so righteous to band together with people and be part of a cause on social media. I mean, we’ve seen misinformation spread as well as way, way, way too much censorship on topics that later are proven to be true. What do you both feel is kind of that right mix of outspoken step, or being able to speak their mind versus censorship versus kind of how the different generations see and use social media as well as kind of some of the pros and cons about it? Zubin Damania: Well, this is like one of the fundamental things we really try to address on our show is this idea of social media as a technological tool that kind of, again, vibrates with each generation differently in that it really does hack our limbic system. It’s a race to the bottom of the brainstem. We have these hyper normal stimuli in the form of these social media things along with this weaponized tribalism in the form of likes, dislikes. We almost instantiate these collective hive minds based on individual neurons, which are like, dislike, that’s our neurotransmitter in these social networks. Zubin Damania: And so you have generations now that are being judged on dumb stuff they said when they were 13, who didn’t? If you could pull up everything and I’m sure there’s stuff somewhere circulating around that I’ve said when I was 14, I would be done in this climate. They would eliminate me from the face of the earth and the truth is that’s not okay because these are neuroplastic children at that age too, right? So they can’t be judged on that. We should be able to be our authentic selves, but we should also have to, again, deal with the consequences of what we say, but not in a way where the mob comes and cancels you. And, look, I’ve been the victim of cancellation. I’ve tried to cancel other people. It’s so seductive on social media, Jeremy. We need to change those social media incentives in order to make it a little better. I think we can absolutely do that. There’s much smarter technology out there that can be used to actually generate consensus and connection as opposed to polarization and cancellation. Robert Pearl: What I see is technology becomes ever more powerful whether you want to look at Moore’s law doubling every two years, and what you’re seeing right now is incredibly powerful technology that can be used for good or bad. Technology isn’t an intrinsic force around morality or immorality. It’s simply a tool that people apply and societies and civilizations have to figure out how to use it. You can think of it as a nuclear power that can generate electricity to light the homes without affecting climate across the globe, or you can think about it as a tool to destroy civilization. I think the time has really come for us to ask how do we want to use this powerful tool? I believe for the best in people. I think we under-utilize it in medicine. I think we probably over-utilize it as Zubin has said in people’s early lives. Finding the right balance will be difficult. Everyone wants a simple solution, a clean solution. It doesn’t exist. This force will happen. It will grow stronger. And we, as humans will have to decide whether we control it, or it controls us. Robert Pearl: Zubin, it’s been great. I can’t wait for next month. This has been a fascinating view to me of the millennials and the Gen Xers, and the boomers, and the future Gen Zs. And now the new Gen A that is coming along. The world will be very different in the future. Together I’m hoping we can make it better. And as I always say at the end of my shows together we can make American medicine once again the best in the world. Thank you for being our guest today. Jeremy Corr: We hope you enjoyed this podcast and will tell your friends and colleagues about it. Please follow Fixing Healthcare on Spotify, Apple Music or other podcast platforms.  If you liked 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 and visit our website at fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter @FixingHCPodcast. 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. The post FHC #46: An unfiltered look at medicine’s generational clash appeared first on Fixing Healthcare.

The Fixing Healthcare podcast welcomes back Ian Morrison, a globalist, futurist and popular returning guest who, in Season 1, taught us that “every healthcare system sucks in its own unique way.” Now in Season 7, podcast cohosts Jeremy Corr and Dr. Robert Pearl are focused on breaking the unwritten rules that hold doctors (and the entire U.S. healthcare system) back. They asked Ian for practical tips on breaking the rules that currently govern: healthcare technology, the revenue obsession in hospitals, the incumbency of industry leaders and asymmetry of information between doctors and patients.   Ian Morrison Interview Highlights On the challenge of breaking the rules “I think the resistance of an industry [must be overcome], because I think the unwritten rule of medicine … is that this is not a profit maximizing industry. It’s a revenue maximizing industry. It seems to me all these board retreats in hospitals, every single one of them has in their top five imperatives ‘growth’ and guess what? We grow. The revenue keeps going up … And I think the U.S. is sort of addicted to growth. And the other one I would point to is addicted to self-insured employers, writing a very big check, massively larger than the actual cost of delivering care. I think those are the two sort of fundamental issues that we need to reevaluate.” On the biggest threat to changing healthcare “I think incumbency … I always say, if you’re going to disrupt American healthcare, the American healthcare system is larger than the entire Italian economy and about as well organized, right? So if you’re going to disrupt healthcare, it’s a bit like disrupting Italy, good luck with that … The thing that prevents us from doing it is incumbency, quite frankly. And we have a lot of institutions who are on this revenue-maintenance track. And it’s very hard to disrupt that at the scale that we currently have invested in the American healthcare system. Not that it’s all wasteful, but that there is considerable power to that incumbency.” On the problem with consumerism in healthcare “It’s a tough industry because of the asymmetry of information. You’re a doctor, you know stuff I don’t know as a patient. And therefore, as a transaction, when I’m purchasing health services or I’m seeking health advice, I really have to rely on your agency to help me get through the difficult times. And that tends to be the experience patients have, having been a patient not that long ago, you cease to be sort of a rational consumer and become a kind of frightened human where you defer to expertise. And I think that is a fundamental barrier that exists to actually having a more market-like or consumer-responsive health system. But that shouldn’t excuse us in healthcare.” On the drop off in telemedicine usage “If all we do is pave the cow path, in other words, substitute an e-visit or telehealth visit for an in-person visit, all we’ve done is really save travel time and parking, right? What we really want [are] productivity enhancers. And I think that requires … rethinking end-to-end clinical processes to be more digital in their mix. And that’s easy to say as a futurist, it’s hard to do because it really requires rethinking the way in which clinical services are organized and delivered … It takes clinicians with the right technological support to really redesign those delivery models for the future.” On the unaffordability of healthcare today “In 1970, if you provided health benefits to a family, it cost about 10% of the minimum wage. Today, it’s 150% of the minimum wage. And … what that leads to in terms of behavior, particularly with the rise of high deductible health plans, has been people foregoing care and about a third of Americans claim they do that. And it was exacerbated through the pandemic … I think the long-term answer of affordability is change the way we do what we do, which is what you and Robbie, I think are trying to do with this series is to draw attention that to fix healthcare, you’ve got to actually fix the care-delivery process going forward. READ: Full transcript with Ian Morrison * * * Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders. Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn. The post FHC #45: Drs. Alexa and Siri? A healthcare futurist weighs in.   appeared first on Fixing Healthcare.