The evolution of “physician culture”

Show Notes

Daniel sits down with Dr. Robert Pearl, former surgeon and CEO at Permanente Medical Group for 18 years, about the culture of medicine and his new book Uncaring: How the Culture of Medicine Kills Doctors & Patients (proceeds go to Doctors Without Borders). Dr. Pearl provides an unflinching diagnosis of “physician culture” dating back to Dr. Ignaz Semmelweis’ battered leather apron in 1844; second, he details the escalating costs of healthcare; and third, he addresses the danger of implicit bias in healthcare with some truly stunning examples that can only come through the lens a former physician turned health care executive.

What is Healthy Conversations?

Healthy Conversations brings together leaders and innovators in health care to talk about the biggest issues facing patients and providers today. Every month, we explore new topics to help uncover the clinical insights and emerging technologies transforming health care in real time.

Dr. Robert Pearl:
What do we call that space at the front of the doctor's office? It's a waiting room. Why do we call it a waiting room? Not a reception area, an educational arena? No. Our expectation is patients will come and wait on us. That's not a consumer mentality. I think the real interesting question to me is going to be how doctors evolve into being able to make the transition.
And I can tell you, having published the book, there are some of them who are in anger, they're angry that I pulled back the curtain and let patients see inside the culture of medicine. They think the right thing to do is to say, "We do nothing wrong, it's all being done to us."
And my answer is "No. We should be very proud of the good things, but we need to be able to acknowledge the other ones."
Then you have bargaining.

Dr. Daniel Kraft:
Hi, I'm Dr. Daniel Kraft, welcome to Healthy Conversations. I'm Very fortunate to be in healthy conversation today with Dr. Robert Pearl. He's a practicing physician and plastic surgeon, also very well known as the former CEO of the Permanente Medical Group.
So you've got an incredibly broad clinical and academic and medical industry perspective, can you maybe fill in a bit more about yourself?

Dr. Robert Pearl:
I've really had three careers: I practiced reconstructive plastic surgery, fixing kids with cleft lip and cleft palate. And then as you say, I got to be the CEO in Kaiser Permanente for 18 years, and now I'm doing the third career, which is the opportunity to write, to speak, to have my own podcast.
From my perspective, all three are equal, when you are a practicing surgeon, you take care of maybe 10,000 people, then you become the CEO, you're responsible for 10 million, and my hope is to at least change the health care of 330 million Americans, if not even a broader audience around the globe. The current system as well as the current culture need to evolve to the 21st century and particularly challenges we're going to face in the post Coronavirus era.

Dr. Daniel Kraft:
Yeah, in your new book about health care, it's actually called Uncaring, the tagline is "How the culture of medicine often kills physicians and patients."

Dr. Robert Pearl:
Our first book was titled Mistreated. While we think we're getting good health care we're usually wrong, and it was about the systemic problems: The problematic insurance industry, the very greedy pharmaceutical world, issues with people not having coverage, social determinants of health, and as I traveled around the country, it was clear that something else was going on.
I tell the story of Dr. Ignaz Semmelweis, an obstetrician in Vienna in 1850, who inherits the leadership for the maternity unit. And he notes that the mortality is 18%. He's embarrassed because the adjacent facility, one run by nurse midwives has a mortality two thirds lower. He makes the hypothesis that something's being carried on either the hands of the doctors or the leather aprons that they wear to cover their pressed three-piece suits into the delivery area and he says, "We're going to change aprons every time and we're going to dip our hands in chlorinated water."
Mortality drops from 18% down to 2%. He publishes it in a leading journal, he sends letters to all the maternity unit directors around the globe, and guess what happens? Nothing. Nothing changes. There was no money involved putting on a clean apron, and it took matter of a few seconds to dip their hands and chlorinated water. No, it was this other fact, the idea that somehow doctors were carriers of disease, was just not even possible in the minds of the people.
And these leather aprons? The more blood, the more pus, the more experience, the higher the esteem. And I tell that story because when people hear it, they say, "Oh, of course, that was 150 years ago."
Except today, the leading cause of death is hospital acquired infection, it's caused by Clostridium difficile, it's carried in the hands of doctors. And multiple studies, one in three times doctors fail to wash their hands going from one room to the next, and the story of today is that it takes 17 years for a great idea to become common practice.

Dr. Daniel Kraft:
Given that there's so many different sometimes specialty types, is there a way to shift it en masse, or is it to happen locally or take that 17 years, which often might be generational from one set of clinicians to the next?

Dr. Robert Pearl:
Well it is generational, because culture is what we learn in medical school and residency, and we carry this across our entire career, so a mid-career physician still has the culture from the 20th century by which he or she is practicing. But the overriding culture of medicine continues to value what it was that made doctors so special in the last century. We value our intuition, so 30% of what doctors do has been shown by the Mayo Clinic to add no value, but we still do it. We don't value things like telemedicine that are very convenient for patients. We don't value things like prevention that could avoid a huge amount of disease. We value the interventions, the multimillion dollar robots and proton beam accelerators shown to be to do nothing. The fact that we only control hypertension 55% of the time, and what we know is that large medical groups were able to do it 90%, and that the difference is 40% lower rates of stroke, heart disease, kidney failure.
It's no different than it was back in Semmelweis' time, or at least it's maybe a little bit less evident, but it's still the same factors going on. We tell ourselves that we treat every patient the same, but early in the pandemic there were not enough testing kits. We tested Black patients half as often as white patients with the same symptoms, even though we know two to three times higher mortality. And when they had pain we gave 40% less pain medication.
I think what drives the change that I believe that we need is going to be the ship from feature service to some variant of a single payment given to a group of doctors and hospitals. If you're being paid a certain amount of money to take care of a population and you're at risk, you start to value prevention, and I've often asked myself, why is it that health care's the only industry in which technology raises costs, not lowering them, because the technology that we love are the things that are expensive, and the ones that we don't pay a whole lot of attention to are the ones that improve the convenience of the patient.
But having said all of that, because as you know, in the early parts of the pandemic when there was not enough protective gear, doctor still came 12, or 24 hours at a time, donning garbage bags when there were not enough protective gowns, salad lids when there were not enough masks.
I'm particularly worried Daniel, about what's going to happen in the post coronavirus era, up to one physician who lost four patients in one day, a resident who started the service on the first of the month with six patients, by the end of the month, they were all dead. How do they process these things? If you were at Mass General, you learned, "Tough it up, never admit a weakness!"
The idea that somehow you needed psychological assistance, you would've gotten thrown out of Boston, had you told that to people.

Dr. Daniel Kraft:
In my day of residency, it was a badge of honor to say that you'd been on call for three days straight and had no sleep, we even had in my time, a surgical resident to unfortunately commit suicide as a resident. I'm wondering now with technology coming into play that it's not just the art of medicine, you might have new data sets, your surgery might be robotically guided, so how do we blend the technology side, the new massive insights, multiomics with the ability for the clinician to still have value, and feel like they're part of the team and care?

Dr. Robert Pearl:
You've really defined it beautifully, but you're raising an important part, which is the burnout of physicians. And if you ask physicians, and we know this this very well, they give you three reasons why they're burned out. They don't make enough money, the bureaucratic tests are too great, and the computer system literally gets between them and their patients. And all three are true, but if you dive inside the data, what you find is that they don't fully explain the variation that happens. So let's take just one example, which is the number one burned out specialty, at least prior to the pandemic was urology. Now urologists make half a million dollars a year, but urologists with double the income are more burned out than primary care physicians, how do you explain this? And the reason, if you go back to about 2010, urology, a decade ago has one of the lowest burnout rates.
And being able to use a $2 million Star Wars like robot gives you a lot of prestige, and so urologists are now near the top of the hierarchy, and what goes on? The national task force and prevention says that the PSA, the prostate specific pathogen test shouldn't be used routinely, and so the number of prostatectomies start to drop. The next thing that happens is we see that watchful waiting starts to become a very acceptable means for a lot of tumors, cases drop even more. So now all of a sudden urologists are finding themselves doing less and less of the operation that gave them the status. Why should this one operation be the defining factor for the esteem of a specialty?
But it is in this culture of medicine, the dropping of status leads to dissatisfaction, a lack of fulfillment, fatigue, the exact symptoms we see with burnout. Again, the systemic issues are there, very real, but the cultural ones are there as much.

Dr. Daniel Kraft:
And tied to status often is our ability to interact in the relationships with our patients, which also have been pressured out. Our colleague Bob Walker at UCSF makes the point that when digital radiology came around, you no longer go rounding with a radiologist, you lose that social interaction as well. And maybe your value, let's say as a radiologist, would be delegated to typing the note but never communicating with the other care team.

Dr. Robert Pearl:
And primary care's a great example of that. Back when you and I were in residence, what we saw is that primary care would often be the admitting physician and certainly the doctor who brought all the specialists together and was the quarterback of the team. And then hospitalists came along, and primary care physicians less and less came to the hospital. Again, I think that if we were able to re-shift both the economics and those values, beliefs, those norms, that we would see both healthier patients and less burned out physicians.

Dr. Daniel Kraft:
Speaking of lessons, you were CEO of one of the nation's largest medical groups. You had 10,000 physicians, 40,000 staff. What lessons did you learn there in trying to institute change at a larger level or what might you wish you had done to shift culture if you were back in that position?

Dr. Robert Pearl:
Well, the first thing I would say is that I was fortunate because in organizations like Kaiser Permanente, the Mayo Clinic, you inherit a culture. And I actually think that they started with a certain culture and then built a system around the culture. Doctors are used to working together, collaboration, cooperation. A great example to me of this, and it's a combination of both economic and cultural, is what we call the V consult, so a patient coming to see a primary care physician who needed to have a referral to a specialist based upon the primary care physician's view of the matter, rather than just sending the patient home to call the office, a specialist would come onto a video consult, and 60% of the time they could resolve the problem there and then. In dermatology we use digital and 70% of the rashes, these are the ones that they were ready to send to the consult, 70% of those got resolved immediately.
They were able to start treatment that day, I don't know what it's like in your community, but across most of the country it's six days, six weeks or six months for a dermatology visit. These were resolved in six minutes with tremendous accuracy and care and treatment being provided immediately. I get asked by a lot of leaders, "Well if you're going to make change, don't you get pushback?"
And my response is, "If you don't get pushback, you're not really leading, you're just administering."
You got to get over that hump. And leadership is about being the catalyst that lowers the height of that activation energy requirement.

Dr. Daniel Kraft:
So disruption's coming, some of that's technology driven, some drones might be delivering your drugs and devices. Certainly the AI coming through your Amazon Alexa speaker will be playing a role increasingly, what would your advice be? Let's put on our futurist hats.

Dr. Robert Pearl:
Now if you look back, remember what we said is that the culture of today came from 20 years ago. We had a very patriarchal type society in health care. Doctors told patients what to do, patients listened. We had all the knowledge and patients were used to a lot of inconvenience. What do we call that space at the front of the doctor's office? It's a waiting room. Why do we call it a waiting room, not a reception area, an educational arena?
No, our expectation is that patients will come and wait on us. That's not a consumer mentality. I think the real interesting question to me is going to be how doctors evolve into being able to make the transition, and I can tell you, having published the book, there are some of them who are in anger, they're angry that I pulled back the curtain and let patients see inside the culture of medicine. They think the right thing to do is to say, "We do nothing wrong, it's all being done to us."
And my answer is "No, we should be very proud of the good things, but we need to be able to acknowledge the other ones."
Then you have bargaining, I think back to December of 2019. This is two months before the Coronavirus comes ashore. And what do we see? The Federal government announces that they've just done a big study and for the next decade, costs of health care are going to go off five to 6% every year. health care is 3.7 trillion, by the time you do a compound interest in five to 6%, it's 6.2 trillion, two and a half trillion more dollars in health care. And when I read that study, I waited. I waited for the organizations, the specialty societies to stand up and say, "This is ridiculous. Imagine what we could do with two and a half trillion dollars for education, for infrastructure, for prevention, for social determinants of health."
I can think of so many great uses and they didn't even pay attention to it. No, it's a broken system that we've got to change. And to do that, we've got to evolve our culture and the two have got to move together. And when that happens, I believe that we can make American health care once again the best in the world, which it is not to date.

Dr. Daniel Kraft:
In terms of changing things, you often get what you measure. So how do you think about measuring culture?

Dr. Robert Pearl:
I tend to do culture like gravity, can study gravity all you want, but you can't see it. You can't put into a box, you can't put it under a microscope. What you do is you observe the impact it has on objects, whether they're falling off the lean tower of Pisa, or yourself trying to climb up a tree and slipping on a branch.
So to me, I want to measure the outcomes. How well do we prevent diseases? Again, in Kaiser Permanente, when I was the CEO, we lowered the mortality from heart disease, 40% below the general overall community. The chance of dying colon cancer, 40% lower. These are the kinds of outcomes that I think come from the culture. Our doctors were good, but no better than the community. Our drugs were exactly the same, but I think the culture is the driver of that.
And when I start to see prevention soaring higher to the levels that I know are possible, when I start to see the number of medical errors going down and the number of unnecessary, by that, I mean procedures that add no value going down, I'll feel pretty confident that it's in place.
And on the other hand, racism to me is a big issue because I understand what's going on. We have a rapid system in our brains to identify people like us, to have empathy and sympathy for them and not for people who don't look like us. And that's the reality of implicit bias today, is implicit bias racism. But implicit bias is not racism, but knowing that exists and doing nothing about it, that is racism. If we don't treat Black patients the same as white patients and we don't do something about it, that is our problem, even if we don't do something because of the action of someone else.
There's a study on what I'll call de facto segregation in hospitals, that if you look at places like New York and LA within three blocks of each other, you have one hospital that's almost all Black and one that's almost all white patients. The hospitals that catered to white patients had empty beds during the pandemic, the ones that catered to the Black community, they had freezers with body bags filled with people who died. Physicians get the privileges at hospitals, it's an accountability... I just hope that people read the book and they ask themselves, "Is this a problem for which I could do something?"
I am so proud of being a physician. It was the best decision I ever made. I don't defend the problems that exist. I just want us to also be able to acknowledge the ones that we can contribute to and start to take steps to address it. And I do believe it will make medicine a better profession, one that you and I embraced a couple of decades ago, one that I'm hoping that your kids will be able to embrace a couple of decades from now.

Dr. Daniel Kraft:
Amen to that. First of all, thanks for all the work you've done as a clinician, as a leader, and now hoping that you will enable us to understand, see, and have a lens of which to shift all the major challenges in culture and beyond as we move forward. So definitely a very healthy conversation, Dr. Robert Pearl, thanks for joining us and I've already went to Amazon and of course ordered your book on caring.

Dr. Robert Pearl:
And anyone else who wants to find out more information about the book than go to the website, robertpearlmd.com, where they can order it. All profits go to Doctors Without Borders.