This transcript has been edited for clarity.
Abraham Verghese, MD: Welcome to another episode of Medicine and the Machine with my co-host, Eric Topol. We are delighted today to have a guest who has a wonderful perspective on American healthcare, someone I've known for some time now. That is Dr Robert Pearl. Robbie is the former CEO of the Permanente Medical Group. In that role he led 10,000 physicians and 38,000 staff and really transformed that mid-Atlantic Permanente group.
He serves as a clinical professor of plastic surgery at Stanford University and is also on the faculty of the Graduate School of Business, where I had the great pleasure of sitting in on one of his classes and understood healthcare for the first time. He is the author of the book Mistreated: Why We Think We're Getting Good Health Care — and Why We're Usually Wrong.
Today we're going to talk about his new book, Uncaring: How the Culture of Medicine Kills Doctors & Patients. Robbie writes regularly for Forbes and other venues. He's often sought out as a commentator, and he has his own podcast. Robbie, it's a great pleasure to welcome you to our podcast. Thank you so much for being with us today.
Robert Pearl, MD: Abraham and Eric, it is my privilege and my pleasure to be here today. I look forward to our conversation.
Verghese: Of all the things that you could have chosen to write about, you chose the culture of medicine. I find that quite intriguing. The book covers many topics but at its root, it's about us. Can you tell us how you embarked on this?
Pearl: In 2017, I published the book Mistreated. (All the profits from that book and this new one go to Doctors Without Borders.) I spoke in that book about all the systemic issues — the problems with insurance companies, drug companies, and hospital consolidations. As I went around the country, speaking at events and talking to different organizations, something was missing. People have talked about these things — moving from fee-for-service to capitation, from fragmentation to integration, and technology left over from the 20th century, though really it's the 19th century, like the fax machine, invented in 1843. Yet so little has changed. I asked myself, what might we be missing?
As I spoke with individuals and did research, I realized there was this invisible force, as powerful as gravity and visible only through its impact on others. There was this second piece, the culture of medicine — the physician culture. I see it like the caduceus, that symbol that doctors wear on their white coats and have on book covers, of the two snakes wrapped around the staff, one snake being the systemic problems and the other being the cultural ones. It's impossible to separate them. What I realized was that if we are going to make American medicine what it should be, we're going to have to address both the systemic and the cultural issues. That led to the book and to the conversations that I've been having with various audiences across the United States today.
Verghese: The culture can actually be an impediment to progress. I was intrigued by some of your historical examples. Semmelweis made the groundbreaking discovery that dipping your hands in lime of carbolic could prevent puerperal sepsis, which was killing 1 in 5 women at the Vienna General Hospital. Yet it took 150 years for that to be implemented because physician culture was resisting it. It makes me wonder, what is our physician culture resisting now that we should be embracing? Is it abandoning fee-for-service? And what is it that we're not doing now that we should be doing?
When Culture Gets in the Way
Pearl: We have a wonderful culture, something you've written about brilliantly. As we try to address both the systemic and the cultural issues, we need to make sure we don't lose the amazing parts. Early in the coronavirus pandemic, physicians were working 12 and 24 hours a day to take care of patients without the protective gear they needed — donning garbage bags and plastic gowns and salad lids in place of N95 masks, inserting tubes in a patient's lungs, knowing that every time that tube went through the vocal cords, the patient would cough and spew virus in their faces, but they did it anyway. And that is the positive side of it.
I sat in on one of your lectures where you talked about that iconic painting The Doctor, and the grief that that individual felt, the empathy he showed, the caring, and the tenderness. But over the course of time, to be able to do that and take care of patients with COVID-19, the culture has been one of denial and repression. We learned that emotions get in the way. We are taught in residency to never admit that we are in pain, never say that we're tired. We'd work for 100 hours, but not now. Residents can work only 80 hours, but that doesn't count driving to work and back, and studying at night for the cases the next day.
I write in the book about my cousin Alan, who had Hodgkin's lymphoma and got treated at Stanford. The doctors were by his side watching him vomit across entire weekends. They didn't desert him, but they couldn't feel his pain because of this denial and repression.
Physicians don't see the many ways that they contribute to the problem. They see the systemic issues, and those are very real. Doctors today are working incredibly hard and there are problems trying to navigate the system, the bureaucratic issues and computers. But they can't see the ways that we contribute by, for example, the fact that 30% of the things we do add no value.
Racism is a great example. If you ask doctors why, during the COVID-19 pandemic, Black patients died three times more often than White patients, they'll point out the systemic issues. They might believe that Black patients are more likely to work jobs that can't be done from home, that they have to go into the workplace, taking buses and subways, and live in multigenerational homes. But that doesn't explain why early in the pandemic, when two patients came to the ED, one Black and one White, with exactly the same symptoms, doctors tested the White patient twice as often. Or why we administer 40% less medication to Black patients than White patients after the same procedure. You may have seen the recent study where we looked at scenarios of patients with chest pain who were perceived to be White. These White patients were tested and treated more often than the Black patients, despite the fact that they had exactly the same symptoms.
What this culture values doesn't always make sense. We elevate certain things left over from the last century — for example, in the way we test medical students. We do it based upon memorization of arcane facts. Why do they burn out in the first year of medical school? Because we are teaching them these facts. They are coming for something that is much more important, but that's what we give them. It's a value left over from the 20th century, when you needed a 50-pound backpack for the medical knowledge you carried around. Today, we call it a smartphone. Why have students take a test without insisting that they bring their smartphone? That's the tool they're going to have in the exam room with them. Why don't we focus on expressing empathy and relating to the family? The culture gets in the way. That's what I think needs to change if we are going to improve healthcare.
The Twin Serpents
Eric J. Topol, MD: The interdependence of the systemic and cultural features is hard to dissect. Most of us go into medicine to care for patients, but that's frequently interrupted and blocked because of the way medicine has moved on, whether it's the reliance on becoming data clerks, the lack of time with patients, or the real presence we need with patients to engender their trust and be able to express empathy. How do you sort these out? How do you make distinctions between what's embedded in the culture vs what's being influenced by medicine becoming a big business?
Pearl: It's the entwining of the snakes. A really great example has to do with the economics of healthcare. In the culture of medicine, we are taught that cost should not be discussed with patients. The reality is that patients are suffering. They can't afford healthcare. As a profession, we haven't taken that on or figured out how we can do the best for our patients.
A lot of this book came out of what happened in December 2019, two months before the coronavirus came ashore. The federal government released data saying that healthcare was going to increase 5%-6% per year for the next decade, every single year. When you compound the numbers, we're going to go from $3.7 trillion to $6.2 trillion — $2.5 trillion more.
Think about the things we could do with that money in terms of preventing disease, managing chronic diseases, educating patients, tackling the social determinants of health, making technology available to every American to improve their healthcare.
I waited for every organization in American medicine to step forward and say this is ridiculous because the underlying assumption is that nothing could be done to improve the efficiency and effectiveness of healthcare, because this is as good as it gets, despite the fact that all the data say we lag behind other industrialized nations. We are last in life expectancy, child mortality, maternal mortality. It doesn't matter. The culture sees what we're doing as being the right and appropriate way. Not a single organization in medicine spoke out and said this is absurd.
Letting Go of Our Inherited Culture
Pearl: One thing that always impresses me about you, Eric, is your patience about how slowly America is embracing technology. I don't know how you have the patience to not be screaming about the opportunities that are lost. Seven years ago I wrote a piece in Health Affairs where I pointed out the opportunities in telemedicine. At that time, we were doing 12 million virtual visits yearly at Kaiser Permanente. I predicted that 30% of what we did in the office could be done using telemedicine. And I waited. For 6 years, not a single thing changed. Then the coronavirus comes ashore and all of a sudden 60%-70% of practices are embracing telemedicine.
There wasn't any improvement in the technology. There wasn't a change in the practice of medicine. How do we explain this? It's mainly cultural, although some of the changes at the federal level, such as allowing interstate use of telemedicine and Medicare reimbursement, helped to drive this. But all of a sudden, the threat to physicians and their staff made us close our offices and telemedicine became a boon.
What's really interesting is listening to doctors talk about telemedicine. They describe it as an inferior method of providing care compared with having the patient come in to the office. But wait a second — telemedicine allows immediate diagnosis, convenience, higher patient satisfaction, and 10% lower cost of healthcare delivery. Why aren't we elevating this and finding out ways to do it? Because it diminishes what we value within the medical profession, which is our offices. What do we call that space inside the front door? We call it a waiting room, as though people are waiting on royalty. That's not how we think of ourselves, but that's the culture that we've inherited.
The question we should be asking is, how do we eliminate offices the way other organizations and industries are doing in the post-coronavirus era? How do we get rid of hospitals? These are the kinds of questions we need to be asking. But the culture is going to make that very difficult. Both snakes — the systemic problems and the cultural ones — must be addressed. If we address only one serpent, we're going to get our hand bitten by the other.
Verghese: You do a wonderful job of laying out the history of American medicine and its funding. At every stage of the game, the physician lobby has resisted anything that took away fee-for-service. The reason we're at this impasse right now has a lot to do with us. Our lobbying organizations aren't lobbying for the patient's welfare or for the cost of healthcare. They are lobbying for our pockets. What I found most astonishing was a paragraph in your book where you quote a study that I was not aware of, showing that the more specialists there are in a particular area, the higher the mortality rate, and the higher the expenses, the higher the mortality.
Pearl: There are two sets of studies that were separated by two decades. One recent study from your colleagues at Stanford and Harvard Medical School found that adding 10 primary care physicians to a community increases longevity two and a half times more than adding 10 specialists. The study you're quoting is when the addition of specialists lowered the outcomes. Eric is very familiar with some research that looked at what happens when cardiologists go to national meetings. Survival goes up, not down, as a consequence of having fewer specialists around. I don't want listeners to overinterpret what I'm saying. Specialists do a remarkable job. What we have to question is the 30% of things that add no value. Not only do they raise costs, but they potentially create more problems and actually shorten life expectancy rather than extending it.
Why Cost Can't Be Ignored
Topol: You bring up an important point that the outcomes in the United States are inferior to all OECD countries, which is remarkable considering we at least double, if not quadruple, the percentage of our GDP spent on healthcare. Most people think that's just because of the lack of access, an uneven distribution of care. But you and many others have pointed out that some of the poorer outcomes are a consequence of doing too much — the incidentalomas, the chasing down rabbit holes, etc., and people are getting hurt because of that.
What do we do? Ezekiel Emanuel wrote a book rating the healthcare systems of 13 countries ( Which Country Has the World's Best Health Care? ). Basically, the United States was the worst, although China was close. He concluded that the main reason is the lack of universal healthcare here. When I was involved with the UK review of the National Health Service, there was no reluctance to embrace technology, nor fear that hospitals would be gutted by remote monitoring, whereas here, hospitals are the top item of our expenditures — over $1 trillion a year and rising quickly.
What are your views on universal healthcare? Is it a remedy, and what other possible solutions can you come up with?
Pearl: Once again, the problem is the two-headed snake. If you don't have healthcare coverage, you can't get excellent care. If you can't get to the doctor because of transportation or cost issues, you can't get great care. So that's the bare minimum. And we need to do that. We're one of the few nations in the world that doesn't have universal coverage. But I also worry that that's not going to be enough because of this culture. Culture is what you value — your beliefs, the norms you follow. It comes through language and stories that are handed down from generation to generation.
We have an opportunity coming out of the pandemic, the first coronavirus era. I'm going to predict (and I'm well aware that making economic predictions is a very dangerous undertaking) that we are going to see economic problems that we don't fully understand or anticipate. The stock markets are doing well, but the federal government has already borrowed $8 trillion that it has to pay back with interest. States by law must have balanced budgets. Even California, with Netflix, Google, and Facebook, is facing problems as the high unemployment rate continues and the cost of Medicaid grows. Small businesses are the engines of employment. Most jobs are not in these big companies but rather in the small and medium-sized companies that have been hit really hard.
We have to lower the cost of healthcare. We've talked about it since 1932 but now we can't afford to avoid it. Our nation has to accept the fact that fee-for-service will never lower healthcare costs, because if you drop prices, utilization is going to go up. And that process of being able to incentivize people to do more will always lead to more getting done. You can do it by rationing, saying someone is too old for surgery or the drug is too expensive to provide. Some countries do that, particularly the lower-socioeconomic countries.
Or you can transform medicine. That's where I think it is going to go. Eric, I think the next step will be capitation. Capitation is something I personally believe in because it aligns the interests of doctors and patients, but it also involves the culture. This is not capitation of insurance companies. This is at the delivery system level. A group of physicians are brought together with a hospital and with a budget to take care of a population of patients. They will start to think differently and culture evolves. Prevention becomes as important as intervention. Avoidance of complications from chronic disease becomes as important as managing the complications of chronic disease. Patient safety, avoidance of medical error, and embracing the technology that is going to improve performance — technology like telemedicine or technology not just of monitoring, but monitoring integrated with care delivery to actually impact chronic disease in a more positive way.
Embracing artificial intelligence and all of the areas that you've pushed for so hard across time start to evolve. You start to elevate the status of primary care in a capitated organization. And I think it's going to happen. I have a little bit of worry because as it happens, I think physicians are going to experience the five stages of grief. They're going to start denying what's going on. Then they will get angry that they are not being heard, they are not being listened to. No one cares about their pain. Then they will go to bargaining. You're seeing this already as more than half of physicians now are employed by hospitals. We're seeing it in rates of burnout and suicide. Ultimately it's getting to acceptance. And my hope is that in getting to acceptance, physicians will come to understand that it's nothing they did; it's the change in the world around them.
When patients come to our offices with printouts from Google, we may say this is terrible medicine, but that's what life is like now. Patients are consumers; they want a better and more convenient service. And in healthcare, we've said, no, we're just not going to provide that to the level that patients get in retail or travel. That's where we're going to evolve too. I'm hoping that's where the cultural change is going to happen. You're going to start to see 30% of the things that we do that had no value disappearing. You're going to see costs potentially becoming ameliorated. Physicians can benefit through that process in a way that's going to allow us to not only have a better professional practice but a diminution in burnout, psychological anxiety, and depression.
The Drivers of Burnout
Verghese: I want to talk about what I think is going to be the thing people remember most about physician culture in this era, and that is burnout. We've never had more people burned out, never had more attrition, never had more people disillusioned, paradoxically, with more students coming in than ever because of COVID. You've done a great job of discussing burnout in this book. Tell us your perspective on physician burnout — what it is and what we can do to address it.
Pearl: Burnout is a terrible problem and it's becoming more prevalent. I think back to that painting, The Doctor, that you lecture on so brilliantly and I talk about in my book. This should be the golden age of medicine. We have the science that we didn't even have in the last century to understand cardiovascular disease. We basically know how to diminish it to a huge extent. That was not possible in the past. We're seeing organizations that are able to lower mortality by 40%-50% and it's no longer the number-one cause of death among populations. We now have technology that we couldn't even imagine. Think about the smartphone that was introduced in 2007 and how much knowledge and information we carry with us all the time. And yet, rather than being the golden age, it's a time of burnout.
This is very much a combination of the systemic and the cultural pieces. Ask doctors about the cause and they will give you three big reasons. First, they don't get paid enough, which means they have to see too many patients. Second, there are all these bureaucratic tasks, particularly prior authorization. And then there's the electronic health record that literally gets between them and the patient. All three of these are valid. They do contribute very significantly, but they don't explain a lot of the variation you see in the data that I think plays into the challenges of burnout and the solutions that need to go into place. Part of it is around the hierarchy of medicine.
If you look at the data, the specialty that was most burned out prior to COVID was urology. Now, urologists earn close to half a million dollars a year. They make double what pediatricians make, and yet they're almost 10 points more burned out. If it's just a question of how much money we make or how many patients we see, we can't explain urology being the most burned-out specialty.
If you look at the other end, what specialties have low rates of burnout, orthopedics and ophthalmology are [about 15-20] points lower than urology. They have to go through the same bureaucratic tasks. They have to get the same authorization, and they use the same computer systems. None of the things that we point to fully explain the variation inside the dataset that's there, and that's why I come to the conclusion that it's not an either/or, it's a both. We have to address both.
But how do we explain urology? Go back to 2010. Urologists had very low rates of burnout. They were similar to orthopedists and ophthalmologists. Then in 2012, the US Preventive Services Task Force said that PSA, the number-one driver of prostatectomy, isn't a particularly good test and it actually creates more problems than it solves. So primary care physicians stop ordering the PSA. Then we have evidence that watchful waiting is just as good as intervention for a significant number of tumors. The number of cases drops, and we have centers of excellence and patients who are now becoming more educated through the internet. The end result is that most urologists are doing far fewer prostatectomies and some are losing their privileges.
Why should this be such a driver of unhappiness? If you look at income, urology has stayed one of the most remunerative specialties in the nation. The answer is because of the culture of medicine. Our status depends upon how technically sophisticated and advanced we are. In urology that driver was the robotic prostatectomy, the Star Wars–type procedure, and as doctors had fewer opportunities to do this, their status started to drop. Michael Marmot has said that what happens relative to status, esteem, and hierarchy, is as important as income. When it drops, researchers have shown that it produces fatigue, lack of fulfillment, and dissatisfaction. Exactly the symptoms of burnout. It makes no sense.
In the minds of doctors, the problem with primary care is that they're not paid enough and that's why they have lower status. The literature would say, no, they have lower status because what they do is not as interventional, not as high-tech or multimillion dollar–machine driven, and that's why they earn less money, particularly as evidence-based medicine comes along and now it's less about your deductive skills. When you put on top of that some of the technology around diagnosis — you're the world's expert in physical examination — but as that becomes less significant, all of a sudden the entire role of primary care clinician starts to drop. The burnout is caused by these external forces, insurance companies, computer systems, the amount of time that it takes to enter the data, and spending more time in billing and documenting than in care delivery. But it's also because of the things inside the healthcare profession, things that we can change.
If you look at the data on burnout in the past 2 years, there's a shift. Now the most burned-out specialty is critical care medicine. Why? The answer, of course, is COVID-19. Some of it is related to being called on to work long hours, but some of it also is encountering the futility of their actions, the impotence of being able to save a human life. We take an oath: First, do no harm and save a life at any cost. They are not able to accomplish all of that in a culture that has repression and denial and teaches people not to deal with their emotions.
I talked to one doctor who said he lost four patients in one day. I talked to a resident who started the service with six patients on the critical care unit and all were dead by the end of the month. How do you deal with that except by repression and denial? The doctor in that painting that you talk about so well didn't have death every day. That repression and denial allowed him to have the empathy to go on in practice and to have the elevated esteem, but today it's very different.
I'm very worried that we're going to see PTSD at the end of this process. That's what we learn from the military. It doesn't happen on the battlefield. It happens afterwards. And we're going to have an entire generation of physicians who are going to be having these symptoms, not able to talk about them, not able to see that they need psychological help. We're going to see these problems get much worse. I'm encouraging every residency director and every hospital director to make sure that they create an environment that is safe, where people can talk about their feelings, admit the pain that they're suffering, and confidentially get the psychological support that they need.
Burnout is a symptom of how broken things are; what's broken is both the system of medicine and the culture.
Topol: I would question that, Robert, because the three of us are the old dogs here, and we were practicing medicine 30 years ago, when there was no burnout. People were happy to be physicians and loved caring for patients, but there were no robots. The culture hasn't changed, so what has changed? What has made burnout a global crisis when it wasn't the case decades ago?
Pearl: What has changed is not the culture. That's one of the issues. We still have the culture of 20 years ago, what has changed is the society. When you were in your training at Cleveland Clinic and you told a patient what to do, the patient looked at you and said, yes, sir. That's different today.
Topol: I never did that.
Pearl: I know, but I'm saying that the patriarchal way that we provided care, the way the physician was held in high esteem, was because we had all the knowledge. For someone to try to understand something about a complex disease, they had to go to the medical library and pull out volumes of books. Now they go online and they have information very quickly. We may say it's not great information, but that's not the point.
Topol: You mean as control freaks, we lost the control and that is what accounts for the problem? Is that what you're getting at?
Pearl: I think we've lost some of our position in the hierarchy and we're struggling with that. We're blaming that on the insurers and on the system. And we're not recognizing that we are making it happen but that we have not been able to take the lead in making the change happen. You said earlier that the organizations that are resisting it are inside the profession and that the organizations that represent us wouldn't be doing it if it's not what we wanted them to be doing.
We've been talking about burnout for 5 years and nothing has changed in terms of the systemic reactions — the insurance companies, the bureaucratic tasks, the computer systems. Do we think we are just not yelling loud enough? Is that the problem? No, the problem is that we are going to have to take the lead at making this evolution happen. Take the opioid epidemic, for example. If you ask doctors about it, it was the drug company's problem. The drug companies were terrible, telling us that patients wouldn't die and they wouldn't get addicted. But we still wrote the prescriptions and we continued to write those prescriptions even when we started to have that knowledge.
Look at another example: surprise billing, out-of-network billing. One in five patients who comes to an emergency department in the United States today or goes to the operating room will have a surprise bill sent by the hospital, but it's related to our actions. How do we justify that? It's like countries that put civilians near their military sites with the hope that the enemy is not going to attack them, but when they do, it's collateral damage; that's how it's defined. Do we see it as something we've got to do to protect patients against insurance companies? No, that's not what's going on at all. And I understand, again, the systemic piece. It's both. It's what we do, and we don't notice that.
We mentioned earlier the racism that exists in chronic disease. Across the United States today, we control hypertension 55%-60% of the time. It's the number-one cause of strokes, a major contributor to heart disease and kidney failure. When I was the CEO at Kaiser Permanente, we did it 90% of the time. Our doctors were good. But your doctors are good too. It's not that we have better doctors or better medications. It's a culture that starts to value what is not valued in our specialty.
This is an imbalance between the things that we believe are important and what the world is telling us is important. That imbalance is contributing, but it's not the sole cause. We've got to address the number of patients seen per day. It's way too many. We've got to address the bureaucratic authorization processes and all of these limitations that get imposed upon us. We've got to deal with an electronic health record that is out of date. And the fact that we can't get comprehensive information is real, but we can't just expect that these things are going to change. We have to also admit our role and take the lead.
I have one word for people who are listening to this and who say, "Well, I'm not sure we really have to do it." The word is Amazon. Amazon is moving into this area in a very aggressive way. Three years ago when Haven was formed, the union of Amazon and JP Morgan Chase and Berkshire Hathaway, I wrote a piece where I said that anyone who believes that Jeff Bezos, the CEO of Amazon at the time, is doing this only for his own employees as a not-for-profit, which is what he was talking about at the time, probably believes that Amazon only sells books. Now, this was going to be a major economic venture. One sixth of retail is now Amazon. Bezos or the CEO is going to want to take on one- sixth of healthcare. They're already offering telemedicine across the entire United States. They're offering on-site care close to their facilities. We know they already have online pharmacies and the ability to provide medication across this nation.
They're going to move into this space. They are going to evolve the system. I love being a physician. I love the medical profession. I want us to be the ones to carry the day and move it forward. But we're going to move it forward by advancing the culture, I believe, not trying to hold on to what we inherited 20 years ago when we were in medical school and residency.
Verghese: The book is Uncaring by Robert Pearl. Every time I hear Robert teach a class, I walk away so educated by his wonderful perspective on medicine. And you'll find the same in the book. It's just been a pleasure to have you on our program, and we look forward to the things that you produce in time. Thank you so much.
Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.
Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.
Robert Pearl, MD, is a clinical professor of plastic surgery at Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business. In addition to being a regular contributor to Forbes, he hosts his own podcasts, Fixing Healthcare and Coronavirus: The Truth.
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Cite this: To End Burnout, Doctors Must Change the Culture of Medicine - Medscape - Jul 09, 2021.