[00:00:01.230] Announcer:

America’s healthcare system is almost unanimously viewed as being unaffordable, dysfunctional and severely in need of transformation. APG President and CEO Don Crane talks with leading healthcare executives, physicians, and other visionaries to explore solutions to lower costs and improving quality of care by accelerating the movement toward value-based care models and away from fee-for-service. Want to be inspired by our nation’s foremost thought leaders in healthcare? Then this show is for you. Here’s your host, Don Crane.

[00:00:35.670] Don Crane:

As listeners may well remember, it was in 2017 that Dr. Robert Pearl published his first book entitled, “Mistreated: Why We Think We’re Getting Good Health Care and Why We’re Usually Wrong.” It was a searing indictment of the American healthcare system and garnered scores of rave reviews, including a Washington Post best seller designation. Robbie spoke of it eloquently at our annual meeting a few years ago. Fast forward to today, May 2021. Robbie publishes yet another sweeping narrative about American healthcare, but this time with a narrower focus on a more sensitive subcategory, namely physician culture.

The title of this book is highly provocative, but apt. It is, “Uncaring: How the Culture of Medicine Kills Doctors & Patients.” As is his style, Robbie is again unsparing in his lavish praise of the physician profession that he loves, but decidedly unvarnished in his condemnation of various aspects of physician culture that he dissects with precision. As you may recall, Robbie was the CEO of the Permanente Medical Group from 1999 to 2017, and was a lead player in the transformation of that fine organization into what many of us regard as the gold standard of capitated integrated care in America.

I had the chance to sit down with Robbie the other day and to talk to him about “Uncaring,” the state of physician culture today, and its somewhat interwoven relationship with the value movement that we both ardently promote. I think you’ll find this conversation interesting. Take a listen.

Robbie Pearl, great to have you with us today. I’m looking forward to this conversation. How have you been?

[00:02:32.810] Robert Pearl, MD:

I’ve been excellent, Don. Thank you so much for inviting me today onto the show. I look forward to our conversation as well.

[00:02:39.020] Don Crane:

Very, very good. So, let’s jump into it, Robbie. In 2017, you released a book entitled, “Mistreated,” a Washington Post best seller that, among other things I analyzed our rather dysfunctional healthcare system. I think it perhaps could be described an indictment of it. Race forward today, ‘21, I guess it can be said that we’re in the latter stages I like to think of our COVID pandemic, but whatever we’re in, you know, mid here ‘21, and you within a couple of weeks, will be releasing what I think is your second book entitled, “Uncaring: How the Culture of Medicine Kills Doctors & Patients.” And that is the principal subject of the conversation today. I had the pleasure of reading it over the course of the last three days, amazed at its content. But before I start to describe it, let me ask you, how did you come to write “Uncaring” and tell us a little bit about it.

[00:03:40.970] Robert Pearl, MD:

As you said, Don, in 2017, I published “Mistreated” that became a Washington Post best seller. And as I went around speaking at conferences, talking to various organizations and meeting with physicians, first, I was convinced that the, I’ll call them as you use the word indictments were accurate, that our approach to delivery of healthcare from how it’s reimbursed to how it’s structured to its lack of modern technology in the absence of leadership, can’t possibly meet the needs of either patients or physicians.

But I also found as I spoke to people, that there was something else that simply the dysfunctional parts of the healthcare system couldn’t explain. Things that were directly under doctor control and yet they were not as optimal for patients and even for the doctors, as I thought they should be. And I started to research this phenomenon, try to figure out what it was and I wrote “Mistreated” with what I discovered, which is this invisible force called culture. A culture that we learned as medical students and residents. The beliefs, the values, the norms we carry with us across our entire professional careers. I could see it a little bit similar to magnetism. You can’t actually see magnetism, but you see its effect on other objects.

You can’t get your hands around culture, but you can see the way that it impacts care delivery and the book, “Uncaring: How the Culture of Medicine Kills Doctors & Patients,” was the result. It will be published next month. All profits, as with “Mistreated,” go to Doctors Without Borders, a 501(c)(3) charity. And any of your listeners who order the book can get some freebies from my website, RobertPearlMD.com, and get a signed book played and discussion guide or reading list and a chance to read the opening chapter. But this book is different from, again, I’ll say, the indictment that you described by giving to the system of medicine, which is very little about it, is actually in the interest of either doctors or patients. The systems are really designed to do well for insurance companies and hospitals and technology manufacturers and drug companies and almost everyone except for the doctor and the patient. But here it’s different. This book speaks to the remarkable, positive aspects of that culture. When it comes to doctors, COVID comes ashore and doctors don’t hesitate to work 12- and 24-hour shifts donning garbage bags when there’s no protective gowns, wearing salad lids when they can’t get N95 masks. When patients can’t breathe, they pass tubes through the mouth, down to the lungs. And they know every single time as that tube passes through the vocal cords, the patient’s going to cough, spewing virus in their face and they do it anyway, Don.

And, when they have two patients, both of whom will die without a ventilator, they figure out a way to put both the one the one ventilator that remains something that had never been done or even considered. And yet, there are these other aspects. The problematic underbelly of that same culture. I mean, think about it, Don, 88 percent of people who died had two or more chronic diseases, most of which could have either been prevented or at least better managed. And you don’t hear people talking about it very much.

Hypertension, the most common chronic disease that people had who got admitted to the hospital, it’s controlled across the United States 55 to 60 percent of the time in the large multi-specialty medical groups, the ones that you lead so effectively…some of them control it 90 percent of the time. How can we have this gap in the number one cause of stroke, kidney failure and a major contributor, heart disease?  What about the 30 percent of things that physicians do that add no value? Then the fee-for-service system are as well or better reimbursed as they are as the things that make a big difference, or the fact that we elevate specialists above primary care, despite the fact that the data says that adding 10 primary care physicians to a community increases longevity two and a half times more than any 10 specialists.

None of these things made total sense to me until I start to understand this physician culture and what it values and what it doesn’t value and how it values intervention far more than prevention. How it values those specialties, those individuals who do the more complex and difficult things and undervalues those who are able to prevent disease in the first place or intervene in ways that are less noticeable. This is the focus of the book, and I think it’s so valuable because not only will an understanding of that change improve clinical outcomes for patients, but I believe it’s an essential pathway towards addressing burnout and physician suicide.

[00:09:54.650] Don Crane:

So, Robbie, having read the book, I can assure our listeners that it is to a very large extent, you know, a celebration really of all that is excellence in the work of physicians. So, but it causes me to ask you the question as I look again over my shoulder here at the title or really the tagline. So, the title is “Uncaring,” but the tag line, “How the Culture of Medicine Kills Doctors & Patients.” Why such a provocative tagline, Robbie?

[00:10:27.950] Robert Pearl, MD:

Because it’s true. Because this culture contributes to hundreds of thousands of deaths for patients every year. And I believe, as I described in one of the early chapters to the physician suicide, burnout, moral injury, we can call it, what we want. You know, you go back, the book opens, you know, with the story of Semmelweis. The middle of the 19th century, Ignaz Semmelweis was appointed the Director of the maternity unit at the leading hospital in Vienna, Austria.

And he’s appalled. He notes that the maternal mortality is 18 percent. And he can’t explain why that mortality is so high in his hospital, but the adjacent hospital, one run by midwives, is two-thirds lower. As you know, in medicine, serendipity plays a major role in one day a colleague of his nicks his finger and he develops a local infection that goes on to have a clinical course like the same women who die after childbirth. For them, it’s called puerperal fever, an overwhelming infection of the uterus that spreads throughout the body. The leading idea at the time is that the problem is caused by women in labor inhaling miasmas, these smelly particles that would waft up from the underlying streets. But why should his laboring mothers inhale more of these particles than the ones in the adjacent facility run by the midwives? He thinks about it and he says, I’m hypothesizing that what’s happening is that these doctors who are doing autopsies, like the colleague who died, or women who’ve had puerperal fever, are carrying it from the autopsy room to the delivery room. And maybe, they’re carrying it on their hands. Maybe they carry it on the leather aprons they wear at the time to cover their well pressed three- piece suits. So, I’ll make doctors change their aprons and dip their hands in chlorinated water. Lo and behold, mortality drops from 18 percent to 2 percent.

Now, what do you think happened? Well, you know what happened. You’ve read the book, but for the people listening in, we would expect that immediately everyone would follow these approaches. Almost everyone ignores him, despite the fact he publishes the leading journal, writes letters to the directors of the maternity wards around the world. The ones who write back to him say he’s crazy, he’s foolish. It’s not possible. Now start to think, you know, when we talk about problems in medicine, we put on a systemic lens. We say, oh, it’s because of money or time. There’s no money involved taking off a dirty apron, putting on a clean one. Not much time dipping your hands in bowls of chlorinated water. No, what’s going on, this is the culture of medicine in the minds of the doctors of the time. They’re healers. They can’t possibly be the source of disease. They’re held in very high esteem. The idea that somehow they are responsible for bringing these infections from the autopsy room to the delivery room, it’s just not possible.

And those leather aprons, the sources of pride in the culture. The more blood, the more pus, the more experience, the more the individual is at the top of the hierarchy. That’s the last place you would think infection could be carried. So, people ignore him because that’s how culture works. So, it allows the people in it to not see it. I often think about this is smokers in North Carolina sitting in some smoke-filled room and someone from Berkeley, California, comes out there and starts coughing and having their eyes run because to them it seems so foreign to the people and it seems so common.

And the story, those not just from the 19th century. I mean, think about it Don. The third, sorry, the leading cause of death among hospitalized patients…the fourth leading cause among all patients…is hospital-acquired infections in the United States today. And every doctor knows that the bacterium that causes it is clostridium difficile. Unlike coronavirus, that doesn’t go through the air, it’s only carried in people’s hands. And what do we see, study after study from the leading hospitals in the United States?

When doctors go from one patient room to the next, a third of the time, they don’t wash their hands. How do we explain it? With alcohol-based disinfectants, it’s a matter of seconds. There’s no cost involved. All the usual explanations fail to work.

And that’s why I talk about it, killing in that case, patients. And I think, in the process, we can talk about in a few minutes, doctors as well. And when the patient dies, what does the culture assure every physician that they didn’t do it. It had to be someone else. They overlooked the fact they didn’t wash their hands. In the same way, they overlooked the fact of how poorly we do at preventing disease and avoiding chronic complications from chronic disease. Culture allows us to see the things that are in our interest and not see the things that are not. It’s not conscious. It’s not bad people. It’s very dedicated, highly motivated people who, in the experience of medical school and residency and in the practice of the profession, get put into a situation where what they do is different than what they otherwise might think they do. And if people still have problems sort of understanding, you know, what do you mean, where does this culture come from or how significant is it? I asked them to think back to what’s called the ‘white coat ceremony’.

You know, every doctor in the first day of medical school comes to this white coat ceremony where a faculty member takes this prestigious white coat and places it, drapes it over the shoulders and the arms of the new matriculating physician, with one exception. And that exception is when the parents of the incoming doctor is a physician. And then he or she is allowed to place the coat on their own offspring. Now, for physicians, we think this is all normal, but step back and think about it. Why would you have this one set of parents put the coats onto their offspring and not all the other parents who are equally proud of their kids who maybe had to work four jobs between the husband and the wife in order to earn the money to keep the kid in school? Why wouldn’t you have every parent do it? Because it’s not about the child. This is about the physician culture passing off the values and the beliefs that the incoming student has been raised in and the parents giving explicit permission to the faculty to now instill its culture into their child. But if the parents are physicians, then they already have that culture and so they are accorded that privilege as well.

[00:18:16.070] Don Crane:

So, Robbie, I get it completely in the example here of white coats. That strikes me as being very much cultural. But I suspect some of our listeners hearing you talk about handwashing, or the lack thereof, in hospitals see that as a systems failure, right? And we talk a lot about systems around here, organized versus disorganized systems and of course, payment models, which we’ll get to in a minute. I think you need to help me out and try and deliver some sort of a distinction between system and culture. In your book, you make the point, if I can paraphrase a number of times, “fixing the systems is not enough.” We’ve got to address culture. So, help us out with a distinction between the two.

[00:18:58.130] Robert Pearl, MD:

Using the example you just gave, the system would be if there were no sinks in the rooms and no alcoholic disinfectant and now the person had to take an elevator to another floor to wash his or her hands. That would be a system problem because it’s so inconvenient that so much time…and we had that some at points in the past. Don’t get me wrong, but today it doesn’t exist. Every hospital has right at the entrance that at least a dispenser of an alcohol-based disinfectant, if not having the soap in the sink right there to make it happen. So, the systemic issues have been taken care of and it still doesn’t happen as often it should. That’s what I mean by the cultural ones that are sitting there. Systemic problems would be if a doctor were not paid. Systemic solution would be if a doctor were not paid to do procedures that added no value, but they are paid to do it. So, in that sense, we could make a systemic improvement going from fee-for-service to pay-for-value. But even though we’ve tried to do that again and again and again, we hit up against roadblocks.

Why is that? And if we think, it’s because something is being done to doctors then why do all of the medical societies nationally, not yours, but the other ones, hold onto this outdated system of care and actually be very supportive of physicians who choose to go out of network, bill patients for services. One in five EDs and hospitals across the United States, according to data that came out last week. And then turn a blind eye when the hospitals that employ them sue the patients, and as we know, the people who are most often sued are not the ones who can afford to pay.

It’s the ones who didn’t pay because they simply don’t have the money. To me, the system and the cultural ones all come together. Everything seems copacetic, but patients, as you know, in the United States live five years less than patients in other industrialized nations. We’re last among the 12 most industrialized nations in longevity, in childhood maturity, childhood mortality, maternal mortality, except we’re the most expensive place by almost a factor of two. Some of that is systemic. Some of that is cultural. The two need to change together.

[00:21:52.930] Don Crane:

So, unfair question now, perhaps, because I don’t read your book as being, you know, a comparative analysis of country to country. But is this problem with culture uniquely American or worse in America? How does it compare with other countries, if you can weigh into that at all?

[00:22:10.810] Robert Pearl, MD:

It is worse in the United States and a good proof point for that is what’s happening relative to primary care. In the United States, primary care is towards the bottom of the hierarchy of specialties. It didn’t used to be like that. But in the later part of the 20th century and into the 21st century, I write about it extensively in “Uncaring: How the Culture of Medicine Kills Doctors & Patients.” I write about how this cultural shift has happened to the point now that the interventional specialties, most of the surgical ones, interventional cardiology, are going to be near the top of the hierarchy and the ones that are taking care of people, preventing disease, primary care, adult medicine, towards the bottom. But there are exceptions, and this is to me what’s fascinating particularly as you look at burnout. Getting back to the question you asked Don, is this a systemic problem?

We asked physicians what are the reasons for burnout in the United States? And they’re going to give you three. They’re going to say we’re not paid enough. They’re going to tell you the bureaucratic tasks and they’re going to tell you the computer systems are clunky. This has been asked, examined many, many times. And they’re right. Particularly in primary care, they’re not paid enough, particularly in some of the specialty areas. There is too much bureaucratic time wasted and the computer systems are left over from the 20th century at best. But, would you now look at the data for Medscape and you start to ask, what about the relative burnout among specialties?

Overall, burnout is 44 percent. But you see the exceptions that to me, belie the analysis, belie the systemic assumption. What you see as an example is that pediatricians are more satisfied than adult medicine physicians, despite the fact that they earn significantly less. And now, when you look at who’s at the top of the list, what’s the specialty with the greatest burnout in the United States today? It’s urology. That’s strange. Urologists make almost half a million dollars a year. They make double what primary care makes. And the bureaucratic tasks…they don’t have to ask for any more authorization than you see in orthopedics or ophthalmology. Computer systems are exactly the same ones that everyone else is using.

So, how do we explain this, particularly when I tell you that if you go back about a decade ago, urology was very low in terms of, very good in terms of having low burnout, high satisfaction. And it comes down to a change that happened in the preventive services recommendation.

I think it was 2012 when the PSA testing was seen to add little value and often cause problems as patients underwent unnecessary biopsies and had procedures done, robotic prostatectomy that didn’t prolong life, but often gave impotence and urinary loss. And following that, research showed that watchful waiting was often just as good as surgical intervention. Now understand that the robotic prostatectomy is the operation…I think of it like the Star Wars of surgery…that elevated urologists up into that top tier. Everyone could imagine this 22nd century procedures being done. The high-tech video game equivalency. And now, all of a sudden it starts to go away. And as the number of cases go down, patients are getting smarter, they’re using the internet. They’re going to set this with higher volumes and more and more physicians stop being able to do this procedure. They don’t lose income by the way. The income is still relatively the same compared to other specialties and continues to go up. What they lose is status. And why this is so important is the research done by a man named Sir Michael Marmot, who’s a sociologist in the United Kingdom.

And what he showed is that not only are the psychological issues, but the physical ones, too, are a reflection in the British society of the esteem held by different classes of workers based upon how the job they did was seen relative to the other jobs where they were held with high esteem and placed high into the social hierarchy and now we’re even talking about the economic one. But more significantly, when one status drops, the people became dissatisfied, unfulfilled, fatigued, exactly the symptoms of burnout. There is an economic piece. There is a bureaucratic piece. There is a computer piece. And that’s why I say they both have to change.

But, until we figure out how to change the culture of medicine…until physicians can feel just as good about all the different ways they add value, not simply the ones that are held up at the top of the hierarchy, given the most esteem and recognition, that type of dissatisfaction, I believe, Don, is going to continue and all of that is under doctor control. No one makes us, as physicians, see our colleagues less well or better. And as you know, primary care is a great example of that. In groups of doctors, primary care physicians overall are seen as having more value. They happen to be paid more money because they’re seen as having more value rather than the inverse.  And they’re more satisfied.

[00:28:23.730] Don Crane:

Very interesting.

[00:28:25.740] Announcer:

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[00:28:33.130] Don Crane:

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[00:28:52.260] Announcer:

We’re back with more from APG on American Healthcare. Once again, here’s your host, APG President and CEO Don Crane.

[00:29:01.980] Don Crane:

Robbie, let me shift to our COVID pandemic. It’s obviously about the biggest thing to hit American healthcare in a long time. And I want to start with a very practical question. So, you started to write your book before the COVID pandemic hit in February, March. So, I think you even started in the prior year. You then continued to write the book as the pandemic unfolded. And perhaps it’s illuminated to a greater extent some of the shortcomings that you’ve identified and was a help or not. And here we are. I think I like to hope, you know, moving out of the pandemic at a time when your book will be published and released to the public here in the latter stages of the pandemic. So, anyway, the course of your book describes pre, during, and to a certain extent, post. How did you handle that as a practical matter? Was that difficult? Was it helpful?

[00:29:59.280] Robert Pearl, MD:

Extremely helpful because the COVID crisis, the pandemic, has elevated all of the observations that I made in the pre-COVID world. As an example, we saw early in the COVID pandemic when testing kits were not easily available, that when two patients came to the emergency department…and this is based upon claims data and research that was done coming out of the claims insurance world…when two patients would come to the ED with similar symptoms…one was a black patient, one was a white patient.

Physicians tested the white patient twice as often. And that statistic impacted me early in the process, reaffirming many of the things that I was in the process of already writing about racism in American medicine. And then the data started coming out after that. That black patients were dying two to three times more often than white patients. You’d say, OK, we should have tested actually black patients more.

And then I write something about artificial intelligence.

There’s an article that I had read about how artificial intelligence supposedly created bias. And I went back and reread that article in the context of all this information happening in COVID-19. This came out of a time when UnitedHealthcare, through their Optum subdivision, was looking at ways of identifying the parts of the population who are most likely to benefit from added resources in terms of future disease prevention. And then they use an AI algorithm to do that. And lo and behold, what happened was the algorithm found a lot more white patients than black patients, compared to what should have happened based upon the actual severity of disease. And the headline screamed AI was racist and biased. And I went back to think about it in the context of what’s happening, and I said, no, it’s the opposite. I said all AI is doing is mimicking what doctors do.

And how did it make the mistake? It looked at the dollars spent as a measure of how sick the patient was. Because doctors gave eighteen hundred dollars a year more care to white patients than black patients with the same equivalent disease, it assumed the white patients were all sicker. It unveiled and wrapped all of this. You know, I looked at the data on pain medication and that physicians give black patients 40 percent less pain medicine after the same procedure. The whole process started to crystallize because we had a specific disease with now a massive amount of data. You know, it’s hard to read a journal without half of the articles being about COVID. And so, as I read each article, I tested it against the hypotheses that I had from my research. And each time it checked itself off to the point that I actually think that this will be…COVID will be a crucial transitional event that I think could lead to disruption in the post-coronavirus era.

And what I mean by that, Don, is, you know, we’ve been talking about the unaffordability of healthcare forever. I mean, it actually started, as I said, 1934 panel of physicians and policy experts got together to try to address what was seen at that time as a growing unaffordability of healthcare. Now, little is very different. So, we’ve been trying to do this for a long time and I think coming out of the coronavirus pandemic, I’m hypothesizing, and I do have the opportunity to teach both at the Stanford Medical School and the Stanford Business School. But I’m putting on my business school hat and I look at what’s going on. I say there’s going to be significant downward economic pressure in the post-coronavirus era. And why I say that…the federal government will have borrowed 8 trillion dollars that’s going to have to pay back or pay interest upon it. The states by law have to have balanced budgets and they’re going to have more Medicaid, more unemployment, lower tax revenue. And small businesses have been killed in this pandemic. They’ve burned through their savings. A lot of them have gone out of existence. A third of them say they can’t survive the year without continued government aid.

It’s all been hidden by these massive stimulus and relief bills. They’re going to end. And when they do, I think we’re going to see a major financial crisis, tremendous downward pressure. And where are people going to look? Healthcare’s 25 percent of the federal budget. Healthcare is a major expenditure for every state. Healthcare has been growing at 5 to 6 percent, double the rate of overall inflation. You may remember back in 2019 at the end, it was projected to continue to grow at 5 to 6 percent year over year for the next decade…10 years of growth, 60, 70 percent higher costs, and no one blinked. Everyone said, yeah, OK, that’s about right. No, it’s not going to be tolerated. And I think coming out of it, we’ve said we must change. We should change. I think we will change because if you can’t pay for it, you won’t. Now, don’t get me wrong. There are companies like Apple and Amazon and Netflix, they’ve done very well and they can continue to do very well. But it’s going to be the companies that employ the greatest number of people, these small businesses, the governments at the federal level and state level, that are going to be trying to address it. And so, again, all that’s happened coming COVID is make everything sharpening the lens. And I think to. potentially at least, serve as a catalyst for the kind of change that we were waiting for decades.

[00:35:56.170] Don Crane:

I sincerely hope so. Let me circle back to a point you made earlier. I think I got it right. 88 percent of those that died from COVID at some point during the pandemic…and this may have even been limited in New York, although I don’t know…but at any rate, a very high percentage of those that died from COVID had one or more chronic disease, right? So, as I look at that…

[00:36:19.390] Robert Pearl, MD:
Two or more. 97-some-odd-percent had one or more. But two, I picked two because you can have one by chance. But two, you start to have a different disease profile.
[00:36:30.970] Don Crane:

Either way, it begs the question. What did they die from, Robbie? Was it COVID or was it the one or more chronic diseases or was it a combination of the two?

[00:36:40.910] Robert Pearl, MD:

Overwhelmingly, it was COVID but the ability of patients to be able to overcome the infection, to not have it progress to whatever it is…whether it was a pulmonary or a vascular or an immune response. These diseases, diabetes is a great example. One’s immune system is not as adequate. And so, when faced with a virus the chances of it being able to continue to progress, to multiply, to go to the long, to go to the body goes up dramatically.

[00:37:16.550] Don Crane:

So, perhaps a rhetorical question, Robbie. Why are we not talking more about these chronic diseases associated with these deaths? I mean, COVID is going to come and go, but those chronic diseases has been very much present pre-COVID, during COVID. And it looks to me like they’re going to be very present post-COVID. I’m not hearing about how we should be addressing those. What systems would be best designed to address them, payment models, et cetera, et cetera. Do you see that picture as I do, or what are your comments on that?

[00:37:48.290] Robert Pearl, MD:

I could not have said it as well as you just did. It’s the culture of medicine that’s getting in the way. Actually, the systemic consequences are obvious. The cost to whoever’s paying, whether it’s going to be the government or the business of the individual, you would think this would be at the top of the list. You asked me before about other countries…it’s at the top of the list in other countries. But in our nation, that’s not the culture of medicine. We don’t focus on it. We don’t invest in prevention. We don’t invest in primary care. We don’t invest in the things that make the biggest difference. We’re enamored by the things that are…I’ll call them the most profitable. In fact, it’s actually fascinating to me…There’s a comic on TV who actually had an entire skit on this and he was asking, why isn’t America? This has happened last week. Why isn’t American medicine more concerned about these areas? And my answer is it’s the culture. Why aren’t people in North Carolina more concerned about smoking? Well, some of it is the fact they make money from growing tobacco. But some of it is the culture they were raised in. That’s what their parents were like. That’s what they’re like. And that’s what their kids are going to be like.

You know, it’s interesting to me, people always want to have me explain, well, where does culture come from? You know, there’s no question that the Italians and the Germans could not be different as people. I can’t tell you exactly why. I mean I can hypothesize the warmer weather, the Mediterranean is different than the more cooler climate of northern Europe.

It’s just the way it is and culture is this ever-remaining force that is just there and influencing everything. And you could only identify it by its impact on people. And when you see behavior, that appears to be illogical, most of the time it’s going to be culture that does it. If we were going to make adjustments to the American healthcare system, we would focus on prevention. We would focus on primary care. We would use modern technology like telemedicine.

What a great example. I mean, you know, almost I think seven years ago I wrote a piece in Health Affairs. At the time, Kaiser Permanente was doing 14 million virtual visits. And I pointed out that all the rest of the United States, they were doing about the same number. Some of that is economic. There’s no question about it, because Kaiser Permanente was a fully capitated system. But a lot of it is the culture that comes out of that and the thinking about it. And lo and behold, COVID comes ashore. And your question was so good about this. How did it change the viewpoint? Because now we had the example with COVID ashore, what happens to telemedicine? Physicians now who don’t want to encounter patients face-to-face, start bringing them…so, doing virtual care, using video, telemedicine rather than bringing them into the office.

Some physicians, 60, 70 percent. And that’s the quickness, the speed of that change now is able to disrupt the culture. Now the question is going to be what happens in the post-coronavirus era? Are we going to go back to the old way with 1 or 2 or maybe 5 percent telemedicine, or are we going to stay with…I predicted in my article 30 percent, I think it’s probably now 40 percent? And again, to the question you posed about the chronic diseases, what I don’t hear being talked about or what I hear talked about is people still thinking about telemedicine as a second-rate solution.

I’m not hearing about very many cases of people with terrible outcomes that would have been better had they come into the office. I’m hearing about people who otherwise might not have been able to get medical care in an easily accessible, quick fashion. I’m predicting that actually it’s higher quality. How many physician leaders have you heard stand up and say telemedicine is higher quality? Now, people may not agree with that, but I would argue that care that you get immediately without delay. Again, when I was the CEO inside Kaiser Permanente, we were connecting primary care physicians with specialists, where the patient was the primary care physician’s office. And if the primary care physician felt that he or she needed a specialty consult, rather than telling the patient to go home and call the specialist’s office or sending a consult, either electronically or before that, through the mail, we would have specialists available who now would virtually come into the room with the primary care physician and the patient, and 40 percent of the time overall, the problem could be solved right there and then.

A great example to me were rashes that primary care needed expertise around. These were not the rashes they take care of all the time. These are the ones that were more severe. And using a digital photograph, 70 percent of the time, physicians could make the diagnosis in six minutes. I don’t know what it’s like where you are, but in the communities that I’ve seen across the United States, it’s six days, six weeks, or six months to a primary…so, a dermatology visit can be scheduled. Here it’s six minutes. Now, let’s look at quality. The patient leaves with a diagnosis, goes right to the pharmacy and has the medication because…starts treatment in a matter of an hour. Is that worse or better than taking several days to go to the dermatologist office? I think it’s tremendously better. We should be talking about this as a major advance or at least debating that and the culture of medicine is not because it undermines what is at the top of the hierarchy in the doctor’s mind, which is his or her office.

[00:44:10.310] Don Crane:

Robbie, let me ask you about payment model, an issue that’s near and dear to our heart. So, in both “Mistreated” and in “Uncaring,” it’s very evident that you are a fervent, I think, proponent of prepayment, of capitation. So, that’s true generally, I think, but with respect more narrowly to culture, can you offer an estimate as to what percentage of our sort of problems with culture right now, if I may say that, are attributable to the payment model, as in fee-for-service versus capitation? You can tell lurking in my question is this notion that I think is possessed by some of our listeners. The payment model is ubiquitously important in terms of covering manifold problems and is almost a panacea. Maybe it is, maybe it’s not on culture. What are your thoughts?

[00:45:06.290] Robert Pearl, MD:

You were exactly correct a few minutes ago when you said that culture and the system move together. It’s not an either or, it’s a both. So, I ask the listeners to step back and think about what’s going to happen in the post-coronavirus era, assuming these economic problems make it impossible for healthcare costs to go up. By that I mean impossible, no one could afford it. What are they going to do? There’s only two ways that it can go. You can put in place…you can’t have a fee-for-service system continue to exist in which people can increase volume. You can ration care. You can tell people of a certain age you can’t get the care and that if the costs keep going up, you lower that age. You can tell them they can’t have certain expensive medications. As the costs go up, you make that list even broader. You know, you can tell them to wait in a line. We don’t have enough…we’ve already run out of our MRI allocation for the month. Maybe we’ll get you an MRI next month. We’ll have you wait three months for a specialist or a year for a routine procedure. You can do all those things or you can capitate. And by capitation, I mean, at the delivery system level. And I want to go beyond that, you know, your audience, Don, is so sophisticated compared to the audiences I speak to in general, particularly around this book. I’m talking about capitation at the delivery system. And I’m talking about models in which the only payment is through capitation. Because if you pay through capitation and fee-for-service, it gets very confusing.

[00:46:47.260] Don Crane:

I agree.

[00:46:48.150] Robert Pearl, MD:

So, now you have a specific population of patients, a capitated payment, and you’re going to be measured on a variety of quality outcomes and patient satisfaction and physician satisfaction. This is going to be the…

[00:47:04.170] Don Crane:

Holy Grail.

[00:47:07.590] Robert Pearl, MD:

This is going to be the test condition. What I mean, it’s not a…we’re going to test it.  But what are we going to predict is going to happen to culture in that environment? In that environment prevention becomes more important, particularly if you’re going to retain the patient, as we did in Kaiser Permanente for 15 years. So, you can have a long, long runway. Avoid some medical error. Complication with chronic disease. These are going to become increasingly important. How likely are physicians to do the 30 percent of procedures that have been shown by the Mayo Clinic and seen by a review of the literature through the New England Journal of Medicine to add no value? How likely are they going to do it in a world that is capitated and that’s why I see these two pieces going together and why I want to stress that is to follow up to the question maybe some of your listeners were asking you, which is the ones who see changes in payment as being the driver. Why hasn’t it happened? I think that’s interesting. Why, if this is going to be a panacea, why hasn’t anyone done it?

[00:48:22.540] Don Crane:

So, now you’re on to my next question, Robbie, and I don’t want to sound negative, but so the commission to which you refer, I think that was 1934, maybe 1932. In either case it’s about 90 years ago. And its chief, I think, recommendation, was pre-payment, right? And you roll forward in time and I’m basically now paraphrasing content of your book, Nixon Administration. Nixon signed the HMO Act in whatever year was ‘74, I think. And it called for pre-payment. Subsequently, Clinton administration proposed through the Hillary plan, managed competition. Again, prepayment a cornerstone of it. Move forward yet again, the Obama administration gave us the Affordable Care Act again calling for prepayment and the movement from volume to value. And then finally, most recently, the Trump administration or not most recently, next to most recently, the Trump administration, scores of demonstrations and pilots all experimenting for pre-payment. But as of today, it still really hasn’t happened. In point of fact, we saw the Innovation Center here just last week, shelved the direct contracted model, at least for a year. We don’t know if it’s a pause or it’s permanent, which provides for global capitation and a professional missed risk model as well. So, I know you look at this picture and you go, oh, my gosh, 90 years of intelligent calls for prepayments. I’ll call it capitation. And yet it really hasn’t happened. It’s still, statistically, a side show and the great preponderance of payment across the country remains in fee-for-service. So, help me reconcile that with your view, Robbie, expressed I think a number of times in your book, I caught it every time when you talked about the movement to capitation, you couched it in terms not of, if, but when, a very positive, I think, projection on the future of payment models. So, are we fated to fee-for-service for yet another 90 years or indeed, will the future be capitation? What are your thoughts there?

[00:50:30.760] Robert Pearl, MD:

This is the combination of systemic issues and cultural issues. The force stopping it is the physician culture because, see, in the physician culture, doctors liked the idea of being paid for whatever they do. The idea of being paid to actually make people healthy by preventing disease goes against the grain. They didn’t spend 10 years trying to figure that out. They spent 10 years trying to figure out how do they replace a heart valve or how do they do a different procedure that maybe wouldn’t have been necessary had they intervened. But that’s where they have the value, the esteem, the status. These are cultural words that sit there. They come together because in this physician culture, collaboration and cooperation isn’t valued. I mean, you’ve heard the stories about how doctors want to be… I’ll call them lone wolves. You know, what do we value? And remember, see, culture is passed down from the previous generation. The 21st century culture wasn’t created in the 21st century. It was created in the 20th century. The 20th century, we didn’t have the information and knowledge of today. So, what do we value?

We value intuition, anecdotal, personal experience. We value, believe it or not, variation. But every study that’s been done has shown that when physicians closely follow evidence-based practice, outcomes are better. It’s the culture that retains the past and the fee-for-service world aligns with that culture. It’s why I wrote in the book about why we said we must and we should and it’d be better for a long time. But I think it will happen under one of two circumstances, Don. First circumstance is going to be the economics of the post-coronavirus era. And, maybe our nation will bounce back. You know, we’re so innovative we may come up with a means to have the GDP truly go up over time. It’s going to go up a lot this year because it went down where it was very flat last year, went down slightly last year. But it’s going to go up a lot this year. But I don’t mean it from that standpoint. We may be able to earn our way out of it. It’s possible.

But I think what’s really going to happen is that there’s going to be the process called disruption. Now, disruption could come from doctors. That’s why I wrote “Uncaring” because I hope doctors will. Because as physicians we lead this process. We’re going to come up with ways that it is better for our patients because that will be the focus that we will do as we try to design the new rules and approaches. It certainly could come out of businesses as they’re struggling and they have purchasing power. They could decide they’re only going to buy some type of capitated, integrated, technologically-enabled approach. The government could do it. I don’t think they will. I think the lobbying pressure of the special interests, the farmer world and the device manufacturers and insurance and the hospitals are going to be too great to make that happen.

And I’d add to it some of the specialty, specialty groups at the national level that had the same incentives sitting in play. No, I think it’s a good chance that someone like Amazon is going to do it. And I think the changes that have happened over the past couple of months should be a major warning shot across the bows of every physician. You may remember 3 years ago, Haven was formed and I wrote about that. My friend Atul Gawande and his leadership. I wrote about Amazon and Berkshire Hathaway and JP Morgan Chase coming together. But what I wrote at the time was that anyone who believes that Jeff Bezos is creating this organization to provide care to his, to the one million employees of those three companies on a not-for-profit basis, probably also believes that Amazon only sells books. No. This was going to be the whole time an entry, an entree into a healthcare, a three point seven trillion-dollar industry. And Jeff Bezos was going to be just as focused on getting one sixth of that marketplace as he was, as he has been getting one sixth of retail. And I think the fact that telemedicine has now come aboard has been a major catalyst towards allowing that to happen because the big problem you have in moving from the old model of healthcare to the one you and I both believe in, is getting enough concentrated volume in a small geography so that people can have enough doctors in an arena to provide that care. Telemedicine solves that. You can bring in the world’s greatest specialists from three thousand miles away into any community you want, using telemedicine at a minimal cost.

So, I think that that’s going to be a major shift. And as you know, he’s also in the areas where he is has delivery system capability selling it to other businesses around them. And who are his friends, the CEOs of other big businesses. The potentiality now to be able to create a virtual capitated, integrated, technologically-enabled system has now gone from being a distant vision to a current early reality. What I often teach the students in the business school, disruption always takes longer than you think, but when it happens, it’s far more powerful than you ever could have imagined. And I think we may be seeing that, whether it will be to the benefit of doctors or whether it will be at the expense of doctors. If I have one piece of advice to them, it is to get into a group practice to figure out how you can create care that is better for patients. I often tell people about a sign that I saw in a health service in Portland, Oregon.

It said quality, service, cost in big letters at the top or at the bottom it said pick any two. That was the mentality of the 20th century. Today, we have to figure out how do we get all three? And I believe that there are ways to do it. As you say, it reflects back to this committee from the 1930s. It reflects back to the things that have been said across time. And one of the pieces I point out in the book that I think is most interesting…I can’t find anyone outside of maybe the AMA who has pushed for the current system of medicine, claiming that it’s better. Doesn’t matter if the president was Republican, a Democrat, liberal or conservative…I can’t find a single person who said what we really need is more fee-for-service and less capitation. What we really need is more fragmentation and less integration. What we really need is more or less technology and more something else. Everyone that I’ve seen has had the same vision to the point you’re making.

It’s only been a question of what it would take to make it a reality. And I don’t tell you 100 percent, but I think there’s a far better chance now over this next five to 10 years than we’ve had at any time that I can remember in my career.

[00:58:15.050] Don Crane:

Robbie, on that hopeful note, I think we’ll conclude. I want to thank you very, very much for this. To be continued, of course, we’ll be talking again. Hope to see you soon. This was hugely educational. I’m sure my listeners are going to really enjoy it. They’ll get to buy your book soon. And I think you made reference to advanced copies earlier. Should I send them to your Web page? Is that a good place for information on how, when, where, why to buy it and so forth?

[00:58:43.250] Robert Pearl, MD:

The best place to go is to the website RobertPearlMD.com. There they will have a choice of nine different suppliers of the book. As I say, all the profits go to Doctors Without Borders. I don’t make any money either from the book or from being the conduit to it. And if they do it before May 18th, they can get the freebies of the signed book plate, the reading list, the discussion guide and the early peek view of the chapter. And I encourage them to contact me, let me know their thoughts after they read it, whether they love it or they hate it. The way that I learn, the way that you and I, Don, together can help move this nation forward is by hearing from people and hearing their thoughts. You know, if I have 60 percent right, there’s still 40 percent of problems, then maybe in the next book I’d get to 80 percent. But that ability to move things forward and I want to thank the physicians who you lead for the feedback they gave you on the first book, because much of their feedback is what led me to research this new one. And I’m hoping they’re going to enjoy it, find it as educational and provide as much guidance for the future as they did for the last. Thank you so much, Don, for having me today.

[00:59:53.480] Don Crane:

Robbie, thank you. Thank you for your dedication. Keep up the good work and stay healthy, my friend. Take care.

[00:59:59.900] Don Crane:

As you may have observed, our Annual Conference this year will now be held in person December 9th through December 11th at the Marriott Marquee San Diego Marina. Please save the date and be sure to register. It will be, to say the least, an extraordinarily welcome and refreshing chance to see each other in person once again. In the meantime, stay safe and be well.

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