May 7, 2021

Dear Interested Readers,

 

Dr. Pearl Says That The Culture of Medicine Kills Doctors and Patients

 

As I was thinking about the subject for this post I was delighted to receive an email notification from my old friend and former colleague Zeev Neuwirth. Zeev hosts a very popular healthcare podcast called “Creating A New Healthcare.” There have now been 117 programs that are usually interviews with innovators in healthcare or with established healthcare leaders. In the past, I have discussed a few of his podcasts in these notes like his interviews with Don Berwick and Zeke Emanuel. Zeev’s podcast has become a “must” for me and for more than 9000 other regular listeners. 

 

I first came into Zeev’s orbit in 2005 when we hired him to be the Chief of Internal Medicine at our Kenmore practice. Zeev brought Lean to Harvard Vanguard. Everyone immediately recognized that he was a very special leader. While I was CEO he became our Chief of Clinical Effectiveness and Innovation before he left us to become a part of the leadership team at Carolinas Health which is now renamed as Atrium Health, a very large system in the Southeast with home offices in Charlotte, North Carolina. Along the way, Zeev has written an excellent book which I have highly recommended, Reframing Healthcare: A Roadmap For Creating Disruptive Change. 

 

Zeev is an inspirational speaker who brings great passion to the discussion of any subject related to the care of patients. His interviews are infused with that same passion for improving healthcare which has always been present as long as I have known him. If you ever have any concerns about the expectation of improving the delivery of healthcare just listen to the enthusiasm in Zeev’s voice in any of his podcasts and you will be energized to get back to the important responsibility of doing as much as you can to support the continuous improvement of healthcare. 

 

I was particularly interested in podcast #117 because it was advertised in Zeev’s email as an interview with Dr. Robert Pearl, the former CEO of the Permanente Medical Group and the Mid Atlantic Region of Kaiser. Zeev had me at the introduction.

 

Friends,

Our guest this week, Dr. Robert Pearl, introduces a fundamental reframe in our understanding of healthcare transformation with his second book, Uncaring – How the Culture of Medicine Kills Doctors and Patients. He convincingly argues that addressing the systemic functional challenges in healthcare is not sufficient. For transformation to occur, we also need to address the entrenched culture; and the first step is in understanding that culture. ‘Uncaring’ is the most comprehensive and scholarly book I’ve come across on the interplay between the legacy culture of medicine and its impact on healthcare delivery and outcomes. Dr. Robert Pearl’s stories are heart-breaking and heart-warming; and the historical facts, medical stats and studies he draws upon are engaging, enlightening and of concern to all of us.  

 

I have enormous respect for Dr. Pearl and was wildly enthusiastic about his first book, Mistreated: Why We Think We’re Getting Good Health Care — and Why We’re Usually Wrong. Zeev had been given a prerelease copy of the new book by Dr. Pearl and seemed to know what was in it and understand its thesis as well as its author did. I was not disappointed by my investment of an hour listening to Pearl respond to Zeev’s questions about his new book which challenges the culture of healthcare and names it as one of the things that really needs an overhaul as we build back better after the pandemic. I learned that the book will not be available until May 18. The good news is that if you pre-buy the book and then electronically send a copy of your receipt to Dr. Pearl’s website you can download an advanced copy of the introduction, a study guide for use with a book group, and a very interesting document that describes fifteen books and articles that are essentially a syllabus for his book. As you might guess, I bought the book and have downloaded the freebies that Dr. Pearl is offering. What follows is gleaned from the interview and from that excellent essay that is the introduction, which was worth the cost of the book. I hope that some of you may also listen to the interview and be interested enough to read the book. You can be sure that I will be writing more after I have read the book which another hero of mine, Malcolm Gladwell endorsed by saying:

 

“I can’t remember reading a more courageous and original critique of what ails American medicine.”

 

Pearl begins the introduction to his book by calling on our recent common experience with the pandemic which underlines what many of us would like to quickly forget and others never acknowledged even as we all accumulated enormous individual and collective losses. 

 

Within a matter of weeks, the itsy-bitsy virus had begun taking lives and devastating complex adaptive systems—political, educational, economic, and social—throughout the United States. The disease shook financial markets, dominated news coverage, and disrupted human existence in ways most Americans had never experienced.

Perhaps no system was hit harder than healthcare. Hospitals overflowed, equipment grew scarce, and the very foundation of American medicine crumbled beneath our feet. As we look back at this acutely difficult moment in medicine, it is easy to forget that trouble had been brewing for some time. Independent research had, by the early 2000s, rated the US healthcare system the most expensive and least effective in the developed world, a label that stands to this day. 

Well before the coronavirus outbreak, American healthcare had staggered, and doctors had been stumbling for decades. The signs of failure were clear and present…

 

Zeev gives us an overview of his interview with Pearl in his letter:

 

 In this episode, we’ll discover:

• Numerous episodes in the history of American healthcare that demonstrate how the culture of medicine is holding us back from transforming healthcare delivery.

• Profound examples of how the culture of medicine directly influences how care is delivered and the grossly suboptimal outcomes that are a result of that culture.

• The only two possible directions American healthcare can take in response to the unsustainable and unaffordable costs of healthcare delivery.

• A new perspective on what is causing the high rate of provider burnout.

• A pathway to confront and change the culture of healthcare.

 

Pearl and Zeev discuss two of the many stories that are used in the book to give color to the contradictions in the culture of physicians. I’ll let Zeev give the details on one of them. I think that Atul Gawande has also used this same historical event in one of his New Yorker articles.

 

It’s been said that if we don’t study history, we’ll be condemned to relive it. This is no more true than in our healthcare system. Dr. Pearl shares a haunting story of an Austrian physician named Dr. Semmelweis who died penniless in the 1860’s, as a result of being shunned by the medical establishment. His heresy was that, through years of rigorous research, he demonstrated that physicians were carrying the source of maternal infections & deaths – on their hands & clothes. His studies revealed that maternal mortality rate could be decreased from 18% down to 2% simply by physicians changing their gowns and washing their hands with antiseptic in between treating patients. One might shrug this off as a historical footnote, except for the fact that today, in 2021, hospital acquired infections are the fourth leading cause of death in the US – leading to over 90,000 deaths per year. The tragic truth is these deaths could largely be prevented by providers washing their hands in between seeing patients. That is the power of culture – “this invisible force” that Dr. Pearl reveals to us.

 

Part of the other story they discuss is also familiar to me because it appears in the excellent 2009 book by David Blumenthal and James Morone, THE HEART OF POWER: Health and Politics in the Oval Office:

 

Pearl sets the story up by talking about a committee of experts who were convened to discuss how to improve American Health Care. The committee discovered that the care offered in America was fragmented, often inconvenient to use, left millions unserved or underserved, was the most expensive care available in the developed world and delivered some of the worst outcomes despite its expense. As the description unfolds one imagines that this is the report of a relatively recent commission, perhaps it is the report of the committee of the Institute of Medicine that produced Crossing the Quality Chasm in 2001. We were shocked when we learned that the committee reported to Franklin Roosevelt in 1934. Pearl goes on to say that FDR wanted to include healthcare in the New Deal but was advised that the AMA and other vested interests in healthcare would fight it and the rest of the New Deal. FDR made a deal and left healthcare out of his reforms in trade for the support of the established healthcare community for the other parts of the New Deal like Social Security. Morone and Blumenthal add another dimension to the story by pointing out that FDR was very persuaded by his son’s father in law who was a powerful figure in the AMA and American Healthcare, Dr. Harvey Cushing, the famous neurosurgeon and Chief of Surgery at the Peter Bent Brigham Hospital and Harvard Medical School.

 

Dr. Pearl aptly uses the pandemic to demonstrate the two faces of physicians. Faced with the challenge of one patient in desperate need or a country under attack from a poorly understood and deadly virus, doctors will commit acts of bravery and sacrifice in the moment that can not be diminished in the courage and compassion that they demonstrate. Away from the acute need and at a time when personal interests or business interests can be influential you can also expect that collectively these individuals will respond more out of self-interest than in the best interest of the community. The result is that we have not treated chronic diseases effectively, millions lack the fundamental preventative care that would have ensured that they were healthy enough to withstand the virus and that collectively our system of care was not prepared to withstand an attack that had been predicted and was virtually inevitable. Pearl describes the result:

 

During the first few weeks of the outbreak, the internet erupted with images of doctors and nurses donning garbage bags for smocks and salad lids for facial shields. These “frontline soldiers” looked more like a ragtag militia than a properly equipped army. Through it all, news outlets documented their struggles and triumphs. Americans watched from home as physicians with darkened and drooping eyelids fought off exhaustion and continued fighting COVID-19. They worked from morning to night in substandard and often dangerous conditions, brimming all the while with looks of determination. They ended their shifts with deep red lashes on their faces, markings left by the snug-fitting N95 masks they were forced to reuse, day after day.

 

Pearl does more than describe the moment. He is really clear about our self-interest and the contradictions in our culture that have brought us to where we are, but he describes this moment as the time when culture must change and implies that the changes must come from within healthcare. The pandemic is best seen as a moment when we began a new culture as we strive for “normalcy.”

 

As Americans long for a return to normalcy, they find themselves standing amid the ruins of financial devastation, tasked with the duty to rebuild their systems: political, educational, economic, social, and, perhaps most challenging, healthcare.

But where to begin? American doctors, policy experts, and academic scholars may offer differing visions, but they are united on at least one point: we need to fix healthcare’s systemic issues.

By this they mean freeing doctors from the red tape and bureaucratic burdens that bog them down. A now common refrain in medical circles is “let doctors be doctors.” Proponents of this mantra insist that American healthcare would improve by leaps and bounds if we simply eliminated annoying administrative matters, pesky prior authorization requirements, and cumbersome computers that (literally) sit between physicians and their patients. Doctors point out that these barriers to better care were put in place by a self-serving array of healthcare-system players: health insurers, governmental regulators, computer manufacturers, and hospital executives. Indeed, these groups, along with pharmaceutical companies and medical technology firms, are guilty of holding healthcare back while inflicting harm on patients and doctors alike. Correcting their deficiencies will be central to healthcare reform. But if those are the only changes our nation accomplishes, then everyone—including doctors and patients—will be sorely disappointed with the results. Contrary to what most people believe, fixing the US healthcare system won’t be enough.

 

Pearl seems to suggest that our “systems issues” are not the primary problem. The primary problem is the physician culture that allows the systems issues to persist. He gets graphic by calling it our “dark underbelly.” Our culture is “dualistic.” He explains:

 

We must also address the invisible and highly influential physician culture. Founded on the ideals of compassion and commitment, the culture of physicians has been passed down through generations of professionals who possess a deep desire to help people in need. This culture proves capable of inspiring superhuman achievements and has spurred some of the greatest advancements in human civilization, from organ transplantation to cancer immunotherapy to the marvels of modern surgery. But this same culture carries a dark underbelly, which is responsible in many ways for the rising costs and decaying standards of medical care that permeate our nation’s inpatient and outpatient facilities. Physician culture contains a duality of human motives and actions, leading to outcomes that range from life-saving to life ending.

 

Dr. Pearl contends that this moment of dysfunction in healthcare is rooted in our healthcare finance system and the variable earning possibilities of different specialties. We do what we get paid to do. If we can make large salaries and increase institutional earnings by providing redundant or unnecessary care by specialists, we do.  Our fee-for-service payment system rewards excessive care and undervalues more essential primary care. Pearl believes that our dualistic system of care and our culture of our “uncaring” is also augmented by our collective self-interest. The solution offered by FDR’s ill-fated commission and then by every other study of our system of care done since 1934 has been to move healthcare finance from a fee-for-service platform to a program of universal access to care financed by rewarding doctors and institutions for the care of populations through a system of paying for value as judged by outcomes, efficiency, and patient satisfaction. In short, capitation with controls to prevent making a larger profit by denying care.

 

Zeev sums up Pearl’s thesis by saying:

 

Like myself and many of you, Dr. Pearl is frustrated and deeply troubled by the complexity, opacity and inertia in American healthcare delivery – and how the culture is greatly limiting access, affordability, efficacy and equity – greatly harming patients as well as providers. 

Two silver linings emerge in our discussion. First, the culture of medicine has tremendous strengths as well as wonderful attributes and values. We make a point to share our firm belief that the providers and staff in healthcare are amazing. Second, the solution is not easy but it’s not that complicated. When I asked Robbie what he would request healthcare leaders do differently, this is how he replied, “To move from fee-for-service to capitation. To work together to improve medical care rather than maximize volume. To embrace technology that makes care more convenient for patients.” 

 

I am eager to read the entire book. I wish that I could be part of a study group that could take advantage of the points that I see outlined in the “Reading Group Guide” that was among the materials available on Dr. Pearl’s website, which I hope that you will visit. Our concerns about the quality, cost, and availability of healthcare are not going to fade away with the establishment of “herd immunity” and the likely waning of the intensity of the pandemic. We really don’t want healthcare to return to its normal pre-COVID state. If what has happened over the last fifteen months has not convinced you that we need a change in how our system of care works, I wonder what it would take to do the trick. What Dr. Pearl is suggesting is that as we change the system we also need to think about the origins of our motivations and our culture. I have never understood why we can be so passionate about the care of a particular individual and have so little insight into how we support and comply with a system that is foundational to the harm our patient is experiencing. Near the end of his introduction Dr. Pearl sums it up this way:

 

Uncaring tells the story of a profession that is both triumphant and dangerously flawed, filled with people who aspire to help others, yet who sometimes act coldly, callously, and indifferently toward the pain of others. This book takes you inside the doctor’s world, revealing unique insights about their training, their daily practices, and the culture they share. It is a book about people striving for perfection and about the impossibility of achieving it. It sheds light on the norms, rules, and expectations of doctors, and shows how culture shapes their thoughts and beliefs. It deciphers their evolving language, symbols, and codes. It highlights what brings doctors together and what isolates them from their colleagues and patients. Finally, this book examines the elements of physician culture that need to be corrected, the ones that should be preserved, and how to accomplish both.

 

That last paragraph is a great summary of the intent of the book. Part of our culture is to think “It’s all about us.” Harvey Cushing was paternalistic, in his conversations with FDR he let his co-grandfather know that he and his colleagues at the AMA knew best how to shape the healthcare world that their shared grandchildren would experience. FDR was not unlike much of the public then and until now, willing to accept the advice of a respected doctor, or perhaps just unwilling to risk confronting it, assuming that the doctors’ intent was always to first address the needs of the patient. That however has not always translated into addressing the needs of the patient’s community especially when addressing those needs might be at variance with the self-interests of the controlling interests of the profession.

 

I have a sense that Dr. Pearl was hoping that doctors would read this book and become introspective in a way that might lead to change. However, I also suspect that he realizes that although we are interested in the advancement of science and the care of the individual, our internal processes have never really produced the changes that make all we have to offer available to everyone, especially if that compromises our control. I would posit that the primary audience for this book is the public. It will be reviewed in the New York Times and the Washington Post. There will perhaps be interviews with Terry Gross on NPR or segments on programs like CBS’s “60 MInutes.” Dr. Pearl is writing for the public’s edification because he knows that we have known for a long time that what he describes is real and we have done little to change our culture. The business of medicine is a powerful force with two faces. We want to be seen as caring, but we are also embedded in a culture that needs to remind itself frequently that it should care about the well-being of its patients and many of its professionals as much or more than it cares about controlling its bottom line. Zeev says it succinctly at the end of his intro:

 

 What I learned from Dr. Pearl is that healthcare leadership must not only  create a new system, it must create a new culture: one that aligns our professional values and purpose with the actual daily practice of medicine and delivery of healthcare. 

 

You can be sure that I will be mentioning this book again in the future. I hope that you will read it and that your patients will find it, read it, and be incensed by its revelations even if you don’t read it.  As a profession, we need some encouragement from the public to make the difficult but necessary changes necessary to undo the uncaring culture that is killing doctors, and plenty of other healthcare professionals and essential workers, as well as patients.

 

Emerging From Gloom With Some Blooms and Hope For The Future

 

I was about to throw in the towel on Spring until yesterday. The picture in today’s header was what I saw any time I looked out of the window from late Sunday until yesterday morning when to my surprise I awoke expecting more of the same but found that the sun had returned. I am always delighted when the weather gurus get it wrong. I love it when the day that we experience beats the day they predicted. The Wednesday prediction for Thursday had been for “Low clouds, then perhaps some sun.” What we got was no clouds and a lot of sunshine that made it feel warmer than in the mid-fifties. It was a day to be out in the yard soaking up the yellow beauty of new daffodils and forsythia. All the trees are beginning to bud in anticipation of bright green leaves that might be everywhere by the end of the week. 

 

I took the better-than-expected weather to be a good omen. On Wednesday, in the rain, my wife had driven me to the Kenmore Center of Harvard Vanguard/Atrius Health for an injection of my lumbar spine. Downtown Boston was in full bloom. I think the spring in Eastern Mass is at least two weeks ahead of our spring.  Going to Kenmore is always like going home for me. I was there on Day One in 1980 when Harvard Community Health Plan moved the Kenmore practice a few blocks from its original site in Kenmore Square on Beacon Street to a huge new site in a repurposed old S.S.Pierce warehouse. Over the last forty years, this same building, just a few hundred yards from Fenway Park, has remained the flagship of the organization. I imagine that I have spent more of my life in that building than in any other site on earth.

 

I take great pride in having been involved in many of the improvements and innovations in care that have occurred within the walls of Kenmore. Throughout its history, we literally moved many walls to accommodate new programs and services in the effort to improve care. During one period of rapid growth in the history of HCHP before two other offices in downtown Boston were opened almost 60,000 people received their primary care at Kenmore. Over the years the clinical areas have expanded to offer the full complement of specialty care and up-to-date imaging and endoscopy units. These days when I go to Kenmore I am just another gray-haired old man walking with a cane and looking for relief. It is very gratifying to see so many of the things that were once the dream of better care for other people are now realities of care that satisfied my needs. 

 

What was perhaps the most unexpected event was that when I entered the building my I-Watch pinged, and I saw a message that welcomed me to the building. I really did not know what to expect. The “spine unit” in my day had been more virtual than what I saw when I arrived. I was taken into a prep area where I was told what to expect and the history and recent meds that I had entered into the Epic “My Chart” ap were verified. With no delay, I was taken into the procedure room and before I knew it my neurologist had done the deed. Now the question is what will happen in time to my inactive anterior tibialis muscle. The experience was great. My pain is gone. I slept well for the first time in over two months. I’ve needed no ibuprofen or other pain med. There is still numbness but no pain in my foot. My hopes are high. Time will tell. Maybe as the spring evolves things will continue to go my way. 

 

Wherever you are, I hope the care you get is as good as what I enjoy at Harvard Vanguard/Atrius Health. Take time to enjoy the spring. It is so good when the clouds go away and you have an unexpectedly sunny day. 

Be well,

Gene