June 4, 2021

Dear Interested Readers,

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Our Culture Is Everybody’s Problem

 

I am sure that you have heard the expression that “culture eats strategy for lunch.”

 

I can’t recall when I first heard the expression, but there is no question in my mind that it is true and that culture was a rate-limiting reality in my tenure as a CEO. Healthcare transformation has had no higher hill to climb than physician culture.

 

I was eager to read Robert Pearl’s most recent book, Uncaring: How the Culture of Medicine Kills Doctors & Patients. Pearl is the former CEO of The Permanente Medical Group, the physician organization of Kaiser-Permanente. He is an excellent writer whose work regularly appears in Forbes and the Washinton Post. In 2017 he published Mistreated: Why We Think We’re Getting Good Healthcare (And Why We’re Usually Wrong) which I reviewed when it was published. As Pearl explained in an article that he wrote for Forbes at the time he wrote the book (2017), he was calling for a transformation of practice that would improve quality and safety. As you can read below, where I have bolded his words, he focused on just how slow change occurs in healthcare.

 

My father was an amazing man. The son of immigrant parents, he put himself through dental school, volunteered to be a paratrooper in World War II and survived D-Day. Sadly, he died prematurely from an avoidable medical error. In retrospect, had all of his doctors had access to a shared comprehensive electronic health record, they could have coordinated his care. Instead, they missed an important step in his medical treatment, an error of omission that led to his demise.

When I tell audiences his story, I invariably hear from dozens of families that have suffered similar tragedies. It shouldn’t be like this. And based on my experience, it doesn’t have to be like this. But change comes very slowly in healthcare.

That’s the very personal reason I’ve written a book, Mistreated: Why We Think We’re Getting Good Health Care and Why We’re Usually Wrong,…I dedicated the book to his memory. By helping the patient in all of us understand the shortcomings of the current healthcare system and how it can be improved, I hope to expand high-quality healthcare for all…

The American healthcare system is ailing, and becoming sicker each year. And if nothing is done, it is likely to become critically ill in the future. 

 

Pearl’s voice is one of many in a choir that includes my voice. The members of that choir know that sooner or later one of two things will happen. It is possible that all the efforts and calls for transformation will eventually make a difference and we will move on to a better day. It is also possible that things will continue to get worse and more and more grief and loss will be our legacy. As we now know, Pearl’s book was interesting and was a terrific description of the “current state,” but there was no radical change in its wake. Now, four years later, nothing has changed. In fact, as the COVID pandemic has demonstrated, things are worse than we have been willing to admit. Our inadequate care of vulnerable populations and our inability to respond quickly to a public health emergency were not deeply examined in the 2017 book. I see Uncaring as Pearl’s attempt to go “further upstream” to answer the question “Why?” in reference to the reality that the rate of change does not match the need to change. It will be hard to correct such egregious problems that impact everyone, the rich as well as the poor, without the leadership of physicians.

 

Pearl is easy to read because he underlines the points he wants to make with stories from the history of medicine and from his own rich experience as a busy surgeon and subsequently his life as a healthcare executive. By the end of the book, he has convincingly established his thesis that the failure of American healthcare to achieve laudable goals like the Triple Aim, improved quality and safety, and equity has been secondary to the self-centered medical profession’s refusal to accept change. Many of the steps required to achieve improved quality and safety and then achieve the Triple Aim are counter to a culture that evolved in the nineteenth century and has its roots in attitudes that go back over two thousand years to the era of Hippocrates. Simultaneously, he describes the dilemma that we have because of the coexistence of the positive benefits of this ancient culture that were so obvious in the darkest days of the pandemic when doctors and nurses disregarded their own personal safety to respond to the needs of their patients. Physician culture is rife with contradictions.

 

Pearl begins with a definition of culture and the power that it holds over us in ways that we frequently don’t recognize. David Foster Wallace had the same message in mind in his phenomenal 2005 graduation address at Kenyon College This Is Water: Some Thoughts, Delivered on a Significant Occasion, about Living a Compassionate Life which was later published as a little book. We are introduced to the question in the first paragraph of the speech. Click here if you have never read the speech.

 

“Greetings parents and congratulations to Kenyon’s graduating class of 2005. There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says “Morning, boys. How’s the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What the hell is water?”

 

To state the obvious, the fish did not recognize water as the determining factor in their environment. Most of us, physicians and non-physicians, never consider the powerful influence of our culture which is literally the water in which we swim. Pearl’s description of physician culture, its evolution, and how each new physician is indoctrinated in its positives and negatives is a remarkable exercise in objectivity and compassion. His wisdom is derived from his reflections on his own training and personal experience.

 

Going back to Wallace’s speech, a little further on he says,

 

The point here is that I think this is one part of what teaching me how to think is really supposed to mean. To be just a little less arrogant. To have just a little critical awareness about myself and my certainties. Because a huge percentage of the stuff that I tend to be automatically certain of is, it turns out, totally wrong and deluded. I have learned this the hard way, as I predict you graduates will, too.

Here is just one example of the total wrongness of something I tend to be automatically sure of: everything in my own immediate experience supports my deep belief that I am the absolute centre of the universe; the realest, most vivid and important person in existence. We rarely think about this sort of natural, basic self-centredness because it’s so socially repulsive. But it’s pretty much the same for all of us. It is our default setting, hard-wired into our boards at birth. Think about it: there is no experience you have had that you are not the absolute centre of. The world as you experience it is there in front of YOU or behind YOU, to the left or right of YOU, on YOUR TV or YOUR monitor. And so on. Other people’s thoughts and feelings have to be communicated to you somehow, but your own are so immediate, urgent, real.

 

Had Wallace been reading our mail? He was describing the typical student who had gone to college to learn how to think, but the description aptly fits the primary orientation that so many of us have in our professional lives. If the world is not working for us or if the world that is working just fine for us is threatened then we are offended even as we bow to the concept of patient-centeredness.

 

Medical culture can be altruistic but it is also self-centered. This focus on self is derivative of the culture that has evolved from experiences and stories that are transferred during the brutal years of training. As Pearl described a period of sixty hours without sleep during his residency when he fought to save the life of an eighteen-year-old young man who was the victim of being hit by an automobile, I could relate to his story. I never had a sixty-hour stent but there were many times in my own training when after 36 hours on-call I was duty-bound by our culture not to turn over a care responsibility to a fellow intern or resident but to complete the task myself. Pearl points out that this culture of individual responsibility has been passed down through generations of house officers and clinical attendings.

 

Except for one month when I was on call every third night, my own internship at the Peter Bent Brigham Hospital in 1971 was an every other night on-call experience. Mercifully, there are now modest limits to the time without sleep in approved training programs, but now with a “merciful” eighty-hour workweek, most training programs are still a brutal introduction to decision-making in a state of sleep deprivation. I am also sure that the use of fear and humiliation are still major components of medical education that reverberate through a lifetime of practice. Many physicians function throughout the length of their practice life with a fear of being exposed as inadequate.

 

There is much much more in Pearl’s description of the evolution and maintenance of medical culture. With his stories, Pear demonstrates how the culture acquired during training leads to problems in patient care and is the origin of much of what we now call “burnout.” Pearl is balanced in his analysis because he also uses stories to present evidence that often this cruel culture enables heroic acts of patient care. As the analysis evolves he moves on to show how medical culture interacts with the business of healthcare and uses physician culture to explain why and how physicians have often resisted positive changes. Acting together through professional societies and the AMA, he presents evidence that physicians acting on the attitudes that are derivative of their culture have blocked most attempts to transform care over the last ninety years.

 

Much like Atul Gawande has done, he offers examples of medicine’s reluctance to adopt any innovation that might change the autonomy of clinicians or the fee-for-service business model. Like David Blumenthal, he recounts how in the early thirties Franklin Roosevelt was persuaded by the AMA not to accept the recommendations of the Committee on the Cost of Medical Care to include universal healthcare in his New Deal. Ironically the specifics of the recommendation included replacing private fee-for-service payment for care with a national program of prepaid, capitated, integrated care. Population health, preventative care, and universal coverage are old ideas. If you click on the link above you can read an overview of the whole scenario that culminated in 1935. This link, as does Blumnethal’s history reported in the book The Heart of Power (see the 2009 NYT review written by Robert Reich) which he wrote with political scientist James Morone, suggests that Dr. Harvey Cushing, world-famous Brigham neurosurgeon and a key member of the AMA leadership, used his influence on FDR to advise “leaving healthcare to the doctors.” Cushing’s daughter was married to FDR’s son. I have also read that because of the opposition of the AMA FDR and his Secretary of Labor Frances Perkins feared that if healthcare was included much of FDR’s New Deal agenda would not become law. It is interesting to ponder this history now as Joe Biden bargains for The American Jobs Act and The American Families Act which contain many provisions that will decrease healthcare disparities.

 

So, resistance to the suggestions of Crossing The Quality Chasm, the changes necessary to achieve the Triple Aim, and even the organized pushback against the ACA are just later iterations of a very long history of proposals to improve care that have been challenges to the preferred status quo of medical culture. Pearl reveals through his stories how change is rejected because it demands too much from its practitioners. The status quo is hard to change even as it denies too much from patients while charging too much for care that is often excessive and ineffective and associated with high levels of harm for patients and burnout for doctors. Culture eats strategy for lunch.

 

Early on in my own tenure as a healthcare CEO my senior management team and I worked with our board to write a strategic plan that was designed to prepare our practice for a return to capitation while both growing and improving our quality and safety. I had become convinced that there was a great opportunity to eliminate waste and improve quality by shifting much of our decision-making to the interface with patients through a process of distributed leadership and management in an organization that was focused on continuous improvement facilitated by the adoption of Lean culture.

 

Lean quickly became very popular with nurses and our support staff. Surveys of their satisfaction identified us as one of the top places to work in healthcare in Eastern Massachusetts. While our Lean transformation accomplished a lot, most of our physicians sat on the sidelines or gave credence to the concepts of “damning by faint praise” and using their busy schedules as an explanation for their limited participation in the Lean improvement process. Looking for advice from the leaders of other organizations that had great success with Lean–Virginia Mason and ThedaCare to be specific— I made a discovery. Both ThedaCare and Virginis Mason had used the consultants at Amicus to help them guide a transformation of physician culture.

 

I had met one of the two partners of Amicus, Jack Silverstein, in the mid-nineties when HCHP tried to implement TQM (total quality management) and had recently seen Jack and his partner Mary Jane Kornacki at a GPIN (Group Practice Improvement Network) meeting. Sensing that our strategy would fail unless we could get more of our physicians excited about the challenge to improve, we hired Amicus to help us. What I Iearned from them was that most doctors functioned under an implicit “contract” that was derivative of the culture. They called physician culture an example of APE syndrome. The ‘A” stands for autonomy. Doctors believe that their most cherished right is their license to do things exactly as their judgment and experience dictate. The unbridled autonomy is the origin of practice variation and resistance to following “best practices.” Autonomy is fertilizer for medical errors and antithetical to safety.

 

The “P” in APE stands for protection. Doctors want a protected environment that speaks first to their security which is justified because of the sacrifices that they have made and the way they are willing to extend themselves to serve their patients. The protections that they most desire are protections of their income and reputations. They have given much and expect a reward. Finally, the “E” stands for entitlement. Need I say more? If you need an explanation ask a nurse. The “cure” for APE syndrome that Amicus offers is a negotiation. The implicit contract that describes the traditional expectations for physicians is replaced by an explicit document that describes what doctors are expected to do and the supports and environment that they can expect from the collective whole of the organization as lead by management. The discussions that flow from the process should lead to greater understanding on both sides of the divide between the practice and management.

 

Pearl is not waiting for the new world of enlightenment that could be achieved through a dialog between doctors and management. His last chapter is entitled “The Virtues of Being Difficult.” It contains a list of aggressive questions that patients can use to judge the advisability and safety of getting care from an individual doctor. I found that many patients have discovered the advantages of asking for certainty about the attention they can expect and the measured levels of expertise that they will receive from their providers. I don’t see this as a universal solution. It is easy to advocate for a cultural change but the sort of change that is needed is what Ron Heifitz calls adaptive change. Adaptive change is a process of acceptance experienced through the loss of old certainties, and the evolution of new skills. The process is hard and requires insight and time. Deep feelings are touched. It is as much a process of accepting loss as it is a challenge of learning new processes and behaviors. Pearl concludes that there are elements of physician culture that must be retained and even more that needs to be jettisoned. The transformation of healthcare has been and will continue to be a long and painful process that will eventually demand the application of external demands and pressures that make the need for change inevitable. I think those changes have begun but there is still a long road ahead.

 

The book was written as an explanation of medical culture for patients. I think that it is also a book that deserves the attention of physicians. Unfortunately, I think it is unlikely that those among us who could benefit the most from its message are the ones most likely to ignore it. That’s culture.

 

Maybe This Weekend Will Be Better

 

The last two sentences in last week’s letter were:

 

The weather prediction is for only occasional showers and temps in the high sixties to low seventies. It should be nice!

 

Maybe I was reading an old newspaper or looking at the weather report for South Florida because the weather at my house last weekend was more like late February or early March than the typical Memorial Day weekend. It rained on Friday, Saturday, Sunday, and Monday. The skies were heavily overcast and the temperature remained in the forties for the whole weekend. There was a persistent damp chilly feeling that was augmented by a stiff breeze. I had not had a fire in my fireplace for several weeks, but over the weekend my fireplace was in continuous use.  When I decided to ride my bike during a brief interruption in the rain I dressed more like I was going skiing than I normally dress for a bike ride. 

 

It’s warmer now. The temp is predicted to be in the mid-eighties over the coming weekend which will be a forty-degree improvement. The better weather is also a boon to the construction project that is in progress in my backyard. We have a deck that runs the length of the house. The deck lies less than twenty feet from the lake at certain points. That is a huge benefit. Laws were passed since our house was built to protect the New Hampshire lakes and require a minimum fifty-foot setback for all new construction. That means that what we have is “grandfathered” but we are precluded from adding on anything between us and the lake. For some time we have thought that it would be terrific if we could enclose one end of the deck as a screened porch. The best that we could do because of the fifty-foot setback requirement was to install a retractable awning which we did about five years ago. The environmental concern that prevented more roof over an existing deck was that a roof would facilitate a quick run-off of rainwater into the lake.

 

Last summer was a buggy summer. Sitting on the deck in the evening was usually impossible unless there was a stiff breeze to blow away the bugs. One day last summer we suddenly decided enough was enough. We hired an architect to design an environmentally acceptable solution as the basis for a request for a variance. 

 

The answer was to dig a large holding pit for rainwater under the deck that would allow rainwater to gradually drain into the ground. The architect went with us to the environmental committee that approved variances. It was a risky negotiation during which we agreed to extend the drainage project to collect rainwater off of an adjoining portion of the roof. It was a protracted process but the architect convinced the board that the project would improve the water quality of the lake. 

 

The drainage system had to be hand dug because it was too close to the lake to allow the use of a backhoe or other digging equipment. Today’s header shows the progress of the project as of Wednesday. The rafters were added yesterday. In the end, the surface of the entire deck will be replaced. Now I can look forward to sitting in a rocker, playing Mexican Train dominoes on the porch long after the sun goes down, and eating long evening meals without citronella candles burning while chatting with family and friends. As I head into my later seventies I look forward to summers on the porch and winters in front of my friendly fire. The best part was that it was a “win-win.” We got what we wanted, and in a small way, the project diminishes rainwater runoff into the lake.

 

Life is full of “win-win” possibilities if we look for them, but to make them happen investment and ingenuity are often required.  Everything is connected. Investment in new energy sources that move us toward less use of carbon-based fuels is a good example of my point. New jobs and less pollution will be good for the environment, good for the health of the nation, and diminish health care disparities. All that is required is a vision and a willingness to invest. Our little project (my wife is the project manager supreme) is just a small example of what is possible with insight and effort. A willingness to put up with what is undesirable never seems to me to be a satisfying strategy in healthcare or in one’s private life. The key to a win-win approach is to make sure that satisfying your own need doesn’t compromise other people or processes. 

 

It is neat for me to dream about writing these notes soon from the comfort of our new porch. I hope that you have some dreams of your own that give you something to look forward to experiencing. Someone to love, something to do, and something to anticipate are foundational to good health. I hope a personal inventory of your own life shows that you have a positive balance in each of these accounts. It is also good to remember that in time the sun always returns. “Interested readers” will always be welcome on my new porch.

 

Be well,

Gene