Uncaring: How the Culture of Medicine Kills Doctors and Patients | Robert Pearl, MD, Author

Speech to text:

Mike Koelzer, Host: [00:00:00] Dr. Robert, for those who haven't come across you online, introduce yourself and tell our listeners what we're talking about today. My name 

Robert Pearl, MD: is Robert Pearl. I'm a physician. I wrote the book Mistreated while we think we're getting good healthcare while we're usually wrong. My most recent book Uncaring, how the culture of medicine kills doctors and patients was published two months ago.

All profits from both books actually go to doctors Without Borders. They are really wonderful charities. And we're here to talk about medicine, the problems with the system, the problems with the culture and wherever else. Our conversation, Mike May go today. 

Mike Koelzer, Host: The subheading of your book kills doctors and patients.

Might I jump to the conclusion that that's suicide. 

Robert Pearl, MD: A lot of conclusions sit in that subtitle relative to patients. What we're looking at is a hundred thousand people who die from medical era each year, we're looking at another a hundred thousand or more who die from failures and prevention from complications of chronic disease that could have been avoided, uh, was a whole long list of ways that the culture of medicine contributes along with the system of medicine to harming patients.

And for physicians, we're talking about a 44% burnout rate, and we're talking about 400 suicides a year, the highest profession that I'm aware of. And it's the stresses of taking care of patients in a system that is problematic and in a culture that is outdated. 

Mike Koelzer, Host: When I think about something as drastic as suicide.

It seems to me and I ain't no psychologist, but it seems to me that it's maybe more than just like stress, that it's like a psychological problem, like not feeling worthy or feeling like they're letting someone down or they're maybe depressed from a life they thought they might have and they're not having.

And I know that maybe stress can bring out some of that, but would it be more than just stress? Is there something there? 

Robert Pearl, MD: A lot of it is the culture of medicine. Now think back to centuries really until about the middle of the 20th century, physicians could do little to help patients. Hmm. In fact, in the net aggregate, there was probably as much harm done as value gained.

and in that situation, try to think about a culture that would evolve. There you are. You're a doctor, you have this newborn six, two month old child in your arms, and this child is dying. The parents are in tears. What you learn to do is to repress your emotion. Hmm. You learn, how do you go out into the plague when you don't have any antibiotics or anything else to treat this problem?

You've gotta repress it. Now think about this. Well, you trade in medicine. You know, the expectation is you're gonna work no more than 80 hours a week, but that doesn't include driving to the hospital away from the hospital preparing for the next day. This is a hundred hours, 120 hours. You have to deny your emotions.

You have to never admit you're tired. Never admit that you're sick. Never admit that you need any help. And these, I think are the, or these values, these norms. These beliefs about the right way to practice now put onto human beings, human beings with all the frailties that we all have into places of stress.

And I think the much higher rate of suicide is less about being a physician, but having to keep that emotion inside. And Mike I'm really worried that in the post COVID world, we're gonna see massive amount of PTSD and suicide. You know, I talked to a doctor, a friend of mine a couple weeks ago. He talked about losing four patients.

One day, I talked to a resident. She had inherited six patients on the first day of a rotation. By the end of the month, all six were dead. How do you deal with those emotions? I mean, I can remember every death I had across a 20 year clinical career, but how do you do it when they all happen in one day or one week or most one month?

And you ha you can't tell anyone you can't admit you're exhausted. You gotta get up the next morning. I think these are the pieces that contribute to the book. I talk about the Cadus, this symbol, these two snakes wrapped in entwined around the staff that sits on the sleeves of a lot of doctors' jackets.

And around the textbook [00:05:00] covers. This is the system and the culture intertwined. They come together in ways that they can support each other. Making doctors heroic, as we saw in COVID 19, but inflicting major harm. And you're raising a great point. It's this total emotional inability to deal with it. And in the book, I'm caring and write about a physician who takes his life and never tells a single person that he's hurt.

Today he's having psychological difficulties and to the best of my knowledge, he never saw it. And he helped. That's the culture. It's a broken culture. It's left over from the past. It doesn't work in today's world, particularly not in the face of a pandemic. 

Mike Koelzer, Host: All of that pressure is put on, you know, they deaden their emotion, they replace it.

Then with unhealthy defense mechanisms, let's say 

Robert Pearl, MD: the two defense mechanisms that I highlight in the book are repression and denial. And these are the ones. If you find yourself powerless to help patients out, that's a difficult demotion. And so you start repressing that if you try to, if every day you have to go to the hospital, take care of patients with COVID 19, 

Mike Koelzer, Host: it went back to the old ages where you have no idea how to solve it.

And 

Robert Pearl, MD: you don't have the protective gear. You have to take a garbage bag and put it over yourself, cuz there's no gowns and maybe a solid put it on your face. There you are. You have to pass a tube into the lung. Knowing every time that tube goes through the vocal cords, the patient is gonna cough, spewing the virus in your face.

How do you do that? You've gotta repress and you've gotta deny. You have to repress and deny that you're tired, that you're having psychological problems. And so I think that people who otherwise could get help and could have done well, find themselves isolated alone and suicide often, unfortunately is the outcome.

Mike Koelzer, Host: I think about Airline pilots. I don't even know if they're still allowed to say that they're on any psychological drugs. I'm not sure the rules on that, but I'm sure that it's not the cool thing to tell your doctor friends that you're gonna go see a shrink for something. 

Robert Pearl, MD: Absolutely. This is the culture of medicine left over from the past inappropriate for today, but the same denial and repression.

That allowed physicians to deal with their inability to help patients to get better are the same ones that lead them to overlook some of the things that they do. I mean, take an example in an area that I know you're very interested in. I know what I mean, personally. I mean, just professionally.

Yeah. Okay. Uh, you know, why did the United States prescribe over 90% of the hydrocodone? You know, why do we, why do we have 90,000 deaths this year from drug overdoses? No question that drug companies were evil. They told lies these drugs can't be addictive. They can't depress your respiration so much that you die.

There were a lot of ways that the drug companies, certainly for profits, were deceiving physicians, but who wrote the prescriptions in the end? And we continued to do so for a long time after, because it was more convenient sometimes to give a patient a hundred pills and not have to worry about filling, refilling a prescription than it would be to give them the five they probably needed or maybe 10, and then have them call your office to get more medication.

But we don't think about that part. We focused on the systemic issues and culturally, we just deny our roles, 

Mike Koelzer, Host: Robert, in that example, break that down. So you're saying that the doctors who had these stressors, it would've been additional stress to do the right thing in that 

Robert Pearl, MD: area. So, in that case, it's not stressful.

It's the reality. You're very. and having a patient call your office, the refills 

Mike Koelzer, Host: you were talking about, it's a refill 

Robert Pearl, MD: and it's a narcotic. So as you know, that requires extra paperwork and triples and other things. So instead of giving the patient 10 pain, pain medications, then saying, you know, if you're still being paid on Friday, call my office and I'll get, you know, the prescription you give them enough for the worst case you've ever seen, not the most likely one or the, hopefully the best outcome, which is the pain will be gone by the end of the week.

Mike Koelzer, Host: Arguably, you could say, well, Hey, let's make refills and let's add more office [00:10:00] visits and more billing and all that stuff. But the refills would've been more of a pain in the ass than it would've been worth. 

Robert Pearl, MD: I wanna be very careful to make sure that listeners understand doctors are very hardworking and very dedicated.

And I don't know any of them who would intentionally do any of these problematic pieces, but. But we're talking about culture and systems put together. Gotcha. Now, to the point that you're making two months after you do a surgical procedure, you can't bill for return visits. It's part of the fee for surgery.

Gotcha. So there isn't any payment, if there was payment, would it be different? Maybe. Maybe not. I can't say, but 

Mike Koelzer, Host: right now it's part of the culture and we 

Robert Pearl, MD: don't know, but the point being that doctors are overworked, they don't have enough time. The computer systems are problematic, everything is working against them.

So they take every shortcut. They can for both good reasons. and the more problematic of both of them is its culture right now, everyone does the same. See, that's the thing about culture. When everyone around you is doing the same thing, you know, what do they say to the fish? How's the, how's the water. They say what water

Uh, cause that's what's around them. Uh, yeah. Right. That's the situation that happens in a culture, every surgeon was doing the same thing. Every doctor was doing the same thing, but why didn't they stop to look at it? I'll give you another, another example. Uh, during COVID 1980 8% of people who died had two or more chronic diseases, the most common one was hypertension across the United States.

Today we control hypertension 55 to 60% of the time when I was the CEO in Kaiser Permanente, we did it 90%. We had, we had excellent doctors, but so the community, we had excellent drugs, but so the community, it's a cultural piece. and we don't notice it in medicine. What we see as clinicians is the systemic issues.

Insurers don't pay enough patients. Don't listen to our advice and we say, this is the best we can do. The fact that someone else is getting better outcomes, doesn't penetrate in a way that forces us to do something differently to achieve a better outcome. That's the culture cuz we're in a culture. What do we value as physicians?

Intervention, not prevention treatment of the complications of hypertension, whether it's the stroke or the heart attack or the kidney failure, but not aggressively continually able to achieve the outcomes that we could. in a different system and a 

Mike Koelzer, Host: different culture. So these were cases that we didn't even know about.

Oh no, 

Robert Pearl, MD: we knew about it. No, we knew about it. They had hypertension. It's just that if it took a year to get it under control or two years, or if it sort of never really happened, that was just the way things were. And it wasn't our fault. It was the system. If the insurers paid more, if patients were more adherent to the medications we prescribed, if a lot of things were different, the computer systems were better.

And every one of those points is true, but mm-hmm, , it also leaves out our contribution. And that's why I wrote the book to try to make people aware of it. Give you another example. I mean, the example is I use COVID only because that's what's happening right now, but you know, I personally don't know any racist doctors.

I'm sure they exist somewhere. I don't know anyone who intentionally provides different standards of care based upon the color of someone's skin, but what does the data say early in the COVID 19 pandemic? When two patients came to the ER with very, very similar symptoms, won a black patient, won a white patient, and there was a shortage of testing kits.

We tested the white patient twice as often as the black patient, despite the fact that the data says that black patients were dying three times as often. People often ask me, you know, is, do we have a racist culture? And at least in this example, I don't think it's a racist culture. Mike, I think what this is is what's called implicit bias.

What that means is 20,000 years ago, we're living in a cave. A human form appears over the edge and we have a split second to say, this is someone from our tribe. Let's welcome them. Or this is someone from the neighboring tribe coming to take our fruit away and let's take the spear and kill them. All right.

This is implicit bias. We see people like [00:15:00] ourselves, whether they have the same skin color, speak the same language or speak the same God as being part of our tribe. And we see people who are not as being in a different one. We can't control that that's biological, but once we see racism in practice, Then we do nothing about it.

That is racism where we see the implicit bias in practice and do nothing. That is racism. What we know is that black women have three times the mortality in childbirth. What we know is that women having a mastectomy get offered reconstruction far less often than white patients with the same procedure.

What we know is that when a black patient has an operation, doctors prescribe 40% less pain medication, these are the facts. And even though we don't think we're doing anything inappropriate, the data says that we are, but that same physician culture allows us to blame the system. The system is problematic.

Black patients had more COVID deaths because they worked in jobs. They couldn't stay home, and worked virtually. They, uh, took buses and subways to get to work. They lived in multi-generational homes. It's all true. and yet once we see the data, you would think we would change our practices, but we didn't, you didn't see any great outrage, at least by most of the white physicians, cuz they all assumed including myself and yourself that the problem wasn't us, it had to be someone else.

It's interesting. Like, you know, you go back to this, holy shit. What is culture? Culture is the values and beliefs and norms. But you know, Igna Summerweiss, I love to tell the story about him. 1850 Vienna, Austria. He's appointed the head of the delivery service there and he's appalled by the 18% mortality rate, but he's also embarrassed because the adjacent facility is run by nurse midwives.

Has two thirds lower death rates. Now at the time, what's the most common cause it's called Al fever, a, uh, infection of the uterus that then spreads to the body. And how does the uterus get infected in the minds of the doctors of 1850? Remember, Louis pastor has not come along yet. It's my asthma's smelly particles drifting up from the streets below and I met a colleague doing an autopsy on a woman with purple fever.

Nick's finger gets a local infection, spreads to his body and he dies with the same disease. Someone who says, oh my gosh, obviously there's something being carried from the autopsy area to the delivery area. Maybe on the hands of the doctors, maybe on the leather aprons that wear to protect their well pressed three piece suits.

He makes them change aprons to go into the delivery area, dip their hands in chlorinated water; mortality falls in less than a month from 18% under 2%. he writes it up in the journal. He writes to the maternal delivery, uh, leaders across Europe. But guess what happens? Nothing. Nothing, no change happens.

All right. You say, okay, that's 1850. What are you talking about today? What's the leading cause of death in hospitals, hospital acquired infection. What's the most common organism CLO Tridium defile? It. Doesn't go through the air like coronavirus. It's carried by people. And one in three times doctors today don't wash their hands.

How do you explain it in S time? It's not because it's money. There was no cost in changing aprons, dipping their hands. It wasn't time. It was the culture that said doctors are healers. They couldn't possibly be responsible. Anyone who was blaming that doctor had to be crazy. And those leather aprons, the more blood, the more pus, the more experience, the higher your respect and self-esteem.

And today, when we go from room to room one third at a time, not washing our hands, it's the same culture. We can't carry diseases. It has to be someone else. But of course it has to be someone and it could just as well be you or me. If we fail to wash our hands, it still takes no money. It still takes no time.

It's purely cultural. It's inexplicable. We look historically when, um, a physician named Herman BOV meets Daniel Freit and he gets to see this thermometer. He says, oh my gosh, we can differentiate health from disease objectively. And how do doctors respond? Forget. Our hands are able to discern this better than any metal and mercury.

It's [00:20:00] not true, but the culture elevates the things that we are most proud about and it makes us ignore opportunities. And of course, as you well know, the rands Institute has shown. It takes 17 years today for a great idea to become common practice. That culture persists and telemedicine is even a better example where we had it all along and we didn't use it until COVID came along.

And all of a sudden, within one week, all the doctors start using it. You see, when you start looking for culture, you see it almost everywhere, intertwined with the systemic issues that doctors and patients and nurses and pharmacists all face. 

Mike Koelzer, Host: My dad. Oh, let's say he'd be talking about the minister, the priest or something like that, you know?

And then someone would chime in. They're like, well, yeah, but they've got such a tough job. They're in charge of all this and all this. I remember my dad, I can hear him now. He's like, yeah, I know. But they're also in that position. And we have to look at that position and find out where the problems are.

It's like, you don't get a pass from that. Doctors hate technology. Tell me about 

Robert Pearl, MD: that. This is another example of where the system and the culture come together. Doctors hate technology for two reasons. They really hate technology that slows them down and makes their job tougher. All right. The electronic health record is a good example of that.

It was never designed for patient care. It literally comes between them and their patient, but they also hate technology. that lowers the esteem of the profession. They love things like robots and proton beam accelerators, cuz that makes doctors special star wars kinds of opportunities. Mm-hmm but things like telemedicine.

Mm they're never gonna see that as good as a doctor's office visit. Because in our minds as physicians, the office is the pinnacle of care delivery. If you wanna come in and see me, what do we call that first room? It's the waiting room. Your job is to wait until it's convenient for me. There's something 

Mike Koelzer, Host: wrong with that.

That's a 

Robert Pearl, MD: cultural piece. I'm not getting it, this is nothing negative about doctors. They are hardworking. They are overworked, but this is the culture. The truth is that telemedicine can provide care quicker. Immediately more conveniently, less expensively. It doesn't replace everything, but let's figure out the things that it does better.

That's not the culture and the mindset of physicians, the things that elevate us. What do doctors hate? Doctors hate algorithmic, artificial, intelligent types of information, coming at them, telling them how to practice. They don't want, you know, that's cookie cutter medicine that lowers everyone to become average.

The data is exactly the opposite. It actually elevates quality and improves outcomes. It's not that there's never an exception, but an exception should be rare. And that's not the way physicians see these tools. Now, remember it's gonna flatten the hierarchy of medicine, right? And a guy named sir, Michael Mormon from England has looked at this phenomenon.

And if your status drops, because now what you do can be done by others. The symptoms are lack of fulfillment, dissatisfaction, and fatigue. Exactly the symptoms of burnout in the profession. And I think a lot of what's happened in the 21st century is physicians have lost that esteem, not cuz they've done anything wrong, but patience rather than accepting the paternalism of the 20th century.

Now I have looked at the internet. We, as doctors say, it's terrible information. Don't look at it. That's not how the patient sees it. The patient says. If I can get these services in banking and travel and retail, if I can get that convenience, why shouldn't I get it in medicine? And doctors hate the idea of the patient as the consumer, but that's what patients expect now.

And as a consumer, that vertical hierarchy has just gotten very much flattened. 

Mike Koelzer, Host: So the technology that's cool, like these robot arms, it's like, if I'm a doctor, I like that because no one else can come into the surgery room [00:25:00] and get to use these Clippers and this kind of thing. But. We don't like the AI in the waiting room or the stuff that just helps the consumer squish the profession because anybody can do that.

So the cool technology's okay. But not the stuff that is taking away. Some of our mystique. 

Robert Pearl, MD: Absolutely. And the cool stuff is really good if it also generates significant income, which the robot does as well, the system and the culture coming together, not consciously in the minds of doctors, but that is if you step back and look at it, what you see, give you another really, to me, fascinating example, it's December of 2019.

The US government puts out an estimate of what's gonna happen to healthcare costs over the next decade. And it says after detailed analysis, they're gonna go off five to 6% in a year for the next 10 years. And that's a compound interest rate. You do. The math healthcare is gonna cost 2.5 trillion more by 2030.

That's a big number. Think about what you could do with 2.5 trillion. Yeah. For prevention, for education, for the homeless, for people who don't have the right food to eat, you can go down the list of opportunities for children and early, uh, development. All the things we could do. I saw this report. I waited to see which of the professional societies would say, this is ridiculous.

The idea that we should assume that medicine will just keep going up at five to 6% of year. Every other industry has used technology at a lower cost. Why are we the only industry that 's raised the cost? Yeah. And no one stepped forward in the culture. This is what was expected. You do the math, you do the calculation.

It's five to 6% more. That's the best that we can do in the culture of medicine. The system of medicine comes together and the people who get harmed are the patients. And as I point out in the title, the doctors who deliver that care, Amazon, 

Mike Koelzer, Host: It used to take me like three weeks to buy a damn Dell computer.

You know, I'd have to, , I'd have to think of all the stuff that I wanted to get and not get. And I'd be nervous and worried. And now you can go on Amazon or whatever, and not all the listeners care for Amazon because of the disintegration of some of the brick and mortar. But if you go on Amazon, you can buy a computer now.

Three minutes just by taking the Amazon choice or the next one down or this or that, but there's still an art in saying, all right, that's fine. But what is this gonna be for Mike and for my family? And what if my kids want to use this? And what about this screen? Am I gonna want to use it on my kitchen table?

And how's the sunlight coming? Do I need a certain angle or a certain, you know, there's a lot of personality that goes on in addition to that base stuff. And so I just think there's a beauty that computers can bring and the physicians are still there maybe solving those big problems that they can't solve for all the mush in the middle that they're still spending 80% of their week on something like 

Robert Pearl, MD: that.

You're raising a really important point. And I would say that I could buy a computer for your family. and a year from now, everyone would be happy with it. I mean, it might not be the one they would pick exactly for their own needs. Yeah. Some people want a Mac. Some people want a PC. Some people want maybe a little bit bigger screen, smaller screen, but 90% it would be just fine to accomplish all that.

Yeah. And we should look at the 10%, if we're gonna buy a computer, it's a lot of money to spend, but we shouldn't overlook the 90%. And at some particular point, we're gonna say, this is basically the equivalent and why not purchase the less expensive one. All we might buy, the more expensive one knows. That it's somewhat of an extravagance to do so, cause it's not gonna really make any difference, but we like it more so we're gonna do it.

And I think we overvalue as people that individualization, you know, 90% of people with the same disease and the same problem, get the same treatment. The 10% are very difficult. They're very complex. They have multiple diseases, but we tend to ignore the part that's relatively straightforward and say, okay, how can we leverage that in a way to improve care for patients to get it to them sooner, more, conveniently, less extensively.

We don't do those things. Cuz [00:30:00] again, it goes against physician culture. We tell ourselves we shouldn't even think about money as doctors. We should just prescribe what we think is best ignored. How many people have economic challenges as a consequence, it's a leading cause of bankruptcy for Americans.

Uh, the Amer the number of people who go to collection, but again, in the culture of medicine, we don't see the, we, we call that an insurance problem. No, for our patients, it's a real problem. And so I'm hoping that we can overcome some of this repression and denial about the healthcare system. Not that it's not broken, we need to work to change it, but also the ways that we, that could help or the ways that we sometimes actually contribute.

Mike Koelzer, Host: So Robert, you brought this up yourself. LinkedIn post, you recently had talking about your book review on Amazon, more than not a lot of iStar, whatever that is. But also some that were way down at the bottom. Probably like a lot of times the negative opinions were not so much an attack on your ideas, but kind of a personal attack, which is easier to do when you can't fight the idea.

But your approach on it was to say, Hey, these last few years, we've all been. Kind of just thrown into these same thought patterns and you kind of groupthink and so on, and you were happy to see the conversation starting, whatever the opinion was. You were happy to see that conversation starting. So in 

Robert Pearl, MD: total, at this point, uh, the book has a four and a half star rating, which actually by the experts on social media, I'm not one of them, but I've read them four and a half is perfect.

Cuz five is unbelievable. Yes. And then when you start dropping down below that it becomes lower, but it's actually interesting to me, as you pointed out that probably, I don't know, 80% of them are five stars and maybe 20% are one star, whatever the numbers turn out to be. Yeah. And it just doesn't happen except when there are other factors at play.

And that was why I was comfortable. In fact, I saw it as an inevitability, cuz I think this change process will involve loss and grief for physicians. Yeah. And I write about it in the book, you know, the five stages of grief by Kula Ross. A great book for anyone who has not looked at it is a great set of research.

You know, the first thing is denial. And I think that that really defines the medical profession for the past 20 years. We didn't see the well yesterday, the Commonwealth fund came out with rankings of the 11 industrialized nations in the US and where were sorry in the world. And where was the US last number 11 last in life expectancy last than childhood mortality.

The highest maternal mortality. That is crazy. We tell ourselves it's the best in the world. We're in denial. It's not the best in the world. So denial is the first age and the second is anger. And that's how I saw the one star ratings. People were angry. I had pulled back the curtain to let people see inside medicine.

You know, it's the wall, the blue wall of silence for the police. Every profession has this way of protecting our own. And I had let people see it. And people were fearful that somehow, by letting people in to see the issues, we were going to make it impossible to get the systemic changes that we needed.

And I saw it exactly the opposite because we've been yelling about burnout for a decade and nothing has changed. You know, it's like being in a foreign country and thinking if you just yell louder and louder and louder, they'll understand you. No, we're not understanding that this is not gonna happen until we lead the way.

So I think it's an important second step. You know, the third step is bargaining and it's interesting to me that 70% of doctors. Are no longer in private practice, 70%, 50% of them get paid either by a hospital, by an insurance company, by private equity, or by a medical group. This is the bargaining, but I don't think it's gonna change.

Cause I think the change is problematic inside medicine itself. And the fourth one that I'm really worried about is depression. And then finally there's acceptance and it's not acceptance saying this is good. it's just saying, this is what is, and how can we lead the way out of it? So I believe that we have to move from a FIFA service system to a capitated system where doctors and hospitals are paid a set amount of dollars to provide care to a set group of patients with quality and service expectations that in doing that, it not only moves the system of [00:35:00] medicine.

It moves the culture of medicine because when you're paid to set a fee to take care of a population of patients, you value prevention, avoids a complications from chronic disease. Patient's safety, you elevate primary care. We know from the data that adding 10 primary care physicians increases. longevity and health two and a half times more than adding 10 specialists.

And yet in the United States today, we elevate the specialists far above primary care, and it leads to a need to create an integrated care delivery system with collaboration and cooperation opportunities to take out costs, not by working harder and longer, right? But taking inefficiencies, how often we prescribe a brand name drug when a generic has exactly the same by law, chemical structure opportunities, to be able to stop doing the 30% of the things the Mayo clinic has shown add no value, the opportunity to be able to use technology.

Like telemedicine for care, that's quicker, higher quality and lower cost. And to embrace a leadership structure, something that doesn't really exist in healthcare today, someone who can organize that entire process to make sure we have the right facilities, the right physicians, the right teams of others, the nurses, the pharmacists, the respiratory therapists, all of the pieces.

And when they come together, all those four parts, I believe we have the opportunity to raise quality 20% service, 20% and lower cost 20%. And that's pretty. Powerful package compared to where we are today. And it would take America from being last to becoming potentially at the top of the 

Mike Koelzer, Host: list. It's embarrassing to rank that low back in December.

So half a year ago, we were that close, uh, half in my fingers, close to closing up shop. And part of it was because of the mixed up reimbursement on brand name drugs, because long story short, we had $500 inhalers on our shelf and the insurance wouldn't pay for the exact same generic. That was a hundred dollars somewhere.

There was $400 that needed to stay in that system because of the way things are set up. And then here we are on the bottom of the list and it's like, that sucks. 

Robert Pearl, MD: So it would be very presumptuous of me to actually delve deeply into the pharmaceutical world cuz you and your listeners are so expert about it.

But talk about a broken culture where the intermediaries are taking money. No one knows who they are. Um, they're only passing it to consumers. If consumers are gonna come and buy the more expensive drug. I mean, I could go down a list. You could probably spend three days educating people about how broken that system is.

And that culture is because the culture accepts that as the way it should be. In fact, it's better when there's no data. From my perspective that 's actually true. My hope 

Mike Koelzer, Host: with medical is that we're still in the buying stage of a Dell computer. I mean, I'd hope that it gets so simplified and I'm not even.

Exaggerating here. You hope it's so simplified where you're almost on your iPhone. You're saying, yes, I, I need a new heart or this or that, you know, I know that's simplified, but they've done it with a Dell computer. I mean, they gotta be able to do it with someone tower. What's the difference? 

Robert Pearl, MD: If you wanted in the 20th century, you know, 20 years ago to carry all of medicine with you, you wanted to have all the information you'd need in a 50 pound backpack.

Right? So what did we value? In the 20th century as physicians, it's the ability to memorize arcane facts, right? Cause that was the piece you wanna get to medical school. You take a test called the MCAT, it's a series of arcane facts. And then you, when you wanna apply for residency, do what's called step one.

It's even a more set of bigger arcane facts. And if you could memorize, you know, every infectious agent and the drug that would be recommended and the exact dose that was there, you did really well. Now, what do we have in your pocket? A smartphone. You don't have to memorize any of this. You wanna know what the Dr, what the drug is and what the dose is.

You take a photo of [00:40:00] your pocket and you click on it. And yet, what do we still use for admission to medical school? This arcane approach, you know, as far as I'm concerned, every medical student should be required. To bring the cell phone, the iPhone to the exam, rehash the test starting with what's available there, cuz that's what you're gonna have in the exam room.

But, but that's not in the culture of medicine we hold onto these values left over, going back to the conversation before it's our intuition. It's our anecdotal experience. Why is that? Cuz the 20th century, that's all we had. But today we have so much more and we don't value it. I'm not saying we never use it.

We just don't value it to elevate it, to maximize it. And the consequences of medicine are way too expensive. And the quality and the service and the convenience are inadequate compared to what is possible. In fact, this whole process begins. I don't know if they have it in the pharmacy world as well, but it's called the white coat ceremony.

You show up for medical school on the first day you come with your parents. You're called one by one to walk onto the stage. And there a faculty member takes the white coat and drapes it over your shoulders with one exception. If your parents are one or the other, or both are physicians, they can put the white coat on you.

Now I want you to think about that. You know, if your parents are physicians, are they less proud of you than the family of two immigrant parents who both work two jobs so they could get to medical school or the one who, maybe who, whose parents were laborers in the farms working 12 and 14 hours? Why should these parents who are doctors get this privilege when no one else does?

And the answer is this ceremony has nothing to do with the pride of the parents. These are the parents saying to the academic faculty. You can instill your culture in my child. I give you that privilege today. Because the ritual is the passing on of the coat, just like in the middle ages. In the medieval times, the king would take his daughter and marry her off to a prince in another land with the permission that she would now adopt the Prince's culture rather than her own.

Even though we never talk about culture and I'm not aware of any of the books in medicine that write about it, besides uncaring, it's clearly built into our institutions, our experiences, and what we spoke about before this absurdity of spending so much time and value on memorizing arcane facts. It should come as no surprise that burnout in medicine starts in the first year of medical school as doctors.

Why are you burned out? They'll tell you it's three things. We're not paid enough. So we have to see too many patients. We have to go through authorization processes because of, uh, prior authorization, bureaucratic tasks. And because we have to use this computer system that comes between us and the patient, but the first year medical students have none of those things.

And yet they equally get burned out 

Mike Koelzer, Host: that ceremony. You're saying that the parents who are up there as the physicians, that's like symbolic of saying, we want. Our culture transferred to the students and carry 

Robert Pearl, MD: on it's that they can be trusted to pass on the right culture to the students cuz they're doctors they've already been indoctrinated and it's these other parents.

They can't be trusted. I gotcha. Because who knows what they're gonna teach, maybe they're gonna teach, you know, that prevention's important or whatever it's going to be. That violates all of these pieces that we're about to instill in medical school and in residency. But the parents who are doctors, they already know pressure.

Emotions, deny that you're hurting. Don't ever admit you need psychological help. All the things we talked about earlier, they know those things. When their child calls them up and says, I'm having problems. They say buck up, they don't say, go see a psychiatrist or a psychologist. Whoever's there. And when the problems happened because the psychology is not addressed.

That's tragic. 

Mike Koelzer, Host: I was speaking to a physician on one of my earlier [00:45:00] shows and they were saying that you could tell what year a physician graduated by the medical choices they were making or the drugs they were using. Mm-hmm . So, in other words, if you took a doctor and said, how did they treat such and such?

Well, they used drug X. Oh, I bet they graduated in, you know, 1980. The point is, I can't imagine. Someone who comes from a world of now I can do my four star Amazon computer purchase. I can't imagine these doctors having to keep up. I mean, you think about the exponential knowledge that's happening in medicine.

And to think that someone's mind is trying to bring in new information, combine it with the past and all that kind of stuff. It's like, yes. Talk about stress and, and also talk about how we could not use technology for this. 

Robert Pearl, MD: Now I'll go back to what I said earlier. Doctors work so hard and I'll use the phrase too hard and you're making a key point.

They don't have time to stay up with every change that's happening, particularly in primary care where you have to be, you have to know the heart, the lung, the brain, the intestines, and so on down the line. So they use what they know works. But the opportunity exists. You just made a really good point, you know, to be, and we have technology, don't get me wrong.

And we have, we have tools to be able to, to do it, but to build that into the learning process of how you care for a patient so that the technology and your skill go together, rather than it being available. If you need it to look it up, no, you start in a different kind of way. Now this, this is the medicine that just needs to be, but it's not today.

And that's why I keep pushing for these I'll call the systems of care. Some of the pharmaceutical problems start to disappear when you have a fully integrated care delivery system where the pharmacy and the care delivery and the insurance process all come together to say, how do we provide the drug that is going to be.

The right one for the patient and make sure that it becomes affordable to the individual cuz the best drug that isn't taken, isn't gonna be very effective. I'm curious, 

Mike Koelzer, Host: and this is getting into the nitty grit, but it's kind of fun as an outsider to talk about this. But you had mentioned in an earlier interview, how some of the urologists they're no longer recommending certain tests being done.

And those tests kind of gave the urologists kind of a higher feeling of status. And as soon as that was gone, they felt like they lowered their status and that was a psychological downfall for them. And that gave them more stress because they were in a lower stratosphere of respect compared to other doctors and so on.

Are there other psychological factors? Things going on like that. Are there anxiety and fears and embarrassment and stature? What are some of those things that doctors come across? 

Robert Pearl, MD: The issue you're talking about is burnout. If you ask physicians about it, they'll give you three reasons, not enough money, which means too many patients, too many bureaucratic tasks around authorization.

And the computer system, those consistently are the top three and they're all problems. But in the book I dig deeper and I say, okay, let's, let's compare some specialties. So you're referring to urology. Prior to the pandemic, the most burned out specialty of all urologists made almost half a million dollars a year.

So if it's money that can't be it. They don't see any more patients than other surgical specialties. They have the same authorization process. Let's say as orthopedists who have 25 lower points in burnout rates, they have the same computer systems as ophthalmologists who have 20 points lower. Um, they make twice as much as pediatricians who have 10 point lower burnout.

So how do you explain urology being the most burned out specialty? And this is the point you were making that 2010, they were actually relatively low. And then the national preventive services task force said we don't need to do PSA on all met over 50. So the number of cases of people with prostate cancer started to.

and then we said, you know, watchful waiting is often pretty good. And by the way, the surgery leaves you impotent and incontinence. So maybe that's not such a good thing to have done. so even fewer got done and then centers of excellence came along. So, so many urologists stopped doing this operation that as you said, was the star wars.

It's what gave me the esteem. [00:50:00] It was a shiny bright object, and now it goes away. And when that happens, you're absolutely right. It's the esteem, the respect that disappears. And we don't think about it that way. But the Mormon has shown that it is as important as money in terms of your sense of fulfillment, your satisfaction, your energy every day, that's there.

So urology is one example specific to the machine, but primary care's another example, you know, what's the problem in primary care. The problem in primary care is we've made so much progress that so many of the things that used to require intuition and experience, we now have algorithmic approaches and C checklists and other things that can be followed.

And what's the problem when it can be followed. Almost anyone can do it. And now you're seeing nurse practitioners and you're seeing PAs taking over a lot of the things, urgent care centers started to do a lot of the pieces and the role of the primary care physician who used to be the most sought after specialists.

You know, if you were really smart, you became a primary care, an internal medicine physician. And if you were not quite as smart, maybe you became an orthopedic surgeon. That's all flipped around now where the people, at least who score the highest on the examinations are the ones who want to become the orthopedic surgeons or the, uh, cardiac surgeons rather than.

Primary care. We highly value deep knowledge in a very narrow piece, but who's gonna coordinate everything. This is a role that primary care can do so well, but you can't expect primary care to have the full, deepest knowledge about every organ and every disease that exists. So they become more, I'll say generalists and what they should be from my viewpoint are quarterbacks of the team, coordinating everything.

It should have the highest value, the same way a quarterback does on a football team, but that's not where it is in the hierarchy of medicine. And therefore we're seeing primary care being one of the most burned out specialties. In addition to. The bureaucratic test in addition to the computers. And in addition to the number of patients that need to get seen every day, 

Mike Koelzer, Host: it seems to me that the primary care guy still is kind of the quarterback because don't a lot of the referrals and stuff have to go through the primary care or is that old thinking on my part, 

Robert Pearl, MD: they don't have to go through there.

They sometimes do. But once the referral happens, they're often out of the picture. Mm. I see. You know, and I use as an example, you know, my mom was in the hospital. She had, uh, chronic leukemia. Yeah. Kind of acute flare up. Then she ended up, uh, having a, uh, pneumonia and a stroke. She, a neurologist, a pulmonologist, a hematologist, and five people.

Yeah. You know, they all came by every day. They wrote notes. There was no connection. There was no one who was quarterbacking that team, the primary care physician never even came to the hospital anymore. They 

Mike Koelzer, Host: made the referral, but it's kinda like calling in the play, but they're not the quarterback of the play still.

They're out of 

Robert Pearl, MD: there. Exactly. They may be the guy in the booth calling in the play, but once it goes on, the field has now become someone else. That's a role that, well, maybe there's no quarterback. Maybe that's a better analogy. And what we need is to have someone there and I believe that that's missing.

And as a consequence, patients fall through the cracks. People can't figure out exactly where I go, who organizes it. And this is a major need today, but patient convenience, patient time in the culture of medicine, isn't that valued. And so when you look back from it, we expect the patient to do all of that coordination navigation.

And we undervalue the individual who we've already trained to be an expert in so many different areas. It's just where medicine is today. 

Mike Koelzer, Host: So Robert pharmacist, maybe they can help. Is there anything that the general public can do or is this all going to be internal slash political slash big business, making these changes?

Where does this change happen? 

Robert Pearl, MD: Well, I think there's a lot of things that pharmacists could do. So let's be, let's, let's start there because of the science. So the classic example is someone who has a need to have heparin, a drug to thin the blood. And I'm sure some of the people listening in are not pharmacists.

The pharmacists are gonna know everything I'm saying, but I'll explain a little bit more detail, wherever else is listening in. 

Mike Koelzer, Host: Explain it to me. Cause I probably 

Robert Pearl, MD: don't have it [00:55:00] either. okay. So I don't mean, sorry, not having warfarin, so a blood thinner, how your dose is based upon your blood clotting results.

And the data says that pharmacists actually do a better job than physicians. It's very formulaic. Pharmacists are experts on drugs and their complications. They understand the dosage extremely well. They're gonna make sure that they get it right. They're not gonna cut corners. And the results indicate that it's far better.

Now when you get to three and four and five diseases, all interacting, that's a very complex patient. But when you're looking at patients, particularly in the early stages, let's say for diabetes, you can do the same thing with all the, with wearables and data and information. And rather than adjusting the medication every three months, you can adjust it more frequently for hypertension.

You can actually take a lot of the tasks that are given to primary care and actually have pharmacists doing it. If they have the full data information and that's the second problem, cuz you need to have complete information. If not, you can make a major mistake, but I think there is a significant role.

And so far in the culture of medicine, doctors have resisted this type of I'll call teamwork because it is threatening from a culture perspective to the esteem and the. But it shouldn't be, we, it just requires a new definition of what's most valuable. And when you start to say preventing disease, avoiding having an amputated limb going blind from diabetes, kidney failure, hypertension, the most common cause of strokes, you go down the list of diseases and you start to say, why wouldn't it be a lot more valuable to prevent them in the first place than to try to treat them.

Now, all of a sudden you open your arms wide and you say to the pharmacist, come on in, this is a team effort. And together we can do far better than either of us alone. That mentality that psychology does exist in a few. Fully integrated medical groups, but not in the majority of American medicine. It's just not valued high enough and wiser not valued because it starts to lower the esteem accorded to physicians.

And again, I want to keep going back to the point. I say this, not as a criticism. This is how every culture works. It's just that when you're talking about the culture of medicine, it's not just about the providers of the care. It's also about the patients who are the recipients of that same medical 

Mike Koelzer, Host: treatment.

You mentioned capitation and so on. And I guess money talks, maybe capitation helps to open people up to say, Hey, if I can get some help with this, I'll take a little lower esteem. If I'm kind of joking, you know, cause we talked about esteem as important as money sometimes, but if I'm gonna lose, maybe both, I might as well at least have my pocketbook still doing okay.

Robert Pearl, MD: You can think about it. A general contractor and all the subcontractors. And, you know, the subcontractors have a lot more knowledge than the general contractor about each of those areas and doesn't feel as though he or she is losing respect because they've asked the electricians to take care of the wiring and the plumbing to take care of the water.

Right. But in medicine, we still have some of that where the, um, uh, the general contractor to me should be the primary care physician has lost both that role and the respect that would exist elsewhere. 

Mike Koelzer, Host: I wish the respect, if we said, okay, guys, the respect is gonna come from really healing people and really making.

The US go from, you know, 14th and the list up to number one, let's get all the other stuff. Let's just make that as the Amazon choice, let the pharmacist help with all that kind of stuff. Let's get our respect from being way up here on the list and saving people in that and not from some cultural respect.

Robert Pearl, MD: So Mike, you know, it's interesting. I did a lot of trips to other countries. I'd fix kids with cleft lip and cleft pate, and I've operated in South America and Central America Samoa a bunch of places around the world. And when I was the CEO in Kaiser Permanente, um, I sent doctors by which I even sent.

They volunteered and I facilitated that. Being able to provide the care. It's remarkable to me that you'd go to a country for 12 or 14 days. You wouldn't get paid. It's volunteer work. You're working, uh, 14, 16 hours a day. There's no air conditioning. It's incredibly hot. You eat rice and [01:00:00] beans all day. You have intestinal problems.

Every doctor came back so fulfilled. So full of energy, right? You know, I think of a physician who volunteered to go to Liberia to take care of people with Ebola. He had to have an IV in his arm because the suit that he had to wear was so hot. It was 120 degrees. He would've passed out from dehydration.

I've never seen a human being so happy. Because he was making a difference and, and we've lost that. Mike, we've lost that in medicine it's been done to us, every physician listening in, yes, the insurance companies have done it. The hospital administrators have done it. The drug companies have done it. We've also allowed it to happen or done it to ourselves.

However you wanna view it. I don't know if the ratio is, you know, 60, 40, or 40, 60, but I think the time has really come for us to acknowledge the things that we contribute to and the ways that our culture stops us from making changes. And in doing that, we can, as you say, make American medicine become the best in the world.

Once again, 

Mike Koelzer, Host: Robert, a high schooler comes to you right now and says I'm gonna be a physician. What are you 

telling them? 

Robert Pearl, MD: You're choosing the greatest career that you possibly can. The privilege to save a human life, to be brought into the intimacy of an individual's existence and problems and wishes and hopes is a remarkable, remarkable gift.

Please do it, but don't forget how you feel today. A decade from now never forget why you chose to become a physician, the mission driven spirit, the purpose that led you to do that. And every night for the rest of your life, before you go to sleep while you're brushing your teeth, look in the mirror and ask yourself one question.

Did I treat every patient today? The way I'd want for me and my loved ones. And if the answer is yes, have a good night's sleep. And if not, make sure that tomorrow you do better than you did today. Hmm. 

Mike Koelzer, Host: Wise words, Robert, what a pleasure talking 

Robert Pearl, MD: to you. That was fun. Thanks, Mike. Yeah, that was fun. We were all over the place, but I, yeah.

You know, I know that a lot of your listeners are pharmacists and, uh, I wanted to make sure I brought a little bit in, but I didn't want any to think that I thought I knew. 5% of what they knew. I can just scratch the surface and hopefully I gave them a view inside the medical profession and they can take the pharmacy world and, uh, extrapolate into their own experience.

Mike Koelzer, Host: That's where we share something in common, cuz I know about 5% of what my listeners know too. So you and I, a good company, there we go. There we 

Robert Pearl, MD: go. And if any of them want more information, they go to my website, which is Robert Pearl md.com. And if they want to obtain the books, they say all profits go to the doctor's upbringing, but they can get information on the nine different sellers of the book.

Doesn't actually go through me and if they do so I really would like to hear their thoughts. This is a work in progress, as I've said several times, this is our opportunity to once again, make American medicine the best I can't do it. You can't do it, but together we all can be successful. So thank you so much for hosting the show.

Mike Koelzer, Host: All right, Robert, take care. Great talking to you.