In this latest episode of Fixing Healthcare, hosts Dr. Robert Pearl and Jeremy Corr welcome Kimberly Powell, vice president of healthcare at NVIDIA, to explore how the company’s technologies are reshaping healthcare.

Powell provides a fascinating lens through which to view healthcare’s future, especially as AI begins to play a more prominent role in patient care, diagnostics and clinical decision-making. The interview, part of Season 10’s deep dive into transformative healthcare technologies, kicks off with a question from Pearl: “What are the three technologies that will have the greatest impact on healthcare over the next five to 10 years?”

Here’s what Powell had to say:

Powell explains how NVIDIA’s GPUs (graphics processing units) have revolutionized data processing, enabling breakthroughs in medical imaging, molecular simulations and AI-driven diagnostics. She highlights how GPUs’ parallel processing power surpasses traditional CPUs, unlocking new possibilities in real-time medical applications.

The conversation turns to the explosive growth of generative AI, powered by NVIDIA’s latest technologies. Powell details GenAI’s capacity to handle massive datasets, train neural networks and power applications like ChatGPT and digital health agents. These tools, she notes, will transform everything from clinical documentation to patient monitoring, and in turn will help to reduce clinician burnout, improve patient engagement and drive personalized treatments.

Powell introduces the concept of “physical AI,” where robots equipped with advanced AI capabilities will redefine patient care. Powell highlights how this technology could automate surgical procedures, creating smarter hospital systems and deploying robots that enhance patient care and safety.  She paints a picture of a future where AI technology not only optimizes operations but also enhances safety and outcomes.The company hopes to leverage its technologies—from real-time patient monitoring systems and digital avatars for mental health to clinical trial optimization tools—to solve healthcare’s thorniest problems.

A recurring theme in the episode is Powell’s emphasis on the “ecosystem of innovation” NVIDIA has built, fostering partnerships with startups and healthcare institutions worldwide. The company is planning to leverage its technologies—from real-time patient monitoring systems and digital avatars for mental health to clinical trial optimization tools—to solve healthcare’s thorniest problems.

Pearl and Powell also reflect on the implications of generative AI in healthcare, as explored in Pearl’s recent Forbes article, “Nvidia’s AI Bot Outperforms Nurses, Study Finds. Here’s What It Means” and his 2024 book “ChatGPT, MD.” Powell speaks to how NVIDIA’s innovations will complement, rather than replace, human expertise.

Pearl concludes the interview by predicting that generative AI will save hundreds of thousands of lives annually, make healthcare more affordable and alleviate the burnout crisis plaguing clinicians. He sees the triad of a dedicated clinician, an empowered patient and generative AI as the key to unlocking medicine’s full potential, delivering outcomes that far exceed what any one component could achieve alone.

This episode is a must-listen for anyone curious about how technology is reshaping medicine.

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #157: NVIDIA expects AI, robots to cure healthcare’s biggest problems appeared first on Fixing Healthcare.

In this week’s Fixing Healthcare podcast, co-hosts Dr. Robert Pearl and Jeremy Corr revisit one of the show’s most memorable interviews: Malcolm Gladwell’s first appearance in 2022.

Known for his sharp insights and masterful storytelling, Gladwell joined the podcast during a season focused on “breaking the rules of healthcare,” offering his perspective on what it takes to drive transformative change in medicine.

Note: Listeners are encouraged to check out Gladwell’s fabulous new book, Revenge of the Tipping Point, a re-evaluation of his groundbreaking work on social epidemics, now reframed for the modern world. It’s an excellent holiday gift for friends and family, alongside Dr. Pearl’s ChatGPT, MD, which Gladwell personally endorsed as a must-read for anyone curious about AI’s role in the future of healthcare.

This flashback episode highlights Gladwell’s exploration of rule breakers in healthcare, emphasizing the delicate balance between innovation and recklessness. Gladwell examines the personalities and motivations of iconoclasts, using vivid examples like Dr. Emil Freireich, the father of combination chemotherapy, and Elizabeth Holmes, the fallen biotech entrepreneur.

Dr. Pearl introduces this flashback by reaffirming the timeliness of Gladwell’s insights, noting that the qualities needed to break medicine’s entrenched rules are as relevant today as they were when the episode first aired. Gladwell’s stories and analysis offer inspiration and a framework for identifying the kinds of leaders who can disrupt American medicine for the better.

HELPFUL LINKS

• Revenge of the Tipping Point: Overstories, Superspreaders, and the Rise of Social Engineering by Malcolm Gladwell (available now)
• Malcolm Gladwell’s Revisionist History (podcast link)
• ChatGPT, MD: How AI-Empowered Patients & Doctors Can Take Back Control of American Medicine (available now)

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #156: Fixing Healthcare flashback with Malcolm Gladwell appeared first on Fixing Healthcare.

In the second episode of Fixing Healthcare’s 10th season, cohosts Dr. Robert Pearl and Jeremy Corr welcome back Dr. David Feinberg, chairman of Oracle Health, for a discussion centered on the future of technology in medicine.

Given the season’s focus on transformative technologies in medicine, Dr. Feinberg brings a wealth of experience as the former CEO of Cerner, VP of Google Health, and CEO of Geisinger Health.

As Dr. Pearl has highlighted throughout the season, technology—including artificial intelligence—is becoming a pivotal force in healthcare. His own book on the subject, ChatGPT, MD: How AI-Empowered Patients & Doctors Can Take Back Control of American Medicine, explores this theme in great detail, and it debuted on the list of Amazon’s Top New Releases. All profits from Pearl’s book benefit Doctors Without Borders.

During the interview, Dr. Feinberg shares his thoughts on the three most important technological developments in healthcare over the next five to 10 years:

1. Technology stepping aside: Dr. Feinberg says one of the most critical advances in healthcare will involve technology getting “out of the way” of the doctor-patient relationship. He notes that while innovations have advanced healthcare, they often interfere with the time and connection between clinicians and their patients. Feinberg envisions a future where technology is present but not disruptive, allowing physicians to focus on their patients rather than on navigating electronic systems.

2. AI’s role in anticipatory medicine: Like many healthcare leaders, Feinberg identifies artificial intelligence as a major player in the future of healthcare. However, he offers a unique perspective by discussing AI’s potential beyond current applications like diagnostics and documentation. He predicts that AI will develop anticipatory abilities, allowing clinicians to foresee medical issues and prevent serious health problems. This could allow doctors to say to patients, “If we don’t get this [health issues] in order, the computer is telling us you won’t make it to your grandchild’s college graduation,” helping patients take critical action before it’s too late.

3. The power of the cloud: Here, Feinberg highlights the immense potential of cloud technology. He explains how the cloud can significantly enhance healthcare, particularly in terms of cybersecurity and data management. By leveraging cloud systems, hospitals can not only protect sensitive patient data but also streamline operations, enabling more effective analysis and use of healthcare information across platforms.

Tune in for the full interview and join the conversation on social media.

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #149: Tech needs to get out of the way of healthcare, says Feinberg appeared first on Fixing Healthcare.

This episode kicks off season eight of the Fixing Healthcare podcast.

The guest: Dr. David Feinberg, currently chairman of Oracle Healthcare, former CEO of Cerner (acquired by Oracle in 2022), and previous head of both Google Health and Geisinger. This is Dr. Feinberg’s third appearance on the show. He joined hosts Dr. Robert Pearl and Jeremy Corr in season one (episode 3) and season six (episode 41).

The focus of Season 8: How better, bolder leadership can fix American healthcare. 

As Dr. Pearl explains at the top of the podcast: “The medical and academic leaders featured on Season 8 of Fixing Healthcare will discuss the difference that strong leadership can make, both for patients and clinicians. I know their insights will be educational and inspirational. Hopefully, 2023 will be the year that our country takes the strides needed to make American healthcare, once again, the best in the world.”

In the episode, Dr. Feinberg and the hosts discuss:

• Getting patients to prioritize healthy choices and lifestyle changes
• Advice for future physician leaders
• What Google knows about maximizing public health
• Why tech has a trust problem among patients and doctors
• The benefits of teams and teamwork
• The government’s role in helping people make healthy choices
• Why good communication improves medical outcomes
• How leaders can rebuild medical care around the patient, not the clinician
• Whether it’s possible to achieve better quality, cost and access in healthcare—all at once?
• What is “human capital management” in medicine?
• Where healthcare leadership can be most effective (be it academic medical centers, community health systems or elsewhere) and the downsides of each

Helpful links:

David Feinberg joins Fixing Healthcare season 1 (episode 3)

David Feinberg joins Fixing Healthcare season 6 (episode 41)

A retrospective on Cerner’s transition to Oracle

The man behind Larry Ellison’s health care gamble

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Dr. Robert Pearl is the author of a new book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.”

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #78: How leadership can fix healthcare, with Dr. David Feinberg appeared first on Fixing Healthcare.

This week, Fixing Healthcare hosts Jeremy Corr and Dr. Robert Pearl conclude their holiday tribute to episodes past with this 2018 interview of Dr. Don Berwick.

Don is the former president and CEO of the Institute for Healthcare Improvement (IHI) and led the organization’s 100,000 Lives Campaign. He’s the former administrator of the Centers for Medicare & Medicaid Services (CMS) and has served on the faculty for Harvard Medical School and Harvard School of Public Health.

This is the third and final Fixing Healthcare flashback episode—all of which have featured ideas from season one to fix American healthcare from the nation’s top leaders.

The purpose? To quote Dr. Pearl: “My hope in replaying these ideas is to help listeners once again realize how much could be done to transform American healthcare and improve people’s lives. And simultaneously, help them recognize how far we are from delivering the excellence in healthcare Americans want, need and deserve.”

Helpful links:

Season 1 explainer: ‘Welcome to the toughest interview in healthcare’

Episode 5 recap: ‘Don Berwick brings a global perspective to fixing US healthcare’

The full transcript of this episode with Don Berwick

Don Berwick: Profiles in leadership

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #77: Fixing Healthcare flashback with Don Berwick appeared first on Fixing Healthcare.

This holiday season, Fixing Healthcare hosts Jeremy Corr and Dr. Robert Pearl are mixing things up with a look back in time—way back, in fact, to the season-one finale with healthcare futurist Ian Morrison.

During this 2019 interview, Morrison earned the distinction of becoming the first (and still the only) guest to propose “Medicare Advantage for All” as a solution for fixing healthcare.

He explained: “Medicare Advantage for All reconciles different (American) values with regard to competition and the role of government, but mandates that everybody is in the system and covered.”

So, is “Medicare Advantage for All” a possible fix for the future of American healthcare? Did any of Morrison’s other healthcare predictions prove true? Tune in to find out.

Helpful links:

Season 1 explainer: ‘Welcome to the toughest interview in healthcare’

Episode 1 recap: ‘Ian Morrison says every healthcare system sucks in its own unique way’

The full transcript of this episode with Ian Morrison

Ian Morrison’s website

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #76: Fixing Healthcare flashback with Ian Morrison appeared first on Fixing Healthcare.

In this episode of Coronavirus: The Truth, Jeremy Corr and Dr. Robert Pearl discuss the long list of viral enemies attacking Americans this winter. Chief among them: Covid-19, RSV and seasonal influenza, the latter of which has tallied 8.7 million cases and 78,000 hospitalizations so far (40 times higher than at this point last year).

How seriously should American take these viral threats as we approach the holiday gathering season? You’ll find this topic and all the other [time stamped] questions from today’s show  here:

[00:52] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?

[02:45] Listener question: What’s the data on the new bivalent vaccine vs. the old one?

[07:48] How might researchers best communicate discrepancies in scientific data to patients? What should organizations like the CDC and WHO do?

[08:47] What’s new regarding the ‘tripledemic’ since the last episode?

[11:03] What’s happening with the flu?

[13:28] Why are Chinese citizens protesting “Zero-Covid” restrictions?

[16:28] What caused the near-global breakdown in public policy during Covid-19?

[18:53] Who are the people comprising the 300-350 deaths in the United States each day from Covid-19?

[22:50]: Kids and Covid-19: what’s new?

[25:03] What’s new in healthcare beyond Covid-19?

[26:44] How can patients help prevent the scourge of chronic disease in the United States?

[28:19] What has happened to cancer screening since the start of the pandemic?

This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #68: The worst flu season in over a decade? appeared first on Fixing Healthcare.

This Fixing Healthcare podcast series “Diving Deep” probes some of healthcare’s most complex topics and deep-seated problems.

On today’s episode, hosts Dr. Robert Pearl and Jeremy Corr discuss two imperatives for healthcare leadership in the 21st century: changing the way docs use technology and changing the way we pay for medical care.

For more information on healthcare leadership, check out Dr. Pearl’s latest columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a discussion guide:

• What does the metaphor of the iron triangle represent in medicine?
• Why is U.S. healthcare lacking effective leadership?
• What is the “anatomy of healthcare leadership”?
• How might a leader begin to change healthcare, locally?
• What would leaders most like to change about the care patients receive today?
• How do we make the ideal real in healthcare today?
• What are some technologies that could transform medical care?
• How could technologies change care for patients with chronic disease?
• Once clinicians agree with the logic of new tech, how can leaders appeal to them on an emotional level?
• How can real patient stories help persuade docs to embrace change?
• In addition to the brain and heart, what is the role of the spine for leaders?
• How did cohost Dr. Pearl use his spine to push technology forward at Kaiser?
• What are the biggest problems a leader might experience when implementing new technological solutions?

• Do Americans get what they pay for from healthcare today?
• What are the biggest cost barriers to reforming healthcare?
• What’s the problem with fee-for-service?
• What is the alternative to fee for service?
• How does “capitation” change the incentives for physicians?
• Doesn’t capitation lead to delayed and denied care?
• Why aren’t doctors jumping at pay-for-value models?
• How do leaders use their brain, heart and spine differently to reform healthcare payments?
• Can leaders make a case for capitation on an emotional level?
• Why do leaders need a strong spine to advance capitation?
• What else is needed to move away from fee-for-service as the method of reimbursement?

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #75: Diving deep into healthcare technology and capitation   appeared first on Fixing Healthcare.

As a college freshman, Fixing Healthcare cohost Dr. Robert Pearl decided that rather than becoming a university professor as he had planned, he’d go into a field without politics: medicine. He laughs about how naïve he was as a 17-year-old.

“Healthcare is about life and death,” said Pearl, recalling his decision, “How could there be politics entwined inside that esteemed world?” Of course, Pearl soon learned that politics and medicine are a tangled mess.

In this episode of Unfiltered, Pearl and his cohost Jeremy Corr join ZDoggMD to look at the relationship between medicine and politics and if there’s any opportunity for logic to prevail.

To find out, press play or keep reading.

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

Jeremy Corr:

Hello, and welcome to Unfiltered, our newest program in our weekly healthcare podcast series. Joining us each month is Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice, then I’ll pose a question to the two of them based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Hey, Zubin, how was your Thanksgiving?

Zubin Damania:

It was thankful. I really enjoyed it. My wife was on call, which meant we didn’t have to go through the full production of the meal. We went to a half meal, which was absolutely great. I had 70% less bloat and 100% more gratitude. How about you?

Robert Pearl:

I had a great time. I was over at my sisters and had a bunch of folks there. Did you do anything special to communicate your gratitude to others?

Zubin Damania:

I texted a lot of people that I had been a little out of touch with, and just to convey how important they are in my whole life and journey.

Robert Pearl:

Excellent. That sounds great. So I don’t know if I ever told you that I became a doctor to avoid politics.

Zubin Damania:

I didn’t know that.

Robert Pearl:

Yeah. So I was in college. I was a philosophy major, and my hero, who was a philosophy professor, quite an excellent one, he went on to become the chairman at Reed College, didn’t get tenure because of his political views, and I decided then that I wanted to do something that would have no politics. I mean, healthcare is about life and death. How could there be politics entwined inside that esteemed world? And so that’s truly why at the age of 17 I decided that I’d become a doctor, and I learned stuff later on. Any thoughts on that observation, and what we can do to minimize the politics in medicine?

Zubin Damania:

Well, you had me at philosophy major. I don’t remember you… You must have told me that, but that’s impressive. If I could go back in time and do it again, I would do philosophy instead of music and molecular biology, although that’s kind of philosophy in a way. Yeah, politics and medicine have been to some degree dance partners for a long time, but I think right now it actually just reflects how politicized everything is, and how everything is so kind of divided. Although, I’ll say this, Robbie, I’m sensing something in the air, and I might have said this at our last conversation, but I really think something is shifting. I feel like people are starting to wake up to the fact that we are really divided over nothing substantial in the sense that we’re all trying to find truth and goodness, and we just have a slightly different spin on it, and medicine maybe will wake up, but as usual, we’re about a decade or two behind the rest of the culture.

Robert Pearl:

Actually, I think that you’re correct, and I think we saw that in the most recent midterms that there was a lot more people I’ll say in the middle rather than the 20%, at both extremes, who were yelling the loudest and typing with all capitals and explanation points, but there’s a lot of people in the middle, and they want to know the truth. And I think in many ways, I’m not talking about the specifics of the outcome, but the election process itself, and, of course, we didn’t even have any attempt except in Nevada to just get rid of the entire voting and somehow have a different method of selecting candidates based upon maybe some sorcery or something else that could go into its place.

Zubin Damania:

Yeah.

Robert Pearl:

But one of the things… Sorry, go on.

Zubin Damania:

No, no, no. I was just going to say in Nevada we have a lot of interesting things like legalized prostitution among other things, so we are a special state.

Robert Pearl:

Oh, excellent. That’s right. You were there. Exactly. Legalized gambling, prostitution, so on. Yeah. One of the things that strikes me as I think about the politics is that you would think that the health status would drive the politics, by which I mean if a lot of people didn’t have coverage, then they would be attracted to a party that would be likely to give them the coverage, and we think about people voting their interests. If there was a lot of opioid addiction in a particular geography, you would think that that would be a very high concern, and yet we see almost the opposite. Tell me where you live, and I’ll tell you your view on a problem. Whether for you it’s a particular medical challenge or not doesn’t seem to be the driver as opposed to where you happen to own a home and in many cases grow up. This seems really strange to me.

Zubin Damania:

Yeah, it does, and again, all things seem strange if you look at humans as rational actors that work in their best interests all the time. And unfortunately I think we’re emotional, intuitive creatures that are the product of our conditioning and our moral sort of taste buds. And I think if your moral taste buds are concerned about say liberty versus oppression or government controlling things, even though you’re desperate for care, and you need it, and it would save your life or your family’s life, I think through that moral lens you’ll see any sort of government “intrusion” into healthcare is something that’s adverse, and you’ll fight tooth and nail.

There’s also a tribal component on all sides of this, like you said, where you grow up, and I think where you grow up is to some degree it conditions how you are, but to another degree you’re kind of attracted to those places that are an expression of your own sort of moral matrix. And so I think it’s a variety of those factors, and so people do not necessarily vote, or act, or think in their best interests always, if you look at their best interests from that standpoint. But if you look at their best interests as a morality play, they almost always do it in that way it seems. Yeah, that’s just my sense of this.

Robert Pearl:

I always love talking to you, because I think about things that I hadn’t contemplated before. About a decade ago, I did some research with a neurologist named George, and George and I looked at brain scans, and we looked at what happens when people get put into situations of great threat or great opportunity, and what we found, George York and myself, was that there’s actually a shift in our brain in terms of perception. In the last show you mentioned the amygdala, the source of great fear, and what you see is that the amygdala first gets stimulated, and then as you mentioned actually in the last show, how the occipital lobes change, and we see things differently, and by see it’s not just a vision. It’s all of our senses.

It’s our perception of the world, and maybe some of these pieces are that there are fears or maybe hopes that people have that actually change their perception. And when you move someplace else where there’s different fears, and different hopes, different views of the world because of circumstances, then you change that perception, and maybe that accounts for some of this great shift in how we relate to each other or fail to do so, and maybe some of it is coming together to recognize that we may share in more common fears and more common hopes than we otherwise might realize.

Zubin Damania:

This is a really interesting insight actually, Robbie, because it made me think of something. You were saying sometimes I’ll prompt you. This prompted me, because there is this idea that part of the reason where… There are many reasons why we’re so divided and politicized nowadays, but one of them might be that your local scenario kind of conditions you and vice versa, but the global village that we have with social media is that now there’s a saying, “Good fences make good neighbors.” When not much about someone else they’re actually all right. The more about them sometimes it’s like, “Hmm, I’m not sure about this.”

And when you take disparate ideas from different geographies that are evolved differently to suit that geography, and you place them adjacent to each other, that’s when the all caps starts happening on Twitter, because somebody that you never would’ve really known that well, and you still don’t know them well, but you know them in a social media way, are hitting you with ideas that seem so antithetical to that moral palette that they do generate that fear. It’s that fear of loss of identity, the fear of loss of self, that this is who I am, right? I’m this liberal, or I’m this conservative, or I’m this libertarian, and suddenly you’re met with somebody who’s giving you totally different ideas, and it becomes instantly a kind of like, “Okay, fight or flight. I must defend this,” sort of identity.

And what may be happening is we’re getting so used to social media now that we might be starting to transcend that initial shock and start to see what you’re pointing out, which is, “Hey, actually we’re all in this game.” And actually when you start to point out how divided we are, people start to wake up and go, “Yeah, we are kind of getting played by this, the news cycle, and social media, and this kind of thing.” So it is really interesting.

Robert Pearl:

So let’s try to meld the politics and the health. One of the areas that I’m increasingly concerned about is the LBGTQ population, and how in this environment they’re going to be able to get good healthcare across the nation in all 50 states. Do you have any thoughts about, first of all, the hatred that’s seems to be often directed particularly at trans individuals, and how will they get their healthcare needs met from an optimal medical perspective?

Zubin Damania:

Yeah. And this is one of those things where… Who said this? It was recently the World Cup, and the Iranian media was questioning American soccer players, and they asked a black soccer player. They said, “What’s it like living in a country where you’re discriminated against?” And obviously this was all politicized because of the whole Iran-US thing. And so this journalist was really trying to provoke this guy to say, “Yeah, we live in a super racist country where people are discriminated against because we keep accusing them of discriminated against women, which they do.” And he said, “Yeah, it is interesting, but I’ll say this, in America, one of the things I’ve noticed is we’re constantly trying to get better. There’s always some feeling that there is a kind of progress, and that makes it much easier to live here and deal with it, and I want to be part of the change.”

And I think with trans, with LGBTQ+, and all of that, I think that’s also what we see. These issues were repressed previously. Now the repression is less, and so we’re seeing them come to the fore, and it’s louder in sort of the culture, and so it’s easy to feel that there’s no progress, but I think that even that the conversations are happening is progress, so it’s a lot of it is ignorance. A lot of it is just lack of knowledge, and reactionism, and that kind of thing, and I think it is going to continue to progress. I mean, just look at the bill now that that’s going through the Senate where they’re going to codify protections on gay marriage say. That would’ve been unheard of a decade ago, and so I’m actually optimistic, but you can’t stop working for it, right? You can’t stop being part of the progress.

Robert Pearl:

Again, another interesting thought that I hadn’t had before about how as soon as you stop pushing forward, you slide back, and that it’s not a question of pushing forward always to make progress. It’s pushing forward even to hold the progress that you have, and I can think of a lot of examples where as soon as people stop pushing, what we see is that everything slides back to where it came from even though I can’t find the rationality for why it started there.

Zubin Damania:

Yeah, I think it takes a collective effort, and you’ll always get resistance and even understanding the resistance is a good thing. If you can see through other people’s eyes and go, “Okay, what is it that… What is this? Is this fear of other? Is this just misunderstanding? Is this a kind of projection where there’s something about them that they feel isn’t as mainstream, and they don’t want… They’re projecting this onto others.” You wrote your book Uncaring about medical culture, and I think what I loved about that book is that you just shined a direct light on things like emotional repression, projection, denial, the things that we do in medicine that we’re conditioned to do, that are really fundamentally quite harmful to progress, and I think it’s true in broader society as well. We have an epidemic, a pandemic of emotional repression, and avoidance, and projection as a result.

Robert Pearl:

Well, for any listeners who might not have read the book, let me point out that a part of why I focused on denial is that denial is what makes the medical culture great. How else do you go into the streets during the plague and take care of people knowing that it’s a contagious disease, even though you have no idea what contagion means, because it hasn’t been yet discovered, or how do you go into ERs and take care of patients early in the pandemic when you don’t have protective gear? You have to deny the risk to yourself in order to put the patient first, but I also note that that tendency towards denial can spill over when there are things that we don’t necessarily want to see, and I thought of that this week. I don’t know if you noticed that the Merriam Webster word of the year is gaslighting. Did you know that?

Zubin Damania:

I didn’t know that, but it doesn’t surprise me.

Robert Pearl:

Yeah, and there’s actually a lot of studies that have come out that said that it’s very frequent, and actually it’s very frequent in the LGBTQ+ population that we talked about, when they go for care. It’s actually very frequent when women go for care. I think many of the groups that have felt as though there’s a certain level of discrimination, the truth is that in the doctor’s office it’s there as well. The complaints are not taken as seriously. Problems that otherwise might be investigated are assumed to be simply psychological, and, of course, in medicine we deny that psychological is as important as physical, and you go on, and on, and on. Your thoughts on what we can do about it?

Zubin Damania:

Yeah, I mean, again, this is our culture. You’re right. I mean, and the gaslighting is an interesting thing because I think a lot of it is unconscious, right? People are doing it not intentionally. It’s a kind of pattern of behavior. You try to make people feel like they’re not right in the head because you’re either projecting or denying something about the nature of their care, and I think it doesn’t happen at a conscious level. So until you bring it into the light of awareness, and you actually make it explicit in a way that doesn’t actually threaten the identity structures of the person you’re talking with. That’s the problem is a full frontal assault, and I think this is why in the culture right now, the full frontal assault of progress on people who are more say conservative, it leads to kind of a psychological reactance, and because, again, we’re going to defend our identity structures on all sides of it.

So there’s a way to do that I think that is much more compassionate and actually effective. So we have to focus on those strategies. Those kind of alt middle strategies that I talk about I think are more effective ways to bring progress that also is inclusive of people that feel they’ve also been left behind.

Robert Pearl:

The reason I like the word denial, although I’ll have to tell you that there’s some readers who didn’t like it, but I like the word because of the point you just made. It’s subconscious. We’re not aware of it. We act in ways without being conscious that this is what we’re doing. We don’t see it, and that makes me think about all the problems that if you read the literature, it’s so clear how important they are, social determinants of health, racial disparities. You know, 10% of Americans are still uninsured. It used to be 16% before the ACA, and I don’t hear a whole lot of conversation about that. Last night, I teach in the Stanford Graduate School of Business, and last night our guest speaker was a guy named Dr. Dr. Devi Shetty, who’s been the podcast, and whom I’ve spoken about before, and it was fascinating.

What he said is that he believes that India will be the first nation in which the healthcare you receive will not be dependent upon the amount of money that you have. In his mind, in a nation of 1.4 billion people. And the podcast he did with me a couple of months ago is just so inspirational. It’s great, and this reflected it. He worries about all 1.4 billion people and asks himself, “How do we provide care to the last of that 1.4 billion that’s as good as we provide to the best?” And in our country we tell ourselves we provide the same care to everyone, but when you look at the data, there’s not a shred of truth about that, and I don’t hear it being talked about in a broader context of people.

I think people look at it very much by what do I and my family get? What do the people that I’m most close with in my community get? And that’s about as far as we look, and we don’t see all the implications. It’s mainly about the system of healthcare, but I think it’s really about the values of the nation.

Zubin Damania:

Yeah, I think what you nailed particularly explicitly there is the values of the nation, and America really was kind of founded in this kind of oppositional way where there’s almost an unwritten social contract that listen, listen, listen, listen, we all hate rich people for being rich and having everything, but secretly we want to be that rich person, and one day we want to have those things, and we want that opportunity to do that, to live at the top of the hierarchy. And I think it’s an unconscious kind of contract that has existed in the strata of American psyche for a long time, and that’s why something as egalitarian as a universal coverage, or everyone being treated equally in healthcare is something in the American psyche that reacts to that, and to be honest, I mean, my parents are from India. It is a vastly hierarchical, horrifically hierarchical.

In fact, when I first visited, I was taken aback by the servant class there that was treated almost akin to slaves. I mean, and part of this is the sort of general caste system, but it’s just all accepted there. And coming from America, it was a shock. It was like, “Wait, wait, you can’t treat other humans like this.” So it’s good to see Devi Shetty actually trying to unwind that, because on some level there’s aspects of Indian culture that are so community focused, and we’re all in this together. And so those things coexist, and so it can be a little schizophrenic at times.

Robert Pearl:

Well, I think that’s very true what you said, because I’ve been there too, and the disparities are massive, but the idea of asking, of starting with the question, “How do we provide excellent care to all,” I think is a fascinating path. It’s the one that he’s on, and interestingly enough, much of his answer is technology. And he says that because in a poor country there’s not enough resources. If I have a sack of rice, and I give half of it to you because you’re hungry, I only have a half sack left. If I have a computer program that allows me to get great care, and I give you a copy, I still have my computer program. And so it’s a resource that you can give away. It’s like gratitude. I can give you all the gratitude in the world, and I haven’t depleted myself at all. In fact, I’ve actually augmented my satisfaction, my happiness, my fulfillment.

Zubin Damania:

I think that’s a beautiful way to put it, and it’s very similar to thinking about compassion as opposed to empathy. Empathy is feeling someone’s pain, affective empathy as your own. That does exhaust you, actually, but compassion, which is love and concern in the face of suffering and an unconditional kind of love, that actually fills you with kind of an elevation, and it’s inexhaustible. And so technology, absolutely, so there was ways to scale what we do in medicine that allow the human relationship at the center to kind of still flourish while scaling, and I think you’re absolutely right. You’re absolutely right. And actually, it’s got to be central to our answer, because we have resource limitation across the globe when it comes to high quality healthcare. So how do you scale it in that kind of way? I like that software analogy. It’s actually a very good one. One piece of software can serve infinite numbers of people.

Robert Pearl:

Absolutely. So let me ask you a slightly tangential question, but it still is this split in society that it’s been bothering me ever since I read the Pew Research study on it about two weeks ago, and I’ve wanted to ask you about it. So in this study, only 41% of people, and this was 12,000 individuals they surveyed, thought that scientific experts are better than others at making policy decisions about scientific issues, and that negative view is held by both Democrats and Republicans. We’ve looked at this question of scientific expertise throughout COVID 19, and we’ve certainly come to the conclusion that those with the scientific backgrounds aren’t necessarily the ones that we should be trusting, and I wonder your thoughts. You’ve been right in the middle of this scrum, if you want to think about it in that way, over this issue of the role of the expert as we look at whether you want to talk about COVID or just healthcare policy in general.

Zubin Damania:

Yeah, this is something that really, like you said, I’ve been kind of in the middle of it, and this is the thing. I have always kind of worked hard, early pre-pandemic especially to defend the role of expertise in healthcare, because it is invaluable. When you’re talking about recommending a type of surgery, having an interaction with a patient where it’s an interpretive dance of their hopes, dreams, and fears, and goals, and your knowledge. The your knowledge component is a very important part of the equation, right? Now, I think what’s happened here though is… And the fact that Democrats and Republicans are both saying this makes you think also of China. So here you have say let’s say a scientific technocracy, autocracy ruling class that says, “You know what? We can actually literally prevent deaths by locking people in their homes, and the number of deaths that result from that will be less than the number of deaths that happen from COVID.”

And to some degree so far they’ve proven themselves correct, because they have the lowest per capita, if you believe their numbers, per capita death rate from COVID, but they’ve had to do these draconian things about policy-wise, and just now people are standing up and saying, “You know what? Enough is enough.” And I think what humans here are saying in America, are saying is, “Yeah, it’s…” or they’re not saying this explicitly, but I think this is the motivation is, “Expertise is great and wonderful, but when it comes to policy, we actually want to determine what our values say in the setting of that knowledge. So it may be that we could prevent all this COVID, but we’re actually more interested in going out to eat, seeing our friends without masks, not having our kids be out of school,” these kind of things.

And so that disjunction between values, which are what politics tries to apply, or policy, and scientific expertise I think has manifested now with people saying, “You know what? I don’t trust these guys to make policy.” And so I think that’s what’s happening. Now, I’m curious what you think, but that’s been my feeling. And the problem is they’re throwing the baby out with the bath water, so now they’re like, “Well I don’t trust these guys to tell me I should vaccinate my children against mumps, because the way they managed COVID I felt was incompatible with my values. What are they telling me about mandates for childhood vaccines?” So it’s really causing all this collateral damage to public health now.

Robert Pearl:

No, I really love that, because as you know, I’ve been focusing a lot the past year on these rules of healthcare that I believe many of which need to be broken, and we have maybe the strongest rule, which is to save a life at any cost, and at any cost means any cost. If kids lose a year of school, that’s a cost to save one life, or two lives, or three lives. Now, we could spend a lot of time debating this issue. It’s certainly been debated by Talmudic scholars across history, but I think at some point we have to accept that death is a reality that we can’t overcome, and we probably need to take a broader view of what that means. What’s the impact to people’s lives of missing a year of education? What’s it going to mean for them and their families? How many people are going to die even though we won’t know exactly who they are as a result of that because of their family’s socioeconomic situations? Those conversations never penetrate into medicine.

Zubin Damania:

Oh, you nailed it, man. And again, it gets to get to that root of what you wrote about in Uncaring. It’s our denial, which again can be an adaptive denial. It’s unconscious about that death is something that is inevitable, and that it’s not necessarily the worst enemy, and it has to do with your values. So Dr. Monica Gandhi, an infectious disease specialist at UCSF, who’s been on my show several times, is coming again on Saturday. Early in the pandemic, we started doing a series of shows where we were really trying to talk people off the ledge a little bit and talk about these issues. And she said to me, and she said this on camera eventually, but initially she told me off camera that she had lost her husband, who was roughly her age, late forties, early fifties to cancer right before the pandemic, and he was a cardiologist, worked super hard.

Who knows if it was radiation exposure or what, but he had a head and neck cancer, and he died, and she has two young sons, and she’s raising them alone now, and the pandemic hits, and she’s watching people, the medical system treating death like it is the worst possible thing in the universe relative to actually living your life. And it became a kind of passion for her to say, “Listen, we all look at risk differently. Here’s how you can look at risk here rather than just save a life at any cost.” And that was part of her motivation. And again, she was woken up by this tragedy that hit her and her family, and sometimes it takes something that horrible to pull the rug out of under your denial, and you shouldn’t have to have that, right? We ought to be cognizant of this as a society and as individuals in healthcare, but it’s not been part of our sort of process.

Robert Pearl:

Let me ask you one last question. It’s one question that I got asked. I was keynoting a large event a couple of weeks ago, and at the end you know you have the Q&A, and an individual stood up, wasn’t a physician, and asked me whether with more and more doctors becoming employees, whether we’re seeing, and he used the phrase, “Loss of motivation to drive change,” whether medicine is just similar to everyone else with quiet quitting, and burnout, and a sense that dedication to work isn’t worth the effort and the energy, or whether the traditional purpose and mission of medicine still persists. You have probably the broadest network of millions of people who follow you and communicate with you. What do you think? How would you answer that question?

Zubin Damania:

That’s a great question, and from the standpoint of say an independent physician, you might ask that question. From a standpoint of an employed physician, you might not know anything differently, but this is my take. Hey, remember when we didn’t have a lot of employed physicians? How much change, progress, innovation, and transformation did we get? Zero. It’s the same thing that they’re all conditioned by their incentives, by their training, by inertia, by fear. And the employed physicians have a different set of conditioning in inertia and fear, but I don’t think it’s vastly different than the old way of doing things in terms of generating innovation. I think if you want to find the roots of our failure to innovate or to feel invested in the change, I think it goes right to medical school, which you’ve talked about.

I mean, we’re basically trained to, we’re conditioned to memorize facts, half of which are eventually shown to be untrue, but they don’t tell you which half, because they don’t know, and then you’re conditioned to obey authority in the second two years, and you’re afraid you’re going to hurt someone, and you don’t want to rock the boat. And so it doesn’t matter. You come out with that conditioning. You’re really trained that way. So employed or not employed, at least if you’re an employed physician, you have this network of support, and you have an organization theoretically that could support you, or it could be seen to be trying to harm you or control you, but a lot of it is our own perspective until we kind of wake up to what we’re repressing, denying, projecting, and so on in our own conditioning, our system is going to be very unlikely to change, because our organizations are epiphenomenon of who we are.

Robert Pearl:

My answer was that, no, what I see is physicians are just as motivated to want to make medicine better, just as motivated to want to do the best for patients. They’re frustrated by the system. They’re frustrated by the inability to make change happen, and sometimes when you’re frustrated you lose the energy needed to try to drive change, but I still believe, and maybe I’m being too optimistic, which is why I asked you, or maybe just too idealistic, that the people who go into medicine are motivated by the right reasons, and that given the opportunity, they would push hard on the block, the cart, whatever you want to be saying it to be, to move it forward, and to make it accelerate at an ever faster rate.

Zubin Damania:

Oh, I think you’re absolutely right given the opportunity, and when they see these little cracks. We all think about our best day in medicine, and it’s always this kind of connectedness. It’s always this kind of autonomy, tools, teams, trust, and the patient. And it just kind of is a flow state, and I think if you give people more opportunities to actualize those flow states, show them bright spots where these things are working, and kind of just point directionally, because we all kind of know where we kind of generally want to be. We just don’t necessarily know how to get there. I think things will start. It’s inevitable. The change is already happening. It’s like what we said earlier in the thing. I sense the shift in the air.

I think the same thing is happening in medicine. There’s huge intractable seeming problems, but it’s always that way before the caterpillar spins the chrysalis and the transformation happens that you could never have predicted. So I think I’m with you on the optimism. I may be less of an idealist in this sense that it’s going to be a lot more brutal I think, and people will feel a certain way about it that’s very negative, but I think it’s inevitably going to go in a good place if we keep on the direction.

Robert Pearl:

I love it, because I’m more of an idealist. I think people have all the right motivation. I’m a little bit less of an optimist, because I think the hurdles are so tall that it’s going to take a massive amount of energy to make change happen, but with that, let’s turn it over to Jeremy for his question to us, and I can’t wait to have the next opportunity to be able to learn from your experience, and to have new views into the world.

Zubin Damania:

Likewise.

Jeremy Corr:

When it comes to politics, many voters on both sides of the aisle seem to think that the elected officials on their side are fighting for them when it comes to healthcare, while believing the other side is making healthcare worse for both them in society, whether it’s the issue of abortion, Medicare, drug pricing, transgender issues, et cetera, and I would say that the hot issue on everyone’s mind right now is freedom of speech versus censoring what some people consider disinformation or hateful speech on social media. What I really want to ask though is for a reality check from both of you. When there is so much money in politics via campaign financing, lobbying, et cetera, coming into both Republicans and Democrats from big pharma, health insurance companies, health tech companies, et cetera, is either side really fighting for the best interests of lower and middle class voters when it comes to healthcare issues, or are they just focusing on keeping these big and influential healthcare companies happy?

Zubin Damania:

Oh, I’d love to defer to Robbie first on this one, because I’m dying of curiosity to hear your take.

Robert Pearl:

I think, Jeremy, you’re raising two separate issues. I think the first issue is relative to the healthcare system, and a professor that I teach with, Robert Burgelman at Stanford, talks about medicine as being a super unmoving industry. Nothing changes over time, and he doesn’t understand why that is the case, and I think you’ve described the reason, which is there’s so many people in it, around it, impacted by it, making money from it for whom change is not what they want, and they have the power, and they have the money to be able to make stability be the example that sits within it. In contrast, I think that within the healthcare itself, that the politics, that the money is not the force that’s restraining change. I think that it’s within the people itself, it’s the difficulty of making that change happen, and I think it’s the amount of time that it takes, and I just think that it’s too much.

And that’s why I’m a big believer that the change will come not through the political process, because I think that will be blocked by the money forces that exist, but it’s going to come actually through the economics, and that’s why I’m a big believer that it’s going to be the retail forces that will drive it, the Amazons of the world and the CVSs of the world, the Walmarts of the world that are going to make the change happen. I think they’re going to drive it not necessarily out of some commitment to improving the health of people. They’re going to drive it out of a profit motive, but I think that it will create a more positive change for the country, at least that’s my optimism, and that I think that once physicians get behind it, and nurses get behind it, and patients get behind it, and they can see an improvement to happen, that there will be what Zubin has talked about, this very major shift suddenly, and what seemed impossible and then seemed possible now will seem inevitable.

Zubin Damania:

Yeah, and I think Upton Sinclair, I think it was, who said, “It’s impossible to make a man believe something if his salary depends on him not believing it.” And I think in medicine for many people, our salaries depend on us not believing, not changing to some degree, and that includes big legacy players like pharma, and insurance companies, and those kind of things, and politics just feeds right into that, and money is all the currency, the lifeblood of that. But once, like Robbie says, once the realities of the economics start to click in, and you do have these sort of disruptive agents like Amazon kind of pushing things like our old Turntable/Iora Health Model that’s now part of Amazon, when those are normalized, and consumers, the patients are able to vote with their feet a little bit, you’ll start to see change, and it will pull in especially the younger generation of healthcare professionals, who have been kind of hungry for this kind of change. They want to do the right thing. They are idealistic, and given an opportunity to practice in that kind of world, they’ll take it.

So it’s actually very, very, very encouraging. I think the shift will happen. Now, the last pitch I’ll give is personal, and I always say this, and I’m sure I can feel this is probably not true, but I can feel Robbie rolling his eyes at me. It is that people have to wake up too to their own transformation. They have to see that this sort of egoic striving that we’ve always been conditioned to do is a bit of an illusion, and once we see past that, we do emerge a world where that is actualized in a way that it’s very hard to predict, but it’ll definitely be better than what we’re going through now.

Jeremy Corr:

We hope you enjoyed this podcast, and we’ll tell your friends and colleagues about it. Please follow Fixing Healthcare on Apple Podcast, Spotify, or your favorite podcast app. If you like the show, please rate it five stars and leave a review. If you want information on healthcare topics, you can visit Robbie’s website at Robertpearlmd.com or visit our website at Fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter at Fixing HC Podcast. Thank you for listening to Fixing Healthcare’s newest series, Unfiltered, with Dr. Robert Pearl, Jeremy Corr, and Dr. Zubin Damania. Have a great day.

The post FHC #74: The tangled mess of medicine and politics appeared first on Fixing Healthcare.

Dr. Jonathan Fisher was practically born into medicine. All six of his siblings became doctors, following in their father’s professional footsteps. Jonathan, himself, became a Harvard-trained cardiologist, working in some of the nation’s leading medical institutions.

But, in the process of making his family proud, he was becoming anxious, depressed and burned out. He was losing an important part of himself. To make matters worse, when Jonathan finally sought the help of a therapist, he experienced profound shame and felt like a failure.

Nowadays, in addition to being a practicing physician, Jonathan is an advocate. He has devoted much of his career to solving clinician burnout. He is a mindfulness and resiliency expert who runs the Ending Clinician Burnout Global Community and co-hosts the annual summit of same name.

In this interview, hosts Jeremy Corr and Dr. Robert Pearl ask Dr. Fisher about the rules of American medicine that must be broken in order to free clinicians from the shame, anger, frustration and dissatisfaction that cause rampant burnout.

“I remember my surgery rotation in third year. We had a very well respected general surgeon, resident and a fellow, and I felt like I was in the military, which was a very bizarre thing … I found myself having to walk quite erect, almost like a group of ducklings following this senior surgical resident. [We had] to speak in exactly the way that he spoke, to present in a way that was expected. This was the first time I remember this jarring sense that there were certain rules that were established, rules of behavior if we were to fit in and to excel.”

“I was a resident at the Brigham and I called [the therapist’s office] and I tried not to over-identify myself. And when I first went, I wore a coat so that I could cover part of my neck, and I wore a hat so that nobody in the neighborhood, other residents, would know that I was going to see a therapist. There was a lot of secrecy and there was a lot of shame that was there. I knew very little about the impacts of shame, which really literally means to cover up. That’s the origin of the word. There was so much covering up that I was doing that, eventually, I was unable to feel positive feelings.”

“There’s an overlap between burnout and depression, but one is a workplace phenomenon, often driven by a certain set of known factors that Tait Shanafelt and others have described beautifully, whereas depression is more of a psychological diagnosis. What I find interesting is … there are overlaps there with the clinical spectrum of depression as well as anxiety … If you look at Medscape’s poll from last year … 70 to 80% of all doctors across 29 sub-specialties reported depression at some point in the last few years.”

“People say, ‘Well, you have to change the system.’ I point out that a system is nothing more than a collection of individuals. If our individuals don’t have the presence of mind and the ability to impact change and influence the thoughts, feelings, and actions of other people, then we won’t have a generation of leaders who can make the changes that people so desperately want.”

“I think part of the problem we’re facing in healthcare is that we’re all siloed. We may be siloed in our own institution thinking that we’re doing it best. We may be siloed in our own specialty thinking that we’re better than others. And we know the jokes that the orthopedists tell about the internists and the cardiologists tell about the neurologists, and it’s funny. At the same time, these silos are what are going to keep us from healing our healthcare system. All of these divides need to be bridged. We need to begin the bridging. And so, that’s really the motivation for my work.”

“If we use a narrow term like moral injury, it’s a focus on one person, which is the healthcare provider who is injured. I would say that there’s a connotation there, that there is an injurer. Once we have that connotation, there are elements of blame, of blaming the system. I’ve watched this for 10 years. Well-meaning doctors who have no recourse, spend hours of their time talking about us versus them, us versus the system … I think the popularity [of the term] comes from a sense of hopelessness and, frankly, bitterness, which oftentimes is appropriate, but after a while becomes dysfunctional.”

READ: Full transcript with Jonathan Fisher

* * *

Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #73: The ‘rules of healthcare’ that cause burnout appeared first on Fixing Healthcare.

This holiday season, Fixing Healthcare hosts Jeremy Corr and Dr. Robert Pearl are mixing things up with a look back in time—way back, in fact, to the first episode of the first season with Dr. Zubin Damania (aka ZDoggMD). Since this interview in 2018, Dr. Z has become one of this show’s most popular returning guests.

Zubin Damania is a UCSF- and Stanford-trained internist and founder of Turntable Health, an innovative primary care clinic and model for Health 3.0. As a way to address his own burnout and find his voice, he started producing videos and live shows under the pseudonym “ZDoggMD.” His persona became a grassroots movement, reaching more than 1 billion people across a wide array of different media.

Today’s program will be the first of three Fixing Healthcare flashback episodes airing throughout the holidays, each featuring ideas to fix American healthcare from some of the nation’s top leaders.

The purpose? To quote Dr. Pearl: “My hope in replaying these ideas is to help listeners once again realize how much could be done to transform American healthcare and improve people’s lives. And simultaneously, help them recognize how far we are from delivering the excellence in healthcare Americans want, need and deserve.”

Helpful links:

Season 1 explainer: ‘Welcome to the toughest interview in healthcare’

Episode 1 recap: ‘ZDoggMD has a plan to fix American healthcare’

The full transcript of this episode with Zubin Damania

ZDoggMD’s website: Health 3.0

* * *

Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #72: Fixing Healthcare flashback with Zubin Damana (ZDoggMD) appeared first on Fixing Healthcare.

In this episode of Coronavirus: The Truth, Jeremy Corr and Dr. Robert Pearl discuss the latest buzzword of the Covid-19 era: Triple-demic.

Earlier this month, the CDC alerted physicians about the triple threat of Covid, seasonal influenza and RSV (respiratory syncytial virus), warning that the threat of multiple infections (and resulting respiratory disease) was greatest among young children and the elderly. Is the triple-demic a legitimate public health threat and what should listeners do about it?

You’ll find that topic and all the other [time stamped] questions from today’s show  here:

[00:52] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?

[05:18] Listener question: “Is the price of Covid vaccines going up next year?”

[08:50] Why do government and insurers seem willing to pay for so many complex services and facilities to treat people once they have a heart attack, stroke or cancer, but reticent to make the investments needed to reduce the incidence of these frequently avoidable problems?

[09:44] There’s still a lot of debate about myocarditis after vaccination. Any new research?

[11:00] What is a “triple-demic” and should we be worried about it?

[13:18] If everyone wore masks and washed their hands this winter, we could avoid millions of infections and thousands of deaths. So, why are Americans less likely than others to do?

[14:38] Listener question: I was recently vaccinated with the old booster and I was wondering about the new bivalent one. Is there data that says I should take it?

[16:30] What’s the latest on Long COVID (since it was featured in last month’s episode)?

[17:47] What are the risks of Covid-19 relative to kids now?

[18:59] What’s new in healthcare beyond Covid-19?

[21:52] How much risk should patients/consumers be willing to accept vs. their social obligation to keep others safe?

[23:13] Are parents of children with diabetes still cutting corners with insulin due to high prices?

[26:05] How does racial bias play a role in the care doctors provide patients?

This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #67: Should Americans be worried about a ‘triple-demic’? appeared first on Fixing Healthcare.

This Fixing Healthcare podcast series, “Diving Deep,” probes into some of healthcare’s most complex topics and deep-seated problems.

On today’s episode, hosts Dr. Robert Pearl and Jeremy Corr discuss the “Anatomy of Healthcare Leadership,” a new way of looking at the skills and qualities needed to transform American medicine. According to Dr. Pearl, leaders must apply logic and creativity (a function of the brain), they must show passion and express empathy (via the heart) and they must also demonstrate courage and resilience (using the proverbial strong spine). Later in the show, Corr gets Pearl to describe his leadership journey and the nationally recognized success he experienced for nearly two decades as CEO at Kaiser Permanente.

For more information on healthcare leadership, check out Dr. Pearl’s latest columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a discussion guide:

• How can strong leadership defeat the “middleman mentality” in healthcare?
• What proof is there that U.S. healthcare lacks effective leadership?
• What kinds of healthcare problems will be hardest for leaders to address?
• Can healthcare leaders really change how healthcare is paid?
• What are the benefits of “capitation”?
• If capitation is the solution, why is it so rare in healthcare today?
• How does the middleman mentality slow healthcare’s financial reform?
• Why would anyone who’s profiting from healthcare’s dysfunction want to drive change?
• Where should aspiring healthcare leaders begin?
• Why has the trio of cost, quality and access been so hard to achieve?
• How can aspiring winning over the people who deliver care?
• What is the “Anatomy of Healthcare Leadership” and how can it change medicine for good?
• How can leaders apply logic and creativity (their brains) to the challenge?
• How can leaders apply passion and empathy (their heart) to the challenge?
• How can leaders demonstrate courage and persistence (the spine) to the challenge?

• What was the arc of Pearl’s journey from plastic surgeon to CEO?
• How were healthcare problems similar/different early in Pearl’s career compared to today?
• How did Pearl become the CEO at Kaiser Permanente in 1998?
• What were his goals for the organization at the time?
•  What are the three biggest leadership lessons he learned as CEO?

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #71: Diving deep into healthcare leadership appeared first on Fixing Healthcare.

In this month’s Diving Deep episode, part of the Fixing Healthcare podcast series, Dr. Robert Pearl and Jeremy Corr dive into two vital topics in healthcare: lessons learned from experts on end-of-life care and innovative solutions to address chronic disease in underserved communities.

The episode begins with an exploration of end-of-life care, revisiting Season 9 of the podcast series, which focused exclusively on this emotionally charged topic. Dr. Pearl reflects on his conversations with guests like Dr. Atul Gawande, author of Being Mortal, and the powerful lesson that “people have goals besides living longer.” The hosts discuss how clinicians need to respect patient autonomy, particularly when the choices revolve around what makes life worth living versus prolonging survival at all costs.

Next, the conversation shifts to the topic of chronic disease management in underserved communities. Dr. Pearl references his recent Forbes article, which outlines how social determinants of health (SDOH) contribute to health inequities in the U.S. He introduces a practical solution: GenAI-driven health hubs, designed to combat chronic disease in low-income areas.

The hosts discuss the implementation of these hubs, explaining how they could provide affordable, targeted and technologically advanced support to individuals in areas where healthcare resources are limited. By leveraging generative AI tools, the hubs would help manage chronic diseases, reduce the burden on overworked doctors and prevent life-threatening complications. With a small investment, Dr. Pearl argues, these hubs could yield significant cost savings by preventing just one major health event, such as a heart attack or stroke.

Click play to hear these insights and more, and explore how healthcare leaders can improve care for patients at all stages of life.

HELPFUL LINKS

• 9 Powerful Lessons On Life You Can Learn From Experts On Death (Forbes)
• GenAI-Driven Health Hubs Can Combat Chronic Disease In Underserved Areas (Forbes)
• Monthly Musings on American Healthcare (Robert Pearl’s newsletter)

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Dr. Robert Pearl is the author of “ChatGPT, MD: How AI-Empowered Patients & Doctors Can Take Back Control of American Medicine.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #148: End-of-life lessons and combatting health disparities appeared first on Fixing Healthcare.

Dr. Devi Shetty returns to the Fixing Healthcare podcast this week—making his first appearance on the show since 2019. At that time, listeners wrote in and posted messages on social media, expressing astonishment at Dr. Shetty’s accomplishments and outlook on healthcare.

Shetty is a heart surgeon, trained in both London and the United States. Today, he owns and operates 11 hospitals in India and a new facility in the Cayman Islands. The cost of care in his health centers is as low as you’ll find anywhere in the world. Yet the quality of care is a good as you’ll find anywhere in the world.

This success was made possible only by breaking the traditional rules of healthcare. In this interview, hosts Jeremy Corr and Dr. Robert Pearl ask Dr. Shetty about the rules of American medicine that must be broken in order to replicate the success he (and his hospitals) have achieved.

“If a solution is not affordable, it is not a solution … But sadly, after spending $10 trillion (on global medical care), less than 20% of the world’s population has access to safe, accessible, secondary and tertiary level healthcare … So we have to break the rule and we have to do everything possible to make healthcare accessible, affordable, and safer for the patient.”

“A typical doctor like me, I see about 50, 100, 130 patients every day in my clinic, apart from one or two surgeries. And good number of my patients are the little children sitting on their mother’s lap. I examine the kid, I look at the mother and tell her ‘Look, your child has a hole in the heart. She requires open heart surgery.’ She has only one question. The question is not about the scar, about the recovery or how to take care of the kid later on in life, nothing. Only one question, ‘How much it is going to cost?’ And if I tell her that it is going to cost, say, 100,000 rupees, which she doesn’t have, that is a price tag on the child’s life. If she has 100,000 rupees, she can save the child. This is what I do from morning till evening, putting price tag on human life. This is what every doctor in all the developing countries do from morning till evening, putting price tag on human life. This is not acceptable, Robbie. If society has given legally, officially the right to put a price tag on human life to people like us, we have failed as a society. This can’t go on.”

“I was privileged to be living in Kolkata at that time, and Mother happened to have a cardiac ailment. I was a senior doctor (of heart surgery) in the city, so it’s just a coincidence or God’s blessings that I had the privilege of being close to Mother when she needed the doctor’s help. And I’m grateful to God for the opportunity.”

“There was a drought in the state of Karnataka, where I live. So, farmers lost their capacity to pay for the healthcare. At that time, we approached our government …  we told the government that if the (state) cooperative society members pay 11 cents per month, that’s approximately the price of one packet of cigarette or Beedi … that money he pays for his health insurance. And initially we had about 4.5 million people paying 11 cents per month. The insurance pays for the surgeries, starting from a routine surgeries like gallbladder, hernia, cesarean section to heart operation, brain operation, everything is cover … Over 1.5 million farmers had varieties of surgeries and about 130,000 farmers had a heart operation. All this was done with 11 cents per month. Poor people in isolation are very weak, but together they’re very strong.”

We are living in an amazing country, which supports innovation and supports a new way of doing things. I have no doubt that within the next five to 10 years, India will become the first country in the world to dissociate healthcare from affluence. India will prove to the world that the wealth of the nation has nothing to do with the quality of healthcare its citizens can enjoy. I have no doubt about it.”

“I’m convinced that when you strive to work for a purpose, which is not about profiting yourself or your own personal interest, if the purpose of our action is to help the society, mankind on a large scale, cosmic forces ensure that all the required components come in place and your dream becomes a reality. I have no doubt about it. I have noticed this so many times, whatever we could do in India, if you really sit back and analyze it scientifically, lot of things couldn’t have been done, but it happens mainly because of the impact which is going to touch millions of people.”

READ: Full transcript with Devi Shetty

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #70: India-based doctor breaks rule that great healthcare must be expensive appeared first on Fixing Healthcare.

In world where it’s almost impossible to tell if someone is lying or delusional, where is line between an unintentional error in perception and intentional misrepresentation? This question is proving to have profound consequences in medical practice.

In healthcare, where the difference between facts and opinion continue to blur, tribalism and factionalism are a growing concern.

In this episode of Fixing Healthcare, cohosts Jeremy Corr and Dr. Robert Pearl join ZDoggMD to probe the many problems with medical misinformation in America.

When both physicians and patients crave simple answers to complex problems, ultimately, is it our fears that drive our perception of what’s real? To find out, press play or peruse the transcript below.

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

Jeremy Corr:

Welcome to Unfiltered, our newest program in our weekly Fixing Healthcare podcast series. Joining us each month is Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice. I’ll then pose a question for the two of them as the patient based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Hey, Zubin, welcome to this month’s show.

Zubin Damania:

Ah, it’s always a pleasure to be back, brother.

Robert Pearl:

With Halloween coming up, do you have a custome in mind?

Zubin Damania:

I’m going to go as a burned out physician who just doesn’t know what to do. In other words, I’m just going to go as myself circa 2009.

Robert Pearl:

Excellent. Yeah, I was planning to be a crazy knife bearing surgeon. I think reality and fiction often overlap and intersect, and I think we both have the same thoughts right now.

Zubin Damania:

Both characters are truly terrifying.

Robert Pearl:

I don’t know about you, but I feel like there’s a dark cloud over the world now with economic uncertainties that exist, the war in Ukraine, the evermore problematic American political system. Would you care to cheer me up?

Zubin Damania:

Yeah, I’ll cheer you up this way. I agree that it feels that way for sure. And actually the only way I cheer myself up is by realizing everything that we think is absolute reality like that is just all a thought matrix we live in. So we do the best we can in that relative world. But in reality, right here, right now is just absolute stillness and peace and perfection. And so those two things exist simultaneously. And if you can tap into both and feel into both, then it’s much less depressing because you realize in the end everything’s going to be okay because it already is.

Robert Pearl:

I love your Buddhist tranquility, but I’m still concerned that as our nation divides wider and deeper, something I’ve thought about a lot is trying to figure out where the line is or how do we establish the line between unintentional errors in perception and intentional misrepresentation. I often find it difficult to ascertain where the people are saying what they truly believe, but it’s just wrong, versus when they’re lying. Any thoughts of how you discern the difference?

Zubin Damania:

So this degree of discernment has become increasingly difficult because there is an aspect of self-deception that humans are really good at. We’re increasingly good at it when we’re divided into these tribal groups and social media creates a virtual belonging for us, this meaning crisis is solved by belonging to a group. So in a way when what we may think is misinformation from the standpoint of one virtual group may be absolutely believed as true from the standpoint of another. And therefore, if you were to say, create a law that says we’re going to fight misinformation this way by these criteria, there’s always going to be groups that say that’s total crap, because from our standpoint, we’re actually telling the truth. And actually humans have evolved to self-deceive potentially to some extent because in order to fool others in a tribe, in order to get away with something, we’re so good, we’re such good lie detectors as humans, that discernment that you’re talking about, that in order to fool people, we have to believe what we’re saying.

And so to some degree, that degree of self-deception then projects in a way that it’s very hard to discern, does that person actually believe what they’re saying? Even though objectively I can measure things and say this is not true. And I think that’s where we are. We’re in this sense making crisis. How do you even know what’s true anymore and who believes what? So I share your frustration with that. It is very hard, but I think you have to get at the meta crisis underlying it, which is this meaning crisis, the sense making crisis and the tribalization.

Robert Pearl:

A few years ago I did some research with a neurologist, George York, and we looked at the literature on perception. What we found was fascinating. In times of great fear or opportunities for pleasure or wealth, people’s brains shift what they see. You put individuals in headsets and you ask them to ascertain where the two images that have been rotated are identical, and 95% of the time they’ll get it right. But you put them in a group of three others who are in on the experiment and all three of the others consciously report a wrong answer to particular problems, and two thirds of the time the unknowing subject will give the incorrect answer.

Now people might say, Oh, this is just going along with the crowd, but interviews of the subjects later confirmed that what they actually saw were the wrong images. And this to me is the question, the tribalism that you’ve spoken about many times and you’ve discussed on your podcasts and other shows. How do we understand this and what can we do to minimize it? At least from my perspective, I don’t think it’s a good thing to have tribalism in healthcare.

Zubin Damania:

Yeah. So I think what you’re pointing at is the fact that we don’t so much perceive reality as constructed. And that construction is a complex interplay between whatever’s input to our senses and whatever we’re constructing. In fact, our occipital lobe, according to Professor Donald Hoffman, is so big and such a huge user of energy in the brain that it would be overkill to actually just re-represent what the senses are telling us. But it’s just about right to construct a world. So since we are humans, we’re contextual creatures, we’re social creatures where as we talked about the last time, we’re right brain and left brain creatures both. And that right brain wants to see things in their context and it sees these other creatures that are in our group or in our tribe constructing things a certain way and it influences our construction. This is absolutely true. It’s probably the explanation for a large component of the placebo effect in medicine too.

That therapeutic alliance, that sense of being heard is bigger than even if you can tell them, Hey, this is a placebo, but we find it works for a lot of people and we’re going to sit with you. And even that just saying that has a therapeutic effect. So I think that tribalism, first of all, it’s recognizing that this is actually how humans are. That objective reality is a very tricky thing. And so if we’re constructing reality from these inputs, then let’s try to understand the ought to, what ought a good healthcare system, good society, good set of ethics look like? And I think that’s where we might agree a lot more than we disagree. We’re always arguing over the is like, well what’s going on? What is this? What is that? No, but what would we like? And I think once we start to align around that tribalism, we might be able to build that corpus callosum between the tribes.

Robert Pearl:

So let’s dive a little deeper. Let’s look at doctors who recommend treatments that prove lucrative to themselves but have been shown to add little clinical value for patients. Do you think they promote them out of conscious greed or do you think they actually see them as valuable regardless of what the literature concludes?

Zubin Damania:

Ooh, another great example of us constructing our reality and our sense of morality and ethics from first principles. And the first principles in this case are, we want to do good, but we also need to survive. We have the Maslow’s hierarchy we have to provide and so on. We’ve done all this training and now they’re telling me that maybe the colonoscopy that I trained to do for all these years, that’s the bread and butter of the generation of cash for my specialty in gastroenterology. Now there’s a study saying, well maybe it’s not as good as we thought as a population wide screening tool. Probably works on some individual level, but as a population, okay, what are you going to do? You are going to immediately, unconsciously, and to some degree consciously react and say, yeah, wait a minute now, you did the study wrong, there’s things you didn’t look at, you haven’t seen the patients I’ve seen.

When a patient comes and says, You saved my life by detecting that precancerous polyp, you haven’t had that experience and you’re just a egghead and a data analyst and you’re missing the big picture. I think that’s all absolutely believed by the person. I think deep down there is a doubt that what if this is true and I must defend against that and so on because there is an existential risk to the income. And Upton Sinclair said it’s very difficult to have a man believe something when his livelihood depends on him not believing it. And that’s just how humans are. We’re constructing this reality. So how do we address that? Well that’s a difficult thing because a straight on attack throwing data at people is not going to change what’s happening. You need to shift in the overall sort of paradigm. And that’s very difficult to do.

Robert Pearl:

Does this phenomenon you’re talking about, explain the 180 degree contrasting views of people about vaccines.

Zubin Damania:

A thousand percent. So those vaccine views are based, I think increasingly on our morality and our moral taste buds. The six moral taste buds that Jonathan Haidt talks about, care versus harm, liberty versus oppression, sanctity versus degradation, fairness versus cheating, authority versus subversion, loyalty versus betrayal. Those are the six. How you feel those taste buds will determine how you look at vaccines. And one of those is loyalty versus betrayal. Let’s say you are conservative and you have loyalty to group and then the group is saying, we don’t trust these vaccines because it just so panned out that Trump wasn’t a big proponent of the vaccine. Well now that tribal loyalty has to conflict with the care versus harm, but they’ll feel care versus harm as, oh we’re actually harming young people by giving them myocarditis with these unnecessary vaccines. So, that’s how they’ll spin it.

Now on the left they’ll say, Hey, care versus harm, I don’t want to kill grandma, I don’t want people to die. So we want vaccines. And their loyalty versus betrayal is, well, I’m loyal to these ideas of “the science,” which is increasingly a politicized feeling. So they will fight tooth and nail for a vaccine, even if in say a 13 year old boy there’s a risk of myocarditis, they’ll very much downplay that as, Oh, the risk of COVID myocarditis is worse. But really there isn’t great data to say one way or the other. So they won’t accept the uncertainty there. And I think that’s entirely moral matrix driven. They’re all trying to be good. And once you see that the tendency to be judgemental towards in group and out groups tends to soften a bit. And then you can just determine, okay, so how can we do the most good here? How can we build some bridges? And I think it’s existential a risk to us that we have to do that now, we have to start looking from that morality standpoint.

Robert Pearl:

I don’t know, it sounds like it’s a pretty big gap to close between people who see a intervention as being so life saving and people who see it as so problematic. I just rarely have seen a gap as big as this one.

Zubin Damania:

It’s really heartbreaking because previously, and actually this is spilling over into childhood vaccines. So now we’re seeing this hesitancy towards childhood vaccines, which was there at a small level before and now it’s increasing because again, the tribalization, the politicization and you can blame all kinds of people and you could probably blame some people more than others for this, but it is an increasing factor. And I think things like social media, the Zuckerverse and all this other stuff have really fed into this because their monetization models benefit from division, they benefit from the outrage and the headline clickbait stuff, but unfortunately, so okay, Robbie, I’m feeling into how you’re even phrasing these questions.

You are very discouraged right now. That’s clear. You’ve said it explicitly, but you can also feel it in your tone of voice and I think many people are, I think many people who are smart people who’ve worked in healthcare feel as you do. I see them when I go talk and things like that. And all I can say is I happen to tend on the optimistic side because the only way out is through. And I think if we fail to destroy ourselves, I think we will increasingly wake up to what’s actually happening. It just is going to be ugly for a while. So we have to keep talking about it. We have to keep pushing through making the implicit that we think we understand more explicit so people can go, Oh this what’s really happening. But it is hard.

Robert Pearl:

Yeah, it’s particularly hard I’ll say as a scientist, you see data, you see logic. If people have problems with the specific information, you repeat experiments. There are ways you could explore questions, but when at the end of that process you still have two seemingly unconnected, completely contradictory conclusions, then that becomes hard to put in a scientific model for which the healthcare world has tried to achieve for 5,000 years.

Zubin Damania:

Yeah. And this is where the fundamental of schism between our science-based consensus reality that we’ve, like you said, 5,000 years of growth of the scientific method, and the way humans actually instantiate these hive mind group thinks that are powered by their moral taste buds and loyalty. And part of it, Robbie, I think is the meaning crisis in a bigger sense. We used to have a common mythology. You and I have talked about the hero’s journey. That’s a common mythology across cultures, but we’ve lost some of the sense. And so now we find our meaning in tribe, in group, in belonging. And when that becomes paramount, then the consensus reality starts to fracture because then we’re creating our own consensus reality within the group instead of within the collective as science has done since the enlightenment and prior. So it can feel very frustrating to a science minded person and it definitely has felt frustrating to me.

Robert Pearl:

Multiple times a month I get a call from a CEO of an artificial intelligence company and the calls are almost all exactly the same. They tell me that first of all, they’re the best engineers that exist in healthcare. Then they tell me that they have an application that will save three hours a day per physician, but they can’t understand why no one is buying it. Now I tell them that they’re delusional, although I say it in much nicer languages.

Zubin Damania:

Good for you.

Robert Pearl:

I say the problem they should be having is managing the line out the door. But we just talked about ourselves as scientists. In practice, we’re just as liable to be misled as anyone else. How do we as physicians minimize that risk?

Zubin Damania:

Yeah, this is great because again, we feel in the scientific community that we’re immune to this stuff, but we’re as susceptible like you said. And I think part of it is how we’re even training ourselves, educating ourselves. Do we talk about these issues of group think and cognitive bias and errors in thinking and even the kind of cardinal signs of conspiracy thinking, or cardinal signs of misinformation. We don’t even train people on that because sometimes we can turn that back on ourselves. Some of them are things like cherry picking data. Well, we in science do that well if we have an emotional investment in something. I gave the example of say colonoscopy. If you’re emotionally invested in something, you’ll cherry pick the data to support what you believe. So the fake experts, pulling up an expert that really doesn’t have a lot of business talking about this, but they have some credentials.

The moving goal posts. No matter what information you present someone, they’ll say, well, but then what about this? And they’ll move the goal post further. The conspiracy thinking, the logical fallacies. If we trained ourselves on that stuff or had it as part of our curriculum, even in elementary school, junior high, high school, boy, we’d have the tools and the agency we then restore our agency, because right now it’s almost like we’re zombies walking towards the abyss. We don’t even know it. In science, outside of science, once we actually can see clearly the trajectory, I think there’s much more chance that we’re going to be motivated to do different.

Robert Pearl:

So let’s dive even a level deeper. You live in the Bay Area and I’m sure you’re well aware of Elizabeth Holmes and the Theranos debacle.

Zubin Damania:

Yeah.

Robert Pearl:

We had Tyler Schultz on our Fixing Healthcare podcasts a couple years ago. And of course there were numerous TV shows and books about what happened. As you know, the attorneys are battling over possible retrial. But I’m fascinated by the question, how much of the deception did she know versus how much was a subconscious shift in her brain that made her see reality different than it was? Of course no one including herself probably knows the answer. So your opinion is as valid as anyone else’s. What are your thoughts?

Zubin Damania:

I love my opinion being as valid as anyone else’s. That’s really empowering, also completely terrifying. Yeah. So with her it’s fascinating. There clearly had to… Again, again, and let’s just pretend that I know what I’m talking about because again, you can’t get in someone’s mind. This is a fallacy in itself, the mind reading policy. But I’ll say this, just looking at this in human nature, self-deception is powerful. She had every motivation to self-deceive and every motivation to then, by self-deceiving, actually be able to easily deceive others because she believes what she’s saying. And she’s got to convince George Schultz, she’s got to convince pretty smart people who’ve been around the block and she managed to do it and it got to be that she believed it herself. And yet you can actually have this cognitive dissonance where you believe that stuff and you’re still trying to cover things up and yo know there’s stuff going on and that’s totally squirrelly and all that can coexist.

And I think with her, it’s a great example and I think there are a lot of people in the startup space and the tech space who are going through that. In a way they know, oh this business model’s never going to work. It’s a pipe dream, but if we just keep believing it, we’ll create a Steve Jobs reality distortion field and people will just go along for the ride and at some point things will work out. And that false optimism it’s actually a very left brain. The left brain is very optimistic because it just thinks it’s right and it can self deceive all day long. And then the right hemisphere goes, wait a minute, but it’s quiet. So I suspect there was something like that going on.

Robert Pearl:

Yeah, people’s desire to see the world differently than if they could be impartial. It’s just so prevalent. What about Anna Sorokin, the probably fake heiress made famous on the Netflix show, Inventing Anna. Here’s someone who’s spending money, throwing a hundred dollar bills around, convincing the world that she is incredibly rich when she’s basically on the verge of bankruptcy. Look at how many people, I don’t know if you watched the show, but how many people she was able to deceive. She’s in prison right now, but I don’t even know if she knows whether she’s a real heiress or a fake.

Zubin Damania:

It’s a great story. And again, it speaks to we create reality in our minds, in her mind, whatever she believes. And that reality distortion actually feeds out to other people, because we’re social. So it doesn’t surprise me at all. In fact, there have been con people throughout history that have pulled this off and continue to pull it off. Say what you will about, say a cryptocurrency, take two stances on, it’s a real thing, it’s deflationary, all these great things about cryptocurrency. And then, but you could also say, well this is a group think led by a few really loud people on social media that has taken people as the Dutch tulip bulb craze did. And if that’s true, then that’s a same self-deception. These people actually believe this. I know a lot of them and maybe they’re right, but if they’re not right, this is a huge self-deception and on a social level.

Robert Pearl:

We should probably spend an entire show on cryptocurrency.

Zubin Damania:

I know. We’ll get canceled for sure man. These guys are vicious, they’ll kill us.

Robert Pearl:

Because it’s a lot more than just the scarcity and fear of missing out on the soaring of the dollars as it was in the Netherlands during the tulip bulb inflation rate of the time. But the crypto has its own notion that somehow there’s this evil force out there that is manipulating the media, that is controlling our lives and that we the populous need to take it out. And we’re going to do that by using the blockchain technology that underlies cryptocurrency so that every voice becomes equal and equally important. So it has this aura of media three or whatever you want to label it to be, that drives not just the economic analysis of the various currencies, but the value, the mission, the purpose, the higher meaning for these dollar bills.

Zubin Damania:

Yes, yes. And what’s interesting, so there’s a moral crusade involved, there’s a deep set of beliefs, there’s a sense of belonging. You see it with the crypto bros on Twitter and all these guys that are, and mostly guys actually that are doing this thing. And I tell you, I know a lot of them, they are truly passionate about the woes of our current economic system. And what’s interesting is money is such a human construction anyways, it’s like when the dollar’s not backed by gold, what is it backed by? Well, the faith of the US government. So what is cryptocurrency backed by? Well the faith of the masses that believe it’s worth something. So it’s fascinating and I have to say this, and I’ll say this to immunize myself against, attacked by the crypto bros. I have no idea what the answer is. I’m not an economist. It’s just a fascinating unfolding and a social group think unfolding too on all sides of it.

Robert Pearl:

I don’t know if you’ve ever heard of a teacher named Ron Jones. He taught-.

Zubin Damania:

I haven’t.

Robert Pearl:

Oh, he taught at Cooley High School in Palo Alto in the 1960s. And he was a history teacher and his focus at the time was on fascism and Nazi Germany. And to teach the ethics, the values, the things that happened at the time, he started his class a movement that he called the Third Wave. On day one of the module he insisted that students stand when they spoke with him and always begin with Mr. Jones to demonstrate strength through discipline. On day two he said they had to salute with a cuffed hand to the opposite shoulder to show strength through community. On day three told the class that they were special and that certain others who didn’t belong were trying to pretend to be members, but they had to be stopped. And this was stray through action.

By day four, the in group had gone from 30 students to 200 and harm was being inflicted on the out group. And, of course, they had to stop the project. In three days he had taken literally hundreds of students and gotten them to get behind a movement which had no value and was oppressing others. I think that’s the same phenomenon we’re seeing now in so many of these tribal areas that you’re describing.

Zubin Damania:

Yes. Again, and I believe all of it, it’s a social group think kind of thing that you can push through, especially if you have a charismatic leader and you don’t even need that honestly. Now with social media, the charisma is all virtual and you can do all kinds of things. Yeah, Robbie, that’s why just understanding even the nature of how we think and what our minds do and what even is consciousness is, I think a fundamental piece to avoiding falling into these traps. And even then you’ll fall into these traps. In fact, in these spiritual circles where you have these gurus, man, these things can devolve into cult-like craziness with all kinds of abuse and misbehavior among the teachers very, very quickly. Even in these groups that are purporting to be enlightened and awake and oh, we understand the nature of reality. Yeah. Okay, let’s see how that goes. Because again, we’re humans.

Robert Pearl:

There’s an expression that where the pie gets smaller, the table matters deteriorate. As the pressures are about to mount in healthcare, how do you see tribalism playing out?

Zubin Damania:

Healthcare is going to implode at the current rate of growth because it’s going to drag down everything. It’s a self-limiting process right now. It’s got no future in this current configuration. And when that becomes apparent, I think either the early adopters of the next phase of healthcare, whatever health 3.0 that I call it, I think will start to run with it and it’ll just go, or again, it’s going to be a bunch of Al Bundy’s sitting around the table with their hands down their pants burping, and the table manners will have degraded to that level because they’ll all be clawing for whatever’s left and it’s going to be really ugly. And I think we’ll see maybe some combination of that, I think. But again, as the eternal optimist, you’re already seeing these bright spots emerging. You’ve pointed them out, I’ve pointed them out. I think that’s just going to become essential and that’s just going to be the next phase. But yeah, who knows? Who knows?

Robert Pearl:

I have to say you’re not doing a great job of cheering me up today. In fact, I would say that I’m a bit more optimistic than you because I actually think there’s a range of technological solutions that actually could be the answer. But we’ll say that also for the next show. An idea that our view is right has killed hundreds of millions of people across history. One of my favorite anecdotes, and it’s a tragic historical story, comes from the 14th century. I don’t know how familiar you are with this history, but in 1349, the world was in the infamous black plague. And the leading experts from the government, science and academia of Western Europe came together to devise a plan to save the population. I realize by this time the black plague gets spread from the Eastern Mediterranean through most of Eastern Europe. It had killed hundreds of thousands of people over the previous three years.

And those coming to the conference decided that they wanted to stop it from ravaging Western Europe. And they said that research had demonstrated that the plague was derived from fleas, which was correct. And then they made the assumption that since dogs carried fleas, by eliminating dogs, they could eliminate fleas and end the plague. So edicts were passed to each nation to kill all the dogs. But of course, as we know now, the fleas that carried the plague weren’t the ones in the back of dogs, but the ones carried by rats. And without dogs roaming the street, the rat population and the flea population soared. By three years later, nearly one in three people in the world had died of the plague. I wonder if 50 years from now people will look back at how we treat various diseases at the conclusions that we have reached in areas maybe such as maybe cancer or even heart attacks with similar disbelief about how ignorant we were.

Zubin Damania:

A thousand percent. They’re going to, there’s no doubt that they’re going to. They’re going to look at this and there’s a great scene in one of the Star Trek movies, I think it’s Star Trek four, where they go back in time to the 20th century and Bones, the doctor is seeing a patient who shows up in the hospital because they’re trying to rescue Checkov who’d fallen and had a head injury. And they’re trying to drill burr holes in Checkov’s head to relieve the pressure. And Checkov is like burr holes. You’re drilling big holes in his skull, man. Barbarians. And he’s applying this 23rd century or 25th century medicine to this and he’s just like, these people are barbarians. Woman comes up and says, I’m on dialysis doctor. And he gives her a pill and says, take one of these and call me in the morning. And the next scene she’s walking and fine and everything’s perfect.

And I think that contrast of what the future paradigm of medical care is and what we’re doing now it’s huge chasm between it. And that’s why I think we really need to almost think completely differently. What we’re doing with this, oh, there’s a drug that finds a receptor and it does this or cancer is this. It’s like, no, no, no, no, it’s way more complex than that and we need a complexity science that fits that. And then where does the mind fit into that? Where does the placebo effect fit into that? Where does expectation, the fact that we create our reality fit into that? How do we merge those things? I think we’re going to look back and go, dude, this was primitive at best. Like, Gilligan’s Island primitive.

Robert Pearl:

My sense, Zubin, is that in medicine, both physicians and patients crave simple answers to complex problems, that it’s our fear that drives and alters our perception, that all of us are at risk of embracing approaches that can seem reasonable, but ultimately prove worthless. How can people as patients, as doctors, as caregivers, as nurses, minimize the probability of falling into that trap?

Zubin Damania:

I think we have to start change shifting a culture and the way we talk about things can’t be, take a pill and call me in the morning. It can’t be just steal heels and just cut this out and you’ll be better. It’s got to be realistic. It’s got to be relationship based. If you’re going to help a patient on their own hero’s journey, as their mentor, as their helper, you have to actually help them create that reality. And some of it is mind created, which means setting expectations, your bedside manner, your connection with them, your relationship, how you treat your peers and your colleagues actually, they pick up on that and your colleagues pick up on that, which changes how they treat the patients and the general level of stress and connectivity and connectedness. So all of that I think has to happen. And actually I think in many ways nurses can lead that because they’re right there with the patient in that relationship. Sometimes we can be a little detached.

Robert Pearl:

I love it. And when you start leading the parade, I’ll be marching right behind you. Jeremy, your question for us.

Jeremy Corr:

So we’re hearing that the COVID vaccine is likely going to be added to the vaccine schedule for children, which would make it a requirement for them to get to attend public schools. We’re also hearing the CDC is pushing ahead on getting the Omicron boosters approved in children as young as five, while not allowing the clinical trial data to be public. Many respected experts such as Marty Makary and Vanay Prasad have been very critical about how all of this is being handled. One of the most respected vaccine scientists in the world in Dr. Paul Offit is even raising red flags about the lack of transparency and how government agencies and big pharma are cutting corners to get this approved.

What are both of your thoughts on what is happening, what is the long term harm of what is happening in terms of vaccine hesitancy for the tried and true vaccines that are already part of a child’s vaccine schedule and people’s faith in the CDC, FDA, NIH overall and increase the levels of tribalism in the country? And also, to sum it up, if you were to be asked to be the next head of the CDC, FDA, NIH, et cetera, what would you do to restore public faith in the organization?

Zubin Damania:

I love these easy questions. These are softball. Okay, so I’ll take a stab at this one. And I’ve had Paul on my show, I’ve had Marty on my show, I’ve had Vanay on my show, I’ve had people who are more aligned to give mandates for childhood vaccines. This is my take on this, a vaccine mandate implies a couple of necessities. One is that the thing that you’re mandating, because you’re trading off again these moral values. One is liberty versus oppression. So you’re saying, okay, I’m going to take away this liberty to decide whether or not to take this vaccine because the greater good of care versus harm and fairness versus cheating is important. So by vaccinating a five year old against coronavirus in school, we’re somehow going to prevent other children from getting sick or teachers from getting sick. There’s going to be a community benefit.

And so the argument for the community benefit is not that it prevents transmission because it barely does if at all, maybe initially, but then it wears off. That’s just the nature of a respiratory virus like Coronavirus. The argument would be, well, we prevent schools from having absenteeism, you prevent other issues like the rare death or disability healthy child from COVID. But the question then is, well, do you mandate that? And when the majority, actually the vast majority of children have had exposure now to coronavirus or vaccine, mostly coronavirus, is it necessary to do that? And what’s the cost of doing that? So the psychological reactance against the loss of autonomy for parents is real because of our tribalized split society.

So the actualization of this mandate may be that you create more vaccine hesitancy for other childhood vaccines, which are absolutely essential for the collective good, where you need a certain level of vaccination to prevent transmission like measles and mumps, et cetera. So that’s my take is I think mandating this for children right now is not going to accomplish an improvement in overall public health, but may have the opposite effect even though the intention is good.

Jeremy Corr:

And then to ask you to sum up the other parts, what are your thoughts on the whole lack of transparency with the clinical trial data and even like Paul Offit raising the flags about them wanting to approve that?

Zubin Damania:

I think that to a degree everything’s been politicized. So yes, it’s in the best interest of whoever’s in power right now to actually have lower case numbers and so on and have people vaccinated and they believe in that. And I think that’s fine. I think the lack of, it’s very easy to tell Pfizer and Moderna, Hey, you have the money, you have a lot of government money. Do a good human trial on these, because this is not flu vaccination, this is a different virus, it’s a different scenario, flu vaccination, and Paul Offit makes a good distinction between the two. You can’t just then say, Okay, this is going to… And because the main question is hospitalizations, severe disease and death. And we don’t have good evidence with a BA.4-5 vaccine in humans, that those issues are actually improved. You may reduce infection for a transient period of time, but then is that worth a mandate, especially for children?

So it is concerning I think, in my mind. But again, it’s also concerning that there are people saying, Oh, this thing is causing cancers and it’s causing infertility. It’s not. So it’s just empowering, I think people to be even more divided about this.

Robert Pearl:

My sense, Jeremy, is that if we had all the data, we would find that the vaccine is safe and it does help reduce the rare 220 children have died under age five from COVID in a couple of years. So it’s not that it’s going to be negative or somehow data’s going to be hidden, that’s going to say that there actually is tremendous risk. But I’m a big believer, and if I led any of these agencies, that’s what I would do in telling the truth. And I think that what people are reacting to and intrinsic in your question is that a mandate doesn’t make sense in this particular circumstance, or if it does, I can’t fully explain it. And what I mean by that is the following. A polio mandate makes sense. Why is that? Because polio is a horrible, terrible, lethal disease that is easily spread amongst children. And a vaccine, from my viewpoint, not the old oral ones, but the current variety is safe and the problems are so much less than the consequences for children who get sick.

Similarly, measles is one of the most contagious diseases, and there are well defined significant problems that children have who develop the disease, including one of my great grandparents, not grandparents, but children of my grandparents who died actually from measles as a young child. So those diseases have a logic. What’s missing in this situation is the logic of mandating it in young children, their risk is very small and you could mandate a lot of things that would have a more beneficial effect than this particular vaccine. Is it possible that the vaccine mandate would improve the health of the nation? It’s possible, worth debating, but that type of question is different than a mandate of the child who’s going to get the vaccine because we mandate vaccines for the individual, not for the bigger society.

Now, experts can disagree upon how effective those vaccines are, whether that mandate for the individual is appropriate given the risks of the vaccine. In this case, risks are very low, but the benefits are equally low. And I think sitting in people’s minds and the critics you’ve described is this idea of why is it being mandated? What is the truth? Is it really being mandated for the people receiving the shots, or is it being mandated for other reasons? And that’s where I have the problem, because I’m not aware of vaccines that we mandate outside of a healthcare setting that is designed to protect other individuals surrounding them. And that’s why I think the skepticism and the lack of confidence in these agencies exists. And every time you cut a corner, you create a problem in medicine and that leads to more negative than positive, more harm than benefit.

Jeremy Corr:

We hope you enjoyed this podcast and will tell your friends and colleagues about it. Please follow Fixing Healthcare on Spotify, Apple Podcasts, your favorite podcast platform. If you like the show, please rate it five stars and leave a review. If you want more information on healthcare topics, you can go to our website, robertpearlmd.com and visit our website at fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter at Fixing HC podcast. Thank you for listening to Fixing Healthcare’s newest series Unfiltered with Dr. Robert Pearl, Jeremy Corr, and Dr. Zubin Damania. Thank you very much and have a great day.

The post FHC #69: An unfiltered (uncensored) look at ‘medical misinformation’ appeared first on Fixing Healthcare.

In this episode of Coronavirus: The Truth, Jeremy Corr and Dr. Robert Pearl discuss new research out of Scotland that finds as many as 40% of people experience lingering Covid-19 symptoms months after infection. Is this data reliable and, if so, what does it mean for the long-term treatment of this disease?

You’ll find that and all the other [time stamped] topics discussed during this show here:

[00:49] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?

[03:23] Are employer and government vaccine mandates gone for good?

[04:48] Are other nations dropping Covid-19 restrictions, too?

[06:43] Are U.S. healthcare providers still under “one-size-fits-all” restrictions?

[08:58] Do Americans respect/heed CDC guidance?

[09:41] Is Paxlovid worth taking for people with Covid-19?

[11:54] What’s the latest on “Long Covid”?

[15:04] Does Covid-19 infection alter the timing of women’s periods?

[17:28] What’s the latest research on Covid-19 and kids?

[20:48] Beyond Covid: Are people more optimistic and fulfilled?

[22:00] Is polio making a worldwide comeback?

[24:56] What is the primary care shortage doing to America’s health?

[27:39] How bad is the medical debt problem in the United States?

[30:14] What does the Amazon acquisition of One Medical mean for medicine?

This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #66: What’s the latest on long Covid?   appeared first on Fixing Healthcare.

This Fixing Healthcare podcast series, “Diving Deep,” probes into some of healthcare’s most complex topics and deep-seated problems.

On today’s episode, hosts Dr. Robert Pearl and Jeremy Corr explore how the middleman mentality is killing American medicine, and then contrast it with how some of the nation’s largest retail companies (including CVS, Walmart and Amazon) are planning to expel the middlemen of medicine with an effective long-term strategy. Whether you provide medical care or receive it, you’ll learn much from this deep dive into the future of healthcare.

For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a discussion guide:

• What is a middleman?
• What did healthcare look like before middlemen?
• When and why did middlemen enter the picture?
• What is the ‘middleman mentality’?
• What are examples of it in healthcare today?
• Are middlemen medicine’s biggest problem?
• How does the middleman mindset harm patients and doctors?
• Why do middlemen love “fee for service” payments?
• How have insurers and insurance purchasers (employers) responded?
• What might effective leadership look like in healthcare?
• Where does change begin?

• Retailers are making major news in healthcare. Why?
• What are biggest, boldest healthcare acquisitions in recent months?
• Based on the past few years, are giant retailers doomed to fail in medicine?
• What reason is there to believe Amazon, CVS or Walmart can succeed?
• What is the short-term strategy for these retailers in healthcare?
• CVS and Amazon paid billions for primary care companies that are losing money. Why?
• What’s the middle game for these retailers?
• Why are they all interested moving from fee-for-service to capitation?
• How do their latest acquisitions and partnerships tie into Medicare Advantage?
• What does the long game look like and how long will it take to plat out?
• How will the winner be determined?

* * *

Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #68: Diving deep into the medicine’s middlemen & the future giants of healthcare appeared first on Fixing Healthcare.

Dr. Ezekiel Emanuel has spent a lifetime challenging the establishment. He says that tendency is very much a part of his family’s heritage.

“My mother, not infrequently, would have to be in school because her sons were opposing rules and speaking out when everyone else was silent.”

Those other sons happen to be Rahm Emanuel, the former Chicago Mayor and current U.S. Ambassador to Japan, as well as Ari, an American businessman and CEO of the massive entertainment agency Endeavor.

Zeke, himself, is an oncologist, medical ethicist and a major contributor to the Affordable Care Act legislation. In this interview, hosts Jeremy Corr and Dr. Robert Pearl ask him about the rules of medicine that deserve to be broken and who among us can lead the charge for change.

“We are rulebreakers. My partner is always saying, ‘You think a rule is a good suggestion and not as a rule in the sense that most people think about it.’ I would say that it comes from our parents.. My mother, very early on, and I mean very early on, when she was a teenager, was very dedicated to Civil Rights well before white people and white women were heavily involved in Civil Rights … And then in 1965, right after the election, when Medicare was being debated and legislation was moving and the AMA opposed it, (my dad) quit the AMA.”

“I would report myself as a reluctant physician … I really was not very fond of medical school, mainly because I didn’t like the hierarchy of medicine that everyone deferred to whoever was the most senior person around as opposed to, let’s have a discussion about this. And I also did not like all the memorization of medicine and what really appeared to me during medical school to be a lot of irrelevancy that I couldn’t imagine would be really related to treating patients and making advances like relearning the Krebs cycle, like the Startling law and things like that.

“There are a lot of things I wish I had pushed harder on, and a lot of things I wish I had thought more deeply about. I would say top of that list of things that I wish I had thought more deeply about and emphasized more is more simplicity in our system. One of the things I think that the Affordable Care Act unfortunately did is to actually make the system much more complicated, and I think that is a problem. I think it’s one of the major problems of the American healthcare system. It’s so damn complicated to use. It’s really, really hard for people who aren’t focused on health. And even if you are focused, we had to invent the whole new category of employment called Navigators because it’s become so mind-numbingly complex.

“I do think that medicine has moved on since the time that you and I trained in the sense that when we were training almost every patient who died in the hospital got resuscitated. DNR orders were still controversial. Withdrawing treatment was still controversial. We didn’t talk to patients about it, and the majority of patients were dying in the hospital. Well, I spent a lot of time in the end-of-life care field, first of all trying to understand what really motivated patients and then trying to change our norms about it. And I think the norms have changed … I think that this notion of do everything no matter what has evolved, and I think that’s super important.”

“Human beings are on a spectrum or a bell-shaped curve or some kind of curve, where some people are cognitively intact, are physically intact well after 75. Most of us are not outliers like that. Most of us are solidly in the middle. And what you see is in the middle, the rate of Alzheimer’s goes up at 75 … People retire, they end up being less creative. They’re just not producing and contributing in the same way, and that’s not the way I see my life. I don’t want my children or other people to remember me in a particular way. I want to go out being very active, totally intellectually engaged, physically fit. And so that’s 75. And, again, it’s just playing the numbers.”

READ: Full transcript with Zeke Emanuel

* * *

Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #67: Dr. Zeke Emanuel on the virtues of rule breaking appeared first on Fixing Healthcare.

Galileo, Darwin and Einstein: three historical figures who changed the way we view the world. Galileo broke the myth that we’re the center of the universe. Darwin proved that humans evolved slowly, not through sudden divine action. Einstein’s theories of relativity led to new ways of looking at time, space, matter, energy and gravity.

Each of these critical thinkers helped humanity take massive leaps forward. But have some of their lessons been lost on the medical profession? In this episode of Fixing Healthcare, sans cohost Jeremy Corr who was out with illness, Dr. Robert Pearl joins ZDoggMD to probe the left and right brain for answers.

Are doctors convinced they’re *not* the center of the universe – or least the center of health and medicine? Borrowing from Darwin, if life is evolutionary and *not* divinely given, then how much of the end-of-life care doctors provide does more harm than good? And if time and space are *not* static or objective, should the scientific method be the final arbiter for medicine or should we follow a different master?

To find out, press play or peruse the transcript below.

* * *

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

Robert Pearl:

Welcome to Unfiltered, our newest program on our weekly, Fixing Healthcare Podcast series. As usual, joining me today is Dr. Zubin Damania, known to many as ZDoggMD. Unfortunately, Jeremy has lost his voice, a terrible problem for a podcaster. As such, I’m going to have to do his part of today’s show as well as mine. For 25 minutes, Zubin and I will engage in unscripted, and I predict, hard-hitting conversation about art, politics, entertainment and much more. We’ll apply the lessons we extract to medical practice. I’ll then pose a question for the two of us to consider that Jeremy might have asked, to conclude the episode. Zubin, are you ready?

Zubin Damania:

Oh, I’m ready. It looks like all your years of being an understudy for Jeremy… Jeremy, they’re finally coming to fruition. You finally get to step up into the lead role.

Robert Pearl:

Excellent, excellent. So, let me start Zubin, by clarifying another of the many rumors about you that I see on social media. So, is it true that they asked you to be the king after the death of Queen Elizabeth, but you turned them down?

Zubin Damania:

I turned them down because honestly, I didn’t have a circular enough family tree to have the requisite recessive genes to be a monarch. I was too out bred, honestly, that was part of the problem.

Robert Pearl:

You could have had a poison ivy, poison oak kind of family tree, I think. Right?

Zubin Damania:

Exactly. I mean, all seriousness though. The loss of the queen was like the loss of a common mythology. We were talking about the hero’s journey the other week, and this idea that we have this shared identity. Most people in living memory do not remember not having Queen Elizabeth as the monarch of Great Britain. So, it actually is a grieving process for everybody in a way.

Robert Pearl:

Well, anyone under the age of 70 wasn’t alive, and probably they don’t have very many remembrances until at least age 10. So, anyone under the age of 80 can’t remember a time before that. Probably anyone over the age of 80 might have forgotten some of the things way back then, so we’re left with the fact that no one could remember a time without Queen Elizabeth.

Zubin Damania:

I think that math is correct. Yes. I believe it.

Robert Pearl:

So, anyways, we heard from lots of listeners that they enjoyed the conversation we had about Amazon’s acquisition of One Medical, and the implications it has for American medicine. Since then, as you know, CVS acquired a company called Signify, and the company employs 10,000 physicians to provide in-person and virtual at home care. United Health, which already employs over 50,000 doctors, signed a 10 year agreement with Walmart. In your opinion, Zubin, how nervous should physicians be and what do you recommend they do now?

Zubin Damania:

Well, I mean, I think this is clearly an epiphenomenon of how we’ve actually failed to do the job of healthcare that Americans actually want. So, private industry is stepping up, and with the probable some degree of hubris that they can do it better than physicians. But the truth is, they have the resources, the drive, the time horizon and the incentive because they’re paying, their footing the bill for their own employees. So, I would be concerned quite a bit if Amazon, if CVS, if these guys are all partnering to do this, that they’re going to at least have a shot at succeeding on some level. That’s going to put the pressure on regular physician groups and multi-specialty groups to step up as well. This is something that’s probably been a long time coming and probably overdue.

Robert Pearl:

I mean, I’d argue that we have refused to take the lead, and as long as there’s a vacuum and a void, someone else will come into it, so why not be one of the big businesses in the United States?

Zubin Damania:

Yeah. I mean I think that’s the bottom line. Especially with the Amazon thing, it’s interesting because again, Iora Health are partners at our clinic in Las Vegas, to see it go full circle back to Amazon, I’m just… Again, if they get it right, they really have a very powerful model in their hands. If they can scale it for chronic disease that the Iora model and for the consumer, the younger people, the One Medical model, I would be very nervous right now if I were in the traditional healthcare system. I think doctors can no longer just say, “Oh, you know what? I’m just going to keep my head down and hope it all settles out.” It’s like, we have to lead, because if we don’t, it really will be the technocracy that leads it, and it won’t be the best for, I think, the physician/patient relationship moving forward. So, we do have to start to lead, because we’ve really dropped the ball, like you said.

Robert Pearl:

This morning, Zubin, I published an article in Forbes on leadership, or at least what I see is its lack in healthcare today. So, the listeners should be aware, you probably haven’t had a chance to read it, but I’d like your thoughts on the following paradox. From my perspective, the challenges in healthcare are massive: lack of affordability, lagging quality burnout, healthcare disparities, we could go on for the entire show today, just listing the ones that are there. Yet most of the efforts I observe that people and companies inside healthcare are doing, they’re focused, Zubin, on a small opportunity often, an incremental improvement. Do you see the need for a massive change? If so, who should and who do you think will lead it?

Zubin Damania:

Well, what I think is happening is this is indicative of our societal shift in general towards this micro thinking, reductionism, left-brain scenario. There’s a lot of misunderstandings about left brain, right brain schism, by the way, Robbie. Like Iain McGilchrist, a psychiatrist, neuroscientist in Great Britain wrote a great book called Master and His Emissary, about the actual debunking some of that mythology. The mythology that the left brain is the rational clear thinker, sees strategically and so on, that’s not true. The left brain takes wholes and breaks it into parts. It always thinks it’s right. It has righteous anger, it’s a reductionist, and it is isolated from the whole, and that’s what it is. It’s a grasping tool.

Zubin Damania:

It’s the right brain that sees things holistically as a bigger picture, and sees parts in their context. In medicine, I think what we’ve done is we’ve tried to, oh, well we can improve this little thing, or we can build this little widget a little better, and we build this little widget, and you forget that this is a multidimensional interdependent organism that is healthcare. Who is going to lead that? It has to be the part of that organism that does the operating end of it, and that’s physicians and clinicians and people in that space. They really haven’t. What happens is now you have this technical reductionism, where you have people working on these different parts, and they talk about, “Oh, now I’m wearing a Fitbit, and here’s this data.” It’s like, how does that data plug into the bigger picture, and what are the hopes, dreams and fears of the patient that you’re getting that data from? How does this relate to outcomes that matter to them, and that also save money in the economic game and so on?

Zubin Damania:

It has to be, I think, physician leaders in partnership with business leaders, in partnership with economists, in partnership with businesses, because they have so much skin in the game. What is it? Half of all the spending in the country on healthcare is from our large employers, employers in general. We have to look at it more with a right brain, left brain collusion, more of a balance. We haven’t done that. It’s just like the rest of society, we reduce and reduce and reduce, and it becomes this technocracy.

Robert Pearl:

Are you saying that the right brain, and again, speaking really metaphorically not anatomically, but that the right brain is the more logical of the two hemispheres?

Zubin Damania:

No. It’s more that the right brain sees things more in context. It is actually more emotionally intelligent according to McGilchrist. He lays out in 1,000 pages why this is so. It actually was the master in the original relationship, and as societies and individuals evolve over time, the left brain, which was the servant, it actually evolved to help the right brain break things into parts and manage little tasks and things like that, it actually started to think it was the boss, and that by breaking things into parts, you could recreate wholes from the parts. It doesn’t work that way. It’s the emissary suddenly usurping the role of the master. This is metaphor, but it’s also based on studies off split brain patients, on people who’ve had strokes in different sides of the brain and seeing what happens.

Zubin Damania:

For example, people who’ve had right brain strokes, where parts of the right brain are knocked out, they tend to not see things contextually. They’re very concrete, they live in abstractions, they’re unable to function in society. Whereas left brain strokes, people tend to overcome them. Often you lose speech or language, and language is a very reductionist thing too because it breaks things into parts and subject and object. But you still function actually reasonably well. So, it’s really quite fascinating that… He points out to western civilization, as society evolves it shifts to a more left brain dominant space before it collapses. He goes to a lot of history and different big civilizations and what ends up happening. They become these huge bureaucracies. Bureaucracy is the domain of the left brain. What you really need is a corpus callosum that connects the two, that actually brings balance, where master and emissary are in harmony. We’re losing a little bit of that balance it feels like, definitely in healthcare, but in society in general.

Robert Pearl:

I love that analogy. Let me take it a step further. It seems to me that the context of medicine is the unaffordability for the patient. It’s the fact that we don’t do as good a job on prevention, avoids the complications from chronic disease, as we might. It’s looking at the technology that we value, like the operative robot and the technology that we tend to minimize, even now, like telemedicine. It seems to me that maybe what you’re saying is that as physicians, we are really trained in the left brain, multiple choice questions and four answers, and that we need to have a lot more of this sophisticated understanding of the right brain.

Zubin Damania:

That’s it exactly. I think you nailed it. I think in medicine we really are left brain oriented through our education. That right brain, that’s why we ought to be screening physicians, not so much on MCAT scores and these reductionist pieces, but on emotional intelligence, creativity, imagination, those pieces that are very right brain, left brain synergies. Like you said, I think taking a patient out of his or her context, is problematic. Their social determinants of health and all of that are a big piece of it, that’s their context. Their family, their community, their culture, all of that rolls in. Then it’s the same with medicine. If you take a piece of data out of context of the bigger picture, it doesn’t mean anything.

Zubin Damania:

In fact, it leads to more reductionist poking and iatrogenesis and cost from causing harm and those kind of things, where we’re doing things to people instead of for the larger person. So, I think it is a very good metaphor actually, a good model for where we might be going wrong. It’s not limited to medicine, but I think medicine is the best example of it, because it’s such a human enterprise. When you start to see it go out of balance, people know it. They may not be able to articulate it, but saying, well here’s a model that might actually put it in words, in some kind of structure, it might be helpful for people to go, okay. So, how can we overcome that?

Robert Pearl:

Do you have a view how it’s going to happen? Is it going to be an individual like yourself who started a program in Las Vegas? It had to close in the end. But today, might have been successful. Is it going to be a medical group led by some CEO? Is it going to be some type of medical society? How do you see this, I’ll call it massive change, disruption is what a business student would call it, happening, a transformation of how healthcare needs to be provided? How are you going to get ahead of the curve, rather than letting these other organizations like Amazon and CVS beat us to the punch?

Zubin Damania:

Yeah. That’s a great question. Disruption in the classical tech, say a tech company or something disruption, it really is a very… It’s almost like a single site mutation. You do this one thing better and you do it cheaper, and initially the quality isn’t as good. Then over time it gets better, and really suddenly that other big old school legacy company is out of business because you’ve disrupted their model. In healthcare that more reductionist left brain disruption can’t happen. It has to be a holistic, multifocal, almost like a caterpillar turning into a butterfly, every organ transforms. That means all the entities that you listed, I think, have to be a part of it. They all have to wake up a little bit to, okay. What’s the problem? Because a problem well defined is already half solved, as they say.

Zubin Damania:

Then each of us starting to work on solutions, but connecting with each other so that we never miss the big picture, because otherwise we’re just spinning our wheels in the dark. Like the old metaphor of the elephant, trying to figure out what is this creature, and blind people, these blind wise men, each touching a different part of the elephant and not understanding that it’s an elephant, until they actually talk to each other. So, that’s what we haven’t really done a lot of, is connecting across these different spectrum. Like you said, the medical societies and the big healthcare organizations and the small healthcare organizations, and the on the ground doctor and so on.

Robert Pearl:

Listening to you, Zubin, I’m reminded of something that I read about three historical figures who change the way we see the world, because I think what you’re describing is that doctors need to see things different, see them in context. These three people, pretty famous, Galileo, Darwin and Einstein, and how their discoveries contradicted how humans see the world and ourselves. Galileo broke the myth that we’re the center of the universe. Darwin proved that we became human through slow evolution, not a sudden divine action. Einstein demonstrated that everything is relative, and maybe we can apply this a little bit to medicine. As doctors, we see ourselves at the center of medical care delivery. We see our judgment as the best way to reach the optimal approach for a patient’s problem. But maybe, just what if it’s actually complex data analytics or even artificial intelligence? How will we know that we need to change and what do you think we’re going to do about it?

Zubin Damania:

Yeah. This is a great question, because as you’ve pointed out, Robbie, in your books, physicians in particular are the masters of denial. So, we can continue to drill down in our little piece of the world, thinking that we’re doing good and at least convincing ourselves of it, because we’re generally pretty good people. I think what happens though is we need to wake up that it’s not working. I think many of us intuitively feel it. Some people will say, well, this is a function of burnout and we don’t get enough resources and we don’t get enough tools and trust and teams and so on. To some extent that’s absolutely true. But to another extent it’s just that we are drilling down in the wrong direction. I think people who work in primary care feel this very acutely because they see what’s broken.

Zubin Damania:

They know intuitively what needs to happen with their patients, that it is a contextual thing. It’s a much more intricate web and they need the time to spend, but also the tools. Like you said, the AI and the data analytics to give them the best possible tools. Everything that can be mechanized is mechanized, and then apply it to that unique complex human entity that’s in front of you. That has spiritual components, it has scientific components, it has psychological components, everything is bio psychosocial at root. To some degree, it’s waking up from our own slumber on this, our own denial on this. I think people are waking up. So, it might be that we don’t even predict it, Robbie, that all of a sudden there’ll be this mass tidal wave, the culture will shift, we’ll all wake up and then it will just start to avalanche, the change. But that’s an optimists view and I tend to be an optimist, so I’m hoping that it’s right.

Robert Pearl:

When I look at it, I wrote a little bit about it in the piece today, it would seem that the people who would really be pushing for a move from Fee For Service to capitation would be primary care. I mean, in a Fee For Service world, the only way you can generate more revenue is seeing more patients. That’s what’s happening today. We’re seeing more and more patients all the time, which means that the amount of time per patient is going away, and all the things you just discussed, all of the contextual ways. We need to understand the individual in terms of the social world in which they exist. There’s no time to figure that out. Whereas in a capitated world, the way you are economically successful is by taking out the things that add little benefit for the patient, and by helping the individual avoid disease and avoid the complications from chronic disease. Yet outside of a few groups that are across the nation in primary care, I’m not hearing the big primary care societies pushing for it. Why not?

Zubin Damania:

I think they’ve been burned by the promise of capitation not actually panning out in their lives. So, if you’re capitated, and everything you said is absolutely correct, and that was our belief at Turntable and Iora, it’s like, give us a chunk of money to care for these patients, and we’ll do it right. Now, the question I think becomes, how much is that chunk of money? Because you can certainly spend more time and apply more levers and resources to those patients if you have a little more money per patient, per month. Then what your panel size is, what’s your support? What are the tools that you have and the teams, the human resources? Then are you given the trust to actually have those outcomes happen if your skin’s in the game somehow? You’re a part of the organization and you feel really invested in it, then you will do that.

Zubin Damania:

But we all know the stories of, there’s some people who… It’s almost like quiet quitting. They’ll phone it in because they know they’re getting this or that salary or whatever, and the patients are capitated so they’ll have a big panel, but they’ll do the minimal necessary and the organization suffers. So, I think it’s just getting the details right. It’s actually just figuring out those bits. Some of that is culture and leadership and those sort of things. But I’m curious what you think, since you led one of these large, very successful organizations for so many years.

Robert Pearl:

My sense is that capitation generates fear, because you’re now actually responsible. You can’t just do something and expect to get paid for it. If things go wrong, and you’re absolutely right, you’ve got to get the amount of capitation right, you have to have some protection against things like a transplant and other things that are just unexpected, COVID hitting this shore. So, you need to have it negotiated correctly. But it does require things that I think are not intrinsically built into doctors after their training. One is this willingness to take risk, that’s much more of an entrepreneurial piece. The second is it requires tremendous collaboration. Third, it requires that everyone agree on how they’re going to take care of a problem and having agreed, actually do it. We love autonomy. We like to be able to do whatever we want to do. I think that that is problematic, and ultimately all the things we learn as physicians are anti capitation. They favor Fee For Service. It’s just that in the current world, Fee For Service doesn’t work, from my perspective.

Zubin Damania:

I think that was really well put. I think that’s directly it. It’s our culture. I mean, there are many doctors even listening to this conversation, who’ll say, “Oh God. They’re talking about capitation, and they don’t understand that that’s a loss of autonomy, and it’s this and the other thing.” To that degree, they’re correct in the sense that you can’t just go and do anything you want. There is a collective shared agreement that you’re trying to coordinate, almost like an organism. If you’re a tissue in a body, you do coordinate with the other tissues and organs and systems, and there is a general ethos and telos and flow to where you’re going. I think we’ve not had that in health 1.0 and 2.0. 2.0 is more of a top down, okay, we’re just going to do this. And then there’s general rebellion or quiet quitting, just phoning it in.

Zubin Damania:

I think a 3.0 model is more, okay. Listen, no. Actually we need to change even our expectations, what it means to be a physician and what it means to work in a large organization, or even a smaller organization or as part of a defacto network of physicians. So, some people opt out and they go, I’m going to do direct primary care and I’ll get a capitated rate to take care of patients and I’ll do it my way. That’s wonderful, except that it doesn’t integrate with the larger system unless they generate structures to do that. So it is kind of one of the big challenges moving forward.

Robert Pearl:

Well, that model requires that people be able to pay a lot more to get the added convenience. There’s a segment that can do that, but it won’t solve the problem of the more general population. Again, I just see that I would much rather generate income by helping patients avoid heart attacks and strokes and cancer. When I became the CEO in Kaiser Permanente, our hypertension control rate, the number one cause of stroke, was similar to the rest of the nation, a little bit better. We were maybe at 60%, the nation was 55. We agreed that every doctor, not just primary care, would look at the blood pressure. Maybe the specialist couldn’t take care of it, but the specialist would know whether it was normal or not and could make sure the patient got taken care of. We got that over 90% diminishing strokes by 30%, the same when it came to heart disease with blood lipids, hypertension, smoking, et cetera.

Robert Pearl:

We dropped the rate of patients developing a heart attack by 40%, the chance of dying from heart disease by 50%. Same thing when it came to colon cancer. Every doctor can look on a chart and say, “Did you have your proper screening?” I don’t mean having some kind of colonoscopy. I’m talking about getting a FIT test, a fecal immunochemical test that you can do in your bathroom in five minutes at home without a bowel prep. How hard should it be? The nation is around 60%. We got up to 90%. Again, saving 40% of people from developing metastatic disease and cancer. These are the kinds of things I would think would drive doctors to say, I’d much rather do those things than add another patient and another patient and another patient. But somehow that passion isn’t there. Again, when you ask me why, I just think there’s this fear that somehow we’re going to give up what we have today. When I look at it, what we have today isn’t that great.

Zubin Damania:

Yeah. I think that’s it. The stuff you’re talking about isn’t sexy. It’s not sexy to prevent a colon cancer, or prevent a heart attack. It’s sexy to go in with a stent and dramatically open up, get Timmy three flow out of this thing that’s acutely occluded. That’s the cool autonomy, and that’s where you’re the Top Gun maverick, doing your thing. I think we’re very conditioned by that kind of glory, and not looking at the just sheer number of lives and suffering, and area under the curve of good we’re doing in the world, by what you’re pointing at. Again, that’s cultural conditioning from years. It’s almost like a karmic thing. How many millennia physicians have had this kind of autonomy and shamonic role in the community, and they feel that it’s being reduced? But I think there’s room for all of that. There is a holistic way of looking at this that actually incorporates all aspects of that. Again, some of it becomes a cultural shift. What gives us joy in medicine?

Robert Pearl:

So, I hate to think of a show when we’re not controversial, so let me look at that in the same context and move on to Darwin. If life is evolutionary and not divinely given, then might much of our end of life care be creating more harm than good? Or phrased differently, Zubin, is the idea to save a life at any cost an artificial construct? If it is an artificial construct, what should we doing? I mean, I think of patients I’ve taken care of with head and neck, cancer of the tongue, who’ve had a series of surgeries, they can’t speak, they can’t eat, they can’t breathe. Or I just read about a patient who spent 900 days intubated on a respirator in the ICU after COVID. When does medical care become torture?

Zubin Damania:

Oh. This, again, it gets back to this left brain, right brain thing. There is no part of a right brain approach to this issue that would do the 900 days COVID post ventilator thing. Because again, that’s doing things to people, it’s turning people into machines that are failing as a model. The left brain is a machine and the machine is working or not working. Humans are not… They can’t be reduced to mechanistics. They’re very dynamic, crazy, complex processes that include this element of spirituality. Even a non-religious spirituality where it’s like, no, there’s meaning, there’s purpose, there’s awareness. That’s what makes humans just absolutely beyond any mechanistic description of them, that could reduce anything to that. So, what we’re doing now is, from an evolutionary standpoint, it’s crazy, because it doesn’t make any sense. Of course, we’re a little beyond even standard evolution now because our technology is helping us.

Zubin Damania:

So, we’re evolving our technology as a proxy for our DNA. It doesn’t even make sense, I think, from any religious based, spiritual approach because it’s decidedly unnatural to draw things out in a way that is against what even the patient would want if they were able to speak. We haven’t had the conversations, we’re fear-based. Ultimately, Robbie, it’s our fear of death because we are in the dark as to what it is we actually are. So, we live in this dark hall of fear, and as doctors we suffer from it because we won’t even talk about it with our patients, because in some way it reflects back to us and our accomplishments and our conditioning and our culture.

Robert Pearl:

I wonder how you’re going to apply this left brain, right brain, right brain putting in context to the things we’ve learned from Albert Einstein. The idea that somehow everything is relative. Is that a question of putting into context, taking it out of context? Is the scientific method, the final arbiter for medicine, or should we follow a different master?

Zubin Damania:

Oh, man, you’re asking a good question. So, Einstein, fascinating guy, because what he would do, you would think, Einstein’s the epitome of the left brained scientist. Not at all. In fact, what McGilchrist argues in his book is that the idea of science and reason is not a left brain thing. Reason is a right brain scenario. It’s taking data from the world, taking information, and actually applying the filter of context and common sense. What Einstein used to do is he would bang away at a problem in a reductionist way as long as he could, and then he would stop and he would just give up and he would go to sleep. The inductive, intuitive processes that are much more right brain oriented, would speak. That’s how he would get these insights that were beyond.

Zubin Damania:

I mean, how would you derive the theory of relativity from first principles? You can’t. It’s almost an intuitive leap that he made. The fact that everything is relative, that time and space are plastic, was a transformative idea. Even Einstein would say things like, “We’re trying to probe the mind of God here. The more you look, the deeper the mystery, and you should celebrate the mystery.” So, again, I think it relates again to this idea that the mind is a mind divided into these realms. Increasingly one realm is becoming ascendant, and it may not be the realm that should be ascended. It’s the servant rather than the master.

Robert Pearl:

With Jeremy not being here today, I have to take a guess, Zubin, about a question he might ask. He’s an historian, so I’m going to ask you, given everything you’ve talked about for the past half hour, if you had to pick a president from the past to lead healthcare into the future, one who could understand this newer definition of left brain and right brain, who would it be and why?

Zubin Damania:

Wow, man. That’s putting me on the spot. Let me think of my history here. I think it would be a split between Teddy Roosevelt perhaps, FDR or JFK. The reason I picked these three is what they found, what they could do it seemed, was integrate very complex information like World War II with FDR. Teddy Roosevelt, more the general milieu of everything in the wars that were going on and so on. But in John F. Kennedy, with the moonshot, the Soviets, the Cuban Missile Crisis, integrate all this kind of reductionist data with deep understanding of the connections between humans, how to inspire them, how to move them through crisis, how to actually embody some of the values that we claim to have in America, and embody them and show them in a way that actually inspires others. I think I would vote for those guys. They were the perfect balance of right brain, left brain, and the transcendent quality that comes when those are in balance.

Robert Pearl:

I too think of three people. One person is Abraham Lincoln, who tackled probably the hardest question our nation has had, that of slavery. Which should be an easy question, but not in the context in which he lived. He had to balance the sides, he had to bring into his cabinet, as Doris Kearns Goodwin has pointed out, individuals from different backgrounds, often not from his own party. He was able to not do what most people would do, I will call it left brain, in quotes, logical approach. But to put everything into a context. I agree with you also about JFK. But to me, the big thing is, he was going to take the leap, put a man on the moon. I think for healthcare, that’s what we need.

Robert Pearl:

We need someone willing to take the risk, willing to make that commitment, not just sometime in the future, but he set a 10 year deadline and met that deadline. The third person I’d put is George Washington. I’d put him for two reasons. First of all, in the context of the immediate, he could see the difference between the United States being a free country, and being a country under Britain, he could see the opportunities through linking together with the French. Then, when he could have become a monarch and taken a third term and fourth term, he could see the problems that would create, and he put the nation in front of himself. I think that that’s going to be required for us to move healthcare into the future. We’ll see whether medicine can have the kinds of leaders that you and I both see and see what Jeremy says in the next program.

Robert Pearl:

For the listeners, we hope you enjoyed this podcast, and will tell your friends and colleagues about it. Please follow Fixing Healthcare on Spotify, Apple Podcasts, or whatever other podcast platform you use. If you like the show, please rate at five stars and leave a review. If you want more information on healthcare topics, you can visit my website, robertpearlmd.com, or our website @fixinghealthcarepodcast.com. You can follow us on LinkedIn, Facebook and Twitter, at Fixing HC Podcast. Thank you for listening to Fixing Healthcare’s newest series, Unfiltered, with Dr. Robert Pearl, Jeremy Corr, and Dr. Zubin Damania. Have a great day.

The post FHC #66: Right brain vs. left brain in medicine  appeared first on Fixing Healthcare.

This Fixing Healthcare podcast series, “Diving Deep,” probes some of healthcare’s most complex topics and deep-seated problems. On today’s episode, Dr. Robert Pearl and Jeremy Corr talk about two of the world’s biggest tech companies and their potential impact on American healthcare.

Later in the episode, the hosts revisit the three biggest threats facing healthcare and discuss solutions that can and must be implemented in the next two years.

For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a time-stamped discussion guide:

[01:08] How much of an impact has technology had on medical practice in the 21st century?

[01:55] Don’t doctors want to be at the cutting edge of technology?

[03:38] How are tech companies trying to penetrate healthcare’s $4.1 trillion market?

[04:18] What is the unwritten rule of health technology?

[05:32] Is Apple breaking or following this unwritten rule?

[07:45] Can Apple make a meaningful difference on human health?

[08:50] Can Apple profit in healthcare without fundamentally improving health?

[11:21] What could Apple do differently?

[12:35] What would be the impact of a medical device created by Apple?

[15:14] Why hasn’t it happened yet?

[16:00] How is Amazon’s healthcare strategy different?

[17:03] What’s Amazon’s long-term goal?

[17:44] Hasn’t Amazon failed twice before in this space?

[18:39] What happened with Haven and Amazon’s telehealth platform?

[19:42] What’s the biggest hurdle Amazon will need to overcome?

[23:20] What is healthcare’s “perfect storm” and is it heading our way?

[24:39] Where will the impact be the greatest from the three “mega forces”?

[25:42] What options do hospital leaders have to temper the storm?

[27:34] What’s the first action needed?

[28:25] How, exactly, could hospital leaders quickly to reduce cost, increase access and improve professional satisfaction?

[30:24] Could the right hire actually decrease the cost of care?

[32:05] What’s the second action needed?

[33:25] How might this concept be applied to the work that doctors do?

[34:42] What’s the third action needed?

[36:44] Why haven’t these changes been made yet and what’s next?

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #65: Diving deep into Amazon and Apple’s healthcare ambitions appeared first on Fixing Healthcare.

In this episode of Coronavirus: The Truth, Jeremy Corr and Dr. Robert Pearl discuss the battle between the current Covid-19 vaccine manufacturers, the next generation of mRNA vaccines, and the latest on America’s monkey pox fears.

You’ll find these topics and others discussed during this show here:

• Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?
• How are future Covid-19 vaccine shots being positioned by the federal government?
• Listener question: “Why did the government decide to stop paying for everything Covid-19 related and leave that to private insurers?” Will this apply to this next generation vaccine?”
• Why aren’t Moderna and Pfizer playing nice with each other?
• How profitable have the vaccines and treatments been for these two companies?
• Are employers still requiring vaccines? What has happened to those that did?
• Have Americans changed their approach to COVID and vaccine requirements since last we spoke?
• Listener question: “Is there any data that Paxlovid actually saves lives?”
• What’s the latest science relative to Covid-19 and kids?
• What is the current science on monkey pox and the people who contract it?
• Listener question: “Has anyone died so far from Monkey Pox?”
• How have healthcare professionals administered monkey pox vaccines?
• How has Covid-19 impacted life expectancy?
• Listener question: “I couldn’t tell from your last episode, are the drug coupons that manufacturers give out is positive or problematic?”
• What’s new beyond Covid-19?
• How would consumers feel about getting medical care through Amazon, CVS or Walgreens?

This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #65: Why are Moderna and Pfizer going to war? appeared first on Fixing Healthcare.

American writer Joseph Campbell famously studied and diagramed the hero’s journey in folklore and literature. That journey begins with a call to adventure, prompting the hero’s reluctance—often due to a fear of failure. Along the way, mentors lends guidance and help, but it is ultimately the hero, alone, who must summon the courage to win the day.

In this episode of Fixing Healthcare, hosts Jeremy Corr and Dr. Robert Pearl join ZDoggMD to discuss the hero’s journey in healthcare. In every medical professional’s career, there is a calling, a fear of failure and people along the way who provide support (or pose additional challenges).

Who are healthcare’s heroes these days? What are the dragons that need slaying? How do we overcome our fears of failure in medicine? What journeys lie ahead for the future of American healthcare?

The show concludes with a question posed in our last episode. We asked listeners on social media: “What medical hero or moment in history deserves its own Hollywood adaptation?” The answers may surprise you.

For more, press play or peruse the transcript below.

* * *

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

Jeremy Corr:

Welcome to Unfiltered, our newest program in our weekly Fixing Healthcare podcast series. Joining us each month is Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice. Then I’ll pose a question for the two of them as a patient based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Good morning, Zubin. How are you doing?

Zubin Damania:

Top of the morning, Robbie.

Robert Pearl:

Excellent. I’ve heard from dozens of listeners, who have said they can’t wait to hear us talk about the hero’s journey that you mentioned in our last Unfiltered episode, and I promised that we would explore it today. So let’s dive in. Can you tell listeners a brief summary of Joseph Campbell’s ideas and his model?

Zubin Damania:

Yeah, so Joseph Campbell studied mythology and what he called the monomyth, the single myth that crosses almost every human culture that he studied, is this idea of the hero’s journey. The idea that the hero, all of us, really, starts out in one place, and then there’s a call to adventure, because there’s something not quite right there. There’s a call to adventure, and then there’s a whole series of things that happens. There’s a mentor that comes and takes them, helps them leave the shackles of inertia and fear, go out into the world and fight the dragons and do the trials and suffer the ordeals, all to gain some sort of atonement or knowledge or elixir that then they return with, for the benefit of all people. And this is such an archetype throughout human history, in a spiritual sense, in a actual, absolute sense, and looking at all our pop culture too, the hero’s journey is woven into much of our most popular movies and books and stories and ideas.

Robert Pearl:

As I remember Joseph Campbell’s work, there’s also early in the path, a mentor, a gnome or a dwarf, someone else who gives the hero the encouragement or the ideas or breaks through a thought process that the hero is stuck on, so that the battles with the dragons can begin. How do you see all of this happening inside of medicine? Who are the heroes? What’s the arc? Where should we be looking? What should we be teaching medical students? Tell me how you apply this inside the medical realm.

Zubin Damania:

I think every single person who works in healthcare undertakes the hero’s journey, in some sense. They start out as having not the knowledge and the skills and the ability to do what we do, which is very difficult, and then they embark on this journey. And the mentor can be anybody, anything. Nowadays it can be a podcast that opens people’s eyes, that suddenly expands their circle of understanding or their circle of compassion. What they thought was one way is actually seemed to be not true. It’s actually a bigger way or a more inclusive way. And sometimes the mentor is very specific. For me, it was Tony Hsieh, who was the CEO of Zappos, who snapped me out of my inertia and my fear and said, “It’s clear you want to do these things and change these things. Why don’t you do it?” And helped me quite a bit.

Zubin Damania:

For others, it may be a teacher. It may be a family member. It may be a physician assistant. For me, it was the person who taught me that procedures aren’t something to be afraid of. I was always so afraid of being a klutz and screwing stuff up. And they’re like, no, no, no, no, no, here, here’s how you need to look at this. And so it can be anything. And the idea then ,there’s the personal heroes journey, but there’s also the systems journey. Our system has gone from what I call health 1.0, and then the hero’s journey through 2.0 and the trials and the tribulations and the struggles of our technocracy, the administrative technocracy of 2.0, to the 3.0 return of the hero. So it actually has ramifications throughout medicine, both individually and from a systems stand point.

Robert Pearl:

Are the dragons the diseases, the system or the people?

Zubin Damania:

Sometimes the dragon is us. I really think that the more I introspect on this, the more our dragons are all self-created, because you can say, “Oh, it’s cost and it’s insurance, and it’s corporate medicine and private equity,” and it’s this and this and this. And those are all projections. We haven’t really addressed the internal dragons. The fact that we are very highly conditioned, fear bound creatures, and we get the system that manifests who we are. So maybe the dragon is us. And that’s a difficult journey, but that’s the classic Joseph Campbell spiritual hero’s journey.

Zubin Damania:

The idea of atonement with the father is a part of what he describes in the hero’s journey. And the father can be God. The father can be this idea of oneness and how we feel so separate, and the idea of our own ego, and how do we square that with this sense, this deep intuition, that we’re much more than we think we are. Yeah, it gets spooky and weird, but honestly this is the heart of the matter. And I think the hero’s journey is such a good framework for looking at that for all of us.

Robert Pearl:

So you described your hero’s journey, becoming a doctor, mastering procedures. How about your journey to becoming a transformational leader?

Zubin Damania:

And I’m still uncomfortable even with that term transformational leader, because I still have such an impostor syndrome around this, but I would say that there are all concurrent lines and levels of development in the hero’s journey. So for me, it’s funny, my story, Robbie, it’s weird. It falls classically into this hero’s journey kind of archetype. And I’m not saying I’m a hero or anything. I’m saying it pencils out. Here I am at Stanford for 10 years as a hospitalist and I feel very dissatisfied with how medicine is done.

Zubin Damania:

I feel we don’t prevent disease. We’re reactionary. We’re spending all this money and I feel disconnected from my patients, from myself, from my family. Then comes the mentor, Tony, who is like, “Are you happy doing what you’re doing? Here’s a book you could read,” The Happiness Hypothesis by Jonathan Haidt. My mind is it blown by that. I get very depressed. And then I overcome the fear. I get this offer to go to Las Vegas and then go on the journey there.

Zubin Damania:

And at this point, I have to learn everything about how does healthcare actually work? What does leadership even mean? How do humans even function? How does the mind even work? Because that’s not something we technically learn in medicine. And so the heroes journey for me was battling all this misunderstanding, misconception of how things are, and then battling my own ego, through meditation and that, the spiritual journey, and then doing the work of building a clinic and doing the business stuff and learning operations and fighting that battle, and the mentor helping you, but stepping away quite a bit. And failing, and then feeling what that’s like, the hero setback, but you learn so much from that. And then trying to return with this knowledge, with this show that we do, going, “Okay, now, how can I actualize this in myself and others the best I can while still feeling like a complete impostor?” And so it’s still a journey that continues to unfold.

Robert Pearl:

You’ve mentioned impostor syndrome now twice. One of the books I really enjoyed reading was by Angela Duckworth, the book Grit. And she talks about how perseverance counts twice as much as talent. First, perseverance allows you to build ability, and then it allows you to apply it. And yet so many physicians feel like they’re an impostor, and I believe that it happens because we think that the successful physicians are just brilliant, and we’re not as brilliant as they are. Or they’re articulate. We’re not as articulate as they are. What they don’t see is how much perseverance and hard work goes in there. Anyone who does really well works hard and they hide that often. I think the impostor syndrome is really problematic because it so undermines the confidence and the willingness of people to step forward, and I believe that the whole idea that we are impostors is an illusion. What are your thoughts?

Zubin Damania:

Oh, I think everything we believe is an illusion, honestly, but I think you’re onto something here, Robbie, and I think impostor syndrome has to be reframed internally as, oh, I’m feeling a little uncomfortable with my abilities in this space, for some reason. That’s great. That means I’m pushing the boundaries and that means more diligence or more doing it, more pushing, is probably a good thing. Within parameters. Sometimes doctors feel like they can work their way out of any problem, and that’s also a bit of a misunderstanding.

Zubin Damania:

But absolutely. They don’t realize what your friend Malcolm Gladwell says, it’s these 10,000 hours of diligence. You can have no talent. You can have a bunch of talent, but if you don’t put in the energy, you’re not going to do it. So public speaking’s a great example. You can feel like a complete impostor and you just keep going and doing it, keep doing it, keep pushing. And then it just starts to click and at some point you go on stage and you’re like, wow, what a gift to be able to be here and connect with this audience. And that sense of impostorness is almost like that egoic reflection of me against the world, me separate, dissolves into the absolute oneness of being present with other beings in this mutually reinforcing way. And so yeah, I’m with you, man. I’m with you. That’s a long way of saying, I’m with you.

Robert Pearl:

You say that for some reason we feel uncomfortable. The reason is, everyone feels uncomfortable when they first learn to put a knife into a human being, I guess, unless you’re some type of sociopath, or stick a catheter blindly into a blood vessel and hope it hits the right place, knowing you may penetrate the lung. There are all these things that we do that are designed by nature to be unusual, because no animal can do them. And so we have to gain those skills. So from my perspective, it’s just an inevitability that all of us will have this discomfort. The question I want to pose to you is that, for a hundred people set off on this hero’s journey, how many of them get to the end?

Zubin Damania:

Well, this is the thing. Is there an end to the hero’s journey? It’s almost like if you’re looking for a purpose of life, which I think is a difficult proposition because life doesn’t need a purpose. It’s just beautifully radiant in the present moment. But if you’re looking for a purpose, it is this perpetual hero’s journey of unfoldment. So you may get to the end of one particular aspect of the hero’s journey and then a new journey begins. You’re called again. I can’t tell you how many times it’s been a reawakened, oh, wait, what? No, there’s so much more to do, and so much more to learn. And there’s a different mentor now, and there’s a different set of challenges. And there’s a different elixir of knowledge that you bring back.

Zubin Damania:

And at each stage, one thing Campbell talks about, is there’s the resistance. So the call to adventure, which is when Luke Skywalker is, he’s there on Tatooine. He’s been moisture farming and Ben Kenobi comes to him and he is like, look, dude, your dad was a Jedi. Come with me, let’s fight the Empire. And Luke’s like, no way, man. I still got crops to harvest. My uncle needs me. That resistance to the call is the first challenge. And in medicine, oh my gosh. If you’re going to call the troops to adventure right now to change medicine or to wake up a little from our own conditioning, oh, the resistance is going to be all over the place. There’s a million excuses the mind makes.

Zubin Damania:

So you’ve got to overcome that. And then when you do get the knowledge, there’s a resistance to coming back with it. You want to stay in this transcendent state. You want to go out and just pontificate about it. So, no, no, no, no, no. You have to come back and embody what you’ve learned. And so that means teaching others. It means maybe going and putting it in practice. And there’s a resistance to that. So at each stage, the mentor can help nudge you, or you can nudge yourself, or circumstances nudge you back.

Robert Pearl:

I don’t know about you, but one of the hardest journeys that I believe that doctors are going to have to go down is going to be confronting the end of life and dealing with the realities that death is an inevitability, no matter how long we can prolong it, particularly as our ability to prolong life becomes that much greater. How do you envision this hero’s journey progressing?

Zubin Damania:

And so many of the classic heroes journeys involve a trip to the underworld, to actually address the face of our biggest fear, which is mortality. The fear of loss of control, of helplessness, of all these issues that are so central to the human, we think are so central to the human condition. And of course, in medicine, we’re on the front lines of that. And so if we don’t heed the call to actually address those things, to look at those dragons in our own psyche, then how can we address them for our patients, and what ends up happening is we obfuscate them with our own projections. So, no, no, no, you know what? One more procedure is what your loved one needs, not talking about comfort, not talking about palliative care or whatever it is, or even having the conversation that you know what, life is not infinite. And it’s not a failure to focus on comfort.

Zubin Damania:

Those are crucial things. And then the economic ramifications, the emotional ramifications of the survivors, all those things. When I do talks, I often perform a song that I did a while ago called Ain’t The Way To Die, which is a parody of an Eminem and Rihanna song about end of life. And I do it for people that [inaudible] why would you do it for this audience? Because every single person in the audience has had a loved one or has interacted with someone who’s been in that position where they haven’t had the conversation, they haven’t talked about end of life. There’s all this resistance. And it illustrates that resistance and how we might actually overcome it by making people feel something, like, oh my gosh, it’s always too soon until it’s too late to have the conversation.

Robert Pearl:

I don’t know if you’ve ever watched a particular YouTube video, but I’ve watched it, I don’t know, many dozens of times. And it’s the Susan Boyle Britain Got Talent tryout. Have you ever seen that one?

Zubin Damania:

Oh, it’s amazing.

Robert Pearl:

Yeah, for people who may not know it, it’s been seen by 260 million people. So most of us have seen it at some point. Susan Boyle comes on stage and she’s dressed frumpier than any other contestant. Simon Cowell asks her how old she is and she replies 47. The audience snickers. She can’t remember the word village when Simon ask her to describe where she’s from. And then all contestants, he asks, who do you want to be? And she says, Elaine Paige and the cameras pan to the audience. They’re rolling their eyes with smirks on their face. And they communicated with their body language, she’s a nobody, she’s a failure. The look of pity, it’s everywhere. And then she says, what song will she sing. And she says, “I have a dream, from Les Miserables.” And the music comes on, first three notes that come out of her voice, beautiful.

Robert Pearl:

A golden voice, shocking people. And then she sings the classic line, “I had a dream so different from this hell I’m living.” And the audience is on its feet. The place goes crazy, but it’s just the start of her journey. Simon becomes her mentor, gives her a record contract, new wardrobe, hairstyle, makeup. She confronts her Asperger’s. She goes through a mental breakdown, maybe from coming in second on the show. She goes on to make eight albums, sell 20 million records, nominated for three Grammys. She comes back at her, she continues to entertain. I watch that to tell myself how wrong we are as doctors when we judge patients and the massive mistakes we make when we dismiss people.

Robert Pearl:

Our mental models of healthy and unhealthy are so strong that even when our brain tells us we’re wrong, we struggle to change them. And I bring that up because again, having watched this dozens of times, you would think that I would now be an expert at not doing these things, but I still have this tendency to make these judgements on externalities and to not take people as seriously as I should. I’m not sure that that hero’s journey, as you say, is ever able to be fully completed.

Zubin Damania:

Wow. And that’s beautifully put. And here here’s a couple thoughts I have just hearing you talk about that. And that Susan Boyle thing is amazing. Every single one of our patients is on a hero’s journey, and once we see that, and once we figure that, hey, maybe we’re partially a mentor on this hero’s journey, in a certain way, on a certain aspect of their journey, that changes everything. And maybe we’re on the hero’s journey, and this patient is our mentor and that changes everything. And maybe when you talk about our judgments, Robbie, that is part of the thinking mind. The mind is a judging mind. It’s a comparing mind. It’s a thought generating mind. It’s a secreter of thought and the thoughts aren’t us. They speak in our voice. They use the word I when a voice in our head talks to make us believe that it’s us, but it’s not us.

Zubin Damania:

We’re actually the space those thoughts arrive in, we’re the awareness of that space those thoughts arrive in. So self-forgiveness when we do judge, when do get caught in that, I think is the order of the day, that then allows us to be better. And sometimes a hero’s journey is not this, Susan Boyle was a great dramatic example of that, but maybe it’s just being a little self, little less reactive with your kids, or a little more present. Maybe that’s your hero’s journey, that one arc and that’s enough. It doesn’t have to be so grand, although those grand heroes arcs are what make it so resonant, the Star Wars arc that George Lucas actually used Campbell’s work to design the first star wars series and that’s why it was so good. That’s why the prequels were such trash, and the sequels, weren’t very good, because the monomyth that we all resonate with deeply is right there. But yeah, self forgiveness, really, really powerful.

Robert Pearl:

Speaking about mentors, what’s the best advice you’ve ever received along one of your hero’s journeys?

Zubin Damania:

It was really, it was Tony Hsieh again. And he said, “You’re so afraid of what people think and how you’re going to be received and you’re always making jokes to try to put yourself, distance yourself from any vulnerability and to make yourself feel safe, it seems like, because anytime there’s two people in the room and I’m with you, you’re joking the whole time. And you’re a pretty, actually serious, reasonably thoughtful guy. Why don’t you just be yourself? Why don’t you just be authentic and don’t worry about the fear of what people are going to think and that sort of thing. It’s something that I’ve just noticed.” And of course, initially I was so defensive. I was like, what do you mean I’m making jokes? And then the more I felt into it, the more I realized, oh my God, he’s absolutely right.

Zubin Damania:

So it was such amazing advice because it allows this huge burden of trying to be somebody that you’re not to protect this seeming self from others, when that relaxes, then you’re truly just authentic. And that’s what Susan Boyle did when she sang that song. She’s like, this is me. How scary must that have been for her, seeing the audience rolling their eyes and Simon Cowell who’s notorious for being a butthole, it’s like, oh my gosh, it’ll make you cry just thinking about it.

Robert Pearl:

Absolutely. Someone once said that courage is not the lack of fear, but the ability to move forward, despite the fear. Has your fear disappeared and you’ve just learned to go past it or have you somehow been able to conquer some of your fears?

Zubin Damania:

The fear is always there. And actually on this last silent meditation retreat I was on for eight days, fear was the main theme, it felt like. It was this fear of helplessness, fear of vulnerability, fear of losing control when you realize that your thoughts aren’t you and your identity is very, it’s a construction, that there’s a deep fear. And I think that the trick is letting that fear be there, but acting anyways, like you said, that’s courage. And understanding that fear is just the mind trying to keep you safe, but it’s not often correct.

Zubin Damania:

It’s just like a car alarm that goes off when it was bumped. It doesn’t mean that someone’s breaking into your car. So you can feel it that’s okay. Let it pass through you, but don’t let it rule you. And it’s easy to say, but very hard to do, and you need support. You need people, again, to help and mentor and be there. And a lot of people, unfortunately don’t have those folks. So again, in medicine, I think it’s incumbent on us to try to be that person for our patients whenever we can.

Robert Pearl:

It’s interesting as you talk about it. I’d never put it into this context. When I think about two of the best pieces of advice I’ve ever gotten, I think now, that there were about fear. I wouldn’t have thought that before this conversation. One was from my mom. I was in 11th grade and I was wanting to become a class officer. And I knew that I could run for vice president and win overwhelmingly, but there was a very difficult candidate who wanted to be president. That’s really what I wanted to do. My mother said, “Never aim lower than you really want to go.” And I was able to run for that and win that particular race and enjoy that opportunity that I never would’ve had, had I yielded to that fear.

Robert Pearl:

And then the same thing actually happened when I was had the opportunity to become the CEO. I’m not even quite sure it’s fear. Although, as you know, at the time, Kaiser Permanente was down to two days of cash and had to borrow cash to stay viable. It was not a great job, but it was just not something that I necessarily thought that I wanted. And I went to one of my mentors, a physician, one of my teachers in residency named Lars Vistus. And I told him this story. And he said to me, “Robbie, windows open and close. And when they open, you better jump through them.”

Robert Pearl:

And so in both cases, whatever the resistance exactly was, whether you want to call it fear or you want to call it wisdom. I’m not sure which it might have been. I think that having that opportunity and it goes along with something that I’ve said learned from other people. We tend to regret the things we don’t do, rather than the things that we do do. And certainly, both of those chances that I had turned out, well, maybe that’s why I have such fond thoughts about them. But I think that the idea of taking action when you have that opportunity for something that you think is valuable, is probably a pretty good lesson for all of us going forward, even when we are afraid.

Zubin Damania:

That’s beautifully put. And I think that idea of, we regret the things we didn’t do rather than the things we did, I look back on my own past, and there’s a lot of stuff that, oh, you could have done it differently. Could have done it that way. Honestly, I wouldn’t have done anything differently. It just landed me right in this present moment where there’s so much still to do and it’s all unfolding perfectly and beautifully. So yeah, be fearless as much as you… Fearless meaning, let that fear be, but don’t let it change what you’re doing. I love your mother’s advice and your mentor’s advice. It’s beautiful.

Robert Pearl:

The last program we had, where we talked about the movies, the one that led to the question about the hero’s journey, I received so many individuals sending ideas from movies they would like to see made about medicine, the conversation that we had. There were people talking about Virginia Apgar who in 1952 developed a 10 point scale associated with her name and it saved tens of thousands of lives of children. Galen, living in the second century, who founded the scientific method in medicine that continues as the foundation of research and discovery today.

Robert Pearl:

The Blackwell sisters in the middle of the 19th century became the first women to become physicians in America. And of course, Marie Curie, who developed the theory of radioactivity, won two Nobel prizes, and ultimately died, as you know, from aplastic anemia, from the research that she did with radioactivity. But as I thanked people for their ideas, and I have to say, probably I had 20 different films, all of which would’ve been great. I was struck. No one mentioned anyone from the 21st century or even from the end of the 20th century. Are there no heroes today, or is it that there’s no problems that’s large enough to require heroes or no way to recognize heroism until after people’s careers are over and complete and maybe until they’re dead? What’s going on? Why does there seem to be so few heroes today?

Zubin Damania:

What a great observation. And I think, it’s all those things you said, but I think there’s also this component that mankind is actually evolving into a complexity level where the single hero, the Steve Jobs, for example. That’s a good example of he was maybe a partially 21st century hero to some and villain to others. But this idea that the single human is no longer so essential as this network of humans. So for example, that NASA and the European Space Agency were able to put an incredibly complex scientific instrument where it’s basically human consciousness peering back into the universe, basically the universe looking at itself, in a way that’s so incredibly beautiful and complex, could never have been the work of one person or one hero.

Zubin Damania:

So instead it’s the transcendent work, often, of a group of humans working in concert together over decades with all the resources of government and industry and private sector together. That’s heroism now. And so pointing to one person is so difficult, but pointing to, wow, look what this group of people were able to do, it’s transcendent, I think that’s maybe where we’re shifting and maybe that’s why it’s a little harder. So it’s less of a cynical, where are the heroes and more of a, oh, we’re all heroes, especially when we work together.

Robert Pearl:

You remind me of a conversation that Jeremy had on one of our other Fixing Healthcare shows. We talked at that time that this is the 15th anniversary of the iPhone, the Steve Jobs reference you made. It’s the 10th anniversary of CRISPR, the technology that can be used to alter genes. And it’s the start of the post-Roe Supreme court. Which of these three factors do you think will be most important a decade or two from now?

Zubin Damania:

I really think it’s that iPhone piece because this is where the existential promise and threat comes in because the iPhone has changed a generation of children. It has really exponentially actualized social media, for better or for worse, and I actually worry about it for worse. And it’s given us the universe’s knowledge in the palm of our hand in a way that, the classic saying is Bill Clinton had less access to information than a tribesman in Africa with a smartphone has now. And that is going to continue to transform society and the human mind in a way that CRISPR, okay, we’re hacking our DNA and that kind of thing, that’s cool. That’s going to have ramifications. Post-Roe world means that’s politics and policy and medicine. That’s all important, but man, that smartphone, the change that that’s wreaking on us that we don’t truly understand yet, I think that’s going to have the biggest impact existentially for us.

Robert Pearl:

Amazing answer. Jeremy, your question for us.

Jeremy Corr:

I know so many people, myself included, who’ve had the situation of either a boss that doesn’t believe in them and says, “Hey, you’re never going to make it further than this,” or, “You’re never going to amount to this,” or a parent or some person in their life who doubts them or pushes them down. And I know a lot of people get inspiration from this. Many of the big famous CEOs and successful people in the country have had someone like that in their life who either is, it gives that said person a chip on their shoulder to either work harder or maybe it gives them the understanding that, “Hey, I’m not in the right line of work. Maybe I need to shift what I’m doing or think differently about some things.” Have either of you had some sort of antagonist like that in your life who’s doubted you or told you you couldn’t amount to what you have amounted to, and how did you deal with that, learn from that, grow from that?

Zubin Damania:

Yeah, this is one of those things where you wonder whether these antagonists are actually really meant to be there, and think they are. They’re really essential. And it’s how you respond, it’s a test of the hero’s journey. It’s one of the big trials and tribulations. For me, it’s funny, part of the hero’s journey in the classic Campbell sense, is the father, this atonement with the father, and it can be the literal father. For me, I think it actually is the literal father. So my dad, internist, immigrant physician, private practice, central valley of California. He was always the voice narrating my decisions through life and even though, because I swore I’d never be a doctor because he was one. Then I went into medicine because I felt the call to it. And then his influence was constantly there.

Zubin Damania:

And it was always a, he began coming from India with nothing in his pocket, seeing that you could be homeless and on the street in a second, conditioned him a lot. So it was a lot of fear based decision making and caution and don’t take risk and that sort of thing. And so for me, it was this atonement with, he’s got a point. You should build up a safe base, but at the same time, use that safe base to go out in the world and do what you’re really trying and meant to do and that means taking risks and making yourself uncomfortable and really going out there where the ice is thin. And what’s funny is it comes full journey.

Zubin Damania:

So the hero’s journey comes back and the father in his eighties now recognizes, wow, oh wow, you did something that I wish I had done. You went out and did what you really loved to do and took risk and so on. And he loved doing what he was doing, but again, he had a different upbringing and a different set of circumstances. I was blessed to have his base to launch my own risk taking from. And so for me it was that antagonist was also one of the loved ones in my life, very important person.

Robert Pearl:

I was fortunate, Jeremy, I had a very supportive family, wonderful parents. And along the way, really at every stage, I had mentors who propelled me. I can think back even to elementary school teachers who were so encouraging, to high school, to college, to medical school, residency. So I would say I’ve not had that experience, not to say I didn’t face complex personal situations, but I could overcome them, and I had enough support to be able to overcome them. But I’d say the one time that I would point out, and I’d say it’s maybe the darkest time when I was CEO, was a vicious attack from the press and the state regulators, and the two coming to together in a way to want to be able to be critical. It was very specific to a transplant program.

Robert Pearl:

150 kidney transplant plants had been done. Not a single patient had died. 149 of them were successful, but it came up against the national transplant body that didn’t like the fact that Kaiser Permanente, not a university, was doing transplants with these kinds of results and the reporter came after us for a variety of small things. There was a whistle blower who had been penalized for bringing alcohol to work and fired. And he was the one who fed the information, and there was a state regulator who wanted to have the support and look for… Everything was aligned in the wrong way.

Robert Pearl:

And the problem is that when you are the leader and you’re watching your people get beaten up, it’s like watching your child get struck by bullies on the other side of fence. And no matter how hard you shake it, the barbed wire at the top stops you from getting over the top. And I think at some point, and that’s why I asked the question to ZDogg earlier, to Zubin earlier, we can’t all complete our hero’s journeys. And I actually think that some of the hero’s journey is not being able to find that elixir at the end, because maybe those elixir’s are not really what life is about, but it’s being able to move on and come back despite not having them and the success that we had from a quality perspective, from a growth perspective and the respect of the nation around the quality that was provided and excellence of the physicians, that became the reward in the end.

Robert Pearl:

But the pain of that moment I felt, and I feel bad for anyone, as you say, who has that boss, who has the power and you can’t do anything about it, or the person who stands in your way, when you know that you should be able to get past that door. It’s just incredibly painful. And maybe the hero is being able to get past that and to be able to resume the wonderful life and productive life that you had prior to that. And to recognize that it’s not about you, it’s about them and be able to move on, but it’s certainly not easy. Zubin, another great show. So much fun. Can’t wait for the next time. Thank you for coming today.

Zubin Damania:

Oh, thank you. It’s like therapy for me. It’s beautiful. Thank you.

Jeremy Corr:

We hope you enjoyed this podcast and will tell your friends and colleagues about it. Please follow Fixing Healthcare on Apple podcast, Spotify, your favorite podcast platform. If you liked the show, please rate it five stars and leave a review. If you want more information on it… If you want more information on healthcare topics, you can visit Robbie’s website robertpearlmd.com and visit our website fixinghealthcarepodcast.com. Follow us on LinkedIn, Twitter and Facebook at Fixing HC podcast. Thank you for listening to Fixing Healthcare’s newest series, Unfiltered, with Dr. Robert Pearl, Jeremy Corr, and Dr. Zubin Damania. Have a great day.

The post FHC #64: The hero’s journey in healthcare appeared first on Fixing Healthcare.

Dr. Tom Lee founded Epocrates, one of the earliest tech-enabled healthcare applications for doctors, and One Medical, the primary care-first organization recently acquired by Amazon for $3.9 billion. He is now the CEO of Galileo, a virtual care-first healthcare startup he hopes will make medical care affordable for all Americans.

Though Lee is no longer with One Medical, and he was not involved in the recent merger announcement, few people are better equipped to weigh in on Amazon’s emerging role in healthcare. Will Amazon disrupt healthcare’s traditional powers? Can the company reshape primary care and fix the broken parts? Where will American healthcare be in 10 years?

In this interview, hosts Jeremy Corr and Dr. Robert Pearl ask Lee to discuss some of medicine’s unwritten rules and norms. These are, as listeners know, the norms and behaviors that dictate the way doctors think and behave.

“Everywhere I looked [in medicine], there were norms that nobody could explain to me. And even as a med student and resident, we did a lot of things that didn’t make a lot of sense. Our mission was to care for patients in a thoughtful manner, but what we were doing seemed antithetical to that. So even as a young physician in training, I just started noticing dissonance with what we were doing from what we thought about why we had joined the profession.”

“What were these mysterious forces driving the systems of care that I felt as a clinician were inappropriate or certainly suboptimal? So that’s what ended up leading to my business career. And this was not something that was considered very vogue or sexy among doctors. In fact, it was viewed as a negative trait. And most of my other colleagues were going into specialist kind of training, but my specialist training ended up being business, and it allowed me to see the world more broadly than where traditional medicine typically is looked at.”

“Relying on clinical memories or human memory to make any kind of judgment, I think, is unwise, particularly as we look at the future. So we need to reexamine what we reward, and (how we) train young physicians and clinicians in training in general. I personally never found memorization to be that inspiring or helpful in my medical training … And I do think that’s something to reconsider as we start to examine the workforce and frankly, the profession of medicine.”

“As a young physician in training, I was like, ‘I don’t want to practice in any of these broken models.’ I had worked in almost every environment, whether it be academic institutions, private practice, capitated HMO models, native health service organizations, all really great organizations with well-intended providers and leaders, but the care model just didn’t make any sense. And so I knew that there was a better care model that could be designed, particularly given how much we were spending in healthcare overall. So for me, the inspiration was to kind of say, hey, primary care is a broken layer. Everybody recognized this 20 plus years ago that primary care was broken. Nobody wanted to invest in reexamining how to improve primary care. And so the real impetus behind One Medical was, can we validate that a higher touch, better primary care model can be built and scaled in an economically viable fashion?”

“I remember something that Don Berwick said way back when I was a resident, ‘The thing that patients want is time with the doctor.’ It’s not a unit, it’s the time with the physician. And so a lot of inspiration with One Medical was how do you actually enable that with a fixed reimbursement model for the most part? And the key innovation there was administrative redesign … The average practice in primary care is overwhelmed with administrative burden, but they don’t have the sophistication, particularly as the complexity has been layered in over decades to redesign that. And so I had the luxury of starting from scratch and redesigning it. And now that technology was more available, I wanted to design it using technology. So that allowed us to 10 x the service at about a third of the administrative overhead of a traditional practice. And then that allowed us to give more time back into the physician exam room, which allowed patients and providers to have more time. And we got all the other people out of the way.”

“At high level, we are reexamining the norms of how should care be delivered, and this had started pre-pandemic, but there are some strengths to an office visit, there’s strengths to a video visit, but there are a lot of weaknesses to that form factor. And we believe in a more data oriented, evidence oriented approach to how care is delivered. So from a quality perspective, how do you redesign quality into the care model. And then in parallel, designing affordability into the care model. And so being more capital efficient, more labor efficient, and covering a broader range of services and scope is really kind of the thesis of Galileo.”

READ: Full transcript with Tom Lee

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #63: One Medical founder Tom Lee on Amazon, primary care, the future appeared first on Fixing Healthcare.

In today’s episode of Medicine: The Truth, hosts Jeremy Corr and Dr. Robert Pearl dive into timely and significant medical topics, focusing on the resurgence of COVID-19, rising healthcare costs and a growing shift toward patient empowerment through at-home testing solutions.

The episode kicks off with an update on the recent summertime surge of COVID-19, particularly in the Western and Southern parts of the country. Despite rising case numbers, researchers have noted that hospitalizations and deaths remain stable. The hosts discuss the release of new COVID-19 boosters, which are tailored to emerging variants. This comes at a time when skepticism about vaccinations persists, still fueled by misinformation and politics.

Shifting gears, the conversation moves to healthcare costs, particularly the burden on small businesses. Rising inflation and the increased use of costly GLP-1 (weight loss) medications are driving up medical costs, with premiums projected to rise sharply in the coming year.

Here’s a snapshot of the topics covered on this episode of Medicine: The Truth:

• COVID-19 resurgence
• Rising healthcare costs
• Long COVID updates
• Climate change and public health
• Mpox (formerly monkeypox)
• Medicare drug price negotiations
• At-home testing revolution
• Uterine transplants and advances in reproductive medicine

Throughout the episode, the hosts touch on the transformative potential of generative AI and other technological advances, arguing that patient empowerment and consumerism will continue to shape the future of healthcare.

Join the conversation as Dr. Pearl and Jeremy Corr tackle the latest medical news and discuss the implications of these trends for the future of healthcare.

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Dr. Robert Pearl is the author of the new book “ChatGPT, MD: How AI-Empowered Patients & Doctors Can Take Back Control of American Medicine“  about the impact of AI on the future of medicine. All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post MTT #87: COVID-19 resurgence, soaring healthcare costs and the push for patient empowerment appeared first on Fixing Healthcare.

New data from the Annenberg Public Policy Center found that 4 in 10 Americans have returned to their normal, pre-pandemic lives. Over half of respondents say they rarely or never wear masks indoors while in public. This, despite 54% of Americans indicating they personally know someone who has died from Covid-19. A third say they know someone with “Long Covid.”

How will these perceptions – alongside the continued loosening of public safety restrictions – affect the future health of Americans? In this episode of Coronavirus: The Truth, Jeremy Corr and Dr. Robert Pearl examine both the science and public opinion of Covid-19. You’ll find this topic, and all the [time stamped] topics discussed during this show, here:

[00:50] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?

[03:38] Listener question: “Is there is any explanation besides bad luck for both Dr. Fauci and President Biden getting ‘rebound COVID’ after taking Paxlovid?”

[05:31] Covid-19 is now an endemic virus: What does that mean and what happens now?

[08:21] What’s new with the monkey pox outbreak?

[12:55] What are the current treatments options for monkey pox?

[17:55] Is monkey pox a major concern for most Americans?

[18:59] How might we “break” of some of healthcare’s most illogical rules?

[24:45] Are Americans putting Covid-19 in the rearview?

[25:59] What’s up with CDC? Is the agency changing course?

[28:42] Kids and Covid-19: any news?

[30:38] What do we know about the Inflation Reduction Act’s impact on healthcare?

[33:09] And what about Amazon’s acquisition of One Medical?

This episode is available on Apple Podcasts, Google, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #64: Are Americans putting Covid-19 behind them? appeared first on Fixing Healthcare.

This Fixing Healthcare podcast series, “Diving Deep,” probes into some of healthcare’s most complex topics and deep-seated problems.

On today’s episode, hosts Dr. Robert Pearl and Jeremy Corr discuss the three biggest threats facing U.S. healthcare:

• Untamed inflation
• The nurse shortage
• A burnout / moral injury crisis

These threats will require urgent and radical action. In addition, the hosts discuss another pressing topic: The threat of Covid-19. How dangerous is the virus today?

For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a time-stamped discussion guide:

[00:59] Cohost Dr. Pearl had an eye-opening Covid-19 conversation with his ophthalmologist recently. What was discussed?

[01:48] Who should get a second Covid-19 vaccine booster?

[02:41] What are the most common Covid-19 questions Dr. Pearl hears?

[05:40] How likely are people to die from Omicron?

[07:44] Why are Covid-19 cases going way up but deaths aren’t?

[11:22] How much should people worry about “Long Covid”?

[15:12] Should people wait for the Omicron-specific booster coming this fall (or sooner)?

[18:38] Is it safe to have a social life now?

[21:40] Dr. Pearl’s recent article “These 3 healthcare threats will do more damage than Covid-19” went viral. Why?

[24:56] What’s causing the most concern in healthcare right now?

[28:03] What’s concerning about inflation in healthcare?

[30:41] How does the nursing shortage affect patient care?

[31:48] What can be done to keep patients safe amid this shortage?

[33:43] With cost and quality under siege, is there any hope for respite?

[34:49] How will we unclog surgical backlogs in hospitals?

[35:13] What about physician burnout?

[36:34] Why are doctors dissatisfied and what can be done about it?

[38:08] What happens when these three forces collide at the same time?

[40:22] What does Dr. Pearl recommend as an “urgent and radical” solution?

* * *

Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #62: Diving deep into 3 urgent threats facing U.S. healthcare appeared first on Fixing Healthcare.

Did you catch the episode of Malcolm Gladwell’s Revisionist History about triplicates—those state-issued prescription pads that produced three copies of every painkiller script written? Many in medicine remember triplicates as a classic example of government overreach. But in 1990s New York, a city beset by a major drug problem, these triplicate pads had an amazing effect: opioid overdoses plummeted when doctors were forced to use them.

In this episode of Fixing Healthcare, hosts Jeremy Corr and Dr. Robert Pearl join ZDoggMD to take an unfiltered look at the impact of triplicates (and regulations in general) on healthcare.

The group also debates Amazon’s $3.9 billion purchase of One Medical and explores the untold lessons of Sesame Street (including: did the Count have an undiagnosed mental health disorder?), and much more.

Welcome to Unfiltered, a show within the Fixing Healthcare family of podcasts that brings together iconic voices in healthcare for an unscripted, hard-hitting half hour (plus) of talk.

For more, press play or peruse the transcript below.

* * *

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

Jeremy Corr:

Hello, and welcome to Unfiltered, our newest program and our weekly Fixing Healthcare Podcast series. Joining us each month is Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice. Then I’ll pose a question for the two of them as the patient based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Good morning, Zubin.

Zubin Damania:

Hey, top of the morning, Robbie.

Robert Pearl:

You know, for a whole week before we do this show, it feels like I’m about to go to a Michelin starred restaurant and the chef’s going to cook me some new dishes. I don’t know what they’re going to be, but I’m certain they’ll be tasty and well seasoned and I can’t wait for today’s tasting menu. So if it’s okay with you, I’d like to revisit the conversation we had in the last episode, about the value of eliminating regulations and restrictions to address problems, rather than adding new ones to deal with the rules and regulations and restrictions that aren’t working. Like you, I agree, we have far too many. But I had an a-ha moment this week, when I listen to an episode from a different podcast, this one, Malcolm Gladwell’s Revisionist History. And he talked about the impact of triplicates, a topic I had never considered. So let’s start by, for listeners who may not know what a triplicate is, could you describe it for them?

Zubin Damania:

So are we talking about the old school DEA triplicates, where whenever you wrote a narcotic, it was copied three times with carbon paper and you had to send one copy to somebody and it was just this onerous process?

Robert Pearl:

Exactly the one I’m talking about. That’s exactly the one or the one he talked about. And he described some research that came, as you say, it’s the old way, so this was research coming out of, I’ll say 1990s. New York, Massachusetts, and New Jersey have similar populations and in the past they had similar incidents of deaths from overdoses. Then New York puts in place the triplicate process, but the other two states don’t. And suddenly deaths from overdoses come crashing down. This is like a natural experiment. It’s what economists love to find. And I want to know if our goal as doctors is to minimize deaths, how can we figure out which bureaucratic tasks are valuable? Which ones are waste of time? Which one will save lives and which will result in harm to doctors and patients?

Zubin Damania:

Man, this is a wonderful thought experiment because you have the regulation, which was designed to make it more difficult, presumably, to give out narcotics and so it adds a little activation energy to the physician’s workflow. So in a way, what you’ve done, is you’ve made it a little less easy for a physician to give a narcotic. And I remember when I trained in the ’90s, if someone needed a narcotic, I would just have to let out this heavy sigh, because now I got to go back to the little office, grab this thick old pad with the triplicates, do all this whole rigamarole, keep the records safe somewhere where they aren’t going to be stolen for a decade or whatever the requirement was. So any way I could get out of having to do that, you’re kind of looking, “Well, does this patient really need narcotics?” Et cetera.

Zubin Damania:

So in a way, what it was, was in my mind, it was saying, “Okay, did the doctors really need to do this?” Now, so it turns out they probably didn’t. Now the question is you didn’t really study how much excess pain was there, how much suffering was there, et cetera. We don’t know the answer to that, but we do know that overdose deaths plummeted. So the question is, was the regulation a good idea in the sense that, oh, we need that kind of regulation. Or was it a more of a test that says, “Hey, maybe we ought to retrain physicians.” Because at that time the pharmaceutical companies were telling us, you know what, a pain is the fifth or sixth vital and we need to treat it aggressively with narcotics and people don’t get addicted if they have real pain and so on. All of which has been proven to be nonsense and or less sensical than they were saying. And there we are. So it’s a matter of teasing out, do we need that bureaucracy or do we just need more awake medicine that looks at the externalities of everything we do?

Robert Pearl:

What do you think?

Zubin Damania:

I think it’s actually, we need more awake medicine that looks at the externalities of everything we do. And it just happened to take a bureaucratic intrusion at that time to teach us that guess what? This is probably not a good idea, how much opioids we’re giving out. Now the thing is, again, you and I are both also I think, although I may be putting words in your mouth, advocates of good system design, like smart system that, to use Jonathan Hyatt’s metaphor of the elephant and the rider. Our sort of unconscious mind that kind of runs the show in many ways. And the conscious little guy riding on top that really often is more the servant to the elephant. How do you shape the path that they’re walking on to make the default actions more beneficial? And to that degree, systems design is good. So would it be great to make it really easy to prescribe narcotics in the setting of a pharmaceutical industry that’s promoting them? No, probably not. So you would need that kind of systems designed. So it’s always a balance.

Robert Pearl:

I think that’s the argument that people make when they put in place restrictions and regulations, which is that if you shape the path in the direction that either will maximize good or minimize harm, that that’s going to lead to a good outcome, but as you and I both know, often that’s not what occurs. And what occurs is you inflict pain on both the doctor and the patients.

Zubin Damania:

So I, yeah. And the way I think about that increasingly is the way we think about any sort of, even if you study existential risk, like nuclear war or environmental catastrophe or these kind of things, you’re always looking at, okay, here’s an intervention that we do, like say social media with tech algorithms that try to draw our attention. Okay, that’s great. It has this outcome that the companies make a lot of money and we get this experience of social media. What are the externalities, the second, the third, the fourth order effects of that technology? And it’s the same with regulation in the healthcare space. We don’t know what those externalities are until you put it into place. And at that point it may be out of the bag, very hard to unwind and you’ve caused a lot of damage. So we need to get better at predicting externalities or considering them. Factoring them into the cost of any intervention. And it just gets tricky, but it’s not impossible. We ought to make it a priority.

Robert Pearl:

I heard interesting, I’ll say study, I don’t know if it was really a study or just an observation, that Sesame Street, the show for little kids, you think is designed to teach them the alphabet and mathematics. You know what it teaches them? Television is about entertainment. It’s not about learning. So although it is introduced at that point, it becomes an addiction for entertainment rather than for growing one’s mind and confronting difficult questions and challenges.

Zubin Damania:

Now that’s really interesting. So I actually revised my history of Sesame Street years later when I went through medical school, because I realized each of the characters had distinctive psychopathology and physical pathology, like the Count. Do you remember him? He would teach kids purportedly how to count, but really he had a severe case of obsessive compulsive disorder. I mean, he was counting everything. He couldn’t stop. One, two, three, ah, ah, ah. Poor Count. He’s suffering. But yeah, I hear you.

Robert Pearl:

Let me ask you about an associated issue that you and I both think about a lot, which is burnout. And one of the first step in addressing any problem, is always to figure out what’s going on and we know that bureaucratic tasks and the prior authorization imposed by insurers and all the rules and restrictions by hospital administrators. We know that this is making the lives of doctors and patients worse. But now I want to ask you the next step, which is recognizing the problem doesn’t, from my perspective, solve it. What you actually do is have to get someone else to take action. In your mind, how can doctors and nurses force the insurers and hospital administrators, to do the things that we know will reduce burnout without creating secondary problems as a consequence?

Zubin Damania:

Mm, I think in this case, it’s one of those situations where we have this adversarial zero sum relationship. It’s kind of like this game A dynamics, where somebody wins and somebody loses. So the administrators win, the doctors lose. The doctors win, the administrators lose. The insurance companies lose. We really have to align the incentives across the spectrum of that, which means maybe it’s more integration. Maybe it’s the integration of the payers and the caregivers together, that allows the incentives to align. And even then, of course, we’re going to have the politics that go back and forth and the different dynamics, but it would be much better. So I don’t know that anybody’s going to be able to force anybody to do anything.

Zubin Damania:

But even like something like a prior auth. Why are prior auths in place? Because a lot of times physicians will do things that are not evidence based, that are costly, that have second order iatrogenic effects, meaning they cause harm because of over-testing, over diagnosis, overtreatment. And the insurance companies say, “Well, okay, it’s also increasing cost. So let’s put a prior auth, let’s throw that triplicate, the barrier to entry here. Make it higher.” And then what happens is the doctors escalate and say, “Well, now my autonomy is threatened. Now my clinical judgment is questioned and my time is affected.” And that creates this injury that leads to burnout. So how about we actually powwow and say, “Okay, so what are the practices that actually do work? And when can we have the clinical autonomy to override those practices?” Because that’s what doctors do best is that deep intuition to say, “This is where the algorithm actually doesn’t apply or where we can actually make an exception.” And that trust then leads to more alignment, less need for these weird negative incentives to be put in place, I think.

Robert Pearl:

I agree with you completely. It’s a lot of why I think we have to move from a fee-for-service volume based mentality to one that’s capitated. The tremendous work you did when you were in Las Vegas, demonstrating how you can improve quality and lower costs, if you all have the incentives that align with each other, but still the progress to that goal seems to be incredibly slow.

Zubin Damania:

It does. Now, what’s interesting is our partners in that effort in Las Vegas, they merged with One Medical last year and One Medical just got bought by Amazon. So it’ll be interesting to see how that sort of intensive primary care model evolves in that space. It’s going to be interesting. And there’s a lot of headwinds to change, because the payment models haven’t changed. You’re still working in this kind of either fee-for-service or capitated without sort of revenue share or positive externalities when you do really well piece. And so we really need to look at how those payment models affect care models. And it’s tough because there’s so many legacy players. So many people with so much to lose and they’re all oligopolies. So how do you even start to crack that? It’s going to be multifactorial.

Robert Pearl:

Let’s follow up on what you just raised, which was the Amazon purchase of One Medical. For listeners who may not know, One Medical is a primary care first organization, Began in San Francisco. It’s now in 180 offices and 24 different cities. It was just purchased by Amazon for 3.8, I believe, billion dollars. Amazon entered into healthcare very slowly. A couple of years ago, they bought PillPack, which is a pharmacy delivery, that was really important because you have to have licenses in every state and they inherited the 50 licenses needed to distribute pharmaceuticals. Then they built some clinics for their own employees. Then they started online telemedicine. And now with One Medical, particularly because One Medical has acquired a company called Iora, about a year ago, which is in the Medicare space. You’re looking at this massive opportunity for Amazon to come into medicine, the way that it went into retail.

Robert Pearl:

It’s began in the book era. And when everyone was worried about the bookstores, they were already thinking about all of retail and then people were worried about the retail. Now they’re thinking about medicine and on and on in that process. How do you see this acquisition? How big a threat do you think it is? Where’s it going to go? When’s it going to happen? How should doctors think about it? How should they behave differently at this point?

Zubin Damania:

So this is an interesting response to the clear market dynamics with big self-funded employers, like Amazon, that prices keep going up. Care, quality and outcomes are not good. And it’s unsustainable, economically and morally actually, because people go bankrupt because of these medical bills and so on. And it’s a drag on the economy. So Amazon said, “Okay, well now we’ve disrupted these other spaces. Let’s see if we can do medicine.” Now, of course, they failed to do that with their enterprise Haven, with Berkshire Hathaway and JPMorgan Chase. So they know already how difficult this space is and they purchased One Medical. Now what’s interesting about One Medical relative to Iora, like you said, Iora’s focused more in the Medicare space because we use the same Turntable Health model that we used in Vegas at Iora, this sort of team based primary care, health coaches, intensive management of at-risk patients.

Zubin Damania:

Now One Medical actually just charges a yearly membership fee for access. So you get easier access. You have this high touch app and so on that you can schedule easily, but they still charge commercial insurance. And so as a result, they were losing money prior to the acquisition. So in order to make this work, Amazon’s going to have to figure out how to actualize really good preventative team based, relationship driven, primary care, that prevents downstream spending that allows some curation of a network of specialists that are actually doing the right thing, which is very tough in the self-funded space, because then that means employees have restricted choice. And they have to do it in a way that they’re going to have to subsidize, because it’s not going to be profitable initially.

Zubin Damania:

Now, if they can do that, they have the power, the money, the scale, the drive to do it. They could actually produce a kind of care that patients are so compelled by and physicians are so compelled to work in, that it does create that disruption and then the payment models start to change and you have true transformation. So that’s the potential outcome there. The more likely outcome is it’ll all fail, but that’s how I think about it.

Robert Pearl:

I would beg to disagree.

Zubin Damania:

Awesome.

Robert Pearl:

I predict that this will be a major transformation of American medicine. I think Haven failed because the other two CEOs really wanted it to be a not-for-profit for their own employees. And Jeff Bezos wanted it to be a sixth of a $4 trillion industry. He already got what he could get in retail, and now he wanted it to do it in medicine. I think that he will. I think that the word, choice, that we use has two meanings. Choice is, I want Dr. Smith. Choice is, I want my problem taken care of next Thursday. And he’ll be able to offer you the convenience. He will design healthcare the way he designed Amazon, which is to make it so convenient to give you lots of choices. And the fee you described for One Medical, I think that sounds like a Amazon Prime subscription model of which he only has 110 million people paying him for exactly what One Medical does.

Robert Pearl:

I think the big problem that One Medical, Iora and everyone else has had is scale. And what is Amazon really good at? Scaling. And I said back at Haven, is there anyone who thought that Bezos was in this as a not-for-profit for his own employees, probably also thought that all Amazon did, was sell books. I think the same thing here. This is not about improving the American healthcare system. This is about making money for Amazon, but his strategy would be to do in healthcare, what he did in retail, which is to make it very patient focused.

Robert Pearl:

And I believe that unless physicians start to change now, they’re going to get left behind, because I guarantee you, he’s not going to pick the best insurance company. He’s going to be his own insurance company. And he’s not going to pick every doctor in every hospital, but he’s not going to pick them because they’re cheap. He’s going to pick them because he provides high quality, good service in an efficient kind of way. And so I’m betting on them. And it’d be a great one to come back in about five years and see whose prediction ended up being more accurate.

Zubin Damania:

So, listen, I hope to God you’re right Robbie, because this is part of… Look, if they can pull that off, it will truly be the kind of American style healthcare transformation that I’ve been advocating. Rather than just straight single payer and paying for our broken system currently, why don’t we actually try real innovation? And if Bezos can do it’d be wonderful. What’s fascinating is don’t forget Zappos, who’s CEO actually funded our clinic, Turntable Health, is a fully owned subsidiary of Amazon. And they actually worked with us and saw our model at Turntable through Zappos. And so that was their sort of first exposure to this sort of intensive primary care.

Zubin Damania:

If they can bring what we were trying to do to scale, it would be absolutely transformative. And so I’m rooting for them. What I am Robbie is, I’m a little superstitious. If I’m too optimistic, what I find is, it’s like what my mom taught me. She never bragged about her kids, things would go wrong. So I’m hoping you’re absolutely right, but publicly I’m going to be very a circumspect because there’s a hubris in tech too, that often leads to failure.

Robert Pearl:

Now, on the other hand, I am worried about the success they’re going to have, because I can predict what it’s going to mean for doctors and nurses. And I’m not sure that they’re going to be happier under, I’ll say under the thumb or under the employment, I don’t know which way it’s going to go, of Amazon. We certainly know there are a lot of issues with the people who work inside Amazon today.

Zubin Damania:

So that was another point. And when I talk about it with my audience, they express the same concern. They’re a healthcare audience. What I’ll say is this, the hope there is that when Amazon acquired Zappos, Zappos was considered one of the best places to work. It would win these awards every year because of Tony Hsieh’s leadership and the general focus on happiness and work/life balance and so on. If Amazon does the same thing with Iora, One Medical, then we’re in good shape. If they try to turn them into Amazon employees, we should be very concerned, because they will create this attempt at cost, quality and convenience on the backs of overworked and underpaid and under automatized employees. But hopefully that’s not the case. And in fact, I don’t think it’s possible, because without engaged, trusted, and resourced healthcare providers, you can’t have quality, cost and outcomes that work.

Robert Pearl:

Yeah. I don’t think it’s going to be a question of not paying them. They’re going to pay them adequately. I think it’s going to be a question of expectations and that the expectations that Amazon will have, which is going to be a customer first notion, will clash with the culture of medicine, where physicians have, as you said earlier, focused on autonomy, focused on their own office, focused on the freedom to do whatever they wanted. And now there will be expectations about how quickly patients need to get care and how broadly they need to be available. And the types of things you could see coming out of Amazon. I think, again, I’ll flip back the other way, like yourself, the idea that somehow you could order shoes and just return them back and all the other conveniences that Zappos did, made no sense, except that it was so successful, because it was so desired by the customer. And I think that that’s the biggest shift. That I think Amazon will make medicine be customer, patient focused rather than provider focused.

Zubin Damania:

I think you’re right. And so the caregivers better get ready for that. But the other thing is, hey, if they just give them the 25% Amazon employee discount, I think everyone will be perfectly happy don’t you?

Robert Pearl:

Yep. I think it will be true.

Zubin Damania:

Just solve burnout. Just solve burnout. Just order a hand massager from Amazon at 25% off.

Robert Pearl:

So Zubin, I love our listeners and our audience is massive and several of them said they really liked our conversation last time about movies. And they wanted me to ask you, what is your favorite movie of all times?

Zubin Damania:

Oh, it’s really a difficult answer because there’s a few, but I’d say one is The Matrix. And the reason I love The Matrix is because it really encapsulates the deepest sort of Buddhist philosophy or any spiritual philosophy, which is you feel like you’re one thing and it turns out that’s an illusion. And at some point you wake up and then you do battle with your demons and then you transcend. You almost die and are reborn as a much more awake being. And that’s why I love The Matrix. Plus it was just amazing effects and action and all of that, but every single frame of that movie, points to this sort of deeper truth. So I love that. And then one of my other favorite movies is The Big Lebowski. Just because it’s The Big Lebowski. The dude abides.

Zubin Damania:

How about you?

Robert Pearl:

I’ll throw you two in return. A movie that probably 1% of listeners may ever have heard of, but I love, was a movie called Burn. It was Marlon Brando. And it’s the story of Marlon Brando, Sir William Walker in the movie, who’s sent to a Portuguese island in the Caribbean, to incite a revolution, because the British wanted to take over this very high revenue, highly profitable, sugar cane growing island. And he finds a dock worker, Jose Dolores. And he teaches him how to be a rebel and how to incite a revolution and it’s successful. And he leaves. And then in the second part of the movie, he returns seven years later, because now the island is in revolution against the British government. And he’s sent there to shut down the revolution. And the only way he can do that is by burning the entire island, because once the revolution begins, it can’t be stopped. So that is one of the best movies I’ve ever seen that I think of often.

Zubin Damania:

I don’t know how to parse that Robbie. It kind of feels like the hospital, like the clinical administrator’s paradox. You come from that space, you’re like, “Okay, I’m going to fix things.” You go become a leader and then you realize how trapped you are. But that’s great. I’d never heard of that movie. I’ll have to check it out. What’s the other one? Oh, go ahead sir.

Robert Pearl:

I just think the revolutionary spirit to make change is why this whole season I’m focusing on, this idea of rule breakers. And I think rule breakers have to understand that once you break the rules, you don’t control the rules, but they need to be broken and basically the entire model of the colony, which is really what it was, whether it was under Portuguese or British control, just was not appropriate. And ultimately the human spirit would survive. Although I guess in the end, the island was burned down, but you can’t stop it once it starts.

Zubin Damania:

Sometimes you have to start fresh. That’s you know.

Robert Pearl:

The other movie and to me, it’s the three part movie, is The Godfather. What I love about movies is when I learn things and what I loved about the three… The first one is one of the best movies ever made, but it’s beyond that. It’s the triple movie where you have the immigrant coming to the United States, starting with nothing, working his way up. And by the third movie, now you’re on the third generation and the last thing they want is to be in any way associated with the past.

Robert Pearl:

This is just the classic three generation story. It was in my family. It’s probably in your family. We see it all over the place. And it’s just so well shown. Without telling people, you just watch it. Everyone moves in the direction that you can understand. And by the end, you’re in a totally different place than you start and The Godfather is all over. So the other thing I loved about that movie is that my dad, near the end of his life, we had a little thing where for three weeks in a row, every Sunday night, we’d watch one of the three. And I still remember being with him in those last days. And it was a very emotional time for me.

Zubin Damania:

Mm that’s beautiful. Yeah. The immigrant story and the fact that everyone can get something from that. That’s beautiful.

Zubin Damania:

Movies, oh, sorry, one last thing. I mean, movies are so powerful, I think for us, because when we’re watching a movie, if we’re truly absorbed, the sense of self evaporates, it’s just the movie. And we lose ourselves in that. And I think that’s why it’s such a powerful archetype for us that going to the movies, especially going to the movies with others. There’s this weird collective thing that happens. It’s really wonderful. I recently saw a movie, Everything Everywhere All at Once, which is about this sort of multiversal Asian immigrant tale that throws in a multiverse. And some sci-fi and some action, but it’s really about a family story. And you could just feel the energy of the audience, many of whom were Asian American and is a very powerful experience.

Robert Pearl:

Wow. I haven’t heard of that movie. I’ll check that out too.

Zubin Damania:

You might enjoy it.

Robert Pearl:

Is it currently playing?

Zubin Damania:

It might be rereleased. It came out a few months ago, but you can get it on the usual rental channels online.

Robert Pearl:

One last topic coming out of what you mentioned earlier, you mentioned Buddhism and I’m always fascinated by your understanding of it, your practice of it, you’re going towards it. A book that I read at least twice a year is Victor Frankl’s Man’s Search for Meaning. And in this podcast, we’ve covered the gamut already. Issues around suffering and happiness. You’ve pointed out many times about Buddhism and the idea that suffering is, it’s integral part of life. Last episode we talked about on the other hand, that we’ve both had great fortune in our lives to have had pretty good lives and excellent upbringing. Victor Frankl talks about the fact that we can’t control the world around us, but we can control our response to that world. I want to ask you about this whole notion about our attitudes, about happiness and what we should do about that in the context of healthcare today. How do we separate what’s real, which is our ability to gain happiness out of purpose and at a function from what is simply Pollyanna deception.

Zubin Damania:

So, this is interesting and I actually don’t consider myself a Buddhist. I actually look at all these different approaches to self-awareness or awakening or however you want to call it. But I think what many of us in healthcare suffer from and I saw this at the retreat we did, I’m actually tomorrow, I’m leaving for another eight day silent meditation retreat, actually with a anesthesiologist, Angelo DiLulo, who’s been on my show a few times at his home. It’s just a small group of people. And it’s interesting, because a lot of these guys are healthcare people at the last retreat.

Zubin Damania:

And what we find is we are so self-referential, we’re so up in our head, we’re so identified with our thoughts and our emotions and our bodies and we feel like we’re the small thing against the world. And so we’re trying to find happiness as a separate self battling against a world that is opposed to us. And the real revelation starts to come when you realize, that’s just not the case. When you can actually examine your experience in the current moment and find no distinction between self and other and in a sense, it’s all happening and it’s happening perfectly. And that automatically realigns attitude, because attitude is a kind of a thought pattern.

Zubin Damania:

And we then interact with the world in a very different way. The energy we put out is different and our responses are different. And it’s all the cliches you hear, everything is love and this and that and all that. Those are just dumbed down ways of saying the experience that’s available in the present moment is beyond words. And people will reduce it to a Hallmark card, but it’s actually experienceable. So instead of thinking about it, talking about it, theorizing about it, just pay attention to the present moment and see what happens. And often the attitudinal changes and all that can just emerge from that, but it takes persistence, awareness and sometimes a teacher and sometimes some striving, which is paradoxical, but that’s been my experience so far on this sort of journey.

Robert Pearl:

How do you stop that from making the individual, the victim and the source of the problem, when it’s really the context around him or her?

Zubin Damania:

Yeah, it’s a paradox because you’re telling somebody, “Listen, this is really in your control. Meaning there’s no control, but you can wake up to that and you have to look.” And so in a way, you’re giving them this sense of agency and responsibility for themselves, which can create this kind of victim mentality. But in reality, that’s to wake up to the fact that they’re really, this is just this beautiful present moment happening. There’s no past and future. It’s really just this.

Zubin Damania:

And that means that when you actually, it’s not even a knowing, it’s an actualized realization. You embody this understanding. The way that you show up in the world actually is better. It’s better for you in the story sense. It’s better for you in the emotional sense and it’s better for others. And so it’s because so many of us are trapped in the kind of, I’m a victim mentality, or it’s all my circumstance, that’s the problem. And the truth is, there is no problem in the present moment, but that again, and that gets back to The Matrix. He says, “There is no spoon,” to Neo. In the end, when you realize that, then you have all the power paradoxically.

Robert Pearl:

To be continued in the next episode. Let me turn it back to Jeremy to pose the question to you and me.

Jeremy Corr:

I’m curious if there is a person or topic or something that happened in medical history, that if each of you had to choose, that you would make a movie out of that you would feel that would be inspiring to not just medical professionals, but to a mainstream audience as well?

Zubin Damania:

Boy, there are a lot of beautiful evolvements in medicine. I think Osler’s story, some people call him the father of modern medicine would be a great kind of biopic to tell, to kind of show what medicine is at its heart. I think the story of Maurice Hilleman who pioneered and discovered and invented some of the first commercial vaccines is a beautiful story. I think Paul Offit actually was involved in a documentary about him, but doing a fictionalized version would be a beautiful piece. There’s so many of these things that would inspire us to reconnect to the kind of sacred heart of medicine, which is that deep connection with other humans. That then you fold in the science and the technology and the innovation, but really it’s about other people. So I’ll turn it over to you, Robbie. But those are my top of the head thoughts.

Robert Pearl:

I love, whether it’s a novel, whether it’s a movie, the vision of an arc. I think every story has to have an arc of one sort. There are lots of different arcs, but it has to have a connection coming up to either a peak or going down to a valley and coming back up afterwards. And the story that I’m obviously focused a lot on right now, I just did a TED Talk on, was the story of Ignaz Semmelweis and the discovery of how doctors were carrying the bacterium, they didn’t know as a bacterium at the time, from the autopsy room into the delivery room and killing large numbers of women. I could imagine the movie opening with the suffering of women who were coming in for, what should have been a glorious event, delivering a child and dying in the hospital and leaving the new baby and the children back at home without a mother. Semmelweis’s fortuitous experience where a colleague nick’s finger, develops a local infection, goes on to a clinical course, identical to these women who develop the technical term’s puerperal fever.

Robert Pearl:

And he goes on to die. Semmelweis comes up with an idea. He’s a scientist. He tests it. He finds that the mortality drops from 18% to under 2%. We expect, as the audience, oh my gosh, this is terrific. People are going to embrace it. Doctors are going to love it. It’s going to spread rapidly. Only to find out that no, they actually hate it, because it lowers their status. It lowers their prestige. And Semmelweis ultimately gets submitted to a psychiatric mental health facility where he goes on to die a couple of years later.

Robert Pearl:

And it’s the pathos of both the experience, the suffering of the women and the families and the arrogance of the physician at the time. And of course, in the end, the pathos of Semmelweis himself, who won’t get a chance 50 years later, to see Pasteur define infection and be able to identify the bacteria that is responsible for this disease. And therefore allow us to then go on to treat the bacterium. And now that’s a relatively rare complication following delivery. So that’s the arc that I would follow in the story. And I think it would make a far, even a far more beautiful movie, than either book or article.

Zubin Damania:

So basically what I’m hearing is, you’re nixing my inventor of the DaVinci prostate robot story. Is that what you’re saying for Semmelweis? Because I think that story is completely boring and uncompelling.

Zubin Damania:

No, it’s beautiful. The Semmelweis story, because it points right back at us, at the culture of medicine. It’s so uncomfortable to think that we could be complicit in harming and creating, suffering in women. And yet there it is, the culture trumps everything else. And Semmelweis, when you talk about the arc, the hero’s journey, what Joseph Campbell, famous mythology professor talked about this hero’s journey. And by the way, a great thing to listen to if you haven’t, Robbie is The Power of Myth. It’s an audio series with Joseph Campbell and Bill Moyers from, I think it was the ’80s. And they talk about this stuff, the hero’s journey, it’s really, really powerful.

Robert Pearl:

I’ve read Joseph Campbell’s book. I love it. And I’m going to make sure we talk about it as the first thing we discuss in the next episode of Unfiltered. So Zubin, it’s been terrific. Thank you so much. And I can’t wait till we get back online a month from today.

Zubin Damania:

Thank you, Robbie. It’s always a blast.

Jeremy Corr:

We hope you enjoyed this episode and we’ll tell your friends and colleagues about it. Please follow Fixing Healthcare and Apple Podcast, Spotify or your favorite podcast app. If you like the show, please rate it five stars and leave a review. If you want more information on healthcare topics, you can go to Robbie’s website, robertpearlmd.com or visit our website at fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook and Twitter at Fixing HC Podcast. Thank you for listening to Fixing Healthcare’s newest series Unfiltered with Dr. Robert Pearl, Jeremy Corr and Dr. Zubin Damania. Have a great day.

# # #

The post FHC #61: An unfiltered look at Rx triplicates & Amazon’s healthcare expansion appeared first on Fixing Healthcare.

Returning to the podcast this week is a household name in medicine, Dr. Don Berwick, who made his first appearance on the show in season one. Back then, Don said something that would turn out to be highly relevant to this: the seventh season of Fixing Healthcare.

“We have made so many stupid rules [in healthcare],” Don said, “and those stupid rules have to be stopped. They have to be taken down. Many of them are rules that make no sense.”

He was referring to some of medicine’s written rules—particularly, the endless performance metrics that so many doctors despise. In this interview, hosts Jeremy Corr and Dr. Robert Pearl ask Don to discuss some of medicine’s unwritten rules. These are, as listeners know, the norms and behaviors that dictate the way doctors think and behave.

Quick bio: Don is the former president and CEO of the Institute for Healthcare Improvement (IHI) and led the organization’s 100,000 Lives Campaign. He’s the former administrator of the Centers for Medicare & Medicaid Services (CMS) and has served on the faculty for Harvard Medical School and Harvard School of Public Health.

“I’ve never done anything alone. It’s with a group of people like you, Robbie, who understand that we’ve got to make changes, our oath needs to be honored, and that’s only going to be done if we change the way we deliver care. I think that the lesson I learned early on is that the receptivity in the workforce is enormous, once offered the opportunity to improve the work they do to get really involved in all the dimensions of excellence. The vast majority of people in healthcare, doctors, patients, nurses, pharmacists, they really want to make changes. And if you can drill down to that energy, you can have success.”

“One of the most dramatically positive experiences in my career, I think, was the 100,000 Lives campaign back in 2004. The architect was my colleague still, Joe McCannon. We developed the idea of trying to mobilize energy throughout the nation in hospitals to adopt a relatively simple set of changes that would save lives by improving processes by standardizing and spreading practices that worked. Well within, oh, barely six months, we had over 3,000 American hospitals enrolled in that project. I think there’s a will in the workforce to work on making things better systemically that can be unleashed through proper leadership.”

“The trick is to learn to think systemically, for clinicians to understand that they are citizens in complex environments, much bigger than themselves. And only when we get involved in, buoyantly, happily, joyfully get involved in celebrating and working in those interdependencies with the support of leaders can we make progress. It’s really frustrating to try to be a hero all the time. It doesn’t work.”

“Prevention is always hard. You don’t actually know what doesn’t happen, but once you bring a scientific lens to this problem of excellence and get honest about the data, you can see it, you can see the harm.”

“We’re in a hammerlock right now. The incumbent financial system is so deeply invested in the technologies and processes of acute care, some of which are miraculous, lives are saved every day by organ transplants and heart surgery and advanced chemotherapy that we should never give up, never ever give up. But in order to support that technocracy, we’ve developed a financial architecture that is confiscatory. It takes everybody’s money and talk about breaking rules. The rules for payment, the rules for profit, for greed that allow greed to enter the system are costing us dearly. And I think the incumbent system doesn’t want to change it. It doesn’t want to see that money shift.”

“We really need to become globalists in our thinking. It’s not un-American to ask how other nations and other communities deal with health and wellbeing and at what price, it’s instructive. And we need to have a humility to do that searching.”

READ: Full transcript with Don Berwick

* * *

Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #60: Don Berwick on ‘breaking the rules for better patient care’ appeared first on Fixing Healthcare.

Dr. Anthony Fauci recently credited the antiviral drug Paxlovid with keeping him out of the hospital. That was after he tested positive a second time for Covid-19. Following a course of Paxlovid pills, Fauci appeared to experience a “rebound” case of Covid-19, stoking fears about the drug.

In this episode of Coronavirus: The Truth, Jeremy Corr and Dr. Robert Pearl examine whether Paxlovid treatment is worse than the disease. You’ll find that and all the [time stamped] topics discussed during this show here:

[01:01] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?

[04:17] Listener question: “What are the facts about ‘rebound COVID’ after people take Paxlovid?”

[06:21] What should we expect from the updated mRNA vaccine coming this fall?

[08:47] How bad was care for patients who went to the hospital for surgery during the height of the pandemic?

[10:51] Are Americans “over” Covid-19, according to polls?

[12:55] What’s new with young kids and Covid?

*This section deals with non-Covid news and events in medicine*

[17:28] What do doctors fear most about the recent SCOTUS decision on abortion?

[26:39] How much does a pregnancy cost in medical bills?

[27:55] Among wealthy nations, the U.S. has had a terrible track record with maternal mortality. What surprising thing happened during the pandemic?

[29:40] The pandemic has made medicine worse in many ways for lower and middle-income families. Are there any national solutions on the table?

[31:40] What about the medical implications of the guns case SCOTUS ruled on recently? What about climate change? Domestic violence? What else is impacting medical care?

This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #63: What causes ‘Covid-19 rebound’ after Paxlovid? appeared first on Fixing Healthcare.

This Fixing Healthcare podcast series, “Diving Deep,” probes into some of healthcare’s most complex topics and deep-seated problems.

On today’s episode, hosts Dr. Robert Pearl and Jeremy Corr dive deep into a pair of controversial Supreme Court rulings with serious medical implications. Then they dive into the rules drug companies play by to keep prices and profits sky high.

For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a time-stamped discussion guide:

THE SUPREME COURT V. SCIENCE

[00:57] What events inspired Dr. Pearl’s latest Forbes essay “The U.S. Supreme Court Is Unscientific, Medically Negligent?”

[02:09] What are critics saying about the Dobbs and NY gun cases?

[02:47] Did the court really break longstanding precedent in overturning Roe?

[05:40] What are defenders of the Court saying about these decisions?

[06:41] How does Brown v. Board (1954) relate to Pearl’s view that today’s Court is unscientific?

[08:48] Did the recent Dobbs ruling on abortion dismiss important facts?

[09:55] What is “originalism” and how does it affect the current Court’s decisions?

[12:23] In the article, Pearl evokes the Spanish Inquisition. Why?

[14:09] Which scientific facts should the judges have considered in the NY gun case?

[16:26] What’s the relationship between mental health issues and gun violence?

[18:57] What medical consequences will women experience as a result of the recent abortion case?

THE RULES DRUG COMPANIES PLAY BY

[20:20] How do drug companies go about pricing new medications?

[21:14] Why are biopharma companies so profitable?

[21:47] How does the drug industry outpace all other industries in revenue?

[22:33] Do pharma companies need to improve drugs in order to raise prices?

[24:51] How does Big Pharma influence drug policy?

[25:33] How do current U.S. policies boost drug-industry profits?

[27:15] Why don’t lower-priced competitors try to disrupt the drug industry?

[29:43] What can patients do about high drug prices?

[30:23] What three things could Congress do to curb high prices?

[31:51] Doesn’t the drug industry deserve some kudos for the good they do?

* * *

Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #59: Diving deep into SCOTUS rulings & drug-industry rules appeared first on Fixing Healthcare.

“I wish I was more authentic, more transparent, more myself from the very beginning (rather) than trying to create a character or a persona,” said Dr. Zubin Damania (aka ZDoggMD) when asked about his social media regrets.

On this week’s show, Dr. Z joins cohosts Dr. Robert Pearl and Jeremy Corr to discuss the false personas that physicians assume as part of their medical training. They are taught, as doctors, to conceal emotions, remain objective and always keep patients at a professional distance.

“The culture of medicine,” added Dr. Damania, “is inauthentic by its own creation.”

Welcome to Unfiltered, a show that brings together iconic voices in healthcare for an unscripted, hard-hitting half hour of talk. A little show history: Prior to Unfiltered, Dr. Robert Pearl had twice appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who had twice appeared on the Fixing Healthcare podcast with Pearl, alongside cohost Jeremy Corr (see: here and here).

For more, press play or peruse the transcript below.

* * *

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

Jeremy Corr:

Welcome to Unfiltered, our newest program in our weekly Fixing Healthcare podcast series. Joining us each month is Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard-hitting conversations about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice. I’ll then pose a question for the two of them as the patient based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Hello, Zubin. I can’t tell you how much I look forward to this program each month.

Zubin Damania:

Oh, it is a lot of fun. I always learn something and then take it home and abuse that knowledge in some way and misuse it. So it’s very important to me.

Robert Pearl:

Excellent. Excellent. I’ve developed this habit. As people tell me various things each month on a variety of topics, I find myself wondering, what would Zubin say? Fortunately, I get to find out.

Zubin Damania:

And then how can I do the opposite of what he just said? It’s interesting. All joking aside, I feel the same way about you. I’m always thinking, how would Robbie interpret this? What would he do, given all his experience? So it’s fun to talk.

Robert Pearl:

All right. So let me start with a conversation we had on Fixing Healthcare with a physician who is very big in social media. This is Rod Rohrich. And I asked him a question about what did he regret having done on social media, and his response was interesting. He said, “There’s nothing much that I regret having done, but there’s much I regret not having done.” Is this your view about social media and yourself, or do you have regrets about social media that you wish you hadn’t done?

Zubin Damania:

Oh, it’s really interesting. I am more with him, actually on this. I wish I was more authentic, more transparent, more myself from the very beginning than trying to create a character or a persona living in this kind of fear that we are ingrained as physicians to make sure we’re always trying to be whatever vestige of professional we can. And I think people really on social media, where it really comes into its own is when there’s authenticity and also kind of a lack of concern about growing followers and growing influence and more like, here’s what I need to say and how I want to say it. And I think I have the authority say it for these reasons, and here I am. And the other regret, I think, if I’m thinking about regret, it’s more early recognizing the addictive quality of social media and how we can have these … There a term that my friend, Peter Limberg, has coined called second selfing. And it means when we put ourselves out as a digital facsimile, like out in the world of social media, say, we have our primary self, like what we do in work and home and all of that. And then we have our secondary self, which is out in the world. We really do fall prey to certain failure conditions that can be fulfilled, for example, the idea that we are actually addicts of the very platforms that we are out on. So we may become addicted to Facebook or Instagram or looking at our stats and that kind of thing. There’s a kind of internalized capitalism that happens where we’re always concerned about what are views and who’s sharing this and what are the comments, and getting those little hits of dopamine from those kind of things. There’s the strange parasocial projections that our audience project onto us thinking that they understand or know a lot about us because we’re out there, but those parasocial projections are often sort of distortions of what our actual reality is. So there’s a series of kind of interesting foibles. So my regret would be not understanding that earlier and then kind of adjusting for that and recognizing that. It took me a while to kind of fall into the flow of that.

Robert Pearl:

What he said that was fascinating to me or pointed out that was fascinating to me was that medicine is intrinsically a very conservative profession. And when you and I were in our training, we were told to have this false persona. Don’t show your emotion. Don’t connect with the patient. Keep a distance. Anything else distorts objective diagnosis and treatment. And so I’m not sure that there is an authenticity in the culture of medicine, and you’re pointing out that it takes the authenticity to engage in broad social media with thousands or hundreds of thousands of individuals.

Zubin Damania:

I think that’s an absolutely central point is that the culture itself is inauthentic by its own creation. And so to then tell a physician, “Oh, be authentic on social media,” that’s not going to happen because it’s antithetical to the training. When I started in 2010 doing social media, there was a kind of internal cognitive dissonance, like, can I really do this? This is absolutely contrary to everything I was trained. And my colleagues were telling me the same thing, like, “Oh, you’re going to get in trouble,” or Stanford’s going to be mad or Palo Alto is going to be mad, whatever it is. And so you’re always operating in this kind of climate of fear, which is very difficult to foster an authentic expression of connection with the audience in that case. You know?

Robert Pearl:

Like you, Zubin, I love asking questions for exactly the reason you said a few minutes ago. I always learn a lot, particularly when the people are expert or at least have unique perspectives. And I often realize how wrong my assumptions are. I thought of this a couple of weeks ago. I had dinner with a friend I hadn’t seen in eight years. And eight years ago, five of us had dinner in San Diego. And I was surprised when she told me that she often thought of the question I posed that evening. I couldn’t remember the details, so I had to ask her what had I said. And she responded that I had asked the whole table which was more important in friendship, truth or loyalty. What do you think?

Zubin Damania:

Oh, man. These are the existential questions. So this is what I think. I think the answer to that question depends entirely on our inborn and somewhat further conditioned personality types. So if we are a type that values relationships, commitments, loyalty, duty, responsibility … There are certain personality types that that’s very high scoring in. Then the answer would be loyalty. And actually, it’s funny, Robbie, because I actually fall into that inbred personality type. It’s kind of like the software that my personality runs on. And what’s interesting is I never take any of this personally anymore because I know that even that software is running in sort of a perfect open expression of awareness that’s running the software. So I don’t identify with my personality, so I can look at it a little more objectively. So for me, the answer would be loyalty and duty to each other, whereas there are many that, say a different personality type that values truth over loyalty. The answer is going to be quite different. And what is fascinating is that will manifest differently in behavior, say on social media. So betrayal might be the cardinal sin among friends questioning each other publicly or whatever, among one type. And among another, it might be just constantly trying to find truth, and any deviation from that would lead to a personal attack. So that’s just kind of my thinking on that.

Robert Pearl:

It was interesting because her answer was that at the time, she thought loyalty was. But now, almost a decade later, she’s come to recognize truth being more valuable. I thought that was an interesting evolution as she’s progressed along her professional career.

Zubin Damania:

Yeah. One might even say that progression to truth is more a question of seeing things clearly, regardless. Right? And loyalty can be folded into truth in that way, in some sense.

Robert Pearl:

I believe that at least with close friends, that loyalty demands truth.

Zubin Damania:

Oh yeah.

Robert Pearl:

Not judgment, but truth. I think that’s the evolution in my life. And when I have my close friends and I have a thought, I don’t try to protect them, but I try to engage them. I don’t judge them. I’m going to like them, whatever I tell them, whatever I perceive. But to me, truth becomes a derivative of that because if I can’t tell them the truth, then no one’s going to. And I’m a loyal friend of them.

Zubin Damania:

Yeah. And the interesting thing about truth is often we cannot see it in ourselves. We’re very good at self deception, especially in healthcare circles. And so having a friend who’s loyal enough to hold up the mirror of truth to you, I think is powerful.

Robert Pearl:

How about in medicine, particularly when it comes to telling patients difficult things and engaging in difficult conversations. Should we and do we tell them the truth, or do we protect them through some type of veil of loyalty?

Zubin Damania:

This is another wonderful question because sometimes, pure, unadulterated truth delivered in an indelicate way can destabilize the situation in a way that actually causes harm. And so because humans are so complex, truth, and even the definition of truth can vary from person to person. But the question is, I think we always have to be as honest with our patients as we can, but delivering that message must be done in a compassionate and thoughtful way, because how we deliver it is actually probably more important than the actual message we deliver for many people because how they receive it, it triggers a physiologic response, an emotional response, a mental response, a logistic response, what they’re going to do with it. So yes, honesty and truth is important, but the delivery vehicle is key as well.

Robert Pearl:

Yeah. My sense is that we often don’t tell the truth not to protect the other person or because they really can’t hear it, but because we don’t want to express it. It’s about us, not about them. And that’s where I think that loyalty and I think the doctor-patient relationship has to go past that, which you’re raising a very important part, that if you don’t have, I’ll say that in depth doctor-patient relationship, which should be one of bilateral loyalty and commitment, then you’re not able to provide the truth without creating harm. And that becomes the problem in medicine, as opposed to the fact itself, which says, yes, you have a disease, and no, there’s nothing I or any other doctor can do to correct it. I will be there with you in your most difficult times to the last moment. I will make sure that you’re not in pain. But you need to know, so that you can finalize your life, that you only have a certain amount of time. I can’t tell you exactly how long, but at the end of the time, you will be dying. And it will not be your hoped for longevity. It will be sometime most likely in the next year, or whatever the medical facts would say is the timeframe. And I think that’s so important so that there are no regrets, either obviously, for the person who died, who won’t have regrets after he or she’s dead, but also the people who are still alive.

Zubin Damania:

I think the key thing there is that you pointed out that contrary to popular belief, there are two human beings in the room when it’s a doctor and a patient in the room. And that physician human being, they have their own defenses and hangups around these conversations. And in many ways, like you say, we’re reluctant because it’s pointing a mirror at our own mortality, our own feelings of success or failure, or our own conditioned beliefs on what makes a good doctor, and giving hope or taking hope away, and all these concepts that we have around it. But in reality, I’ll never forget when I was a resident at Stanford, I had a clinic at the VA. And I had a youngish, like in his 50s, vet who I had diagnosed. We did a chest X-ray for some other reason and diagnosed a lung cancer. And he took me out to dinner along with my girlfriend, who became my wife, at the time. And I said, “Why are you doing this?” He said, “I really wanted to thank you for being able to show me what was going on. I know it’s going to be a tough thing, and I know I may not survive. But being able to know the truth and you delivering it very directly and compassionately was so important to me.” And I’ll never forget that. I’ll never forget the dinner. I’ll never forget him. And that’s what it was. There’s two human beings in the room. They’re connecting.

Robert Pearl:

If I can shift to another conversation, this one I had with a medical student who contacted me and wanted some career advice. He was trying to decide whether to get an MBA, whether to get a PhD. There were a variety of choices he had to make in his life. And he asked me a fascinating question. He said, “You’ve done so much in your career. You’ve achieved so much. Are you just a lucky person?” So let me ask you, Zubin. You’ve achieved so much. Are you just a lucky person?

Zubin Damania:

Oh, I’m the luckiest person on earth. All of it is a serendipitous, brilliant, interdependent connection. And to say that I had anything to do with it is to overstate it by an order of magnitude in that sense that yeah, I was lucky to be born to two physician parents who made me feel like there was struggle all the time and that there was scarcity. And so I fought for every little tooth and nail. And then I had mentors that were amazing and all that. But here’s another twist in that, is that we have the choice in any moment to make ourselves open to what my late friend, Tony Hsieh, calls return on luck, ROL. Are you open and available when luck strikes to actually do something, to be there, to actualize it? And that’s in your control. And so everybody has these vestiges of luck. It’s just how open are we to actually be there when it happens. And I think many people in medicine are so conditioned by inertia and fear that we close ourselves to return on these serendipitous gifts that life throws our way.

Robert Pearl:

There are clearly some people in this world who get born into tremendous poverty in Bangladesh and have bad luck, so let’s exclude that. But amongst most of the people around us in the United States, do some people have more luck than others? Or is it just that when the luck comes along, they’re better prepared, and they can take advantage of it in ways that others do not?

Zubin Damania:

It’s definitely a mix of things. If you can look at the kind of karmic background of people, what are the causes and effects that led to their current situation? And it’s intergenerational. It’s trans culture. These are things that are … It’s kind of a momentum that you’re born into. For example, if your life is like a wave, how big was that wave when it started? What was the nature of the currents and everything that led to it? And now here you are on this big wave coming towards the shore, versus somebody who was on a more subdued wave. And you look at the person in Bangladesh, who from our standpoint looks like they’re very unlucky, and you actually poll what’s their level of self-reported happiness. You may be surprised at how high it is because even though their wave was a little weird, they’re around people that are connected. There’s a sense of community, a sense of love, a sense of presence. And so their general level of happiness is high, even without all the material and health-wealth that we purport to have.

Robert Pearl:

You’re exactly right. It’s fascinating that I didn’t think about that when he asked me, because the studies on happiness have shown how much greater happiness exists in parts of the world that we would think would have misery. But people have family. They have relationships. They have to have enough food to survive and enough housing and protection against the elements. So there’s some basic pieces that if they don’t have it, then obviously, their life is in total crisis. But beyond that, there’s not very much. And as we said in our last podcast, the psychological literature even in the United States says that beyond a number that is at least among physicians, a level most of us pass, which is about $125,000 to $150,000 a year of income, beyond that there’s zero correlation with added happiness. And obviously, if people are having to make major compromises to generate a bigger number, there could be more dissatisfaction. And how distorted our minds are about what generates happiness in our lives.

Zubin Damania:

Yeah. It really gets back down to that central premise of a lot of the spiritual traditions, which is desire and aversion are the operating system of the mind, and it is also the root of all suffering. So once we reach a certain level of material comfort, if that desire machinery keeps going, you don’t get happier or more stable. You just get more anxious. So as they say, more money, more problems.

Robert Pearl:

So what’s the biggest piece of luck you’ve ever had in your life?

Zubin Damania:

Oh man. I would never be able to isolate it to one thing, but I would probably say just being born into the exact family I was born into led to pretty much everything after that. And then … Oh, sorry, Robbie. I would be remiss if I didn’t say this. The biggest piece of luck I ever had in my life was meeting my wife. They say in business, the best business decision you can ever make is who you marry. And I would say, yeah, that’s true. But it’s also your happiness, your stability, your mental health. All of that goes with how you’re partnering. And again, a lot of it is luck. I would say 99.9% of it is luck. So I just happened to get lucky to meet a person that was a very good fit. We’re very different, and we complement each other. And we’ve managed to make it work so far.

Robert Pearl:

Wow. Congratulations about that. Let me move into a little bit of a weirder area if it’s okay, because I was reading about this Google employee who was convinced that the AI application that existed was sentient and that had contacted an attorney. And he was the spokesperson for the AI application that was being deprived of the rights that it should have given its ability to perceive and feel things. But it made me think about a movie. Did you ever see the movie, Her, the 2013 movie with Joaquin Phoenix and the voice, at least, of Scarlet Johansson?

Zubin Damania:

I never saw it, and I heard I should see it.

Robert Pearl:

Yeah. So it focuses on Theodore, who is played by Joaquin Phoenix. He’s a sensitive and soulful man, and his job is to write personal letters for others. And he’s left heartbroken after his marriage ends in divorce. And he becomes fascinated by this computer operating system named Samantha, who is the voice of Scarlet Johansson. And her bright voice and playful personality lead to what he experiences as friendship, a date, ultimately love. I don’t want to spoil anymore of the movie, either for you or the listeners out there. But I’m fascinated by this line or lack of line or blurring of line between people and machines. I read that by 16 years from now, neural networks in AI will equal the number of neural networks in the human brain. The Turing Test will be easily passed by machines.

Robert Pearl:

What do you think? Will a time come when this line between machine and person will disappear? We can date machines. We can date people. We can have our doctor be machines, doctor people. Where do you think it’s going to go 50 years from now? You’re a visionary of the future. Where is it going to be, Zubin?

Zubin Damania:

Oh, the easy questions, always. Every podcast, you throw these softball questions. Yeah. It’s funny. I actually interviewed Federico Faggin. I may have mentioned in a previous podcast, he co-invented the world’s first commercial microprocessor. He’s kind of Silicon Valley royalty, worked with Andy Grove at Intel. And he studied AI for 30 years after, and also has had a series of little mini spiritual awakenings and has kind of studied consciousness. And he is quite convinced that machines, they can fool us. So in other words, you can get these complex neural networks that can behave for all intents and purposes like a human, and humans will be fooled. It’ll pass the Turing Test, all of that other stuff. But it’s really in essence, a zombie. The lights are not on inside. It’s just going through these prescribed motions that humans are conditioned to believe is actually sentience. So this person who’s saying, “Oh the Google AI is sentient,” is easily fooled by patterns, basically of behavior or action. And so why wouldn’t the AI actually have an internal life? Why would it not have a subjective experience? And that gets to the fundamental question of what is consciousness and what is our immediate experience. I will argue, and Federico argued the same thing, that organisms like us are unique in that the internal experience is so transcendent of what we think mechanical intelligence can do that it actually has a kind of inductive intelligence that you will never touch with computers. You can facsimile it, but it doesn’t have an internal state. And so if you want to fall in love with something that pretends to be a human, that’s great. That’s great for you. That’s wonderful. But if you’re telling yourself that it actually has an internal experience, that’s a tougher thing to wrap something around because it probably doesn’t and probably never will.

Robert Pearl:

So let me challenge you a little bit, which is if you are correct that there’s something truly unique about humans that doesn’t exist in other animals and to your point might not exist in a machine or a computer application, what is the evolutionary reason that it happened and persisted, because if it doesn’t have evolutionary value, then as we went from chimpanzee to human or from reptile to mammal, it would have not been a factor that would have persisted and now become ubiquitous. What is it about that you believe has tremendous advantages specific to survival?

Zubin Damania:

Okay. I should clarify a couple things. One is, I do think actually animals are sentient. It’s just I don’t think that something we create in terms of mechanical intelligence can be sentient in the way that we understand sentience. The second thing I’ll say is, so this idea of consciousness as an evolutionary sort of epiphenomenon that has evolved and may have advantages and disadvantages for reproduction, you can talk about that at length, but I actually think that we’re getting it backwards. I’m actually an adherent of what professor Donald Hoffman’s theory is and some others, which is instead of saying the material stuff is primary, and consciousness evolved somehow from it in a way that we can’t quite understand yet because maybe we’re not smart enough, or whatever, I actually take the stance that consciousness was primary, and the material world is what consciousness sees when it constructs a kind of interface. So there is an objective reality, but it’s all consciousness. And we’re sort of like consciousness in a vast sense, social network of consciousness, evolving and competing with other interfaces that see the world differently. And so in that sense, consciousness is evolving, not so much consciousness evolved. That’s my roundabout way of totally avoiding your question.

Robert Pearl:

Well, I’ll push again.

Zubin Damania:

Yes.

Robert Pearl:

Which is that so much of human survival, so much of human existence, is being able to read other people and respond back in ways that are empathetic, sympathetic, engaging. Why, when a machine does that using an AI application … Not now, but we’re talking about 16 years from now, when it’s a thousand times more powerful. Why is that different than the human interaction and experience?

Zubin Damania:

Ah, what a great question. I’ll just point us back at our own experience in the present moment. So if we think that we can make a computer and we can describe in parameters and terms and sequences how that computer can create the taste of chocolate or the internal state of love or something like that, I would then point us back to our immediate experience of any of those states without the conceptual overlays. So just experience what it looks like looking at your desk or your microphone, and really, really pay attention without labels. Look at that in a very mindful, present way. And what you will find as that experience unfolds is that it is indescribably vivid, intense, and without stability. It’s totally ephemeral. It’s radiating. And those words are not even coming close to doing it justice. So the actual conscious experience is unfathomably complex. And that’s why I think even if we were to use the microscope and the science of our own introspection, we would realize very quickly that it’s beyond our ability to create a facsimile of it mechanically. So that would be my take. And I’m probably wrong.

Robert Pearl:

The beauty about talking about 50 years from now is no one really has any idea. But I think it’s important because I actually do believe that there can be an evolution in machines beyond which we are capable of controlling. There was another movie around the same time. I think it was called Ex Machina.

Zubin Damania:

Oh, yeah.

Robert Pearl:

That was exactly about this theme and an AI application deciding that no longer did the AI application want to be under the direction of humans. And this is certainly the fear that people have talked about in AI getting out of control or computerized systems getting ahead of humans, not the ability to just memorize, but the ability to actually have more sophisticated neural connections than we do.

Zubin Damania:

Yeah. And what’s interesting is I don’t think consciousness is even required for that to be a threat. Even the mechanical intelligence that can happen can be a threat to humans because it will vastly outstrip any human intelligence in that way. But it may not have comprehension. It may not have an internal state. But does it need it to actually destroy us? Probably not. So, yeah. This is hours of fun, Robbie. Either one of us could be right, and yet civilization could end.

Robert Pearl:

Well, I feel like we owe it to our listeners to at least bring this back into reality. So one last observation that I learned about this week, which is that the business of psychological literature now is focused on an interesting phenomenon about people, which is that we always like to add and rarely subtract. And by that, I mean if you give people a problem, you give them a Lego structure with two towers, one that’s slightly higher than the other, and a ramp connecting the two sides, and you ask them to horizontalize, if there’s such a word, that ramp, 90% of people will add a block to the lower side, rather than just subtracting one from the elevated side. And they’ve pointed out how much in our lives we move to adding when we face a problem, rather than thinking about ways to subtract from it. And my sense in medicine is that’s what doctors and healthcare leaders do. We add a new policy when there’s a problem, rather than perceiving that maybe there is a policy that needs to be taken away. Or we add a new procedure or approach, rather than recognizing that maybe something we’re doing needs to be eliminated. What do you think? Do you think that this problem is real, and what can we do about it?

Zubin Damania:

Yeah. You have a great way of pointing out these things that people don’t think about. That’s exactly it. If you ask doctors, what’s the best day you’ve had in recent memory at work, they’ll always point to something where things were stripped away. There was less administrative stuff. There was less charting. There was more time with the patient. But that more time with the patient is almost like a presence or a silence. It’s almost subtractive in itself. It’s taking away all the garbage and just allowing this to be. And in medicine, it’s exactly that, especially in the West. It’s all about adding, adding, adding. Well, if these three click boxes weren’t enough, something isn’t working. Let’s just add another click box, instead of thinking, well, maybe the concept of all these click boxes is probably not the right way to approach this particular problem. Technology, same thing. Add more features, more of this. How about just make the technology more focused on what it is we actually need and strip away all the stuff you don’t need? And again, I always bring it back, because you see where my head is these days, to any kind of spiritual practice. It’s all about letting go and surrendering and letting things sort of regress back to almost childlike wonder. And we don’t do that in medicine at all. We generally do the opposite, as you said. It’s interesting that the psychological literature then kind of reifies that, that people just do that. Maybe it’s a function of human beings, or maybe it’s a function of how we’re conditioned in society.

Robert Pearl:

In my book Uncaring, I write about my aunt, who at the time was in her 90s. She ultimately died at 99. And I was visiting her, and she had this big garbage bag full of medications. I don’t know how many she was on, 8, 10, 12. Every doctor continued to have a drug they prescribed for her and then added more as she had an abnormal lab result or an abnormal finding. And I suggested she see a geriatric physician. And the first thing the doctor said is, “You only have one medication you need. I’d throw the rest of them away.” And she felt so much better. She didn’t have complications and lightheadedness. She was steadier in her gait. Now, this is not the right advice for everyone at every point in their life. But no one thought about saying, “Maybe you should stop some of those medications. You don’t need to lower your blood lipids. You’re 97 years old. How long are you going to live?”

Zubin Damania:

It’s a disease we have in healthcare that we’re conditioned to do that. At our clinic, Turntable Health, we have this thing because again, so much of it, as you all always point out, Robbie, is your incentives. So if you’re paid to do stuff to people, you’re going to do stuff to people. And what we were at our clinic in Turntable … And I know you were doing this at Permanente Medical Group. It was a capitated rate to take care of a population. And so what we would do is we had in our huddle room bags and bags and bags of medications that we’d taken patients off on a wall. And that was sort of our pride was like, look at all these medicines we’ve stopped on people. And they’re doing so much better. They’re so much happier, instead of just the knee jerk of wanting to add more stuff. And it all gets right back to your Lego analogy. We really need to learn that less is more in medicine more than anything, often.

Robert Pearl:

And in many ways, that’s what prevention is. It’s less disease. Not treating the disease and avoiding complications from disease, eliminating disease, figuring out ways to avoid hypertension, to avoid diabetes, to avoid chronic lung disease. And in medicine, we don’t value that highly enough. And again, I like to think about these unanswerable questions. I wonder how much of that is just the human mind, that we want to see ourselves as problem solvers, not as problem preventers.

Zubin Damania:

I think you have been one of the clearest voices in pointing out our own internal conflicts around this and in medicine, and I think that’s one of the central ones. That’s very brilliantly put.

Robert Pearl:

And you did it in Las Vegas.

Jeremy Corr:

So we just celebrated the 4th of July here in the United States, and this year it felt very bittersweet. I’m a firm believer that America’s the greatest nation in the world, in spite of some of the dark things in our past, such as slavery and the horrible treatment of indigenous people. That being said, America in my opinion was a great experiment in democracy, and largely it worked. It has worked for some people more than others though. You guys talked about luck earlier. And some people have obviously lucked into good situations or being born with wealthy parents or wealthier, more educated communities, et cetera. And I’ve seen many people on social media in the last couple of weeks, boycotting July 4th or having F the 4th of July parties, while others celebrate it like we’re some sort of flawless nation.

Jeremy Corr:

We even had a mass shooting again over the weekend in Illinois. And I don’t think at the time of this recording, his motivations are known yet. But what I have seen on social media is a lot of people claiming he was a right wing nut job and an equal number of people claiming he was a left wing nut job. One thing that was very clear though is that he was very, very mentally ill. How can we as a nation heal this divide, focus on helping those that are less fortunate, in less lucky situations, people that are mentally ill? And how can we focus on community and togetherness and healing instead of all this material and tribal things? And before I ask you your thoughts, I kind of want to close it with this Thomas Jefferson quote. He said, “Yes, we did produce a near perfect Republic, but will they keep it, or will they in the employment of plenty lose the memory of freedom? Material abundance without character is the surest way to destruction.” What are your thoughts?

Zubin Damania:

Back to the unanswerable. No, I think this is actually something that we can wrap our heads around. We know there have been multiple reasons for division and all of that in this country, and some of it’s social media. Some of it’s cable news. Some of it is our sort of general natural evolution as humans to differentiate apart from each other before we integrate to the next phase of development. And one of the things you pointed out were these F the 4th of July parties and this kind of reaction to celebrating in a patriotic way, US democracy and independence. I think that’s a form of nihilistic reaction to problems and excesses that we see in our country. And rather, I think, than focusing on the nihilism, or even focusing on the people who are behaving in a nihilistic way, we ought to focus on, okay, yes and. So, yes, our country is wonderful and it has problems. So what’s the next thing? What’s more inclusive? Yes, there are people at all different stages of luck, wealth, development, personal development, spiritual development, economic development, and intellectual development. How do we nudge everybody at their stage of development to the healthiest version of that stage that we can without judging, without condescending, and without rejecting? That’s the kind of focus that we need as a society to bring us back together. And some of that means we’ve kind of lost a sense of collective meaning, a collective purpose. There’s a kind of meaning crisis as we’ve secularized and everything. And so how do we bring back a sense of meaning? And these are the questions we ought to be really trying to process through rather than getting, I think too much into the weeds of, what do we do with this kind of division and that kind of division and this situation and that situation. It’s a bigger picture move forward that we ought to be seeking out.

Robert Pearl:

My thought aligns very closely with Zubin about the fact that we try to have an or, and we need to have an and. I heard a program this morning on the radio comparing the shooters in the most recent tragic events and whether we want to label them having mental health problems. I can’t imagine taking a high velocity rifle with a lot of ammo and shooting into the crowd and killing a lot of people, particularly killing a lot of children as in any way consistent with mental health. The other point that they all shared was social isolation, and we have a problematic society where people are excluded. And if we ignore that and we don’t figure out ways to increase community, we’re going to have more people for whom this seems to be the only way that they can address the pain that they have because they don’t go to get the care that they should receive personally. But even then they need to be able to build the relationships around them. And it’s not unexpected that all these shooters are sort of 18 to 21. They’ve left high school. They’re not in college. They find themselves really socially isolated from people, from friends, from family, and this is their means of addressing what’s going on. And that to me, Jeremy is the bigger problem that exists right now. You’re a historian. If you look at Hamilton versus Jefferson, Hamilton was an individual who very much elevated the elite, and Jefferson was an individual who created and viewed broad community as being vital to a healthy country. And we’re moving in the opposite direction right now. I think the recent Supreme Court decisions are really problematic. I think basing it upon a world that existed back in 1783 or the whatever year exactly the constitution was put into place, when you had a world with a life expectancy of 35 years, when you had women being seen not just as property, but as the possessions of their husbands, when you had the existence of slavery, all the pieces that existed at the time, and to believe that we could use that as the foundation of modern society, I think the crises that are about to come up are going to be even more problematic than the present. And we need to come to grips with this as a nation, or we’re going to see even more ongoing deaths, tragedies, ruined families, ruined communities, ruined relationships. So I’m a very optimistic person, but right now, I think I have as many concerns as hopes for the future.

Jeremy Corr:

We hope you enjoyed this podcast and will tell your friends and colleagues about it. Please follow Fixing Healthcare on Apple Podcast, Spotify, or your favorite podcast platform. If you like the show, please rate it five stars and leave a review. If you want more information on healthcare topics, you can visit Robbie’s website at robertpearlmd.com. Visit our website at fixingpodcast.com, and follow us on LinkedIn, Facebook, and Twitter at Fixing HC Podcast. Thank you for listening to Fixing Healthcare’s newest series, Unfiltered with Dr. Robert Pearl, Jeremy Corr, and Dr. Zubin Damania. Thank you for listening, and have a great day.

The post FHC #58: An unfiltered look at inauthenticity in medicine appeared first on Fixing Healthcare.

Dr. Rod Rohrich has broken the unwritten rules of medicine across his career. He turned a traditional paper-only, medical journal into a digitized force, full of videos and evidence-based rankings that has become one of the best in the nation. And he revolutionized rhinoplasty surgery and plastic surgical education and training.  

Today, Dr. Rod Rohrich is one of the most influential plastic surgeons in this century and continues to be voted the best in publications like Newsweek, US News and Harper’s. A proponent of social media as a tool for patient education, he has hundreds of thousands of followers on Instagram and Twitter and continues to break medicine’s outdated rules.

In this interview, hosts Jeremy Corr and Dr. Robert Pearl—himself, a reconstructive and plastic surgeon—discuss the lines that need to be crossed to make medicine better for doctors and patients.

In medicine, there are so many times we do things that have absolutely no rationale (for) but we’re told that that’s how we’ve always done it. And I was at one of those famous hospitals in Boston where we were told that all the time, and we did it without question. I think we need to now question that and say, “Is that really the best way to do it, or is there a better way? Is there a simpler way? Is there a best medicine way?” If it’s breaking the rules, so be it, but I think it’s really doing it to get us out of our cages that we’re in that really impede best care.”

“You should always be yourself and you should use social media to empower your audience and not to impress them. You should use it to educate them and not to overwhelm them. And I think people appreciate that. Because if you approach social media by educating them about their own health, how they can be better, how can they do things better, how they can find plastic surgery or doctors better, that’s a good thing.”

“There was a great chasm between aesthetic surgery and reconstructive surgery for many, many years, and I think that’s come together in plastic surgery; but then there was even a deeper chasm between our specialty and our sister specialties, from dermatology to facial plastic surgery and otolaryngology, but I think that also has had a coming together. And I really think that social media has played a big part in that, and the ability for leaders to say, ‘Hey, we want to teach people to do the right thing and to provide best care.’ I personally do not care what your background is, I just care about how good you are and how good you can become to do and give great patient outcomes and do patient safety. And I think that hopefully is becoming the bottom line.”

On academia vs. private medical practice

“I think you learn the rigidity of academic medicine and the pros and cons, which are fantastic. When I helped build our incredible plastic security department at UT, it actually taught me the discipline of staying focused because there’s so many different ways where you can go by the wayside, especially in universities. Because there’s a lot of barriers to progression and advancement in academics, because there’s so much bureaucracy, politics, and red tape that are a burden … I think the private sector has been an epiphany for me to say, ‘Wow, I learned all these things in academics, but now I can apply them in the real world without all the impediments.’ So it’s been a total breath of fresh air.”

“The worst thing you can do is solve a problem and then say, ‘Oh, we solved it.’ You have to say, ‘We’ve solved this part of the problem, let’s see how it works,’ because it’s not a solution, it’s always an evolution. That’s really important, because times change, people change, and the processes change. So I think we need to keep working on it.”

On the next-gen of rule breakers

“I think that today, the Gen Zs and the Millennials, they aren’t rule followers. They actually like to break the rules. That’s their norm, which is a good thing, I like that. They challenge us, they want to know what we don’t know, and I really like that. They challenge us every day to say, ‘Hey, I learn differently. You need to teach me in a different way,’ and I think that’s good.”

READ: Full transcript with Rod Rohrich

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #57: Dr. Rod Rohrich on how to change the rules of medicine appeared first on Fixing Healthcare.

The New York Times surveyed 362 school counselors on the effects of the pandemic on children. The results were both predictable and troubling. Not only have kids fallen behind in the basics like reading and math, but counselors also described students as “frozen, socially and emotionally, at the age they were when the pandemic started.”

Nearly all counselors (94%) said students were showing more signs of anxiety and depression than before the pandemic. What can be done about these troubling developments? Are there reasons for optimism in the data? What’s new with vaccine approvals for young children?

Jeremy Corr and Dr. Robert Pearl examine these questions and many others in this episode of Coronavirus: The Truth. You’ll find all the [time stamped] topics discussed during this show here:

[00:51] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?

[03:08] There are new concerns about long-COVID. What have researchers found?

[05:40] Listener question: “The World Health Organization estimates that 5 times more people have died from Covid-19 in India than reported. Is the same true for Africa?”

[09:16] Listener question: “I feel fine, but I tested positive for COVID 10 days after coming down with infection. What does this mean?”

[14:35] Dr. Pearl wrote a recent Forbes article titled “Why Omicron Is About to Make Americans Act Immorally, Inappropriately.” What did he conclude?

[18:27] Will sporting events and indoor weddings see capacity crowds this fall?

[19:46] For parents, is there any new research on kids and Covid-19?

[23:03] Is a vaccine for Omicron coming soon?

[25:00] What do we know about other Covid-19 vaccines in the works?

[28:15] Listener request: “I listened to your show last month about monkeypox and hope you can provide an update during your next show.”

[30:02] Listener question: “One of your episodes included data about how the U.S. spends so much more on medical care than other nations and yet trails other industrialized countries on all clinical outcomes. But isn’t cancer an exception in America?”

[32:06] Listener question: “Almost everyone I know has gotten sick with Covid-19 lately. A few of them have been sick for several days, but none of them needed hospitalization or came close to dying. How dangerous is it  to get COVID now?”

[34:12] Cohost Jeremy Corr’s had a recent experience with Covid-19. What happened?

[35:51] What’s the big non-Covid-19 news story this month?

This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #62: Has the pandemic ‘frozen’ kids emotionally, socially? appeared first on Fixing Healthcare.

This Fixing Healthcare podcast series, “Diving Deep,” features a robust and probing discussion into some of healthcare’s most complex subjects and deep-seated problems.

On today’s episode, Dr. Robert Pearl and Jeremy Corr dive deep into the unwritten rules of healthcare and American society. Together, they’ll ask the question, “What is it about Omicron that is making Americans act immorally and inappropriately?” They’ll also focus on the hidden causes of outrageously high drug prices.

For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a time-stamped discussion guide:

WHY OMICRON IS MAKING PEOPLE ACT IMMORALLY

[01:03] What was the inspiration behind Dr. Pearl’s popular Forbes article “Why Omicron is about to make Americans act immorally, inappropriately,” which was read by nearly half a million people?

[02:40] Why are people’s behaviors starting to change?

[04:07] What are “cultural norms” and which ones are changing because of Omicron?

[05:44] What’s a culturally immoral act today that will be culturally appropriate in the near future?

[07:33] Are people’s actions really “immoral” or are they to be expected given the nature of the disease?

[09:30] How do external forces (like the virology of Omicron) change culture and behaviors?

[15:04] What evidence demonstrates this cultural shift is already under?

THE UNWRITTEN RULE THAT KEEPS DRUG PRICES SO HIGH

[19:31] Do high-priced drugs in the U.S. overachieve, meet expectations or underachieve for patients?

[20:40] Do drug makers lack the scientific knowhow to make highly effective drugs?

[22:06] Why are drug companies so risk averse? Has it always been this way?

[24:30] When did the unwritten rules of drug-industry profits begin to shift?

[26:24] Don’t drug companies need high prices to protect R&D investments?

[27:00] What are examples of high-priced medications that deliver limited or no value for patients?

[30:11] What’s suspicious about the new FDA-approved breast cancer drug?

[32:50] Are Covid-19 vaccines an exception to this rule?

[34:09] Is there more to this rule listeners should know?

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #56: Diving deep into odd pandemic behaviors and overpriced drugs appeared first on Fixing Healthcare.

This Unfiltered episode of Fixing Healthcare features Dr. Jonathan Fisher, a respected cardiologist and advocate for physician well-being, and Dr. Robert Pearl, healthcare leader and author of ChatGPT, MD. Jeremy Corr, CEO of Executive Podcast Solutions, adds the patient’s perspective, as always.

In this episode, the trio takes a deep dive into the intriguing applications of Game Theory in healthcare. Dr. Pearl introduces Game Theory—a concept that analyzes how individuals or groups make decisions in competitive situations—drawing from its use in business to better understand interactions between physicians, insurers and healthcare organizations.

Today’s topics include:

• Game theory and healthcare economics: Dr. Pearl explains how Game Theory can help reframe the often adversarial relationships between doctors and insurers, exploring ways to move from lose-lose situations to more collaborative, win-win outcomes.
• The role of autonomy: Dr. Fisher explores the inherent conflict between physician autonomy and collective decision-making, noting how the fragmented nature of healthcare impacts both patient outcomes and physician satisfaction.
• Collaboration vs. competition: The group discusses the need for healthcare professionals to shift from tribalism and competition within and between specialties to a more cooperative approach that benefits patients.
• The prisoner’s dilemma: Dr. Pearl introduces this classic Game Theory scenario to illustrate the difficult choices doctors face when limited healthcare resources force tough decisions about patient care.

To discover more, press play and check out these helpful links:

New book: ‘Just One Heart’ (Jonathan Fisher)

New book: ‘ChatGPT, MD’ (Robert Pearl)

Monthly Musings on American Healthcare (RobertPearlMD.com)

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #147: Game theory and healthcare—the complex relationship between doctors, payers and patients appeared first on Fixing Healthcare.

Said ZDoggMD: “Oh, man, OK. You said, hey, let’s do a podcast together, Z. It’ll be fun, you said. It’ll be easy. It’ll be flow. Then you ask a question like this?”   Replied Robert Pearl, MD: “It’s easy for me to ask the questions, Zubin. That’s what I meant.”

Welcome to Unfiltered, a show that brings together two iconic voices in healthcare for an unscripted, hard-hitting half hour of talk. In this episode, Dr. Pearl wastes no time getting serious with Dr. Damania (ZDoggMD). The two talk about the unseen forces holding healthcare back. These invisible elements including tribalism, bias, fear, inertia, hierarchical struggles and a cowboy culture that all combine to harm patients, increase medical errors and prevent high-functioning teamwork.

A little history on the show: Prior to Unfiltered, Dr. Robert Pearl had twice appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who had twice appeared on the Fixing Healthcare podcast with Pearl, alongside cohost Jeremy Corr (see: here and here).

For more, press play or peruse the transcript below.

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

UNFILTERED TRANSCRIPT

Jeremy Corr:

Welcome to Unfiltered, our newest program on our weekly Fixing Healthcare podcast series. Joining us each month as Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice. Then I’ll pose a question for the two of them as a patient based on what I’ve heard. Robbie, why don’t you kick it off.

Robert Pearl:

It’s amazing, Zubin, how fast a month passes. Feels like we just recording last month’s Unfiltered episode yesterday, and here we are recording the new one.

Zubin Damania:

The dirty secret, Robbie, that I’ve learned as I got older is the older you get, the shorter time feels because it’s a smaller portion of your overall life. For me, it’s like the days just go click, click, click, click, click, and then we’re doing another one. It’s kind of nuts.

Robert Pearl:

It’s just a question. When you’re having fun, time passes rapidly.

Zubin Damania:

Oh, the flow state argument?

Robert Pearl:

Yeah. Yeah.

Zubin Damania:

Yes. There’s that as well. There’s that as well.

Robert Pearl:

I thought of you the other day. I was talking with an ER physician and an ER nurse. They were passionate about patient safety and frustrated by how difficult it was to make systemic improvements. They reached out to me wanting my thoughts and advice on how to get people to do what seemed so logical: save lives. They pointed out the extensive research that had been done on the topic of safety, going all the way back to Ralph Nader, the car industry, aviation history. I acknowledged the frustration they felt. I talked with them about a personal experience. Chronicles my first book, Mistreated, about my father’s premature death from preventable medical error. I offered my view that when logical things don’t happen, like systemic improvements for patient safety, there’s always another factor, one that’s either not visible or not being considered. I said that based on my experience, you can’t solve the problem staring you in the face without bringing the other one out from the shadow and addressing it. If it’s okay with you, Zubin, I’d like to learn from your insights about what’s not being seen or said about a few of these seemingly obvious opportunities. Let’s start with patient safety. Over 200,000 people die every year from medical error. Research shows that most result from a combination of systemic problems and a failure of people to follow evidence-based approaches. Seems like a no-brainer to me to follow the experts. What’s not being recognized when it comes to patient safety?

Zubin Damania:

Oh, man. Okay. “Hey, let’s do a podcast together, Z. It’ll be fun,” you said. “It’ll be easy. It’ll be flow.” Then you ask a question like this.

Robert Pearl:

It’s easy for me to ask the questions, Zubin. That’s what I meant.

Zubin Damania:

I know. This is a question that I wrangle with almost every day, especially since my father is in and out of the hospitals these days. I’m always terrified because I know all the statistics you just said apply, and it’s not one of those vague things. They apply personally. You told your story about your father. I was there at Stanford, I think, when your father was there. Let’s speak about it honestly. A lot of it that’s unspoken is the shadow culture of medicine, I think, that really, it’s inertia-driven. We are fear-based, so errors of omission are actually punished or are considered more powerfully than errors of commission. What we fail to do is actually, we worry more about malpractice than what we actually do, so we tend to do a lot of stuff. Each thing tends to have its own downside, including a certain level of unnecessary testing and screening and treatment that has consequences. Iatrogenic, the physician-caused, medical system-caused consequences. But we’re acculturated to actually do things to people to some degree, to avoid getting in trouble for the opposite, which is failing to do something, failing to do the scan, failing to do the procedure that actually, it may have been better not to do. In the house of God, Sam Shem says, “One of the rules of the house of God is, do as much of nothing as possible.” I think there’s that cultural component, but then there’s the autonomy component where I think many people in healthcare don’t want to be part, or they want the support of a system, but they don’t want any infringement on their perception of autonomy. If you’re doing a root cause analysis or you’re going through a just culture algorithm for dealing with patient safety, I think some physicians feel like, “Well, they’re telling me how to practice. This is stepping on my autonomy and they are bureaucrats doing this.” To some degree, maybe that’s true in certain settings. But in others, this idea of a systemic, thoughtful and somewhat algorithmic, meaning there are some algorithms that actually are shown, hey, you just got to go through a checklist when you’re flying a plane. Why wouldn’t you go through a checklist in the OR? Why wouldn’t you make sure you’re not operating on the wrong side? All these other things. But we resisted as a culture, the culture of cowboy autonomy. The culture of individuality has been ingrained into medical training. Then the fear-based stuff, really, I think prompts us to do things to people that probably result in harm just in and of itself. That’s just a tip of the iceberg, I think, in terms of patient safety.

Robert Pearl:

Let me ask you about another area that I know is very close to your heart, and this is about high-functioning teams. We live in an era where medicine is complex. Patients often have multiple chronic diseases. You can’t achieve the best outcomes as lone cowboys and cowgirls, you just said, and yet rarely do we put in place highly effective, highly functioning teams. What’s not being said that’s getting in the way?

Zubin Damania:

I think again, it is we’re conditioned as these hierarchical agents in healthcare, that a team is another way of either saying, I’m the boss and you guys are going to listen to me, you’re my support. Or they’re trying to usurp my autonomy by giving me this “team”. I think that’s some subtext to it, not always. Again, we’re conditioned not to like our autonomy taken away. The other problem is I think we don’t allow people on the teams to really practice at the full extent of their abilities, with the support of the team. We give them these pigeonholed roles and that makes it difficult. Then we don’t have a culture that really elucidates the brilliance of a team as well. It’s still a lone wolf culture, but then we go, “Oh, but there’s a team.” Then it becomes a dominator hierarchy where there’s somebody who is the boss on the team and everybody else is just doing scat. That’s one outcome that can happen. We haven’t actualized team-based care. The real team-based care is everybody’s living their most actualized piece and it’s self-managing and self-governing. At our clinic, our team, there’d be a different member of the team that would lead the huddle every day, and that could have been a health coach with no formal medical training that was trained on the job or hired for certain attributes, and then allowed to use those in service of the team. It was a growth hierarchy that we were trying to build there, but it involves culture shift, training shift, system shift, technology shift. Why shouldn’t you be able to all write in the same note in the EHR at the same time? That was something that we explored when we were building our technology.

Robert Pearl:

All right. One more. How about the disparities and health outcomes based upon race? We certainly know they exist, but we don’t seem to be making any progress. What’s not being said here?

Zubin Damania:

Oh. Oh, man. You make it so easy, Robbie, so easy to hurt yourself. Really, would you hit those hard topics that are difficult? Again, there are so many people who can weigh in on this, and I’ve interviewed people like Ian Tong, Black doctor, and his perspective was very, very valuable in helping me understand it a little better. But yes, there’s unconscious bias. Yes, we use heuristics in medicine that are often unconscious, sometimes they’re conscious, to pigeonhole patients quickly. Could race be a part of that, that could then lead to unequal outcomes? Sure. But I think actually, there’s also the component of yet we don’t have enough minority physicians, physicians from different socioeconomic backgrounds that take care of patients, because that seems to be associated with better outcomes because there’s more understanding of the community. The way we tried to hack that problem is we would get health coaches who were drawn from the community they served, and often were in the same socioeconomic status as a lot of the patients we were taking care of. That helped a lot because they were developing these trusting relationships and really understanding the patients. Not just the social determinants of health, but what their goals and hopes and aspirations were, so that we could tailor care. But then there’s the bigger elephant in the room, which is we are dealing with the societal issue of inequity that has been generations in the making. It falls on the healthcare doorstep to say, “Hey, fix this problem.” But the truth is, this is a massive problem that comes from cycles of violence in communities of color and poverty. All the things we reduce to social determinants of health are actually incredibly nuanced and complicated things that don’t have a simple, let’s have a quality of outcomes answer, and even a quality of opportunity. How do you accomplish that? Even in medical admissions, how do you accomplish that? That’s where again, the further we get out from the original sin, say of slavery say, the further we get out from that, the more we have to think. Okay. We need to start to wake up in a broader way that changes society, that then will ripple through healthcare. But again, those things that are our direct purview, we need to address, but it’s hard.

Robert Pearl:

Let’s shift a little bit. Did you have a chance to read the report by the Surgeon General on burnout this week?

Zubin Damania:

Well, I just got to say one thing. I love it. You throw this on my lap, I answer the question in a hand-waving way, and then you’re like okay, moving on. I’m like, “What about you, Robbie? What do you think about it?” Because I know. I’ve read your books. You think about this stuff clearly. But all right. All right.

Robert Pearl:

No, I will answer you. To me, there’s a lot of unspoken things. I think each of these types of problems exist, and I think that there’s a level in which, and I will even say the majority of people have call it implicit bias, call it acting in racist kind of ways. They’re not consciously racist, but I think they make those decisions and they have trouble seeing that in the mirror. It’s uncomfortable, and that’s why I always bring up these issues. Because as long as we want to say that racism as an example, doesn’t exist, then we’ll talk about the problems, but we won’t solve it. To me, you look at the issue of gun violence. What do the gun proponents want to say? It’s all about mental health. Well, it’s not. But why do they say that? Because they can’t win the argument about keeping high-firing, multiple-round guns out of the hands of 18-year-olds who are socially isolated in high school. And the consequences are predictable. But if you don’t want to talk about the problem, you find someplace else to focus and you dismiss it. That’s who I see again and again in medicine. If we just look at this question, why don’t we have high-functioning teams, it’s what you said. Because people like their place in the hierarchy and they’re not about to give it up. On the other side, the question’s really going to be, how do you create a high-functioning, equal team of people with different levels of expertise and experience?

Zubin Damania:

Yes.

Robert Pearl:

This is the kind of questions we never address. My frustration, why I write the books, why I have the podcasts is for all of the time we talk about these things, when I measure progress, it’s in inches. It’s not in miles and hundreds of miles that we should be going. I look at the outcomes in medicine. What are we seeing? We’re twice as expensive as any other country in the world and our outcomes are lagging. I just can’t believe I look at data on maternal mortality and I see it’s four times higher than other countries. It just jumps out at me, and that’s again, why gun violence to me is another example of that. Look how many more guns we have in the United States. Look how many more people are getting killed. I think other countries have some mental health problems, too. So, why don’t they have the same level of difficulty? If it’s not the guns, what is it? It’s somehow sitting in the political process that we have. You’re hearing me just being frustrated by the slowness of change and the waste of human existence.

Zubin Damania:

What you’re pointing at is repression and denial, and projection and all. It always comes back to us. It always comes back to the human at hand. Personal growth, we’re avoiding that. When you talk about implicit bias, for example, yes, of course, of course, of course. You know how we know this is true? Because all of us have it. If you actually introspect, you’ll see it arise, and instead of acting on it unconsciously and automatically, you’ll actually go, “Oh, wow. Well, there’s a little bias. Let me think about that and act more responsibly.” But it requires introspection. It requires looking at these difficult things, whether it’s guns, whether it’s race, and that’s why it’s so uncomfortable. We feel it. Even talking about it, it’s like, oh, I get a little constricted because you’re feeling your own stuff and you’re going, “Ooh, am I missing something in myself?” That’s why we got to have these conversations, brother. I ditched your question on the burnout thing because I haven’t read the report. So fill me in.

Robert Pearl:

He pointed out, as we all know, that it is a major problem. I don’t want to say he underestimated. I just don’t think he detailed it as much as he should. He talked about a variety of things. He said, there’s a need for living wage and paid sick time and family leave, evaluation of workloads and staffing, which is all true. He talked about reducing the documentation and other administrative burdens for healthcare workers. He talked about the need to have mental health support. He talked about the opportunity to protect healthcare workers from violence and unsafe conditions. He talked about a lot of the problems that clearly exist, we know exist, and people would like to see changed. But I raised the issue, Zubin, because again, when I look at burnout, I don’t know how long it’s been, at least a decade we’ve been talking about this. I don’t know about you, but I don’t see that things are very much better today than they were five years ago. The question I have is, if it’s not much better now than five years ago, why do we really think it’s going to be any different five or 10 years from now? Why are we paying that price? But more importantly, what can we do to avoid having to experience both the lack of fulfillment, the fatigue, the moral injury, and the implications for both doctors and for patients?

Zubin Damania:

I agree. It’s only gotten worse, and the pandemic’s only made it worse. You talk about the Great Resignation and people are just waking up to, is this really what I want to do with my life? Was this the calling I felt it was? I think what you’re pointing at is a fundamental … There’s a few issues, and you’ve brought up some of these in your books too, which is one of the issues is physicians in particular, they have a certain idea of what this thing was supposed to be and then they’re met with this kind of 2.0 version, which is mechanized and bureaucratized. There’s this administrative technocracy that seems to run it. It’s so discordant with what their image was and their own self-image of the cowboy doctor, that it creates this tension. But that’s a part of it. Obviously, it’s all those things. What’s required is a dramatic, and again, you said things are measured in inches, not miles. That may be true, but at some point, there’s a phase shift that happens where we just go, “Oh wait. Wait. Wait. We’ve seen some bright spots here. We know where this works there. They’re emerging in fits and starts.” Maybe well-resourced, team-driven, primary care that gives you the tools, the teams, and the trust to do your job, and actually systems that support that and a slow but steady culture shift towards this kind of team-based care, maybe that. Then we train our medical students like, “Hey, this is how it’s going to be”, so expectations and competencies are matched to what the actual system is going to be. Then we might start to see a shift. When you talk about teams, that’s when you start pulling in nurses and pharmacists and respiratory therapists, and everybody else on the team that has been suffering as well. Then look for bright spots within medicine. Who are the specialties and aspects of medicine where the self-reported signs of emotional exhaustion and cynicism and depersonalization, all the burnout, end-stage moral injury stuff, where’s that the least and what can we learn from what’s going on there? It’s a multi-factoral thing. I’m glad Vivek is talking about it. Vivek is such a compassionate, thoughtful guy, but again, it’s like we can list out the problems and knowing the problem is half the battle. But what’s the next step? We really have to start actualizing this stuff.

Robert Pearl:

Let me ask a, I’ll say uncomfortable question, which is-

Zubin Damania:

Oh, you haven’t asked any of those so far, Robbie. This isn’t-

Robert Pearl:

No, this is more so, Zubin, because I sometimes ask myself the following question. In the current world, a world that is the way it should be, with often two people working, I think you said last time that your wife’s a physician, is work-life balance possible without some kind of personal sacrifice being put into play?

Zubin Damania:

Ooh, and this is such a complicated issue because there are gender dynamics here. There’s socioeconomic dynamics, there’s race dynamics. But to put it as simply as possible, I think my late friend, Tony Hsieh, used to say, “There’s work-life balance and then there’s life.” If life is your thing, where everything is part of your life, then there’s not work and life. There’s just life, which means you better start to, first of all, understand that what you’re doing at work is an authentic expression of you, and figure out ways to integrate it into life and make it life itself. That could fly in certain industries very easily, but in medicine, we’re expected to do all these things, be heroic, especially women, and then come home and manage the kids, and come home to take them to soccer practice. Or if we have to hire someone to do that, then we have to work more shifts. We can’t go down to part-time to do those things, because then we can’t pay the nanny. Sounds like first-world problems until you experience them, and then you realize that man, this is as stressful and unhappiness generating. Then you look at the person living in a slum in Mumbai and you measure their subjective happiness and they’re happier, because they have community, they have support, they have some sense of higher purpose, even though they’re in economic squalor by our standards. Why is it that Americans seem just generally less happy? Well, because I think we fragment our psyche into this is work, this is home, this is responsibility and so on. Then we don’t have the social structures. We don’t have proper maternity leave, availability to breastfeed, paternity leave that some of the European nations have. We have the lowest ratio of doctors per capita, practically in the developed world, I think short off South Korea. We wonder why workloads are so high and we have a nursing shortage. Those are just the tip of the iceberg. I’m curious what you think, Robbie, because you’ve had to deal with this for so many decades as leader of such a large organization.

Robert Pearl:

Again, I’m focusing a lot on what’s not being said or not being, to use the word which you said earlier, that we’re denying. If I said to you, “Zubin, what’s it like for you to work full-time,” you describe a very fulfilling career, full-time with a certain amount of money that you’re earning, and I said to your wife, “Okay, you tell me what a full career for you,” she describes the same thing, and they’re both accurate, they’re both wonderful. Now, I say, is it possible to take these two pieces and have them coexist simultaneously? My conclusion is it may not be possible that someone’s going to pay both of you to be able to do that in a context where you’re going to have work-life balance. It may turn out that you both have to cut back on your both professional and economic expectations, and gain from it the fact that now you’ll have more time with your family, with your kids in your interpersonal life. You may not need the same size house. You may not have some of the other accoutrements of life. I don’t know where that would come, but we built professional expectations on the last generation, where you had one person working and not the other person working, and the dollars were adequate to support that family but it wasn’t a life in terms of possessions as we have today. I just wonder whether the societal expectations have exceeded the reality. All you have to do is look at the stock market these days to see that rebalancing that’s going on–on its own, and I just wonder whether that is what’s not being talked about in medicine.

Zubin Damania:

Ah. Once again, you’re pointing inward. You’re saying, what is it we value? What’s self-actualization? Is it acquisitions? Is it material wealth? Is it this socially validated esteem that we have from driving a Mercedes G-Wagon and so on and so forth? Or could we get away with the Camry, upgrade it to a hybrid, get a faux leather interior and be happy with a family life that’s more balanced? Again, with me and my wife, we’ve had to alternate the sacrifices. You asked about sacrifice. We’ve had to alternate. For years, I was a full-time hospitalist while she went back and trained because she had done internal medicine, board certified and realized this is not my calling. She realized it late, and that she was going by societal expectations or parents’ expectation. Then she went back and said, “I need to do radiology.” That’s another four years of training where I’m making 30 grand a year. I said, “Well, let me go ahead and work full-time, even though I don’t know that this is exactly the right path.” I did that. Then we shifted. We said, okay, now she wants to do more of the career building, and let me then do a career where I have more time to help with the kids to do these kind of things to be present. It is this kind of give and take, and you do have to understand what you value it. Now, if I was going by societal roles and this kind of thing, no, I have to be the co-breadwinner, at least, if not in a chauvinistic way, the guy who makes the most and does all of this. Then you’re trapped. Then of course, there’s going to be unhappiness and that mismatches your expectations. I’m with you, brother.

Robert Pearl:

I don’t know if you ever listen to Laurie Santos. She’s the Professor from Yale who runs the course on happiness that one-fourth of Yale students take. It’s the most popular course at the entire university and it’s available online for anyone who wants to do it. But she talks a lot about the way that we misinterpret and misanticipate happiness. One of the pieces that I was listening to the other day is she talked about the research that says there’s a level, and the level is somewhere between 100 and $200,000, beyond which there is not a single shred of evidence that more money adds happiness.

Zubin Damania:

Yes. Yes.

Robert Pearl:

Yet, as a physician, I don’t think any of us see that as a landing spot for us in our family.

Zubin Damania:

Especially if you live in a high-cost area. Then the truth is many physicians gravitate to these things and we start to accelerate our spending, and our outflows become so high that we’re goldenly handcuffed to a career path of FTE and workload that is unsustainable. It’s not what we wanted. Again, we think we’re chasing happiness. We’re not. I think that requires a reality check, a gut check. I think people are waking up more though. I think the next generation is changing its expectations. They’ll complain and they’ll say we have lesser quality of living, standard living than our parents for the first time. But to some extent, that’s an opportunity to go, what does that mean? What should you be doing with that extra time and space? Are there self-actualization things you can do that’ll lead to more happiness, family connections, relationships, et cetera?

Robert Pearl:

I think in our next conversation, I want to talk a lot more about some of these psychological areas, but let me raise one right now. Again, these are the things I’m thinking about a lot, which is that the research is very clear that gratitude and generosity are two of the best ways to maximize happiness, your own happiness. In fact, there’s a lot of data that says, if you give someone $20, as opposed to getting $20, you actually experience a lot more happiness, fulfillment, and joy in your life than whatever you’re going to do with the $20 that you receive. I don’t know, in medicine today, how much gratitude and generosity exists. I think there’s problems. There are reasons why it might not exist. But again, I’m just wondering whether we trip over our own feet in trying to get what we think we want, but in the process, actually rob ourselves of what we could have.

Zubin Damania:

Yeah. There’s no doubt that’s true. Just to some extent, the term mindfulness is misused. It really means remembering. At any moment that you’re mindful, you’re remembering what’s actually true in this moment, and gratitude is a powerful part of mindfulness because you remember how incredibly lucky you are, how much you’ve been given, how many mentors you’ve had, how many opportunities you’ve had that have led you to this part of your career in medicine. That mindfulness, that remembering can center you right in this glow of gratitude that reminds you of the compassion that was given to you. Then it comes out of you. It really is a powerful practice, and more and more doctors are actually, I think, waking up to this. I hear them talking about it more, these kind of practices, so that’s a good sign.

Robert Pearl:

I don’t want any of our listeners to think that in any way, I’m trying to minimize the problems that exist, and recognize the economic challenges people have or the bureaucratic tests that they have. Again, I’m always looking to say, is there a crack in the wall that is being missed? That maybe if we focused on that along with rebuilding the rest of the wall, we would end up being more fulfilled. I would also say, and I often think back to Kübler-Ross and the idea of acceptance, that if the reality is that we’re not going to be able to get the changes that would be optimal, that maybe we should get, that maybe we’re entitled to, but we’re not going to get it, what are we then going to do? How can we add joy and fulfillment into medical practice that maybe today we’re taking away? I know there’s a lot of fear that if in any way we acknowledge that somehow we’re not the victim, that people will not give us what we want. My observation is they’re not giving us what we want right now, so let’s look at these opportunities, whether through mindfulness or whatever other practices it’s going to be, creating these high-functioning teams, even if it means a little bit less respect, seeing patients in a different kind of way, all the parts that we’ve talked about. Is there a way that we can uncover some of these unspoken aspects, have the conversations and come out of it, maybe not as great as we would like, but far better than today?

Zubin Damania:

You’ve said it perfectly, and the truth is it comes back. I keep bringing it right back to the self, the personal development. I’ll take it one step further and say, by doing those practices, you’re not giving up on the fight for all the things you talked about or fixing the system. What you’re doing is you’re enabling yourself to emerge a better system, because when enough people do that, they wake up themselves. Then actually the system starts to transform. In many ways, the system I think, and this is speaking kind of metaphysically, but also I think there’s truth here, the system is an emergent property of us. If we’re a mess in that way, then our system is a mess and it feeds back. What if we start to change ourselves? Well, our system will change, and maybe that’s why we’re at an impasse, Robbie. Maybe that’s why it feels so intractable. It’s always darkest before a phase shift, before you wake up. That’s when it’s darkest, and I feel like we got to talk more about those unspoken things that you’re pointing at.

Robert Pearl:

Well, I’m a big believer as you know that the first thing we must do, if we want to address the panoply of challenges that we have, is move from fee-for-service to capitation. Then in that process of doing that, we now can create the dollars and the resources to fund the things that need to happen. We can pull out those bureaucratic tasks. We can find opportunities to gain purpose, by being able to make the lives of people easier and better. And that standing in our way is this fee-for-service system that as you say, makes us run faster and faster and faster on a treadmill to generate more and more dollars. The insurance companies fight back by trying to limit what we do, because they can’t afford the dollars. The purchasers get somewhere in the middle of the battle, and in the end, as I say, a lot of smoke and very little actual change.

Zubin Damania:

Yep. That’s it. Our incentives matter. But again, I’ll bring it right back to us. Our incentives are an epiphenomenon of what we think we want. Fee-for-service is a lucrative, lucrative kind of like a carrot dangling there. Oh, if I just see more, if I do more, if I bill more, if I code more, I can get that Mercedes G-Wagon, which I’m expected to have, or whatever it is. We have to change, too. We have to change. In Europe, the doctors get paid less, but there are more of them so it’s a different balance. I don’t think any system’s gotten it perfect, so we learn what we can and then look for that phase shift in our own awareness.

Robert Pearl:

You said it perfectly. I can’t wait for our next conversation.

Zubin Damania:

Hey, me too, man. This is intense and fun.

Jeremy Corr:

Earlier, when you were talking about implicit bias, it made me think about a conversation I recently had with a couple of people who were upper-class, educated, East Coast liberals. It made me think about this. The nation is doing a lot now to address the inequities in minority communities. However, one of the things that I think has frustrated many in the rural communities, such as where I grew up, is how they feel as though there’s still a significant bias against them. They feel frustrated because they’re called deplorables or rednecks because they’re poor people from rural America with conservative values. It’s very frustrating to someone who grew up in a dying small town as the generational family farms are being lost to corporate farms and the downtown is dying to Walmart, maybe there might be a factory too in town or whatever. But you have somebody who maybe grew up with a meth addicted or alcoholic mom, an absent father who lives in a trailer park, yet they’re told they have white privilege just because of the color of their skin, in spite of growing up in very tragic circumstances, just like someone in a poor urban minority community. Many of these people feel like there’s a lot of implicit bias against them, and that’s the only kind of bias that is now still socially acceptable. They feel like their communities are often forgot about by the government and they’re spit on and laughed at by what they consider to be the coastal elites. As two Ivy League educated people on the coasts, I’m curious what you think about this.

Zubin Damania:

Oh, man. This is something that I talk about on my show a lot, because I actually grew up in rural Central California and I came from that community. It’s funny. I’d add another component into that. People who are obese get the same kind of discrimination still. It’s still okay to discriminate against the obese. This is my take on this is yes, this is a real phenomenon, at least at the level of the perception of the community in question. And so it becomes real. As a result yeah, that’s going to actually perpetuate further disparities, socioeconomic disparities. It’s also going to change politics in this country because with the electoral map, those communities have a lot of power too. We ought to be unfolding, especially in communities that value these progressive values, they should say, well, all right, one of the progressive values is inclusion, love, compassion, and understanding. So, why don’t we understand the moral palettes that folks that come from these communities have? And they’re powerful. When we travel around the country doing talks and stuff, when I go to rural Texas or Idaho or somewhere like that, I’m just struck by the warmth and the compassion. Yeah. These are very conservative politics. Okay. What is it about the environment and the community that makes that adaptive? Trying to understand that so then we can come up with compromises, allow a lot of local stuff to be hashed out at a local level and so on. It’s just even being aware of it, instead of the blindness that we show so often on all sides of this. A conservative in one of those communities would not understand a highly progressive San Francisco native, unless they’re opening lines of dialogue and understanding that they have common, actual, moral reasoning.

Robert Pearl:

My view, Jeremy, is that tribalism is built into human genetics. It’s the way you survived 20,000 years ago. You could never survive as an individual. But it was all within the people living in your set of caves, and that tribalism rears its head anytime a society or a group in that society is dropping. You see it come up in times of economic challenge, and that’s what we’re in right now. You see it come up in times of winners and losers, and that’s what we have right now. What you’re describing is a particular tribe, or two tribes. You can talk about it as an urban East and West Coast tribe, begins the Central part of the country tribe. You can talk about it in terms of race. You can talk about it in terms of religion. You can talk about it in a lot of different ways, and my own bias about what’s not being said is how the United States as a nation is slowly dropping from the dominance that it had in the past. Sir Michael Marmot, who’s a sociologist in England that I respect a lot, has written and talked about how what you experience when your status, when your hierarchy, when your position in whatever’s going to be, your local community, the nation, the world, starts to diminish, is when you become dissatisfied, unfulfilled, fatigued. In many ways, it’s the same symptoms that we have as burnout, and I think that’s what you’re seeing in the United States today.

Robert Pearl:

Instead of people coming together, as Zubin has talked about, to create a better future, they prefer to focus on someone else’s being the problem, the so-called classical scapegoat mentality, and feel like they’re getting left behind. Have we left rural America behind? Absolutely. They don’t have access to broadband. They don’t have the economic jobs that are in place. They’re working hard in the fields far longer than people in other places are working in industries that add no value and put no food on the table, and they’re not making much money. You can apply the same mindset inside of medicine. You can apply it as I say, to almost everything in our country, race being a classic example, but it’s far more than that. Education. As Zubin said, the people in the center part of the country, what do they value? Because culture is about what you value and you believe. They value family. What do the people on the coast tend to value? They tend to value education, jobs, titles. You come to the coast, the first question you get asked is, what do you do for a living? You go to the middle of the country, what do you first get asked? Tell me about your family. Tell me about your kids. Tell me about your relationships. It’s just different values. From my perspective, they’re both important. But that’s not the way it plays through. As I say, in a time of economic difficulty, there’s an expression someone once told me, “As the pie gets smaller, the manners deteriorate.” I think we’re seeing a lot of lack of manners, a lot of lack of civility, and my concern is it’s going to get worse before it gets better.

Jeremy Corr:

We hope you enjoyed this podcast and we’ll tell your friends and colleagues about it. Please follow Fixing Healthcare on Apple Podcasts, Spotify, your favorite podcast app. If you liked the show, please rate it five stars and leave a review. If you want more information on healthcare topics, you can go to Robbie’s website at robertpearlmd.com, and visit our website, fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter @FixingHCPodcast. Thank you for listening to Fixing Healthcare’s newest series Unfiltered with Dr. Robert Pearl, Jeremy Corr, and Dr. Zubin Damania. Thank you very much for listening and have a great day.

The post FHC #55: Is it time for doctors to temper their career expectations? appeared first on Fixing Healthcare.

Author and historian Dr. Lindsey Fitzharris is fascinated with medicine’s grisly past and the extraordinary physicians who changed the profession by breaking the rules.

One of those rule-breaking doctors of yore is the protagonist of her newest book, The Facemaker: A Visionary Surgeon’s Battle to Mend the Disfigured Soldiers of World War I (available June 7). In it, Dr. Fitzharris tells the riveting and true tale of Sir Harold Gillies, a pioneering reconstructive and plastic surgeon.

Set against the backdrop of the first World War, the book takes place in a time when military technology was radically outpacing the science of medicine. The machines of war were ravaging human bodies. And so, Gillies, a Cambridge-educated New Zealander, dedicated his career to picking up the pieces, rebuilding the broken and burned faces of frontline heroes. Along the way, the surgeon didn’t just break the rules of medicine. He rewrote them.

This interview, the first since the book’s publication, pairs Fitzharris with hosts Jeremy Corr and Dr. Robert Pearl—the latter is, himself, a reconstructive and plastic surgeon who has published two highly acclaimed books on medicine.

“It wasn’t really until the First World War that there was this huge need suddenly for facial reconstruction. And that had to do with the brutality and savagery of this kind of war. This was a time when losing a limb made you a hero, but losing a face made you a monster to a society that was largely intolerant of facial differences. So Gillies really filled in there to help these men, and to mend their faces and their broken spirits.”

“[There were] so many advances in weaponry at this time that a company of just 300 men in 1914 could deploy equivalent fire power to a 60,000 strong army during the Napoleonic war. You have the invention of the flame thrower, the invention of tanks. You have chemical warfare at this time. So really the medical community was just playing catch up when all of this began. And there was this huge need to figure out how to mend these broken bodies.”

“Harold Gillies, what is extraordinary about him is that he’s a very creative individual. He’s one of those annoying people that’s good at everything he does. He’s a competent artist. He’s a great sportsman. And that creative aspect to his personality served him very well going into reconstructive surgery. He’s also very collaborative. He’s willing to work with other technicians and practitioners at this time.”

“One of the terrible tensions for Gillies in World War I was the fact that he had a duty to his patients, but he also had a duty to the army. And so, in some instances, I’m sure he would’ve wanted to continue working on the reconstructive process, but perhaps the function had been returned to the face. And the feeling was that the man could be returned back to the trenches. And I think that was a really heartbreaking tension that played out throughout the war for him.”

“Gillies’ attitude, this positive attitude, and the way he could look at the humorous side of things, really served him well because he had such a heavy burden on his shoulders. If you imagine the psychological damage as well to these men coming into the hospital, I think he was really able to nurse them in many ways, not just fixing their faces, but he was able to fix their spirits.”

“I think that the biggest trait is perseverance. When you look at Joseph Lister, he could have given up quite easily in the face of the pushback because he received enormous pushback when he started to champion germ theory … And it was a huge leap of faith, but he persevered. Also with Gillies after the war, he could have just given up and gone back to his old practice … But he really believed that what he was doing was transformative, that it was important, that it would serve humanity beyond the war.”

READ: Full transcript with Lindsey Fitzharris

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #54: The incredible rulebreakers of medicine’s past appeared first on Fixing Healthcare.

About a month ago, Dr. Anthony Fauci said that the United States is “out of the pandemic phase,” but he later clarified that the country is, “out of the full-blown explosive pandemic phase.” Americans are decreasingly concerned about the distinction, as only 9% believe Covid-19 still represents “a serious crisis.” What’s the official status of the Covid-19 pandemic now?

Meanwhile, several listeners wrote into the show with concerns about a recent outbreak of monkeypox, with 10 cases now confirmed in the United States and hundreds in Europe. The W.H.O. warns it could be just “the peak of the iceberg.” Is a new pandemic coming?

Jeremy Corr and Dr. Robert Pearl examine these questions and many others in this episode of Coronavirus: The Truth. You’ll find all the [time stamped] topics discussed during this show here:

[00:49] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?

[04:45] Worldwide Covid-19 deaths have surpassed 15 million. Why?

[06:36] Looking at China: What went wrong?

[08:37] What is the U.S. doing about the global toll of Covid-19?

[09:55] Is the Covid-19 pandemic over yet or not?

[15:11] What should parents know about Covid-19 now?

[17:46] Does Paxlovid (the new oral medication) eradicate the Covid-19 disease?

[20:22] Will unvaccinated people take Covid-19 medications once infected?

[21:34] Based on new research, how many Americans would have lived if all were vaccinated?

[23:38] Is it safer to host a small indoor event or a large outdoor one?

[25:49] Listener question: Is monkey pox like COVID? Should I be worried?

[28:16] For immunity, is Covid-19 infection ever better than vaccination?

[32:37] What’s the big non-Covid story in healthcare this month?

[34:25] Will the government try to drive lower prices and greater healthcare access?

This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #61: Is the Covid-19 pandemic over? Is a monkeypox pandemic next? appeared first on Fixing Healthcare.

Welcome back to the Fixing Healthcare series, “Diving Deep,” which features a robust and probing discussion into some of healthcare’s most complex subjects and deep-seated problems.

In this episode, Dr. Robert Pearl and Jeremy Corr dive deep into the unwritten rules of healthcare, which have long dictated for doctors and patients “the right way to act.” This installment focuses on the hidden causes of physician burnout and the growing divide between the CDC and public sentiment when it comes to dealing with Covid-19.

For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a time-stamped discussion guide:

[01:00] What was the most surprising insight from the 2022 Medscape survey on physician burnout?

[03:46] Beyond the stress of treating Covid patients, how do doctors explain their burnout?

[05:12] What then explains the significant uptick in burnout for OB/GYNs and pediatricians?

[06:44] How do burnout rates compare between men and women physicians?

[09:19] Studies show that work-related stress impacts a doctor’s personal life, but do problems at home spill over into a doctor’s job performance or feelings at work?

[13:58] What solutions might address the hidden causes of physician burnout?

[18:56] How do Americans perceive the risks of Covid-19 and what do public health officials have to say about it?

[23:28] If health officials and Americans can’t agree on appropriate safety measures, what happens?

[24:39] Why do Americans believe the pandemic is over (even if the CDC hasn’t declared it)?

[26:38] Does the CDC have any influence over the public’s perception of safety right now?

[28:20] Given the change in public opinion, how can health experts and elected officials save the most lives?

[29:25] How can we protect people who are at the greatest risk of dying from Covid-19?

* * *

Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #53: Diving deep into physician burnout and America’s views on Covid-19 appeared first on Fixing Healthcare.

Welcome back to Unfiltered, a show that features two iconic voices in healthcare for a half hour of unscripted, hard-hitting talk.

Dr. Robert Pearl has twice appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who had twice appeared on the Fixing Healthcare podcast with Pearl, alongside cohost Jeremy Corr (see: here and here).

This episode (the third in this series so far) covers a lot of ground, starting with questions of censorship and medical misinformation as talks continue around Elon Musk’s pending ownership and overhaul of Twitter.

Also in this episode:

• Financial incentives vs. intrinsic drivers: What motivates doctors?
• Should we do away with the MCATs and change physician education for good?
• Why are women physicians more burned-out than male colleagues? And, according to the latest surveys, why is the problem getting worse?

To get started, press play or peruse the transcript below.

* * *

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

UNFILTERED TRANSCRIPT

Jeremy Corr:

Welcome to Unfiltered our newest program in our weekly Fixing Healthcare podcast series. Joining us each month is Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare experts, they’ll apply the lessons they extract to medical practice. I’ll then pose a question for the two of them as the patient based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Hello, Zubin.

Zubin Damania:

Robbie, always a joy. I look forward to this time.

Robert Pearl:

This is our third podcast and I wonder, would you feel comfortable with my asking you a personal question?

Zubin Damania:

It could have been the first podcast. You know I’m a bit of a scary open book.

Robert Pearl:

Well, I heard, Zubin, a rumor that you just paid $44 billion to buy Twitter. Is that right?

Zubin Damania:

It is. They say it’s Elon Musk, but when you rip off his latex mask, it’s that old man Damania underneath, just scared of those meddling kids.

Robert Pearl:

I see. Well, I’m always confusing you with someone else, but you do drive a Tesla, right?

Zubin Damania:

No. I’m not rich enough to drive a Tesla. I have a Camry hybrid, so I am gas efficient, but also cheap.

Robert Pearl:

Okay. But seriously, no, let’s put this potential change in a healthcare context for our listeners. I’d like to explore the dividing line between opinion and science. Free speech is a right in the country, but shouting fire in a crowded building is not. You can have an opinion that Putin is the most horrific human being in the world or the savior of Russia, or if you think that swallowing bleach is an effective way to cure COVID-19, telling others to do so is likely to lead to someone’s death. If Mr. Musk called you, wanted your opinion how best to draw that line, what would you tell him?

Zubin Damania:

This is such a challenge because, yes, there are certain types of disinformation, whether intentional or unintentional, that can lead to havoc. And I think this idea of yelling fire in a crowded theater is a good version of that. Remembering that our right to free speech, that’s government stuff. It does not apply to companies. So companies can do whatever they want to your speech, in theory. What I would tell Elon is, listen, don’t entirely abandon the idea that extremely dangerous and direct disinformation that is clearly outrageously wrong shouldn’t be removed from the platform. There is a certain responsibility, I think, to do that. Where it becomes difficult is where there’s scientific debate or there’s opinion or whatever that is and allowing that to air is very different. And I think who the arbiters are of that truth has become difficult. Dr. Vinay Prasad has looked at who are these sort of filters that some of the companies, the big tech companies, have hired to determine what’s disinformation. And often it’s just the loudest voices on Twitter. So that may stifle scientific debate. You do want to a very vigorous, open debate, especially in a time when we don’t know everything, the time of a pandemic.

Robert Pearl:

How would you set up the panel, the algorithm, the AI application? How would you set up somebody to make this decision?

Zubin Damania:

Oh, man. If I knew that … Honestly, because I am much more on the free speech angle of it, I think it’s really … I don’t know, Robbie. What would you do? I don’t know that it can be done well, honestly.

Robert Pearl:

I think when it comes to healthcare, I tend to be a bit more conservative than I am when it comes to almost any other issue. I’m not so in believing you should censor anyone’s opinion unless there’s an implication for others. I’m worried and bothered by the fact we crossed a million deaths in the United States. I don’t think we should have had anywhere near that number of people perishing from this virus. Yes, in the first year, we didn’t know quite what to do. But the second year, we really should have done a lot better. I don’t know whose responsibility it is, but I know that what whoever’s it was, it’s a failure. Not an easy question, but somehow we had to figure out a better way and be prepared at least the next time to do so. If anyone on Twitter wants to tell the world that you or I or Jeremy or anyone else isn’t very smart, our ideas are wrong, that’s okay. There’s no problem doing that. But I just really worry. When we have a means of being able to advise people positively and the risk is tragedy, not just for themselves, but their family, their kids, their loved ones. I just somehow feel that we need to do a bit more, because it is good public health. And that’s where I separate out medicine from everything else that I can think of.

Zubin Damania:

So this is interesting. I think actually what we find is when these companies did label these things as disinformation or block them or whatever, whether it’s a Marty Makary op-ed in The Wall Street Journal or something more even very much to the fringe like Robert Malone or Peter McCullough, these sort of anti-vaccine activist physicians. What we found is that this is the internet, so people will go somewhere else where they aren’t censored. And the very act of censorship confirms the conspiracy bias of a segment of the population that’s prone to believe these things for whatever reason. And some of that is just having a sense of control. They don’t understand how this could all be happening to us and so they’re looking for meaning. And when these guys say, “Oh, the government’s doing this or Fauci’s doing that,” they’re very receptive to that because they say, “Oh, well that at least makes sense. It’s this nefarious plot.”

Zubin Damania:

And my concern is when we start doing those things, we drive people to those other locations and it doesn’t solve the problem. But where I think we can do better as healthcare professionals is we need to step up and say, “Okay, well …” If we think there’s good things like, say, vaccines or certain interventions to prevent the spread of COVID, then we have to be vocal in a way that isn’t judgmental, that isn’t partisan, that isn’t overtly political because the whole thing’s been so politicized. And that would go a long way, I think. Having a louder voice for science and truth and process than for disinformation is one way to drown out the noise without canceling the noise makers that then confirms the bias of the people who are prone to believe it.

Jeremy Corr:

ZDogg, you bring up a very good point of the whole canceling people from those said platforms. For example, when you saw Trump get removed from Twitter and then he moved over to Truth Social and all these kind of right wing people that get banned from Twitter and then moved over to Truth Social or these other kind of platforms, they’re going to be in these echo chambers of people that only think the exact same way as them and spreading whatever information or misinformation or whatever you want to call it. But when you have Twitter as more of a public square type of thing, for example, when you had the QAnon phenomenon going on. For every person that posted some crazy conspiracy theory, you had 20 people responding, being like, “Look, you’re being dumb. Here’s proof. Look, this doesn’t make any sense. Here’s why.” What are both of your thoughts around that, out of curiosity, about is it better to not censor them and engage with them further versus driving them into those echo chambers?

Zubin Damania:

So my take on the echo chambers is that it’s an existential threat, actually, to all of us, this idea that we are polarized into chambers that just reflect what we already hear. And those chambers don’t connect. They only connect through virtual violence. In other words, this antagonism. They’re almost these hive mind, group minds that form. And you’re right. Whether it’s a Truth Social hive mind or a Twitter hive mind or a Rumble hive mind or wherever it is, they tend to attract like minds and then echo the sentiment. So making that corpus callosum, those fibers that connect those different hive minds, is actually key, which means a dialogue. That’s why I’m … And I get it, Robbie. I totally get that this is healthcare and people’s lives are at stake, so we as physicians really want to intervene. And so the question then is what’s the best, most effective way to do that? I wish I had a direct answer, but it’s quite nuanced.

Robert Pearl:

Yeah. I think what you’re hearing from me is just frustration. I can’t stand to see human life wasted, and we wasted human life. And I’m looking for a better answer and that’s why I thought I would ask you about that. But let’s switch maybe to another topic. Zubin, our discussion of the four existential questions in the last podcast, it stimulated lots and lots of great conversation from our listeners. I heard from quite a number of them. And a physician and former student of mine at the Stanford Graduate School of Business asked if you and I could talk about the difference between transactional and transformational leadership. As you know, transactional leadership is quid pro quo. You increase your screening for colon or breast cancer in patients in the recommended age group from 50 to 60%, you get an extra $1,000 a year. You go from 50 to 70, you get $2,000 more. In contrast, transformational leadership, inspires people and attempts to improve medical outcomes by connecting with their inner motivation as people. You led Turntable Health in Las Vegas. What did you learn about the value and role of financial incentives versus intrinsic motivation?

Zubin Damania:

Ah, what a great question. This is the central piece because how do you motivate people through leadership rather than management, through, like you said, transformation instead of transaction? And what I think, I think the data shows this too, and what I found was that pay for performance just doesn’t really work. Doctors are intrinsically motivated to do the right thing. They’re also a bit competitive. They want to actually do better than their peers on average. They don’t want to be the one that’s the last in their class or whatever it is, or the one that has the lowest scores on whatever. They’ve always been intrinsically motivated. So how do you then lead in that sort of setting? And what it seems is, first of all, you got to just set this culture that we’re trying to do the right thing for patients and for each other. And then you provide the tools, the team, and the trust to actually accomplish that.

Zubin Damania:

And the tools will be the technology that’s actually there to enable what they’re trying to do to make them feel capable to do it. The teams are the support structures, the human support that allow everybody to do the top of their game and support each other too. And then trust is the key thing, which is where you’re saying, “Listen, I’m not going to nickel and dime you and give you an extra $1,000 for this outcome. I am going to actually give you the autonomy to accomplish what we have as goals here together that are partially intrinsically motivated, and then give you those tools and team to actually accomplish it.” And yeah, we may measure it as an outcome in a big sense, like how are we doing here, and then have the discussion as a group and maybe have a healthy competition around it. But pay for performance just is not going to motivate intrinsically motivated people.

Robert Pearl:

If that’s the case, and I concur with you, everything you said, why are financial incentives used so often by leaders across the United States?

Zubin Damania:

I think it’s a currency that they understand, especially non-clinical leadership. And I think they think that humans are motivated by that sort of financial reward. But these are medical professionals. After they reach a certain point, it’s more about that intrinsic motivation. For me, when I was practicing fulltime too, that’s how it felt. It’s like, I wanted to feel valued. I wanted to feel like I was providing value. I wanted to feel like I was part of a team that I felt responsible to, and that felt responsible to me. And I felt that I wanted resources to be able to do my job, meaning technological resources that didn’t suck. And I think when I had those, when everything was firing on all cylinders, giving great care just became the default and you are always striving to be better. But when it became about RVUs and when it became about productivity, when it became about these rewards for clicking the right boxes and getting the things done that way, it really stripped away the intrinsic motivation. And I think it had bad outcomes. But I think our leaders are conditioned that way, many of them, especially non-clinical leaders.

Robert Pearl:

Maybe a theme from today’s conversation, Zubin, is my frustration in how slow our progress is. And I want to figure out how we can make it happen faster. Earlier today, I spoke at Rochester at a really excellent organization that was there. And there was a dinner last night and we were talking about the fact that four miles from we were sitting, life expectancy was 10 years less than the people who were living in the area where we were. And I asked them, I said, “What’s going on to change that?” We know what many of those factors are. And the answer was in a motivated community, not much was occurring. How do we accelerate this change to get the best health for people?

Zubin Damania:

So much of it is all healthcare is local. So actually having members of the team from the community you’re trying to serve, who understand that community, having skin in the game, knowing that every community is different, is motivated differently. Not having a one size fits all platform, but maybe having a central thesis like, “These are the goals we want to accomplish. So how do we do it here, versus here, versus here and making it a priority?” We talk a lot about equity and things like that, but when the rubber hits the road, it’s really about financial outcomes or just playing the same old game. And I’m as frustrated as you are, Robbie. It’s very frustrating.

Zubin Damania:

There’s a female physician at Penn. I’m forgetting her name now, but she was on my show. And she works with health coaches from community areas that are zip codes of tremendously poor outcomes and found that bringing those health coaches that go to homes, that interact with the patients. We did this at Turntable, too. Driving these very empathic, motivated interviewers from the communities they’re going to serve. That was 90% of the battle. And then really tailoring it to how do those patients want to communicate? Maybe they don’t want to do a telehealth thing, but they would love to text. So can we set it up so that they can text us because that’s culturally what they do? Or whatever it is. It’s really being adaptable to the community at hand, and then having the motivation to actually want those disparities to go away.

Robert Pearl:

So let me be a little bit controversial and look at another area related to this, which is how we select medical students. Malcolm Gladwell popularized the 10,000 hour rule, implicit in the idea is that if you want to become, let’s say, a great guitar player, it takes that level of dedication and commitment. And maybe coincidentally 10,000 hours is about the amount of time a resident’s in a three year program like internal medicine spends. As you know, I think Malcolm is one of the most talented non-fiction writers, and he was a guest on a recent Fixing Healthcare podcast. But I’d like to add a second rule, and that I’ll label the three step rule. And just so listeners aren’t confused, unlike the 10,000 hour rule that has deep research background, my three step rule, it’s completely made up. I don’t have the least bit of scientific data, but it comes from my life.

Robert Pearl:

And the rule concept is that we all are born with intrinsic ability in each category, how high we can jump, how good looking we are, how well we do mathematics. And let’s just say we have a number between one and 10. With 10,000 hours of practice, we can go up, this is my hypothesis, three spots. I use my life as an example. One of the greatest gifts I ever got was how terrible I am at singing. I was between a one and a two. Had I been a five or six, I might have deceived myself into becoming a rock professional musician. But no matter how hard I worked, I knew the best I could become was five. So if you, at least for the time being, will agree that talent is equally important to dedication and hard work, let me ask you what are the skills we should screen for in medical students? We both know that traditionally we screened from memorization through Step One tests and MCATs and other pieces. But today with the smartphone, memorization is less crucial. Should we be screening for empathy? Should we be screening for communication ability? Should we be screening for ability to motivate? What do you think we should be screening for picking the next generation of doctors?

Zubin Damania:

Oh, all of those things. All of those things are crucial. And I love that theory. I think that’s fact. I’m going to go further and say for my own life, it’s the same thing. There’s this controversial thing in leadership. It’s like do you work on your weaknesses? Do you spend all this time working on these weaknesses where you’re at a one or a two, try to get it to a three or a four? Or do you really just boost those strengths? And I don’t know. I’m always a fan of boosting the strengths. So if you’re looking in healthcare, the truth is there isn’t a one size fits all because you need surgeons, you need urologists, you need psychiatrists, you need primary care doctors. They all do different things. My neurosurgeon doesn’t necessarily have to be the most empathic person in the world, but they better be a really disciplined technician and highly learned to be able to do what they do.

Zubin Damania:

So maybe you have some latitude for how you’re screening, but I would say the more we screen for things like communication, bedside manner, empathy, compassion, interesting stories that people have overcome adversity, the idea that they would then have real compassion for people who are struggling, those kind of things are … We always give lip service to it, but we’ve never really screened for it. We screen by, like you said, by the tests. And that’s why it’s interesting. A lot of times you’ll get into a school system like a D.O. School system where they screen maybe a little bit differently, and those doctors are trained differently too. And you wonder like, “Oh.” When you’re sitting in the room with them, it’s a different vibe and often in a good way. So it really … And again, I don’t mean to paint it with a single brush, but it really does speak to how we’re even picking people who go through medical school.

Zubin Damania:

Now, the other problem is if you screen based on empathy and those kind of things, and you do underemphasize the testing, then you may set up people for failure in a medical school education system that is designed to continue that process of test taking brilliance and not necessarily all those other factors. I’m curious what you think, Robbie.

Robert Pearl:

Well, I think we need to change not just the acceptance process, but the educational process and the evaluation process. I believe, and I’ve written about it, that rather than banning cell phones from all these exams, you should be required to bring one. We shouldn’t be testing your ability to find the Kreb cycle. For listeners who aren’t doctors, it’s a very famous set of information that’s hard to exactly discern that physicians get tested on in their second year of medical school and never again ever use. So it’s the ultimate metaphor for the problem that we’re talking about. In fact, the entire step one examination is one that’s 16 hours of testing on about 10,000 arcane facts. Medical students spend six to eight weeks, 12 hours a day memorizing all of these, again, 95% of which they’ll never ever use unless they happen to be on the Amazon river somewhere in the jungle encountering some kind of protozoan that they only read about and they, of course, would never have the medication anyway.

Robert Pearl:

No. We’re in the 21st century. Smartphones are with us all the time. I think we should be evaluating people on their ability to take that information that’s readily available now and apply it to difficult situations, to be able to figure out with access to all of that smartphone what really is going on with this patient and this family and how am I going to impact that person’s life. We really don’t measure the change in the patient’s health. We measure simply the advice the doctor gave. And as you well know, we have major problems with patients getting prescribed maybe the right medication but not taking it, sometimes getting prescribed the wrong medication, but getting prescribed the right medication and not taking it. The opportunity to be able to engage in opportunities to improve and prevent chronic disease and treat chronic disease. Diet, nutrition, relaxation. There’s a whole litany of opportunities that exist and we don’t do a very good job of helping patients. Some is the system of medicine. Some is the society around it.

Robert Pearl:

But I personally think that the physician skills going forward in a world where increasingly there are patients with multiple chronic diseases, each of which interact with each other, all of which are overwhelming. The ability of the physician of the future, I think, will be very different than the past. I just wonder how you would screen the 50,000 medical student applicants for the 20,000 physicians that exist every year in the United States?

Zubin Damania:

Yeah. And the screening is one piece, but like you said, how we’re even teaching them medical school is such a … It’s not set up to manage all that chronic disease. It really isn’t. And I almost feel like you should have as part of medical training a week long silent meditation retreat where these students are forced to introspect for a week and come back very sensitive to their environment and very much using nonverbal cues and things like that where they get out of their head and into this space around them with the patient and with each other and with themselves. And I think that would really help open up the motivational aspects of how do you connect with another human being. We don’t teach it very well in medical school. More clinical stuff would be nice, starting very early and really saying, “Hey, this is what it is.” Again, that’s not to lessen if you’re going to be a pathologist or you’re going to do something that’s more research oriented. You want to accommodate for that as well, because that’s important. But man, we’re doing it wrong. Whatever we’re doing now, it’s not right. It’s not working

Robert Pearl:

Well, that’s also why I asked you about this rule of three steps, because unless you’re convinced that everyone who applies to medical school is a seven or eight in the ability to communicate, the ability to empathize, the ability to understand what an individual from a different background is telling you, then we probably do need to figure out the individuals best able to do that, if those are the skills of the future. But I also would agree with you. I think the classes should involve using that technology to be able to now understand, let’s say, the physiology of the heart or the pharmacology of the medications. Why should you have to memorize the dose of a drug when you can look it up with 100% accuracy rather than relying on your memory? But understanding things about lifestyle that affect the drug, that’s a different set of skills that I think we don’t focus on nearly as much.

Zubin Damania:

And I think that that speaks again to mechanical intelligence versus human intuitive connective intelligence, relational intelligence. Why don’t we optimize for that since the computers are going to take everything else and do it better than us? So I agree. I agree a hundred thousand percent. Everyone’s using Up To Date now anyways as a source reference for a lot of stuff. We ought to train how do you use that effectively? How do you overcome bias in it? How do you think from the human side taking that data? Absolutely. But we would just memorize stuff. I mean, that was our thing when I trained.

Robert Pearl:

And the errors in it, not because the science is wrong, but because the application is wrong, as you said, based upon a given population or given set of individuals. So let’s go one more step. I want to talk a little bit with you today about burnout among doctors. I don’t know if you looked at the most recent Medscape survey. It had the information that we would expect. Burnout’s gotten worse in the context of COVID. The two specialties that have been that at the highest level are the two you would predict, ER and critical care. These are the people who have had to deal with the majority of individuals who’ve gone on to die. These are situations where physicians have been overwhelmed by the sense of loss, the inability to change the trajectory of a disease, the frustration of being unable to be effective as doctors. You had the isolation with COVID and families not being there. On and on and on.

Robert Pearl:

But what struck me as being most interesting was the third specialty on the list. The third most burned out specialty today, it wasn’t true two years ago, is OB/GYN. Now OB/GYN physicians don’t have a lot of patients who had COVID. They didn’t see a huge number of deaths. And why did this specialty soar in burnout rates compared to the other specialties? And as I looked at it, my conclusion was it’s one statistical fact, 85% of physicians in OB/GYN are women. And they took on another job, eight to ten hours more work outside the medical office or the hospital because they bore the brunt of child care. And I haven’t heard a whole lot of physicians talking about, and I’ll call it the two-way flow of the world inside medicine and outside. It’s almost like, as you said, the corpus callosum which connects the two sides of the brain was severed. And our minds are, we either have a work environment or our personal environment, and maybe the work environment negatively affects the personal, but not necessarily that the personal affects the work.

Robert Pearl:

I wrote a piece for it on Forbes and I expected about a third of the people would say I was right, a third of the people would say I was a total idiot and I had gotten it completely wrong, and a third would’ve said, “Oh yeah. We knew this all along.” But instead I think there was a pretty good resonance, at least amongst the women responding, that this was the reality of the past two years. How do we have a more broad understanding of burnout to recognize what happens in our practices that we don’t control, what happens in our practices that we can control, and what happens in our life outside of medicine that impacts our satisfaction, our job fulfillment and our level of fatigue?

Zubin Damania:

I read your Forbes piece and I was actually really … I said, “Yeah.” And the thing is, it’s difficult because you and me are mansplaining this thing. But I would say this, I mean, my wife is a female physician and the truth is when you look at burnout, you have to look at it’s not work-life balance. It’s life of which work is an integrated piece and they all resonate together. So for men, they have this, at least in the typical roles that we see, they’re not necessarily always the primary caregiver also of children at home. They’re not caring for elderly loved ones directly. They can be, but it’s not the primary thing. We often see that to be more a female role historically in society. And it’s dragged into current where women are now a huge part of the medical workforce.

Zubin Damania:

So they go to work, they do all the stuff that we have at work that is hard for us, but then they have the extra element, which this is going to be controversial, but if you look at personality tests, women score higher on agreeableness than men. So when asked to do extra stuff, they tend not to say no as often as men do. Men are jerks on personality tests. Again, just trying to stick with the data here, Robbie. I’m editorializing occasionally. And so they get sucked into stuff at work. Then they go home. They’re the caregiver for the kids. They have all that other stress. And even if they’re part-time, it’s like the equivalent of 1.5 FTE full-time equivalent. Duh, it’s going to be harder for them in many ways. And so it’s not surprising to me that that OB/GYN and maybe pediatrics too, which is more female, higher up on the list of people who self-report burnout.

Robert Pearl:

Pediatrics was another specialty that went up quite significantly. But why don’t we talk about it? Why don’t we talk about gender inequality in the context of burnout? Why don’t we talk about the parents who are sick or other environment or personal issues? We just keep separating our work experience and our dissatisfaction, and there’s no question the bureaucratic tasks and the computer systems and all of the problems are very real. But these other pieces, when I look at the data, seem to be quite significant as well. And yet at least I don’t hear it. You talk to far more physicians than I do. Are you hearing this type of outside world impinging on our personal professional satisfaction? Are you hearing that discussed very much?

Zubin Damania:

Absolutely. And when I talk to male physicians who are experiencing high degrees of burnout, often they will report having a child who either has special needs or who is having difficulty through the pandemic and has required a lot more attention from the male parent. And so these things are absolutely intertwined but we reduce it to, well, it’s Epic or it’s an electronic health record problem, or it’s too much insurance interference. All that’s there and that’s been going on, but what is it that really this is about is we try to make doctors try to feel like they’re these invincible, off the grid kind of super humans. And in fact, we codify that in our cultural response to the pandemic and say, “Oh, heroes work here. These are healthcare heroes.”

Zubin Damania:

And so what is calling somebody a hero says, well, then you’re more than human. So you can take on all this stuff. And the truth is, no, we’re absolutely human. And the hero’s journey is the human going on the journey, right? And coming back and returning with new knowledge, new insight, new awakeness. But we’ve taken away the journey and we’ve said, “Oh no, no, no. You’re just going to do inhuman amounts of work and then suffer at home too with all the responsibilities you have.” And we’re not going to talk about it, Robbie, because you asked that. Why don’t we talk about it? Because it’s stigmatized. People are afraid to talk about it. They’re afraid of getting canceled for saying the wrong thing. They’re afraid of … You call this series Unfiltered. You and I will just say what we think, right? But there’s still that subtle fear, like, “Well, I don’t want to come off like I’m mansplaining about what women are going through.” And so everybody’s just all uptight about it. We just need to have these open conversations. You’re very good at that. Your book about physician culture was … I mean, I was like, “This is it right here. And it’s going to generate anger.” But, man, that’s what we need to do.

Jeremy Corr:

All right. So I guess my final question for you both is in 2021, 107,000 people died from a drug overdose in the US, roughly a quarter of the number of deaths attributed to COVID during the same time period. The opioid epidemic is something you hear about in the news significantly less, yet I do not think there’s a single person who has not had a friend or family member that’s been impacted by the opioid epidemic, many of them due to fentanyl. There’s also a massive mental health crisis in this nation that’s been very much exacerbated by the pandemic. I didn’t see the 2021 numbers for suicide, but in 2020, there were over 45,000 deaths by suicide in the US. And a couple days ago, the House overwhelmingly voted to send $40 billion in military aid to Ukraine. This is during a time of record inflation, gas prices, baby formula shortages.

Jeremy Corr:

And I saw one comment on Twitter that I found fascinating that I wanted you both to discuss. I saw someone say that if a member of the House proposed $40 billion to fight the opioid epidemic or mental health crisis here in the United States, they’d be laughed out of the room. I understand that to an extent. This is an apples and oranges comparison. But as healthcare experts, what are your thoughts on this? And why isn’t more being done to address the domestic issues around the mental health crisis and opioid epidemic?

Zubin Damania:

Jeremy, this is what some friends of mine call COVID myopia, for example. We’re so focused on what’s an obvious pandemic, a million dead and so on, that we’ve always ignored actually a very iatrogenic, medically caused epidemic, the opioid epidemic that, like you say, is a significant fraction of the COVID deaths, but it continues year after year after year and only seems to get worse. And the pandemic does not make it better. And so to some degree, our shortsighted responses to one thing tend to either exacerbate, because it’s all connected. During the pandemic, of course, seems like drug use, mental illness has gotten worse because we’ve destabilized society with some of the response to this, which again, gets back to our original discussion of like, well, do you censor people’s discussions when they disagree with our response?

Zubin Damania:

And the answer is no, because some of them may be looking at bigger picture stuff. And sending money to Ukraine, we’re printing that money. It’s not like … We’re just deficit spending. So our children are paying for that and they’re going to pay for the opioid crisis that the Sacklers helped create. And it just becomes a very frustrating stew of not being able to see context and the holistic picture of what’s going on. And I think that really has come to a head here with this.

Robert Pearl:

My take is that in our nation, we do not see all lives the same. And if you are in a group such as someone with mental health illnesses, someone with opioid addiction problems, heroin issues, someone who’s very old with lots of chronic disease, our nation doesn’t value those lives, doesn’t see them as being productive and doesn’t make the investments. Whether they spend the money someplace else, and I personally believe that the war in Ukraine is one that’s vital for our future, because I think the aggression that Russia has shown is only the start. We’ve seen it many times in the past. But that’s my political views. As a physician, my view is that all lives are not the same. I mentioned earlier, the zip code four miles away, people are living. You can run there in 40 minutes. And yet the people dying 10 years earlier are simply not seen as being as important lives worth saving as the people living in the houses surrounding your own home.

Robert Pearl:

This, I think, is a part of the human existence. In particular, we know this from implicit bias that people who look like you, act like you, talk like you, believe like you are ones whose lives you think are more significant. And I think what you’ve pointed out, Jeremy, is the price that we pay, 107,000 people dying now. It was 60,000. We didn’t notice it back then. It could be 125,000 a year from now. And maybe I’m just an idealistic doctor. I just think that every life that is lost unnecessarily and not from a disease we can’t control, but for a problem we could take care of is simply a tragedy. And we have a growing number of tragedies across our nation.

Jeremy Corr:

We hope you enjoyed this podcast and will tell your friends and colleagues about it. Please follow Fixing Healthcare on Spotify, Apple Podcast, your favorite podcast platform. If you liked the show, please rate it five stars and leave a review. If you want more information on healthcare topics, please go to Robbie’s website at robertpearlmd.com and visit our website at fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter at Fixing HC podcast. Thank you for listening to Fixing Healthcare’s newest series, Unfiltered, with Dr. Robert Pearl, Jeremy Corr, and Dr. Zubin Damania. Thank you very much, and have a great day.

The post FHC #52: The future of medical misinformation, education and motivation appeared first on Fixing Healthcare.

One hard part about interviewing Dr. Eric Topol is knowing where to begin.

Topol wears a seemingly infinite array of hats: He is the director of Scripps Research Translational Institute. He’s a professor of molecular medicine. He’s an expert on artificial intelligence, Covid-19, genome editing and precision medicine. He’s a bestselling author, the editor of the popular healthcare publication MedScape, and one of the most followed physicians on Twitter.

Thus, another hard part about interview Eric Topol is knowing you’ll always have far more questions than time to ask them. For this interview, the questions of cohosts Jeremy Corr and Dr. Robert Pearl center on rule-breaking in medicine—and, specifically, the unwritten rules doctors follow. Who better to ask than Topol, one of healthcare’s biggest rule breakers?

“We have a huge number, every year, of serious diagnostic errors. And our treatments are based largely in clinical trials, where maybe 10 people out of 100 in a really good trial might derive benefit. But the 90 people who don’t derive benefit, we give them the same therapy. That’s not exactly an accurate and precise way of delivering care. So, we can do far better, but it involves dealing with lots of data, a tsunami of data. And we aren’t well equipped to do that yet.”

“The way things are in medicine, we can’t handle the data. So, we need to acquiesce and we need to say, ‘We need help.’ You’re well aware of the crisis, the global crisis we have of burnout, and disenchantment, and depression. Part of that is non-ability to care for patients because of being overwhelmed. And part of that being overwhelmed … is not being able to get our arms around all the data of any given patient because it takes time. But that’s what machines are really good for.”

“Part of the unwillingness for cardiologists to accept smartphone ultrasound is that their first reaction says, ‘Well, I don’t want have to do that. That’s what ultra-stenographers are for. I don’t want to have to acquire the images. That takes time and I’m not getting reimbursed for it,’ and every possible excuse. But in reality, every cardiologist should know how to acquire an echo … It takes just a minute or two. It’s so much more effective in time-use than with a stethoscope because you’re seeing everything.”

“They want to be more autonomous than they are, not so dependent. And we have the tools to do that. Already, we have emerging tools to deal with very common conditions like skin rashes and lesions through a smartphone picture and AI algorithm, ear infections for children, UTIs with an AI kit, heart rhythms through a smart watch. I mean, we have a lot of common diagnoses that are not life threatening that can be screened by patients and that list is just going to keep growing.”

“The biggest thing in my concern about the way the pandemic has been managed actually with the boosters, Robbie. I think this has been a fiasco. I think that we, as a country, are ranked 70th in the world for boosters in our population. We’re only at 30%, whereas most countries that you would consider peer in Europe or Asia are 70, 80%. And most importantly, in people over age 50, where in the US, 1 out of 125 Americans have died over age 50. And that’s for confirmed deaths, not even excess mortality in the COVID era. And we know that booster shots reduce death. They also reduce hospitalizations. They reduce long COVID.”

“I’m very into free speech. However, we need to, in my view, at least draw the lines about when there’s clear, unequivocal, medically harmful disinformation, lies, misinformation, fabrication, because we’re talking about people being hurt or dying from it. And so that’s different than expressing opinions or providing data that’s real instead of just making things up. And there’s been a lot of that. We’re not talking about Galileo here. We’re talking about people who are purposefully, if not unwittingly, trying to hurt a lot of people.”

READ: Full transcript with Eric Topol 

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #51: Eric Topol on breaking the rules and putting patients in charge   appeared first on Fixing Healthcare.

The biggest Covid-19 news of the last month came out of Florida, where a federal judge struck down the CDC’s mask mandate on planes, trains and in transportation hubs. As Americans jubilantly removed their masks, the Justice Department quickly filed an appeal.

Importantly, however, the DOJ did not immediately request a stay on the ruling in Florida. Thus, Americans will be flying mask-free for months before the appellate court can hear and rule on the appeal. What does this mean for Covid-concerned travelers? Are masks as good as gone or could they still make a comeback?

Jeremy Corr and Dr. Robert Pearl examine these questions and many others in this episode of Coronavirus: The Truth. You’ll find all the [time stamped] topics from this show below in the notes:

[01:18] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?

[02:58] Why are masks no longer required on planes and public transportation?

[04:16] What should we know about the new strains of Covid-19?

[07:02] If VP Kamala Harris tested positive for Covid-19, but didn’t have any symptoms, does this mean she’s not contagious?

[10:55] Survey says: Are Americans worried about Covid-19 anymore?

[13:12] What’s the latest science on Covid-19 and young kids?

[18:18] How are healthcare workers coping today with the trauma of Covid-19?

[22:42] Do patients think about how their actions affect doctors?

[23:50] How are teens coping with mental health challenges of the pandemic?

[24:56] Why are so many elected officials getting Covid-19?

[27:17] What’s good this week?

[30:11] What’s the biggest non-Covid story in healthcare?

[32:19] Do Americans still believe U.S. healthcare is best in the world?

This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #60: Will mask mandates return to planes and trains? appeared first on Fixing Healthcare.

Welcome back to the Fixing Healthcare series, “Diving Deep,” which features a robust and probing discussion about some of healthcare’s most deep-seated problems.

In this episode, Dr. Robert Pearl Jeremy Corr dive deep into the unwritten rules of healthcare, which have long dictated for doctors “the right way to act.” Two examples featured in this show include the doctor’s use of intuition when making medical recommendations and the current rules surrounding hospital care, which lead to high prices but not necessarily better care.

For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, here’s a discussion guide:

• When it comes to medical decision-making, where should the science end and gut-feelings take over?
• What is evidence-based medicine and why does it matter?
• Why do doctors (and people in other industries) distrust science-based guidelines?
• What can go wrong with intuitive medical decision-making?
• When (if ever) is intuition is better than science?
• Why don’t doctors have time to talk with patient about their hopes, fears and values?
• How can patients know whether or not a hospital offers good care?

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #50: Diving deep into physician intuition and hospital prices appeared first on Fixing Healthcare.

Welcome to Unfiltered, a new show that brings together two iconic voices in healthcare for an unscripted, hard-hitting half hour of talk.

Dr. Robert Pearl has twice appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who has twice appeared on the Fixing Healthcare podcast with Pearl, alongside cohost Jeremy Corr (see: here and here).

This episode ventures into uncomfortable territory. It starts with “the slap” at the Oscars and asks whether making fun of a medical condition is ever okay. Next up, the two doctors discuss emotion in medicine: should physicians show more of it at work? And finally, four existential questions for healthcare professionals, including: What’s our purpose?

To get started, press play or peruse the transcript below.

* * *

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

UNFILTERED TRANSCRIPT

Jeremy Corr:

Welcome to Unfiltered, our newest program on our weekly Fixing Healthcare podcast series. Joining us each month as Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice. Then I’ll pose a question for the two of them as a patient based on what I’ve heard. Robbie, why don’t you kick it off.

Robert Pearl:

Zubin, I’ve heard great feedback from our listeners about the first show and our willingness to tackle controversial issues. You’re my social media maven. And I have to ask you about the event that garnered twice as many social interactions than Ukraine, and four times as many as the president of the United States. And of course that was the confrontation between Will Smith and Chris Rock at the Oscars. But rather than talking about the slap, Zubin, I’d like to ask you a different question. Why do comedians think it’s okay to make jokes about people’s medical issues?

Zubin Damania:

Ah, well, boy, there’s so much here. I mean, the truth is comedians, like anybody, their job is to make people laugh or to point out absurdities and that kind of thing. Now, whatever Chris Rock knew or didn’t know about Jada Pinkett Smith’s alopecia, I actually am with Bill Maher on this, where again, there is a free speech protection here where Chris Rock can make jokes all he wants and Will Smith can protest verbally, legally, however he wants to do it. That’s fine. What’s inexcusable is hitting anybody and hitting a comedian for making a joke. Now, whether or not he knew, because Jada Pinkett Smith has been public about her alopecia, there’s a lot to nuance here. It’s more common in African American women. She’s a public figure. So it is traumatic for her. But as Bill Maher said, “If the worst thing you have to deal with is alopecia, I don’t think someone should slap somebody for making a joke about it.” So, I tend to fall on the free speech side on this one myself just being somebody who dabbles in comedy.

Robert Pearl:

Yeah. I agree with you completely. First of all, we both agree that the violence is inexcusable. So that’s why I didn’t want to talk about that. And I also agree with you on this free speech. He has the right, the legal right, the constitutional right to do so. I guess the question I’m really asking, is it worth the pain that’s inflicted?

Zubin Damania:

Mm, this is a great question. I mean, look, in comedy, you’re not supposed to punch down. Anytime you make fun of someone with a chronic disease, you’re punching down, kind of by definition, like Putin could suffer from end-stage renal disease. And if you make a joke about him being on dialysis, you’re still punching down because he didn’t choose to have that disease, and it doesn’t do well for other people with the disease, and it’s stigmatizing. So, as a general rule, right, you don’t punch down in comedy.

Robert Pearl:

Probably because I fixed so many kids with clef lips in the past, and I’ve heard all the jokes and I’ve seen the pain that they experience, I am overly sensitive about this issue. But I guess, as a physician, I would hope that we would keep people’s diseases out of comedy. It may be funny, don’t get me wrong, but I think the pain inflicted on the individual, now, if it’s the president of the United States or it’s Putin or someone, these are very public figures who are at the center of the discussion. If it was about Will Smith, you could say, “Okay, well he’s about to win an Oscar, but” his guest, who happens to be a public figure, but still, to make that be the brunt of the comedy, again, I’m probably overly sensitive, but I’m reacting as a doctor to this. And that’s why I wanted to ask you, because you’re a social media leader. And as you say, you’re quite a funny comedian.

Zubin Damania:

Well, I mean, that’s a great perspective, Robbie, that you’re bringing because you’re actually seeing the suffering that these diseases can cause. And so you compound the suffering if you’re making jokes about it as a public comedian and so on. This situation is a little murky. It’s just hard to know what Chris Rock knew about… Maybe she, in his mind, she had just chosen to shave her head as a style point, in which case, as a public figure, you’re fair game. Right?

But I think your point is very well taken. And again, it’s a question of, are you generating net suffering in the world or are you generating net joy or well-being? And I think that’s a good moral compass for all of us. That’s why comedy, in general, I’ve seen comedy where I’m just like, “Yeah, that was just, not only was it not funny, but it was kind of hurtful.” So it’s kind of like, well, there’s no net benefit. Like I’ll defend your right to make the joke, but it’s just not good comedy. Right? So I think you bring a very valid point here.

Robert Pearl:

Zubin, your comments about the emotional aspect of this encounter, they make me think about a class that I took at the Stanford Graduate School of Business on politics and public speeches. It was about the relative power of emotion versus logic. My favorite clip was from Oliver North and his testimony to Congress in the Iran-Contra affair. It begins with one of the senators who wasn’t a fan of Colonel North showing a video of the FBI agents storming into his office in Washington, DC, as he sat at his desk, shredding all the incriminating evidence. The senator, certainly no fan of North, believes that he’s made Oliver look like a fool. He says, “What were you doing?” North says, “My job.” The Senator’s flummoxed, this is not what his prep team has predicted. The senator stammers. He asked the colonel, “Why do you think this is your job?”

And in this totally unemotional calm face, he says, “If it wasn’t my job to shred documents, then why would the government have given me a shredder? And why would Congress have paid for it?” This complete lack of emotion is powerful. And in contrast, in the same class, the professor showed the 1988 debate between the democratic candidate, Mike Dukakis and the republican candidate, George Bush. The CNN correspondent Bernard Shaw asked Dukakis whether he would support the death penalty if his wife were raped and murdered. His response purely cerebral, “No, sir. I don’t see any evidence it’s a deterrent to deal with violent crime.” The pundits think he may have lost the election because of that one completely unemotional response. So now let me ask you, doctors are taught not to show emotion. Don’t cry, don’t yell. Don’t admit how unfair life can be when it comes to who gets cancer. And yet we’re expected to be authentic. How should we, as physicians, as clinicians, resolve this contradiction?

Zubin Damania:

Man, this is why I love doing this podcast with you, Robbie. I say no to every podcast invite I get. And Robbie’s like, “No, we’re just going to talk about this kind of thing.” I’m like, “Yeah.” So look, this is central to who we are as human beings. And you said the word authenticity. We’re expected to be authentic. And yet we can’t show what we are, which is largely emotional creatures with a little reason tacked on evolutionarily. We really are, as Jonathan Haidt says, “We’re all elephant with this limbic system that is evolved actually to keep us safe”. Emotions are there for a reason. They’re feelings. They call them feelings because you feel them in the body, they’re an energetic pattern. You ignore them or you repress them at your peril. And the reason, Dukakis lost that thing, the reason we loved Spock is not because he was all logic. It’s because you could feel clearly Spock was half-human.

The underlying emotion was there and watching him try to repress it, watching him try to be a good Vulcan and fail very often was what made him human. And that’s why Kirk, at the end of Star Trek II, says, “Of all the souls I’ve encountered in my travel, his was the most human.” And that’s why in medicine, I think it’s important that we’re authentic with our patients. We do need to show some emotion, but we also need to have that kind of cognitive empathy that says, “You know what? Yes, I feel that you’re suffering. I know that you’re suffering and you can feel some of my emotion, but also I’m going to be a source of stability for you. So I’m not going to let it cloud decision-making. I may help with you to use our emotions together to inform what values matter to us.”

And I think that’s important when we ignore that. When we ignore our own emotions, we end up with all kinds of problems. And physicians in particular are the masters and mistresses of emotional repression. Yeah. So to me, focusing deeper on understanding our own emotions and unrepressing them and really feeling them and getting rid of this stigma, oh, there are negative emotions and positive emotions. No. There are energetic patterns that we call emotions, e-motion, energy in motion. Let’s feel them because if you don’t, they’re not in motion, they almost become solidified. And then you tell stories about them and then you act unconsciously on them. So, you know what happened with will Smith? Undoubtedly, there was deep emotional repression for years of being a celebrity and having to swallow this stuff and whatever was going on with him and his wife. And then what happens? It comes out in violence. You don’t have to do that if you’re actually in touch with that stuff on a regular basis.

Robert Pearl:

Let me ask you where the line is. I was talking to a doctor who lost four COVID patients in the same day. This feels to me to be beyond the possible human tolerance. How are we going to address this? And how are we going to deal with the PTSD that invariably is now about to start in even greater force than during the pandemic itself.

Zubin Damania:

Yeah. You know what’s interesting is I think human tolerances are beyond our imagination. Like we, humans are able to tolerate insults and traumas that would just theoretically break anyone and they seem to do it. And some actually find meaning in it and grow stronger. But the difference is you have to have that, in my opinion, in medicine, what we miss is this communalization of pain. We don’t make it okay to talk about this stuff. We don’t make it okay to say, “You know what? I’m suffering too.” And that way, you could tell people, “Look, we’re all in this together. Yeah, man, four patients that we’ve known forever, and now they’re not here.” That is a trauma. So let’s sit and process that, let’s feel the emotion. It’s okay to have grief. That’s normal. If you’re suppressing grief, that’s what’s not going to be good for you.

So providing the tools and resources to actually process that stuff will be important to mental health resources, et cetera, but just changing the culture to say it’s okay to feel these things. This is normal. In fact, if you don’t, maybe that’s the pathological state. And we ought to think about that. So again, I don’t have a magic answer, but I’d say that diving into the pure emotion of loss and grief… One of the things that happens when you go down any sort of self-realization or meditative path is strong emotions start to arise that were repressed by the mind for years and years and years. And they start to unrepress because the mind relaxes and the thought-based structures relax. And one of the things that can happen is you can feel unmitigated sorrow out of the blue, be driving and just burst into tears. And we have no societal container for that. So in medicine, it’s even worse. So we have to start building those containers and those structures to process.

Robert Pearl:

Well, I want to dive a tiny bit deeper and ask you how. Because I’ve seen the response that people have had to individuals who say, “I need therapy,” or “I’m not able to work to my best today because of the emotional experience I had.” I mean, I’ve seen people, a physician get a diagnosis of cancer in the morning and come back and take care of her patients in the afternoon. I mean, I just keep feeling as though this problem is going to be so hard to burst through. How can we start?

Zubin Damania:

Oh, my gosh, man. I mean, that stuff is heartbreaking and you’ve seen it so much as leader of the group. I’ve seen it when I was on the front lines with my own team. And people I used to work with still email me and they go, “I’m at my wits end. I don’t know what to do. Do you have any advice?” And I think… Okay, I’m going to give you an answer that is going to be unsettling for some people and they’re not going to like it. But the truth is, I’m just going to tell you what I know. Recently, I did like a six day semi-silent meditation retreat led by another physician. And they were all healthcare professionals, about six or seven or eight doctors, many nurses, physical therapists. And this was just in November.

So COVID had been going on. People were traumatized and they came in. Many of them had never meditated and had never had this kind of practice, but they saw my show and they’re like, “You know what? I want to do this thing.” And what we found was people opened up and just torrents of emotion and sharing in the non-silent parts in the evening when we did group activities. And the being with yourself and processing that stuff, that unconscious stuff, in a safe space with other people who do what you do is so powerful, Robbie.

When the thing was done, many of them were saying this was the most powerful experience they’d had. And that they went back with renewed sort of resilience to their careers. That doesn’t mean that’s the single answer, but you can see how powerful unrepressing that stuff, having a safe space with your colleagues and doing the deep work of actually introspection. We tend to externalize everything. We project everything we say, “Oh, this is the problem. It’s this guy or that guy.” But when you actually look inside, it’s really all right there, and we create the world. So that’s my really questionable answer to that.

Robert Pearl:

Your story, Zubin, reminds me of a talk I heard Yo Yo Ma give in Silicon Valley. And for any of our listeners who don’t know his background, he was a child prodigy. He performed from the age of four and a half. At something like five or six, he and his sisters gave a concert for President Kennedy at The White House. He’s recorded 90 albums, 19 Grammy Awards. He’s the best celloist of the time. At the event I attended, first he played a series of some of the most beautiful and moving cello pieces I’ve ever heard in my life.

But then he talked about four existential questions that he said he often thinks about. He said that he wonders first, who am I? Second, what am I grateful for? Third, what is my purpose? And fourth, what do I want? Sitting in the audience, Zubin, I wanted to scream at, “Who are you? You’re the greatest living celloist in the world! You’re a musical genius! What do you mean, who are you?” But I didn’t. Fortunately, I didn’t. But it did inspire me, somewhat similar to your six-day event, to ask myself these kinds of questions at various points in my life. So let me ask you, as a profession in the 21st century, as physicians today, first, who are we?

Zubin Damania:

Oh, these are the easy questions, Robbie. These are the easy questions. They’re very hard. So here, okay. I’ll give you two answers to this question that I’ve struggled with myself. There’s a deep who am I question, which is one of the spiritual questions that we ask, who am I? And when you actually investigate and look for yourself in the present moment, keep looking, keep looking, because you will not find a solid self there. And as you keep looking, you may find something really interesting, the real self. And so that’s answer one. That is a little woo-woo for this talk. Answer two is your authentic self, which is in this present moment, you’re an expression of reality, you are. And what is that? So Yo Yo Ma probably knew from a young age, “Look, this is who I am and being authentically me is standing on stage in front of the Kennedys with my sisters doing this and talking about it,” and so on.

Now, many of us in healthcare, we knew authentically. We were drawn to, it’s not something we chose. There was no agency involved in many ways. We were called to do this. And yet, we’re often made to compromise on what it is we know is authentically us. And I think that’s part of that moral injury component that we have to make these compromise. We have to do things we know are antithetical to, maybe not just… Forget about our interests and aptitudes. It’s more just what we fundamentally know we are, and that causes this tension, which you could call… The Buddhist will say is the nature of suffering that you’re diluting yourself by trying to be something you’re not. Now when you really… And that’s why I think that meditation thing was powerful because people could feel in. Like when I did it, what I realized was, I’ve often undervalued my own compassion.

I feel like I’m not compassionate enough. I can be a jerk. I’m self-centered, all these other like me, me, me, me, me, beating yourself up type of things. But during meditation, I realized, wow, there’s an infinite well of compassion there. And I do express it. And sometimes you have to forgive yourself. And when you do that, you can then be authentic. You can say sometimes there’s tough love, like being a little bit hard with people is an act of compassion. And again, that’s connecting with your authenticity. So how do we train or create… It’s hard to train, right? You create a space for people to be them. And that means again, giving them tools, resources, and autonomy to be who they are, which some of its systems change. But some of it is working on ourselves.

Robert Pearl:

Are we healers, experts, teachers, businessmen and businesswomen? As a profession, who are we?

Zubin Damania:

Yes. All of those things. We could be any and all or none. I mean, we may be something totally different within there. And each person is different. Each person may have aspects of it. As a profession, I think it’s tough to paint us with a single brush. The people that we admire the most may have one or two or three of those aspects that are so powerful and we just really are drawn to it. And that’s why mentorship is so important, right? Because the mentors can show us who we, not only who we are, because that’s our aptitude or our draw, but who we can be. Right? So more mentorship, more openness about that stuff, and then we find out who we are.

Robert Pearl:

So then as doctors, what should we be grateful for?

Zubin Damania:

Gratitude is a central practice. It actually is an anchor through all kinds of suffering. Anytime, I was just talking to my mother and she’s now entering our 80s. And my dad is in his 80s and they have their problems. They have health problems. They have problems with their house, the kind of things that happen with your elderly parents. And we were talking about it. And she said, “A year ago, I would’ve really been upset by all these things. And I would’ve stressed and we would’ve been anxious, and so on. But all I have to do is watch the news for five minutes to see people in Ukraine suffering, who didn’t ask for it. And I’m filled with the gratitude that I live here, where I have these first world problems and everything is great. It’s wonderful. It’s beautiful.”

So that gratitude practice is so powerful. In healthcare, the gratitude that you can be with people when they’re at their most vulnerable and they open up in a way they don’t do for anybody else, and they let you be with them in that sacred space. That is deep gratitude. The fact that you are, regardless of your loans and all of that, you’re actually doing okay overall in the grand scheme of things. And you get to do a trade that, there’s almost no other profession on the planet where you get this kind of connection with humans and get to help people this way, no matter what aspect of medicine you’re doing. So there’s an immense well of gratitude there that’s available if you choose to be aware, make yourself aware of it.

Robert Pearl:

If we’re going to deal with burnout, should we be expressing a lot more gratitude about the positive things that we have than I believe we are today? Or is that just too Pollyannish?

Zubin Damania:

Ooh, burnout is such a… I mean, again, it’s that end stage of the chronic injury. So it has multiple facets. So yeah. Gratitude is a powerful prophylactic against… It’s like taking lisinopril when you have chronic hypertension. It’s going to protect your kidneys a little, protect your blood pressure and your heart a little bit, but it’s not the only answer. It’s a piece of it. You also have to stop eating the salt or stop stressing yourself out, so environment matters. Your own personal framing matters. And gratitude is a powerful piece of that. Some kind of spiritual practice, whether it’s prayer or meditation or looking at the night sky and with awe, whatever it is, that’s a piece of it. But then it’s also asking yourself, am I authentically me in this thing? And sometimes, Robbie, I hate to say this, but you got to stand up and say, “This isn’t me. I got to go do something else in medicine or out of medicine.”

And for some people that is the answer and they know it, they know it. I had an OB reach out the other day on Instagram. I was taking a ask me anything thing. And she just said, “Look, I’m an older, morally injured, upset obstetrician. Should I retire?” And I said, “You know the answer if you actually feel into it. You know what the answer is. So why are you asking? You’re really asking for permission to do what you know is right already, whatever that is.”

Robert Pearl:

So that leads into the question of what’s our purpose? Because I’m thinking about that woman you just described. I’d hate to see her lose the purpose that she entered medicine for at the start of her career, maybe different ways she could express it. But as physicians, as doctors, what’s our purpose?

Zubin Damania:

Yeah. It’s great. It’s a great framing of it because if she really feels into what her purpose is, she will figure out a way to fulfill it, authentically. My feeling is I really like what writer Jonathan Haidt, the same Elephant and Rider writer wrote about purpose. He says, “The meaning of life, it’s not without, so it’s not outside us. And it’s not even within us. You don’t find meaning within. You find meaning between.” So humans are, we’re relational creatures. We find meaning in the connections between us and others. And so when we feel into our authentic selves and then we express it in the world in a way that connects with other people, that’s all the meaning you need, even if everything is empty void and it means nothing in that sense, it means something in the relational sense right here and now in this second.

The universe, man, I showed my daughter a picture of the Andromeda Galaxy taken by Hubble. And as you zoom in at 8K on YouTube, you see every single star in that galaxy of a billion stars. And as you start to see, each of those stars has planets around it. And some of them probably have life. And you’re thinking, “God, I feel so small.” I could see her face start to just shrink in horror at the existential terror of that. What is my purpose when I’m this small? And then I told her, “Your purpose is right here. Look what’s happening right in this minute. You and I are having this connection. That’s a purpose. That’s all that matters. It’s right here right now.” So it’s the same with medicine, really focusing on what is and what our relations are with others. I think that’s where a lot of meaning can be found.

Robert Pearl:

I believe, and I hope again, that I’m being realistic, that the purpose of medicine is around health and that medicine today is focused on disease. And I think that a lot of the burnout type of experience, the lack of fulfillment, the lack of satisfaction we have, is that we’re focusing on the wrong purpose. Any thoughts?

Zubin Damania:

Oh, I mean, I think you’re absolutely right. Now, what people would say on the front lines is, “Well, of course, Robbie and Zubin can say that because they’re not having to chart 40 patients a day, and click all these boxes, and to get yelled at for low productivity, and so on and so forth.” And so sometimes it’s tough to see the purpose from the immediate feeling of lack or of overwhelm or of stress. And that’s absolutely valid, but there are solutions to these problems if we work together with people who lead rather than just manage. Right?

So I do think reconnecting with what the purpose is means that you use technology to actually enable the purpose instead of using technology to enable an outside purpose of whatever it is, billing or nonsense like that. The technology ought to enable the human relationship that allows us to connect and heal with our patients and help each other. So if people have those tools, resources, and autonomy, then the purpose is the guiding beacon. But I think what we’ve done is we’ve made the purpose too skewed towards one thing or another, whether it be profit for an institution or whether it be quality measures that don’t measure quality, whatever it is, get those things right. And then the purpose shines through.

Robert Pearl:

We’re in complete agreement. I mean, I think the people who are experiencing these emotions, they’re the victims. There’s no question about that. The question is how to get from here to where we need to get to. And I think that by being able to understand the purpose and exactly what you said, figure out, how do we augment the things that we can do, use the technology to accomplish that, put together the teams to accomplish that? Then that is how we can eliminate our own pain, but more importantly, fulfill our purpose. So what do we want?

Zubin Damania:

Yeah. You’re the master of this, man. You’ve been doing this for so many years. I would be asking you this. But I’ll just say one thing, which is Garry Kasparov, right? With the chess champion who was defeated by Big Blue, the IBM AI, it was written about this quite a bit. He could have gone into a deep depression and felt a lack of purpose and so on when that computer beat him with mechanical intelligence. But what he said instead was, “No, this is a huge opportunity to use a tool, the AI, with a human, me, and I could beat anybody alive in any computer with that tool.” And that’s what we need in medicine is those tools, that technology that takes all the mechanical intelligence away, that it does it better than us.

Let’s just be honest. And so then we get to do what only humans do with our awareness, our comprehension, our emotion, our intuition, our connection, those are the things, and our intelligence, that computers will never have that comprehension. So that’s what we need is those tools and resources that enable us to do the job better. And that means better systems thinking better individual awareness and awakeness, all those things are connected and integrated. That’s why it’s so hard. People say, “Oh, how do you solve this problem? It’s so complicated.” Well, you have to go in all the parts and they add up to bigger than the sum of the whole. So you have to work on everything.

Robert Pearl:

I love the answers and I hope the listeners learned a lot from it. Jeremy, your question as the patient listening to this conversation.

Jeremy Corr:

You both talked about grief and being authentic and being human. As patients, we often look up to doctors, especially in times of major crisis, such as early on in the pandemic, or if a loved one just got in a car accident as being almost above human, almost a godlike figure that can, I mean, essentially perform miracles, help us in our time of need and save lives. We expect perfection from doctors and almost stoic brilliance, but we expect human empathy from physicians, but we really do not allow them and maybe cannot allow them to be truly human. Humans get burned out at work, have marriage problems, have loved ones pass away, things that happen in their personal lives that can impact job performance. But we do not, as patients in our minds, view physicians as having the luxury of being human, making mistakes, having bad days. How do physicians deal with that pressure? And should patients look at physicians as being humans who can make mistakes? And is it dangerous to have patients lose that reverence for physicians? What are your thoughts?

Zubin Damania:

Hmm. This is something that I’ve personally struggled with because there is this aura around the physician that actually has a potential healing piece to it. There’s this therapeutic alliance. Now, what I’ve learned over my years is that the more honest, open, and authentic I can be with patients, the more they actually are able to connect within parameters. You’re not going to behave the way you behave with say your best buddy when you’re at the gym or something, making jokes with a patient. That’s just never going to work, right? So there’s the use of humor. You have to be very careful, and thoughtful, and respectful with patients, but at the same time, some of it is an authentic expression of connection and a rapport. So I think what we, patients are already waking up to the idea that their doctors are not robots or superhuman, and they don’t want that, because a doctor who stares at the computer is not a good doctor in their mind.

They want their doctor to make eye contact, to show a little bit of connection, at least probably more than a little. Surgeons, they’re a little more lenient with, but in surgeons, maybe there’s different degrees of this for different professions, but I’ll tell you for internists in general, they want a little bit of that connection in humanity. And I think that’s one of the reasons that whatever I do online is vaguely popular. As I think people are like, “Oh, this guy’s not so uptight like a lot of doctors that I’ve met. Maybe he goes too far, actually, in the other direction.” But it’s a balance that we have to strike. And some of it is modulating patient expectations, which happen when there’s a million doctors on YouTube making videos that are a little bit funnier and more open.

Robert Pearl:

My answer, Jeremy, is to start with what the data says, which is that paternalism, and now maternalism, doesn’t work. The top-down approaches to work. We know that patients don’t take the medications as effectively as they should, as in terms of their best health. We know that they don’t often follow up on recommendations that will improve their health. The current system doesn’t work and yet we ignore it. And I think physicians don’t recognize the gap between what could be and what is, because they believe that it’s time-inefficient to establish a real relationship with the patient. But I think that that’s what’s necessary. If you don’t have that relationship, and you don’t build the trust, if you don’t build the trust, you don’t develop a level of commitment. And without the level of commitment, the healthcare system doesn’t move forward. And I believe that that’s what we’re seeing today.

And so I think it’s essential that physicians be able to be human. Now, the reality is the person who is sick has come to your office and you’re the healer role. You can go to someone else’s office and they become the healer for you. And you should do that as well. But if there is a complete lack of authenticity, to use Zubin’s word, or a complete lack of openness, then I think the patient leaves and feels like maybe they got some information, but they’re not sure that they’re really going to trust it, believe it, or follow up upon it. I think the teachings of the past around the lack of emotion was really a defense by doctors for their complete inability to treat almost every disease. I mean, if you think about it, doctors could repair lacerations for centuries. They could fix, put bones back in place.

After anesthesia came along, could do appendectomy. But the kinds of problems that we’re facing today, the kinds of treatments that we have, they are so complex that if we don’t invest the time upfront to educate patients, to make certain that they understand the disease they have, the treatment that will make it most likely to get better, if we don’t have a mutual commitment coming out of that meeting, I think it is going to fail. I think doctors wanted to protect themselves from their inability and their lack of success. They saw their job as telling patients. And I think we need to ask more and engage more. And I know a lot of listeners are going to say, “We don’t have time.” Somehow we find the time when the complications happen to treat the problems that ensue, we need to figure out how we can invest in the front to improve the outcomes of the back end, and minimize the need for rework and treatment of medical issues that could otherwise have been avoided.

Jeremy Corr:

We hope you enjoyed this podcast and we’ll tell your friends and colleagues about it. Please follow Fixing Healthcare on Apple Podcasts, Spotify, your favorite podcast app. If you liked the show, please rate it five stars and leave a review. If you want more information on healthcare topics, you can go to Robbie’s website at robertpearlmd.com, and visit our website, fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter @FixingHCPodcast. Thank you for listening to Fixing Healthcare’s newest series Unfiltered with Dr. Robert Pearl, Jeremy Corr, and Dr. Zubin Damania. Thank you very much for listening and have a great day.

The post FHC #49: An unfiltered chat about ‘the slap,’ emotional doctors, and more appeared first on Fixing Healthcare.

Season seven of the Fixing Healthcare podcast focuses on the unwritten and outdated rules of American healthcare—many of which Dr. Marty Makary would badly like to see broken.

In this episode, the nationally renowned surgeon, author and educator sets his sights on the outrageous rules of medical education, healthcare spending, the “appropriateness of care” and much more.

With cohosts Dr. Robert Pearl and Jeremy Corr, Dr. Makary shares his candid comments on the rules of American medicine that need to be broken.

“The AAMC continues to inflict tremendous damage on a generation of young people, who are trying to learn how to be great doctors. They’re forcing them to do all of this rote memorization, and it comes at the exclusion of other important skill sets … The AAMC has too much power. It’s the concentration of power in medicine, it’s not healthy. And by the way, many of these organizations lack diversity. Look at the editorial board of the New England Journal of Medicine and JAMA, I think it was like one African-American out of 50 editors.”

“Well, I think the cost crisis in healthcare is really a function of three factors. One is pricing failures in the marketplace that enable price gouging, and they also enable the second factor which is a giant growth of a middleman industry. This is a group of thousands of millionaires that we’ve created who are not patient facing, who are not contributing to patient outcomes … And finally, the third biggest driver of our cost crisis is care coordination.”

“Financial toxicity is a medical complication, and billing quality is medical quality. These are things that are measurable, but up till now, we’ve only been measuring infection rates and readmission rates. We’ve got to start measuring billing quality performance and the price of services.”

“I can point and show you in detail areas of waste in healthcare where anybody, doesn’t matter what political party they have allegiance to, will agree that it’s egregious, it’s corrupt, it should stop, and it is wrong. Now, there’s a lot of those things in healthcare, actually. There’s a lot of area where there’s broad consensus, but reining in inappropriate care at the end of life is one of the most challenging, because it is still and always will be an art form. It’s not something that can be managed with policies or rules.”

“There was a time in the medical profession where in order to get a medical degree in the English empire, you had to have a degree from Oxford or Cambridge, at a time when neither Oxford nor Cambridge offered pre-medical education. It was just a royal lineage, if you will. It was an oligarchy, and they had all of these rules and we still have these rules in American medicine. And many of them live in this so-called academic promotion process, and that is a major barrier in my opinion to scientific advancement. People playing the game to get promoted, and we see that a lot.”

READ: Full transcript with Marty Makary

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #48: Marty Makary on breaking the rules of medical education appeared first on Fixing Healthcare.

In the first episode of Fixing Healthcare’s 10th season, cohosts Dr. Robert Pearl and Jeremy Corr speak with Dr. Eric Topol, a healthcare visionary and global technology leader.

This season focuses on the future of technology in healthcare, a topic close to Dr. Pearl’s heart. His newest book, ChatGPT, MD: How AI-Empowered Patients & Doctors Can Take Back Control of American Medicine, debuted as an Amazon top new release. All profits from the book go to Doctors Without Borders.

Dr. Topol is a renowned cardiologist and founder of the Scripps Research Translational Institute. He has been a pioneer in predicting how technology will shape the future of medicine. His bestselling book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again, explores the transformative power of AI in healthcare. During the interview, Dr. Topol highlights three ways technology will break the traditional rules of medicine:

• Precision Preventive Care: Dr. Topol emphasizes that AI will revolutionize preventive care by moving beyond the outdated practice of relying solely on age and sex to determine who needs screening. Instead, generative AI will analyze vast datasets, including polygenic risk scores, biomarkers and proteomic data, to identify individuals at the highest risk of developing life-threatening diseases like cancer or heart disease. This proactive approach will allow for targeted prevention, significantly improving outcomes.
• Reducing Misdiagnoses: The conversation turns to the persistent issue of diagnostic errors, a leading cause of preventable harm in healthcare. Dr. Topol discusses how AI can alleviate this problem by giving clinicians more time to think critically, providing deep analysis of patient data and interpreting medical images with unparalleled accuracy. This would dramatically reduce the current rate of misdiagnoses, which remains a significant life ending failure in healthcare.
• Transforming Clinical Documentation: Dr. Topol also explores how generative AI is already freeing from the burden of administrative tasks, particularly documentation. By automating the creation of high-quality electronic health records from conversations between doctors and patients, AI will allow clinicians to focus more on patient care, improving both efficiency and the patient experience.

Throughout the episode, Drs. Topol and Pearl discuss the broader implications of these technologies, including the potential to revolutionize medical research, the challenges of data security and the cultural shift required in healthcare to fully embrace these innovations.

Tune in for the full interview and join the conversation on social media.

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #146: Dr. Eric Topol on how AI is changing healthcare appeared first on Fixing Healthcare.

A group of researchers in the UK examined hundreds of brain scans that were taken both before and after people became infected with the coronavirus. The study, published in Nature, concluded that “there is strong evidence for brain-related abnormalities in Covid-19.” Some of the recorded disease effects included tissue damage, along with reductions in both grey matter and overall brain size, post-infection.

This study raises more questions for scientists and medical professionals about the possible long-term consequences of Covid-19. Jeremy Corr and Dr. Robert Pearl examine these questions in this episode of Coronavirus: The Truth. You’ll find all the [time stamped] questions from this show in the notes below:

[01:15] Each show begins with the most recent and relevant facts concerning the Covid-19 pandemic and its impact on American life. What’s happening and what does it mean?

[10:23] What’s the latest on Ivermectin, the Covid-19 treatment therapy?

[14:41] How can patients distinguish science from pseudoscience?

[16:48] Did researchers uncover data that shows brain damage after Covid-19 infection?

[18:06] What do we know about “long Covid” now?

[21:12] Is the CDC finally agree with the WHO on vaccines?

[23:18] What’s good this week?

[27:15] Why are medical workers abandoning the profession?

[29:55] How do employer vaccine requirements and mask mandates affect local businesses?

This episode is available on Apple Podcasts, Google Play, Spotify and other podcast platforms.

If you have coronavirus questions for the hosts, please visit the contact page or send us a message on Twitter or LinkedIn.

*To ensure the credibility of this program, Coronavirus: The Truth refuses to accept sponsorship, outside funding sources or guests with any financial or personal conflicts of interest.

The post CTT #59: What does Covid-19 infection do to the brain? appeared first on Fixing Healthcare.

Welcome back to the Fixing Healthcare series, “Diving Deep,” which features a robust and probing discussion about some of healthcare’s most deep-seated problems.

In this episode, Dr. Robert Pearl Jeremy Corr talk about two areas of medicine where the existing “rules” seem out of date. The hosts begin with a bizarre norm in healthcare: that technologies must, above anything else, boost the status of the physician. That’s followed by another odd norm: that primary care physicians, the doctors who save the most lives, are among the least-valued in the profession.

For more information on these topics, check out Dr. Pearl’s latest healthcare columns on Forbes and LinkedIn. For listeners interested in show notes, each episode of this series will feature a time-stamped discussion guide (as follows):

[01:07] Why is healthcare the only U.S. industry that has failed to use technology to lower prices or improve quality?

[04:26] Why doesn’t medical technology improve life expectancy?

[06:51] How are patients affected by the rules of health-tech?

[08:58] Which technologies actually benefit patients?

[12:36] What’s the difference between episodic and continuous medical care?

[14:34] Which technology in medicine is most underutilized and undervalued?

[18:37] How do we break the current rule of health-tech?

[20:08] Why are primary care physicians undervalued in healthcare?

[25:24] Can primary care solve our nation’s chronic disease crisis?

[26:26] How do we break the outdated rule of primary care?

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

The post FHC #47: Diving deep into primary care & health-tech appeared first on Fixing Healthcare.

Welcome to Unfiltered, a new show that brings together two iconic voices in healthcare for an unscripted, hard-hitting half hour of talk.

Twice, Dr. Robert Pearl has appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who hosts of the internet’s No. 1 medical news and entertainment show. And twice before, Damania had appeared the Fixing Healthcare podcast with Pearl and his cohost Jeremy Corr (see: episode 1 and episode 26).

In the first episode of their new show Unfiltered, part of the Fixing Healthcare franchise, the duo dives into the differences—and similarities—between generations: from Boomers on up to Gen Z. Along the way, they discuss everything from techno-economic structures of healthcare to cancel culture to rap lyrics. Press play now or peruse the transcript below.

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

UNFILTERED TRANSCRIPT

Jeremy Corr: 

Welcome to Unfiltered, our newest program in our weekly Fixing Healthcare podcast series. Joining us each month will be Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice. I’ll then pose a question for the two of them as the patient, based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Zubin, welcome back to the Fixing Healthcare show.

Zubin Damania:

Dang, Robbie, I’m ready to get Unfiltered. I don’t know what that means, but we’re going to do it.

Robert Pearl:

Okay. Let’s begin in a place you love, Broadway. I had the chance to see a remarkable show called The Lehman Trilogy. It traced the history of the Lehman brothers from when the first generation came to the U.S., middle of the 19th century. And then it ended at the financial collapse in the first part of the 21st. What was most interesting was the continual clash of generation. Three brothers began in the South manufacturing clothes from cotton, but the next generation, it realized that it was more profitable to become transporters of cotton from the South to the industrialized North. Then the next generation recognizes it’s more profitable to be the financiers of industry and they start banking. Then the next generation says, “Why not expand to all businesses?” And they create the stock exchange, or contribute to its founding.

Robert Pearl:

And, finally, the company no longer at this point led by the family, introduces an array of financial products that ultimately proved to be Lehman’s downfall. What was so powerful to me was watching this inevitable clash. Each generation with the one that follows, one generation holding onto power, the other one coming of age, embracing change, and rejecting the values of their parents. I’d like to start by hearing your thoughts on this issue of the generations battling, whether it’s society overall, or how it plays out in medical practice. What are your thoughts, Zubin?

Zubin Damania:

Man, I love generational conflict because first of all, it’s entertaining. Second of all, it is an indicator of the natural evolutionary process of everything, like the entire universe unfolds this way. So you have generation one, let’s call them the boomers, for example, who did things a certain way. They were actually the rebels of their time. They pushed the envelope. In the ’60s the emergence of this sort of cultural revolution and the plurality and multiculturalism and postmodernism and all of that. They were the leading edge of that evolutionary chain. And then the generations that followed kind of emerged, and each of them takes a tact of first kind of learning what the previous generation kind of did. And then dis-identifying from it saying, “Oh, this has this many problems, and I don’t really like this, and this is not how I want to live.” And then trying to grab a foothold in something new and saying, “Okay, well, no, this is what we are.” And identifying with that.

Zubin Damania:

I think where that becomes healthy is where you integrate what the previous generation was able to do and actually say, “Yeah, that was necessary, but it’s partial. We need to keep striving for whatever truth is.” But if you don’t integrate it, if you just reject it and you never integrate it, then you’re in a difficult situation, then you have this kind of conflict. Now I think some of that’s inevitable, but some of it isn’t.

Zubin Damania:

As I started growing older in medicine and having house staff you could watch this play out. First, you have me, Gen X and then you start having millennials and you see a kind of a contrast in styles and expectations in sort of work ethic in a sense of it’s not that the work ethic isn’t there. It’s just it’s a different balance of what they want. They’re quite clear of saying, “I actually want to learn.” Whereas, we were like, “Well, whatever we need to do, we’ll do to kind of power through.” And so this kind of conflict to me it’s fascinating. I think it’s necessary to some degree, but understanding it allows us to actually transcend to a more integrative evolutionary approach to generational kind of thinking.

Robert Pearl:

One of the things that’s fascinating to me is how the events of the time so shape a group of individuals. As you mentioned, you have the boomers, they watched a man land on the moon, and President Kennedy talking about getting to space in less than a decade, anything’s possible. And Gen X this is the latchkey generation. They watched the breakup of the family. I’m not so sure anymore that this hard pushing is the best thing for people. Gen Y comes along and there’s 9/11, the world, it could collapse at any moment. And then Gen Z, the people who grew up during the 2008 recession. Now they’re moving back, look a lot more than the boomers.

Robert Pearl:

My sense is that the underlying motivation of people doesn’t change. It’s not that one generation is more purpose-driven or mission focused. No, it’s how it’s presented out. Is it going to be in the external world? Is it going to be in the family? Is it going to be an accomplishment? Is it going to be individual? And I fear a little bit, and this is overall, but medicine in particular that we personalize it in a negative way. My approach is better rather than understanding how as humans, we’re all shaped by what’s around us. What’s your sense?

Zubin Damania:

It’s like every disease is biopsychosocial. It has biomedical component. It has psychological component. It has social and technological components and environmental components. Everything in generational thinking is exactly that. For example, for me, Gen X we were shaped by our memories are the Challenger disaster, and the ’80s. And like you said, the sort of slow decline of family, the culture wars, these kind of things kind of shaped us and destabilized us to some degree, but I think that interaction with the system, the environment, the techno-economic structure.

Zubin Damania:

In healthcare, it becomes really fascinating because you have Gen Z now and Gen Y that have a very different upbringing than we did. They are digital natives. They started with an iPhone in their hand, the Gen Zers. And they’re entering a system where we have fax machines still. We have pagers still. We have this archaic set of payment models and CPT codes, and all this stuff. And they look at it and they cannot understand why this exists, and that pushback that they might feel, or might exhibit can be interpreted through the older generation’s lens as you’re just not paying your dues. You don’t understand, this is how we’ve done it. And we got stuck with this crap and you should too, but I don’t think that’s the right way to look at it.

Zubin Damania:

What we have to do is understand that both the techno-economic structures of healthcare and everything, and society have to adjust and vibrate along with the generation that’s coming into being, that’s going to be the predominance of the workforce, and all that, instead of us, like a lot of Gen X attendings now are just, “Oh my gosh, these millennials and these Gen Zers they’re impossible to deal with.” I don’t think that’s the right way to look at it at all nor is it for a Gen Z-er. It’s usually millennials looking at boomers going, “Yeah, okay, boomer, you guys wrecked everything. You guys don’t even know what you’re doing. Like, let us handle this.” That’s the wrong way to look at it too.

Robert Pearl:

I’m just so excited I have to tell you about Gen Z. If I were back in college, I’d study Mandarin, because I’d see that as what the future world is going to be rather than what was in the past. I’d be really interested in this narrowing of the line between humans and robots and seeing a world in which we actually will interact with these technologically created creatures that biologically don’t exist, and yet in so many psychosocial ways do. It’s interesting that I somehow have this view of the future rather than the view of the present and the past. I think it’s true for you too, Zubin. Am I right?

Zubin Damania:

Yeah, this merging of, so you cannot separate our tools and toys and technologies from us. We are intertwined with that. I recently had a guy named Daniel Schmachtenberger on my show. And we talked about this, that technology and society those structures feed back on the human mind. They feed back on us in ways that evolve us that are beyond our DNA, actually. Although, some of it is our DNA, methylation, and these sort of Lamarckian effects on our DNA, but the truth is even beyond that we are absolutely changed by these structures, so we ought to actually approach the future with kind of a mix of kind of techno optimism, like let’s design systems that actually encourage the kind of outcomes that we want as a people, which right now we haven’t done.

Zubin Damania:

With social media, we haven’t done that. We’ve encouraged fear of missing out. We’ve encouraged bad body image. We’ve encouraged division and polarity with those structures because they are purely incentivized by money. So we have to change those sort of incentives and structures to understand what you’re saying, right, Robbie? Like to actually respect that so that we can create a world that actually is what we want as opposed to what’s just going to happen to us.

Robert Pearl:

There’s no way we can stop the progress, and so I agree with you completely. We should be trying to shape it in the best way power and recognize that some of it is beyond our simple control. Zubin, you are a musical genius. At some point on this show I’d love to have you sing for people and rap for people, but let me ask you now just for your perspective on the evolution of music in a generational context. Elvis to hip hop to heavy metal to rap, where are we? What’s coming next? What is exciting to you in the musical world?

Zubin Damania:

Man, this is, and by the way, I’m a real crappy musician, but the bar in healthcare is quite low. So all I have to do is show up and I’m going to rap over a track, and I’m probably okay, but in the real world I would die instantly. So what I think about this is fascinating. It’s almost like karma, right? Cause and effect, like everything you do kind of ripples out and has effects on everything else. And it’s all a web of interdependency.

Zubin Damania:

So Elvis was basing his music on black music and blues and jazz, and that evolved into rock and roll, and that evolved into Prog rock, and that evolved into hip hop, and all these things kind of are interdependent. Everything is appropriating from everything else. When you talk to any good musician, the first thing they’ll do is tell you who their influences are. They never say, “Oh, I just made this stuff up from scratch.” No, they go, “No, no. I listen to this. I listen to that. I listen to this.” And they process it through their unconscious and out it comes. They open a hole in the universe. They take all this input and outcome something completely novel that’s actually made of these building blocks. So music is like that.

Zubin Damania:

So that’s why it’s funny as I get older, Robbie, I listen to new music and I go, “God, this sounds just like this, this sound just like this, this sounds just like this.” Because you start to pick out that karmic influence from all the generations before because you have the age and perspective to see it. Whereas, I think young people they’re just like, “This is my music. This is brand new. This has never happened.” And as they get older, they start to put it into the context of this evolutionary chain of music that’s beautiful. I mean, it goes back to the beginning of art the earliest Gregorian chanting, and before that cave singing, and all that, it all is this uninterrupted line as far as I see it.

Robert Pearl:

I read that unless you’re exposed to new music early in your life you’re never going to be able to embrace it. That there’s a cerebral neurobiological way that music gets incorporated into your brain, and yet you seem to keep evolving. I mean, I think the Super Bowl halftime show was one of your most favorite musical events. Is this your experience, or are you able to keep taking in the newest forms of music and finding value inside them?

Zubin Damania:

It’s a real challenge. I think that this window to novelty starts to close in our 30s. There’s been some data around that that if we’re not exposed to something new before we start hitting our 30s that novelty window closes and we’re more resistant. And some of it may just be biological conditioning. Some of it may be some other effects, but my experience is musicians who are the most open-minded they already emotionally personality wise they’re born with a set of tools, high openness to experience these kind of personality traits that allow them to be open to different things.

Zubin Damania:

And they’ll often say, “Oh, my parents played all kinds of music in the house, or my father was a musician,” or something like that. And that often opened their it’s like learning, like you said, you’d learn Mandarin. Like if you learn a bunch of languages before you’re 10, they’re really easy to learn. Once you get older the window of plasticity starts to close. It doesn’t close entirely. It never does, but it does make it harder. And I think the same is true with music. So some of the best musicians are the ones that had the most musical exposure when they were young.

Zubin Damania:

For me watching that Super Bowl show was like a take back to 1993. I was elated as a generational thing as Gen X going, “Oh, that was our music.” That was when I was in college. That’s when we were this was the edgiest, craziest music, and now it seems like classic rock it’s so crazy tame. And to watch them do it in the Super Bowl, and really crush it was just a lot of fun really kind of elating to see.

Robert Pearl:

I’ve heard that 50% of all music is about love either the unrequited love, the fulfilled love, the early love, the late love, the good love, the bad love. Does the music shape our view of relationships, or is that something, again, that we should be leading and directing?

Zubin Damania:

Ooh, what a lovely question. Man, I haven’t thought about this enough, but I’d say this, that it’s an epiphenomenon of our relationships and it also does shape our relationships. And in some ways it’s unhealthy because the concepts of romantic love often espoused in music are reductionist and a little cliche, and they don’t take into account the broad breadth of how humans are. So in a way romantic love is so interesting to begin with because you can contrast it in a meditative experience, or a spiritual context unconditional love, where you feel absolute acceptance unconditionally for all beings where we’re all one thing. And that kind of love feels very different than romantic love, which is in many ways kind of conditional and kind of dependent, and is dualistic in the sense that it has its highs, and then it has its very much lows, right? So music captures that because music is the emotional human state in a crystallized vibratory form. That’s why it triggers emotions, but it also is created by emotions in a way. So it’s mutually interdependent in my mind.

Robert Pearl:

I’m going to ask you a question that I would hesitate to ask to almost anyone else, but I’m very interested/really concerned about racism in medicine. I was at a karaoke club, believe it or not, about two weeks ago. And a lot of the songs were rap songs. And if they had come out of individuals who were white they would have been very offensive, I believe. Of course, the singers were black in this particular case. How do you view the language sitting in rap today that sits on this boundary around racism?

Zubin Damania:

Oh, that’s interesting because you’re talking about the N-word, which is used profusely, I think, in rap music. And it is, it’s not a word that say a Caucasian person, or me as an Indian American can use. It’s not a word that I think we can use. Now, in the music it’s interesting because it is in cadence, in incisiveness, in context of the experience of that community in the rap it is the perfect word in many ways. And so that’s the tension there and that’s art. Art is that kind of tension, the tension between society, between the social structures, between the weight of history, and between that performance in the present moment, right? So I think there’s no single answer to this. And if you asked 20 people they’ll all tell you different things depending on their background, their race, their own lived experience.

Zubin Damania:

I recently had a doc named Ian Tong on my show who is the chief medical officer of a company called Included Health. And he’s written extensively on race and medicine. He’s a black physician and he talked quite powerfully about his own experience. And I think what we have to do is listen to these perspectives and see how we can incorporate change in a systemic way, but at the same time we have to be careful about the reverse, where we’re starting to attack and marginalize say Caucasian people based on their race. Like we’re just assuming you’re a racist, we’re assuming this. And it just becomes this very self-fulfilling prophecy and a big mess. So I think just being open and authentic and honest in our conversations is 90% of the battle. And trying to really inhabit the other person’s lived experience and position as an empathic sort of exercise is crucial.

Robert Pearl:

When I was on your incredible podcast I think it’s the best one in all of healthcare. Congratulations on it.

Zubin Damania:

I’ll give you that honor, Robbie. Actually, my podcast kind of sucks for healthcare.

Robert Pearl:

You asked me a question about racism. We talked about the fact that early in the pandemic that when there was a shortage of testing kits that physicians under-tested black patients that when two patients came to the ER with the same symptoms, one a white patient, one a black patient, the likelihood was that the white patient got tested twice as often. And we talked about the nature of implicit bias that it’s biological most likely dating back 20,000 years we were cave people. Someone shows up at the door to the cave. We have a nanosecond to decide whether it’s someone we should welcome in and feed or throw a spear at because they’re coming to kill us. And that that biological piece isn’t an excuse for racism.

Robert Pearl:

And most importantly, that not recognizing it and not putting in place systems to be able to address it and prevent it that was racism. And I see that in medicine today. I see artificial intelligence as possibly being able to say, “Zubin, when you take care of this patient, usually you prescribe ex dose of medication. This patient you’re prescribing half of the pain medication, even though the pain is likely the same, do you want to reconsider?” And I don’t see medicine either acknowledging it. I mean, you can find it in the literature, but acknowledging it in how it’s changing. I don’t see residency building it into place. I don’t see technology coming in. I’m concerned and we’re seeing it in the data, women’s mortality who are black women in labor. We’re seeing this problem continue and actually become worse on what I’ve seen recently. Your thoughts on how we can best address racism in American medicine today?

Zubin Damania:

I mean, this is a massive topic. One thing you mentioned about AI is interesting because it’s a double-edged sword. AI is only as good as the information you feed it. And actually it can lead to perpetuating systemic bias if it’s fed information that is innately incomplete, or biased, and this has been something that’s been documented in AI in medicine too. And so what I think this is tricky because there are a lot of like sort of like when we point a temperature gun at someone’s head when they’re coming into a restaurant and we call that COVID screening, that’s called hygiene theater, right? It’s not really doing much of anything, but people feel better by having done it.

Zubin Damania:

I think some of the techniques and things that they’re doing in medicine are along those lines. They make people feel like, well, we’re doing something about race, but it’s really not doing anything. And what we really need to do is what you’re saying, which is look at our systemic structures and see, okay, are these contributing to this situation? And also we have to be careful about reductionist diagnoses of what’s going on because sometimes we’re missing a broader problem that is contributing to an outcome, right? Because we want equality of opportunity everywhere we can. And so any way we can knock down barriers to that equality of opportunity we need to look at systems that do that, but it’s hard, man. It’s really hard. And people don’t even want to talk about it because it makes them uncomfortable.

Zubin Damania:

Whereas, every time when I would round and we’d have a multiracial team, which was every time, right? I would talk about race all the time because I wanted to put it. And by the end, everyone was like, “This is our culture. This is what we do.” And even just having an open dialogue and people are afraid. I could get away with it because I’m off white, right? So I felt like, oh, I can say this. I don’t feel bad about it. I think a lot of Caucasian people feel bad about doing that. They’re nervous about it. And I think we have to get over that too. And that’s going to take some generations probably.

Robert Pearl:

I heard an interesting dialogue between two physicians. The first one, this is relative to the issue of change how fast we can make it. One said, “Rome, wasn’t built in a day.” And the other one said, “But it could have been.”

Zubin Damania:

I like that, could have. That sounds like Gen Y right there. Just get on Instagram and take a selfie of you with Rome, and there it is, it exists, it’s there in the picture.

Robert Pearl:

How fast can we, and should we evolve the American healthcare system?

Zubin Damania:

Man, if I could wave a magic wand, I would just start entirely fresh. And that includes medical education. And that includes our concept of what wellness and health actually mean because that’s a cultural and personal context. And, again, biopsychosocial, there’s a whole wave of that. So if I could do it, I would completely reboot it, so I’m in the camp of like, hey, it could have been built in a day, right? Because in a way, trying to undo these legacy systems at some point it just gets to be you’re banging your head against the wall, which we’ve been doing for quite some time.

Zubin Damania:

At the same time it’s very destabilizing to even talk like that. Markets would collapse if we suddenly did that, although we’d get a lot of our GDP back, probably. So I’m somewhere in the middle on that. I think we need real disruptive change, but at the same time, we’re going to have to work with structures that we have. And we’re going to have to work with a legacy population of healthcare professionals that have been conditioned and cultured in a system that is no longer going to exist if we do things right.

Robert Pearl:

So I’d like to return one last time to the generational questions. You have a massive following on your podcast. How many people follow your podcast now?

Zubin Damania:

Well, on Facebook, it’s about 2.5 million. YouTube, about half a million. Instagram, about half a million.

Robert Pearl:

I’m guessing you have a pretty broad population of generations, ages, et cetera.

Zubin Damania:

Yeah.

Robert Pearl:

Do you see, do you hear, do people respond differently based upon the generations, and if so, how is that?

Zubin Damania:

Yeah, actually they do. And each platform has a different age mix. Instagram skews younger. YouTube skews more male and younger. Facebook skews female and older. And they all respond to different, like, I can put the same piece out on different platforms and the response may be a viral million hits on one, and 5,000 meh with no comments on another. And so different generations do respond to different material quite differently whether it’s a music video from a certain era, or whether it’s just a topic that they’re interested in or not interested in and there are gender differences for sure. So it’s a real cross section of all of healthcare actually are following. Some of it depends, too, on what their profession is. Nurses respond differently than doctors respond differently than physical therapists respond differently than respiratory therapists. So there’s just so much diversity there. It’s almost impossible to know what’s going on so you just try to talk about stuff you care about authentically.

Robert Pearl:

In the end my conclusion based upon everything I’ve just heard from you is that everyone is motivated to make positive changes happen. It happens across generations. It happens across training and backgrounds. And I think that the separations that we have done personalizing it around your generation is a problem. My generation is right. I think it’s standing in the way and I would encourage you on your show and continuing in our conversation on this show to look at the similarities, to find the ways that the motivation is the same. The driver is the same because as you’ve said, I have had really wonderful experiences in my medical career in training residents and working with colleagues regardless of the particular year they were born. We should understand those influences, but we shouldn’t let them stay in the way. That’s my view of generations. Closing thoughts by you.

Zubin Damania:

I think that’s spot-on. I think we should embrace these differences as part of the normal evolutionary wave of how humans are and try to really, really put ourselves in each other’s shoes. So if we can really feel what it’s like growing up as I say a Gen Z, you can actually feel a lot of love and compassion for their struggle too, as well as the opportunities that they have. I think we’re in a spot to do that, but I do think that we get calcified as we get older and we’re more resistant to that kind of thing. Whereas, the younger generations, I mean, we ought to just make it a cultural norm that that’s how we behave.

Jeremy Corr:

ZDogg and Robbie, you guys talked about the generational differences in healthcare. One thing I hear frequently in many industries is that the younger generations are too self-obsessed, self-righteous and arguably fragile, especially on social media. Social media is obviously a blessing and a curse. It gives people the ability to share with the masses in a way they’ve never done before, but also to attack and cancel people for what they believe is wrong things like never before.

Jeremy Corr:

We see people raising awareness for humanitarian crises all over the globe, but also mobs of people canceling people for things they tweeted, or said back when they were in high school. People feel so righteous to band together with people and be part of a cause on social media. I mean, we’ve seen misinformation spread as well as way, way, way too much censorship on topics that later are proven to be true. What do you both feel is kind of that right mix of outspoken step, or being able to speak their mind versus censorship versus kind of how the different generations see and use social media as well as kind of some of the pros and cons about it?

Zubin Damania:

Well, this is like one of the fundamental things we really try to address on our show is this idea of social media as a technological tool that kind of, again, vibrates with each generation differently in that it really does hack our limbic system. It’s a race to the bottom of the brainstem. We have these hyper normal stimuli in the form of these social media things along with this weaponized tribalism in the form of likes, dislikes. We almost instantiate these collective hive minds based on individual neurons, which are like, dislike, that’s our neurotransmitter in these social networks.

Zubin Damania:

And so you have generations now that are being judged on dumb stuff they said when they were 13, who didn’t? If you could pull up everything and I’m sure there’s stuff somewhere circulating around that I’ve said when I was 14, I would be done in this climate. They would eliminate me from the face of the earth and the truth is that’s not okay because these are neuroplastic children at that age too, right? So they can’t be judged on that. We should be able to be our authentic selves, but we should also have to, again, deal with the consequences of what we say, but not in a way where the mob comes and cancels you. And, look, I’ve been the victim of cancellation. I’ve tried to cancel other people. It’s so seductive on social media, Jeremy. We need to change those social media incentives in order to make it a little better. I think we can absolutely do that. There’s much smarter technology out there that can be used to actually generate consensus and connection as opposed to polarization and cancellation.

Robert Pearl:

What I see is technology becomes ever more powerful whether you want to look at Moore’s law doubling every two years, and what you’re seeing right now is incredibly powerful technology that can be used for good or bad. Technology isn’t an intrinsic force around morality or immorality. It’s simply a tool that people apply and societies and civilizations have to figure out how to use it. You can think of it as a nuclear power that can generate electricity to light the homes without affecting climate across the globe, or you can think about it as a tool to destroy civilization. I think the time has really come for us to ask how do we want to use this powerful tool? I believe for the best in people. I think we under-utilize it in medicine. I think we probably over-utilize it as Zubin has said in people’s early lives. Finding the right balance will be difficult. Everyone wants a simple solution, a clean solution. It doesn’t exist. This force will happen. It will grow stronger. And we, as humans will have to decide whether we control it, or it controls us.

Robert Pearl:

Zubin, it’s been great. I can’t wait for next month. This has been a fascinating view to me of the millennials and the Gen Xers, and the boomers, and the future Gen Zs. And now the new Gen A that is coming along. The world will be very different in the future. Together I’m hoping we can make it better. And as I always say at the end of my shows together we can make American medicine once again the best in the world. Thank you for being our guest today.

Jeremy Corr:

We hope you enjoyed this podcast and will tell your friends and colleagues about it. Please follow Fixing Healthcare on Spotify, Apple Music or other podcast platforms.  If you liked the show, please rate it five stars and leave a review. If you want more information on healthcare topics, you can go to Robbie’s website RobertPearlMD.com and visit our website at fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter @FixingHCPodcast. Thank you for listening to Fixing Healthcare’s newest series Unfiltered, with Dr. Robert Pearl, Jeremy Corr and Dr. Zubin Damania. Have a great day.

The post FHC #46: An unfiltered look at medicine’s generational clash appeared first on Fixing Healthcare.