Fixing Healthcare Podcast Transcript Season 5 Recap Jeremy Corr: Hello and welcome to the Fixing Healthcare Podcast. I am one of your hosts, Jeremy Corr. I'm also the host of the popular New Books in Medicine podcast and CEO at Executive Podcast Solutions. With me is Dr. Robert Pearl. For 18 years, Robert was the CEO of the Permanente Group, the nation's largest physician group. He is currently a Forbes contributor, a professor at both the Stanford University School of Medicine and Business, and author of the best- selling book Mistreated: Why We think We're Getting Good Healthcare—And Why We're Usually Wrong. Jeremy Corr: His new book Uncaring: How the Culture of Medicine Kills Doctors & Patients was published last month. All profits go to Doctors Without Borders. If you want more information on the book and a broad range of healthcare topics, you can go to his website, robertpearlmd.com. Together, we also host the bi-weekly podcast Coronavirus: The Truth. Most seasons of Fixing Healthcare have six guests, but in the current season five, which focuses on the culture of medicine, we invited eight due to the breadth of the subject, and we only scratched the surface. Jeremy Corr: In this is our final episode, I'd like to try something different. As I mentioned each of our guests from the season, I'd ask you to extract one challenge they talked about relative to the culture of medicine and expand on it based on the research you did and the conclusions reached in your book Uncaring: How the Culture of Medicine Kills Doctors & Patients. But before we begin, let me ask you to review for listeners what people mean when they talk about the word culture and how does it apply in a medical context? Robert Pearl: Jeremy, culture includes the values, beliefs and norms that groups of people embrace and pass from one generation to the next. It's transmitted through the stories that are told, the language that is used and the customs that are followed. You can think of it on a national level, and contrast the values, beliefs and norms of people who live in Italy as opposed to Germany. Or you can think of it relative to fans of particular sports teams or the jerseys they wear and the way they show their support. Or you can observe it through seeing the impact of culture on doctors and the care they provide to patients. For physicians, culture is passed down beginning the first day of medical school. It's what's called a white coat ceremony that has become a memorable event for so many matriculating medical students. Robert Pearl: In the audience, the students and their parents sit. And one by one, the students are called to walk onto the stage and a faculty member drapes a white coat over his or her shoulders with one exception, and that is when one of the parents is a physician. Now, think about how strange this rite of passage is. Certainly the parents who are doctors are proud of their children, but what about the parents in the audience? Some of whom have to work two jobs, each working two jobs in order to allow their child the time and opportunity to get the grades needed to become a doctor? Surely they're just as proud of their children as the parents who are physicians. Robert Pearl: What you quickly realize is that this white coat ceremony isn't about the pride of the parents. It's actually a rite of passage in which the parents cede the responsibility, the ability of the authority to pass culture from their family onto the faculty members. So why can the parents who were doctors drape the coat? Because they are already immersed in that same culture and can be trusted to make sure that the right values, beliefs and norms are passed on. Robert Pearl: This physician culture can make doctors act in heroic ways or lead them to actions that harm patients. In the early days of COVID-19, physicians were heroes. They worked 12 and 24 hours at a time, donning garbage bags when hospitals ran out of protective gowns, and putting on salad lids when there were no protective masks. But the same pandemic also highlighted problems that have not only systemic reasons for their existence, but also cultural ones. And our guests, Jeremy, this season I think did a great job of pointing out many of these examples for our listeners. So please go down the list. I'll try to provide an example of the challenges the culture of medicine creates for each one of them. Jeremy Corr: Our first guest this season was Dr. Zubin Damania, best known to his fans as ZDoggMD. He along with Zappos CEO Tony Hsieh started Turntable Health in Las Vegas as an alternate to the broken healthcare system they observed across the United States. What was one lesson you took away from his comments? Robert Pearl: Zubin highlighted the intersection of systemic issues and cultural ones. His Turntable Health clinics emphasized prevention, patient education, and ease of access. The doctors, nurses, and staff who worked there were focused on the whole person. The clinical results were superb. And yet, the program was forced to close. The reason was the inability to get the rest of healthcare, particularly specialists in hospitals in the community to participate in the organization's evolved culture and the superior approach that it took to medical care. And they couldn't find employers willing to embrace a capitated model of reimbursement. Robert Pearl: I think of this problem of culture and system as being similar to the two snakes wrapped around the staff on the Caduceus, the common symbol of the medical profession. These systemic issues and cultural ones are tightly entwined with each wrapping around the other, impossible to separate fully one from another. As Zubin showed, the system of reimbursement impacts the culture and the culture affects the model of payments. In order to improve health care for patients and reduce the burnout doctors are experiencing, we need to address both the failures of the healthcare system and the problematic aspects of physician culture. Robert Pearl: As an example, research from New York City showed that 88% of people who died from COVID-19 had two or more chronic diseases. The most frequent one was hypertension, high blood pressure. And across the United States it's controlled 55% of the time. And yet, some multi-specialty medical groups control it over 90%. They have excellent doctors, but no better than in the communities around them, and they use the same medications. So what's different? What's different is how the physicians in the organizations value prevention, how they view collaboration and data transparency. Without question, insurers is the United States don't pay enough for the time that it takes to maximize prevention. But at the same time, the culture doesn't value prevention. It doesn't value the primary care doctors who help patients avoid occlusion of the arteries to the heart and brain as much as it does the specialists who unblock them after a heart attack. Both the systemic and the cultural issues have to evolve and change. Jeremy Corr: Our next guest was Dr. Amanda Calhoun, a resident of the Yale School of Medicine and the keynote speaker at Yale's White Coats for Black Lives event. She talked about racism in healthcare. How did racism impact the care provided during the Coronavirus pandemic? Robert Pearl: Jeremy, ask doctors why Black individuals died two to three times more often than White individuals from COVID 19, and they'll point to the systemic problems. Black patients work jobs that required them to leave their homes rather being able to dial in virtually over Zoom. They had to take buses and subways that were filled with people, many of whom were infected. And they lived in multi-generational households in close proximity with each other. Of course, these explanations are accurate, but they don't fully explain why early in the pandemic, when there were insufficient testing kits, ED doctors tested White patients twice as often as Black patients when both came to the ED with similar symptoms and complaints. And they didn't explain why doctors prescribed 40% less pain medication to Black patients compared to White patients after the same procedure. Robert Pearl: The reasons aren't logical. The discrepancy is best explained by implicit bias. When you think about it, 20,000 years ago when a human form appeared in front of us, we had but a nanosecond to decide whether to embrace someone from our tribe, or risk being killed by a foe. We developed the ability to what is called thin-slice, make decisions with insufficient information. And that continues today. People have a tendency to be more empathetic and sympathetic to individuals who look like themselves, speak the same language and worship the same God. This is the phenomenon, as we said, is called implicit bias. Robert Pearl: Jeremy, I was asked in another podcast whether implicit bias is racism. And I said that it wasn't, but I added knowing that it exists and not doing anything about it, that is racism. Research shows that two thirds of White doctors harbor implicit bias against Black patients. And in almost all cases, they are unaware it exists until they're tested. With the data in healthcare disparities being so clear, there is no excuse for physicians not to acknowledge the racism that exists, their contributions to it, and to seek ways to minimize the damage that it produces.