Workforce – The Race to Value Podcast™

This week’s episode is the second part of our conversation with Dr. Robert Pearl. In his book, Uncaring: How the Culture of Medicine Kills Doctors & Patients, Dr. Pearl asserts that doctors are taught how to cure people, but they don’t always know how to care for them. There are many contributing factors, ranging from how doctors are trained, to increasing workloads and lack of resources, a widening disconnect between patients’ and doctors’ values and expectations, and increased risk and death due to the pandemic, all of which are intertwined with systemic and cultural issues. These are people who, with the highest ideals of caring for people, have entered a system rife with misaligned incentives that undermine and contradict their own hopes and expectations, and a culture that shapes them into being unable to care in the way they originally intended. The book examines the elements of physician culture that need to be corrected, the ones that should be preserved, and how to accomplish both.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group (1999-2017), the nation’s largest medical group, and former president of The Mid-Atlantic Permanente Medical Group (2009-2017). In these roles, he led 10,000 physicians, 38,000 staff, and was responsible for the nationally recognized medical care of 5 million Kaiser Permanente members on the west and east coasts. He is the author of Washington Post bestseller “Mistreated: Why We think We’re Getting Good Healthcare—And Why We’re Usually Wrong,” and “Uncaring: How the Culture of Medicine Kills Doctors & Patients” which is scheduled to be published in spring 2021 (all proceeds from the book go to Doctors Without Borders). Dr. Pearl also hosts the popular podcasts Fixing Healthcare and Coronavirus: The Truth.

Episode Bookmarks:

00:30 The cultural hierarchy in medicine

01:00 Research on effects of concentrated primary and specialty care on life expectancy

03:00 Dr. Pearl explains how primary care was once on top of the cultural hierarchy before technology advancements

04:00 The need for Primary care to adjust to the current world (The Acceptance stage of the Kübler-Ross grief cycle)

05:30 Leading innovation in Primary Care and the success of ChenMed as a primary care model that can lower cost and improve outcomes

06:30 How the current fee-for-service model creates ineffective primary care delivery to ensure population health (e.g. lack of access and availability)

08:00 The use of telemedicine in the primary care setting to improve patient outcomes

09:15 The need for interdisciplinary, technology-enabled primary care teams and the integration of specialty services

10:00 How Kaiser Permanente leveraged telemedicine and other digital tools for clinical integration

11:30 PCP/SCP collaboration to determine evidence-based practices in a consistent, technologically-enabled, efficient way

12:00 Redefining primary care to elevate its value.

12:20 “Primary care shouldn’t just be the gatekeeper for referrals; they should be the facilitators of higher quality care by collaborating with specialists.”

12:40 Inefficient, low-value referrals from primary care for consultations that could be prevented with better integration

14:00 Onsite primary care clinics for Apple employees that are improving collaboration with specialists

14:30 Consumerism and Patient Experience — patients feel disrespected by long wait times, short visits, and poor communication.

17:00 “Culture, to some extent, allows you to avoid the harm you inflict and take privilege in what you desire.  Some of that exists within the physician world.”

17:20 Physicians that refuse to value patients’ time as much as their own as seen by long wait times, limited access and availability, and limited consumer-driven technology

18:20 The culture of customer-focused technology and service, exemplified by Amazon, has changed patient expectations

18:50 Patients value empathy, listening, and being available – not a provider’s medical training, publications, degrees, etc.

19:55 “The culture of the consumer will end up winning in healthcare. If the traditional medical system doesn’t offer it, someone else will.”

20:10 Amazon as a force of disruption in healthcare. Anyone who doubts the ability of Amazon to take over healthcare is in denial.

21:30 Dr. Pearl’s Fixing Healthcare podcast episode with a patient diagnosed with advanced breast cancer

23:00 Loss of purpose and mission in medicine as a positive force for physician culture change

23:45 The story of a physician treating an Ebola patient in the most miserable of circumstances but feeling immense happiness due to a connection with purpose

24:50 Physician’s returning from medical missionary trips deeply inspired and fulfilled

25:40 Providing care that is equitable and magnanimous with a deep sense of gratitude helps the physician heal as much as the patient

26:45 The invisible component of physician culture: the gap between what physicians know and what they actually do (e.g. handwashing)

27:15 In-hospital deaths in 1850’s Vienna, Austria blamed on miasmas by physicians, and how Semmelweis’ research on hospital cleanliness was rejected by his colleagues

31:40 The leading cause of death in U.S. hospitals is a hospital-acquired infection, and how 1 in 5 doctors today still fail to wash their hands

33:00 Killing patients with a hospital-caused infection as a source of inspiration for the book’s title “Uncaring”

34:00 The irrefutable public health data shows that U.S. medicine threatens the health of the African American community more than police brutality

34:40 Denial of institutional racism in medicine by physicians and how poor outcomes are instead attributed to external factors or biological falsehoods

36:10 Two-thirds of white physicians have implicit bias against African American patients

37:45 Recognition of the problem of unintentional, implicit bias (physicians are simply not aware that their actions are biased)

40:10 Dr. Pearl’s article on the use of Artificial Intelligence as a means to address racism

41:00 The limitations of using medical claims data for AI models

44:30 Using unbiased AI models and clinical decision support alerts to inform physicians of possibility of biased decisions

47:40 In Buddhism, a bodhisattva refers to anyone who is able to reach nirvana but delays doing so out of compassion in order to save suffering beings. This sacred role, which requires great personal sacrifice, mirrors the virtues of medical practice.

48:00 As healers, doctors have traditionally put the needs of others ahead their own. In the twenty-first century, however, physicians are focused on their own suffering.

50:00 The Five Cs of Cultural Change as an approach to help evolve complex organizations and help people move forward.

50:30 Confront (understanding and confronting reality)

52:11 Commit (making change happen)

53:50 Connect (physicians connecting together in ideation)

55:00 Collaboration (how physicians work together for the greater good)

55:35 Contribution (sense of purpose in the practice of medicine)

57:16 Parting thoughts from Dr. Pearl on the death of his father and why he wrote “Mistreated” and “Uncaring”

In a year of great need, during the pandemic, Americans saw and celebrated an army of physician heroes. In doing so, they overlooked an uncomfortable reality. Doctors are humans who share a culture that produces both remarkable successes and abysmal failures. As in Robert Louis Stevenson’s gothic novella The Strange Case of Dr. Jekyll and Mr. Hyde, it is possible that one person — or this case, one culture — can be both a virtuous force and a destructive influence. Until now, the negative aspects of physician culture have remained largely invisible. But like a virus, it affects people even if they can’t see it. Physician culture wields tremendous influence over the lives of patients, doctors, and the nation, regardless of whether people acknowledge (or are even aware of) its existence.

This week, we have as your guest Dr. Robert Pearl.  He will be discussing his new book which tells the story of a profession that is both triumphant and dangerously flawed, filled with people who aspire to help others, yet who sometimes act coldly, callously, and indifferent. This book takes you inside the doctor’s world, revealing unique insights about their training, their daily practices, and the culture they share. It is a book about people striving for perfection and about the impossibility of achieving it. It sheds light on the norms, rules, and expectations of doctors, and shows how culture shapes their thoughts and beliefs. It deciphers their evolving language, symbols, and codes. It highlights what brings doctors together and what isolates them from their colleagues and patients. Finally, this book examines the elements of physician culture that need to be corrected, the ones that should be preserved, and how to accomplish both. If we are to win this Race to Value, we must fully understand and reform physician culture so it can be more caring.

Episode Bookmarks:

2:00 “The Strange Case of Dr. Jekyll and Mr. Hyde” – Is it possible that one culture can be both a virtuous force and an equally destructive influence?

2:40 If we are to win this Race to Value, we must fully understand and reform physician culture so it can be more Caring.

3:00 Dr. Robert Pearl’s new book, “Uncaring : how physician culture kills doctors and patients.”

4:45 Physician culture tolerates low value care, inequitable outcomes, excessive profiteering, and perpetuation of institutional racism.

5:40 Despite the clear link between avoidable chronic disease and excessive COVID-19 deaths, physicians are not speaking out on this.

6:45 Dr. Robert Pearl defines what culture really is and how drives physicians to perform but also inflict harm

7:30 The “invisible” nature of physician culture

8:45 The heroism of physicians during COVID-19

10:00 Systemic issues and cultural issues go together – Why Mistreated and Uncaring are perfect companions in solving for healthcare.

10:45 Chronic diseases and the lack of accountability in physician culture

11:30 The focus on Prevention is not elevated in medicine, as illustrated by how we undervalue primary care

11:50 Research study showing that adding PCPs increases life expectancy in communities, while adding specialists does not have a comparable effect.

12:30 Primary care physicians are paid more in large multispecialty medical groups like Mayo Clinic, Kaiser Permanente, and Geisinger

12:50 Pre-Order information for “Uncaring” and all profits go to Doctors Without Borders/Médecins Sans Frontières (MSF)

14:00 How the “Art of Medicine” philosophy in physician culture prevents progress towards evidence-based medicine

15:30 Research showing that as much as one-third of physician services is low value care, offering little to no benefit for patients

16:30 The long lasting and pervasive effects of a physician culture that pre-dated scientific advancements

17:45 “It is not a question of how we maintain the esteem of the past, but how do we create the esteem of the future?”

18:15 The economic fallout of COVID-19 and how that will affect physician satisfaction

20:20 “What we have to understand as accountable physicians is that the care we provide is not affordable and it is not world leading.”

20:45 The entitlement of physicians feeling like they need a 5-10% FFS increase every year despite not delivering good outcomes in population health

20:55 The US is last among the 12 industrialized nations in life expectancy, childhood mortality, and maternal mortality.  Physicians don’t see it as their fault.  Instead they blame they systemic parts around them.

21:30 The role of technology in elevating the medical profession

22:00 The U.S. is last among the 12 industrialized nations in health care outcomes, and physicians don’t see it as their fault.

22:20 Healthcare costs in the post-coronavirus world will get lowered because people won’t have the resources to pay.

22:45 Rationing of care inflicts harm

23:00 Prospective payment is the only way to deliver care that is higher quality, more convenient, and at a lower cost.

23:40 The cultural evolution of the medical profession can give us hope.

24:55 Transformation will not be easy, but seeing physicians thrive in value-based care will enable change.

25:25 Roger Bannister breaking the 4-minute mile is similar to what we will see in physician culture transformation.

28:00 Confronting the truth about clinical outcomes and physician performance through transparent reporting

28:15 Dr. Pearl’s leadership at the Permanente Medical Group in creating a physician culture of transparency and “group excellence”

32:00 Kaiser Permanente went from “middle of the pack” to “number 1” with physician satisfaction that was 20% higher and total cost of care that was 20% lower

33:00 “The mindset of the 20th century is “Quality, Service, Cost:  Pick any Two.” We need a different mindset that we can achieve all three.”

36:25 Roughly 15 percent of physicians struggle with depression, and 20 percent report having had suicidal thoughts.

36:40 Physician burnout is affecting over half of the physicians in practice, and a recent Harvard report even called burnout “a public health crisis that urgently demands action.”

38:00 Physicians focus primarily on three causes of burnout (compensation, bureaucratic tasks, and technology) but ignore cultural issues within their profession

38:40 Pediatric physicians are paid less than adult medicine physicians, but they are actually more satisfied.

39:00 Urologists earn over half a million dollars annually, but they are extremely dissatisfied (more than twice than other surgical specialties).

41:00 Esteem in medicine is driven by doing the “coolest interventions”

42:20 Fewer prostatectomies in urology caused the rising burnout of the specialty because esteem was tied to that surgical procedure.

43:20 Moral Injury in the medical profession is real, but part of the reason is what physicians actually do to themselves.

44:30 The justification of surprise medical billing in the medical profession as a cause of physician moral injury.

45:40 Institutional racism in healthcare as a cause moral injury.

46:00 Dr. Pearl extensively outlines the racial inequities in our healthcare system and how physicians are not leading with the issue of health equity, racism, and unacceptable mortality.

48:00 Burnout with critical care and ID physicians and “Why Doctors Can’t Cope with Anguish of COVID-19 Casualties”

51:00 “PTSD in combat doesn’t happen in the battlefield but afterwards.  That is why I am really worried about what is going to happen to physicians in critical care and ID.”

52:00 Suicide rates in physicians projected to skyrocket once post-COVID PTSD sets in

In this virtual panel discussion, Dr. Ernest Grant (President of the American Nurses Association), Dr. Jan Jones-Schenk (Senior Vice President – College of Health Professions, WGU), and Jason Thompson (Vice President – Diversity, Equity and Inclusion, WGU) will discuss how we must eliminate barriers to equity in access and learning in order to reduce racial disparities in care.

Progress in advancing diversity in the US health care workforce has been slow. This is evidenced by the low numbers of people from historically underrepresented populations joining the health professions workforce, ongoing reports of bias and discrimination in health professions learning environments, and a continuing dearth of proven and replicable best practices to advance diversity. Many of our health professions schools and clinical practice sites are taking some action on diversity and the more contemporary concepts of equity and inclusion, but without making the necessary commitment to comprehensive, system-wide approaches that create meaningful culture change. As a result, addressing harmful bias and eliminating discrimination remain critical challenges to achieving excellence in health care and health professions education.

Within the registered nurse (RN) workforce, according to the National Council of State Boards of Nursing (NCSBN), 81% are White/Caucasian (vs 60% of the US population), while 19% of nurses are from underrepresented racial/ethnic populations. The Accountable Care Learning Collaborative believes that nursing programs must address bias and reduce discrimination in health professions learning environments because, in not doing so, racial disparities in care will persist. In our Accountable Care Atlas, we identified a specific competency to “understand the unique cultural characteristics of the population served to implement changes in the organization to provide high-value care”. This cultural competency failure is reinforced by research that shows that care.

If you would like to watch a video recording of this webinar, you can do so here.

Bookmarks:

1:40 ACLC Leadership takes a stance on institutional racism and how BLM movement is a public health issue

4:00 Introduction to panelists: Dr. Ernest Grant, Dr. Jan Jones-Schenk, and Jason Thompson

4:50 Reference to population health research that shows us that the American health care system is not immune to institutional racial discrimination

8:05 Jason Thompson on how we can engage in a societal conversation to foster a better understanding about the presence of racism

8:26 “I can’t make you racist in 45-minutes…and I can’t undo it in 45-minutes.  It takes multiple conversations and constant engagement.”

9:51 “There has never been any period in American history where the health of blacks was equal to that of whites. Disparity is built into the system.”

10:19  “Advancing health equity will require a justice-oriented framework that identifies structural racism’s manifestation in medical care.”

10:50 Reference to Don Berwick’s recent article, “The Moral Determinants of Health“

12:05 Dr. Ernest Grant on how our country can reorient value-based care and public health policies around racial and health justice

13:30 Dr. Ernest Grant on how the nursing profession can mobilize around the issue of institutional racism and health inequity

13:50 Dr. Ernest Grant references his testimony to the House Ways and Means Committee on the disparate impact of COVID-19 in the African American community

14:37 “As nurses we have the responsibility to use our voice to call for change.  Our code of ethics obligates us as nurses to be allies and to speak up against racism, discrimination, and injustice.”

16:00 Dr. Jones-Schenk speaks to how we need to “go upstream to the source” to address seek solutions in reforming society

17:05 “As a profession, we make a promise to society that we will address the health needs of society. We have a responsibility for outcomes in diverse populations – not just caring for illness.”

17:45 Reference to recent article, “Value-Based Health Care must Value Black Lives” and its suggestion to reorient value-based care policies around racial and health justice

19:30 Dr. Ernest Grant on how we can hardwire conformance to social justice within the nursing profession by leading by example

20:43 Dr. Ernest Grant on nurse role modeling and the eradication of stereotypes

21:21 Dr. Ernest Grant on advancing equity in health care by reforming education, having diversity in the workforce, and offering mentorship in the profession

24:47 Dr. Jones-Schenk on how to lead a social movement in health equity with data (“Historically tyranny of the aggregate” and the need to stratify data by populations)

27:09 Dr. Jones-Schenk on the need for faculty diversity in nursing programs and how this perpetuates the problem

28:33 This month is the 10th anniversary of Institute of Medicine’s landmark report, “The Future of Nursing: Leading Change, Advancing Health” (Has anything changed?)

29:51 Jason Thompson addresses how intentionality and direct action is needed to address under-representation of women, minorities, and nurses on corporate boards and senior leadership roles

31:37 “If we are really about saving money and being efficient, and providing better care, let’s call it out for what it is. Let’s not call it health disparities…this is racism.”

33:25 Dr. Jones-Schenk reflects on the IOM “moonshot” goal of 10,000 nurses on Boards, and the progress we have made over the last decade in the leadership and empowerment of nurses

35:18 “Language matters.  Sometimes we used softened language because we don’t want to hurt people’s feelings. We’re hurting more than people’s feelings right now by using overly nuanced language to describe this problem.”

36:14 Dr. Ernest Grant expounds on the “Nurses on Boards” initiative and the need for community involvement to drive change, including the type of food accessible in communities

39:10 Dr. Jones-Schenk shares a personal story about a nursing student becoming personally involved in the public health of his community by running for mayor

41:47 “The fact that the nation’s health professions have not kept pace with changing demographics may be an even greater cause of disparities in health access and outcomes than the persistent lack of health insurance for tens of millions of Americans.” (referencing the groundbreaking report, Missing Persons: Minorities in the Health Professions)

43:35 Jason Thompson discusses institutional barriers in Higher Education that disadvantage students of color

45:16 “We haven’t thought about a systematic solution…we all work in our own silos…If you have a systematic problem, you need a systematic solution.”  

47:42 Dr. Ernest Grant discusses the implicit bias in the NCLEX-RN exam for nurses and other barriers in nursing education

52:00 Dr. Jones-Schenk on how to reinvigorate the promise of education for people of color and what institutions of higher learning can do to provide equity in access and learning

53:55 “We have to declare our commitment through action.  This means empowering groups who can identify structural issues that support racism and then resourcing their recommendations.”

58:13 Dr. Jones-Schenk on implicit bias and micro-inequities and how to eliminate bias in teaching and learning

59:33 “We are trying to correct longstanding errors in our culture. We have to be bold and stand up to detractors that say this is just political correctness and not a big deal.”

1:00:43 “Are psychometrics considering population-specific differential analysis?”

1:01:02 “Until you see it, you can’t change it. And once you see it, hopefully you can’t unsee it. Higher Education doesn’t have a choice!”

1:01:16 Dr. Jones-Schenk refers to the recent statement from 40 health systems that racism is a public health crisis

1:02:00 Dr. Jones-Schenk refers to Macy Foundation recommendations (Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments report)

1:04:48 Dr. Ernest Grant discusses what ANA is doing to empower nurses — both socially and economically – to create meaningful change in communities and within the political arena

1:09:00 Jason Thompson discusses how health disparities are created by the summation of all of our individual behaviors, and how the individual commitment makes a difference

1:10:00 Jason Thompson on how “mandatory” training doesn’t work! Only “consistent and regular” training works.

1:11:15 Drs. Ernest Grant and Jones-Schenk on how the word “mandatory” creates apprehension in the workforce and how we need to reframe the dialogue