Fixing Healthcare Podcast

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: HOW DANGEROUS IS COVID-19 NOW? [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? THREE HEALTHCARE THREATS WORSE THAN COVID [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. UNFILTERED TRANSCRIPT 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. Interview Highlights On fixing healthcare with help from colleagues “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.” On the ‘100,000 Lives’ campaign “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.” On changing the system of care “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.” On preventive care “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.” On breaking hammerlock of healthcare financing “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.” On thinking globally to change healthcare “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. 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 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. Interview Highlights On how to know when a rule needs breaking 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.” On tips for using social media “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.” On bringing medical specialties together “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.” On resisting complacency “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 * * * 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? * * * 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.

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. * * * 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.