EP. 19: TRANSFORMING THE CULTURE OF MEDICINE

WITH ROBERT PEARL

Jul 12

WITH ROBERT PEARL, MD

The former CEO of the largest medical group in America discusses the virtues and ills of physician culture and how we can improve it.

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Episode Summary

As former CEO of the Permanente Medical Group, Dr. Robert Pearl was responsible for the work of 50,000 healthcare workers and the medical care of 5 million Americans through Kaiser Permanente hospitals across the country. A leading expert on healthcare management and strategy, Dr. Pearl is the author of two bestselling books, “Mistreated: Why We Think We’re Getting Good Healthcare–And Why We’re Usually Wrong” and “Uncaring: How the Culture of Medicine Kills Doctors and Patients,” a regular contributor to Forbes, and the host of several popular medical podcasts. He is a board-certified plastic and reconstructive surgeon, clinical professor at Stanford Medicine, and lecturer at the Stanford Graduate School of Business. In this episode, Dr. Pearl shares his thoughts on why American healthcare is failing not only patients but also physicians, and what we can do to address inherent problems in the culture of medicine.

Dr. Robert Pearl is former CEO of The Permanente Medical Group. Board certified in Plastic and Reconstructive Surgery, Dr. Pearl received his medical degree from Yale University School of Medicine. He completed his residency in Plastic and Reconstructive Surgery at Stanford University and currently serves on the faculty as a Clinical Professor of Plastic Surgery. He is also on the faculty of the Stanford Graduate School of Business where he teaches courses on strategy and leadership, as well as lectures on the subject of health care technology.
Selected by Modern Healthcare as one of the most powerful physician leaders in the nation, Dr. Pearl has published more than 100 articles in various medical journals and has been a contributor to many books. In the past several years, he has been a visiting professor at the Johns Hopkins School of Medicine, Haas School of Business and Harvard School of Public Health. Most recently, he became the Chairman of the National Council of Accountable Physician Practices (which includes the largest medical groups from across the country such as the Mayo Clinic, Geisinger and Intermountain Healthcare).
Dr. Pearl is a frequent lecturer on the opportunities to use 21st Century tools and technology to improve both the quality and cost of health care, while simultaneously making care more convenient and personalized. As a regular contributor to Forbes.com, Dr. Pearl publishes a weekly blog on the nexus of health care and business. He is an advocate for the power of integrated, prepaid and technologically enabled health care delivery systems. He is also a strong believer that organizations like Kaiser Permanente in which physicians collaborate rather than compete, and in which a multi-specialty medical group works in partnership with a not-for-profit health plan and hospital system, are able to provide superior quality of care over fragmented insurance-based systems.
In this episode, you will hear about:
• Dr. Pearl’s journey to a career in plastic surgery - 2:13
• Grappling with complications that arise during surgery - 9:40
• Dr. Pearl’s transition from a surgeon to CEO of Permanente Medical Group - 12:49
• The mission that Dr. Pearl brought to his role as CEO and how he implemented that mission - 17:21
• How Dr. Pearl paved a path for increasing both the quality of care and physician satisfaction, while keeping costs low, and why so often these goals seem at odds with each other - 20:32
• The toxic culture of denial in medicine and why it is killing doctors and patients - 27:45
• How status and compensation disparity contributes to physician burnout, and what to do about it - 35:47
• Dr. Pearl’s administrative strategy that led Kaiser Permanente to much success during his tenure as CEO - 43:08
• Dr. Pearl’s advice to physicians on how to stay connected and empowered in their careers - 46:38
Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:03] The Permanente Medical Group is the single largest medical group in the United States, with around 10,000 doctors and 35,000 nurses in its network. Caring for nearly 5 million patients through the Kaiser Permanente Health Plan and its affiliated hospitals, Kaiser Permanente has established itself as a leader in integrated care, disease prevention and early intervention. Our guest today is Dr. Robert Pearl, a plastic surgeon who was CEO of the Permanente Medical Group from 1999 to 2017. Dr. Pearl is the author of two bestselling books on The Strengths and Flaws of American Medicine and as a regular contributor to Forbes magazine. In addition, he hosts two popular podcasts, Fixing Health Care and Coronavirus The Truth. Details of his writings and podcasts can be found in the program notes. Finally, Dr. Pearl teaches courses at the Stanford Graduate School of Business on Health Care, Leadership and Strategy. In this episode, Dr. Pearl shares his path to medicine and leadership and discusses how the culture of medicine negatively impacts patient care and physician burnout and what we can do about it. Dr. Pearl, thank you very much for joining us today to kick us off. I'm wondering if you can take us all the way back to the start before the leadership, before the writing, before the podcast, and tell us what first drew you to medicine.

Robert Pearl: [00:02:23] Much of my transition into medicine, including becoming a CEO in Kaiser Permanente, was serendipity, and I can trace it back to college where I went to school expecting to become a university professor. I loved philosophy. That was my major. And in my first year I was disillusioned because the individual who was my hero, who I thought was amazing, he went on to become chairman of philosophy at Reed College. So he was pretty amazing. Didn't get tenure and he didn't get tenure because of his political views. And I decided that I didn't want to be in any field where one could be good and not have that recognition. If I wasn't good, that was okay. And I decided that I would go into something that I was sure had no politics at all. And that was medicine because it was life and death. How could you have politics? I mean, if you do a good job and patients end up well, you should have the respect. And if you don't, you should have to get better or receive the punishment that they all seem very fair. And so it was I was 17 years old at the time, the naivete of youth.

Henry Bair: [00:03:52] So that is what brought you to medicine. Can you tell us more about what drew you to plastic surgery in particular?

Robert Pearl: [00:04:00] Again. Serendipity inside medicine. I went to Yale Medical School, but I came to Stanford to do my residency in cardiac surgery. Again, the same principle, because what could be more life and death than operating on the heart? And I became once again disillusioned because the surgeons who are getting the most referrals weren't necessarily the best doctors with superior clinical outcomes. They were often the ones with the best social connections belonging to the right country clubs. And I actually considered leaving medicine because I had the same disillusionment that drew me to it in the first place. And I had the opportunity to rotate on different services. And I happened to be on plastic surgery where the chairman at the time, Dr. Don Laub, took me on an inter trip to Mexico to fix children with cleft lip and cleft palate. And I fell in love with that operation. The look on the mother and the father's face when the when they saw their child who no longer had a severe deformity, you could go on to live a normal life. That, to me was exciting. And fixing children with cleft lip and cleft palate was the focus of my plastic surgical career, and I did over 10,000 total operations before I moved into becoming the CEO.

Tyler Johnson: [00:05:31] I have to ask you, as an internist, one of the things that I value most about my particular niche in the medical profession is that I almost always have time, right? So I make what I think are very complicated and sometimes nuanced and fraught decisions with my patients about as a medical oncologist were deciding about whether they should get chemotherapy and which chemotherapy and for how long and when to give it and when to stop and all those things. And I think there's a lot that goes into those decisions, but we can make those decisions over the course of days, sometimes even weeks. And one thing that's always fascinated me about the psychology of a surgeon is that when I think about being in the operating room and there is a decision that has to be made, but not only does it have to be made, but either sometimes life or death hangs on the decision, or at least the, let's say, the survival of a skin graft or the esthetic result that comes from a plastic surgery, as you're talking about, to repair a cleft palate or what have you. And it hangs on your ability to make this momentous and often incredibly meticulous decision right then and there at that very moment, the very thought of that makes my palms start to sweat, and I want to run from the imaginary operating room in my brain. So I'm I'm just curious either did that very prospect speak to you like was that something that got you up in the morning and get you excited? Or if not, was sort of how do you deal with the burden of the life and welfare of your patients hanging on your ability to make these very difficult decisions moment to moment?

Robert Pearl: [00:07:09] As you know, Tyler, there tend to be different personalities that tend to be attracted to different specialties and emergency room physician versus a neurologist versus a surgeon who's operating on patients, as you say, in a life and death moment that tends to attract different people. And I was fine with the as what you call the pressure of the operating room, the momentous decisions of the time. I tend to have the personality that is pretty comfortable and cool in the moment and can handle those types of life and death choices pretty well. And so it was a pretty good fix for me. What I would say is that in a surgical discipline like mine, general surgery is somewhat different. But in my specialty, usually the patient is aware of what they have. They have a birth defect, could be a cleft lip and cleft palate. It could be a more complex craniofacial anomaly or someone else has diagnosed breast cancer and now you're going to do a breast reconstruction where they come in and having lacerated a tendon, you could go through most of the operations. Usually the diagnosis is the easy part of the conversation because they usually come with that diagnosis. That's how they got referred. On the other hand, exactly what to do about it. How to prepare the family. Cleft lip and cleft palate is actually a series of four or five, sometimes six or seven operations, as you have to repair the different parts that have all been deformed by this birth defect process. So that becomes the conversation. Like yourself, one of the things I really enjoy about the work that I did is how long someone stays your patient. I had situations where in the first year of my practice, I'd fix a cleft lip, and then as that person became an adult, they'd have a child also with a cleft lip. And I fixed several families, I would say, of multigenerational and still receive graduation and wedding pictures from them. And that to me fills me with tremendous gratitude when I can see the impact that I've had on people's lives.

Tyler Johnson: [00:09:40] As the paired question to that I have to ask, even for the most skilled surgeon, there are times when things don't at least don't go to plan and sometimes go terribly, terribly wrong. Now, I admittedly, I guess I don't know what the scope of things going wrong might look like if you're repairing a cleft lip or a cleft palate. But nonetheless, there must have been time when times when things didn't turn out the way that you hoped they had. Can you talk a little bit maybe about an experience where that was the case and more broadly, how you grapple with that as a surgeon?

Robert Pearl: [00:10:14] The worst. I'll call them days, but it's usually weeks and months are exactly that. When something goes wrong and a major complication happens and you replay it in your mind again and again and again. And in the two books that I've written, both Mistreated: Why We Think We're Getting Good Healthcare - And Why We're Usually Wrong and Uncaring, the more recent one about how the culture of medicine kills doctors and patients, with the profits from both going to Doctors Without Borders to support the kind of international work that I enjoyed during my both training and clinical practice. I talk about these, a particular case that I spoke about and wrote about in my most recent book was a young girl that I was taking care of who developed a necrotizing fasciitis. But as you know, making that diagnosis can be difficult to figure out whether to do what is a very severe operation where you have to literally flay open an arm in order to relieve the pressure that's inside and try to restore the circulation. And the emotions are terrible as you sit there and you just feel so unable to make a difference, to intervene. You watch a patient literally dying in front of you. And that is the type of emotion that is the flip side of all the joy that you get as you operate on people and then you watch them for what otherwise would have been a isolated and potentially even financially complex and difficult life to one that is now very fulfilling and one in which they can achieve all the success that the rest of us who are fortunate enough not to be born with the type of deformity are able to experience.

Tyler Johnson: [00:12:16] Thank you. I should just note parenthetically, for our listeners who may not be familiar, necrotizing fasciitis is like a sort of a tissue-eating skin infection where an infection gets underneath the skin and is eating away the tissues in the arm or the leg or the groin or wherever it is. And as Dr. Pearl says, sometimes it is the case that if you don't intervene with this very big deal surgery that has its own set of very difficult side effects, sometimes the that there's no other way to stop the infection and the person can die quite quickly if it's not brought under control.

Henry Bair: [00:12:49] So Dr. Pearl, thank you very much for really humanizing your work for for illustrating what you go through with very real stories. These are often the best parts of our podcast and what our guests share. But now I would like to turn our focus to your leadership and administration career. So can you tell us more about how you transition from a practicing surgeon to a health care leader? What motivated you to make that transition.

Robert Pearl: [00:13:19] In Kaiser Permanente, the transition tends to be a bit smoother than it is in the rest of medicine because there is a trajectory that people can go on across their career, taking on ever greater administrative responsibilities. So again, I mentioned earlier the serendipity when I finished my training at Stanford, my plan had been actually go to South America and fix children with cleft lip and cleft palate for an entire year. Then I figured I would do whatever I might do differently after that. And about six months before the end of my first year as a resident, the plastic surgeon at Kaiser, Santa Clara, who was a private pilot, crashed in a very tragic circumstance and died. And the people there called me and asked me whether I would come and work for six months until they could hire a full time individual. And I had never actually heard of Kaiser Permanente. Now it's part of the residency training program, but at the time it wasn't. But I said, Sure, what can I lose? I didn't have anything specifically that I wanted to do except take care of patients. So I went there and I fell in love with the model that existed. And after my first year, I received a phone call from the chief of staff and he was asking me, would I consider becoming the head of the operating room committee and overseeing operations and functioning of the operating room. Now again, is a pretty young, naive individual. I assumed he was calling because I had a Yale degree and a Stanford degree, and I was so talented. I later learned everyone else to just turn down the job. And I was the last person, maybe the one most foolish to say that I would take on this job because it was a terrible job. There was shortage of nursing at the time and ORs had to be canceled. But I did a pretty good job at it and I actually enjoyed the problem solving part of the equation. And once you do a pretty good job administratively, people tend to ask you to take on other jobs, and that's how the process went year over year. I ultimately became the head of the Santa Clara Medical Center, and then the opening came for the CEO role, and it wasn't something I really wanted to do. I love clinical medicine. You know, some people talk about getting into administration because they don't like clinical medicine. I loved what I did. I loved my my patients. And I asked a couple of other people that I knew and respected whether they would want the job.

Robert Pearl: [00:16:07] I don't know how much you know about the quality of internal functioning in Kaiser Permanente, but the medical group is an independent medical group with its own board and its own CEO, and it is selected by the physicians of the Permanente Medical Group. And these are the two individuals. Turned it down. At the time, Kaiser Permanente was in big trouble. It had lost a lot of money in the 1990s. It was down to two days of cash. It had to borrow a day of cash. It wasn't a great, attractive job. But when I looked around and I looked at the people who wanted the position. I said, No, I don't think I'd want to keep working here if they took the helm because I was worried that the course would be ever downward. Now, maybe that was a bit, I don't know, grandiose thinking or something that I could do it better than they could. But by this time, I had a lot of experience and a pretty good track record. And there's a process that goes by which the board reviews the various potential candidates, and I was selected out of that to become the CEO, the fourth CEO in the history of Kaiser Permanente.

Henry Bair: [00:17:21] That's that's really incredible. Can you tell us about a particular moment or an event during your leadership career that really, really demonstrates and epitomizes why you wanted to be a leader like that if whether or not you had a mission in mind going into this position.

Robert Pearl: [00:17:39] Well, I definitely had a mission in mind because it was my approach when I was the head of Santa Clara back way back then and I'm talking now, this is now about 1998 and the time before that it was known for being a low cost option for patients. And I had a vision that it would become the quality and service leader, not just in California, but of the nation. It seemed to me it made total sense. It had the right financial incentives. It was essentially fully capitated. It had the integration of different specialists and specialties working together. It actually had a long history of technology dating back 20, 30 years to the early use of the electronic health record. And it had a structure, leadership structure capable of making decisions and being able to make things happen. So I had a vision of it becoming I want to call it the Stanford of Medicine on the East Coast. I call it the Harvard of Medicine. But on the West Coast, it's got to be the Stanford of Medicine. And that was my vision going in, that we'd become the leader in quality, and we became that of 1000 programs in the United States. According to the NCQA, we were number one at being able to take care of breast cancer, diabetes, heart disease.

Robert Pearl: [00:19:05] I also had a view that we'd be the leader in access and in service, and we were able to do that. J.D. Power Associates ranked Kaiser Permanente significantly higher than the alternatives in the both the California and East Coast marketplaces. I had the vision that we would become the leader in technology, and we implemented the electronic health record during my time, long before anyone else around us and embrace telemedicine, long before it became popular during the COVID pandemic, and that we would not only have high satisfaction of patients, we'd be the leader in physician satisfaction and compare it to national at the state level to the various surveys that are done. Satisfaction inside the medical group was 20 points higher than doctors in the community. And then finally, I believed that with all the advantages we had, we could provide market leading quality service and technology somewhere around 15 to 20% less than the alternatives, which was what we did. And across my time as CEO, we went from about a 33 to 34% market share to a 46% market share. Almost one in two insured Californians belong to Kaiser Permanente.

Tyler Johnson: [00:20:32] Now. Okay. So, Rob, without questioning the reality or validity of any of those remarkable accomplishments, I'm going to tell you something that you already know, but I think it's important to set up the context for our listeners. If you want to get the hackles up of a bunch of doctors, just walk into the room where they're sitting and talking and say, "Hey, somebody from the hospital's C-suite called and said that..." And you can just stop there. And already all of the doctors are suspicious and defensive, right to the point that there's a, I think, relatively famous op ed that was written in The New York Times about three years ago. The title of with which is "The Business of health Care depends on exploiting doctors and nurses." And then the sort of sub line is "One resource seems infinite and free: The professionalism of caregivers." And the author goes on to argue basically that there's this evil interplay where what happens is that health care corporations want to make more and more and more and more money, whether that's a hospital or a health care system or what have you, and doctors and nurses and advanced practice providers and all the rest feel morally obligated to provide the service that they're called to provide and so basically they continue to get sort of squeezed as the Health Care Corporation is trying to maximize its profit, whether it's not for profit, quote unquote, or not, then the health care workers get sort of infinitely squeezed and they're asked to do more and more for what feels like less and less. And so I guess what I'm curious about is you mentioned very briefly when what you were talking about just a moment ago that not only did you increase all of the quality metrics and the cost metrics and all the rest of it, which normally I think many health care practitioners would assume that if you were going to do those things, it would be at the expense of the satisfaction of physicians. But the you were actually able to somehow magically decouple those things so that you increased both things at the same time. So I guess I'm curious, what is it that makes health care practitioners usually feel as though increases in quality or improvements in cost are going to come at their expense? And how were you able to decouple those things at Kaiser and make it so that both things got better at the same time?

Robert Pearl: [00:22:48] This is the central question, I believe, about the future of health care. The reason. The negative process you describing happens, I believe, and it's the source of both the book Mistreated. And the book on caring is that the American healthcare system is just broken. It's a 19th century cottage industry. It's fragmented, with doctors scattered across the community, unable to communicate with each other, unable to connect with each other. It is paid on a piecemeal basis. We call it fee for service. I think that is the driver of the hamster wheel that doctors feel and other clinicians feel that they are on. It uses technology that is outdated from the last century, although in actuality it's from the century before. Because the most common way that doctors communicate vital information, as you know, is over the fax machine and 1834 invention. And there is no structure to be able to make care, become more efficient. And what listeners need to understand is how motivated, how dedicated, how committed physicians are. They go to medical school because they want to provide great care. And the truth is, they just can't do it. In most of American medicine today, no matter how hard they try and as you point out, increasingly and today, as you know, more than half of physicians get worked for and get paid by another entity, whether it's a hospital administration or whether it's a health plan administration.

Robert Pearl: [00:24:32] And I think that that is the driver of the dissatisfaction inside Kaiser Permanente. It's very different. In the Permanente medical group, as I said, it's physician led board. It's an entire physician board with a physician led CEO. And so there's not this sense of working for an administrator. Now, don't get me wrong. I don't want to tell you it's a smooth ride everywhere. People in leadership roles tend to want more. And people feel often that they're going to be pushed to do more. I believe the solution and the sweet spot is to find the inefficiencies in the system and take those inefficiencies out and then be able to use that money to be able to reward the people who made that happen, as opposed to, in many situations, rewarding shareholders or other individuals. And that's what I would say. And I offer the praise not to me, but to Dr. Sidney Garfield, who started this literally 50, 60 years ago in the Mojave Desert, where he moved. And this is in the 1840s, 1850s, before any of us were born. He moved to a situation of capitation where there's a single payment received by the people providing the care. So the incentives align around prevention, keep people healthy. Why just become a sick doctor? Why not becoming a well doctor to keep them healthy in advance in aligns it to minimize complications.

Robert Pearl: [00:26:19] But as you said earlier, doctors hate problems. Why not be rewarded when they can avoid it? Because it's always more expensive to take care of a problem than to avoid it in the first place. Why not be able to find opportunities to coordinate care? Know a really great example to me is telemedicine and I wrote a piece in the Harvard Business Review about various uses. People think of this as being just a doctor and a patient. We created the opportunity. If you're seeing a primary care physician like yourself and you know, you often have a question you'd like answered and your only choice in the fee for service world is to tell the patient, to call the specialist or send the referral and wait for something to happen. We create the opportunity using technology to bring the specialists into the exam room when the patient is still there. And now you have two doctors working together to take care of a patient's problem. So when they left, they had a solution to what they came for. Treatment could be started immediately and higher quality. To me, that's so satisfying as a doctor and you could never do it outside of an organization that was capitated, integrated and technologically technologically enabled.

Henry Bair: [00:27:45] Thank you for sharing your answer to the central question of the future of health care. You have mentioned your book, Uncaring, several times now. I first read the book a little over a year ago when it was released. The book really breaks down to a granular level the challenges, dangers and often beautiful aspects of the culture of medicine. I found it quite the enlightening book. For our listeners, can you tell us what you mean exactly by the culture of medicine and what some of the most prominent big picture problems with the culture of medicine today are?

Robert Pearl: [00:28:19] When I talk about the culture, what we're speaking about are the values, the beliefs and the norms that exist. One aspect that I talk about in the book that I think highlights it is what I would call a culture of denial. Now, why do I talk about it as a culture of denial? And I go back to Ignaz Semmelweis, who in the middle of the 19th century is appointed the head of the maternity service at the leading academic facility across Europe. And he's appalled because mortality amongst women giving birth in his hospital is 18%. And he's embarrassed because the adjacent facility, one run by nurse midwives, it's a third lower. At the time, the thinking about what causes women to die after childbirth, while the etiology was puerperal fever, infection of the uterus that spreads to the body, but its cause was thought to be miasmas these smelly particles drifting up an air currents from the street below. But he can't understand why should his patients who are breathing the same air as the laboring women next door, die so much more frequently? And as you know, often in health care, advances happened by serendipity, sort of as in my life and in this case, a colleague of Semmelweis nicks finger while doing an autopsy on a woman and a woman who has just died from puerperal fever. And he goes on to develop a local infection and systemic spread and dies with a clinical course identical to these women after childbirth.

Robert Pearl: [00:30:01] And Semmelweis hypothesizes, hypothesizes that the cause may be something that either the doctors carry from the autopsy room into the delivery suite, or maybe it's carried on the leather aprons they wear to protect their well pressed three piece suits. And so he puts chlorinated water outside the maternity area and clean leather aprons, and everyone has to dip their hands in the water and put on a clean apron before they go inside. And within one month, mortality drops from 18% to 2%. He writes it up in the leading journal. He writes letters to the maternity services across Europe, and I'd ask listeners to think about "What do you think would happen?" This is a 90% reduction in mortality and no one follows it. Now, how do you explain that, Henry and Tyler? You know, you need a lot of change. If you ask doctors, why doesn't why does a heart to get changed to happen? They'll talk about time or money. There's no time to dip your hands in chlorinated water. There's no money involved in putting on a clean apron. This is the culture of medicine. It's a culture of denial. You see, at the time, doctors see themselves as being healers. They can't envision themselves carrying bacteria that those bacteria, Pasteur, will come along 50 years later and finally change will occur.

Robert Pearl: [00:31:27] The idea that somehow they are the source of disease is just not visible. And those leather aprons, they are the source of they are a symbol of excellence. The more blood, the more pus, the more guts, the more experience. They would no more give up those aprons than, as you know, the professors at the academic centers who wear these long white coats would give them up for the short jackets, the short white jackets that interns wear. This is the culture of medicine. I am. I think it's. That was last century. What are you talking about? Well, two centuries ago. Well, as you know right now, the leading cause of death in the United States, the fourth leading cause of death in the United States is hospital acquired infection. 1.7 million people a year develop an infection, 100,000 to 200,000 die every year. Everyone knows the leading reason and the leading bacterium is C difficile. Clostridium difficile. It's carried not is carried in the hands of people. It doesn't go through the air like rotavirus. And study after study has shown community hospitals and academic centers one in three times. When doctors go from one room to the next, they fail to wash their hands. It's the same culture of denial. But I also want to point out for listeners how it's this culture that makes doctors into heroes.

Robert Pearl: [00:32:47] This is why it's so complex and interwoven, because in the COVID pandemic, what happened? We had a virus that came from Wuhan, China. We didn't know what it was. We know it was lethal. We had no vaccine to protect anyone. We didn't have any medications to treat anyone, and we didn't even have protective gear. And doctors would don garbage bags because they'd have gowns and they would put on salads when they didn't have 95 masks every day. They would go there when a patient couldn't breathe, they'd pass a tube through the mouth and to the lung, knowing full well that as a tube went through the vocal cords, the patient would cough and they did it anyway. And this is the yin and the yang, the two sides of the coin of this culture. It makes doctors be blind to some things, but it also makes them heroes in other areas. Another great example to me research done was actually at Stanford and out of Harvard showed that adding ten primary care physicians to a community increased longevity two and one half times, adding ten specialists. And as both of you know, in the culture of medicine, who's valued the most? The specialists, not primary care. It's the doctor who unblocked the coronary artery who gets all the praise. It's the doctor who prevents it from being blocked in the first place, who is seen as lower in the hierarchy of medicine.

Robert Pearl: [00:34:17] This is the problem that exists, and I would say that it plays out in terms of patients because they don't get the preventive care, they don't get the avoidance of complications from chronic disease, they don't get the coordination. They don't even get the best technology, by which I mean, the telemedicine is available today because all of those things, from a cultural perspective, start to diminish the value of the physician. And I want to add, I also believe that it's a powerful contributor to the burnout that physicians experience through the eyes of the physician. It's all about the systemic problems. It's all about the bureaucratic tasks they have to do, the fact they're not paid enough. So they have to see too many patients the electronic health record, the computers that literally get between them and their patients and all those things are correct and they all need to be addressed. But what's missed in the culture of medicine, what's missed in this culture of denial are the ways that inside the health care system that. We actually cause problems for ourselves by this hierarchy that exists, by the relative positioning, by the esteem and the respect that we give to people, rather than what I believe needs to happen. All of us working together as a single team.

Tyler Johnson: [00:35:47] Yeah. You know, it really is so interesting. I for many years as a doctor and as a specialist who among internists, I think that oncologists are viewed as being I don't know, I guess at least they are one of the better compensated internal medicine subspecialties. We can say that. And I think that some people would say that because cancer has such a I don't know, almost a mystique about it. I think oncologists tend to draw on that mystique and are seem, as you mentioned, as sometimes as heroes or whatever. But it has struck me as such a it's just so bizarre at the end of the day that there are certain parts of medicine that are valued and admired and respected and others that are not right. I mean, everybody who goes to a especially a fancy medical school, it's just an acknowledged, if unwritten rule that if someone goes into family practice or general internal medicine coming out of that, that's seen as a almost as a failure by some people. Right. To be clear, I don't think that it is. But I'm just saying that's the way that it's viewed by many people.

Tyler Johnson: [00:36:57] Right. Let alone if you look at compensation, if you compare what a general internist or a general pediatrician makes or a person who's working in a rural area as opposed to a dermatologist or a cardiovascular surgeon or what have you, the the disparities there are striking. And it is no wonder, as you put it. I mean, I think that internists have general outpatient internists have one of the most difficult jobs of any kind of doctor. And yet in most settings, the treatment that they receive is the opposite of that, right? The value and admiration that they receive from the system and sometimes from their peers doesn't reflect that at all. And it it's little wonder in some ways that they often feel burnt out because what they do, in spite of its absolutely fundamental importance, is not valued and respected in the way that what many other doctors do is. And that's a but it is a hugely deep seated problem. So I'm curious if you could wave a magic wand or maybe you did this in your time at Kaiser. How would you how would you fix that part of the culture?

Robert Pearl: [00:38:01] Well, first, you're absolutely right that the status positioning of individuals has tremendous psychological consequences. Sir Michael Marmot, who's a sociologist in England, has pointed out that people who are at the lower end of the status or whose status drop, they end up feeling dissatisfied, unfulfilled and fatigued and tired. Exactly the symptoms that we equate with burnout. And so I think that that's a vital part of understanding. Not, again, that the systemic issues are not very real and need to be addressed, but the cultural ones that are under our control, the ways that we actually can make change happen fast are equally contributing to the problem that exists. So how do you address it? I think much of it comes down to rebalancing the value of each of the specialties and recognizing that the primary care physician who prevents the patient having a heart attack in the first place in a capitated system where the called the revenue and the income relate to how effectively you can keep people healthy, that individual has a far higher status. Now, one of the mistakes I think that people often make is they believe that the lower status is because of the lower income. It's the exact opposite. Income is a reflection of status. And as you can raise that status, you drive up the income. And so as an example, compared to the community, we paid primary care 20% more.

Robert Pearl: [00:39:54] And because we had to have the same total physician compensation compared to the community around us, we paid specialists less than they otherwise could have earned. But you had that mutual respect because the specialists didn't have to go out and I'll say in quotes, hock his or her wares by finding patients and attracting patients and doing all the things that are. Well, is that occur? I know they're needed in a fee for service type world because the integration of primary care and specialty, the respect. It wasn't a question of sending a patient from primary care to a specialist and having there be an economic transactional type of relationship and sending gifts at Christmas time. It was a day to day respect for each other, recognizing that all of us together are responsible. It's going from individuals being elevated to being group excellence. And that was a major focus of mine. How do we emphasize group excellence as measured by the outcomes for our patients? Not trying to figure out, is the cardiologist more important than the primary care physician and is the neurosurgeon more important than the heart surgeon? No. How do we understand that together we can provide better quality, greater patient satisfaction and care that's more affordable in a way that is professionally satisfying for all of us across each of the disciplines.

Tyler Johnson: [00:41:37] So if I can just ask a pointed and provocative question if if someone just handed you the reins and I recognize that even a CEO is constrained by his or her constituents and all the rest of it. But nonetheless, if somebody just handed you the reins to Kaiser again, in an ideal world, would you make it so that a primary care doctor makes just as much money as a neurosurgeon?

Robert Pearl: [00:42:01] No, I would not do that because there are differences in terms of training and the years that it takes. It takes ten years to become a neurosurgeon and residency, and it's three years or four years in primary care. And you have to recognize the sacrifices, the dollars that were made. But I would have and did have and by the way, it didn't come from me. It was actually part of the culture of Kaiser Permanente that I was fortunate enough to come into a much closer relationship of the dollars that are available. Now, the one thing that I did do was there is a small amount, no more than about 10% of total salary that is paid out as a bonus based upon performance. And those dollars were distributed the same to the neurosurgeons and to the cardiac surgeons, to the primary care adult physicians and pediatricians. Every physician equally shared in that, because my view was that by working together as a single team, they earn that together.

Henry Bair: [00:43:08] Dr. Pearl, one of my medical school classmates, recently started his internship year at a Kaiser Permanente hospital in the Bay Area. They were telling me that during the orientation and onboarding process, you and your philosophy featured prominently. Even though you are no longer CEO specifically, your overarching vision for Kaiser during your time as CEO and your definition of excellence were ideas that all new interns were exposed to. Can you tell us more about that and why you put such a strong emphasis on it?

Robert Pearl: [00:43:44] Across my time, I thought it important that every clinician understand what is going on both strategically -at the business school. As you know, I teach strategy- So understanding strategically what we were doing, not only that, but be able to understand how that is going to impact doctors. So from a strategy, I think if you went around and ask the physicians -and again, I'm no longer the CEO, I moved on to my third career doing podcasts and writing books and articles for Forbes, and people can find more information on my website. Robert PearlMD.com- But in my second career as CEO, you know, I wanted every physician to know our strategy. And it was pretty straightforward. Quality and service differentiation at a competitive price. But it's quality. We can list the outcomes. Fewer people dying. Longer life expectancy, fewer complications, reduced operative problems. I mean, we can go down the whole list of things that people would agree is higher quality service differentiation means that we better have easier access. The time it took for referral from primary care to specialty care for 70% of patients was 1 to 2 days. I can guarantee you that's not what happens in most communities or academic centers. And a competitive price is one that is not skimping in any way, but it reflects the fact that you've put in place the most efficient and effective ways.

Robert Pearl: [00:45:23] And in terms of the rewards, and this is the joy, it's the fact that you're going to have both a fair salary, an appropriate salary commensurate with the world around us. And you'd be able to have a life after retirement to be able to have both income and retirement security. And as you note, being able to find the ways to create the joy which to me came out of this group excellence. And that was probably the biggest piece that I would say that I pushed. That is very different that as you know, that in an academic or community center where it's about who is the best department, who is the best doctor, and it was very clear to me that if everyone could match the performance of the best today, that we would be able to accomplish all the other goals. And as I said, I think it played through in terms of the overall physician satisfaction and as a result of that, much of the joy that is possible in what I believe to be the greatest profession, which is that of medicine.

Henry Bair: [00:46:38] Dr. Pearl, over the course of this conversation, you've talked about what you personally found the most meaningful in your surgical career and how you attempted to create a system and culture at Kaiser Permanente that fostered better satisfaction amongst its workforce. I'd like to bring it down to a more personal level and ask What advice do you have for clinicians and doctors in training about what they can do, what mindset they can adopt, whether on a daily basis or in thinking about their careers to stay connected with the things that matter most in medicine.

Robert Pearl: [00:47:16] Getting back to the point you made earlier. At some point, if you're always swimming against the current, you're going to get tired. Maybe you can swim a little bit longer, but at some point that current's going to defeat you. And that's how I see medicine today. So to give people, I will call to some extent a false sense of what is possible. At the same time, where I believe they should be going right now is to change the model, to work in ways, and they can do that in medical groups. They can do that in the community by coming together as a group of doctors to be able to take. I'll use the word again, capitation, a single payment going forward. If you look across the United States today, outside of Kaiser Permanente, some of the most satisfied high performing groups are actually primary care groups that are able to take capitation through Medicare Advantage. Now, I've just thrown out a lot of terms for your listeners. Medicare has two ways that doctors get paid. They get paid as a fee for service, which is the so called traditional Medicare, or they get paid through a capitation, a set amount of dollars to take care of a population of individuals. And the ones who I see being the happiest are the ones sitting in that more capitated way. But you can't be capitated unless you're going to work together.

Robert Pearl: [00:48:48] So again, finding ways to be able to use. Size to be able to increase performance and then decapitated is a great way to utilize technology. And I think if they can look for the opportunities to do that and implement it, let me give you a simple example. And I spoke to the CEOs of the largest organizations in New York City a couple of weeks ago. And I said to them. It's 10:00 at night. You have a four year old with 103 fever. You're not sure whether to drive to the ER immediately, whether to wait till the morning to the pediatrician's office opens. Who do you call? Now, these are people with really good health care. These are people with plenty of money. And most of them said, there's no one I can call because there's no one available. In the mid-Atlantic part of the country, Washington, DC, Maryland and Maryland and Virginia, where I was also the CEO. As in my role of Permanente, there is a physician in the call center available 24 hours a day on video. And if your child is lying there, essentially unresponsive, The doctor immediately knows this could be meningitis. Says call the ambulance raced to the ER. I'll call the doctor. They'll meet you at the door and they'll start taking care of your child immediately. The kid's riding the bike around the living room. You know, the kid's probably fine, especially if they're laughing and smiling.

Robert Pearl: [00:50:30] No single doctor can offer that service unless they can do a concierge practice for 100 people who pay $10,000 each. But no, a group of doctors could do that. And I believe that what they will find is a lot of joy in doing so. 21 doctors could do it one day each every three weeks, 30 to 48 doctors one day each, every four weeks. Those are the kinds of opportunities that I think people are missing today. And if all they do is get on the hamster wheel and ask themselves, how do we get more satisfied? How do we find more joy spinning this wheel? My belief is they're not going to. And my fear. Is that it's actually about to get much worse, particularly in the context of the post-COVID world with the inflation going up, the rate that it's going up with insurers going to have to raise rates. With purchasers being dissatisfied at higher rates, you can be sure that the pressure on clinicians is going to increase and many of those who today might be moderately satisfied are going to find themselves, I believe, increasingly dissatisfied if they don't lead the way. So that's the biggest advice I would give to people. Lead the way, find the ways to create the groups, find the ways to take the capitated payments. Find the ways to use the best technology in terms of the patient.

Robert Pearl: [00:52:02] And be willing to accept a leadership capable of making decisions for everyone. As you know, autonomy and mastery and purpose are what drive fulfillment in most professions. Autonomy in medicine has been every doctor doing whatever he or she wants. I think in the future it's going to be groups of doctors coming together, looking at the literature, figuring out the best evidence, best ways to treat patients, and then everyone following it, knowing that it's going to increase overall quality. Mastery will no longer be the specialist at the top of the hierarchy. It's going to be groups of physicians who understand that they all have a important role to play and they value each other for the excellence that they contribute. And I think purpose will be moving away from a disease focus to being how do we increase the wellness? How do we increase the satisfaction of patients and give them a better life? As I think back to the first questions you asked me today and I never thought about it before today, I love the technical aspects of cleft lip and cleft palate surgery. But what did I talk about? The look on the mother and the father's face when they saw the child. I think we've lost that in medicine today. And if we don't regain that, I think the dissatisfaction and the burnout will only get worse.

Henry Bair: [00:53:36] Well, on that note, Dr. Pearl, I'd like to thank you for taking the time to join us today and for sharing your vast vision for a better future of health care.

Tyler Johnson: [00:53:48] We really appreciate this. And you've offered a distinct and I think really interesting perspective and hopefully our listeners will find it valuable to. Thank you so much for your time. I know you're a busy guy.

Henry Bair: [00:54:01] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the doctors art. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:54:20] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.

Henry Bair: [00:54:34] I'm Henry Bair.

Tyler Johnson: [00:54:35] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.