Robert Pearl, MD on doctors and the 5 stages of grief [PODCAST]

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“Physicians have had a rough century, so far. In addition to battling COVID-19, doctors have spent the past two decades fighting the health care industry’s fiercest players and losing, badly.

Power in the industry now belongs to health insurance companies, major drugmakers, and hospital tycoons. Physicians feel beaten up, burned out, and abused by a system so overrun with regulations that clinicians now spend more time filling out paperwork than helping patients.

Doctors long for the last century. Back then, they were paid well, revered by everyone, and largely left alone to practice as they please. As the war against COVID-19 winds down, doctors believe now is the time to demand a return to the glory days when physicians ruled medicine. To get there, doctors want more money, respect, and autonomy. They’ll get none of that because our nation can’t afford to give it to them.”

Robert Pearl is a plastic surgeon and author of Uncaring: How the Culture of Medicine Kills Doctors and Patients. He can be reached on Twitter @RobertPearlMD.

He shares his story and discusses his KevinMD article, “Doctors and the 5 stages of grief.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today we welcome back on the show Robert Pearl. He is a plastic surgeon, and he wrote the book Uncaring: How the Culture of Medicine Kills Doctors and Patients. Robert, welcome back to the show.

Robert Pearl: Thank you, Kevin. And for your listeners, I want to make sure they know that all the profits from the book go to Doctors Without Borders, a tremendous and wonderful charity providing relief around the globe.

Kevin Pho: And how’s the book doing?

Robert Pearl: The book is doing incredibly well. It’s doing exactly what I wanted, which is stirring up a lot of conversation. There’s quite a number of people who said, “Got it just right. You touched on everything I’ve been feeling.” And an equal number, or actually much smaller, but a vocal majority of people who say, “You got it all wrong. You’ve been unfair to doctors.” I think the conversation and debate is exactly what we need to evolve both the system of medicine and the culture of medicine as soon as possible. Physicians need it, and patients need it. The American health care system requires it.

Kevin Pho: We’ll get into those topics in a little bit, but for those who don’t know you or didn’t listen to our first episode, tell us a little bit about yourself and your journey.

Robert Pearl: I’ve had three wonderful, wonderful careers. I began as a surgeon. I went to medical school at Yale and trained at Stanford. I’m a plastic surgeon; my focus was children with cleft lips and cleft palates. I traveled around the world doing a lot of mission work, as well as doing it as part of my clinical practice, and had tremendous satisfaction. I took care of about 10,000 people. I had the opportunity to operate sometimes on parents and children, both of whom had clefts. It was incredibly rewarding.

Then the over 10,000 physicians of The Permanente Medical Group, where I worked, selected me to be their CEO, which is a role that I served in for 18 years, responsible for the medical care of Kaiser Permanente members on both the East and West Coasts. I was able to move Kaiser Permanente to the top of the 1,000 organizations in clinical quality, elevate the service provided, and be able to reduce costs at the same time that quality and service were going up.

And then my first book, Mistreated: Why We Think We’re Getting Good Health Care, We’re Usually Wrong, was published. It became a Washington Post bestseller, and I had the opportunity to speak to national organizations. As CEO, I was responsible for the health care of 10 million people, and now I could try to move American health care systems forward for 300 million people. That’s the third career and the journey I’m currently on.

Kevin Pho: I always like to ask physician CEOs this question: For those doctors who want to step into leadership positions, what do you think is the single most important characteristic they must have?

Robert Pearl: I have to give you two, because one is foundational, and then one is what’s required to move forward. Foundationally, you have to be a highly respected physician. Doctors will not follow individuals that they don’t respect. So I say, spend your first five years becoming the best clinician you can be, regardless of what your specialty is.

And then I think you need to have a passion for change. That, I would say, is the single most necessary ingredient. People often say, “Well, if I try to make people change, I’m going to get resistance, pushback.” My answer is, if you’re not getting resistance and pushback, you’re not making change happen. That’s what leaders do. They have a vision for the future, something that they can see based upon the facts that exist. They’re then able to communicate that to other individuals. They can let them see that it may be a difficult journey, but at the end it will be a better landing place. And then they have to lead the process to make it a reality, and motivate people to come along. It’s a very complex set of skills that one learns across one’s career, in conjunction with what one reads and the academic pursuits that they follow.

Kevin Pho: All right, so let’s transition into some of your recent KevinMD articles. The first one is titled “Doctors and the 5 stages of grief,” and the second is “Doctors can’t cope with the anguish of COVID-19 casualties.” Let’s talk about the first one. Now, for those who didn’t read that first article, “Doctors and the 5 stages of grief,” can you just summarize it and walk through it for my audience?

Robert Pearl: This really became the driving force for the book Uncaring: How the Culture of Medicine Kills Doctors and Patients. It’s a recognition that we cling, as physicians, to things left over from the past. That’s what culture is: the values, the norms, the beliefs that we have.

I’ll give you a simple example. You know, what does it take to get into medical school or a great residency? What do we highlight? We highlight the ability to memorize arcane facts, whether it’s the MCAT or whether it was Step 1. That was relevant in the 20th century. If you wanted to have all of medical knowledge with you, you had to carry it on your back in a 50-pound backpack. Today we call it a smartphone. How many medical schools insist that every student bring their smartphone to the exam? That’s how medicine is practiced today, but the culture lives in the past.

I think the same thing is happening right now. The American world has changed. Patients don’t like, won’t accept, the paternalism of the past. They demand the same kind of convenience in the health care they receive as in travel or retail. They’re suffering. The world is changing, and COVID will have made it worse. We’ll come out of this, and the federal government will have borrowed $8 trillion that it’ll have to repay with interest. States by law have to have balanced budgets, and they’re going to have higher unemployment rates and greater Medicaid payments to be funded. And then there are small businesses, a third of which can’t make it through the year without additional federal support. The pressures on health care are going to be great.

Now, I want to emphasize that physicians are also suffering. You know it very, very well: the 44 percent of doctors who are reporting the symptoms of burnout, the lack of fulfillment, dissatisfaction, the fatigue, the growing demands, the higher need for authorization for insurance companies, clunky computers that literally come between us and our patients, the need to see more and more patients to maintain income. Both of these forces exist at the same time. But any of us who believe that simply by telling the world about our pain, it’s going to respond and give us what we need to provide the care to patients, even though it’s the right thing to do, don’t understand the economics around us.

I have the chance to teach at both Stanford Medical School and Stanford Business School, and I look at these competing forces right now. That was the driver of the article on the five stages of grief, because we will have lost much of what we had in the past. We had a lot more control, a lot higher esteem. We today are going to have to adjust to the world around us, not ask that world to adjust to us. Not because that’s the right answer, but because that is what is going to happen in this world, where so many people, so many patients, can’t afford the care that we provided in the past, and those demands are going to increase. And if we try to go back to the past, Kevin, we are going to fail. So now we need to accept, I believe, what’s happening in the world, and move forward and lead the process as doctors for the best outcomes that are there.

Initially, there’s denial, and I think we’re seeing a lot of that. We’re denying that we contribute very much. Maybe it’s only 10 percent, but it’s something, and unless we as physicians are willing to acknowledge that, and there are physicians who are not willing to be able to acknowledge it. I mean, look at the opioid crisis. Ninety thousand people died this year. Much of the blame, the majority of the blame, is the pharmaceutical world that pushed opioids, but still, we wrote the prescriptions. Over 90 percent of the world’s hydrocodone prescriptions were written by physicians. Data says 30 percent of what we do doesn’t add any value, and yet we still do it, particularly in areas of specialty medical care.

And let’s take telemedicine. We’ve noted for a long time that it was available. We never implemented it. What did we blame? We blamed interstate restrictions and lack of reimbursement. We spiked up to 60, 70 percent early in the pandemic, and now it’s going back down, despite the fact that the problems, or the solutions that were implemented in the past, still remain. We have to understand some of the ways that we contribute. So denial is there.

Then anger. We’re forced to confront what’s going on: anger. We’re seeing that in all caps on social media. You see much of it in the world that you lead, with exclamation points. That anger is invariably going to happen, and then it’s going to lead to bargaining. What we already see is that 70 percent of doctors work for an organization, an insurance company, private equity. Over half of doctors’ salaries come in these structures. It’s not going to solve the problem. It’s not going to solve the problem because physicians will once again feel like they can’t fulfill their mission and purpose when they’re actually trying to fulfill someone else’s economic, someone else’s strategic plan.

That leads to depression, and I’m very worried about that, Kevin. I’m worried about that because we’re seeing so much of it already: more than one suicide a day, the 44 percent burnout. But it’s acceptance, and that’s where I believe that we have to go: Understand the world around us, and then take the actions, lead the change process, not just complaining about the problems, but actually implementing the solutions. That’s part of both of my books, Mistreated about the systemic issues, and Uncaring about the cultural ones. Like the caduceus, you know, that symbol that we wear, the two snakes entwined around the staff, that’s what I see happening. We’re going to have to change both the system and the culture if we want change to occur. I know we can do it. Part of my push, part of why I wrote that article, but also part of why I talk about the five stages of loss and grief, is that it’s not going to be easy for us, and I think we’re in the midst of that change happening.

To that end, though, let me touch on the other article, if that’s OK, because it ties right into that same cultural piece, into that same depression piece. COVID-19 has inflicted massive damage on physicians, particularly in critical care and the emergency room area. I talked to a physician the other day who had lost four patients in a single day. Four patients! Not very many doctors lose four patients in a year, and now, in COVID, he had lost four in a day. I talked to a resident who started the month with six patients in the ICU; by the end of the month, they were all dead.

And in the culture of medicine, Kevin, we repress and we deny. It came from the past. It had to. There was so little doctors could do until the second half of the 20th century. You’d be out taking care of a family, holding a child in your hands with the parents next to you, and you’d have to tell them there’s nothing you could do. That pain required us to not recognize much of the things that existed, to deny our emotions. That’s how we were trained: If you’re emotional, you can’t make objective decisions. I think the physicians working in the critical care arenas are going to have PTSD, because that emotion ultimately comes out once the crisis passes.

I wrote the article to urge hospital leaders to provide the psychological help, and residency directors to create the opportunities for people to express their emotions. And not just physicians, because the nurses are going through the same, and the respiratory therapists, the same experiences. We have to understand the psychological consequences that this virus has caused, not just on our patients, but on ourselves. And the emotional isolation left over from a different century, I think, is going to harm us, and it’s something we can control.

Kevin Pho: Now, when you talk about physicians needing cultural change, one of the lines of pushback I often read is: What proportion of the blame goes to the culture, and what proportion of the blame goes to the physician himself or herself? Because if you take that example of the opioid crisis, for instance, there’s one school of thought that, like you said, the ultimate decision is up to the physician. But also, that physician is under pressure from various incentives, like patient satisfaction, like the Joint Commission saying pain should be a vital sign. What proportion of that blame should go to the system, and what proportion should go to the individual physician?

Robert Pearl: That’s why I like to talk about that symbol of the caduceus. You can’t separate the two. I think the majority is systemic, but we can’t address the systemic without addressing the culture. And when we fail to talk about the things that we can control, what happens? We feel like victims. We feel helpless. We start yelling louder and louder, sort of like a tourist in another nation that doesn’t speak English, as though someone’s going to listen to us and now suddenly change. I think what it does is it creates an inertia, instead of solving and addressing the problems.

If it’s 20 percent, let’s acknowledge the 20 percent. This is fear, and I’ve read it online, that if we acknowledge the 20 percent, the 80 percent won’t change. My view is that the 80 percent is not going to change until we acknowledge the 20 percent and lead that process of change.

You know, I think we need to shift the reimbursement methodology, and insurance companies drive that; the government drives it. But physicians need, from my perspective, to embrace a capitated system of health care, because that aligns our mission and purpose with what we do. When you capitate, when you pay a set fee and take care of a population of patients, what becomes valued more? Prevention, primary care, avoidance of medical error, prevention of complications for chronic disease, the things we believe in, the reasons we went into medicine.

If you’re in a situation where you’re paid fee-for-service, you’re right, these are systemic forces that drive you to do more and more. In a capitated system, you can benefit by being better, higher value: integration, working together, teams of people finding ways to eliminate the inefficiencies. The idea that the only way we can earn our income is by being inefficient and doing 30 percent of things that add no value doesn’t make sense to me.

You know, I look at the question: Why are medical students burned out in their first year? They haven’t yet had to see more patients in a day. They haven’t had to use the computer systems. They haven’t had to get authorization. All the reasons that we think are there, they haven’t experienced yet. I think it’s this mismatch between the purpose of medicine and the way it is currently done, some of which, as you say, is the system. But I think there’s this cultural piece, if we don’t acknowledge it and start to evolve it.

Think inside medicine: Who do we value? We elevate the specialist above primary care. And specialists, I’m a specialist, we do excellent work. But who saves more lives: the interventional cardiologist who unblocks the coronary artery, or the primary care physician who, day after day after day, prevents dozens of patients from having the coronary block in the first place? We don’t value that inside medicine. We blame it on the reimbursement system, but listen to how doctors talk. Go inside that hospital and listen. We do some of it to ourselves. So even if that’s 1 percent, that we put down our colleagues, that 1 percent, I believe, has to stop if we’re going to address the unfulfillment and the dissatisfaction that exist in medicine today.

Kevin Pho: We’re talking to Robert Pearl. He’s a plastic surgeon, and he’s the author of the book Uncaring: How the Culture of Medicine Kills Doctors and Patients. Robert, you mentioned the physician burnout rate being close to 50 percent. One of the reasons I think that number is so high is that physicians are losing their autonomy. They’re being disempowered when they practice medicine. But one of your five stages of grief is that they have to come to an acceptance of how the culture of medicine has to change going forward. So to me, those are a little bit in tension: that they have to accept a situation that they may feel is unpalatable. How do you resolve that tension?

Robert Pearl: Again, I wrote the book because there is both the systemic and the cultural part that’s there. So let’s look at what specialty was most burned out prior to COVID-19. That was urology. Now, urology is a specialty where the average income is close to half a million dollars a year. It’s hard to argue that money is the main driver. It’s a specialty that, by the way, used to have a relatively low amount of burnout a full decade ago. If it’s the computer system, then why are orthopedic surgeons 25 points lower in terms of burnout? They use the same systems. If it’s the authorization process, why are the ophthalmologists 20 percent less burned out?

Let’s look at what changed in urology, and ask the question: How much of this is imposed on us, and how much of this do we put onto ourselves? So in basically 2010, urology has a relatively low rate of burnout, and then two things happen. Number one, the preventive guidelines say that PSA testing is more problematic than helpful, so the number of prostatectomies declines. And then we have discoveries that say maybe for cancers you don’t have to operate, so the number of prostatectomies declines even further. And then you have centers of excellence that are doing that, so the majority of urologists are not. And now burnout goes up and up and up.

Why should this one operation, the biggest change, the reduction in prostatectomy, be such a driver of this burnout? Because in the culture of medicine, and remember, urologists didn’t lose any income; they replaced those patients with other patients, this ability to do this Star Wars-like procedure with these robotic arms is what elevated urology in terms of respect and esteem, and as physicians lost this skill, they became more burned out and less satisfied. It’s not a logical piece that is there; it’s just embedded into the culture of medicine. So that’s the part that I would say, when it comes to the acceptance: accepting the fact that you can add value without having to do robotic prostatectomy. That is not who we are. That is not what we value.

I’m sure you’re familiar with the work of Sir Michael Marmot from England. He looked at the relative satisfaction of people across various job descriptions, and what he found is that yes, income is a factor, but a far bigger factor is this level of respect, the cultural issues that are there. Other researchers have shown that when that level of respect drops, one becomes increasingly burned out. I think that that’s what we’re seeing in a lot of medicine today.

We’re seeing it in terms of the things that we know. Evidence-based medicine: What do we call it? We call it cookbook medicine. What do we call it? You know, we say that it can make every doctor average. The data is exactly the opposite. It’s going to elevate outcomes and performance. So why are we leading the way and embracing it? Because that says that we’re not special as a profession. And you’re exactly right, this is not any individual wanting to do something negative. This is the culture.

But also, before we finish, I want to make sure people who are listening understand this is a wonderful culture. You know, I love being a doctor. I think being a physician is the highest profession you can go into. You know, I looked at what doctors did during COVID-19, going in and taking care of patients 12 and 24 hours a day without the protective gear they needed, you know, donning garbage bags where they didn’t have gowns, and solid limbs when they didn’t have masks, you know, passing tubes into the lungs of patients who couldn’t breathe, knowing the patient would cough and spew virus in their face. This is a remarkable culture.

It’s my cousin Alan, who I talk about in the book, when cancer, Hodgkin’s disease, was early in the evolution. Doctors were by his bedside, but they were there recognizing the advances in science, but being somewhat protected by the repression, the denial we talked about, against the pain. But they evolved it, so today it’s no longer a death sentence. We should celebrate that culture.

But I think we also have to, and this is the acceptance, accept the ways that it no longer is the right match for the world around us. And rather than expecting that our patients are going to change to meet our needs, ask: How do we evolve for the benefit of both the patients and ourselves? I’m just worried that we’ve now yelled about burnout for how long, Kevin? Five years, 10 years? You’ve been a loud voice, and your publications have had an even louder voice in this area. When I look back over five years, nothing is better today. If anything, it’s worse. So why do we think that that same strategy, done again and again, is going to solve this problem? I don’t think so.

The acceptance that I’m saying is to reshift that culture. Start to value prevention in a way that we don’t, as doctors, value it today. Start being able to look at integration and team-based care differently than we did in the past. And if we can do that, and embrace modern technology, be able to figure out how we use telemedicine even more than we did during COVID-19. You know, our offices are not the ultimate destination for patients. They’re where they have to come if we need to stick a knife or a needle into someone, or palpate an organ. But we have to recognize the world of our patients.

I think this aligns with our values and our mission, Kevin, because we’ve always been, across time, patient-centric. I believe that today we remain, as individuals, patient-centric, but as a culture, we haven’t evolved into the 21st century to offer them what they need in their lives. We’ve not understood the economic harm that’s generated, some of which we do. We’ve not recognized the ways that we could do better in a very broken system. That’s what I think of as acceptance. Acceptance isn’t, “I like it. This is the right answer.” It’s that this is the reality that exists, and I’m going to do the best that I can to move it forward.

I have tremendous faith in physicians. You know, across centuries, we’ve done almost the impossible. I believe that we can do it today, but it’s not going to happen by talking about our pain and our problems. It’s going to happen by us leading the evolution.

And one last set of thoughts for your listeners: If we don’t do it, someone else is going to do it. If I have one word for people, it’s Amazon. Amazon is taking the lead, and I can assure people that they’re not going to worry anymore about the doctors. They worry today about many of the people who are working in their warehouses. They’re going to focus on the consumer. We can say all we want about problems with a company like Amazon. They offer a clear, transparent, relatively low cost, delivered with excellent service to your home. That will be their model: with telemedicine, with in-person sites, with home delivery. I think as doctors, we can do better, but if we don’t do it, someone else will, and they and others will lead the way.

Kevin Pho: And how can people find your book, Robert?

Robert Pearl: They can find the book on Amazon. They can find it in almost any place they find their information, or they can go to my website, robertpearlmd.com, where they can find a lot more information on all these topics, and information on the books. I encourage them to read the book. Don’t make judgments before you’ve read it. Read the book, offer your thoughts, and write to me. Let me know where it’s wrong, where the facts are wrong.

I think, Kevin, you made a tremendous point today. The cultural problems, the ones we control, are the minority, but they exist. And if we’re going to change one of the snakes on the caduceus, we’ve got to address both of them. I encourage the debate; I encourage the discussion. I don’t have all the answers, but together, I believe, we can once again make American health care the best in the world. I thank you for the opportunity of being on your show today.

Kevin Pho: Robert, thanks again for coming on, and again for sharing your time and insight.

Robert Pearl: Thank you, Kevin.

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