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FHC #64: The hero’s journey in healthcare Sep 07, 2022

Show notes

American writer Joseph Campbell famously studied and diagramed the hero’s journey in folklore and literature. That journey begins with a call to adventure, prompting the hero’s reluctance—often due to a fear of failure. Along the way, mentors lends guidance and help, but it is ultimately the hero, alone, who must summon the courage to win the day. In this episode of Fixing Healthcare, hosts Jeremy Corr and Dr. Robert Pearl join ZDoggMD to discuss the hero’s journey in healthcare. In every medical professional’s career, there is a calling, a fear of failure and people along the way who provide support (or pose additional challenges). Who are healthcare’s heroes these days? What are the dragons that need slaying? How do we overcome our fears of failure in medicine? What journeys lie ahead for the future of American healthcare? The show concludes with a question posed in our last episode. We asked listeners on social media: “What medical hero or moment in history deserves its own Hollywood adaptation?” The answers may surprise you. 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 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: Good morning, Zubin. How are you doing? Zubin Damania: Top of the morning, Robbie. Robert Pearl: Excellent. I’ve heard from dozens of listeners, who have said they can’t wait to hear us talk about the hero’s journey that you mentioned in our last Unfiltered episode, and I promised that we would explore it today. So let’s dive in. Can you tell listeners a brief summary of Joseph Campbell’s ideas and his model? Zubin Damania: Yeah, so Joseph Campbell studied mythology and what he called the monomyth, the single myth that crosses almost every human culture that he studied, is this idea of the hero’s journey. The idea that the hero, all of us, really, starts out in one place, and then there’s a call to adventure, because there’s something not quite right there. There’s a call to adventure, and then there’s a whole series of things that happens. There’s a mentor that comes and takes them, helps them leave the shackles of inertia and fear, go out into the world and fight the dragons and do the trials and suffer the ordeals, all to gain some sort of atonement or knowledge or elixir that then they return with, for the benefit of all people. And this is such an archetype throughout human history, in a spiritual sense, in a actual, absolute sense, and looking at all our pop culture too, the hero’s journey is woven into much of our most popular movies and books and stories and ideas. Robert Pearl: As I remember Joseph Campbell’s work, there’s also early in the path, a mentor, a gnome or a dwarf, someone else who gives the hero the encouragement or the ideas or breaks through a thought process that the hero is stuck on, so that the battles with the dragons can begin. How do you see all of this happening inside of medicine? Who are the heroes? What’s the arc? Where should we be looking? What should we be teaching medical students? Tell me how you apply this inside the medical realm. Zubin Damania: I think every single person who works in healthcare undertakes the hero’s journey, in some sense. They start out as having not the knowledge and the skills and the ability to do what we do, which is very difficult, and then they embark on this journey. And the mentor can be anybody, anything. Nowadays it can be a podcast that opens people’s eyes, that suddenly expands their circle of understanding or their circle of compassion. What they thought was one way is actually seemed to be not true. It’s actually a bigger way or a more inclusive way. And sometimes the mentor is very specific. For me, it was Tony Hsieh, who was the CEO of Zappos, who snapped me out of my inertia and my fear and said, “It’s clear you want to do these things and change these things. Why don’t you do it?” And helped me quite a bit. Zubin Damania: For others, it may be a teacher. It may be a family member. It may be a physician assistant. For me, it was the person who taught me that procedures aren’t something to be afraid of. I was always so afraid of being a klutz and screwing stuff up. And they’re like, no, no, no, no, no, here, here’s how you need to look at this. And so it can be anything. And the idea then ,there’s the personal heroes journey, but there’s also the systems journey. Our system has gone from what I call health 1.0, and then the hero’s journey through 2.0 and the trials and the tribulations and the struggles of our technocracy, the administrative technocracy of 2.0, to the 3.0 return of the hero. So it actually has ramifications throughout medicine, both individually and from a systems stand point. Robert Pearl: Are the dragons the diseases, the system or the people? Zubin Damania: Sometimes the dragon is us. I really think that the more I introspect on this, the more our dragons are all self-created, because you can say, “Oh, it’s cost and it’s insurance, and it’s corporate medicine and private equity,” and it’s this and this and this. And those are all projections. We haven’t really addressed the internal dragons. The fact that we are very highly conditioned, fear bound creatures, and we get the system that manifests who we are. So maybe the dragon is us. And that’s a difficult journey, but that’s the classic Joseph Campbell spiritual hero’s journey. Zubin Damania: The idea of atonement with the father is a part of what he describes in the hero’s journey. And the father can be God. The father can be this idea of oneness and how we feel so separate, and the idea of our own ego, and how do we square that with this sense, this deep intuition, that we’re much more than we think we are. Yeah, it gets spooky and weird, but honestly this is the heart of the matter. And I think the hero’s journey is such a good framework for looking at that for all of us. Robert Pearl: So you described your hero’s journey, becoming a doctor, mastering procedures. How about your journey to becoming a transformational leader? Zubin Damania: And I’m still uncomfortable even with that term transformational leader, because I still have such an impostor syndrome around this, but I would say that there are all concurrent lines and levels of development in the hero’s journey. So for me, it’s funny, my story, Robbie, it’s weird. It falls classically into this hero’s journey kind of archetype. And I’m not saying I’m a hero or anything. I’m saying it pencils out. Here I am at Stanford for 10 years as a hospitalist and I feel very dissatisfied with how medicine is done. Zubin Damania: I feel we don’t prevent disease. We’re reactionary. We’re spending all this money and I feel disconnected from my patients, from myself, from my family. Then comes the mentor, Tony, who is like, “Are you happy doing what you’re doing? Here’s a book you could read,” The Happiness Hypothesis by Jonathan Haidt. My mind is it blown by that. I get very depressed. And then I overcome the fear. I get this offer to go to Las Vegas and then go on the journey there. Zubin Damania: And at this point, I have to learn everything about how does healthcare actually work? What does leadership even mean? How do humans even function? How does the mind even work? Because that’s not something we technically learn in medicine. And so the heroes journey for me was battling all this misunderstanding, misconception of how things are, and then battling my own ego, through meditation and that, the spiritual journey, and then doing the work of building a clinic and doing the business stuff and learning operations and fighting that battle, and the mentor helping you, but stepping away quite a bit. And failing, and then feeling what that’s like, the hero setback, but you learn so much from that. And then trying to return with this knowledge, with this show that we do, going, “Okay, now, how can I actualize this in myself and others the best I can while still feeling like a complete impostor?” And so it’s still a journey that continues to unfold. Robert Pearl: You’ve mentioned impostor syndrome now twice. One of the books I really enjoyed reading was by Angela Duckworth, the book Grit. And she talks about how perseverance counts twice as much as talent. First, perseverance allows you to build ability, and then it allows you to apply it. And yet so many physicians feel like they’re an impostor, and I believe that it happens because we think that the successful physicians are just brilliant, and we’re not as brilliant as they are. Or they’re articulate. We’re not as articulate as they are. What they don’t see is how much perseverance and hard work goes in there. Anyone who does really well works hard and they hide that often. I think the impostor syndrome is really problematic because it so undermines the confidence and the willingness of people to step forward, and I believe that the whole idea that we are impostors is an illusion. What are your thoughts? Zubin Damania: Oh, I think everything we believe is an illusion, honestly, but I think you’re onto something here, Robbie, and I think impostor syndrome has to be reframed internally as, oh, I’m feeling a little uncomfortable with my abilities in this space, for some reason. That’s great. That means I’m pushing the boundaries and that means more diligence or more doing it, more pushing, is probably a good thing. Within parameters. Sometimes doctors feel like they can work their way out of any problem, and that’s also a bit of a misunderstanding. Zubin Damania: But absolutely. They don’t realize what your friend Malcolm Gladwell says, it’s these 10,000 hours of diligence. You can have no talent. You can have a bunch of talent, but if you don’t put in the energy, you’re not going to do it. So public speaking’s a great example. You can feel like a complete impostor and you just keep going and doing it, keep doing it, keep pushing. And then it just starts to click and at some point you go on stage and you’re like, wow, what a gift to be able to be here and connect with this audience. And that sense of impostorness is almost like that egoic reflection of me against the world, me separate, dissolves into the absolute oneness of being present with other beings in this mutually reinforcing way. And so yeah, I’m with you, man. I’m with you. That’s a long way of saying, I’m with you. Robert Pearl: You say that for some reason we feel uncomfortable. The reason is, everyone feels uncomfortable when they first learn to put a knife into a human being, I guess, unless you’re some type of sociopath, or stick a catheter blindly into a blood vessel and hope it hits the right place, knowing you may penetrate the lung. There are all these things that we do that are designed by nature to be unusual, because no animal can do them. And so we have to gain those skills. So from my perspective, it’s just an inevitability that all of us will have this discomfort. The question I want to pose to you is that, for a hundred people set off on this hero’s journey, how many of them get to the end? Zubin Damania: Well, this is the thing. Is there an end to the hero’s journey? It’s almost like if you’re looking for a purpose of life, which I think is a difficult proposition because life doesn’t need a purpose. It’s just beautifully radiant in the present moment. But if you’re looking for a purpose, it is this perpetual hero’s journey of unfoldment. So you may get to the end of one particular aspect of the hero’s journey and then a new journey begins. You’re called again. I can’t tell you how many times it’s been a reawakened, oh, wait, what? No, there’s so much more to do, and so much more to learn. And there’s a different mentor now, and there’s a different set of challenges. And there’s a different elixir of knowledge that you bring back. Zubin Damania: And at each stage, one thing Campbell talks about, is there’s the resistance. So the call to adventure, which is when Luke Skywalker is, he’s there on Tatooine. He’s been moisture farming and Ben Kenobi comes to him and he is like, look, dude, your dad was a Jedi. Come with me, let’s fight the Empire. And Luke’s like, no way, man. I still got crops to harvest. My uncle needs me. That resistance to the call is the first challenge. And in medicine, oh my gosh. If you’re going to call the troops to adventure right now to change medicine or to wake up a little from our own conditioning, oh, the resistance is going to be all over the place. There’s a million excuses the mind makes. Zubin Damania: So you’ve got to overcome that. And then when you do get the knowledge, there’s a resistance to coming back with it. You want to stay in this transcendent state. You want to go out and just pontificate about it. So, no, no, no, no, no. You have to come back and embody what you’ve learned. And so that means teaching others. It means maybe going and putting it in practice. And there’s a resistance to that. So at each stage, the mentor can help nudge you, or you can nudge yourself, or circumstances nudge you back. Robert Pearl: I don’t know about you, but one of the hardest journeys that I believe that doctors are going to have to go down is going to be confronting the end of life and dealing with the realities that death is an inevitability, no matter how long we can prolong it, particularly as our ability to prolong life becomes that much greater. How do you envision this hero’s journey progressing? Zubin Damania: And so many of the classic heroes journeys involve a trip to the underworld, to actually address the face of our biggest fear, which is mortality. The fear of loss of control, of helplessness, of all these issues that are so central to the human, we think are so central to the human condition. And of course, in medicine, we’re on the front lines of that. And so if we don’t heed the call to actually address those things, to look at those dragons in our own psyche, then how can we address them for our patients, and what ends up happening is we obfuscate them with our own projections. So, no, no, no, you know what? One more procedure is what your loved one needs, not talking about comfort, not talking about palliative care or whatever it is, or even having the conversation that you know what, life is not infinite. And it’s not a failure to focus on comfort. Zubin Damania: Those are crucial things. And then the economic ramifications, the emotional ramifications of the survivors, all those things. When I do talks, I often perform a song that I did a while ago called Ain’t The Way To Die, which is a parody of an Eminem and Rihanna song about end of life. And I do it for people that [inaudible] why would you do it for this audience? Because every single person in the audience has had a loved one or has interacted with someone who’s been in that position where they haven’t had the conversation, they haven’t talked about end of life. There’s all this resistance. And it illustrates that resistance and how we might actually overcome it by making people feel something, like, oh my gosh, it’s always too soon until it’s too late to have the conversation. Robert Pearl: I don’t know if you’ve ever watched a particular YouTube video, but I’ve watched it, I don’t kno…

Full show notes at the publisher

FHC #63: One Medical founder Tom Lee on Amazon, primary care, the future Aug 30, 2022

Show notes

Dr. Tom Lee founded Epocrates, one of the earliest tech-enabled healthcare applications for doctors, and One Medical, the primary care-first organization recently acquired by Amazon for $3.9 billion. He is now the CEO of Galileo, a virtual care-first healthcare startup he hopes will make medical care affordable for all Americans.

Though Lee is no longer with One Medical, and he was not involved in the recent merger announcement, few people are better equipped to weigh in on Amazon’s emerging role in healthcare. Will Amazon disrupt healthcare’s traditional powers? Can the company reshape primary care and fix the broken parts? Where will American healthcare be in 10 years?

In this interview, hosts Jeremy Corr and Dr. Robert Pearl ask Lee to discuss some of medicine’s unwritten rules and norms. These are, as listeners know, the norms and behaviors that dictate the way doctors think and behave.

Interview Highlights

On being a healthcare ‘rule breaker’

“Everywhere I looked [in medicine], there were norms that nobody could explain to me. And even as a med student and resident, we did a lot of things that didn’t make a lot of sense. Our mission was to care for patients in a thoughtful manner, but what we were doing seemed antithetical to that. So even as a young physician in training, I just started noticing dissonance with what we were doing from what we thought about why we had joined the profession.”

On ‘specializing’ in business as a doctor

“What were these mysterious forces driving the systems of care that I felt as a clinician were inappropriate or certainly suboptimal? So that’s what ended up leading to my business career. And this was not something that was considered very vogue or sexy among doctors. In fact, it was viewed as a negative trait. And most of my other colleagues were going into specialist kind of training, but my specialist training ended up being business, and it allowed me to see the world more broadly than where traditional medicine typically is looked at.”

On memorization in medical training

“Relying on clinical memories or human memory to make any kind of judgment, I think, is unwise, particularly as we look at the future. So we need to reexamine what we reward, and (how we) train young physicians and clinicians in training in general. I personally never found memorization to be that inspiring or helpful in my medical training … And I do think that’s something to reconsider as we start to examine the workforce and frankly, the profession of medicine.”

On the inspiration behind One Medical

“As a young physician in training, I was like, ‘I don’t want to practice in any of these broken models.’ I had worked in almost every environment, whether it be academic institutions, private practice, capitated HMO models, native health service organizations, all really great organizations with well-intended providers and leaders, but the care model just didn’t make any sense. And so I knew that there was a better care model that could be designed, particularly given how much we were spending in healthcare overall. So for me, the inspiration was to kind of say, hey, primary care is a broken layer. Everybody recognized this 20 plus years ago that primary care was broken. Nobody wanted to invest in reexamining how to improve primary care. And so the real impetus behind One Medical was, can we validate that a higher touch, better primary care model can be built and scaled in an economically viable fashion?”

On spending time with patients

“I remember something that Don Berwick said way back when I was a resident, ‘The thing that patients want is time with the doctor.’ It’s not a unit, it’s the time with the physician. And so a lot of inspiration with One Medical was how do you actually enable that with a fixed reimbursement model for the most part? And the key innovation there was administrative redesign … The average practice in primary care is overwhelmed with administrative burden, but they don’t have the sophistication, particularly as the complexity has been layered in over decades to redesign that. And so I had the luxury of starting from scratch and redesigning it. And now that technology was more available, I wanted to design it using technology. So that allowed us to 10 x the service at about a third of the administrative overhead of a traditional practice. And then that allowed us to give more time back into the physician exam room, which allowed patients and providers to have more time. And we got all the other people out of the way.”

On his new virtual-care company Galileo

“At high level, we are reexamining the norms of how should care be delivered, and this had started pre-pandemic, but there are some strengths to an office visit, there’s strengths to a video visit, but there are a lot of weaknesses to that form factor. And we believe in a more data oriented, evidence oriented approach to how care is delivered. So from a quality perspective, how do you redesign quality into the care model. And then in parallel, designing affordability into the care model. And so being more capital efficient, more labor efficient, and covering a broader range of services and scope is really kind of the thesis of Galileo.”

READ: Full transcript with Tom Lee

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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 #63: One Medical founder Tom Lee on Amazon, primary care, the future appeared first on Fixing Healthcare.

CTT #64: Are Americans putting Covid-19 behind them? Aug 23, 2022

Show notes

New data from the Annenberg Public Policy Center found that 4 in 10 Americans have returned to their normal, pre-pandemic lives. Over half of respondents say they rarely or never wear masks indoors while in public. This, despite 54% of Americans indicating they personally know someone who has died from Covid-19. A third say they know someone with “Long Covid.”

How will these perceptions – alongside the continued loosening of public safety restrictions – affect the future health of Americans? In this episode of Coronavirus: The Truth, Jeremy Corr and Dr. Robert Pearl examine both the science and public opinion of Covid-19. You’ll find this topic, and all the [time stamped] topics discussed during this show, here:

[00:50] 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?

[03:38] Listener question: “Is there is any explanation besides bad luck for both Dr. Fauci and President Biden getting ‘rebound COVID’ after taking Paxlovid?”

[05:31] Covid-19 is now an endemic virus: What does that mean and what happens now?

[08:21] What’s new with the monkey pox outbreak?

[12:55] What are the current treatments options for monkey pox?

[17:55] Is monkey pox a major concern for most Americans?

[18:59] How might we “break” of some of healthcare’s most illogical rules?

[24:45] Are Americans putting Covid-19 in the rearview?

[25:59] What’s up with CDC? Is the agency changing course?

[28:42] Kids and Covid-19: any news?

[30:38] What do we know about the Inflation Reduction Act’s impact on healthcare?

[33:09] And what about Amazon’s acquisition of One Medical?

This episode is available on Apple Podcasts, Google, 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 #64: Are Americans putting Covid-19 behind them? appeared first on Fixing Healthcare.

FHC #62: Diving deep into 3 urgent threats facing U.S. healthcare Aug 17, 2022

Show notes

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?

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The post FHC #62: Diving deep into 3 urgent threats facing U.S. healthcare appeared first on Fixing Healthcare.

FHC #61: An unfiltered look at Rx triplicates & Amazon’s healthcare expansion Aug 09, 2022

Show notes

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 pre…

Full show notes at the publisher

FHC #60: Don Berwick on ‘breaking the rules for better patient care’ Aug 03, 2022

Show notes

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

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CTT #63: What causes ‘Covid-19 rebound’ after Paxlovid? Jul 26, 2022

Show notes

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.

FHC #59: Diving deep into SCOTUS rulings & drug-industry rules Jul 17, 2022

Show notes

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.

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?

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The post FHC #59: Diving deep into SCOTUS rulings & drug-industry rules appeared first on Fixing Healthcare.

FHC #58: An unfiltered look at inauthenticity in medicine Jul 11, 2022

Show notes

“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 mome…

Full show notes at the publisher

FHC #57: Dr. Rod Rohrich on how to change the rules of medicine Jul 04, 2022

Show notes

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

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