Show notes
Said ZDoggMD: “Oh, man, OK. You said, hey, let’s do a podcast together, Z. It’ll be fun, you said. It’ll be easy. It’ll be flow. Then you ask a question like this?” Replied Robert Pearl, MD: “It’s easy for me to ask the questions, Zubin. That’s what I meant.” Welcome to Unfiltered, a show that brings together two iconic voices in healthcare for an unscripted, hard-hitting half hour of talk. In this episode, Dr. Pearl wastes no time getting serious with Dr. Damania (ZDoggMD). The two talk about the unseen forces holding healthcare back. These invisible elements including tribalism, bias, fear, inertia, hierarchical struggles and a cowboy culture that all combine to harm patients, increase medical errors and prevent high-functioning teamwork. A little history on the show: Prior to Unfiltered, Dr. Robert Pearl had twice appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who had twice appeared on the Fixing Healthcare podcast with Pearl, alongside cohost Jeremy Corr (see: here and here). For more, press play or peruse the transcript below. * * * Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn. UNFILTERED TRANSCRIPT Jeremy Corr: Welcome to Unfiltered, our newest program on our weekly Fixing Healthcare podcast series. Joining us each month as Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes, he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare policy experts, they’ll apply the lessons they extract to medical practice. Then I’ll pose a question for the two of them as a patient based on what I’ve heard. Robbie, why don’t you kick it off. Robert Pearl: It’s amazing, Zubin, how fast a month passes. Feels like we just recording last month’s Unfiltered episode yesterday, and here we are recording the new one. Zubin Damania: The dirty secret, Robbie, that I’ve learned as I got older is the older you get, the shorter time feels because it’s a smaller portion of your overall life. For me, it’s like the days just go click, click, click, click, click, and then we’re doing another one. It’s kind of nuts. Robert Pearl: It’s just a question. When you’re having fun, time passes rapidly. Zubin Damania: Oh, the flow state argument? Robert Pearl: Yeah. Yeah. Zubin Damania: Yes. There’s that as well. There’s that as well. Robert Pearl: I thought of you the other day. I was talking with an ER physician and an ER nurse. They were passionate about patient safety and frustrated by how difficult it was to make systemic improvements. They reached out to me wanting my thoughts and advice on how to get people to do what seemed so logical: save lives. They pointed out the extensive research that had been done on the topic of safety, going all the way back to Ralph Nader, the car industry, aviation history. I acknowledged the frustration they felt. I talked with them about a personal experience. Chronicles my first book, Mistreated, about my father’s premature death from preventable medical error. I offered my view that when logical things don’t happen, like systemic improvements for patient safety, there’s always another factor, one that’s either not visible or not being considered. I said that based on my experience, you can’t solve the problem staring you in the face without bringing the other one out from the shadow and addressing it. If it’s okay with you, Zubin, I’d like to learn from your insights about what’s not being seen or said about a few of these seemingly obvious opportunities. Let’s start with patient safety. Over 200,000 people die every year from medical error. Research shows that most result from a combination of systemic problems and a failure of people to follow evidence-based approaches. Seems like a no-brainer to me to follow the experts. What’s not being recognized when it comes to patient safety? Zubin Damania: Oh, man. Okay. “Hey, let’s do a podcast together, Z. It’ll be fun,” you said. “It’ll be easy. It’ll be flow.” Then you ask a question like this. Robert Pearl: It’s easy for me to ask the questions, Zubin. That’s what I meant. Zubin Damania: I know. This is a question that I wrangle with almost every day, especially since my father is in and out of the hospitals these days. I’m always terrified because I know all the statistics you just said apply, and it’s not one of those vague things. They apply personally. You told your story about your father. I was there at Stanford, I think, when your father was there. Let’s speak about it honestly. A lot of it that’s unspoken is the shadow culture of medicine, I think, that really, it’s inertia-driven. We are fear-based, so errors of omission are actually punished or are considered more powerfully than errors of commission. What we fail to do is actually, we worry more about malpractice than what we actually do, so we tend to do a lot of stuff. Each thing tends to have its own downside, including a certain level of unnecessary testing and screening and treatment that has consequences. Iatrogenic, the physician-caused, medical system-caused consequences. But we’re acculturated to actually do things to people to some degree, to avoid getting in trouble for the opposite, which is failing to do something, failing to do the scan, failing to do the procedure that actually, it may have been better not to do. In the house of God, Sam Shem says, “One of the rules of the house of God is, do as much of nothing as possible.” I think there’s that cultural component, but then there’s the autonomy component where I think many people in healthcare don’t want to be part, or they want the support of a system, but they don’t want any infringement on their perception of autonomy. If you’re doing a root cause analysis or you’re going through a just culture algorithm for dealing with patient safety, I think some physicians feel like, “Well, they’re telling me how to practice. This is stepping on my autonomy and they are bureaucrats doing this.” To some degree, maybe that’s true in certain settings. But in others, this idea of a systemic, thoughtful and somewhat algorithmic, meaning there are some algorithms that actually are shown, hey, you just got to go through a checklist when you’re flying a plane. Why wouldn’t you go through a checklist in the OR? Why wouldn’t you make sure you’re not operating on the wrong side? All these other things. But we resisted as a culture, the culture of cowboy autonomy. The culture of individuality has been ingrained into medical training. Then the fear-based stuff, really, I think prompts us to do things to people that probably result in harm just in and of itself. That’s just a tip of the iceberg, I think, in terms of patient safety. Robert Pearl: Let me ask you about another area that I know is very close to your heart, and this is about high-functioning teams. We live in an era where medicine is complex. Patients often have multiple chronic diseases. You can’t achieve the best outcomes as lone cowboys and cowgirls, you just said, and yet rarely do we put in place highly effective, highly functioning teams. What’s not being said that’s getting in the way? Zubin Damania: I think again, it is we’re conditioned as these hierarchical agents in healthcare, that a team is another way of either saying, I’m the boss and you guys are going to listen to me, you’re my support. Or they’re trying to usurp my autonomy by giving me this “team”. I think that’s some subtext to it, not always. Again, we’re conditioned not to like our autonomy taken away. The other problem is I think we don’t allow people on the teams to really practice at the full extent of their abilities, with the support of the team. We give them these pigeonholed roles and that makes it difficult. Then we don’t have a culture that really elucidates the brilliance of a team as well. It’s still a lone wolf culture, but then we go, “Oh, but there’s a team.” Then it becomes a dominator hierarchy where there’s somebody who is the boss on the team and everybody else is just doing scat. That’s one outcome that can happen. We haven’t actualized team-based care. The real team-based care is everybody’s living their most actualized piece and it’s self-managing and self-governing. At our clinic, our team, there’d be a different member of the team that would lead the huddle every day, and that could have been a health coach with no formal medical training that was trained on the job or hired for certain attributes, and then allowed to use those in service of the team. It was a growth hierarchy that we were trying to build there, but it involves culture shift, training shift, system shift, technology shift. Why shouldn’t you be able to all write in the same note in the EHR at the same time? That was something that we explored when we were building our technology. Robert Pearl: All right. One more. How about the disparities and health outcomes based upon race? We certainly know they exist, but we don’t seem to be making any progress. What’s not being said here? Zubin Damania: Oh. Oh, man. You make it so easy, Robbie, so easy to hurt yourself. Really, would you hit those hard topics that are difficult? Again, there are so many people who can weigh in on this, and I’ve interviewed people like Ian Tong, Black doctor, and his perspective was very, very valuable in helping me understand it a little better. But yes, there’s unconscious bias. Yes, we use heuristics in medicine that are often unconscious, sometimes they’re conscious, to pigeonhole patients quickly. Could race be a part of that, that could then lead to unequal outcomes? Sure. But I think actually, there’s also the component of yet we don’t have enough minority physicians, physicians from different socioeconomic backgrounds that take care of patients, because that seems to be associated with better outcomes because there’s more understanding of the community. The way we tried to hack that problem is we would get health coaches who were drawn from the community they served, and often were in the same socioeconomic status as a lot of the patients we were taking care of. That helped a lot because they were developing these trusting relationships and really understanding the patients. Not just the social determinants of health, but what their goals and hopes and aspirations were, so that we could tailor care. But then there’s the bigger elephant in the room, which is we are dealing with the societal issue of inequity that has been generations in the making. It falls on the healthcare doorstep to say, “Hey, fix this problem.” But the truth is, this is a massive problem that comes from cycles of violence in communities of color and poverty. All the things we reduce to social determinants of health are actually incredibly nuanced and complicated things that don’t have a simple, let’s have a quality of outcomes answer, and even a quality of opportunity. How do you accomplish that? Even in medical admissions, how do you accomplish that? That’s where again, the further we get out from the original sin, say of slavery say, the further we get out from that, the more we have to think. Okay. We need to start to wake up in a broader way that changes society, that then will ripple through healthcare. But again, those things that are our direct purview, we need to address, but it’s hard. Robert Pearl: Let’s shift a little bit. Did you have a chance to read the report by the Surgeon General on burnout this week? Zubin Damania: Well, I just got to say one thing. I love it. You throw this on my lap, I answer the question in a hand-waving way, and then you’re like okay, moving on. I’m like, “What about you, Robbie? What do you think about it?” Because I know. I’ve read your books. You think about this stuff clearly. But all right. All right. Robert Pearl: No, I will answer you. To me, there’s a lot of unspoken things. I think each of these types of problems exist, and I think that there’s a level in which, and I will even say the majority of people have call it implicit bias, call it acting in racist kind of ways. They’re not consciously racist, but I think they make those decisions and they have trouble seeing that in the mirror. It’s uncomfortable, and that’s why I always bring up these issues. Because as long as we want to say that racism as an example, doesn’t exist, then we’ll talk about the problems, but we won’t solve it. To me, you look at the issue of gun violence. What do the gun proponents want to say? It’s all about mental health. Well, it’s not. But why do they say that? Because they can’t win the argument about keeping high-firing, multiple-round guns out of the hands of 18-year-olds who are socially isolated in high school. And the consequences are predictable. But if you don’t want to talk about the problem, you find someplace else to focus and you dismiss it. That’s who I see again and again in medicine. If we just look at this question, why don’t we have high-functioning teams, it’s what you said. Because people like their place in the hierarchy and they’re not about to give it up. On the other side, the question’s really going to be, how do you create a high-functioning, equal team of people with different levels of expertise and experience? Zubin Damania: Yes. Robert Pearl: This is the kind of questions we never address. My frustration, why I write the books, why I have the podcasts is for all of the time we talk about these things, when I measure progress, it’s in inches. It’s not in miles and hundreds of miles that we should be going. I look at the outcomes in medicine. What are we seeing? We’re twice as expensive as any other country in the world and our outcomes are lagging. I just can’t believe I look at data on maternal mortality and I see it’s four times higher than other countries. It just jumps out at me, and that’s again, why gun violence to me is another example of that. Look how many more guns we have in the United States. Look how many more people are getting killed. I think other countries have some mental health problems, too. So, why don’t they have the same level of difficulty? If it’s not the guns, what is it? It’s somehow sitting in the political process that we have. You’re hearing me just being frustrated by the slowness of change and the waste of human existence. Zubin Damania: What you’re pointing at is repression and denial, and projection and all. It always comes back to us. It always comes back to the human at hand. Personal growth, we’re avoiding that. When you talk about implicit bias, for example, yes, of course, of course, of course. You know how we know this is true? Because all of us have it. If you actually introspect, you’ll see it arise, and instead of acting on it unconsciously and automatically, you’ll actually go, “Oh, wow. Well, there’s a little bias. Let me think about that and act more responsibly.” But it requires introspection. It requires looking at these difficult things, whether it’s guns, whether it’s race, and that’s why it’s so uncomfortable. We feel it. Even talking about it, it’s like, oh, I get a little constricted because you’re feeling your own stuff and you’re going, “Ooh, am I missing something in myself?” That’s why we got to have these conversations, brother. I ditched your question on the burnout thing because I haven’t read the report. So fill me in. Robert Pearl: He pointed out, as we all know, that it is a major problem. I don’t want to say he underestimated. I just don’t think he detailed it as much as he should. He talked about a variety of things. He said, there’s a need for living wage and paid sick time and family leave, evaluation of workloads and staffing, which is all true. He talked about reducing the documentation and other administrative b…
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