Episode 20: Looking Toward the Future: Part 2

How will today’s technological advances empower patients in their health care and ease the strains on providers? What are the key actions that will make care safer, more accessible, and more affordable? Join Dr. Robert Pearl, a leading medical voice and premiere visionary, and host Karen Wolk Feinstein as they share reasons for optimism about the future of the healthcare industry.

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Episode Transcript

[00:00:00] Robert Pearl: This is not a problem unique to health care. It exists every place where the incumbents like what they have and they’re blinded to what might be coming, and I think this is the time for all of us to be able to try to push the system forward with the idea that we can, keep care affordable, if we can truly increase quality and do convenience using the best operational approaches and using the best technology.

[00:00:34] Karen Wolk Feinstein: Welcome to Up Next for Patient Safety. We continue conversations with the most interesting people doing important work toward our common goal of making healthcare safer, but also more reliable and even more satisfying for both patients and practitioners. I’m your host, Karen Feinstein, president and CEO of the Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative, which is a multi-stakeholder quality collaborative located here in my hometown, but with statewide, national, and even global links.

We’ve been working to reduce medical error for 25 years, and I will say, we never believed progress would be this slow. I do know that revolutions come from hope and not despair. I’ve found that these conversations inspire me with hope as we hear from safety leaders of distinction.

This episode is part of a three-part series on the future of health care. We’ll be joined by some notable futurists who will share their insights on where health care is heading and how to ensure that patient safety will be part of this future. Given the challenges facing health care today, many exacerbated by the pandemic, even if longstanding, we wanted to hear where these experts envision the industry moving toward a safer, more trustworthy future.

In this episode, we’re joined by one of the leading medical voices and premier visionaries in the industry today, Dr. Robert Pearl. We’re sure to have a lively conversation around how to solve health care’s most pressing problems, and also a vision into the future.

Dr. Pearl is the former CEO of the Permanente Medical Group, and former president of the Mid-Atlantic Permanente Medical Group. In these roles, he led over 10,000 physicians, staff, and was responsible for the nationally recognized medical care of 5 million Kaiser Permanente members on the west and east coast.

Named one of Modern Healthcare’s 50 Most Influential Physician Leaders, Dr. Pearl is an advocate for the power of integrated, prepaid, technologically advanced, and physician-led health care. He serves as a clinical professor of plastic surgery at Stanford University School of Medicine and is on the faculty of Stanford Graduate School of Business, where he teaches courses on strategy and leadership and lectures on information technology and healthcare policy.

He’s the author of the bestselling book Mistreated: Why We Think We’re Getting Good Healthcare and Why We’re Usually Wrong, which offers a roadmap for transforming American healthcare and also the book Uncaring: How the Culture of Medicine Kills Doctors and Patients. All proceeds from both books go to Doctors without Borders.

Dr. Pearl hosts his own popular podcasts, Fixing Healthcare and Medicine: The Truth. He publishes a widely read newsletter, Monthly Musings on American Healthcare and is a regular contributor to Forbes. And he will be featured in an upcoming documentary that we’re producing on tech solutions for patient safety, which will be released in the spring with Tall Tale Productions. So, welcome, Robert. Let’s get started.

[00:04:01] Robert Pearl: Thank you for having me today, Karen. I look forward to our conversation.

[00:04:05] Karen Wolk Feinstein: I do too, and I’m sure our listeners do. You surveyed listeners to your own podcast about where they think health care will be in five years and posted the results on your blog. They were somewhat disheartening. What were some of the most common themes that you heard?

[00:04:21] Robert Pearl: Unfortunately, as you say, the results were quite pessimistic. Eighty-three percent of people thought that medical care would become even less affordable in the future than today. Seventy-five percent thought the number of uninsured would rise. Seventy-two percent thought clinician burnout would increase. Sixty-seven percent thought the patient’s satisfaction would decline, and only 13 percent believed that life expectancy would rise. And this pessimism is understandable given what has happened in health care over the past 20 years. But Karen, I’m optimistic. I believe that the opportunities are massive.

We have new technology coming forward. We have the potential of the empowered patients and ways that the healthcare system overall can be improved to increase quality, improve access, and make medical care more affordable.

[00:05:21] Karen Wolk Feinstein: And here’s a big question. Do you think healthcare systems will invest in the new technology, particularly that related to safety and taking the burden off their frontline staff?

[00:05:33] Robert Pearl: Clay Christensen, who is the late professor at the Harvard Business School, wrote several books about disruptive change. And he pointed out that in numerous industries, whether you’re talking about computers, whether you’re talking about steel, what you saw is that the incumbents rarely lead the process of change.

Instead, what they see is that the current way that care or industry is provided is in their interest, and even though they could lead the process, they rarely do, and I fear the same is going to happen in health care. I’m a clinician. I’m a physician. I hope that’ll be led by doctors and nurses and hospitals, but if I had to bet, no, I think it’ll actually be led from outside the healthcare industry. And if I had to, again, make a bet, it would be on the retail giants, the Amazons, CVSs, and Walmarts of the world.

[00:06:37] Karen Wolk Feinstein: Well, they certainly have changed commerce. Not only commerce–those same giants have changed the way we live, the way we shop, how we think about our relationship to consumer goods, so no reason not to think that they might have this profound impact on health care.

[00:06:55] Robert Pearl: Well, more than that, they’ve already taken steps in that direction. You have Amazon that purchased PillPack, a pharmacy company. They purchased One Medical, a national primary care organization. They already are providing care on site and virtually to various self-funded businesses. You have CVS that has an insurer, Aetna, they purchased. They provide pharmacy services. And they just purchased Oak Street, which is a primary care organization. And they also purchased Signify, a home health agency. You have Walmart that signed a 10-year deal with UnitedHealthcare. UnitedHealthcare employs 10 percent of all American physicians, not the contracted method, but directly employs them, and they’re in negotiation now with ChenMed, which is one of the leading primary care groups, and all of them are looking for opportunities to have a greater share in what’s called Medicare Advantage, the prepaid form of Medicare.

So I think they already are moving forward, assembling the pieces, and over the next five to ten years, we’re gonna see them not just augment health care, but actually displace the current leaders in the field.

[00:08:11] Karen Wolk Feinstein: And it’s interesting to me, I don’t sense the kind of panic that you would expect among the legacy players.

And the other issue I have is, They don’t seem to want to be bold, look at the horizon and say, we’re going to have to change to catch up. You know, I can’t get any of the leaders of, I call them all the initials, that oversee physician, nurse education, etc., I can’t get anyone to come to the Consumer Electronics Show with me, just, just to have some idea of what’s coming around the corner because I always get a very good idea of the future when I go to the CES, but I can’t get anyone to be excited about understanding where technology is going. Do you encounter that?

[00:09:02] Robert Pearl: Well, absolutely. I mean, that’s why I mentioned Clay Christensen’s work because this is not a problem unique to health care. It exists every place where the incumbents like what they have and they’re blinded to what might be coming, you know, when I was first selected CEO in Kaiser Permanente. I got a chance to speak at the Oregon Health Sciences building. And at the end of my talk, I had about a half hour before I had to go to the airport. And I walked along the corridor and I saw a sign there that I often think of these days. There in big bold letters across the top, it said, Quality. Service. Cost. And below is small letters, it said, Pick any two. And that was the mentality of the 20th century. And I think the incumbents who grew up in that era still think that that’s the best that we can do.

And I’m a big proponent of what’s called value-based care, as I know you are, as well. And I define value-based care as the ability to lower costs, make care more affordable by raising quality and improving access, by keeping people healthy and avoiding heart attacks and strokes, by avoiding medical errors that lead to prolonged hospitalization and more costs, by avoiding the 400,000 deaths each year from misdiagnoses by treating, preventively, chronic disease and avoiding hundreds of thousands of deaths.

By the time we take the 250,000 people who die from medical errors, 400,000 misdiagnoses, several hundred thousand more from chronic disease that could have been avoided or better managed, you talk about a million Americans dying every year, and it’s costing us a lot of money to let them die rather than investing in keeping them healthy.

[00:10:58] Karen Wolk Feinstein: I know that maybe not all the people running our health systems and all the CFOs are very smart people, but a number of them are. And they’ve decided, right, that they actually don’t need to work hard at being the safest place to get care, the place that is most reliable, the place with the happiest frontline workers.

They’ve decided they don’t have to be best because unlike other industries, they’re really not that competitive. So what surprises me is, Where’s the public? Where are the patients and where are the employers, where are the purchasers? Why aren’t we saying, We don’t want to buy from you unless you are the best?

[00:11:48] Robert Pearl: Let me step back a half step before I get to the patient, because I think it’s important to put the patient in the context of the health care system. Charlie Munger, who died, Warren Buffett’s former associate and partner, said, Tell me your incentives, and I’ll tell you the outcomes you’re going to get.

The United States healthcare system is paid on a fee for service basis. The more you do, the more you get paid, whether you get a good result or not. And by the way, as you know, often, not always, Medicare is different, but in most areas, if you have a complication, you get paid twice, first to create the complication and then to try to take care of it.

In fact, there was a study that showed that if hospitals eliminated medical errors in the operating room, their revenue would go down dramatically because of all the added hospital days and additional procedures that follow a medical problem resulting there. So I think the incentive system, a fee for service, the more you do, the more you get paid, whether there’s any good doesn’t really matter, is why they don’t care as much.

I don’t think they’re, you know, they are almost all of them smart, and they are caring, but the incentive system blinds them, is how I think of it. And that’s where I think the patient gets stuck. Because if I asked you, the local hospital near your house, what’s the hospital-acquired infection rate? You are one of the few world’s experts on patient safety, and I defy you to tell me what that infection rate is in your local hospital, where you might need to go for care or family member might need to go for care. So I think the medical profession has hidden it. Now again, not with a nefarious purpose, but simply because it is not particularly important. And in a fee-for-service world, that’s not how you compete.

You compete by shiny objects that attract people to come to your facilities, particularly for the most expensive, most complex care.

[00:14:05] Karen Wolk Feinstein: So I love what you’re saying. I mean, I don’t love it. I probably hate it, but I agree with it. We have in our state, one of the best mandated public reporting systems–it’s pretty reliable–called PHC4. But of course even PHC4 has to deal with some data that get doctored. People I know in the health professions do not consult it before they go in for serious surgery. I don’t even know what to say. I mean, we’re lucky to live in a state where those data are available. But I’m heartbroken, and all the people who call me and say, I had a terrible experience with Surgeon X. And I said, Well, did you check the PHC4 data? And they didn’t.

So here’s something that mystifies me. Picking up on what you just said, Harold Miller and I wound up on the cover of Modern Healthcare a number of years ago for doing a study that showed how hospitals make money on hospital infection. We go to a meeting at the hospital council after, our local hospital association, after the article had come out, and nobody’s mad at us. So we say to the CFOs, You’re not mad at us? They said, No, we knew that. So, I don’t know what to say, but here’s my quandary. Since I do love to travel, I’ve been around the world to many different health systems that get better outcomes than we do and that are not on a fee-for-service basis. There is absolutely no incentive in England, Australia, New Zealand, Israel, a lot of the countries I’ve visited, there’s no incentive the way we have in our system to do more, make more, but they also are full of medical errors. They haven’t, they haven’t aced the safety issue either.

[00:15:56] Robert Pearl: You want my thoughts why, you mean? I think this is, I think there’s two parts to it. The first is there is a, I’ll say, a global medical culture, and it’s a medical culture that elevates those clinicians who intervene rather than those who focus on prevention.

We elevate the interventional cardiologist who unblocks a patient who’s having a heart attack. And we underestimate in every nation, primary care. who is able to prevent the heart attack in the first place. Add 10 primary care physicians to a community–longevity goes up two and a half times more than adding 10 specialists.

And we train a lot of specialists, not enough primary care. Other countries train more primary care, but they still elevate the status of the specialists. So intervention salvage is the type of area that we see more of, and so people don’t invest the time in prevention, not because the economics in their country might not be oriented there, but just simply because we don’t value it. We don’t have as a high norm in the medical profession.

But I still think that if you dig down inside those systems, even though at first glance they may be government funded, what you see in the end is that the people providing the care still get their income related to the volume of work that they do because I’ll use the word capitation, which for listeners who may not know what it means, it’s paying a group of doctors and hospitals a set fee to take care of a population of patients. And once you do that, and there are risks for the consequences, they do best when they prevent disease in the first place. They do best when they avoid a medical error, preventable medical error. They do best when they don’t make a misdiagnosis. They do best when they are able to have the safest facilities.

And the best management of the types of diseases that lead to those very expensive, life-threatening problems. And despite all the conversation, we don’t see a whole lot of that. Now, other countries are better than the U.S. simply because they force a different ratio of primary care to specialists. They do it by a heavy-handed government. We don’t have that right now in the United States, but I think that that’s why you’ve seen not as much attention to patient safety as there should be. But I can tell you again, when I was the CEO in Kaiser Permanente, we made that a very high priority. We cut preventable errors down by at least 50, probably 75 percent.

And you have to do it out of leadership. Saying it’s most important and if leaders are talking about three other things being more important, whether it’s new patients or revenue or profit, whatever it might be, a building expansion, then people don’t hear the message and they don’t value it as much as they should.

[00:19:08] Karen Wolk Feinstein: I’m hearing what you say. My husband went to university in England for a couple years, Cambridge and the student who was top in the class went to medical school and became a general practitioner. Now I have my American mindset on, right? And I said, why would you be a GP when, you know, you could be a plastic surgeon, you could be an orthopedic surgeon, you can be anything you want.

And he said, because the GP is highly regarded in England. If we get it wrong, nothing goes right. And so, you know, we’re kind of the Sherlock Holmes of health care. And he said, That’s where your brightest students should go. How is that for flipping the norm in the United States? [00:19:56]

[00:19:56] Robert Pearl: Absolutely, you know, and I often talk to physicians in primary care in the United States who say we don’t get enough respect because we don’t make enough money. And I often say, no, it’s the opposite.

The amount of dollars you’re going to get paid is going to have to do with the respect. And we know that when you look at the salary structure of many of these nations, including Great Britain, what you see is that primary care physicians get paid as well as other clinicians because their contributions are well valued in a national healthcare system that is going to be strained increasingly if the demand for care goes up without the resources to meet it.

[00:20:40] Karen Wolk Feinstein: Yeah, and the sad thing to me in some of these countries is the specialists are now going outside their regular workday and seeing patients, you know, just so they can add to that sort of base salary.

There’s something interesting to me about what you say, and give me your comment on this. I was surprised, the very recent Commonwealth Fund Study Tour, we went to some Pacific Rim countries and Singapore. And they were talking a lot about how they are now putting much more pressure on the public to keep themselves healthy.

That putting, they said, well, if we put a lot of energy, this is hard to believe, in easy access to primary care, then we’re taking away the responsibility that everybody should take for their welfare. It’s, it’s this, it’s a social good. You owe it to your country to take care of your health. And, you know, as an American, I said, are you kidding me? You know, I’d get hung out to dry here if I started saying, We should put more burden on the patient to stay healthy. What’s your perspective on that?

[00:21:55] Robert Pearl: This is a terrific question because one year ago I would have given you a different answer than today. So it’s changing fast. And what happened in that one year? Something called ChatGPT. If you go back a year ago and we said that to a patient, the patient has a few things he or she could do. They could certainly make sure they got some more preventive screening that maybe now they wait on. Maybe they could decide to exercise and eat a better diet, although they wouldn’t be quite sure how to do all of that.

And I think that the expectations of patients in the past were almost, were very difficult to accomplish. And that is about to change. I don’t mean the ChatGPT or generative AI systems that are available today. They’re doubling in power every year. And by five years from now, they’ll be 30 times more powerful. Ten years, a thousand times more. I’m talking about the ones that are five years away. And now we have the ability that I think of as the empowered patient. And this to me is the holy grail of medicine. It is the way that we are going to be able to rebalance the demand for care against the supply of doctors’ time, which today is inadequate in the United States and actually in most countries based upon the recent Commonwealth Fund survey of primary care, to be able to meet that demand without just running faster and faster on a treadmill. And you and I both know what happens when you run faster and faster on a treadmill. You make a medical mistake because you have to cut a corner.

So how, why am I so now bullish on this empowered patient? And I think of it in three ways. First of all, we’ve already talked about this opportunity for the patient to obtain preventive services and once, not today, but once the generative AI is connected to the EHRs, and maybe multiple if you have several doctors that are unconnected to the health system, we know what care you need. The application can arrange, can monitor that, notify you, schedule it, arrange your transportation.

Already it’s being used to provide better menus to the specific problems, the medical problems of the patient. It can certainly organize exercise and provide programs. Understanding how powerful this is at prevention, I think, will allow the patient to be able to do more for him or herself. But I want to go way beyond that, because a second level is chronic disease.

As you know, chronic disease affects 60 percent of Americans, and it accounts for 70 percent of costs. And chronic disease by its name, you have it every single day. And how do we manage it? Come back to my office in four months. No, that doesn’t make any sense at all. Connecting the patient. From wearable devices and from monitors off of glucometers and other places into a generative AI can now allow the application to tell the patient every day how they’re doing and when they’re not responding to antihypertensive medications appropriately, it can point that out.

And doctors can change the medications without having to see the patient, because the wearable device is accurate, the analysis has been accurate, now all they need is someone to write the appropriate prescription sitting in play. And already these tools are as good as physicians, and in most studies, better than doctors at making diagnoses.

We know that it scored the top 10 percent on the licensing exam for physicians. We know that when you give complex problems, out of the New England Journal of Medicine, to doctors and to technology, that the current technology scores better. We also know, by the way, in responding to patients that it delivers more empathy and when these tools get more powerful, patients with the kinds of problems ,we’re talking about basic rashes, we may be talking about some musculoskeletal problems, viral infections, the technology can establish the diagnosis, and now going way back to you started with your question, we can empower patients to do their part, which is a combination of prevention, disease management, and diagnosis, and be able to free the time up for the doctor and improve the doctor-patient relationship, because there’s no longer that rushing through the visit to get to the next person in a way that raises quality, improves access, and lowers cost.

[00:26:47] Karen Wolk Feinstein: I am thinking that what you just said is so prescient and such a window into our future, that my relationship with my doctor is going to be very different. They’re going to say, Hey, how did you use your Apple Watch? How are you using your iPhone? What are you doing about your arthritis? What are you doing about this and that?

Because you have the power to fix it instead of the usual, Hey, magical physician, fix everything that’s wrong with me. It’s a very different relationship, but I’ll also add one thing to your list. How about experimentation? So I decided to test on my iPhone how is my sleep? By the way, before I had an iPhone, I didn’t know quarter from REM from deep sleep, but you know, now I know my sleep patterns.

How is it affected by either drinking bourbon in the evening, wine, or beer? Okay. So I did my own experimentation. You know what? It is affected, by the way– bourbon is the worst–but I’m saying we’re going to be able to do our own experiments. I mean, that would fundamentally change what I talk about with my doctor.

So I think this is a very exciting new era. But here’s my big question. What are we teaching in our medical schools and our other, you know, the other primary care schools where we train professionals? How are we preparing them for this new, it’s only new to U.S., by the way. If you go over to the Pacific Rim, go to Australia, New Zealand, go to Singapore, by the way, this isn’t new, but it is new here. How are we going to prepare them? There’s so many things we’re not preparing them for in this new world of generative AI and all of our digital devices. But how are we going to change education? I think we’re preparing them for things they don’t need anymore and not preparing them for this new world.

[00:28:48] Robert Pearl: I completely concur, but this is not in any way a new problem. You know, if you look at how do we select medical students and how do we grade them and evaluate them when they want to apply for residencies and get the best positions, it’s predominantly based on memory. We give them 10,000 facts and ask them to commit them all to memory, and the ones who can have best recall get the highest scores.

Now, why did we do that? Because prior to 2000, that’s what we had. You couldn’t go race into the library every time a patient told you something to be able to look up a textbook. It just wasn’t possible. So memory was the main skill that doctors needed to be able to have, along with the compassion and the human to human relationship and the doctor-patient relationship.

Something happened in 2007. Well, the iPhone that you had described earlier, we now have that ability, from 2007 forward ,to be able to find that information by reaching into your pocket and pulling out this little device. And did medical schools now start teaching doctors how to use that iPhone? No, they didn’t.

In fact, they banned them from exams. You would have insisted they bring one. Like you bring a computer to answer the questions. You should have an iPhone to be able to research, because that’s the situation. But they stayed in the 20th century. And then. We had telemedicine. A decade ago, I wrote a piece about how it would replace 40 percent of what doctors did, and until COVID, it was used by low single digits.

COVID changed it, of course, because clinicians became afraid of having patient to human encounter for disease spread. And so it soared to 60 percent. And now it’s dropped back down. No, we keep missing those pieces, because the technology of the past has been designed around maximizing the physician. And if a physician thought that memory was a better way to get recognition, rather than using an iPhone, or felt that an in person visit, as most doctors did, it was superior to a virtual one, even though it’s so much more convenient for the patient and so much rapid, more rapid to accomplish, that’s what we kept doing. And we often, at the same time, bought operative robots that slow down the surgeon, raise costs, and have never been shown to extend life or avoid complications, despite the multi-million dollars that they cost, but that’s another story. Why do am I so bullish on and I keep using the word generative AI or ChatGPT?

Because it’s different than the AI that’s existed to this point The AI up to this point has been designed around doctors using it, like the old technology, radiologists using it to read mammograms, or ophthalmologists using it for retinal scans. Generative AI is not the same. It actually becomes empowering to patients.

You don’t need your doctor to tell you what to do. You’d like the doctor to offer ideas, to go into your computer, to help you align what you’re doing with what the doctor thinks should get done. But today, even on this very primitive, and I call it a toy version, GPT-4, you put all your medical information in place? It will give you very reliable outcomes. There’s a story of one of the professors from Harvard in economics, who was hospitalized with the most severe abdominal pain and his doctors basically told him he was fine. Maybe he had some gallbladder disease. And he checked with ChatGPT and said, you know, you got a 40 percent chance of a ruptured appendix. You better make sure they’ve done an MRI. And of course, when they did it, they found the ruptured appendix that could have been life threatening. I’m not telling listeners to go and use it for your own medical care today, but go use it to see what it might be like. And the more information you put in place, the more specific questions you ask, the better the answer is going to be.

As I say, every study that I’ve seen shows that the technology can match. The average physician today, and by five years from now, it’ll be better than the best.

[00:33:14] Karen Wolk Feinstein: So, I try to think about who’s aligned with my interests. I’m wearing my patient hat, not purchaser, not student of the healthcare system. As a patient, who’s aligned, who should be aligned with my interests?

So I think of, Medicare and Medicaid, maybe CDC, and certainly the Joint Commission. Why do I not feel that they’re aligned with my needs? And if you were talking to them, what would you tell them?

[00:33:48] Robert Pearl: They’re not aligned. It’s not that they’re not aligned. They just don’t, I’ll say, have the motivation and ability to move forward quickly.

Why is that? Medicare and Medicaid is a political process. Very little major change can happen without congressional approval. You just take a very simple area, which is the interoperability of electronic health records. If you’re sitting in a typical community, you might see three or four different physicians if you have several chronic diseases, and most likely their systems don’t talk to each other, and none of them talk to the hospital, which is probably on an Epic or a Cerner system.

That’s the problem. We could solve that if we open what’s called the Application Programming Interfaces, the APIs. There actually is a rule that says they should be doing it, but they’re not doing it. In the same way that hospitals are not really disclosing what it costs to get care so far, despite the fact that it exists.

But a major overhaul would require congressional votes, and as you know very well, today that’s essentially an impossibility sitting there. The Joint Commission is similar. I mean, the Joint Commission is there to help regulate hospitals, to keep them open. It’s not designed to be able to drive change. I have a lot of respect for the work that it does.

The idea of transformation. Of making something really different, of really shifting from fee for service to a capitated model. Well, Medicare’s done it, Medicare Advantage, but outside of that, no one really has the oomph and ability. And again, it’s why I see the retail giants stepping in, not because they are so motivated to do good, but because it’s in their economic interest to be able to do that.

If any of them can capture 10 percent of the 4 trillion healthcare market of today, that’s 400 billion dollars of added income. It would double what already is one of the nation’s six largest businesses.

[00:35:49] Karen Wolk Feinstein: I wish they would listen, would listen to you. So, I call them my, now my quadruple traumas. We’ve been through a lot of trauma as Americans over the last three and a half years, but I worry that we didn’t learn much from the pandemic.

Give me your perspective. Are there things we learn that will permanently prepare us for just a better approach to infectious disease and a better approach to giving Americans trust in their healthcare system and their health providers? What impact, lasting impact, did the pandemic have and what do you think it should have had?

[00:36:30] Robert Pearl: I don’t think we learned very much at all, at least as measured by its ability to change care delivery. We’ve known for a long time, as an example, that what’s called the social determinants of health has a three times greater impact on how healthy you’re going to be and how long you’re going to live than actually the medical care you receive.

We know it’s probably the leading factor. I had a chance to speak at a conference in Rochester, and I saw a map. Five miles apart, there was a 15-year gap in life expectancy. Born in one zip code, you’re going to live 15 years longer than being born five miles away. This is the impact. We saw the problems of COVID in terms of public health. We saw people dying—so 88 percent of the people who died in New York City had two or more chronic diseases. We saw the issues around discrimination and racism. We saw problems with access to care. I could go down a litany of things that we saw we should have learned from. And at the end, we haven’t changed anything different.

Our public health systems today, our focus on social determinants of health is no better than it was before the pandemic, and it shouldn’t surprise anyone that our life expectancy came out last week. It’s still a year less than it was before the pandemic, basically unchanged from 20 years ago. We’re the only nation in the world, by the way, because other countries do make these investments. So we should have learned. We should be changing our policy. We should be investing more in these nonmedical, nontraditional medical areas. But we didn’t learn that lesson.

The second one I alluded to earlier is telemedicine. It worked. I’m not aware of a single patient who suffered harm, who didn’t get excellent quality care, and yet outside of mental health, we use it still single digits. And I don’t mean using it just for patients. Connecting doctors. When I was the CEO in Kaiser Permanente, we put in place a system where if a patient was seeing a primary care physician and needed some expertise for an orthopedist or a cardiologist, we brought that specialist into the primary care physician’s office using video.

And 40 percent of the time, we totally solved the problem in a matter of minutes. And another 30 percent, we started the workup so when the patient saw the specialist, they weren’t starting at time zero. And the cost of doing that was minimal. But we forgot about telemedicine as a source of solutions. All I’ll say is what’s different about generative AI is it’s not going to be driven by the doctor. It’s going to be driven by the empowered patient, who knows that he or she can use it, who can figure out the care they need, and the physician who doesn’t want to provide it in the most high-quality, convenient way, at a cost that’s affordable, I think the patient will start, as you had mentioned earlier, finding someone who will.

[00:39:49] Karen Wolk Feinstein: I am hoping that your insights and reflections get to the highest places because so far, I’m very excited about everything that you’ve said. So let me ask you about something that is troubling to me. So I look at the satisfaction surveys for nurses and doctors right now. I’m, I’m beyond shocked and appalled.

I, I can’t, I don’t know if I could imagine a more unhappy workforce. And I think we attribute a lot of that to the pandemic. We say, everyone’s just exhausted from the pandemic. It’s strained everyone and now people are just collapsing. Once things got better and the pressure was off, they realized that that they were drained.

What if that isn’t the reason they’re that unhappy? What if they’re that unhappy because they recognize that the things you’ve said should be putting in motion changes in education, in payment, and how we regulate and how we measure health care? You know, what if, what if it’s not the pandemic that is making our health care workforce so unhappy? It’s perhaps that the pandemic didn’t bring about changes that seem so obvious.

[00:41:10] Robert Pearl: I don’t believe that the source of burnout was the pandemic. I think it made worse the burnout that existed before that. For listeners who may not know the data, if you survey physicians now, 60 percent of them, maybe 70 percent, will say that they’re burned out.

And by that they’re exhausted. They don’t have fulfillment. They don’t feel that they’re able to do a good job. You know, Christina Maslach has described this in 1981. So it’s been around for 40 years. The pandemic made that worse. But if you ask doctors, and Medscape does a survey every year, why do you think burnout is so bad? They actually point to things uniquely present in the American healthcare system, the for-profit nature of American health care; the for-profit insurers who put in place bureaucratic tasks and prior authorization. The electronic health record that is really clunky. It was designed for billing and for claims and it’s not really that helpful for direct patient care.

Very uniquely American aspects. And again, if you had asked me six months ago, I would have focused on those areas because they are all problematic and they need to be fixed. But what struck me was that Commonwealth survey I mentioned earlier. If you take the 10 most wealthy industrialized nations, places like Great Britain and France and Sweden and the U.S. and Canada and Australia, I would have told you that burnout in the United States was going to be off the chart. I would have said in the same way that our country is so much worse in longevity, five years less than the other countries, or maternal mortality, where it’s twice as high in the United States, or infant mortality is twice as high in the United States as any other nation, I would have said we’d be off the charts.

I was shocked. We were middle of the pack. There were four above us and four below us. We were very average. And so I said to myself, well, if we’re average, then it can’t be the things that are uniquely American. So what is global? And this is where I came to recognize as this imbalance and demand against the supply of time that doctors have and I step back even further and said, what’s the next most common denominator or the underlying common denominator. And I think it’s the proliferation of chronic disease, because if I see you for an acute problem, which by the way two generations ago, that’s all doctors took care of pneumonia, appendicitis, trauma. But in chronic disease, I’d see you and I see you three, four, five times and then you’re healed. If I have chronic disease, I’m going to see you four times a year for the rest of your life. We have increased the amount of work, not because intentionally we’ve done it, but the diseases we treat, the environment in which we work, and so particularly, again, primary care because they’re the people who see the patient first, they’re just running faster and faster on the treadmill.

They can’t keep up. They go home at night feeling exhausted and feeling like they haven’t done a great job, and we’re talking about the classic symptoms of burnout. So yes, during COVID, those things also got worse. And it was made even worse than that because patients were dying. I talked to a doctor who lost four patients in the same day.

You know, I never lost four patients in a year. And here it was in every single day and they had to go back to work. But I think the underlying problem is this imbalance of supply and demand. And it’s why I’m so bullish on the empowered patient.

If you ask me, do I think it’s really going to happen? I don’t know. What did Yogi Berra say? The future is hard to predict, especially when it hasn’t come along. But what I would say is that it’s the only solution that I can see. I haven’t seen anything else that tells me how we can get this major imbalance back in line except to keep people healthier, avoid medical errors, avoid misdiagnoses and need to keep doing testing that’s going to lead you down a blind alley, maximize patient safety, all the things you’ve been leading across your career.

Now I think we have the imperative to do it. And I’ll add one more piece on top. I don’t know if you saw the survey, the results from the actuaries in the government, that looked at healthcare costs between now and 2031, and they estimated that it would go up 3 trillion dollars. I don’t know people who can afford to pay that kind of additional money. I don’t think the businesses can, I don’t think our government can. It’s not going to happen. And if we don’t change care delivery, what I worry about is we’re going to ration. And that I think would be the worst thing for the health of the nation and the spirit of our country.

[00:46:11] Karen Wolk Feinstein: I think we’re already getting closer to rationing. A number of people I know have concierge primary care. I don’t think that’s the answer. Not because it’s for the privileged, but because I honestly think the empowered patient, the sort of tough love that I’m seeing in other nations that actually have much better health outcomes than we do, and are every bit as developed and enlightened, I do think we’re all going to have to have shared responsibility with more of it placed on the population at large than it ever has been. I think it’s probably not an imperative, maybe it’s an ultimatum, maybe it’s like we don’t have much choice. We’re really in a very bad place if we don’t, and there’s a lot of potential.

It’s not just that this is out of desperation. I think it could be an improvement. In our relationships with our providers and how we get over the idea of “the doc god” is going to keep us well and we just do whatever we please. So this has been a terrific conversation. I can’t thank you enough. I think you have extraordinary insights. I’m so glad that we have the opportunity to bring those insights to the people who connect with us and listen to our podcast. So Dr. Robert Pearl, I cannot thank you enough for taking the time and I’m going to be watching for anything that you write or say as we go forward.

[00:47:40] Robert Pearl: Can I add one more thought to the conversation at the end? Because I think your comment just now was very accurate, which is about what’s happening relative to rationing of care. As a piece I wrote for Forbes, and anyone who wants to read any of this stuff, go to my website, robertpearlmd.com, and I talked about shrinkflation. You know, what’s going on right now, I bought a box of cereal and it was three-quarters full. It looked like I was buying the same product. I wasn’t paying that much more, but I was getting three-quarters of the flakes that otherwise had been there. And when I had that experience, like I always do, I go back and research something in healthcare.

And it’s actually interesting from 2010 to today, we have not seen healthcare costs rise as fast as they had previously. And I looked at that and I said, Well, why haven’t they risen as fast? And a lot of people would say it’s the Affordable Care Act and higher quality, but the quality has gone down. Longevity has been flat. Nothing that I can find objectively says we’ve lowered costs by raising quality or improving access for a lot of people. And I realized that what we have done is this shrinking of health care. That we have ,we haven’t overtly rationed it, but we’ve made it harder. I don’t know if you realize, 90 million Americans are on Medicaid. Medicaid is for the poorest of Americans. That means almost a third of our country, more than a fourth is poor, poverty level. That’s remarkable in our country. And I think what we’ve done is that we have figured out ways to do less care because anyone who belongs to Medicaid knows that it’s not the same as good insurance.

I think we may see this in Medicare if we’re not careful going forward. We’ve seen transfer of coarse costs from the government to the private sector in hospital payments. The article has a whole list of ways that we’ve managed to dampen costs, not by improving quality, but by limiting care. And it’s like so much in history, you don’t notice it until it affects you and your family.

But I fear that if costs try to rise by three trillion dollars, that many of the listeners who are today able to access good care are going to find that it’s compromised. And I think this is the time for all of us to be able to try to push the system forward with the idea that we can keep care affordable if we can truly increase quality and do convenience using the best operational approaches and using the best technology. Thank you so much for having me today.

[00:50:24] Karen Wolk Feinstein: I cannot thank you enough. And I will tell you, I think all of us, there’s probably not a listener here who hasn’t experienced just what you said. Dental, my dentist’s office said you can only see the hygienist once a year now. We don’t have enough hygienists to come twice a year. So forget that twice a year tooth cleaning. And my eye doctor had COVID in the first week in September. So they canceled my eye appointment and they moved it to November 29th. I said, What? And they said, Well, that’s the next first appointment.

But here’s the thing. I do think what didn’t come with either of them are (a) these are the reasons you should tell us if you need that eye exam sooner and (b) here are things you can do in lieu of seeing a dental hygienist that will keep your teeth and gums healthy. That’s the part that I thought was missing, but many of us could give you lots of examples. We’re seeing it everywhere. So I will continue to tune into your insights. Thank you so much for being such a congenial guru and an optimistic pessimist. And this has been a great conversation

[00:51:40] Robert Pearl: Until the next time.

[00:51:42] Karen Wolk Feinstein: Thank you. Up Next for Patient Safety is a production of the National Patient Safety Board Coalition in partnership with the Pittsburgh Regional Health Initiative and the Jewish Healthcare Foundation. It’s hosted by me with enormous production support from Scotland Huber and Lisa George. This episode was edited and engineered by Jonathan Kersting and the Pittsburgh Technology Council. Special thanks also to Lisa Boyd, Carolyn Byrnes, and Robert Ferguson for their ongoing assistance. Special thanks also to Arianna Longley and Lauren Payne for helping with the series.

Thank you for listening, and please take action, whatever you can do, to advance patient safety.