In Uncaring: How the Culture of Medicine Kills Doctors & Patients (published by Public Affairs), Dr. Robert Pearl, a Stanford professor, plastic surgeon, and former chief operating officer of Kaiser Permanente, writes a well-documented panoramic narrative and insider view that demystifies the complicated healthcare system. His book offers a disturbing look at healthcare system that has lost its purpose. Pearl relates inefficiencies and slow changes, as patient centric views held by physicians and systems that have failed to adapt, both to cultural and individual principles, held so dearly for decades.
Dr. Robert Pearl is the former CEO of The Permanente Medical Group (1999-2017), the nation’s largest medical group, and former president of The Mid-Atlantic Permanente Medical Group (2009-2017). In these roles he led 10,000 physicians, 38,000 staff and was responsible for the nationally recognized medical care of 5 million Kaiser Permanente members on the West and East Coasts. Named one of Modern Healthcare’s 50 most influential physician leaders, Pearl is an advocate for the power of integrated, prepaid, technologically advanced and physician-led healthcare delivery. He serves as a clinical professor of plastic surgery at Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business, where he teaches courses on strategy and leadership, and lectures on information technology and health care policy. robertpearlmd.com
One of his central ideas is that the current U.S. healthcare system is hurting more than helping patients. He notes the inability of healthcare over the years to respond to systematic and logistic changes, as well as healthcare’s resistance to change. People at the helm and those in healthcare, he argues, have become drivers of the healthcare enterprise, placing money over patient and community needs.
The author provides a systematic analysis of healthcare, illustrating individual silos, which lead to a fragmentary system with poor outcomes and high cost, a system which does just the opposite of its intentions. Pearl tries to outline plans and ideas to fix the system. Historically, most Americans, thought doctors exhibited high moral standards and social status, with hearts of gold and solid ethical principles. However, with skyrocketing healthcare costs, complex medical bills, and poor results and outcomes, public skepticism has grown. Healthcare bills are the leading cause of personal bankruptcy in the United States. The COVID-19 pandemic reenforces the author’s call for improved healthcare outcomes and a culture of change.
Arguing that factors involved in the fallen system are greater than those of the Roman Empire, Pearl’s candid assessment implicates everyone: hospital administrators, insurers, regulators, and medical societies. At the heart of the uncaring health care system is the inability of physicians to maintain the standards and professional ideals entrusted to them. Humanistic ideals, which maintained physician autonomy and power, have been restaged and reset by management. Money and leverage in the fragmented system, along with an unchanging physician culture, only heighten the erosion of medical outcomes. Societal changes and lack of community care, along with individual treatment, results in interventions instead of prevention, allowing diseases like diabetes, asthma, obesity, and cancer to remain uncontrolled and unabated.
The book provides an eloquent and disturbing look at the lack of health care administrators’ abilities to align hospital services to provide care for communities and to enhance physician passions to affect change. Dr. Pearl argues that physicians are slow to adapt to change, especially if the process affects individual salaries. Physicians lose their advocacy for patients, becoming ineffective leaders.
The author describes how the sacred doctor-patient relationship is becoming a misadventure of computing checklist and check boxes to complete cookbook medicine supported by salary bonuses. In doing meaningless tasks, the rituals, roles, and beliefs of medicine become less of a reality than the once beloved doctor patient relationship. Computer tasks and work RUV reimbursement has made the current health care culture time oriented; time remains a major theme for medical burnout. The author is clear that the current health care system is at war with advanced technology – this checklist and check box culture has not improved outcomes in population health and prevention. Physicians lack control; control has been handed over to unqualified business administrators that have no sense of the work needed. They appear more concerned about profits over care, utilizing quality metrics to drive care with little physician input. This newer healthcare is characterized by doing more with less, spending hours on the computer and not with patients, and getting little change in needed healthy outcomes that everyone desires.
In Pearl’s analysis of the healthcare system, he emphasizes physicians’ loss of autonomy within the system. Reduced autonomy in care decisions, from which device, catheter or antibiotics can be used, to the endless amount of paperwork and time wasting peer to peer calls, leads physicians to question their "calling in medicine.”
What is to be done? Pearl sensibly advocates a shared evolution, suggesting structural changes that coincide with science and technology, which also need to consider personal responsibility of patients for their own health. Pearl uses personal narratives and anecdotes to illustrate healthcare problems and their relation to history, change resistance, institutional racism and sexism, scientifically sketchy research, technology, and lack of data driven decisions, exemplifying the current environment. Although failure and unwillingness of providers to stand up and work through issues abound, many seek to work around and manipulate the system, instead of advocating for patient care.
Pearl is one of the first authors to address physicians as part of the system problem, focusing on procedures and status. He articulates issues, physician culture, and financial rewards in the system wherein doctors are asked to do more with less, driven by more profitable procedures and prescriptions. While the author and all physicians are holding on by a string, Pearl discusses suggested changes to the structure of the healthcare system. Collectively, physicians, administrators, and insurance companies need to work together. Yet, Pearl acknowledges that this collective work will not happen until profit becomes less of a focus.
Pearl discusses the need for workforce diversity, research on at-risk populations, and stronger free preventive health services. The author understands that legislation and help are needed to support these initiatives. Pearl describes segmented physician societal groups and fragmented nonaligned, advocacy programs. Physician societies, like the American Medical Association (AMA), American College of Physicians (ACP), American College of Osteopathic Interns (ACOI), and American Association of College of Osteopathic Medicine (ACCOM), are only a small group of strong academic professional societies, which take part in any legislative discussions. However, most individual care providers are not academicians and are willing to continue in the current miasma and fractured system. While Pearl’s book does not have definitive solutions, it is not short on ideas and academic talking points. Many new critical perspectives are needed, especially now, as fractures in healthcare appear in the aftermath of the COVID-19 pandemic.
In the end, the right to better healthcare is well worth the effort. I personally like that Pearl calls out the healthcare system and its stakeholders, administrators and physicians alike, who have designed a system that results in the opposite of what is desired. He discusses how stakeholders continue to over-rely on the idea that technology will fix all problems. Pearl explains how this culture is driving cost higher. Touting the achievement of the electronic medical record (EMR) and his own work as an administrator, despite the consensus of empirical data showing that EMRs lead to significant upcoding without improvements in health, inefficiencies contributing to burnout, and a deleterious impact on the traditional doctor patient relationship, may ignore negative aspects of EMR adoption. Uncaring is a compelling read. The book advocates for all of us collectively involved in healthcare to come together to improve the system. Only caring healers can advance the profession we hold dear to our heart.
That doctors are part of the problem is a unique perspective from Pearl that might initially startle readers. The book provides not just information, but also provides a call to action for the profession. Pearl’s tome is of interest to more than just physicians – administrators, health policy analysts and patients can all benefit from his critique of U.S. health policy and systems. —Timothy Barreiro
Timothy J. Barreiro, DO, MPH, FCCP, FACP, FACOI, is Professor of Medicine at Northeastern Ohio Medical University (Rootstown) and Ohio University Heritage College of Osteopathic Medicine (Athens) and faculty at Lake Erie College of Osteopathic Medicine, Erie, PA. Currently multidisciplinary team director for complex pulmonary diseases at St. Elizabeth Hospital in Youngstown, Ohio, he completed residency at Allegheny General Hospital in Pittsburgh and specialty training in pulmonary, critical care and sleep at the University of Rochester School of Medicine & Dentistry. After serving as Health Disparities Scholar at USDHHS, PHS, NIH, he completed his MPH at the University of Illinois Chicago School of Public Health and has served as a Governor’s Commissioner at the Ohio Commission on Minority Health, as well as CMS appointee on the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) committee. Founding member of the task force commissioned by the American Osteopathic Association Committee of Equity and Advancement with American College of Osteopathic Interns, and author of numerous publications over several decades his foci remains to care for the underserved and to educate and mentor medical students and residents. He is a certificate graduate of the Columbia University Narrative Medicine program and teaches reflective practice at NEOMED and via a hospital-based narrative medicine program for faculty, residents and medical students.