FHC #55: Is it time for doctors to temper their career expectations?

Fixing Healthcare Podcast

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.

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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 burdens for healthcare workers. He talked about the need to have mental health support. He talked about the opportunity to protect healthcare workers from violence and unsafe conditions. He talked about a lot of the problems that clearly exist, we know exist, and people would like to see changed. But I raised the issue, Zubin, because again, when I look at burnout, I don’t know how long it’s been, at least a decade we’ve been talking about this. I don’t know about you, but I don’t see that things are very much better today than they were five years ago. The question I have is, if it’s not much better now than five years ago, why do we really think it’s going to be any different five or 10 years from now? Why are we paying that price? But more importantly, what can we do to avoid having to experience both the lack of fulfillment, the fatigue, the moral injury, and the implications for both doctors and for patients?

Zubin Damania:

I agree. It’s only gotten worse, and the pandemic’s only made it worse. You talk about the Great Resignation and people are just waking up to, is this really what I want to do with my life? Was this the calling I felt it was? I think what you’re pointing at is a fundamental … There’s a few issues, and you’ve brought up some of these in your books too, which is one of the issues is physicians in particular, they have a certain idea of what this thing was supposed to be and then they’re met with this kind of 2.0 version, which is mechanized and bureaucratized. There’s this administrative technocracy that seems to run it. It’s so discordant with what their image was and their own self-image of the cowboy doctor, that it creates this tension. But that’s a part of it. Obviously, it’s all those things. What’s required is a dramatic, and again, you said things are measured in inches, not miles. That may be true, but at some point, there’s a phase shift that happens where we just go, “Oh wait. Wait. Wait. We’ve seen some bright spots here. We know where this works there. They’re emerging in fits and starts.” Maybe well-resourced, team-driven, primary care that gives you the tools, the teams, and the trust to do your job, and actually systems that support that and a slow but steady culture shift towards this kind of team-based care, maybe that. Then we train our medical students like, “Hey, this is how it’s going to be”, so expectations and competencies are matched to what the actual system is going to be. Then we might start to see a shift. When you talk about teams, that’s when you start pulling in nurses and pharmacists and respiratory therapists, and everybody else on the team that has been suffering as well. Then look for bright spots within medicine. Who are the specialties and aspects of medicine where the self-reported signs of emotional exhaustion and cynicism and depersonalization, all the burnout, end-stage moral injury stuff, where’s that the least and what can we learn from what’s going on there? It’s a multi-factoral thing. I’m glad Vivek is talking about it. Vivek is such a compassionate, thoughtful guy, but again, it’s like we can list out the problems and knowing the problem is half the battle. But what’s the next step? We really have to start actualizing this stuff.

Robert Pearl:

Let me ask a, I’ll say uncomfortable question, which is-

Zubin Damania:

Oh, you haven’t asked any of those so far, Robbie. This isn’t-

Robert Pearl:

No, this is more so, Zubin, because I sometimes ask myself the following question. In the current world, a world that is the way it should be, with often two people working, I think you said last time that your wife’s a physician, is work-life balance possible without some kind of personal sacrifice being put into play?

Zubin Damania:

Ooh, and this is such a complicated issue because there are gender dynamics here. There’s socioeconomic dynamics, there’s race dynamics. But to put it as simply as possible, I think my late friend, Tony Hsieh, used to say, “There’s work-life balance and then there’s life.” If life is your thing, where everything is part of your life, then there’s not work and life. There’s just life, which means you better start to, first of all, understand that what you’re doing at work is an authentic expression of you, and figure out ways to integrate it into life and make it life itself. That could fly in certain industries very easily, but in medicine, we’re expected to do all these things, be heroic, especially women, and then come home and manage the kids, and come home to take them to soccer practice. Or if we have to hire someone to do that, then we have to work more shifts. We can’t go down to part-time to do those things, because then we can’t pay the nanny. Sounds like first-world problems until you experience them, and then you realize that man, this is as stressful and unhappiness generating. Then you look at the person living in a slum in Mumbai and you measure their subjective happiness and they’re happier, because they have community, they have support, they have some sense of higher purpose, even though they’re in economic squalor by our standards. Why is it that Americans seem just generally less happy? Well, because I think we fragment our psyche into this is work, this is home, this is responsibility and so on. Then we don’t have the social structures. We don’t have proper maternity leave, availability to breastfeed, paternity leave that some of the European nations have. We have the lowest ratio of doctors per capita, practically in the developed world, I think short off South Korea. We wonder why workloads are so high and we have a nursing shortage. Those are just the tip of the iceberg. I’m curious what you think, Robbie, because you’ve had to deal with this for so many decades as leader of such a large organization.

Robert Pearl:

Again, I’m focusing a lot on what’s not being said or not being, to use the word which you said earlier, that we’re denying. If I said to you, “Zubin, what’s it like for you to work full-time,” you describe a very fulfilling career, full-time with a certain amount of money that you’re earning, and I said to your wife, “Okay, you tell me what a full career for you,” she describes the same thing, and they’re both accurate, they’re both wonderful. Now, I say, is it possible to take these two pieces and have them coexist simultaneously? My conclusion is it may not be possible that someone’s going to pay both of you to be able to do that in a context where you’re going to have work-life balance. It may turn out that you both have to cut back on your both professional and economic expectations, and gain from it the fact that now you’ll have more time with your family, with your kids in your interpersonal life. You may not need the same size house. You may not have some of the other accoutrements of life. I don’t know where that would come, but we built professional expectations on the last generation, where you had one person working and not the other person working, and the dollars were adequate to support that family but it wasn’t a life in terms of possessions as we have today. I just wonder whether the societal expectations have exceeded the reality. All you have to do is look at the stock market these days to see that rebalancing that’s going on–on its own, and I just wonder whether that is what’s not being talked about in medicine.

Zubin Damania:

Ah. Once again, you’re pointing inward. You’re saying, what is it we value? What’s self-actualization? Is it acquisitions? Is it material wealth? Is it this socially validated esteem that we have from driving a Mercedes G-Wagon and so on and so forth? Or could we get away with the Camry, upgrade it to a hybrid, get a faux leather interior and be happy with a family life that’s more balanced? Again, with me and my wife, we’ve had to alternate the sacrifices. You asked about sacrifice. We’ve had to alternate. For years, I was a full-time hospitalist while she went back and trained because she had done internal medicine, board certified and realized this is not my calling. She realized it late, and that she was going by societal expectations or parents’ expectation. Then she went back and said, “I need to do radiology.” That’s another four years of training where I’m making 30 grand a year. I said, “Well, let me go ahead and work full-time, even though I don’t know that this is exactly the right path.” I did that. Then we shifted. We said, okay, now she wants to do more of the career building, and let me then do a career where I have more time to help with the kids to do these kind of things to be present. It is this kind of give and take, and you do have to understand what you value it. Now, if I was going by societal roles and this kind of thing, no, I have to be the co-breadwinner, at least, if not in a chauvinistic way, the guy who makes the most and does all of this. Then you’re trapped. Then of course, there’s going to be unhappiness and that mismatches your expectations. I’m with you, brother.

Robert Pearl:

I don’t know if you ever listen to Laurie Santos. She’s the Professor from Yale who runs the course on happiness that one-fourth of Yale students take. It’s the most popular course at the entire university and it’s available online for anyone who wants to do it. But she talks a lot about the way that we misinterpret and misanticipate happiness. One of the pieces that I was listening to the other day is she talked about the research that says there’s a level, and the level is somewhere between 100 and $200,000, beyond which there is not a single shred of evidence that more money adds happiness.

Zubin Damania:

Yes. Yes.

Robert Pearl:

Yet, as a physician, I don’t think any of us see that as a landing spot for us in our family.

Zubin Damania:

Especially if you live in a high-cost area. Then the truth is many physicians gravitate to these things and we start to accelerate our spending, and our outflows become so high that we’re goldenly handcuffed to a career path of FTE and workload that is unsustainable. It’s not what we wanted. Again, we think we’re chasing happiness. We’re not. I think that requires a reality check, a gut check. I think people are waking up more though. I think the next generation is changing its expectations. They’ll complain and they’ll say we have lesser quality of living, standard living than our parents for the first time. But to some extent, that’s an opportunity to go, what does that mean? What should you be doing with that extra time and space? Are there self-actualization things you can do that’ll lead to more happiness, family connections, relationships, et cetera?

Robert Pearl:

I think in our next conversation, I want to talk a lot more about some of these psychological areas, but let me raise one right now. Again, these are the things I’m thinking about a lot, which is that the research is very clear that gratitude and generosity are two of the best ways to maximize happiness, your own happiness. In fact, there’s a lot of data that says, if you give someone $20, as opposed to getting $20, you actually experience a lot more happiness, fulfillment, and joy in your life than whatever you’re going to do with the $20 that you receive. I don’t know, in medicine today, how much gratitude and generosity exists. I think there’s problems. There are reasons why it might not exist. But again, I’m just wondering whether we trip over our own feet in trying to get what we think we want, but in the process, actually rob ourselves of what we could have.

Zubin Damania:

Yeah. There’s no doubt that’s true. Just to some extent, the term mindfulness is misused. It really means remembering. At any moment that you’re mindful, you’re remembering what’s actually true in this moment, and gratitude is a powerful part of mindfulness because you remember how incredibly lucky you are, how much you’ve been given, how many mentors you’ve had, how many opportunities you’ve had that have led you to this part of your career in medicine. That mindfulness, that remembering can center you right in this glow of gratitude that reminds you of the compassion that was given to you. Then it comes out of you. It really is a powerful practice, and more and more doctors are actually, I think, waking up to this. I hear them talking about it more, these kind of practices, so that’s a good sign.

Robert Pearl:

I don’t want any of our listeners to think that in any way, I’m trying to minimize the problems that exist, and recognize the economic challenges people have or the bureaucratic tests that they have. Again, I’m always looking to say, is there a crack in the wall that is being missed? That maybe if we focused on that along with rebuilding the rest of the wall, we would end up being more fulfilled. I would also say, and I often think back to Kübler-Ross and the idea of acceptance, that if the reality is that we’re not going to be able to get the changes that would be optimal, that maybe we should get, that maybe we’re entitled to, but we’re not going to get it, what are we then going to do? How can we add joy and fulfillment into medical practice that maybe today we’re taking away? I know there’s a lot of fear that if in any way we acknowledge that somehow we’re not the victim, that people will not give us what we want. My observation is they’re not giving us what we want right now, so let’s look at these opportunities, whether through mindfulness or whatever other practices it’s going to be, creating these high-functioning teams, even if it means a little bit less respect, seeing patients in a different kind of way, all the parts that we’ve talked about. Is there a way that we can uncover some of these unspoken aspects, have the conversations and come out of it, maybe not as great as we would like, but far better than today?

Zubin Damania:

You’ve said it perfectly, and the truth is it comes back. I keep bringing it right back to the self, the personal development. I’ll take it one step further and say, by doing those practices, you’re not giving up on the fight for all the things you talked about or fixing the system. What you’re doing is you’re enabling yourself to emerge a better system, because when enough people do that, they wake up themselves. Then actually the system starts to transform. In many ways, the system I think, and this is speaking kind of metaphysically, but also I think there’s truth here, the system is an emergent property of us. If we’re a mess in that way, then our system is a mess and it feeds back. What if we start to change ourselves? Well, our system will change, and maybe that’s why we’re at an impasse, Robbie. Maybe that’s why it feels so intractable. It’s always darkest before a phase shift, before you wake up. That’s when it’s darkest, and I feel like we got to talk more about those unspoken things that you’re pointing at.

Robert Pearl:

Well, I’m a big believer as you know that the first thing we must do, if we want to address the panoply of challenges that we have, is move from fee-for-service to capitation. Then in that process of doing that, we now can create the dollars and the resources to fund the things that need to happen. We can pull out those bureaucratic tasks. We can find opportunities to gain purpose, by being able to make the lives of people easier and better. And that standing in our way is this fee-for-service system that as you say, makes us run faster and faster and faster on a treadmill to generate more and more dollars. The insurance companies fight back by trying to limit what we do, because they can’t afford the dollars. The purchasers get somewhere in the middle of the battle, and in the end, as I say, a lot of smoke and very little actual change.

Zubin Damania:

Yep. That’s it. Our incentives matter. But again, I’ll bring it right back to us. Our incentives are an epiphenomenon of what we think we want. Fee-for-service is a lucrative, lucrative kind of like a carrot dangling there. Oh, if I just see more, if I do more, if I bill more, if I code more, I can get that Mercedes G-Wagon, which I’m expected to have, or whatever it is. We have to change, too. We have to change. In Europe, the doctors get paid less, but there are more of them so it’s a different balance. I don’t think any system’s gotten it perfect, so we learn what we can and then look for that phase shift in our own awareness.

Robert Pearl:

You said it perfectly. I can’t wait for our next conversation.

Zubin Damania:

Hey, me too, man. This is intense and fun.

Jeremy Corr:

Earlier, when you were talking about implicit bias, it made me think about a conversation I recently had with a couple of people who were upper-class, educated, East Coast liberals. It made me think about this. The nation is doing a lot now to address the inequities in minority communities. However, one of the things that I think has frustrated many in the rural communities, such as where I grew up, is how they feel as though there’s still a significant bias against them. They feel frustrated because they’re called deplorables or rednecks because they’re poor people from rural America with conservative values. It’s very frustrating to someone who grew up in a dying small town as the generational family farms are being lost to corporate farms and the downtown is dying to Walmart, maybe there might be a factory too in town or whatever. But you have somebody who maybe grew up with a meth addicted or alcoholic mom, an absent father who lives in a trailer park, yet they’re told they have white privilege just because of the color of their skin, in spite of growing up in very tragic circumstances, just like someone in a poor urban minority community. Many of these people feel like there’s a lot of implicit bias against them, and that’s the only kind of bias that is now still socially acceptable. They feel like their communities are often forgot about by the government and they’re spit on and laughed at by what they consider to be the coastal elites. As two Ivy League educated people on the coasts, I’m curious what you think about this.

Zubin Damania:

Oh, man. This is something that I talk about on my show a lot, because I actually grew up in rural Central California and I came from that community. It’s funny. I’d add another component into that. People who are obese get the same kind of discrimination still. It’s still okay to discriminate against the obese. This is my take on this is yes, this is a real phenomenon, at least at the level of the perception of the community in question. And so it becomes real. As a result yeah, that’s going to actually perpetuate further disparities, socioeconomic disparities. It’s also going to change politics in this country because with the electoral map, those communities have a lot of power too. We ought to be unfolding, especially in communities that value these progressive values, they should say, well, all right, one of the progressive values is inclusion, love, compassion, and understanding. So, why don’t we understand the moral palettes that folks that come from these communities have? And they’re powerful. When we travel around the country doing talks and stuff, when I go to rural Texas or Idaho or somewhere like that, I’m just struck by the warmth and the compassion. Yeah. These are very conservative politics. Okay. What is it about the environment and the community that makes that adaptive? Trying to understand that so then we can come up with compromises, allow a lot of local stuff to be hashed out at a local level and so on. It’s just even being aware of it, instead of the blindness that we show so often on all sides of this. A conservative in one of those communities would not understand a highly progressive San Francisco native, unless they’re opening lines of dialogue and understanding that they have common, actual, moral reasoning.

Robert Pearl:

My view, Jeremy, is that tribalism is built into human genetics. It’s the way you survived 20,000 years ago. You could never survive as an individual. But it was all within the people living in your set of caves, and that tribalism rears its head anytime a society or a group in that society is dropping. You see it come up in times of economic challenge, and that’s what we’re in right now. You see it come up in times of winners and losers, and that’s what we have right now. What you’re describing is a particular tribe, or two tribes. You can talk about it as an urban East and West Coast tribe, begins the Central part of the country tribe. You can talk about it in terms of race. You can talk about it in terms of religion. You can talk about it in a lot of different ways, and my own bias about what’s not being said is how the United States as a nation is slowly dropping from the dominance that it had in the past. Sir Michael Marmot, who’s a sociologist in England that I respect a lot, has written and talked about how what you experience when your status, when your hierarchy, when your position in whatever’s going to be, your local community, the nation, the world, starts to diminish, is when you become dissatisfied, unfulfilled, fatigued. In many ways, it’s the same symptoms that we have as burnout, and I think that’s what you’re seeing in the United States today.

Robert Pearl:

Instead of people coming together, as Zubin has talked about, to create a better future, they prefer to focus on someone else’s being the problem, the so-called classical scapegoat mentality, and feel like they’re getting left behind. Have we left rural America behind? Absolutely. They don’t have access to broadband. They don’t have the economic jobs that are in place. They’re working hard in the fields far longer than people in other places are working in industries that add no value and put no food on the table, and they’re not making much money. You can apply the same mindset inside of medicine. You can apply it as I say, to almost everything in our country, race being a classic example, but it’s far more than that. Education. As Zubin said, the people in the center part of the country, what do they value? Because culture is about what you value and you believe. They value family. What do the people on the coast tend to value? They tend to value education, jobs, titles. You come to the coast, the first question you get asked is, what do you do for a living? You go to the middle of the country, what do you first get asked? Tell me about your family. Tell me about your kids. Tell me about your relationships. It’s just different values. From my perspective, they’re both important. But that’s not the way it plays through. As I say, in a time of economic difficulty, there’s an expression someone once told me, “As the pie gets smaller, the manners deteriorate.” I think we’re seeing a lot of lack of manners, a lot of lack of civility, and my concern is it’s going to get worse before it gets better.

Jeremy Corr:

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