Episode #117: Transforming the Culture of Healthcare – with Robert Pearl, MD


Our guest this week, Dr. Robert Pearl, introduces a fundamental reframe in our understanding of healthcare transformation with his second book, ‘Uncaring – How the Culture of Medicine Kills Doctors and Patients’. He convincingly argues that addressing the systemic functional challenges in healthcare is not sufficient. For transformation to occur, we also need to address the entrenched culture; and the first step is in understanding that culture. ‘Uncaring’ is the most comprehensive and scholarly book I’ve come across on the interplay between the legacy culture of medicine and its impact on healthcare delivery and outcomes. Dr. Robert Pearl’s stories are heart-breaking and heart-warming; and the historical facts, medical stats and studies he draws upon are engaging, enlightening and of concern to all of us.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group, which he led from 1999 to 2017, and former president of The Mid-Atlantic Permanente Medical Group, which he led from 2009 to 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. He currently serves as clinical professor of plastic surgery at the Stanford University School of Medicine.  He is also on the faculty of the Stanford Graduate School of Business, where he teaches courses on strategy and leadership, as well as lecturing on Information technology & healthcare policy. Dr. Pearl has been named as one of Modern Healthcare’s 50 most influential physicians.

In this episode, we’ll discover:

  • Numerous episodes in the history of American healthcare that demonstrate how the culture of medicine is holding us back from transforming healthcare delivery.
  • Profound examples of how the culture of medicine directly influences how care is delivered and the grossly suboptimal outcomes that are a result of that culture.
  • The only two possible directions American healthcare can take in response to the unsustainable and unaffordable costs of healthcare delivery.
  • A pathway to confront and change the culture of healthcare.

It’s been said that if we don’t study history, we’ll be condemned to relive it. This is no more true than in our healthcare system. Dr. Pearl shares a haunting story of an Austrian physician named Dr. Semmelweis who died penniless in the 1860’s, as a result of being shunned by the medical establishment. His heresy was that, through years of rigorous research, he demonstrated that physicians were carrying the source of maternal infections & deaths – on their hands & clothes. His studies revealed that maternal mortality rate could be decreased from 18% down to 2% simply by physicians changing their gowns and washing their hands with antiseptic in between treating patients. One might shrug this off as a historical footnote, except for the fact that today, in 2021, hospital acquired infections are the fourth leading cause of death in the US – leading to over 90,000 deaths per year. The tragic truth is these deaths could largely be prevented by providers washing their hands in between seeing patients. That is the power of culture – “this invisible force” that Dr. Pearl reveals to us. We discuss many other examples, including the story of the ‘Committee on the Costs of Medical Care’, which reveals the powerful influence of the legacy culture of medicine in resisting recommendations that could vastly improve the health and well-being of our nation.

Like myself and many of you, Dr. Pearl  is frustrated and deeply troubled by the complexity, opacity and inertia in American healthcare – and how the culture is greatly limiting access, affordability, efficacy and equity.

Two silver linings emerge in our discussion. First, the culture of medicine has tremendous strengths as well as wonderful attributes and values. Second, the solution is not that complicated. When I asked Robbie what he would request healthcare leaders do differently, this is how he replied, “To move from fee-for-service to capitation. To work together to improve medical care rather than maximize volume. To embrace technology that makes care more convenient for patients.”

Healthcare leadership is struggling to break free of a legacy maladaptive healthcare construct. What I learned from Dr. Pearl is that healthcare leadership must not only create a new system, it must create a new culture: one that aligns our professional values and purpose with the actual daily practice of medicine and delivery of healthcare.

Until next time, be safe and be well.
Zeev Neuwirth, MD