EP412: Leadership of the Art and Science of Medicine, With Robert Pearl, MD
You can listen to the episode here.
[00:00:00] Stacey Richter: Episode 412, "Leadership of the Art and Science of Medicine". Today I speak with
Dr. Robert Pearl.
American Healthcare Entrepreneurs and Executives You Want to Know, Talking.
Relentlessly Seeking Value.
One of the questions I often get asked is this, actually, it's more of a comment, usually, than a question. Someone says, seems like this whole transformative primary care thing is pretty much just, let's go back to the old country doctor.
Let's just have a single doctor out there taking care of patients like a Norman Rockwell painting. To which I reply, and I'm channeling many experts including my guest today, Dr. Robert Pearl, when I do, Yeah, except, No, in the golden olden days of the ye olde country doctor, there was a lot of art in medicine and a lot less science.
If someone got cancer or even heart disease, what was required, fairly exclusively, was comfort and compassion. Now, first and foremost, so there's no confusion, am I dismissing the importance of bedside manner and of providing comfort and compassion. Hell no, would rather have that any day of the week than deal with a, in air quotes, drive by PCP or drive by specialist with a throughput of a freeway who has no idea what I may befall the second I step out of his or her exam room.
But in the olden days, medicine was fundamentally art with a lot less science. Because there wasn't much science. For the most part, we didn't have data or MRIs. This was before the whole pharma industry. For the most part, we had weird heroin infused tinctures, but we didn't have oncology meds or biomarkers or even statins for Pete's sake.
Consider all the new diabetes meds and biologics and artificial joints and sub sub specialists who have through data and advanced analytics by looking at patients across the country. Proven out some best practices that might be fairly unintuitive or disproven some conventional wisdom. It's a different and much more complicated world today, and what's required now is a healthy appreciation for not only the art of medicine, but also the science.
And science inherently means that, yeah, there are standards of care to be adhered to. That's what science is. Means there are rules and better ways to do things as proven by looking at the data and not relying primarily on personal recollections of what may or may not have worked in the past. Listen to the shows with Bob Matthews or Alex Akers for more on this topic.
But this all leads me to the interview with Dr. Robert Pearl today where we get into some concepts that he covers in his new book Uncaring. Today we're talking about some how to's for being a leader of doctors, going about that against the backdrop of this evolving art and science of medicine dynamic and the impact of this evolving art and science dynamic on physician culture and self esteem.
Because spoiler alert, if a doc is following evidence based guidelines, not relying solely on their own personal experience, does that make said doc feel like they are being devalued? And that they are about a cog in a wheel and practicing so called cookie cutter medicine. So many nuances, so little time.
But yeah, there's a lot going on , which at its core is this tension that can play out in some big, bad ways. I asked Dr. Pearl for some advice for today's healthcare leaders, and he did not disappoint. He suggested using a model that he calls the A to G model. And in short, you got to have A. An aspirational vision.
B. Behaviors. C. Context, D, Data, E, Engagement, throughout the organization and also with the patient, F, Faculty, and G, Governance. You'll have to listen to the episode for the why and how of each of these. My guest today, aforementioned, is Dr. Robert Pearl. I am sure that most of our Relentless Tribe who is listening to the show today already knows Dr. Pearl. Put in short, he was the CEO of Kaiser Permanente for 18 years. Now he hosts a podcast called Fixing Healthcare. He teaches at the Stanford Graduate School of Medicine and Business. He writes articles for Forbes and elsewhere. He's also an author. He wrote a great book called Mistreated, and now there's a new one called Uncaring.
I would recommend both. My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. Dr. Robert Pearl, welcome to Relentless Health Value.
It is a pleasure and a privilege to be here this morning. I can't wait for our conversation.
Well, it is a pleasure and a privilege to have you here. If we're going to talk about the art of medicine, which you spend three chapters of your book talking about, so this is the incredibly short version.
But if we're going to talk about the art of medicine and how historically this has been a very important part of a doctor's self esteem and also sort of societal esteem, do you want to just tee that up? What is that whole idea?
[00:05:04] Dr. Robert Pearl: If you look at the history of healthcare, It really wasn't until the middle of the 20th century that medicine was able to significantly help patients in terms of measurable clinical outcomes.
So what did doctors do for 2000 years? They were very trusted. They provided compassion, empathy. They were able to help people navigate through the most difficult of medical problems. And along the way, there were things that they could do, a small amount of surgery and some very basic medications. We then saw an explosion in the second half of the 20th century where medicine advanced massively.
We came to understand the basis of heart disease and cancer. We had drugs that were now effective at helping patients lower cholesterol, manage blood pressure, treat cancers that otherwise would have been lethal and now could be cured. This was a remarkable time in the evolution of medicine. We had the introduction of a variety of technology.
New procedures, transplants, heart surgery, brain surgery that weren't even imaginable one or two generations earlier. And so what you're alluding to is this balance between art and science. Now, intrinsic in science is the idea that there's only One right answer, a mathematical equation, a chemistry reaction.
There is one answer. Inherent in art, every one of us has a different way we do things, how we relate to patients. In art, almost everyone has their own answer and this balance between objectivity and subjectivity you're highlighting is so important. I personally think that we have to recognize. That when there is a science and evidence based way to accomplish an outcome and you follow that rigorously, the results are consistently better than when each individual tries to figure out his or her own way.
We can't lose the art because this is the doctor patient relationship. This is the trust that's built there. So how in the 21st century should we be applying these two parts of medicine? I think science, when we have the answers, art in response to the anxiety that patients feel, the fear that they have, the hope that they want to embrace, art when we don't know what to do, but make sure we follow science when we do.
[00:07:45] Stacey Richter: And I think what you're articulating there, is really actually powerful because the main point that you're making is that if evidence exists from a scientific perspective, what is the right pathway? What is the right drug to use in this particular circumstance? What does the evidence suggest that it's very important that every patient within that population gets that same standard of care, because if they don't, then equity dot, dot, dot, you can't do continuous improvement. So there's a lot of downsides to having a like situation and not having a standardized evidence based way to approach it. However, there's a difference between being evidence based and evidence bound, like if you go too far on the everybody gets treated this way, then what we're dismissing is patient preferences and variables.
A lot of times when you hear about problems, it's because there are variables that haven't been taken into account. It's very difficult for technology or processes or whatnot to. Take everything into account that a human brain may be able to process in the art side of the equation. And if we're evidence bound, then two bad things happen.
Number one, patients get treated like the average patient, not the individual that they are. But then also you wind up with maybe some of the things that we're seeing inflicted upon doctors or other clinicians who really feel devalued in this whole, you know, you hear I'm a widget in this machine. No one trusts me.
I had Dr. Vivek Garg on the show. One of the things that he was talking about is just the intrinsic motivation of clinicians of doctors. in this current world has plummeted. What's your response there?
[00:09:43] Dr. Robert Pearl: You are pointing out the most important part, but if I can back up, what you said was based upon the patient's preference, not the doctor's subjective response.
And I think that's. The reality in the 21st century, it's not as though one doctor says, well, I think we should give more insulin. Another one thinks we should give less insulin. When this research shows the right amount of drug to give, that's what we should be giving. It should not be based upon the doctor.
How do we approach end of life? That's an important conversation to be had. Medicine has advanced so far that what we see is that often the line between treatment and torture gets blurred. Doctors need to use the art of medicine to engage in those conversations to find out what does life mean to that individual.
When is their life, in their mind, not worth Living and how can they then palliate them to allow them to make it through this transition with the greatest dignity, respect, the least amount of pain and so forth. But you're also pointing out such an important piece, which is that in the Culture of medicine, this approach that I'm talking about feels as though it's devaluating doctors, and if you start now adding on technology, adding on variety of algorithmic solutions that offer the best answer or generative AI with chat GTP, This is going to make the problems even more difficult for clinicians unless we can evolve to understand what needs to be accomplished.
And to me, that is back to the mission and purpose of medicine. Because if we start to look at why do people become doctors in the first place? It's in order to keep people healthier, allow them to avoid disease, allow them to return to health when they have disease, to do that with colleagues, for populations of patients, as well as individuals to take pride in winning by being able to maximize.
Clinical outcomes, avoid chronic disease, prevent complications from them. And in the culture of medicine and culture by definition is always left over from the past 20 years ago. It was all about the individual physician and creating remarkable outcomes in the face of death. And now we're defining it in terms of health.
And I believe that the evolution. And what leaders are going to have to do is help people understand what that is, what patients want, and to take great pride in being able to accomplish it.
Yeah, I,
[00:12:35] Stacey Richter: I love how you summed that up. Take pride in accomplishing this greater health in the context of the place in the time space continuum that we are now.
Because in the past, what doctors took pride in is their individual accomplishments. But it feels like. In the now, what we have to take pride in as a team is the outcome of the entire team, and that is kind of a fundamental change in a really big way. Especially from a leadership perspective, I mean, having led operations myself, the one thing that you figure out on the quick is that you can't process judgment.
And what I mean by that is that if you're trying to be operationally excellent. There has to be a beautiful combination of really good processes, but then people who don't blindly just follow those processes, because the second that someone just blindly follows processes, you wind up making really dumb mistakes.
Because everything, unless you're going to have a process that has 900, 000 steps, which is never going to work because no one's going to follow it. There are always judgment calls that need to be made, you know, like, is the next step in this process actually the right step? Let me think about that. So I could really see that if you, you've got incoming on the left, a physician culture that really values the art and not the science, not the process of medicine.
And I'm exaggerating here for purposes of clarity, I know, but if, if there's this pride in this individual accomplishment. And then on the other side, you've got just the whole creating processes that are optimized. And then you've got the whole navigating a team or leading a team that's all going to work together to deploy all this.
I could see that it could take a very
[00:14:37] Dr. Robert Pearl: Let's start with what it might have looked like in the past, which was the, and we'll keep using the word pride, came from the ability of the doctor to reverse a life threatening issue, reverse a stroke, reverse a heart attack, transplant the kidney. Those were very highly elevated in the hierarchy of medicine and culture is often about hierarchy and they are associated with a single individual for the most part.
The one who held the catheter that was going to be unblocking of the blood vessel or the suture that was able to connect the arteries and veins in the kidney transplant. But if you really look at it from a patient perspective, what does a patient really want? They'd like not to have a stroke, a heart attack, or a kidney failure in the first place.
And if you think about that, the challenge is that in the first case, you can name the patient. You can show that they would have died and they lived in the second one, avoiding it. It's impossible to know who would have gotten it. You have to take care of large numbers of individuals, and that's why the point you're making about teams is so vital, because you can't take care of that population as an individual.
Without getting completely burned out, that's the transition that we're sitting in right now, I think, between the past and the future. Technology that allowed the patient to be part of the solution, to be able to take the steps necessary through lifestyle medicine, as an example, in order to avoid some of these problems.
That wasn't seen as really important, but it is. I'll give you an example from when I was CEO. Across the nation, hypertension, which is the number one cause of strokes and a major contributor to heart and kidney disease, was controlled 55 to 60 percent of the time. We controlled it over 90 percent of the time.
Number one in the entire nation. How did we do it? We did it because at every point of contact, everyone, every clinician, even specialists like myself, who don't manage hypertension, I can recognize it and make sure the patient had treatment provided. That's a team effort.
We knew exactly what needed to happen to maximize the individual's health. At the end of the day, the chances of patients dying from cardiovascular disease was 30 percent lower. How can you not celebrate that victory over disease as a team and with your patients? But that's not really deeply embedded in the medical tradition, because it's still left over from a different time.
When we didn't understand the etiology of these problems, we didn't have the medications to treat them and all we could do was identify disease when it came about and try to respond to it to the best, and I'll say it, of the individual clinician's ability. Sue, let's
[00:17:47] Stacey Richter: Let me give you a counter example.
And then as a leader, I'm going to ask you for your advice here. So I was speaking with a maternal health nurse who has a community clinic. And one of the things that she has said is a very big issue actually is they recognize, again, on the hypertension example.
That if they have a woman who is trending toward a problem, right, like she may not have off the charts, dangerous hypertension right now, but they've done three blood pressure checks in a row and the trend is really bad or just in their experience, they just can recognize the signs. I'm not exactly sure of all the clinical markers, et cetera here, but they just know that this woman is going to wind up in a crisis situation in an acute situation.
And she says. It happens so often that they call that woman's obstetrician and they say you need to see her now. And the obstetrician is just like, oh, but her blood pressure, her clinical markers are not acute right now. So no. And then that woman winds up crashing in an acute environment. And then the obstetrician says, Look, I'm a hero.
I saved her.
[00:19:01] Dr. Robert Pearl: You're describing very well the traditional cultural problems, battles between doctors and nurses, uh, the hero when you can solve a problem, and the lack of position in the hierarchy when you intervene early in the process. Where we might, I don't think it's necessarily an opposite example.
Where I might differ from you, however, is that the idea that says, well, we can recognize it. That's a supernatural power, and we need to figure out what do you mean you can recognize it? What are you looking at? Because as you're describing well, if the blood pressure goes up for three levels and 70 percent of the time that leads to a true hypertensive crisis, that's a science.
Anytime there's three elevated blood pressures. We should have it evaluated and treat it. So it's converting that art to the science. And again, why I'm a big proponent of technology, because I think technology can allow us to understand those things at a more objective level and have everyone agree. So it's no longer the nurse and the doctor battling with each other.
No, we all agree when it goes up three times in a row. We're going to intervene. But the question I think you're really asking is, how do leaders achieve evolution? And in the podcast today, I can only touch on a model that I teach in the Stanford Graduate School of Business. And I call it the A to G model.
And it starts with A, which is an aspirational vision. And I use the word aspiration because it connects. Two parts. It has to be inspirational, but it also has to be reality based. If it's just inspirational, we call that a dream. And if it's just reality based, that's what we, that's what work is. It's day to day doing the right thing each time.
But an aspiration is seeing something that is yeah, Higher in value, but achievable. And I think that's what we're talking about today. I'm embarrassed by the performance of the American healthcare system. I'm embarrassed we're last amongst the 12 industrialized nations and half of Americans say they can't afford healthcare today.
I'm embarrassed the fact that over half of our clinicians are burned out. I can go down the list of things that I find embarrassing, but I don't see a lot of change happening. So creating an aspirational vision is crucial. But that's not enough, because for people to be able to embrace it, they need to know the B, which is the behaviors.
What are they specifically going to have to do? So that obstetrician you described is going to have to be willing whenever the blood pressure goes up three times in a row. to see the patient or do whatever is appropriate for hypertension actually manage it and they may need to be able to coordinate it.
But whatever those pieces are, it's not asking people to do the impossible. It's not to be available 24 by 7. It's to be part of a team that's available 24 by 7.
Seize the context. What's different?
I think the world is changing right now with retail giants like Amazon, CVS, Walmart, UnitedHealthcare. Four of the nation's six largest businesses based upon revenue, according to fortune magazine, all going deep into health care today, hiring in the United States, 70,000 positions.
This is the context. You can't ignore it.
And the data. Leaders need to be able to not only look at data and understand it, but ask themselves the following question. If I'm going to tell everyone on the team a particular piece of information that I think is so important, and nothing changes, What am I going to do about it?
Because leaders often point to the problems, and then when nothing changes, the people believe, guess it can't be that important, because if it was, the leader would do something else about it. The time to think about it is before the problem fails to improve, rather than afterwards. Ease engagement of the leader.
There's no way to delegate this. You have to go out. I went out to the 19 medical centers. Twice every year, a whole day spent meeting with doctors and nurses and other clinicians . F is faculty. There's no leader who can do it alone. Who's going to help you?
Who's going to understand the vision, the strategy, the way to make operational change happen? And finally, governance is a reflection that yes, you do need to change. your formal structure, but you need to recognize the informal structure. Who is the head nurse? Who is the most important person in that hospital?
Because everyone else listens to her based upon her expertise and her experience. And that's how change really happens. And then finally, the incentives. And I'll make a point to all listeners. Incentives always work. We teach them in the business school. The problem in medicine is they rarely work the way you planned.
Yes, you can get people to do more testing for hemoglobin A1c. If you give them a certain amount of money for tests, but that doesn't mean you're going to get better management of diabetes. And it also probably means they're not going to do something else. The way to make change happen is not financial incentives or threats and sticks.
No, it's going to be by creating mission and purpose, bringing people together and helping them to be motivated to maximize the health of patients.
[00:24:35] Stacey Richter: Let's go through your A to G. So this is your advice for leaders. And I couldn't love this more because it's a great Mnemonic or just kind of set of considerations to really think about as a leader to help an organization navigate the place that we are, wherein, as you just described, we've got technology and coming from the left, we've got new entrance coming in from the right. We have the science of medicine accelerating at a rapid pace. We've got all of the burnout and just the way that clinicians have been frankly treated over the past. However, many years and the construct of medicine causing a lot of intrinsic motivation to have been sapped and the joy of medicine to, to have sapped.
So you know, if you think about that, then your A to G model really makes a lot of sense. So number one, as you said, A was start from aspiration, aspirational. Vision, if you teach at a business school, and many of our listeners have gone to business school, like this is change management 101, right? You have to have something that you're striving to.
Number two is to really think about behaviors, which is B. And then C is context, which is a little bit what we just were talking about, like what is the world that we live in? Really think about that. D is vision. Data, not only collecting it, but then also if there's a problematic trend in the data, then as a leader, the things that the leader does is the signal to the organization relative to what's important, which is what you just said.
Like if there's data that indicates there's some harrowing issue going on with patients and then no one does anything, that's a probably an issue in and of itself. E is engagement, engagement of the leader. Being visible, being on the floor, listening, number five or F is faculty, which is something that we probably could talk a whole show about because this is the whole idea also.
It's not only making sure that the leader has help. But it's also engaging clinicians so that everyone within the organization buys in to whatever is going on and has contributed to it. And it actually works for them that they are doing things together as opposed to having things done to them. And then governance, as you said, how's the whole formal structure of the organization if there are champions and key opinion leaders internally, how is their influence leveraged?
Because if it's not leveraged, it's going to be working against. The change. And then lastly, we tossed in a bonus I, which are incentives, which are always going to be there and a leader should figure out how to harness them. And as you said, you know, it's so frequent, there's a whole science of incentive compensation.
And one of the reasons why there is a whole industry built around it is because it's very difficult. Goodhart's law is a thing. There's been several episodes where we talked about that. If you create a measure as an incentive, is the moment that that measure becomes a terrible benchmark because the system is so easily gamed and it may not result ultimately in better health of patients or the ultimate outcome that you're striving for, it will result in a better score on the quality measure, period.
I love how you summed all of this up. It sounds like the students in your class have been given a really important framework. To contemplate as, of course, this is incredibly difficult and you listed a lot of things. What do you think that leaders who work in organizations today consistently underestimate, right?
Like if you were going to pick maybe one thing in that whole list that you think would be really important to be taking a look at because it's so frequently as an unknown unknown, what might that
be?
I don't want to pull one piece apart and for any listeners who want more information, they go to my website, robertprolemd. com because I point out there that these pieces all fit together. They're really all the reason, you know, we say change is hard, people resist change. No, they don't. I don't think they really resist change. They're sometimes fearful of change. They sometimes don't trust leaders. There's a variety of things that make them not do it.
So if I had to pick one, I'd probably call it the engagement of the leader, because that's how all these are communicated, is going to be, or predominantly communicated is through the leader. But I want listeners to think you have to do all of these. Because they fit together, you know, I said, I talk about the fact that leadership has three parts.
You know, leaders have to create a vision, something about the future that's far better than today. They then have to align people around it and motivate them to move forward. And probably if you ask me, the hardest part about leadership is by definition, it is more difficult than people imagine. Great ideas usually fail, and they don't fail because the idea was bad.
They fail because it takes leadership to make them happen.
I also really liked how Zeve Neworth put it, Dr. Neworth, on one of your podcasts. You had discussed when is a good time for leaders to take action, and his response was great leaders are always able to overcome the present circumstance. There's never a good time, but a great leader can overcome whatever is going on. They're able to be rooted in the present, but, but still supersede that moment, which I think basically, we're all in alignment here.
[00:30:13] Dr. Robert Pearl: Let me expand a tiny bit on that. And I think particularly for leaders of health systems. And again, you know, I led over 10, 000 physicians. They were working amazingly hard every day taking care of patients. I had the privilege as the leader to be able to be at conferences, to be able To read what's in both the medical literature and what's going on in the world of health care overall, it was my job and my obligation to help them to see what was happening, to give them the tools to be able to be successful, not once it happens, but anticipated in advance.
That's what leadership is about. And I think all too often leaders, by leaders, I'm talking about an insurance and in business and in medicine, every place they're in, they're looking in the rear view mirror, they're trying to figure out how do I solve yesterday's problems, because those are the ones are still dealing with today, rather than tomorrow's.
The ones that have yet to come. And I think that that's the number one job that leaders, that great leaders have, because without that, the people who are doing the hard work today will suffer even more tomorrow.
[00:31:30] Stacey Richter: Well put. People can find your books, you have two books, Mistreated and Uncaring.
[00:31:36] Dr. Robert Pearl: So the two books are Mistreated and Uncaring, Where the Culture of Medicine Kills Doctors and Patients.
They both have somewhat negative titles to draw interest, but they're actually both very positive about the tremendous contributions that clinicians make every day as they provide care to patients. And all profits from both books go to Doctors Without Borders. My homepage, my website is robertpearlmd.com
[00:32:00] Stacey Richter: Dr. Robert Pearl, thank you so much for being on Relentless Health Value today.
[00:32:03] Dr. Robert Pearl: My pleasure. Thank you so much for having me.
[00:32:05] Stacey Richter: So let's talk about going over to our website and typing your email address in the box to get the weekly email about the show that has come out. Sometimes people don't do that because they have subscribed on iTunes or Spotify and or we're friends on LinkedIn.
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