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Book Review: Uncaring - How the Culture of Medicine Kills Doctors and Patients

Dr. Robert Pearl spent 20 years leading 10,000 physicians for the Permanente Group and five years on the faculty of Stanford (in both the business and medical schools). As a nationally recognized health policy expert, Dr. Pearl has plenty of perspective--some might even say pearls of wisdom.

One reviewer described his most recent book, Uncaring, as "...Lifting the veil on the deeply conditioned culture that drives American physicians and our multi-trillion dollar healthcare system…” Indeed, culture does drive policy and we need to change both if we truly want to improve healthcare.

And a great place to start is a quick review of his book, Uncaring. The key takeaway from his book is that primary care is our greatest asset and our most potent solution and yet the multi-trillion dollar health system is destroying it. If that piques your interest, I encourage you to read my full review below.

Uncaring begins with an uncomfortable truth: “US healthcare is the most expensive and least effective in the developed world.”

So how does Dr. Pearl suggest we change the system? He notes that numerous researchers have concluded that primary care is by far the most significant variable related to health status. Yet, the current system is killing primary care. He references a study in the Annals of Medicine which showed that visits to primary care have declined by more than 24 percent over the last decade. That same study also noted that 46 percent of individuals do not have a primary care physician, up from 38 percent a decade earlier.

As I've often argued, a lack of care coordination leads to fragmented care, which is wreaking havoc on our healthcare system. Dr. Pearl agrees: ”Physicians undervalue the generalist, the doctor who connects all the pieces. As a result, rarely does any one doctor take responsibility for the totality of a person’s care.”

A big part of that undervaluing is cultural and status driven. As Dr. Pearl notes, physicians themselves look down on primary care: “Today, primary care is undervalued, even looked down on, by much of the medical community and by specialists in particular…As a result of its lower average salary and overall lack of esteem, primary care sits near the bottom on the list of desired residencies.”

The key takeaway here is that primary care is our greatest asset, and our most potent solution, and yet the multi-trillion dollar health system is destroying it.

What's even worse is the billing system, which burdens primary care physicians with complex bureaucracy. Dr. Pearl describes it as follows: “Walk into any doctor's office nowadays, and you will find as many people working on billing, claims and collections as you’ll find people providing care. Since 2011, the cost of managing the finances of primary care shot up 74 percent. All this time, energy and investment are being wrested from doctors.”

In fact, these billing practices literally discourage physicians from talking to their patients or each other because coding does not pay for “conversations.”

As a consequence, physician morale is at an all-time low and continues to decline. Dr. Pearl believes there are solutions to all these challenges. He looks to adopt capitation as the universal payment model for healthcare, make physicians follow evidence-based medicine more closely and reorganize health delivery so that physician practices are integrated so that capitation will work. In other words, make implementing the Kaiser model the future of healthcare.

There is a great deal of merit in this approach to reforming healthcare, and while I agree completely with Dr. Pearl’s diagnosis of the key problems, we differ in our proposed solutions. My recommended approach would be to focus on changing the payment model in healthcare for primary care (which only consumes 4.7 percent of health spending) because it is incremental and would have a great impact on improving health care. My book, The Journey’s End, describes the path forward on these recommendations in greater detail.

In closing, let me conclude with a final pearl of wisdom because it illustrates how important good primary care is for the elderly. The elderly, with their many chronic health conditions, need a physician to guide them through the health system and coordinate their care. Absent this support many elderly patients are the victims of fragmented care and end their lives in a hospital ICU. This poignant quote from Uncaring makes this point.

“Times have changed. Walk into any ICU, and you’ll find the majority of beds are filled with incapacitated patients in their 80s and 90s. Most will never be able to live without constant medical care. Many will never eat, breathe or urinate again without machines. They’re too weak to get in or out of bed without assistance. Once discharged, they will languish and deteriorate requiring hospital readmissions within months or even weeks. Few, if any, will ever return to vibrant life.”

Yes, we must return to a vibrant life, and that requires changing both our culture and healthcare policy--together. Anything less would be...uncaring.

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