A Doctor Prescribes Change for His Overconfident, Overworked Colleagues

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Doctors are taught to think fast and to ignore their doubts and failures. | iStock/FangXiaNuo

Americans love their doctors, but they believe our health care system is broken. In surveys, patients criticize the high cost of treatment, limited access to care, and the bureaucratic maze of insurance rules. If the system is the villain, doctors are often seen as the heroes.

Yet in his latest book, Uncaring: How the Culture of Medicine Kills Doctors & Patients, Dr. Robert Pearl points the finger at his fellow physicians, asking them to accept their share of the blame for America’s poor health. “What I’m hoping is, if I could pull back the covers and let patients see the physician culture, they’re going to demand change,” says Pearl, a lecturer at Stanford Graduate School of Business. “And if doctors see it, then they’re going to be willing to change.”

Pearl, a plastic surgeon and former CEO of The Permanente Medical Group, defines physician culture as the silent, invisible forces that shape doctors’ beliefs and values, which in turn underpin their medical judgment and their patients’ health outcomes. Young doctors are taught to think fast and decisively, he writes, to take charge and to project confidence, even when they’re not sure if a procedure or medication they’re recommending will work. They learn to repress their doubts and failures, to forget the memories of the patients they didn’t save, so they can give the next patient their all. So they can inspire hope. So they can power through 100-hour workweeks or a yearlong, nonstop pandemic.

But there’s a flip side to this single-mindedness. The same repression and denial that enable doctors to play the savior also make them resistant to change and reluctant to admit mistakes.

Deadly Denial

Pearl illustrates this enduring trait through the story of Dr. Ignaz Semmelweis, an early 19^th-century obstetrician in Vienna. When he noticed one out of every five women in his hospital’s maternity unit did not make it out of childbirth alive, he developed a blasphemous hypothesis: Doctors marching around with blood-stained hands were responsible for transmitting lethal infections to laboring moms. Semmelweis ordered his colleagues to disinfect their hands before examining new patients and the maternal death rate in the hospital fell from over 18 percent to a little more than 1 percent. But for years after Semmelweis published his findings, the broader medical community ignored them or outright rejected them.

Pearl says this history is repeating itself today. Even though contemporary doctors fully understand how bacteria and viruses are spread, and they score perfectly on written exams about the importance of hand washing, they still fail to do it one out of every three times they enter a patient’s room. Health care-acquired infections kill 100,000 Americans every year.

Faced with these statistics, today’s doctors react the same way doctors reacted to Semmelweis’ findings in the 19^th century. In his 18 years as CEO of the largest medical group in the U.S., overseeing 10,000 doctors, Pearl observed many hospital staff meetings about hand hygiene where doctors responded with indifference. “When a patient dies from a hospital-acquired infection, each treating physician assumes it was someone else’s fault, probably the housekeeping staff or one of the nurses,” he writes. “These denials aren’t scientific or logical. They are cultural.”

Throughout his book, Pearl chronicles the ways he believes doctors’ sense of exceptionalism and denial hurt patients, particularly when confronting difficult issues:

• Death: Doctors, Pearl argues, can’t get past their own defenses to acknowledge when treatments and surgeries won’t work or when there is nothing else that can be done. This can lead to dishonest conversations about survival, leaving patients’ dying wishes unsaid and unmet.
• Money: When surgeons or ER doctors believe an insurance company’s pay rate is too low, they charge their patients the difference, saddling them with enormous, unexpected bills.
• Racism: Doctors believe they treat all patients the same. But studies show two-thirds of white doctors hold unconscious bias against African Americans. When these physicians are confronted with data that show Black patients died from COVID-19 at twice the rate as white patients, they blame socioeconomic factors like income, education, and diet. They ignore findings that show that when COVID testing kits were in short supply, ER doctors were far more likely to test white patients than Black patients, even when their symptoms were the same.

Putting Patients First

While Pearl offers many other examples of doctors’ shortcomings, Uncaring is ultimately not a condemnation of doctors but rather a plea. He wants his colleagues to be recognized for their sacrifice and skill. But he’s also asking them to evolve, to confront their own conditioning, and to collaborate on solutions.

Rather than resisting efforts at health care reform — Pearl illustrates how doctors’ groups have repeatedly stymied attempts to control medical costs since FDR proposed a national health insurance plan in the 1930s — doctors will have to accept change, even if it means they make less money and enjoy less independence. Instead of claiming the right to perform a range of procedures, they will have to acknowledge the data that shows specializing in one procedure results in better outcomes for patients, though it may not be as fulfilling for doctors.

Pearl suggests doctors take a cue from the retail industry, which has adapted to make online shopping easy and enjoyable for consumers. Meanwhile, medical consumers are frustrated they can’t communicate with their doctors by email or find out upfront how much their recommended care will cost. “Physicians don’t want to play by the rules of retail, bending over backward to please people,” Pearl writes, adding, “60 percent of physicians feel too much emphasis is being placed on ‘patient satisfaction.’” But more patients are prioritizing convenience in their health care, choosing urgent care clinics over traditional doctors’ offices. Pearl says if doctors want to stay in business, they will have to shift and make health care more user-friendly and more humane for both patients and providers.

He points to the caduceus — the medical symbol of two snakes coiled around a winged staff that adorns doctors’ white coats and prescription pads. “The two snakes represent, on the one hand, the health care system, on the other hand, the physician culture,” Pearl says. “They’re completely intertwined. You can’t change one without changing the other.”