A Sobering Look at America’s Physician Culture

Uncaring: How the Culture of Medicine Kills Doctors and Patients, by Robert Pearl

My desire [… ] isn’t to castigate the culture, belabor its shortcomings, or embarrass individual doctors. Instead, my hope is to improve healthcare delivery in our nation, evolve physician culture, and restore the joys that have been stripped from the profession.

Robert Pearl, M.D. is a Stanford professor, plastic surgeon, and former CEO of the The Permanente Medical Group. He writes and podcasts about issues in healthcare and medicine, and in his latest book Uncaring, he lays bare the disturbing ripple effects of physician culture into how patients are treated and how doctors view their work, positions, and cope with stress and bureaucratic difficulties.

Pearl writes beautifully, weaving history, economics, science, and statistics seamlessly into sensitive personal narratives and anecdotes. I was moved to tears more than once at stories from his experience, and it underlined what the greater meaning of healthcare in our culture is. We’ve gotten away from that, to the detriment of both patients and practitioners.

The problem of what’s wrong in American healthcare is a many-tentacled one, and unfortunately because of the deep roots of the US system that are tangled up with insurance companies, it’s not an easy fix. (As is always the case when a lot of money is involved.) But Pearl has seen the issues from multiple angles, and he presents a wise and measured analysis of the problems without allowing for excuses, and explains how both those within and outside of healthcare can actively work to change the culture to achieve better outcomes for clinicians and patients alike.

One major issue is the “illogical and perverse obsession doctors have with prestige and status, two of the strongest influences in physician culture.” This is upsetting, since the point of medicine is to help. But there’s a clear hierarchy of specializations grouped by prestige, with doctors who don’t work in particular favored areas faring worse psychologically despite their work being crucial, sometimes especially in prevention — an area that our current handling of medicine does not fare particularly well in.

He touches on so many other issues – from placing of blame instead of accepting responsibility, the unbelievable burden of tasks on physicians, unconscious biases, physician rankings and assessments, and grappling with a system that financially rewards more tests, procedures, and prescriptions. It is so disturbing. It’s easy to be infuriated with insurance companies and see them as the villains, and this is not to make a hard shift of blame onto doctors, but there are a lot of things going wrong and it will take changes from all sides to right this ship. Pearl writes that patients don’t realize the extent and role of physician culture in “the difficulties they experience with their healthcare” but he makes these often opaque systems and procedures understandable and accessible for those outside of the medical field, no insignificant achievement.

It’s full of sobering statistics, which help to drive home how crucial it is that we change physician culture and the structure of US healthcare US. We are beyond out of time on changing this, and his many examples incorporating the pandemic underscore this.

Consider that “the US ranks ninety-seventh in ‘access to quality healthcare’ and forty-first in life expectancy — statistics that are on par with much poorer nations like Chile, Jordan, and Albania. Among the world’s most developed countries, the United States has the lowest life expectancy, highest infant and maternal mortality rates, and most preventable deaths per capita. In studies that assess a broader definition of quality, the United States consistently ranks last in overall healthcare performance among the world’s wealthiest nations.” American exceptionalism promotes living in denial about facts like this, but this is the reality. And with many people facing uncertain financial futures and public healthcare programs and initiatives always near the chopping block when federal funds run low, this does not bode well.

I was also sobered by his citation that the annual expenses of healthcare that even insured patients must pay — like insurance premiums and out-of-pocket costs, “keep rising despite the fact that eight in ten Americans live paycheck to paycheck.” I knew, around the time Covid lockdown financial effects first started making headlines, that we were in a bad way here, but I had no idea it was that bad. He says costs have reached “an historic apex” despite the fact that we’re also facing major economic changes post-pandemic.

Pearl is diplomatic in his analysis of the many problems that are plaguing this system, and although the behavior associated with physician culture is central, he also identifies the ways physicians try to help (and of course, acknowledges so much about the incredible, often selfless work they do even under extremely trying circumstances). But sometimes their attempts to force change are misguided, like the dreaded surprise billing. He explains that doctors sometimes use this method to “force insurance companies to pay the extra charges. Physicians see this as the only way to get insurers to raise their payments. They don’t see it for what it is: using patients as human shields.”

Another huge issue is the discrepancy in quality of care between white patients and patients of color. He uses early COVID-19 testing as an example, when tests were highly rationed and doctors were less likely to test Black patients who exhibited obvious COVID symptoms despite already knowing that Black patients were dying at higher rates. He blames a “quick-fire deciding process played out at a subconscious level,” and emphasizes how dangerous racial bias is, especially since doctors think they don’t have it, but “systemic and cultural issues” are intertwined in medicine just like they are everywhere else in America.

And not to completely terrify you, but rather to emphasize how important patients’ roles in being aware and advocating for themselves are, he notes that “physicians fail to wash their hands as much as one-third of the time, according to clinical research studies. That’s because doctors see themselves as healers — incapable of spreading disease to patients — and are therefore entitled to skip this important step.” Let’s hope we see a sea change in this with the ubiquitous hand-washing importance awareness post-COVID, but it’s disturbing enough that it ever happened to begin with. Somewhere in Vienna, Ignaz Semmelweis is rolling over in his grave! But it’s proof that physician culture is causing failures in areas that should be no-brainers.

This book is absolutely crucial, especially coming at the moment that it does, as we navigate healthcare after the pandemic and at that historic apex of patient-borne costs. Pearl lays out the problems clearly and presents equally clear ways patients can advocate for themselves and for change in physician culture. I think it’s crucial for any clinician as well, because part of the issue is blindness to what’s actually causing the problems, and US healthcare is near a breaking point. We simply cannot afford these errors and the negative effects of this culture anymore. We deserve better both for the patients paying for and relying on the healthcare system, and for the doctors practicing within it.

American physicians are among the best in the world. When their culture aligns with what patients desire and deserve, they achieve superlative outcomes in the most compassionate ways imaginable. Doctors are capable of almost anything. And that’s what makes it so heartbreaking when cultural values obstruct their mission, and cause harm to patients and themselves.

published May 18, 2021 by Public Affairs.
I received an advance copy courtesy of the publisher for unbiased review.