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.

26 thoughts on “A Sobering Look at America’s Physician Culture

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    1. I found it really helpful for getting some answers to certain problems I had in getting care too! It doesn’t account for everything but shows how doctors are thinking and why they might make certain decisions and what culture is behind that. I hope it can help!!

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  1. I think a big part of the blame falls onto the shoulders of the drug manufacturers pushing medications that are often times questionable and then making it quite lucrative for the doctors to prescribe.

    It’s a tragedy as we have seen with the opiods pushed by Purdue, Johnson and Johnson and others. After having been “caught” they settle for minimal amounts for those affected.

    The poor doctors are forced in so many directions. It’s not an easy life for those who are dedicated health providers.
    Excellent review of what seems like an informative book.

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    1. I agree completely. He covers that too, about the drug companies – there was just SO much here it was hard to cover it all or even close in a review – but he points out how all the money that’s poured into advertising and marketing drugs directly to doctors really works. It seems that many of them don’t even realize how strong that influence is but he clearly demonstrates it. The whole thing is such a mess!

      It made me reconsider so much about the doctors’ position that I think I’d misunderstood or misinterpreted very often. They really do have so much that’s put on them and forcing them so many directions. He uses the recent example of doctors being pressured to discuss gun control and ask whether there are guns at home, etc. Of course gun violence is a horrific epidemic in this country that needs much more action, but to place one more burden on them, as if it’s their sole responsibility to fix this when they’re already exhausted, overworked, swamped with paperwork and bureaucratic responsibilities and so many “clicks” to make on the computer for each patient, now they should also take this on too? It really helped to see things from this different perspective.

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  2. I’ve been dealing with some health issues the past few years, and it has gotten to the point where I am afraid to visit the doctor. I am wanting to have a baby but I’m terrified of the hospital experience and can’t imagine feeling relaxed in that environment enough to deliver a baby. There are certain doctors who handle issues a certain way, and some who are nice, and some who don’t really listen. It’s very hard to advocate for myself when I don’t know what’s going on with my body and am trusting strangers with medical degrees. Also, have you heard of Dr. Death? Just google it, and look up the wikipedia on the doctor. It’s a crazy true story!

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    1. Oh I am so sorry you’re going through that! No one should have to be afraid of how they’re going to be treated by a doctor, but I know it can be traumatic. I’ve gone through it with chronic health problems too and been astounded at how some doctors have managed to make things even worse, been negligent, dismissive, and a host of other bad treatment. I’ve found advocating for myself really difficult because I don’t want to seem like I think I know more than them because I’ve researched. It’s a really fine line that I haven’t mastered yet, but he does have some helpful advice here.

      I wish I could tell you more that’s helpful for getting through your situation! The thing that’s worked best for me so far, and I hope this doesn’t come across the wrong way, is choosing women doctors as much as possible. On the whole I’ve found them more willing to listen, accept feedback, consider alternatives, and just be more compassionate in general. Out of all the doctors I’ve seen in more than a decade of chronic illness there were 2 male doctors who did this. 2. So I know it’s not all of them, but that was a good enough sample for me to gravitate towards women going forward.

      There’s a great book called Doing Harm by Maya Dusenbery about how women are mistreated and misdiagnosed in medicine. It’s an upsetting but also very illuminating read, and gives some insights into certain treatments and circumstances that maybe you might find helpful. I’m hoping you can find more helpful and compassionate treatment soon!

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      1. Thank you for your response! I totally agree with you about choosing female doctors. All of my current doctors are female now, but I had a few male ones in the past and learned I’m much more comfortable with women! Thank you for your kindness!

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  3. This sounds really interesting, if a difficult read. I think that some of the issues you highlight, especially about prestige and hierarchy, have been problems over here too, but the issue of hierarchy at least is gradually resolving. There are still some individual specialities that are very rigid and difficult to work with (orthopaedic surgery was a nightmare to deal with at my old hospital – which I think was a side effect of the fact that so many of those surgeons had started out in the army). Mostly, though, the younger generation of physicians is much more willing to listen to patients, junior doctors, and nurses – it’s really hammered home in nurse training and medical school these days. Hopefully the fact that it is starting to change in some countries will in time provide evidence that it’s better for everyone when senior doctors listen to their patients and colleagues!

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    1. That’s so interesting to hear! Especially that orthopedic surgery had those problems from the surgeons having started in the army…not that I’m surprised that the army could have those kind of toxic effects on the culture, but I just didn’t make the connection.

      And it’s wonderful that the culture is changing and some of those issues at least are resolving, if gradually. I agree it’s a major problem with many older/senior physicians. Like you say there was just a different method of training. I agree that the younger generation has been much better to deal with, and I hope that’s signalling a sea change in the physician culture.

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    1. We’re going to have to agree to disagree that it’s a better system than most — see some of the statistics quoted above — but I do think we could have an extraordinary healthcare system with outstanding results if we were willing to make changes that benefit everyone instead of those who can afford it, as well as changing the physician culture. I’m glad you could find the right doctor for you, it makes such a world of difference and can be such a tough road to get there! Happy you enjoyed the review 🙂

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      1. My bad! I missed those statistics in my first read (that’s what I get for starting, stopping and restarting) and retract that assertion. Thanks for singling that out. How utterly horrible.

        I’ve had troublesome healthcare for most of my adult life until I found my current doctor four years ago. She’s provided helpful, responsive and pragmatic care that’s reflective of her listening to me. She suddenly left her practice in 2019 and I couldn’t find her until she landed at another six months later. I went without one until then because she’s unique in her approach and delivery and literally hunted her down.

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      2. Utterly horrible is the right description for it for sure 😦 and just so disheartening. I didn’t even share everything that he does in the book, it’s a lot of bad news. I still have hope we can reform our healthcare system to everyone’s benefit, it’s just going to be a difficult uphill battle thanks to Republicans and corporate interests.

        I’m so sorry you’ve had to have that bad experience for SO long in finding the best and right healthcare for you. It is just so frustrating and should absolutely not be the case, not least considering what we pay for healthcare here! Thank goodness you’ve found someone who listens and has been helpful and responsive. There is just nothing better. I can understand why you’d follow her between practices as well! As I mentioned to another commenter, I really hate to generalize, but it’s been my experience over and over that female doctors have treated me better than male ones. I do everything I can to avoid seeing male doctors now. I hate that it’s like that but it does seem there’s something to it.

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      3. I abandoned male doctors when I was in college after years of them dismissing my menstrual issues as me just needing to exercise. I vowed I wouldn’t see anyone who couldn’t experience what I could health wise. When I moved to NC, I found an OB-GYN who was wonderful, discovering what my male doctors should have 20 years before. I stayed with her for everything until my referral problem was fully resolved and I could no longer go to her (lasted about 7 years). It took me almost another ten years to find the doctor I have now. It’s such a shame.

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      4. Isn’t it incredible, when a female doctor just immediately diagnoses something male doctors have been missing for years? This shouldn’t happen – it’s not like every female doctor has experienced exactly the same conditions – and yet! I had the same, albeit I didn’t have to wait 20 years, only about 4, but still!! I’m so sorry you had to go through all that. It sounds like a frigging nightmare. At least you’ve found good help now though, and can stick with her. But yes, it’s such a shame that it’s so difficult, complicated, confusing, painful, and expensive to find the right doctors! It should never be this way.

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  4. As an English person who was lucky enough to be born into the UK when it already had the NHS, I am always shocked by the US healthcare system, in particular that people go into terrible debt because they have the misfortune to have a health issue and are met with enormous healthcare bills. But by coincidence this morning a sobering reminder that no healthcare system is perfect and as you mention in your review, some areas of medicine are “sexy and career advancing” while others are not, and not much kudos seems to be given to the hard work of actually nursing the patients. And lots of sloppy stupidity going on and some nurses glued to their workstations and not getting round the wards https://www.bbc.co.uk/news/uk-england-cumbria-57254855

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    1. Our healthcare system never fails to boggle my mind. Especially having seen it from the perspective of living in other countries now. It embarrasses me that we don’t accept that healthcare is a human right here, and that some people deserve better care than others, etc. This was less about the healthcare system as a whole and more about the dangerous physician culture and how even some well-meaning doctors are still mucking things up, while others are exhausted, burnt out, demoralized, and depressed. It’s all just a mess!

      And that story, wtf!! So she’d already fallen because a nurse hadn’t come to help when she called, and THEN when they operated after that they somehow dropped her off the operating table?? Way to go, everyone, well done. And didn’t want to do a postmortem, don’t look suspicious or anything. I hope her poor husband at least receives some compensation, of course it’s nothing after losing her and in that way, but still. He deserves the recognition that that was abysmal treatment and hopefully an inquiry into what exactly happened.

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      1. Yes that news story broke my heart, just awful and the poor lady was only 70 so not old. Healthcare is I think always a bit of a lottery, here despite the NHS and free healthcare which is of course absolutely marvellous one does need to be a strong advocate for oneself or have a family member fight your corner if necessary to ensure you get the right help and not left ignored in a corridor etc and there are also a lot of people here who have healthcare insurance through their work or privately that choose to go to private hospitals where the same doctors also work, and then often they flip back into the NHS system when things go wrong. Also when you mentioned the author worked for Permanente it made me think of The Usual Suspects….

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  5. Sounds like an excellent book. Being self-employed and raising 3 kids, one with chronic health issues, having to buy our own insurance when pre-existing conditions weren’t covered… I’ve witnessed far too many downsides to our health system over the years. I shudder to think what our family has paid in medical costs/insurance in the last twenty years–a small fortune. Each time I was saddled with another outrageous bill for little or no care, I would first be angry, then grateful that at least we had the money to pay it, then back to angry as I thought about all the people who can not.

    FYI: I’m currently in the middle of watching a PBS Frontline documentary called the Healthcare Divide. Our safety net hospitals that have been caring for the uninsured are in dire straights. Meanwhile, venture capitalists seem to be finding ways to suck the last drops of blood out of them and walk away with substantial money in their pockets. I’ve been wondering for years what it will take for Americans to realize that our privatized system is a disaster for far too many Americans.

    Such an important subject. Thanks for covering it.

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    1. Ugh, I’m so sorry you’ve been through all of that too. As a fellow self-employed person I commiserate greatly. Coming back to the US after nearly nine years in Europe was a massive culture shock for the reentry into the healthcare system alone. I just don’t know how we can even prop this system up, it’s reprehensible and inhumane. And once you start thinking about the amounts paid into it it makes your stomach churn.

      Thanks for the heads-up about the documentary, I hadn’t heard of it and I’m really interested. I wonder this all the time, what exactly is it going to take for us to realize how messed up this system is, and even for those who can afford it, it’s massively overpriced (the charts showing the cost of the same equipment/drugs/procedures in other countries vs. here send me into a rage). But we just seem to accept it because the alternative of “socialized” medicine sends everyone into a complete freakout. It is exasperating.

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  6. This sounds infuriating and depressing, but also really necessary. I wouldn’t have guessed that it would have practical advice for patients as well; that’s great! It also seems like the author takes a really evenhanded approach to presenting the many problems with the system. Systemic bias seems like one of the great modern problems and I’m not surprised to find it at work hear, but my brain exploded when you mentioned that hand-washing is also an issue. That seems like something we should have solved centuries ago!

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    1. Isn’t the part about the handwashing just flat-out insane? Even worse was some of the reasoning behind it, like that physician culture conditions them to see themselves as healers and so, I guess, above this basic principle? It makes no sense and yet that’s the response they’re giving — they see themselves as helping and healing and so no way they’re spreading pathogens from room to room or patient to patient. Utterly horrified. If he didn’t present the stats to back it up I wouldn’t have been able to believe it myself. I did find it very evenhanded and reasonable, he does a pretty good job of considering the many facets of issues that are plaguing this system.

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