FHC #225: Kindness, burnout and the limits of medical leadership

0:11Hello and welcome to Unfiltered, the newest program in our weekly Fixing Healthcare podcast series. I'm Jeremy Corr, host of the Popular Books of Medicine podcast and CEO of Executive Podcast Solutions. With me is Dr. Robert Pearl. For 18 years, Robert led the Permanente Group, the nation's largest physician group. His newest book, ChatGPT-MD, How AI-Empowered Patients and Doctors Can Take Back Control of American Medicine, is a current bestseller on Amazon. Information on a broad range of medical topics can be found on his website, robertplmd.com, and in the monthly musings published the second Tuesday of each month.

0:41Joining us is Dr. Jonathan Fisher, cardiologist, author of Just One Heart, and esteemed leader in helping healthcare professionals to prevent and address burnout. For 30 minutes, Jonathan and Robbie will engage in unscripted and hard-hitting conversation. As nationally recognized physicians and healthcare policy experts, they'll apply the lessons they extract to medical practice. Then I'll pose a question for the two of them as the patient, based on what I've heard. Robbie, why don't you kick it off?

1:04Jeremy Corr: Hi, Jonathan. You just came back from Australia. What were you doing down under? Hey, Robbie. Yes, got back last week, and I was on faculty for a program led by Cherie Johnson, who is helping with burnout in a lot of the healthcare systems in Australia, and it's a real issue that they've got. and we had a hundred doctors and other professionals coming in from around the world. We met in what's known as the heart of Australia, which is the dead center of Australia, called Uluru, formerly Ayers Rock, for about five days. And we had conversations about individual well-being, organizational well-being, policies.

1:47We met with tribal elders because we were on sacred Aboriginal land. and it was fascinating. And we were outside hiking half the time.

1:58Jeremy Corr: I was told that the center part of Australia is the most dangerous place in the world based upon the number of venomous and deadly animals, snakes and others that live there. Were you not worried on your hiking? Ignorance is bliss. So there were probably a hundred things that could kill me, including certain spiders, which we talked about. And I was so in awe of the surroundings. It was hard to be in fear of what was around me. And I guess it was a willful choice to be ignorant of it. Robbie, I've never in my life been in a place, and this was just a vast desert where we were hiking, where at sunrise, as the sun was rising, I could see the sun rising over the horizon.

2:47On the opposite horizon, I could see the moon setting. And it was a full moon setting. And that later that evening, the exact opposite went out to watch the stars and we could see the moon rising as normally you'd expect the sun over the horizon. It was just fascinating. It's one of these final places on Earth where they've preserved the darkness and there's a real respect for the land. So it was literally a wild experience.

3:18Jeremy Corr: How did the burnout conversations differ, given that you were in a very different environment than American medicine? So the environment became part of the conversation in an unexpected way. There's something that anyone who's familiar with Australian culture knows, that there's an acknowledgement of land often done before any meeting starts, recognizing the 500 Aboriginal tribes that many of them are still there. The land that we were on was of the Anangu people, and this is the longest extant tribe in the world, going back more than 30 ,000 years on this land. And the elders came and spoke with us about the integration of land, of traditional tribal remedies and medications in health care, which is their modern health care system.

4:13and some of the ways that they improve patient care by honoring people's connection with the land. So they would bring in Bush medications. They would bring in some of their tribal doctors to work alongside traditional doctors. And they found that there was a reduction in self-discharge, So there was improved hospital care and outcomes among patients, indigenous patients. And that's a huge part of their population in one region in Australia, a place called Alice Springs Hospital. They did an experiment bringing Aboriginal healers in and liaisons and found that the 84 % of their patients, by the way, are Aboriginal.

4:57They found that their patients were just more trusting of the system because they felt, as they said, they felt like the system was honoring their culture, their tradition, and was bringing their connection to the land into their healing process.

5:12Jeremy Corr: Sounds very much like the data that I've seen on the fusion of so-called Eastern and Western medicines, obviously a somewhat different culture, many thousands of miles away, but has the same traditional respect for tradition that it sounds as though it's embedded inside the health system that you saw. Yeah, it wasn't positioned as a replacement in any way. And even the tribal leaders said that. They said, we're not trying to say, don't take chemotherapy and don't do angioplasty. It's just, please allow us to bring in some of these safe remedies, which we've been using for thousands of years, so that our people feel like they can trust the more Western approach.

5:59And as far as the burnout conference or the well-being conference, you and I have talked a lot, Robbie, about how things are similar or different in different countries, depending on the healthcare system, I can tell you that there's no difference in the challenges that the doctors I met with are facing than the doctors in this country. They're overwhelmed by their schedules, they don't have enough time to themselves, they're overwhelmed with information and bureaucracy, literacy, paperwork, et cetera. And we were sharing very much the same struggles and pointing to some of the solutions that are available.

6:39And at the heart of it all, the reason people came away feeling better is that there was a strength in numbers. There was this collective sense that we were helping each other get through either difficult times or become more effective change makers. And we had sessions on how do you make change in healthcare systems? It was really a wonderful experience.

7:02Jeremy Corr: The graphs show that the rate of inflation, not the absolute dollars, just the first derivative, the rate of inflation is actually very similar in all nations. The United States started the highest, way out of line with everyone else, and it's continuing to go up at that same pace, which means the total dollars that are added each year are far greater than any other country. But the economic challenges that all the industrialized nations face, the ones that don't restrict care, at least consciously, or don't admit to restricting care, creates the same forces everywhere. And I think what we're seeing is this unstoppable force against this immovable object where somehow or another no nation can accept, can tolerate, can integrate a rate of inflation that is significantly higher than the rate of growth measured by GDP or by wages or by general inflation.

8:16Jeremy Corr: And that's what we're seeing worldwide. So it doesn't surprise me in any way that we're seeing this increase. A lot of our conversations in the past, Jonathan, to me have really been about the fact that as clinicians, I don't think we've acknowledged that. I certainly don't think that as clinicians, we feel like we're responsible for it. I think there's still a belief that says someone else is doing it to us. They shouldn't do it to us. And just more money should be coming. And whether you look at England, that I know quite a bit about, look at many of the Asian countries, or Australia, by the way, where I too have spoken, the same forces are sitting there.

8:58Jeremy Corr: How do we restrict the growth in costs without restricting the care that we provide? That's a huge question. And as you mentioned that, it reminds me that there's a fascinating pattern among Australian physicians. You know, we have different systems here. So we either work inside a traditional healthcare system here, or we have a private practice there. Almost every doctor has both, Robbie. And so in order to make ends meet, doctors spend part of their time in the nationally regulated system, socialized, and then they have their own private practice, which is just a fascinating split model, almost a kind of a split mind when they would go from one system to the other.

9:48Jeremy Corr: And yet, despite having that control in their own office, where I assume most of it is self-paid rather than government paid, because I assume the government care is paid for and provided by the same clinicians, they are, as you said, equally burned out. Yeah, very much so. And part of it is a supply and demand issue. Because Australia is so vast, and it seems as though they already have a shortage of clinicians and physicians, there were some doctors that were taking care of tens of thousands of people in their community all by themselves with limited backup. There were surgeons who would have to drive for hours every one or two months to spend a week at a regional center just to do all of their sort of backed up surgery, specialty surgeries in a specialized center.

10:37So it was an example of, you know, how do you practice rural medicine when you're already understaffed while trying to split between a federal system and a private practice.

10:49Jeremy Corr: Was there a requirement that they work inside the government as well as in their own office? That was an expectation. Yeah, they all practiced in a socialized context as well. Was it cultural or legal? Do you know? I don't know the answer. Because again, it's interesting to me that the fundamental driver of too much work isn't addressed, but the experience of it is. And by that, I mean, if there's a shortage of clinicians, the question is, how do we have enough clinicians? And if we can't have enough clinicians or enough, let's say enough doctors, then how do we have others who can provide that care?

11:34Jeremy Corr: And how do we use the technology to accomplish it? I don't know if I'm always just looking for solutions, but when I look at the health care challenges in every country, because what you describe in Australia is just equally true in England, where all of the care is provided under the government. What I see is lack of action, lack of solutions to the economics that exist, a lack of forward progress with the unhappiness growing as a consequence. Yeah, there was not a lot of conversation about the economics of health care there. I would say that this group skewed towards physicians who were really, many of them were struggling with a sense of isolation more than anything else because they hadn't seen their colleagues in many weeks, some of them.

12:26And so just this feeling like, am I alone in this struggle? So it was nice to see that sense of community. It'll be interesting if there are any outcomes that we can measure as a result of this. I'll keep you posted on that. Let me move on to, I'll call it maybe a more positive topic, which is that I recently read a review of the literature on kindness.

12:55Jeremy Corr: And I know you're an expert about this. And it was clear from the data that when we are kind to others, that our levels of cortisol and adrenaline fall, lowering our anxiety and helping us return to normalcy. And from a biological sense, this would seem positive as a means to reduce inflammation. And even from an evolutionary sense, it makes sense since kindness to those around us is beneficial, particularly when we used to live in small tribes. But health care is massive, as we just discussed in size, and leaders around the world must make difficult decisions. How do you view the value of kindness for medical leaders?

13:35Jeremy Corr: And are there counterbalancing forces that may make it a liability in leadership? Well, first of all, Robbie, I may be an expert in the cardiovascular benefits of certain emotional states, including kindness and compassion. But I myself have been known to be unkind and sometimes have been called a bit of a cold person. This is probably my former self. I've remedied a lot of that, but I want to be clear that I am not an expert in being kind, though I do my best every day to try to do that. And my patients, for the most part, and colleagues, too, would say that I am. It's interesting, and I think it has to do with definitions.

14:21So what you were referring to is that when we are kind and compassionate and caring towards others, if we are actually helping others' well-being and doing something meaningful, our stress, cortisol, other levels actually improve and oxytocin, serotonin goes up. So it's a net positive emotional and physiological state when we're caring for others, as long as we're not overwhelmed and we're not depleted in doing that. I would challenge the definition of kindness. So what I think you're getting at, Robbie, is that we think that to be a good leader, we have to make other people feel good. We have to say things that don't hurt people's feelings.

15:07We have to accommodate everybody's individual needs so that they don't feel like they're left out and that the group doesn't take over. I would say that that is being more nice than kind. Specifically, kindness is, as I see it, when we're considering the needs of other people, we're acting out of compassion, and we're doing something that considers both the individual people that we're leading and also considering the organization and the team as a whole. So it's not taking the individual in isolation and making sure that they feel good. I don't think that's being kind at all. In fact, doing something that makes somebody else feel good in the short term, like, let's say, not offering some critical feedback, that may help them in the short term.

15:54And it may actually assuage our sense that we don't want people to dislike us as a leader. But it's doing harm. When we don't give accurate feedback, when we don't speak up in a clear way, it can be potentially harmful. So I would say that kindness itself involves doing things that can cause short-term discomfort to people. Absolutely, that can be kind. You can be compassionate and kind. I think what we want to be careful with is being nice. And there's a lot of leaders that try to be nice, and they get into trouble because they think that being nice, which really is not about other people at all.

16:38Being nice is about what other people think about you. So I think when we're trying to be nice to people, we're more concerned with our own self-reputation. When we're being kind, we're actually more concerned about other people's well-being, both long-term, short-term, and the broader view. So I would reframe the conversation a little bit that way. That may help us move forward.

17:01Jeremy Corr: I completely agree, Jonathan, that kindness, by which I mean telling people the truth, can be very positive, assuming they're able to change around it. I think some of the challenge that leaders have is that we know individuals have various struggles, have various shortcomings, have various problems that aren't temporary, but are likely to impact them for a long time to come. And their performance is just not going to be as good as other individuals in a particular department. Surgeons whose skill level may not be as great, and they're not really going to become equal to everyone else. and the only option you have in that circumstance, I guess you could send them back for multiple years of residency training, but for most leaders, that's not possible, is to basically tell them that they can't work there anymore, but that's a big problem.

18:06Jeremy Corr: You're going to have a major, major negative impact on their life, on their families. So it's this balance where you have an obligation, a call to everyone, but also how to deal with the individual in that much bigger context that leaders find themselves in. Yeah, this is it. And I really, what I like about our conversations is that you naturally tend to resist the either or choices, the black and white decision. Well, you have to do it this way or that way. What you just said is being kind as a leader when something isn't going well, has to consider both the individual, their experience, their feelings, I would say, and their outcomes, their well-being.

18:50But also the obligation is to consider the well-being of the organization, which will be there long after every individual leaves. And I think one way to do that is to bring a sense of fairness and a sense of clarity to every communication and a sense of timeliness. So the times when I've faced leaders where I've had difficult conversations with them and they've had to tell me things that were, let's say, I didn't find very easily palatable. What made it easier was when the leader was very prompt, rather than delaying their response or the conversation or shoving it under the rug, which would be the worst, they addressed it.

19:33The second thing was being very clear about the process by which decisions were made. In other words, explaining the rationale, treating me like a grownup. I think the problem that leaders get into is that they think, well, rather than either disciplining somebody, let's say, I won't say firing, let's say we're not there yet. Let's say it's not too late. Rather than having that disciplinary conversation, just putting it off for a while or being in denial, that's an unkind thing to do to the physician themselves because it's delaying the inevitable and it's creating more harm for their patients.

20:07So I think the focus on promptness of feedback, I think the focus on clarity of the feedback. And then I was researching, Robbie, how do we ensure that for physicians, there's a sense of fairness? And I saw where fairness comes down to four different factors as a physician who's experiencing feedback from a leader, let's say. And a physician who experiences a leader as being fair may not care so much about the perception of kindness as to whether their overall experience is negative or not. There's fairness as to the outcome. So, you know, is my firing fair or not? That's actually the least important to most people.

20:55What's more important is fairness of the process. You know, was the decision making to my discipline made clear to me all along the way? Were there objective facts that were shared for me about my performance compared with other people's performance that I could actually review or not? Or did it seem arbitrary? And then the other two factors have to do with, did this leader respect my dignity? Did they ask me questions instead of just telling me things? Did they want or care to know what was going on with me? And then lastly, how did they speak to me? Was the leader obnoxious and abrupt and hierarchical, or was it more collegial?

21:37Look, I know you've been having trouble. You haven't been meeting the standards, and so we have to make these decisions. Those are some of my thoughts about how do we have those conversations, bringing a sense of fairness to it.

21:51Jeremy Corr: I frequently hear from people wanting and really enjoying our conversations about leadership because it's what they're struggling with. And what they would say if they were in the room or on the podcast today is that fairness is a very subjective view contrary to the model you just described. So someone has a series of complications and they can explain most of them away. Often they'll blame a colleague. Often they'll blame a patient. That's their view of the world. They were just as good. It was not their fault, but it's circumstances and you're being really unfair singling me out. Maybe there's even a reason you don't like the fact that I have something, did something, whatever it might be, it's very personalized.

22:40Jeremy Corr: I think that's what leaders react to and it gnaws at them and they're looking to be able to understand, are they being kind? Are they being fair? They have the data. They think it's right. The person doesn't think it's right, but they can't agree. Mrs. Jones didn't take her medication, but you didn't know it in the chart for three weeks because Sally Jones was supposed to be covering it and so on down the line. Now, maybe you don't have that experience as much in your leadership role, but it's what I hear from a lot of individuals, and it makes them very uncomfortable because they feel as though they're having to be, in quotes, the bad person.

23:25So you're right. Fortunately, that's not a big part of my leadership role and responsibility. So how do they deal with it, Robbie? How do the best leaders that you work with address that when it's really hard to say who's in the right, who's in the wrong.

23:43Jeremy Corr: Well, they'll make their best judgment around it. They'll often ask others for perspective and advice, but often who you ask determines the response you're going to get. And as you will know, as you move up through an organization, you tend to see things differently. You know, now that you're the chief, you're no longer Jonathan, the great colleague. Jonathan, and what happened to you. I think that's a common view of the people who move into that role. And I think it's why we have so few individuals in medicine today pursuing these leadership roles that are so vital to being able to drive the change that we need to have.

24:25Jeremy Corr: So I think they do the best that they can. But at the end of the day, when our colleagues that we've often worked with for a long time, before we stepped into that leadership role, start to view us as being them, not us, I think psychologically it's very hard for clinicians. Well, this conversation is not doing too much to improve the situation. If anything, it might scare people off. So I'm interested. I think it does come back to, yes, you could say that fairness is subjective. And my initial response is, okay, well, how do you introduce more objectivity into it. And then it would come down to what are the data?

25:08And so you look at if an individual is consistently underperforming their colleagues, and this is also a sensitive subject because as we know, we physicians, many of us have big egos and we don't like to have our performance evaluated, or some of us do. Maybe it's just that we don't like it when our performance is evaluated as less than perfect, I think it comes down to comparison. And this, again, is a very slippery, uncomfortable subject among physicians. We don't like to be compared. But if you're going to talk about fairness and make a judgment against me and my performance as subpar, I would want to see some comparison there.

25:52So it's not easy because on the one hand, I don't want to be compared to my colleagues on a regular basis and have that put back in my face because I'm doing my best and I'm outstanding. I know all these things. I'm putting that in quotes, by the way. But on the other hand, I think it's imperative for organizations to have benchmarks and standards and to be transparent about what are they. And those standards can be about lots of things. It could be about safety, patient outcomes. What's your complication rate? Well, if my complication rate is 6 % and the department average is 3%, well, there's no way around it.

26:32I can't continue to blame other people and patients for those numbers. So I do think there's a role for objective data.

26:42Jeremy Corr: I concur with you. The challenge is going to be getting the data to be objective. And yes, you can do a very detailed analysis, case match people, make sure that I don't get the tougher referrals or my patients aren't of a different age, different ethnicity. You can go down the whole list of reasons why I might look a lot worse than someone else in the department. If I had to offer a view to people who might want to think about doing leadership despite this, what I would suggest to them is that there is a role of leaders who have to put the patient first. In medicine, ultimately, we say that, and now someone has to make that happen.

27:29Jeremy Corr: where I want this doctor to be taking care of my family or my friends? How do I feel about the patient that I've never met because it was someone else's patient, but who suffered a terrible complication that as I review the data and talk to other people about it, it looks like it could have been avoided, but it wasn't. And yes, there may be a lot of reasons that it wasn't, but in the end, there's a patient who got harmed. And I think it's that mission-driven piece. And it goes back to the same conversation we keep having about leadership. And the challenge that I see is that we keep moving away from the mission of medicine, which is where I think the joy and the fulfillment and the happiness is, and we move much more into, and here's where it splits, between the organization that doesn't care, has no emotion, and the individual who personally feels as though he or she is being harmed.

28:27Jeremy Corr: and we miss the most important person from my perspective in the equation, who is the patient. It reminds me, there's a quote by William Osler saying that, you know, medicine is not a business. He said, it's a calling and it's an art and it's a calling that requires the heart as much as it does the mind, which speaks to, you know, the changes in modern healthcare. When we become purely cold and calculating and analytical, there is very little room for the complexity of a physician who is having bad outcomes, let's say. And what do we do in those situations? Because often it's something going on with their home life or something with reactivity or a broader pattern.

29:20And rather than addressing that, so often it's easier to simply make a decision, you're out. And I've seen people depart from organizations, and I've seen these conversations that you and I are talking about now happen in good ways. And I've seen them where there's a residue or a negative ripple effect when they happen in bad ways, Robbie. We aren't really talking about that. So when the leader makes a decision, a blanket decision, and somebody is out, everyone else in the department notices and everyone starts talking. And then there's questions about trust. And it can really poison the well and the culture when these things are handled poorly.

30:08Jeremy Corr: Your comments make me think of an article that I recently read on misdiagnoses in the ER. and they found that generative AI could identify the majority of these misdiagnoses, many of which led on to significant patient harm. But of course, in doing so, it also introduced a moderate number of false positives, as you would expect. Possibly doctors would like to know this information and reconsider their course before the patient goes home or is admitted. but every time a busy doctor gets a false positive, we can expect that it will engender rejection and what might seem like a great initiative to reduce the harm created in the ER.

30:56Jeremy Corr: I don't know that it would be very pleasantly received by the individuals getting the feedback for a general AI tools. And yet we also know that 400 ,000 Americans die each year in the United States for misdiagnoses. How would you square these competing forces if you were the leader looking at the problem of patients who get harmed in the ED and wanting to be able to prevent that from happening, and yet at the same time knowing that the people in the ED might respond negatively because they would see any and all of the false positives as being simply and a position on them? Well, you just answered the question in the way that you posed it.

31:39And I would change one word that the ER physicians who are going to now be working with these AI tools, which are going to help them make fewer mistakes, but are going to create more false positives. I wouldn't say that they might be hesitant to have more information. They will not want to be overwhelmed by more information. I don't know any, at least where I work, There's no emergency room physician who is sitting around with time on their hands to review yet another source of data. They're already overwhelmed cognitively, and it creates a tremendous mental load, which has a direct impact on ability to make decisions and ability to communicate, which ironically, those are factors leading to malpractice and misdiagnoses in the emergency room, which accounts for a lot of these tens of thousands of not just death, but which you mentioned 400 ,000, but there's another 300 ,000 plus disabilities per year that happen because of medical errors.

32:37So we're talking, you know, seven to 800 ,000 complications because of errors that, yes, maybe AI could help prevent, not maybe, definitely AI could help prevent. So how do we square it? We do not expect the overburdened physician to be the one to be screening this onslaught of new AI-related data, even though it's beneficial data. We have to create downstream resources so that the data can be parsed in a timely manner and that action can be taken. It's not just enough to know the information. Somebody, either a person or an AI bot, will then have to do something about the information. So I think the first answer is do not expect the already overburdened physicians to take on another piece of information, even though it may be helpful because of the excess of false positives that are built in to any model that is geared to be more sensitive.

33:42It's a tradeoff. You want more sensitivity for errors? You're going to have less specificity. You're going to have more false positives. So don't expect the physicians to do it. Find another solution.

33:55Jeremy Corr: I'm not sure. And again, you didn't get a chance to read the article because it just came to my mind as you were speaking about it. They were really talking about how this tool would say to the clinician, did you consider a different diagnosis? Did you consider it could be ketoacidosis? Did you get the appropriate? You didn't appear to get the proper workup for that particular problem. And if you considered it, you feel like you ruled it out, then the question was a good question. And the answer was, yeah, I did consider it. But if not, you might say, oh, maybe let's check that before the patient goes home or gets admitted.

34:32And that may not be a great example, but it's one that came up in some of the problems that

34:38Jeremy Corr: they were accurately identified that did create harm for a patient where the right diagnosis was missed. So I think I'm not sure that there's someone else who could do it. I think you're absolutely right that what we need is more resources. And again, it gets us back into the same question of if the system is fully functional, if that ER is running as well as it could be done, then all you can do is add costs, add more resources, and it's the right thing to do, and every place should do it. But usually what happens, and this is where I get, I'm trying to get to what the leaders are saying. The leaders are saying, but I know there's inefficiency there.

35:23Jeremy Corr: Yes. No, what's happening is not what you described, Jonathan. What we're seeing is a redundancy of requests for consultation that are now slowing things down and back in the ER. So yes, the clinicians are busy the whole time, but there are things that could happen there to free it up and allow the individuals to do that. Now, that perspective would be totally wrong, but that's the perspective that someone might have in an administrative role. And how do they know whether that is accurate or not versus basically being able to respond to the chief who always wants more resources and being able to decide whether that's the best use of it or whether it should go to the cardiology department that is coming in every night to unblock coronary arteries?

36:11Yeah. Well, going back to this specific study, I think you were talking about the one where there were 288 encounters and the physicians, there were these missed diagnostic opportunities that AI was able to pick up on. Just sticking with that for a second, anytime an AI is programmed to screen for missed diagnoses that are potentially going to cause patient harm, there has to be some threshold of sensitivity for warning, some level of alert, each of these warnings is not necessarily going to prevent patient harm. And so what I'm suggesting is that if you're the physician and you've got five new warnings that show up on your screen, in addition to the other best practices alerts that you've already been dealing with and learned to dismiss, there is an overload.

37:04There's a cognitive overload that happens. And among those five, all five aren't going to prevent harm. Maybe one will, and maybe four of them will lead to more unnecessary consultations with specialists or more unnecessary testing. You know, I think about, you know, in cardiology, when high sensitivity troponin came out years ago, Ravi, it was wonderful because it allowed emergency physicians to no longer miss that patient with chest pain who would then later go home and die of a heart attack because the test is so sensitive for even microvascular damage to the myocardium. Wonderful news, right?

37:45Well, it turns out it wasn't so wonderful because it led to tens of thousands of patients who were now sitting in the emergency room with subclinical levels of troponin leak, where the emergency room physician, even cardiologists, weren't sure what to make of this. These were not patients who were having heart attacks. There were many other reasons for these levels, and it required additional beds for hospitals, observation units, extended hospital stays, and ultimately increased costs, patient anxiety. This is just now over the years, there's been net benefit, but this is a cautionary tale. I don't see AI algorithms as much different.

38:27There's a threshold effect. If you set it too low, then we won't miss any complications potentially. The physicians will be warned at every mistake that they would have made. And if you set it too high, you won't catch any of them.

38:40Jeremy Corr: I love this concept, Jonathan, because I think it now is actionable, which is to say to application developers, one's building generative AI tools. You need to include in your tool that you're going to be providing the ability for the clinicians to set that level, I'll call it a level of risk. You could have five options. I mean, as an example, in patients who you're, I'm going to shift now to chronic disease that I'm often talking about, where we want to know if the patient's doing well or not doing well. You can set it to say, you know, a 5%, a 10%, a 15 or a 20 % variation is where I am worried.

39:30Jeremy Corr: If I'm not going to really be worried, I don't want the information. But if I really should be worried, then I want it. And in my experience, 10 % or 15 % or whatever the number is going to be. But now you have a basis for conversation and justification. Because if you say to me, Robbie, you know, on the troponins, I want it to be 25 % or whatever the number would be based upon the data. I'm going to say to you, Jonathan, why? And then you're going to have to say back to me, well, I looked at the study. I looked at the patients and out of 300 patients, only one of them actually had a heart attack.

40:07Jeremy Corr: But we ended up hospitalizing 50. That's not a pretty good ratio that we're going to be able to make clinical decisions around because there's always going to be a point where it's just too much. So I like the fact that you're now going to have to set that. And now we have something we can both talk about and agree as to why you chose that particular level. I have another thought here, Robbie, and this is me coming back to where I was at the beginning of this part of the conversation, which is in the world that I live in, physicians already are stretched thin, which is partly where many medical errors happen.

40:47You know, there's a correlation between burnout and medical errors. The wrong medication is prescribed. The wrong dose is prescribed in a split second when someone is distracted by an emergency in the next emergency room, in the next room. You know, radiologists who are exhausted are literally reviewing hundreds of images every, you know, few minutes or so. Whereas decades ago, we didn't have this much information. and medical errors are happening because we miss things. Cancer, lung cancer is missed. Pulmonary embolism, small pulmonary embolism is missed in the emergency room because the radiologist is exhausted.

41:30They've been working at the end of a long shift. So what I'm suggesting is that I think it's wonderful if we add these safety nets. I think it's critical that we add these AI-driven safety nets, but somebody has to be there to hold the net and it can't be the person who's already at their cognitive limit. I think that's unhealthy and it's unwise. Now, it doesn't mean it's not possible. Maybe it's another physician whose sole responsibility it is, is to be kind of the gatekeeper there or the net holder for their colleagues. Maybe it's a dedicated physician who's not already exhausted and being called in five different directions so they can be laser focused on their one mission, which is to prevent medical errors and to serve the system.

42:19Jeremy Corr: What you're describing is very accurate. It's what happens in medicine today. It's why there are 400 ,000 people who die from this diagnosis every year. It's only a time factor. It's rarely a knowledge factor. It's not that doctors don't care. They just don't have the time to do all the things that are needed within it. So I like the idea that we now have a need to accomplish it. The question I guess maybe haunts me, and maybe it's the fact that I'm looking at it a little bit differently, which is how can we get patients to pay for it? And by that, I mean, can they afford it? A study came out this week that said fewer than half, less than half of the nation, people are saying they can afford the medical care that they are responsible for should they get sick, because that's the deductible, that's their copayment, that's the other requirement.

43:16Jeremy Corr: I'm not even talking about the people who have no insurance. I'm talking about the people who are insured, who say they can't do it. And so again, I think that we have to start with the patient and ask, what's going to be best for this patient? And the answer very well may be that we can't do a lot of things because, as you say, a clinician who's overworked is going to make mistakes. On the other hand, we may say, no, if we can't get access, then care is always bad. I don't know the answer, Jonathan. I think this is really what this podcast is often about. How do we get out of the quagmire that we're in today?

43:55Yeah, I know that we're not going to solve the crisis of healthcare economics during this conversation, but I also have an intuition. The point of this conversation is, yes, there's a human cost of medical errors, but there's also a financial cost of medical errors. And I would wager that if I'm an AI startup and I can provide a low cost, at least for the trial period, a low cost solution to preventing medical errors, there's going to be downstream savings without question if I prevent readmissions and complications and deaths. So the cost of the patient will ultimately be less if there are fewer medical errors, but in the short term, the cost will potentially go up.

44:43Jeremy Corr: And maybe that's the leadership challenge we should take on the next time, which is that how do we get through the short term in order to get to the long term?

44:54Jeremy, let's turn to you for your question. So earlier we talked about Jonathan's travels to Australia. Both of you have traveled internationally rather extensively. And I'm curious, what are some of the things you've seen, experienced, or learned about both as a physician and a patient in relation to medical practice in some of these other countries that have really impressed you and wish were being done back here in the United States?

45:24That's a great question. I think it has to do with an attitude. Taking away the incredibly high rates of burnout in socialized systems and the National Health Service, there is an attitude in countries where there is socialized medicine that everyone deserves equal care or a basic level of equal care. And I think part of our Western system, there are many who have lost that basic sense, that basic sense that everyone deserves that basic care. We've become so competitive, so cutthroat, so driven by the numbers in some situations that we've lost that basic humanity. I don't want to speak broadly here, but it's more of a feeling that I've gotten, especially talking to these Australian physicians who are caring, you know, in these remote villages for caring for aboriginals.

46:34um yes they're exhausted yes they're uh burnt out and they're questioning their their career choice but at the same time um they have such a deep sense of of connection with the people and with the land and with the community and with that everyone is getting the best possible care that they can give um at least within the public system that uh i noticed that as a as a difference a felt difference.

47:03Jeremy Corr: About two decades ago, I traveled to Sweden with Dr. Don Berwick, and we visited a hospital there that I found truly remarkable in terms of the care that they provided. The first thing is to understand how much social support there is in Sweden for people. New parents get, I think, half a year in total, and it has to be taken by both the man and the woman in that particular situation where they're defining it, or by both partners in a relationship in order for them to qualify to be able to take it. Very quickly, there's support for taking care of children so that parents can do the things that they have to do in the work environment without worrying about whether their child will be safe and well taken care of.

47:57Jeremy Corr: There's adequate housing, there's food. All of the so-called social determinants of health are built into the nation as a high priority. And I often think in medicine, we struggle against these social determinants of health in the United States. And that's an unfair load put onto the medical profession, but someone has to take it if the government and others are not going to do so. And the second part about it is that all of the clinicians worked together as one. They met, they figured out standards, they made agreements about the right way to take care of particular problems, and then they all followed it.

48:38Jeremy Corr: And the consequence was that their outcomes was significantly better than in the United States, as well as in a variety of other countries. So I put it together that there's a collaboration and cooperation, and there's adequate support for patients so that the problems that could be better taken care of outside of the doctor's office, outside of the hospital, are taken care of there, freeing up the clinician with more time to take care of the problems that are uniquely medical and clinical. Please follow Fixing Healthcare on Apple Podcasts, Spotify, or your favorite podcast app. If you like the show, please rate it five stars and leave a review.

49:17If you want information on a broad range of medical topics, you can visit Robbie's website, robertpearlmd.com, and visit our website at fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter at FixingHCPodcast. Thank you for listening to Fixing Healthcare's newest series, Unfiltered, with Dr. Robert Pearl and Jeremy Kaur, and Dr. Jonathan Fisher. Have a great day.

49:38Thank you.