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A diagnosis of the health care system

Yale Medicine Magazine, 2017 - Autumn


Robert M. “Robbie” Pearl, M.D. ’72, recalls the days nearly 15 years ago that changed his life—and ended his father’s. A series of medical miscommunications resulted in a medical error that a few years later in 2003 would lead to the premature death of his father, Jack. Myriad specialists tended to his father during this last hospital stay, each recommending a different operation. Once the family concluded that no additional treatment would lead to the quality of life his father would want, Pearl said, they declined further aggressive procedures and the physicians stopped coming.

“There’s no CPT code for compassion,” Pearl said.

Now Pearl is on a mission to return compassion, expand prevention, and reduce medical errors in American medical practice. Pearl, who for 18 years was CEO of Permanente Medical Group and is now chair of the Council of Accountable Physician Practices, recently published his first book, Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong.

“I’ve heard fiction writers talk about the characters coming alive, but I think it’s just as true for nonfiction,” Pearl said. Not just characters, but memories, experiences, and convictions demand to be narrated—and the reasons for writing “start bubbling over.” His father’s death and his observations as a physician and CEO of Permanente solidified his conviction: there’s something rotten in the system of health care in this country.

After training at Stanford, Pearl began his career as a plastic and reconstructive surgeon, enthralled with the specialty’s capacity to redirect the trajectory of patients’ lives. “Plastic surgery is the rebuilding of life, not just the correction of disease,” Pearl said.

Health, he believes, needs to be the focus of modern medical care. In contrast, medical practice in America was fixated primarily on correcting disease rather than preventing it in the first place. “I think that in many ways I’ve spent my entire career wanting to change American medicine, and this book has opened a new chapter,” Pearl said.

He describes medicine as an industry operating two centuries in the past. The fee-for-service structure of payment resembles that used among the scattered British population of the 19th century, and paper-and-pencil record keeping belongs in the 20th century, Pearl said. America’s health care system is “as destined to fail as the economy of England was before the Industrial Revolution,” he said. “What we need is a new revolution—a revolution that’s going to change the structure, and change economics, and change the technology.” According to Pearl, the structure of American health care is not integrated, but fragmented along specialty lines, with poor communication and patients falling through the cracks. A legion of specialists treated his father, he recalled, each assuming his father had received an essential vaccine following his spleen removal, and none administering it.

In Mistreated, Pearl uses neurophysiological research to show how context shifts perception and changes behavior. For example, physicians—particularly specialists—need to communicate with those in other disciplines, he said. “When care is integrated, you see everyone as being on the same team as you. As a result, you’re going to collaborate with them. You’re going to cooperate. You’re going to coordinate. You’re going to interact,” he said. “And as patients, most people assume that it’s happening in the health care they receive, but often it’s not.”

Pearl points to his experience at the School of Medicine as a contrast to this structural weakness. “My classmates were not my competitors. They were my partners,” he said. “It was the best environment I could have been in to understand collegiality and the power that it can have.” That same atmosphere is one that, as CEO, Pearl strove to incorporate into Permanente Medical Group. His integrative approach extends to his own combined pursuits of medicine, management, and writing. He authors a health care and business column on, and serves on the faculty of Stanford’s medical and business schools. He has also spent eight years as Stanford’s plastic surgery residency director, training future physicians. “What I tell all of them about their future is that it’s going to be multiple careers,” Pearl said.

The route to better health care, Pearl said, begins with acknowledging medicine’s shortcomings—and addressing them through a model of integrated, preventive, and compassionate care. This vision echoes the philosophy of Sidney R. Garfield, M.D., who co-founded Kaiser Permanente in 1945: “We need a health care system—not a disease system.”

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