>> search for elizabeth hinton or the title of her book america on fire usingthe box at the top of the page . >> here's a look at some of the best-selling nonfiction books according to the washington post . english is i alone can fix it, washington post look at the final year of the trump administration followed by charlie mckesson's illustrated fables. the boy, moore, fox and the horse. after that is michael pollan's examination of the psychoactive properties of certain plants in this isyour mind on plants . next is michelle bonner's memoir crying at h-mart and last is a travel guide by the late author and travel host anthony bourdainsome of these authors have appeared on the tv and you can watch their programs anytime at booktv.org .

>> my name is joy and i am a senior managing director for healthcare at fti consulting. i am also a hospital board system member and i'm the daughter of a kaiserphysician . so this means i spent a lot of time thinking about how we can improve health and healthcare for our physicians and our patients and all who serve it. honestly i cannot think of a more important issue in healthcare today then discussing the role of physicians since they are critical to the functioning and this functioning of our healthcare system . and i can think of no one more important and prepared to discuss these issues and our featured guest here today on today's program, doctor robert pearl. as some may know doctor pearl is the former ceo of the

permanente medical group and he's at graduate school of business. he is also the author of the best-selling book mistreated and is also the host of a podcast fixing healthcare. today we are here to discuss his new book "uncaring: how the culture of medicine kills doctors and patients". with those introductions out of the way, one more quick important note. of housekeeping before we get started today. if you have a question, please use the youtube chat feature, the questions will be submitted to me throughout the program and i will try to ask as many questions as possible during today's program. so let's jump in. doctor pearl, if i may when

did you first realize you wanted to write about physician culture? was there a formative moment where you thought, this culture thing is the problem, i should write about it or did you accumulate over time? >> thank you judy. in 2017 i published the book mistreated. and it pointed out all of the problems of this system of american healthcare. the problems with insurance coverage, the problems with egregious pharmaceutical pricing. technological problems, i point that out at the time the most common way that physicians exchange information was with the fax machine, and 1832 invention. all this systemic issues were there and as i traveled around the country speaking

in meetings, talking to hundreds of physicians, it became clear to me that there was another part of the equation because if that was the onlyproblem, we would have already addressed it . this is what i saw in my research talking to physicians, talking to healthcare professionals and uncover the physician culture. this invisible force and beliefs that we learned in medical school and residency and carry across our careers and that led to the writing of uncaring on the culture of medicine between doctors and patients and all profits from this book as well as the first book go to the amazing charity for doctors without borders and today it's in india and brazil and other places around the world that are suffering and as they say all the profits are dedicated to that great organization.

>> that's great, i'm glad you mentioned that and i'm sure they are very pleased for your awareness of the organization and contribution to them. if you'll allow, before we get too far into the program perhaps you can summarize for us what it is about this physician culture?>> the values and beliefs and norms and is not in the classroom, it's not found in the textbook. you learn by observation, through the stories people tell. ruby language that they use. and before we go to far i want to point out that often this physician culture is wonderful. it allowed physicians early in the coronavirus pandemic to take care of patients for

24 hours a day when there were no, when protective gear was not available. they'd gone garbage bags and in place of masks. they knew that every time they omitted a patient's that the patient would cough, human viruses in the face and they did it anyway when patients needed a ventilator, they figured out if they put both of them on the same machine, it wasn't even thought of as a possibility and yet at the same time, that same culture as other consequences. we're in the greatest culture developed across time whereas until recently, very little physicians to an denial and repression were essential, essentials let them get through the day as children would be dying in front of

their parents and they had no ability to reverse the course or as they say in the book i have a story about my cousin alan had hotchkiss disease early in his life when he was a college student and how the researchers of stanford, the physicians there would give him incredibly toxic medication so that he was vomiting with diarrhea and pain and allowed him to continue doing that so that today we now can take care of these types of cancers with a high rate of success and without the same morbidity. this culture has been an amazing culture across time and yet it's been the same culture that gets often in the way and allows physicians to not notice many of the things that happened. i'm just tell the story it's okay of the 1850s they had a

team in vienna austria and at that time 80 percent of women died in childbirth of an infection of the uterus that spread throughout the body and the thinking was caused by particles that drift up through the streets below but the cases were like nurse midwives. they can't explain this, their breathing the same air, how could it be? and one day a colleague mixes finger in the autopsy room with a woman who died from fever and goes on to develop not just the local infection but a systemic disease. he said maybe the persons carrying it on their hand on

the leather aprons they wear to protect theirthree-piece . it says will change aprons and get their hands in coordinated water and lo and behold lethality drops to two percent. he writes it up, he writes letters to the directors around the world and guess what happens? nothing. nothing happens. it's not logical. here's a 90 percent reduction in mortality and yet doctors ignore it. and the reason is this invisible culture because doctors see themselves as being incapable. they see themselves as signs of experience, the more cost to better it is. he dies alone in a mental institution four years later nothing changes until louis pasteur comes along.

and it's not a story where they're making the leading cause of hospitals in the united states is hospital in acquired infection. unlike the coronavirus is not carried through the air, it's carried on our hands and get one in three times physicians don't wash their hands and they go from one room to another. we tell ourselves about the systemic problems. there's not enough money or it's too expensive. no, it's inexpensive. it would take less than three seconds. it's the same culture because whatever the patient dies, everyone assumed it wasn't them it has to be someone and that's why i write about this . when you talk about racism you see the same phenomenon. when they talk about

technology in so many different areas it's not the physicians . there dedicated, hard-working but the truth is that patients are being harmed as far physicians. >> you think that the reason, do you think it's because to try to re-summarize restate the things you talk about is it's a very ethical culture assembled by people who are creative and know how to problem solve. they desperately want to do the right thing at the right time when there's your story about the experience of coronavirus and being really, figuring out what to do to take care of the most people as possible and in many ways their heroic and yet the mundane thing where there may be a sense of invincibility that they can say they learned in school. it's not important enough to

take seriously. is it something along those lines? >> i think culture is about esteem and respect. it's sometimes associated with money and again, in the minds of many physicians the issues are around income and patients being seen for days and these are true and very problematic and need to shift. but i make the point in the book we have to shift the systemic problems and the cultural ones that are there so when you start looking at what do physicians value, they value intervention over prevention. >> i was going to ask about that. >> is it something you need to know and do what it's just not that important. you're going to skip step, it's not the issue . the value the things that they uniquely can do, not the

things that can be more routinely done so they don't value things that can be evidence-based, practices that keep up the riches even though their elite for excellent result as a consequence. they value multimillion dollar machines that are shiny and bright and star wars like. like robots and proton beam accelerators. they don't value telemedicine. they see it as being better and having a patient come to their office during covid but the idea that says this might be better care, more cost, more convenient for the patient. doctors value their time much more than the patient's time and every one of these has a systemic basis but they also have a cultural one.

>> i do want to talk about telehealth but right now i want to circle back . you were talking about that position culture elevates prevention and you talk about how that comes into play with managing or managing chronic conditions which we know that maybe the majority of americans are over 65. talk to us a little bit about how financial motivation and financial incentives you know, and maybe that hierarchy of medicine that you write about of specialists versus primary care physicians. how those things all play in together to in fact prioritize and prize intervention? >> if it's possible to totally separate the systemic and cultural pieces, people

influence each other. and so as an example, primary care. what the data says is anything primary care physicians through a community increases longevity 2 and a half times more than adding 10 specialists. and yet we train a lot more specialists than other nations and a lot fewer primary care physicians. now again, there's a salary issue exists although we also may talk soon about burnout and the specialty that's most burnout is not primary care urology which is a surgical specialty but overall to ask medical students about primary care, they don't see it as being near the top of the hierarchy. they also can see the financial issues but they don't see that, they see it becoming an eventual cardiologist for orthopedic

surgeon as being a higher valued position despite all the data that says no, primary care shouldn't be at the top. similarly we elevate the value of the interventional cardiologist who unlocks the vessel to the heart or the interventional radiologist on the blood vessel versus stroke more than the physicians who objected in the first place. again i want to keep talking about this balance. insurance companies don't pay enough or doctors to do preventative care. they don't value is as much as well, but we have that same issue. if you look at covid, 88 percent of people admitted to the hospital went on to die

of two or more chronic diseases and we can look at one in particular, high blood pressure. of course the united states today we take care of them, we have it under control . only 55 to 60 percent of the time. and when i was the ceoof kaiser, we were at 90 percent . the doctors were just as good. medications were identical. why would there be this difference and it comes down to a culture where everyone is committed to prevention, to avoiding strokes, avoiding heart attacks and how the mortality drops as 40 percent compared to the humidity around us. some of that is the system but a lot of that is the physicians culture . >> i would guess again being the daughter of a kaiser doctor and being a kaiser patients myself remember, it's the culture as you say which will be interesting if

moore comes out about how you created that culture but i also seems there online. so it all works in everyone's favor. it is sort of a righteous or virtuous cycle. the system connects and incentivizes and promotes to everyone's benefit if they're all in the same heading in the same direction but which is not always the case. where the community physician is maybe on a different kind of payment model so those are importantconsiderations . >> absolutely right. the system affects the culture the culture affects the system . we are playing in a capitated which means that a group of doctors and hospital and a certain payment takes care of the population of patients and now your risk but what you see is the register

becomes more important. primary care because you start lowering the incidence of medical errors. you start avoiding complications from chronic disease or elevating the importance a lot because you have a financial incentive to do that but it gets spoken to the culture and as a culture shifts, you start wanting to take this type of payment the cause it fits in with your values and your beliefs and your norms and that's why these pieces reinforce each other and when we look to the future , what you see is you're not going to be a change just a system for just the culture. they're both going to have to the involves together. >> which is very difficult with kaiser since the beginning. now we see many other organizations and systems trying to replicate something similar with that alignment

of the system and the culture and behaviors and norms stacked up in the way you're discussing . we have a question from one of our listeners here. you might well ask it because it fits right in which is this question is around the difference between a physician culture in the united states versus physician culture and other countries. is that something you could speak for? >> this country as you said earlier has a much greater number of primary care physicians and their role becomes more central and the salary differential becomes less actually with a system and a culture together. so it is significantly different. we look at the statistics. what do you see? the unitedstates we spend

$11,000 per american on average . germany it's 7000 and almost every other country less than half of the united states. when you look at the outcomes , what do you see? less than half of the most industrialized nations, housing mortality, the term mortality. we have in the culture of american medicine the values of health confused with the ways to be able to, the greatest opportunity to avoid disease and the greatest opportunity to extend life and improve health. >> while this is perhaps outside the point, doesn't other countries have other societal benefits that are when we talk about maybe you could talk a little bit about the role of social determinants of health and

how society and what is valued in a society helps allow people to be more healthy which is an important question. >> absolutely. health has been seen as being as significant in terms of people's overall health and life expectancy. as the medical interventions themselves. but social determinists were talking about is going to be the housing, the food. transportation. the social economics, educational systems. the pieces that add a lot of value are not necessarily inside the traditional culture of medicine. so if we look at this issue of racism in the time of covid, you see this coming

out very powerfully. what you see is that black patients at immortality and it was 2 to 3 times higher than white patientsand course it's still happening today . if you ask physicians why does that happen, no point to the system issues. don't point out the fact black patients often work in jobs that require them to take buses and subways that were crowded in places where disease can be transferred. they live in multi generational homes and all these pieces are crucial. nations that face the same issue found a way to let people be able to isolate, socially distance during the pandemic. there was much lower mortality than the united states but at the same time there's a cultural piece because we tell ourselves

that as physicians we treat every patient the same and yet the data says that the from the earliest period of covid when there was not enough testing kits physicians tested white patients twice as often as black patients despite the fact that the chances of black patients dying was 2 to 3 times higher. you get 40 percent less a medication to black patients after the same procedures we already know the mortality is three times higher most women giving birth. except when the attending physician is a black physician. and then they disappear this week alone what we saw is tremendous differences between hospitals in the same community, simply between a few blocks where the majority of the patients were black patients versuswhite patients . despite the fact they were close by when patients in the

white hospitals were receivingmedications and food , there was the black hospitals often the facilities receiving freezers and body bags as the mortalities was so much higher and yet, as a specialty, we don't react and say this is just wrong. what can we do to make that difference and that's why i wrote the book. because to point out that in our culture is not our problem. we don't see it, we deny it. then maybe we talk about it a bit but we don't see an obligation to make the change and i think embedded in the best values in the physician culture there they were going to allow the doctors to take care of thepatients . it's their is part of our mission and purpose and having lost that connection some of it comes systemic portions but having lost that connection i think it's harming not just patients but the doctors themselves. >> let me just spend a longer

moment on this because it's such an important point that you're raising and it's probably a disturbing point that you just made. i don't think you're saying that doctors are purposefully racist. it is it a blind spot or is it, what do you think that difference is in treatment is due to? >> that is such an important question because we know the answer and the answer is it's what's called implicit bias. think about the evolution of human beings. 20,000, 30,000 years ago we saw a person coming over the horizon. we have a fraction of a second to decide whether this is a welcome or so that was coming to kill us. that we can shoot an arrow at

work in some other way harm before they could harm us and we developed a certain tribalism. there are the things that are inside people who look like us, speak the same language. worship the same god and people who are different than us. and it's implicit bias which by the way it has been shown to exist in two thirds of what physicians when it comes to black patients. it's just part of our evolution . and i was in a podcast a couple weeks ago and i asked this question, it said is implicit bias racism and my answer was implicit bias is not racism. but having seen it and doing nothing about it, that is racism and that's why i want to point out doctors are well motivated. ideally a third of the patients are not even in their mind possible that they would treat patients differently based on the color of their skin . that is not possible and yet

i wrote the book to show the data and we're talking about dozens and dozens of studies. the outcomes in terms of quality do vary by these various factors and having seen that i believe that we have an obligation. despite the systemic issues that exist . the recognition that many of the forces around us we can't control lead to the same outcomes, i believe we have this obligation to do something and again, i wantto stress i think we will feel better about it . although classic plastic surgeon my focus on cosmetic surgery, i did a lot of trips around the globe. and we would go to countries and in central america and hundreds of degrees out,no air-conditioning, eating rice and beans . and you come back. energy after working 12 hours, having volunteered to do this. there's something that i

write in the book about a physician. he had ids going into his arms because the protective suit against the evil of that he was treating it so high he would become dehydrated and passed out yet i've never seen someone come back so excited about the work that he did. i think we've given up a lot because of the systemic issues and we have to work to change them while we evolve and transform physician culture. >> i think that's why your book is so important because after my experience working with physicians and my father as i mentioned seeing those kinds of physicians we would, they would always tell us you want to change behavior, bring it back to the patient. they will do anything to improve patient care. if they take patient care, i think that we can get into

burnout in the second but that's really a court is as all caregivers, not just physicians they are there to try to be significant in their work and did you see that they can't work to improve patient's lives in the gets buried right under so much of this administration so before we go there let me ask one question because are talking about some things that are some things that people will find disturbing. you probably get a lot of feedback from your colleagues say he, you're not right at all. i didn't agree with you and in reading your book, it reads a little bit like you're an insider writing and expose on your own culture. and i'm wondering you see somebody, do you see yourself as the person who's exposing the proverbial elephant inthe room ? how do you view yourself in this? >> first of all there's no greater cheerleader for being

a physician and for practicing medicine and i am. and at the end of the book i talk about the fact that the best decision i ever made in becoming a doctor and i hope the next generation can do the same. >> is not an exposc because only the reader will see that i have such massive respect for what physicians do. they worked incredibly hard under difficultcircumstances . >> training. >> .. and you are right, some people have not been that i expose it. i don't believe that is the way to improve it either. eve though the doctors or the

patient's product actually welcome the discussion and the disagreement. talked about the five stages of grief. i think we have to understand that is somewhat what is happening in american medicine with physicians today. i want to differentiate the things that are done by for-profit insurance companies or drug companies whose societal changes are happening around us. i mean patients are more knowledgeable. why is that? it is the internet. they can explore and find details on a variety of diseases and they have a i helped to make diagnosis. they're going to come with more information. that is supposed to level the playing field and start to eliminate the paternal approaches of healthcare in the 20th century. patients become a consumer. they want the same convenience

and healthcare whether to make online appointments engage in video, those are going to be there. that is going to grow more. every time that change happens it's a flattening of the hierarchy, physicians and patients have become much more collaborators on disease can intellectually it makes change to the doctors. we know is it relative of a hierarchy starts at the climb i could be satisfied unfulfilled and fatigued the exact symptoms we see and burnout. i think those things are happening the book is written as much for doctors as patients to point out these things. now people disagree with the data and facts. they say no black patients

aren't dying more often. okay, let's look at the numbers. they are dying let's look at the causes. there is a group that's gone from denial to anger. we accept no blame. it is all being done to us. maybe the majority the ovi writing majority is systemic. if we make the rest of the world respond we have the obligation to change as well the things that are under our control. whether it's 10%, 30% 50% that is a less crucial than the fact it is there. i believe in accepting it. focuses on denial and repression. when you are a resident you just do the work, 80 hours, 100 hours you were told never

acknowledge your feelings. never say you are hurting. and there is nothing more dangerous in the context of covid than those actions and those defense mechanisms. i talked to one physician who lost or patients in a day. the resident started a month rotation by the end of the month every patient he had inherited was dead. we have to deal with talk about these things and explain these things. the idea of saying i need to suck assistance. it is just taboo in the culture of medicine. this is what has to change. and by the way we are focusing on physicians the same kind of pain as happened to the nurses providing care in the critical care unit. i think nurses are bit more open. i wrote a book about doctors because that's what i know the best. in the hundreds of people i

talked to for publication someone else can write about nurses. i suspect it's going to be just as prevalent among nurses as physicians. >> i suspect that too. the talk a bit about physician satisfaction and burnout. i do and to underscore one of the things you were talking about. the physician and the culture i think is a hallmark of why physicians have special status in the professional hierarchy. i think that is reasonable. it is also what you are mentioning being degraded a bit with the information and access to information and leveling that playing field in

terms of the regular person being able to come up to speed and maybe come into your office and sit i read up some doctors may like that some may not like that. we talked about loss of control and status. there are many reasons that i would suspect people who will become patients one day take more control like they do and all other regards of their life. it's not always met with the greatest open arms by our physicians. those potentiate better outcomes for patients? also maybe an estrangement for

the physician and their job. >> you are correct that a growing number or a large number of doctors see this as problematic. the point out all of the misinformation that exists in places like the internet, patients don't care. that is the reality they feel they want more information they reject a lot of the physician culture. think about it, what do we call that area when you walk to the door to the office? it is the waiting area. your is to wait for dwight is in a reception area research area we do the kinds of things that places to be accomplishing because we don't see that patient as a customer. we see that is a very

paternalistic the patient is incapable of a booking an entire trip to europe once he covered restrictions are gone from the comfort of their home the airlines the transportation, the tour and yet they can't be transmitted to a doctor using secure e-mail, using telemedicine that is in place. these are the pieces i think of the culture of medicine that is there. the time of the patient is just not valued and that system. don't get me wrong, doctors are working incredibly hard. they are overwhelmed with time and the idea of wasting time are problematic. i think the response to that is to ask how do we of all this? how do we find the right tools to allow us to provide care to

patients that are higher in quality not more problematic. easier to access, more convenient. physicians are afraid to say i'm already working so hard. they are right that is why an evolution move away from individual physicians all working by themselves to a collaborative group is a powerful tool to do that. you can create a virtual line that prevents a label. it is an integrated multi- special thing group. you can create that without physicians have to move out of their office into someone else's building weren't necessarily give up the things that are valuable to them. it's required leadership

structure. the smart leadership and healthcare today the culture of medicine every physician clings to their autonomy. even when their outcomes are shown to be not as good as they potentially could be in the hypertension example. this is the cultural shift that has to happen. i believe it will be happier in the new role. i think some will disagree. it's going to beat this of movement through the stages of grief to acceptance. acceptance is not saying this is the best way. acceptance does not say this is what i want. it is saying this is the new reality of the world. as a health science building i saw a sign that said quality, service across the top below it said the 21st century now , two is not good enough. we have to find a way to

elevate the quality make the access easier more patient focused and at lower cost think we have the tools today the culture stands in the way. and the systemic issues are problematic. but i believe we can change them if we can involve that culture going forward. >> before i ask you specifically more about telemedicine let me ask you is there might be some erosion getting into kind eating away what is typically or historically the domain of the physician do you think will be better for patient care and better for outcomes? if what the evolution happen?

>> if in fact the status of the physician over time. because patients are taking a bigger role in their healthcare. >> i absolutely believe if doctors and patients work together as one we can achieve remarkable outcomes. the problem is the culture will stand in the way. we do not necessarily value those things that doctors and patients do together as much as the things are they can uniquely do. again it's made worse by the systems of taking the time to have those conversations. let's look at issues like diabetes. one third of people who have diabetes is going to lead to blindness, amputation, heart disease, kidney failure. we do not do a lot about it.

some of it for systemic reasons and some of it for cultural reasons. we take home cancer screening across the united states we screened for colon cancer about 60% of the time. we couldn't take it down to zero but we get lower it dramatically the people dying for colon cancer. i think it was a result of the cultural aspects recognizing with the economic ones that don't exist and the mortality from : cancer deaths dropped 30% below the nation as a whole. we don't see this. i keep wanting to go back to this theme. another example to me was december 2019, 2 months before covid would comes sure. the federal government publishes data saying healthcare is going to go up

five or 6% a year every year for the next decade. that is six-point to trillion dollars. $2.5trillion in added expense. i look at that numbers and say that is unaffordable. for families, for employers, you did not see any of the national medical organizations saying that. the culture of medicine the assumption is were going to keep doing things the way we've been doing them and accost costs are going to rise. it is a good thing because patients will get more care instead of i think is shifting at the same not maximize the outcomes. how to be more effectively use the resources. another great example is the mayo clinic. they show as no value and we keep doing those things how

can we use that money better? we could use it to put in place of the president plans around infrastructure rebuilding, education and childcare. we could be invested in more primary care. we can invest in giving doctors there are a lot of ways we could use that money. that is not the conversation that we have had. again it's why i wrote the book to stimulate that. it will require changes in the systems around us and drug company pricing. why should physicians not meet meeting about process rather than fighting these sums victims. >> that is part of the question for my mind. because you have a great deal of experience as an example of

integrated house a line is a great example it is proof. and we have known this for a long time. they have access quality and outcomes we know all of that we've known that for many years. there are many papers written about that. we see the change happening outside of healthcare.

see them coming into business they may not be traditionally healthcare players who have started these companies. they may be test companies. the migrating care in the virtual environments. he would sit on your phone, computer, text, you don't know anything about that doctor. that dr. does not know anything about you but they guarantee can get the care when you want to on demand. we see that change because the doctors i don't think are taking ownership. it is taking advantage of they are seeing the change. to make things that should

have a higher quality, lower cost. do you think these companies are good thing? >> the word good is not the issue. we find in greater problems. the $8 trillion paid back with interest. here in california we have amazon, google, netflix. pretty good tax revenue but across the country that's not the case. as higher costs for employment higher costs for medicaid. and small businesses are going to be in trouble. i think we can expect the download pressures going to occur it is going to be in one

of two ways. literally for decades future servicers are going to work well at all pushing in the same direction goes up fragmentation you know there's a lot of push that is happening there. in the positions that are still doubtful horn the denial phase or the anger phase the word i give you is amazon. it was formed a few years ago the combination of amazon and berkshire hathaway i wrote a paper talking about the impact

it has had. i sent anyone who believe jeff bezos' joined this alliance in order to do as the ceo said at the time provide care only to his employees probably still believes amazon only sells books. this will be a for-profit venture. and now we are seeing it for the reasons you say. telemedicine can offer nationally. prime numbers once you get a visit with a physician you comprise a ten or $15 and obtain one easily through amazon. they are offering access to their sites right now in seattle with the most they will ask span that nationally. we know friends which is longer the ceo but his friends run a large company. they are interested in the same things that are out there. the idea that going to contract with every hospital

and every doctor in the community amazon does not just sell books. people often say amazon is that a bad company. i am not going to work them not going to comment on what it's like to work there. i am a prime member they can make clear transparency on the price. they delivered as promised it is a lower than going to a local store. it is hard for me too imagine an experience would want to pursue if they can be fully developed. i think that's going to be the future. so in him in three years, five years, seven years i am not sure. maybe some physicians as they just hold on it will go away. that might work. i think the process of change

had to be led by clinicians. my big concern is that as the financial pressures grow, what is going to happen is not that we are going to transform healthcare we are going to move to a system of rationing for their going to someone is too old to have surgery. it's just too expensive week can't pay there's a cure of one year get to the back of the line. that will become the system of medicine. i think it so values mission and purpose. that is white medical students became medical students. i think that's going to be far worse. as difficult it is thinking about that it's going to be the better of the two.

>> i think your point regarding the experience of care and the ability to provide excellent and customer service is critical. i don't think we think about that enough or value it enough and healthcare. we have waiting rooms, and those waiting rooms and so forth. i've information about the disease are difficult to get. finding the doctor's phone number to the office is tricky. think there's also some younger people data say they prefer ease use. and if they can get that great service they are used to why

can't they get it when needed something and resell. i think it's a big pressing issue and my mind and healthcare we don't value enough. but any few minutes i went to ask from the audience as it couple questions that have been around, all of the patients being a source of profit. it's kind of rubbing people the wrong way. not that you're saying or advocating it the importance of the patient. in all of this discussion around cost-containment, or even rationing you just mentioned, it is hard to hear, right? as an individual, as a patient we all have love into our

patients at some point. would like to believe the doctor and the healthcare system is there purely because they want to take the best care of us. not be thinking about bonding and cost. that is attention is in it? have to pay attention to the bottom line, how do you address that? i've never found a physician who intentionally harmed a patient prick never met a physician who is not dedicated for first doing no harm to be able to maximize the health. the ideas of what i'm saying is it's going to be problematic. it's not the intent of the physicians. yet at the same time when i look at data see this in play.

i feel controversial surprised billing which is been outlined by congress, how does that makes sense to put the patient in the middle? annette and the physician culture we look at the largest organizations. last year got a bill. one in five people surprise bill. how do we explain that if not motivation i don't think they think about money that way. the last in the do's and want to do more procedures to make more money. it is the opposite. they are hard working dedicated people who when you look at the outcome the last think they want to do us harm someone based on the color of their skin. but if it is happening we got to recognize it and i am really glad the listener and the viewer called and that question. this is not any intention. doctors do not see patients

that way. they see themselves in a loving relationship. that is not necessarily the patient sees that experience. the sanding cost and quality outcomes. >> i think we have time for one more question. let me ask you this. in your book i am hearing has been passed down for ceremony, norms and value. you have talked about that today. much like a child learns from watching ann's parents behaviors are learned and mimicked. what new values do you want to teach youngsters and drink medicine? >> i think the values are the right values. it is just the system of medicine has caused us to act

in ways against those values. i would focus on them. i would as an example say to every medical student and resident and doctor, did you treat every patient today that you want your family and friends? knowing the answer is no which i think it often would be i would say we can do better. and how can we do it together to improve the care that is there? i want to advance health into the 21st century. look at burnout and medical school it is the first year. first year medical students, they don't use the electronic health that can't be the cause. so what is going on? when we elevate in medical school, first year medical school is the ability to have memory. doctors are really smart people. they are really good at that's

how they became doctors in the first place. they memorize these facts they get tested on. then one to move up the hierarchy the fastest of the ones who can memorize these facts most quickly. it is the last thing we want. on the last decade if you carry around all medical knowledge you need 100-pound backpack for textbooks is now called a smart phone. the last thing you want to do is have doctors memorizing where they can easily obtain on a smart phone and teach them how to do the things they are able to, they care better higher-quality to access. i would send them all to business school for a month to learn how to create groups. to learn how to improve performance. i think in the end i would really try to reshape the values of the physician that

traditionally has a focus simply on one patient in the focus of popularization of patients the care delivered in a comprehensive view. i point out from decades before those same doctors appendicitis we took up the appendix, not with complex product disease we are dealing with problems, social problems never existed before. this is the opportunity to make change. i would sure physicians when they focus on mission focus when they have people who otherwise can't get it they will get more from the experience that they will give on the culture of medicine will begin to care more about those values, about those individuals and we will diminish the harm to patients.

unfortunately we have run out of time but that is all the time we have. there are so many more questions that i wish we could have gotten to the role of the patient, there are so many things. i have enjoyed my time immensely. perhaps in the future at the beat another time we could speak. but i want to thank you for joining us today on today's commonwealth club program. i encourage all listeners and viewers to purchase his important new book on the culture of medicine kills doctors and patients. this program will soon be posted on a commonwealth club website w ww.commonwealth club.org. my name is joy of sti consulting in this commonwealth club program is now adjourned.

>> during a recent virtual discussion hosted by the john locke foundation matthew spalding executive director president trump 1776 commission and peter was author of 1620 took a critical look at the 1619 project. >> the whole thing is based on a series of facts and claims that his overarching interpretation that says america was founded and it began because of and for the sake of an order to defend slavery. that is the essence of the central idea for all of american history. that is factually incorrect overarching the historically incorrect.

my point is it is intended to get around the actual facts of history in order to spin this other argument to go after the very claims of things like the american founding and american history. it has to do with establishing right now and fighting current politics this country is systemically racist and we have to have certain policy outcomes. i use the fact of the 1619 project. i know you. [inaudible] >> that's incredibly on points. this is the process that america was from the get-go. in august 1619 month later had

passengers they had been captured into the caribbean and brought forth by will were actually pirate ships. said that was beginning of slavery and america. that's a very murky point he did not recognize slavery. simplified the category of indentured servants. most of them were set free. they intermarried with the white population became citizens of this country. the very basic idea of 1619 as the beginning of slavery in america, that itself is false. that seed is grown up into claims every significant event

in history was part of the scheme by which black people were oppressed and treated as chattel. there is american history that needs to be told. even the most basic parts. >> you can watch this program on her website booktv.org and use the search box of the top of the page look for peter wood, matthew spalding in the 1619 project. >> joining us on book tv is doctor deidre mccroskey. she is the author of over 30 books a long time economist with the university of illinois at chicago. her most recent book veteran human onyx is just out. when you mimi a human onyx. i am an