Whether we recognize it or not, all doctors adhere to a set of unwritten, unspoken rules that dictate the “right way” to act and heavily influence our behavior. These rules aren’t taught in textbooks or in lecture halls. They are observed and subconsciously absorbed by medical students and residents, and they’re carried throughout their entire professional careers.
At the second National Primary Care Transformation Summit this week (December 4-7, 2023), I spoke about the problematic state of American healthcare today and the dire need for doctors to break the unwritten rules of medicine.
Speaking to a virtual audience of more than 5,000 attendees, I began by describing the problem.
Despite spending more per person on healthcare than every other nation on the planet, clinical outcomes in the United States lag those of other wealthy nations. These aren’t small problems or debatable failures. We are last in longevity, a full five years behind other industrialized countries. American maternal and infant mortality ranks last and, in fact, ours is the only country in which deaths per 100,000 births are getting worse. Today, half of Americans can’t afford out of pocket medical expenses should they get sick. Meanwhile, clinician burnout has reached “crisis” levels, especially among primary care physicians.
These facts underscore the gravity of the problems our country faces, and they shine an unflattering light on how far our nation is from where we want to be in terms of our healthcare. As with every overly expensive and ineffective industry, healthcare is poised for disruption.
And to disrupt American healthcare, we’ll need to break the rules. To be clear, I’m not talking about current laws or regulatory requirements. Nor am I referring to the biological and chemical rules that comprise the science of medicine.
Instead, I’m referencing the normative, economic, and technological rules that make healthcare unaffordable, erode the satisfaction of doctors and undermine the value of primary care.
As an example, consider the unwritten rule Steve Jobs broke in 2007 when he introduced the iPhone. Until then, the rule was that a phone (even a smart \phone) was used only to facilitate two people talking. His invention combined a phone with a camera, music player and minicomputer capable of accessing the internet. Airbnb also began in 2007. Prior to its founding, the rule was that to be a landlord or hotel operator, you had to own large numbers of rooms. Today Airbnb is the world’s largest renter of accommodations despite not owning even a single property.
What follows are some of the unwritten rules of healthcare that must be broken>
1. Healthcare’s Normative Rules
In healthcare, a longstanding normative rule relates to who can determine how medical care is provided. Although there is debate as to whether the process for care delivery should be led by doctors, hospitals, insurers, or drug companies, all agree it must begin with a healthcare insider. But increasingly, retail giants are grabbing the mantle.
Amazon, Walmart and CVS have their sights set on medicine. Like an invading army, they’re gathering the weapons needed to win the war over healthcare’s future. They’re scooping up medical groups, primary care practices, telehealth firms, insurance providers and more.
And if doctors decide that they aren’t willing to break the other unwritten rules of healthcare, then they will find themselves disrupted by (and potentially employees of) one of these retail giants.
2. Healthcare’s Economic Rules
In practically every transactional industry, the economic rule goes like this: the more you do, the more you get paid. And that’s how it works in medicine. You get paid twice as much if you see a patient four times a year rather than twice.
Last century, this rule made sense. Patients suffered mostly acute problems that required immediate care and very little long-term treatment. Today, we face a different problem. In the U.S., 60% of patients live with at least one chronic disease that requires lifelong management.
And in that context, “fee for service” medicine makes no sense. Not only that, it diminishes the value of primary care.
In a fee for service payment structure, the interventionalist will always have more value than primary care because the interventional procedures can be directly observed and lauded. The lives saved can be counted and the responsible physicians can be celebrated.
Compared this to what skilled primary care physicians do. Although they can prevent a problem from happening in the first place, no one can be sure exactly which patients’ lives were saved though the work they did. Research from Harvard and Stanford prove that adding 10 primary care physicians to a community has a 2 ½ times more positive impact on life-expectancy than added 10 specialists. And yet, we can’t see or know exactly when a physician saves a life or which patient did or didn’t die or experienced a life-altering medical crisis as a result of preventive care. In the United States, we currently train too many specialists and pay them far more than we do primary care.
If we can break the economic rule on how to pay doctors, shifting from FFS to capitation, then the value of primary care will rise, as will salaries and resources. In capitation, primary care’s work is visible and valued. It aligns with what’s best for the patient and the health of our country overall. Patients don’t want to have a heart attack or stroke or have cancer. Capitation aligns what benefits the providers of care with what is optimal for its recipients.
Some believe the respect the healthcare system accords primary care physicians is diminished because they don’t earn enough. The opposite is true. American medicine doesn’t pay primary care enough because the work the clinicians do isn’t valued in a FFS world. To raise the respect that people have for the contributions of primary care, we need to break this antiquated, economic rule.
3. Healthcare’s Technological Rules
Throughout medical history, the No. 1 tech rule has been that technology exists to maximize the performance of the clinician. This explains the rise of multimillion dollar pieces of equipment, like surgical robots, which resemble video games on steroids. While doctors like these tools, research shows that they slow down ORs, raise costs and fail to significantly improve clinical outcomes or reduce complications.
Going forward, we need to break this outdated technological rule by embracing tools that will empower patients. Generative AI technologies like ChatGPT and others are already giving patients unprecedented access to medical expertise. And when, as predicted, in five years, they are 30 times more powerful, they will allow people to do much of what clinicians currently do, freeing doctors to spend more time with the patients they see, improving quality outcomes and reducing clinician burnout.
Ultimately, if we don’t break these and other “unwritten” rules, longevity will languish, costs will skyrocket, primary care will remain underappreciated and the burnout doctors experience will get worse.
Now is the time for clinicians to evolve another normative rule. As has been true for five millennia, primary care doctors have to provide safe, effective, personal care to patients – but in the future, they also have to lead the way to transforming American healthcare.
The second National Primary Care Transformation Summit continues through Thursday, December 4 and features a “who’s who” agenda of speakers, including:
- Elisabeth Rosenthal, MD, Editor-in-Chief, Kaiser Health News
- Amir Dan Rubin, Chief Executive Officer, One Medical, an Amazon Company
- Amar A. Desai, MD, MPH, Chief Executive Officer, Optum Health
- Andrew M. Slavitt, Former COVID Senior Advisor, Biden Administration
- Sree Chaguturu, Chief Medical Officer, CVS Health
- Sachin H. Jain, President & CEO, SCAN Group & Health Plan
- George Halvorson, Chair and CEO, Institute for InterGroup Understanding; Former Chairman & CEO, Kaiser Permanente
- David Blumenthal, MD, Former President, Commonwealth Fund; Former National HIT Coordinator
Of course, it takes an army to produce an event of this magnitude. So, I want to extend special thanks to the summit’s producers and people behind the scenes, including:
- Suzanne Tyler, president of VMA Global Events
- Ann Greiner, Chief Executive Officer, Primary Care Collaborative
- Don Crane, Former President & CEO, America’s Physician Groups
- Peter Grant, Chair and CEO, Health Care Conference Administrators
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Dr. Robert Pearl is the former CEO of The Permanente Medical Group, the nation’s largest physician group. He’s a Forbes contributor, bestselling author, Stanford University professor, and host of two healthcare podcasts. Pearl’s newest book, “Uncaring: How the Culture of Medicine Kills Doctors & Patients,” is available now. All profits from the book go to Doctors Without Borders.
