Latest / Faisel and Friends: A Primary Care Podcast / Ep. 1: Happy Doctors = Healthy Patients w/ Dr. Robert Pearl

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Ep. 1: Happy Doctors = Healthy Patients w/ Dr. Robert Pearl · Faisel and Friends: A Primary Care Podcast

• Dr. Faisel Syed [00:00:10] I'd like for everyone to think for a moment about the value of human life. And does one person's life have any more value than another person's life? The current fee for service system health care is rationed out based on the patient's ability to pay. I believe it's unethical. This premium 95% of the country still functioning in the model. I definitely believe everyone should be treated the same and everyone should have access to primary care regardless of their ability to pay. Hi. I'm Dr. Faisel. Welcome to another episode, Faisel and friends. We're here because we believe everyone deserves access to quality primary care, and ChenMed needs physicians to take care of them. Today's topic is happy Doctors equal healthy patients. I'm very excited about our special friend joining us tonight. But before Dr. Dan, how are you guys? Good. It's great to be with you. Looking forward to it. Fabulous. And tonight with the questions and comments, we're going to try our best to answer them at the end of the show because we've got some questions for our guests. And I really want to get through those questions. Well, without any further ado, I'm so excited to welcome tonight's guest. He is one of modern health care's 50 most influential physician leaders. The former executive director and CEO of the Permanente Medical Group, professor at the Stanford Medical School and Stanford Graduate School of Business and a visiting professor at the Johns Hopkins School of Medicine, High School of Business and Harvard School of Public Health. He's also Chen Med's favorite author. His book, Mistreated Why We Think We're Getting Good Health Care and Why We're Usually Wrong is required reading for Chen Med physician leaders. We're also anxiously awaiting his next book on caring how the culture of Medicine kills doctors and patients. Please join me in welcoming Dr. Robert Pearl. Hi, Rob. How are you doing? Dr. Robert Pearl [00:02:26] Great. Faisel, great to see you and looking forward to the show tonight. Dr. Faisel Syed [00:02:29] We are so thrilled to have you here. So as one of the top 50 most influential physician leaders in health care, what do you see as the number one issue in health care that needs influencing today? Dr. Robert Pearl [00:02:44] The number one issue without question facile is cost. Now, we've talked about cost for decades. We've said we should change, we must change. I want to make the point that in the post coronavirus era, we will change. Now, during the past year, some companies like Amazon and Apple Netflix have done well as we try to deal with our isolation being at home. But most of the country has suffered financially, by the way, including a lot of physicians. What we know is that the United States, by the time it's all done, will have borrowed between eight and $10 trillion that will need to be repaid with interest. We also know that the states by law have to have a balanced budget and the tax revenue is projected in almost all of them to be significantly reduced. And the expectations around unemployment and Medicaid will go up. And businesses, the ones that still exist, a third of them says say they can't survive without continued government payments. We are about to enter the Post-coronavirus era a difficult financial time. Now, what I believe is that people will look at the numbers that we spend $11,000 per American. Switzerland at nine, Germany is seven. Everyone else spends half of what we spend and we know the outcomes across the United States. Longevity, childhood mortality, maternal mortality lag the other 12 nations. They're going to look to health care and expect that we become much more efficient and effective. What we know is that it's impossible to guarantee reduced cost and a fee to service world. Doctors and hospitals often simply increase volume as the price of their pain declines. Our nation will face, I believe, two choices. First choice rationing. Rationing is done in a lot of nations. You set an upper limit when you can have heart surgeries, held joint replacement. Rationing happens because you create long queues for consultation and routine procedures and you keep expensive medications off of the formulary. Or our nation will decide to transform how health care is provided. Moving from a fee for service world to a global type payment capitation. Technically, it's term. And in doing that, it's going to change how physicians practice. They're going to have to come up with ways of being able to take care of populations, of patients in a better way, higher quality, more convenient, rapid access, lower cost. I think that will challenge us. But I also believe and I'm sure talk about a lot more tonight, that in doing that and putting the patient at the front, we'll have the opportunity to restore purpose and mission. I think some doctors will step forward and once they do so, that others will follow them in the same way that when Roger Bannister broke the four minute mile, people thought it was impossible. And within three years, ten of the runners had done that. That's my hope. And I believe that that will be one of the organizations leading the way. Dr. Faisel Syed [00:06:14] Thank you. Thank you. Many people. Dr. Robert Pearl [00:06:17] Find it difficult. Dr. Faisel Syed [00:06:18] To hear about physicians struggling in the current system and to know that we have this option. We have. Chen Med, a physician led organization scaling out the full risk model across the country, is quite promising to any of the doctors who are suffering in the current fee for service model. So now you've worn many hats in your career. You've been a doctor, a business leader, an author, educator. What's the one thing that you learned as CEO of Kaiser Permanente that you wish to pass on to health care? Leaders listening right now. Dr. Robert Pearl [00:06:56] When I became the CEO of Kaiser Permanente was a recession that was struggling. The quality was not yet nation leading. The service was somewhat lagging. And I believe that the thing we had to do was to improve in both areas. And the advice that I give to people in the 21st century is look to technology. And I don't mean the technology that's been used to simply drive a volume, the robotic surgery and the proton beam accelerators. The showed very little value. I want to be much more specific, and I'll use three examples from the work that I did as CEO. First one in partnership with the Health Plan leader was to make the billion dollar investment in a high functioning electronic health record. And the reason we did that was a belief that we could increase quality when every physician has comprehensive information, when not just primary care, but every doctor can look at things like hypertension and be able to communicate, not necessarily treat it, but recognize it. I mean, we learned that the first week of medical school sits there. You know, of course, the United States today vessel hypertension controls 55% of the time. We can show that 90% of the time we lowered the mortality from heart disease and half of the national number because at every point of contact could do the things that were needed in terms of prevention, early detection. And you can't do those things without an electronic health record. So anyone out there who is working without one and I mean in the air because everyone has one, but one does comprehensive needs to figure out what they can do next. The second thing we did was to connect primary care and specialty care using a combination of video and digital technology. It meant that when the patient came in to see the primary care physician and the primary care physician felt that he or she needed to have a specialty consultation before the patient left. We brought the two groups together to bring in that expertise, something, by the way, we also did out at some of the businesses that we served, like Apple in doing that. Dermatology is a great example. 70% of the rashes that primary care wanted a specialty consultation, not the ones that they took care of themselves got taken care of in a matter of 6 minutes. And it was like in the communities that you serve, most of the nation was six days, six weeks, or even six months to get access there. And then finally, using the same telemedicine and texting and secure email, the ability to provide care to patients without forcing them to miss a day of work, come to the office, etc. By the time I left as CEO in 2017, we were seeing 16 million people in person and 14 million virtual visits, many of which were able to resolve the problem in a way that led to sooner care, higher quality care, greater patient satisfaction. Dr. Faisel Syed [00:10:15] While it's very similar to the world that we're in and think about while we're in training, when I needed to curbside someone, I didn't have to take the patient and move the patient from one part of the hospital to the other part of the hospital. Just to get the opinion of the specialists. Many times in the hospital where we were able to curbside and get the advice that we needed in order to take care of the patient. And these days, with all the technology that we have available to us, it's it's ridiculous, especially when you're talking about a vulnerable patient population, having them come to the center just to see a specialist for a few minute visit when it could have been easily handled by the primary care doctor. Dr. Paul No conversation would be complete without talking about your book Mistreated. I was touched that you dedicated the book to your father, and when I read the book, I was struck by how you articulated the costly, often unnecessary health care decisions that don't lead to better health. How do we help Americans who are often intimidated by doctors and the system to make better health care decisions when the entire system itself is often stacked up against them? Dr. Robert Pearl [00:11:23] What you describing is a very big problem, and I would say not just the patients per se, but doctors. And so although I'll be speaking about a lot of other aspects tonight, I do want to make the point that the system is broken. And we talk about physician burnout, which hopefully we'll cover later on. We're talking about the fact that physicians often are not paid enough and have to see too many patients. We're talking about bureaucratic tasks that take a lot of their time and energy. We're talking about a broken H.R. that's very inefficient. But I think we also need to talk about the other aspects. And as physicians, we need to own them. So the book, as you say, is about a medical error that led to the demise of my father was remarkable to me is when I speak at conferences where we used to have actually conferences, we were happening where we have video and Zoom chat now, but at the end of the time I'd come off the stage and there'd be a line of people, and three quarters of them told me the same story about how their mother or their father or their spouse or their kid died from a consequence of a medical error. And we can do better at being able to adjust that. And the fact that my father had one when both myself, my brother, my brothers, the chairman of anesthesia at Stanford, were there to help him, tells me it can happen to everyone. But I do want to stress that there are a lot of books out there saying you got to go to the hospital to protect your parents. This is this has to be a mutual, respectful relationship. And I think what I would say to the people who are not in health care but are listening in anyway, is that you can't be hesitant to have an open, honest conversation. The kind of patriarchal relationship has to be left in the past. We have to be informed consumers and uncaring. I have a whole chapter on the questions that patients should ask. I'll give you three examples in the short term. You see a patient for a problem. There needs to be some kind of follow up, but it's not going to require any kind of intervention. The questions have to be, How can I get back to you? Most easily I text you, Can I email you? Can we set up a video appointment? Why should I have to come back in to tell you that I'm doing well? I understand it's an important piece of data for you to have, but is there a more efficient way we can do that? And that's with the kinds of things that are I'll call them for routine, urgent, but not emergent. The second area where patients need to be asking the right questions is when they need to have some kind of intervention or procedure done. And in that area, the kinds of questions to ask is how many of these did you do last year if you were the patient? How many would you insist your physician do before you would agree to doing that? When we give informed consent, we have 55 items on the list. I want to know what's most significant. Is it an 80% chance or a 20% chance? These are the kinds of questions I talk in the book about OB-GYN and the operation that is done a lot. There's a laparoscopic hysterectomy. I asked you, what's the average number of procedures A or B, Q and physicians does in the United States today, this operation? How many times a year? I told you half of the positions do fewer than ten. I don't think that you would recommend that patients don't know. And so it's that kind of question that needs to get asked. And then finally, we have people who are I'll call them, near the end of life, heart failure, multiple admissions, pulmonary failure, multiple admissions. When you are in that situation, a very advanced cancer, the first question to ask is what other options exist? What else could I do? What about hospice? What are the other services that could be provided? And then I think maybe the most important question, if I decided I wanted in, what treatment will you be there for me? What will I be left alone? So the book has those kinds of questions. And I would say to all the people listening in who are not in the health care field, the most respectful thing you can do is to engage with your doctor on these crucial areas and together to come up with a plan that is going to be satisfying and I believe will be even more satisfying. The physicians, again, as it touches back in to mission and purpose. Dr. Faisel Syed [00:15:56] The doctors and the patients working together to find that common goal of improving the patient's health. Well, Dr. Pearl, thank you so much for answering these first couple of questions. I loved your answers. But at this point now, we'd like to take a little break. Stay tuned because following the commercial, we're going to be getting into Dr. Robert Pearl's new book, Uncaring How the Culture of Medicine Kills Doctors and Patients. We'll see you right back. Ad Break [00:16:26] ChenMed honors seniors with affordable top-of-the-line care. And we're expanding. We're opening 25 new centers this year, including centers in two new cities, Houston and Detroit. Join us as we bring better health care to more seniors. Head chenmed.com/physicians for more information. Dr. Faisel Syed [00:16:45] And we're back. We just asked Dr. Pearl a couple questions about his background, its history. His advice to young physician leaders. And right now, we're just about to get into his new book, Uncaring How the Culture of Medicine Kills Both Doctors and Patients. So, Dr. Perl, what's your new book? I'm Caring, that's coming out on May 19. You dedicated this book to your mother. I was touched by that. What's the book about? Dr. Robert Pearl [00:17:18] The book is about the physician culture. And for listeners who may not be very familiar with what that means, culture is the beliefs, the values. It's the norms, the stories. It's the language that we learn in medical school and residency and carry across our career. I picked the word uncaring for the title because I think it's important. Two things. First, I'm not saying in any way doctors are uncaring. They're very caring, they're very dedicated, they're very hardworking. What's not caring is the culture. And the second is that uncaring doesn't mean it's good or bad means that it's all situational. Give you a few examples. When the coronavirus came ashore, hospitals were overwhelmed. Critical care units were overwhelmed. Physicians went there 12 hour shifts, 24 hour shifts when they didn't have the protective gowns that they should have had. They put on garbage bags with N95 masks. They put on salad lids when they had to pass a tube through someone's mouth into their lung. They knew that every time the tube went through the cords, the patient would cough spewing virus in their face. They did it anyway. The culture gave them the courage, and when they ran out of respirators, they figured out how they could put two people on the same respirator, something that had never been done before, never contemplated before the physician culture. Made doctors into heroes. But I wrote the book, as I mentioned to you earlier in the book, I talk about the love between my parents, my father. So my mom is perfect. My mom saw my dad as she loved him just as much, but she could see the flaws by pointing out the flaws. I think that maybe it made things a little bit better. And that's what I was hoping to do with this book. And I believe that a lot of physician burnout and I want to be clear, physician burnout definitely comes from the system. The system is very problematic and much more so now. But I'd ask people to be asking themselves, do we really believe that in no way, as doctors, do we contribute? Do we really believe that having yelled about this for five years and nothing has changed, that we need to just scream louder? So this research that led to this book on caring how the culture of medicine kills doctors and patients came out of a desire to understand that. And one thing that I discovered found was we tell it to ourselves things through the culture that allow us to do some of the things we'd like to do, but may not be what's in the best interest of the patients. And I believe that as a consequence of that, it the culture works like a fine grained sieve and some of the emotion comes forward. So I'll give you a few examples. We tell ourselves we save a life at any cost. And we did that when we intubated patients and took care of them. Absolutely. What else do we know? We know that 88% of people who died at two or more chronic diseases don't do very well at chronic taking care of chronic disease. It's not that we couldn't, as I pointed out earlier, integrated multi-specialty groups are capable of changing hypertension from 55 to 90 plus percent, capable of screening for colon cancer at over 90% rather than 60%. We can do it. The culture says it's not very important. We elevate intervention. We elevate the invasive cardiologist, interventional cardiologist above primary care. Now, what does the data say? The data says that primary care physicians in primary care community and you increase longevity two and a half times more than adding similar number of specialists. And yet we put the specialists in the hierarchy of medicine that we control. No one makes us do it above the primary care physician. You'd expect it to be the opposite. But that whole process of elevating intervention over prevention. What else did we see? We tell ourselves we treat every patient the same. Do we really? The data says that when a black patient did, a white patient walked into the E.D. early in the pandemic, when there's not enough testing kits, exact same symptoms, exact same fever, exact same. We tested the white patients twice as often as the black patients. Dr. Faisel Syed [00:21:48] My goodness. Dr. Robert Pearl [00:21:49] What else do we know? We knew. We know that women, black women have three times the mortality of white women, except when the attending physician is black. Remarkable statistics. We know that when you we had two patients of the same operation, we get 40% less pain medication to the black patient. We as physicians have to, I believe, own that. And I believe in doing so that we will diminish our burnout and improve our sense of purpose and mission. And I'll be even more controversial, which is that we tell ourselves that we always put the patient first. But how do we explain at a network billing where the patient got caught in the middle between our battle with the insurance company? How do we justify the fact that doctors actually sue patients who can't pay and usually not thought by the doctors, then by some administrative group that runs the practice? But as for the things that we do, how do we explain the 30% of the procedures we've done according to the Mayo Clinic at no value and we keep doing them. The most commonly done Operation Orthopedics is an arthroscopy with cartilage trimming. It's been shown by studies from Canada in the United States multiple times to add no value, and we still don't do that. That opportunity, I think, to improve patient care will not only benefit people who trust their lives in our hands, but I think our profession and us individually as well. That's what the book focuses on. Dr. Faisel Syed [00:23:23] Many people outside of the health care system aren't familiar with the concept of doctors practicing the defensive form of medicine, And that's basic. One of one of the points you're talking about here. It's very provocative. You're basically saying that the current health care system culture is literally killing doctors and patients. If you can please share with the doctors and the health care leaders who are listening right now. Your top three survival tips until we can change this culture. Dr. Robert Pearl [00:24:00] I'm not sure I'd put it in terms of three survival tips per say, because I think the two things that have to change together is the system and the culture. And it's that combination. I think they'll make the difference. And I hadn't seen the video from the start of this show before. I watched it tonight with everyone else. But many of the things I talk about in the book and believe in are embedded within that. The first thing is moving from fee for service to some form of capitated payment. And as part of that, once physicians take that accountability, what I believe happens next is that they figure out very quickly they can make the change happen without integrating, without bringing together a bunch of physicians and sharing technology among them. But I also would tell the listeners that when that happens, the culture starts to evolve because suddenly it's in your interest to elevate prevention, avoid complications from chronic disease, eliminate any type of medical error. You elevate primary care when you do that because the contributions become far more visible, because now we're measuring clinical outcomes, improving life expectancy, reducing the chance of dying prematurely. And when you start to do that, you realize that how technology can add value, whether it's having information on quality outcomes at every point of contact, whether it's being able to have telemedicine to provide care sooner leading to better outcomes, avoiding negative things happening in the consequence. You start to recognize that what's done in most of the United States, which is we closed the office at 5:00 and have it closed at least for one day on the weekend, puts patients in a situation where they have no choice but to go to an emergency department. And anyone who thinks that we can give the same quality of care, when you seeing a position for the first time, whose main job is to figure out whether to admit you or not is not accurate is we do it because no one doctor can keep an office open. It's not that one doctor should, but a group of doctors can and you can bring in expertise from anywhere in the country where it's as optimal as it can. And I want to add one other part that I truly believe and really forms the basis of the program. And I think it aligns a lot with ten that has done particularly yourself and Chris and Gordon Chen, and that is that it restores mission and purpose. Every one of us went into health care to save lives, to make a difference in people's lives. If we wanted to make a lot of money, we're going to finance or some. Place else. That's right. For all the right reasons. I've done quite a number of global trips. Led them. People come back after a week of working 12 hour days in the heat with problems with their diet and their GI tract and everything. And it's the greatest experience of their life together. We have to put that back into medicine. And I don't know anyone who can lead it as well as the physicians. Hopefully those on the line will join you and me going forward. And I think if we do so, we can make American medicine once again the greatest in the world. Dr. Faisel Syed [00:27:18] Thank you, Dr. Perle. Thank you, Doctor. Well. Robert Longyear [00:27:21] Dr. Pearl, I have a question for you. Dr. Robert Pearl [00:27:24] You're Robert. Robert Longyear [00:27:25] Hey, everybody. Sorry, I was a little bit late, but Dr. Paul, let me ask you this. So medical education is a big driver of the future of the health care industry. How do you transform the ways that we train physicians and medical school to reflect these values that are largely kind of system based concepts? So how do you actually ingrain this people from earlier age rather than waiting for them to kind of get out and have to be burned by the insurance system and fee for service to actually get out there and say, I'm going to advocate for my patient? Dr. Robert Pearl [00:28:00] I don't think it's actually that hard to change the system. I think the people who run the system don't really want to change the system. They're happy to be training a lot of specialists because in the training process, they earn a lot of money. They're less happy to train primary care physicians. Why is that? It's not economically beneficial for the organizations that are out there. They could easily train people on how to come together in an integrated fashion, to prioritize prevention, to use telemedicine. But that would diminish their income and billing. I think the problem is intrinsic in the culture. And remember, every culture is passed on to the generation before. And so making that having a culture shift going forward, that's the challenge. It's a very difficult thing to do, is why it hasn't happened yet. But again, I'm optimistic that when physicians look at this choice between rationing care and transforming medicine, they will step forward. They'll go through the five stages of Kubler-Ross denial, probably going on. There has been anger when you're forced to do it. Bargaining to keep the pieces that are going to be there, depression. But ultimately it's going to be acceptance. And acceptance, I'm hoping, will also mean seeing it as being better, as being better for patients and better for themselves. The other piece that I would say and I wrote a piece for this for the New England Journal of Medicine, was that I believe in the fourth year of medical school. I remember the fourth year of medical school as we traveled around the United States, and now no one travels anywhere. They do it all on Zoom. Why not have every medical student spend a month in business school learning how to create groups, learning how to do financial analysis, learning how to do the skills I teach both medical school and the business school. And there's a two sets of skills, but they're very complementary. The way business leaders think is the scientific method that we learn in medicine. We never put the two pieces together. So that's what I would hope. We change the curriculum and we motive and we force the institutions to do that. They're slowly evolving, but I think it's a very slow evolution. Robert Longyear [00:30:09] I fully agree with you. So I study health care management and policy, and we learn a little bit of medicine and a whole bunch of business and policy which drive a lot of the behavior of the system in the United States. And I think there's certainly a place for a lot of physicians in the world to be able to also learn a little bit more about the finance and the business of health care. Because at the end of the day, when you graduate medical school, you get residency, you end up in the world of business in the private health care system of the United States. So I think it's an excellent point. I might also add that, you know, a little bit of technology education, the world is becoming more data driven. It's becoming more reliant on digital technologies, on electronic medical records. And physicians that can speak that language will be a powerful tool for changing patient care. Dr. Robert Pearl [00:30:57] I'm not I'm less concerned about that because I think most of the people on this line who are in medical school or in residency, they're pretty good with the technology that exists. I think they could use it very easily. How to build it into the system is a different question, but I think I'm less concerned about them having to learn it. I'd like them to figure out in a business environment how to apply it and then be able to do that and to lead the way going forward. Dr. Faisel Syed [00:31:24] Dr. Perl, thank you so much. You definitely need. Robert Longyear [00:31:27] A business case to make it viable. Dr. Robert Pearl [00:31:29] Well, well, one of the things I could add on that is that we think about leadership training, the way we think about receipts and expenses in a given year, we should think about as we think about capital. It's a 30 year investment. I know the people in Shin Bet do a lot of investing and leadership development, and it's not designed to pay back in one year. It's designed to pay back in two, three decades of time. You know, when I was the CEO in the premier, the medical group, I led 12,000 physicians and over 25% of them had at least a month of leadership training. A massive investment that I think was why so many improvements happened. We did a lot of really innovative things, and I'd like to say I took almost no credit for thinking about them. Someone else figured it out. Someone else figured out how to. 60% of our orthopedics total us as outpatients. Someone else figured out how to take care of pneumonia in a patient's home. Someone else figured out the referral system so that rather than sending a piece of paper that someone got in the mail, the patient got the call. It was done electronically before the patient left the doctor's office. I found those things as CEO, but without the leadership training, without that mindset, the thinking never could happen. And again, I know and congratulations to you and to the two of you and to Gordon and Chris. I think that's very much endemic in a culture of Gen Z and kind of innovative leadership in a broader, supportive sense. Dr. Faisel Syed [00:33:04] Doctors must be savvy. The transition from the fee for service system must be physician led and the days of doctors kind of putting their hands up and trusting an administrator to figure it out. Those days are gone, and anyone who still believes that is going to be left behind. Well, Dr. Dan, I'm sure that you have at least one question that we could bring in. And to Dr. Pearl from the audience tonight. Dr. Robert Pearl [00:33:29] Yeah, absolutely. Dr. Faisel Syed [00:33:32] So Robert, Mary Beard has a question. And I think it's good. It reminds me of the way Don Burke Don Berwick will close a conference. He'll talk about these grand ideas because then he'll say, Think big, but start small. So she's asking how she works with UHC and what could she bring back to encourage still during these trying times. So for the people that are sort of stuck, at least in a mostly fee for service world, what kind of optimism can you give those doctors to refocus on or look into as they move forward next week? Dr. Robert Pearl [00:34:16] Well, often actually has a prepaid bearing it, so she might be in one that's not in California. A lot of the patients in Medicaid there were in a prepaid form. So I think it's a very good way to go. There are two things that I would say. One, I remember a conference I read several years ago when I gave a very impassioned speech from the standpoint of disease prevention and chronic disease management. And the next speaker was from the community clinic. And she said, well, when she asked the patients, they're their highest priority, nothing that I said was on the list. They worried about housing, heat, food, transportation, having a job. These were the things in their mind that were health. And so we have to be very aware of the mayors, obviously very aware of, which takes care of it every single day. But for the other listeners that are there, the thing that I would suggest to her is two things. First, what can she do with the resources that she has to leverage the technology that exists? Again, I'm sure she's thought about that, but smartphones are relatively ubiquitous and finding actually tools that we can give to patients because our patients are going to have the greatest problem coming to our offices and getting the care and needing the reminders of care that are there. And we can do that very easily using some type of digital technology. But what I also might suggest, and I'm encouraging people everywhere in the United States to ask the broader question, how do we put together some kind of integrated function? If we can't build hospital those facilities and do the kinds of things that groups like Kaiser Permanente or Chen that might have already been done? How do we use telemedicine so that providers in one area are able to provide care to patients in another? Because we know that demand is up and in some areas and down in other areas. I can tell you that in the community clinics getting specialty access is almost impossible. But how do we find one or two orthopedic surgeons, cardiologists willing to be available to provide the expertise? My observation is that much of the time when primary care sends a patient to a specialist, they need a small piece of. They don't need a total evaluation. They're not quite sure about a medication or treatment. And how do we leverage that in a way? Dermatology being a great example of that. We are a dermatologist. Using digital pictures can take care of twice as many people as they can in person. And I'll give you one other example, which this came out when I was also the CEO on the East Coast, as well as the West Coast and the mid-Atlantic region, put an ad doc available into the call center at night using telemedicine. And 70% of people who otherwise would have come to the E.D. were able to get their problem solved at home. Imagine the mother or the father who has both school for the other kids and work the next day having decided to weather 103 fever. Requires bringing the child to the E.D. We know there's going give be a three or four hour wait. Those are the kinds of thinking when you start to ask, what can I do? And again, I'm sure mayors is asking that all the time. But as we ask that across all of the venues in which we practice, I believe we would have come up with ways that we otherwise might not have thought about. It's going to change the experience first for the patient and I think for us to give us a greater sense of satisfaction. The last thing we want as doctors is to feel like we're letting our patients down and the opportunity to offer them something they never thought was even possible, I think will not only meet their needs, but fill us with a greater sense of mission and purpose. I welcome the thoughts of all the people. Have ideas. Send them to me. I'd like to learn from your expertise so I can tell other groups about it across the nation. Again, I think that together we can change American health care. We can once again make it the best in the world. Dr. Faisel Syed [00:38:34] Gosh. Dr. Robbie Pearl, thank you so much for joining us this evening. Dr. Robert Pearl [00:38:38] My pleasure. And thank you so much for hosting. Thank you, Robert and Dan, for your questions as well. Dr. Faisel Syed [00:38:44] And to anyone who is listening. Dr. Pearl, if you wouldn't mind sharing them, you've got a special announcement. Dr. Robert Pearl [00:38:50] Anyone who preorders uncaring of the culture of medicine, pills, doctors and patients will receive in addition to the book, they'll be delivered to their house on May 18th. When it's published, they'll get a signed bookplate from me, a discussion guide if you want to use it in discussion group, a book reading list, and you'll get to see the introduction to the book before anyone else in the United States does. So if you'd like to do that, please do. And if you want more information, my website is Robert Perl indeed.com. We can get a lot more information just on a broader area of health care. And once again, thank you so much for hosting this. I'm hoping that we are a major, major force to moving our nation forward. Thank you. Dr. Faisel Syed [00:39:31] Thank you. Dr. Pearl and Dr. Dan, thank you so much for manning the chat room. I thought there was a lot of activity there. It'll be interesting to go through that later on. Afterwards, I actually do read through all the comments and I try to reply to as many of them as possible. Robert, thank you so much for joining us today. It's always great to have you. Robert Longyear [00:39:50] Yes, I apologize for being late. I was at a dinner with an AARP related organization, so I was a little late. I tried to make it. But Dr. Pearl, thank you very much for joining us and enlightening us with all of your your insights into the health care system. Dr. Faisel Syed [00:40:05] And to all of our audience. Thank you, too, for joining. For more information about today's topic and to explore career opportunities with ChenMed, please visit chenmed.com. We believe access to primary care is a right, not a privilege.