Subtitled “How the Culture of Medicine Kills Doctors & Patients” the book lays a good deal of the blame for our health care miasma on physician culture.

Doctors point out that these barriers to better care were put in place by a self-serving array of healthcare-system players: health insurers, governmental regulators, computer manufacturers, and hospital executives. Indeed, these groups, along with the pharmaceutical companies and medical technology firms, are guilty of holding healthcare back while inflicting harm on patients and doctors alike. (page 4)

Because physician culture elevates intervention over prevention too, many human lives have been lost to COVID-19. And because of the dysfunctions of both the US healthcare system and physician culture, American patients became unwilling yet ideal hosts for the deadly coronavirus. (pages 6-7)

Blood was thought by some to be one of the four bodily humors that had to remain in proper balance to preserve good health. Each humor was thought to be centered in a particular organ – brain, lung, spleen, and gallbladder – and all related to a specific personality type. Doctors believed that bloodletting rebalanced these humors, which is why it remained the most common medical practice performed for at least three thousand years. (pages 15-6)

I have examined in my role on the faculty of the Stanford Graduate School of Business, healthcare’s lack of change stands apart, particularly given how inefficient, inconvenient, and technologically outdated the industry is. The reason for its unchanging consistency is simple. Doctors benefit too much, financially from the way things are and stand to lose too much, culturally (their prestige and privilege), by changing. (page 27)

Unlike the spleen, you need a liver, so you can’t just take it out to stop the bleeding. (page 33)

Like my colleagues, I had been taught and trained to never let the patient lose hope, even when the prognosis was hopeless. I had not yet learned that the majority of patients and their families prefer truth over fantasy. (page 42)

Instead, they went on the attack, rejecting the notion that medical practice could or should be standardized. Rather than promoting the scientific merits of consistent care delivery, physicians saw comparative performance reports and algorithmic approaches as threats to their intelligence, intuition, and hard-earned independence. (page 45)

All doctors believe they are outstanding and exceptional. Howe dare the comparative performance reports challenge and undermine that assumption? (page 47)

Every day, doctors feel stripped of their dignity and decision-making abilities. They are forced to jump through bureaucratic and regulatory hoops. They’re expected to follow the checklists embedded in their computers, not to think creatively. (page 54)

In hosp0itals, urgency takes precedence over the kind of patience and tenderness that builds trust. (page 59)

That’s the problem with chemotherapy, I thought. Too much of it and the patient can die from the medication. Too little and she dies from the cancer itself. (page 60)

No longer do the doctor’s intuition, experience, and independent judgment matter most in medicine. Instead, these cultural virtues of the past are being replaced as patients, insurers, and administrators exercise greater authority in determining how medical care should be delivered. Physicians are now struggling to cope in a world where everything is changing quickly except their culture. Once a respected profession, even a calling, medicine has become just a job for many – one that half of all doctors wouldn’t recommend as a career. This shift is important to understand because the attitudes and feelings of doctors bear directly on the way they treat patients. (pages 69-70)

Doctors survive medical school and residency by accepting the myth of their own invincibility. But like many professionals, physicians live with secret insecurities and anxieties about their abilities. They’re ever concerned about being exposed as a fraud. When afraid, they rarely admit it. Thus, when they’re overwhelmed or at their limit, they’re taught to suck it up and not ask for help. (page 77)

More than 90 percent of parents in the United States would encourage their children to become doctors (a career that’s second only in parental approval to engineering). Within Gallup’s top five “most trusted” professions, doctors join engineers, nurses, pharmacists, and dentists as the professional held in highest esteem by the general public. (page 81)

Herein lies the struggle. The “white coats” see the problem as a failure of an overly regulated healthcare system. The “suits” see the problem as a failure of the care-delivery system, led by self-serving doctors who try to earn more money by driving up volum, regardless of whether the tests are required, the procedures needed, or the overall care effective. (page 84)

The moral injury argument goes like this: when the demands and requirements of today’s healthcare system conflict with the doctor’s duty to heal – that is, when the system prevents doctors from doing what’s right, thereby forcing them to inflict harm on patients – physicians themselves experience a form of injury. The imperative to do no harm, a pledge that dates back to Hippocrates and supersedes all other medical priorities, is sacred to physicians. Doctors have kept their end of this promise for millennia. But now physicians feel the promise to do no harm is being broken – not by themselves but by a greedy, corrupt, and dysfunctional healthcare system, led by a racket of insurance executives, regulatory bureaucrats, and hospital administrators. (page 85)

More and more, specialists look at primary care physicians as referral sources, not as medical equals. (page 100)

I remember a mentor in medical school telling me that medicine starts out as a job, then becomes a career, and ends as a calling. But for Sarah, and for many doctors, it now goes in the opposite order. (page 116)

Healhdrates, RateMDs, or Vitals (page 124)

In the service industry, the customer is always right. In medicine, doctors are never wrong. These divergent outlooks on who’s right and who’s wrong produce two vastly different interpretations of what it takes to deliver “healthcare quality.” (page 125

But if you’re one of the thousands of patients unlucky enough to experience a potentially life-threatening heart problem on weekend, well, what you define as a “medical emergency” is something many doctors define as a problem that can “safely” wait until Monday morning. Ultimately, the line between an emergency and an inconvenience blurs when a patient’s problem threatens to disrupt the doctor’s weekend. (page 132)

Fast-forward half a century to early 2021: medical costs consume 18 percent of the nation’s GDP, more than three times the percentage of the 1960s. Recognizing something has to give, insurance companies are trying to tame the storm and drive down prices. Their money-saving methods involve playing hardball with doctors when negotiating their annual contracts and reimbursement rates. Physicians have answered in ways my uncle, and earlier generations of doctors, would have deemed unforgivable. (pages 135-6)

These days, physician groups are being bought up by for-profit practice management companies that specialize in finding out-of-network billing opportunities. The success of these companies has turned surprise billing into the single largest per-dollar burden for patients with commercial insurance. (page 138)

In late 2020, Congress approved legislation to protect patients from surprise medical bills starting in 2022. Though the law was touted as a win for consumers, it was an equally large victory for doctors, hospitals, and their private equity investors. The bill, rather than abolishing the practice or reducing exorbitantly high medical prices, merely shifts more of the financial accountability over to the insurance companies. (page 140)

Pharmaceutical representatives are trained in the art of taking advantage of the doctor’s moral naivete. (page 146)

Like a jilted dating partner, doctors assume it will only be a matter of time before patients realize that drugstore clinics and urgent care centers are no match for their unique expertise. Then they’ll come crawling back, right? Right? Once again, doctors are wrong. (page 153)

Nobody enters medical school hoping to learn how to carefully craft half-truths for dying patients. And yet, by the time doctors finish their training, all are well versed in walking that fine line between fact and fiction. (page 171)

And here’s the ugliest part: most patients have no idea that the doctors who administer chemotherapy are paid a percentage of the drug’s price, usually around 6 percent, whether the infusion helps or harms. (page 172)

The problem with most pancreatic cancers is that their symptoms are too vague to diagnose until it’s too late to intervene. The Whipple is reserved for those rarest of occasions when the pancreatic cancer is diagnosed at a curable stage. (page 175)

In my career, I have heard the mantra many times: “a chance to cut is a chance to cure.” Always spoken resolutely and with confidence, it gives surgeons permission to operate even when they shouldn’t. It is yet another way that physician culture inhibits medical excellence. (page 176)

doctors always welcome additional resources and expertise, provided no one’s income is negatively impacted. (page 180)

“Is the blood in the stool or only on the outside?” helps separate cancer from hemorrhoids. (page 188)

The curse of Tithonus has been resurrected in modern times: not through the hubris of gods but through the actions of doctors. (page 192)

n the ever-distressing, noise-polluted, sick-care environment of today’s hospital, it’s not clear whether these patients are being treated or tortured. Doctors today are struggling to confront the reality that medicine can simultaneously preserve life while inflicting hell on earth. (page 193)

At his retirement party, David told the crowd that he’d made two great decisions in his career. The first was going into medicine. The second was leaving it. (page 197)

differential diagnosis (the totality of conditions that share similar sings or symptoms) (page 202)

Hoping to right the ship, the so-called Committee on the Costs of Medical Care (CCMC) issued a series of landmark recommendations. First, the committee put forth a proposal to tackle the rising unaffordability of medicine. The solution, according to the report, was for American healthcare to be “prepaid.” In today’s healthcare system, prepayment is called “capitation.” From the Latin caput, meaning head, the word refers to a “per-head fee.” In practical terms, capitation involves a fixed, annual, per-patient payment, made up front for all healthcare services that will be rendered in a given year. This sum is typically calculated based on the patient’s age and known diseases. (page 264)

And, strange as it may seem, doctors often do better, financially, in the fee-for-service model when they make their patients sicker. (page 264)

Compare to capitated payments, fee-for-service incentives nudge doctors in the direction of recommending complex, pricey, and excessive services even when they add little medical value and involve greater risk to the patient. (pages 264-5)

So instead of pushing Congress to enact a national health insurance plan as proposed in the CCMC’s majority report (and as the president himself had desired to do), Roosevelt took the politically expedient path. In 1935 he signed into law an iconic piece of legislation: the Social Security Act. Few Americans today realize this bill was a negotiated compromise, allowing all workers sixty-five and older to receive continuing income after retirement in exchange for a law that omitted all language aimed at reforming US healthcare. (page 267)

Because patients experience insufficient access to hospitals, doctors, and healthcare services, about 90 percent of childbirths in India take place at home. (page 278)

Indeed, denial proves healthy in moderate amounts. It allowed the oncology pioneers to advance the field of cancer research and treatment. Without denial, the pain and harm they inflicted on patients would have tormented and overwhelmed physicians, preventing medical progress. In contrast, denial becomes unhealthy when it is prolonged, all-encompassing, and unshakeable. And in that respect doctors’ ongoing denials of the need for change in healthcare over the past two decades have been destructive, preventing them from seeing their contributions to the growing unaffordablity of medical care and to the declining quality of American healthcare. (page 290)

Being on the receiing end of a malpractice lawsuit is one of the worst experiences in any physician’s life. It puts doctors in a dangerous psychological state. They feel personally attacked, bringing up deep-seated emotions that may include shame, insecurity, and fear. At work, they may become resentful or distracted. Either feeling can put patients at risk, exacerbating the threat of committing future medical errors…..It began as soon as the plaintiff’s attorneys mailed notice of intent to sue. These documents were always sent to both the individual doctors and our entire medical group (the more defendants and the deeper the pockets, the greater the potential payout). (page 298)

Patients worry that stating an objection or questioning the physician’s expertise will compromise the care they receive. It is this fear of offending the doctor that helps explain why people tolerate long wait times, unclear medical explanations, and rudeness in the doctor’s office. (page 313)

It’s important to understand that physicians are legally obligated to disclose what can go wrong during a procedure. But when deciding whether to proceed with a doctor’s recommendation, patients will want to know how often something does go wrong. (page 317)

Leapfrog Group for surgical volume standards. (page 320)

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