Uncaring

Starred review from April 1, 2021
The former CEO of the Permanente Medical Group takes readers into the world that shapes the medical practitioner's mindset and lays out necessary changes for a broken system. By the early 2000s, the U.S. health care system, once a global leader, had become the most expensive and least effective in the developed world. Of course, Covid-19 has only exacerbated the situation. Among the number of factors that have led to our current state of affairs--a situation that implicates everyone from hospital administrators to insurers, regulators, and pharmaceutical giants--Pearl singles out for examination the flawed culture that guides doctors in their practice. Physician culture, writes the author, "elevates intervention over prevention," resulting in a lack of effective treatment for chronic killers such as diabetes, obesity, hypertension, and heart disease. In a brightly delineated--and highly disturbing--dissection, Pearl lays out the rituals, rules, and beliefs that often isolate physicians from their colleagues and their patients. The foundation of the culture may rest on concepts of healing, resilience, and artistry, but it also breeds a hierarchical sense of individual exceptionalism, heroism, and invincibility. This entitlement and autonomy often clash with the implementation of advanced diagnostic technology, undercutting the doctor's sense of status and control. In this new environment, characterized by long hours, lowered pay, diminished decision-making, and erasure of prestige, more and more physicians are experiencing burnout. Pearl sensibly advocates a coevolution of these two streams, taking advantage of a doctor's experience and independent judgement while tapping into the structural and scientific changes in medical practice. Incorporating peer-reviewed research, personal experience, and anecdotal evidence, the author excoriates overtesting and overprescribing as well as institutionalized racism within the medical community, and he advocates for "broadly available, prepaid, integrated, high-quality healthcare," a system that is open to change, collaboration, and "safe, effective, patient-centered, timely, efficient, and equitable" care. In a well-documented, panoramic narrative, an insider demystifies what makes many doctors tick.

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