The Peter Attia Drive - Qualy #125 - Hierarchies in healthcare, physician burnout, and a broken system

Episode Date: March 10, 2020

Today's episode of The Qualys is from podcast #37 – Zubin Damania, M.D.: Revolutionizing healthcare one hilariously inspiring video at a time.   The Qualys is a subscriber-exclusive podcast, released Tuesday through Friday, and published exclusively on our private, subscriber-only podcast feed. Qualys is short-hand for “qualifying round,” which are typically the fastest laps driven in a race car—done before the race to determine starting position on the grid for race day. The Qualys are short (i.e., “fast”), typically less than ten minutes, and highlight the best questions, topics, and tactics discussed on The Drive. Occasionally, we will also release an episode on the main podcast feed for non-subscribers, which is what you are listening to now. Learn more: https://peterattiamd.com/podcast/qualys/   Subscribe to receive access to all episodes of The Qualys (and other exclusive subscriber-only content): https://peterattiamd.com/subscribe/  Connect with Peter on Facebook.com/PeterAttiaMD | Twitter.com/PeterAttiaMD | Instagram.com/PeterAttiaMD

Welcome to a special bonus episode of the Peter Atia Qualies, a member exclusive podcast. The Qualies is just a shorthand slang for Qualification Round, which is something you do prior to the race, just much quicker. The Qualies highlight the best of the questions, topics and tactics that are discussed in previous episodes of the drive. So if you enjoy the quality, you can access dozens more of them through our membership program. Without further delay, I hope you enjoy today's quality. I had a similar experience at UCSF when I did a graduation speech that actually launched my whole career as E-Dog MD because I later put it on YouTube.

It's in my 1999 UCSF graduation speech. It's there. It's all captioned and everything. And it was, I just went through it as I saw it. And it was all just like, this is bullshit, this is bullshit, this is bullshit, this is why, this is bullshit. It's about actually connecting with our patients, isn't it? And the majority of the faculty behind me were just like stone-faced for 90% of it.

And then finally, start to crack. And you see Michael Bishop who's like a Nobel Prize winner finally he's like and afterwards they were like that was very well done but there was one guy who was like that kid shouldn't be allowed to graduate and actually was lobbying to have my graduation revoked for giving that speech. I mean so this is the thing it's a hierarchy and I can tell you don't like hierarchies so much. I probably have more thing, it's a hierarchy. And I can tell you don't like hierarchies so much. I probably have more respect for it than you actually. Being a surgeon. Yeah, I don't know.

I feel like I'm not as, I don't bristle as much at it is probably some people. I mean, I would say for a surgical resident, I respected it much less than the other residents and I definitely got into trouble on a few occasions as a result of it. Yeah. Yeah. I've met people who completely have absolutely disregard for any hierarchy and many of them go on just to the most amazing things.

So I always felt like I wish I had less respect for it. Well, you know, it's a complex thing because I think certain personality types don't like to be in the middle or bottom of hierarchies. They either want to be on the top or they want to be off the hierarchy. It's hard for them to feel like other people are controlling them or they're beholden to others in the higher hierarchy. And they either have a tendency to dominate those underneath or to treat them as equals inappropriately, in which case the lower down in the hierarchy don't have the competence

and what they need is actually to be trained and lifted and supported. And instead, it's like, why aren't you at the level that I'm asking you to be? And so it's interesting. It becomes tough in the higher echelons of performance and stuff people. I think the problem I had in residency was, I really loved hierarchy when I could respect the person

I was reporting to. So luckily, I did my residency at a hospital where most of the residents were just exceptional. So for the most part was really easy to respect the hierarchy. But the problem was, when I encountered somebody, and I didn't think that they were good enough, or smart enough, or new enough, I wouldn't hesitate to just steamroll them.

And that gets you into a lot of trouble. I saw that in you when you were a medical student. I remember it. It was one of your characteristics that I actually respected a lot. Because again, if you, like you said, and you kind of described our team pretty well. And the person at the top is fairly narcissistic. The one in the middle was kind of a non-entity. Then there was me who was the class clown, and then there was you. And it speaks to our medical training

in general that it really is about kissing the ring of the authority figure. So one day you will be the ring that's kissed. That's the majority of our training. The first two years were fed a bunch of information, 50% of which is wrong, but they don't tell us which 50%. And then the 50% of the residual will be outdated by the time you finish. Exactly. So it's 100% bullshit.

And yet we're expected to kind of suck it all in and regurgitate it with respect for this hierarchy. And we don't ask questions. we don't accept out of that. And you're right, you have to respect your authority figures which is important when you trust and respect them. But when you're questioning things, like why are we doing this? Why are we giving lay six to this person?

Or why? What's going on with this renal failure? Actually, what about the root cause of that? You start asking this question, no, no, no, no. That's when I was told, hey, you speak then think you should reverse that. They don't want to hear that from a medical student. And we had the short white coats and everything.

You guys had the long white coats. It wasn't as high as that. It was very unusual. Yeah, I didn't realize how, quote unquote, special that was until I saw that there were many programs where even the interns were still in short white coats. And I didn't realize what a big deal that was, like how much obsessing went into the white coat thing. I feel like an idiot even just voicing this right now, because I've never thought about this for like 20 years,

but what a big deal that white coat is. And I feel bad, maybe I should be more respectful of the white coat. You know, when I came from UCSF, nobody wore a long white coat except for fellows and attendings. So even the residents wore short white coats. I think Hopkins was that way. They're just starting to change it. When I came to Stanford, I saw you wearing a long white coat and my conditioned unconscious wanted to smack you. Like, how? I haven't earned it.

You haven't earned it. I haven't earned the long white coat I'm wearing as R1 as an intern. It's such an interesting process. It's almost militaristic, it's a very military hierarchy. And the question is, is that good? Do we need that? I think some degree of organization hierarchy is important when people's lives are on the line, same within the military, right? Your friends with Jocco will link in these guys,

I mean, what would he say about this? I don't know, I'd hate to speak for anybody, especially Jocco, but the challenge comes when you have to make a decision that is probably not the best decision for the patient, but it's the one that's coming down from the person just above you. And I always found the stickiest situations were, and I had an example, and I wanna be very careful,

I don't reveal too much because this was such a vivid example in my residency, but there was a time in my residency when I was an intern, and it was a small surgical service, so it was me and a chief resident only. So you didn't have all like the 17 layers. So you basically had attending fellow chief resident intern. So there was only only four people in the chain of command. And there was a situation that was in my mind clearly a case of someone that needed to go to the operating room. I don't think you even needed to be a physician to know that this person needed

to go to the operating room. I think if you walked into McDonald's and just pulled 100 people there, 97 would say, yep, that's a surgical case. Yeah, and the third would be like, I want extra. Right. The other three, I missed some finer detail. So I called the chief resident, and this was a weekend that I was on call, and I said to him, hey, I got this case, and you know, blah, blah, blah, blah, blah, it needs to go to the OR, and he was like,

just deal with it yourself. And I said, look, I know you're upset at me, I've already called you twice today. This was 8 p.m., and I had already called him twice on the Sunday, and he had had to come in today. This was 8 p.m. and I had already called him twice on the Sunday and he had had to come in both times because of the injuries were so severe that I was calling him about that they had to be taken to the OR. So he'd already been to the OR twice that day. It's a Sunday. He's pissed. It's his day off. So now I'm calling him at 8 p.m. or 8 p.m. to say, this is a surgical case. He's saying, you

fix it yourself. I'm saying, look, I technically could address this in the ER, but that's not the best thing to do. And he was like, stop being such a fucking pussy. Huh. So this is your attending. No, no, this was the chief resident. Chief resident. Yes. Yeah. So again, I don't want to get into details of it because it could kind of give away the identity of any of the people involved. In the end, I did deal with it in the ER. And I dealt with it the best I could, admitted the patient the next day,

everyone's rounding and they see the patient and they're like, God damn, how did this not go to the OR? So what I realized in that moment, and I was very early in my internship, I mean, days into my internship, actually, what I realized was the mistake I made was I didn't call the attending directly. Go right above. Yeah. Again, it was so obvious that this chief resident was wrong. It's so obvious he was being a lazy sack of shit. So I should have just called the attending. Now at the time, that wouldn't even occur to me.

I mean, that's like, you can't break the chain of command. But I look back at that and I view that as probably, certainly one of probably my five biggest failures in residency was the weakness, the inability to break that chain of command and deal with the consequences of it because there would have been consequences of that. Even though it was the right thing to do and even though that patient would have got much better care, I would have paid an enormous price for that through the duration of my residency, at least in that era.

And I don't know, I feel like in some ways I was just a coward, you know, or deer and headlights, I just didn't know what to do. So I thought, okay, I'll do the best I can. You know what? I want to dig into that because this story is at the center of what we're now calling burnout. And I don't think it's burnout. I think it's moral injury and Talbot and Dean and others have written about this in stat and other places. You were in a position where all the system was arrayed to make it very difficult for you to do the right thing for the patient. You knew it was the right thing. You knew the patient needed to have this done. And you knew that it would cause serious consequences to you to have it done. And you aired on the

side of, okay, well, maybe the system is this way for a reason, and it'll be okay in the morning. And it may not have been. And then you had to live with the shame and the guilt of not having done something that was self-destructive, that was not in your best interest to help this other person. And to this day, I can tell sitting across the table with you that this bothers you deeply, you're saying it's one of five things. This bothered me so much that for at least 12, 15 years after I would contemplate asking one of my friends who was still at Hopkins, you know, by this point now, a few of my friends who had finished were who was still at Hopkins. You know, by this point now, a few of my friends who had finished were still

attendings at Hopkins. I had contemplated asking them to dig through the medical records to find out what happened to that patient because I couldn't remember the patient's name, but I remembered the date. So I was going to say, Hey, go back to this date and look at everyone that came in the ER on that day. And I will be able to figure out which this person is. I want to know what this person is doing today.

And I kid you not. This is actually a really funny story. I mean, funny in this one twist. I know you're a huge fan of Dr. Oz, right? Massive, love him. Yeah. So glad you were on a show, by the way. Right, so I was on that show and a little embarrassed, truthfully, because I felt silly

and I didn't think it made sense for me to be on, but nevertheless I was on. And I didn't know when it actually aired, but when it aired, I heard from the patient's mother who was also there. And to make it very long, sort of short, it reconnected me with the patient who was doing exceptionally well.

And it was, you know, in a way, maybe it's wrong that I could alleviate some of the guilt by knowing that the patient turned out okay, but it was unbelievable because even this patient said they'd never watched this show before, this Dr. Oz show. They just happened to be in the waiting room, I don't know, getting their car fixed or something and they saw it on TV and they're like, hey, I know that, dude. That patient recognized you across the years. Yeah, this would have been 15 year Delta.

And then connected with me through my blog or something like that. Really, we have to let that sink in. That at the heart of all of this, and you're, you know, listen, you're an amazing scientist, your podcast is unbelievable. Like, I listen to it, I'm enthralled by it

because I'm also a huge nerd. But the fact is that was a human connection that you made that also was a victim of a system that was so broken that it caused you moral distress that lasted for years and was only partially ameliorated by reconnecting with that human at the center of that. Now, let's take that that you suffered and scale it

by a thousand times every single day when we have to take care of patients. We know full well what needs to be done. We know where the fuckups are and where things have gone wrong and where our system has failed. And we have powerless, not only powerless. If we do the right thing, we will lose money. We will lose time with our family.

We'll be charting all night and still may not work for the patient. Hope you enjoyed today's special bonus episode of the quality. New episodes of the qualities are released Tuesday through Friday each week and are published exclusively on our private member only podcast feed. If you're interested in hearing more, as well as receiving all of the other member exclusive benefits, you can visit peteratia-md.com forward slash subscribe. This podcast is for general informational purposes only, does not constitute the practice of medicine, nursing, or other professional health care services, including the giving of medical advice.

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