Welcome back to Unfiltered, a show that features two iconic voices in healthcare for a half hour of unscripted, hard-hitting talk.

Dr. Robert Pearl has twice appeared on The ZDoggMD Show (see: here and here) opposite Dr. Zubin Damania, who had twice appeared on the Fixing Healthcare podcast with Pearl, alongside cohost Jeremy Corr (see: here and here).

This episode (the third in this series so far) covers a lot of ground, starting with questions of censorship and medical misinformation as talks continue around Elon Musk’s pending ownership and overhaul of Twitter.

Also in this episode:

• Financial incentives vs. intrinsic drivers: What motivates doctors?
• Should we do away with the MCATs and change physician education for good?
• Why are women physicians more burned-out than male colleagues? And, according to the latest surveys, why is the problem getting worse?

To get started, press play or peruse the transcript below.

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Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple Podcasts or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

UNFILTERED TRANSCRIPT

Jeremy Corr:

Welcome to Unfiltered our newest program in our weekly Fixing Healthcare podcast series. Joining us each month is Dr. Zubin Damania, known to many as ZDoggMD. For 25 minutes he and Robbie will engage in unscripted and hard-hitting conversation about art, politics, entertainment, and much more. As nationally recognized physicians and healthcare experts, they’ll apply the lessons they extract to medical practice. I’ll then pose a question for the two of them as the patient based on what I’ve heard. Robbie, why don’t you kick it off?

Robert Pearl:

Hello, Zubin.

Zubin Damania:

Robbie, always a joy. I look forward to this time.

Robert Pearl:

This is our third podcast and I wonder, would you feel comfortable with my asking you a personal question?

Zubin Damania:

It could have been the first podcast. You know I’m a bit of a scary open book.

Robert Pearl:

Well, I heard, Zubin, a rumor that you just paid $44 billion to buy Twitter. Is that right?

Zubin Damania:

It is. They say it’s Elon Musk, but when you rip off his latex mask, it’s that old man Damania underneath, just scared of those meddling kids.

Robert Pearl:

I see. Well, I’m always confusing you with someone else, but you do drive a Tesla, right?

Zubin Damania:

No. I’m not rich enough to drive a Tesla. I have a Camry hybrid, so I am gas efficient, but also cheap.

Robert Pearl:

Okay. But seriously, no, let’s put this potential change in a healthcare context for our listeners. I’d like to explore the dividing line between opinion and science. Free speech is a right in the country, but shouting fire in a crowded building is not. You can have an opinion that Putin is the most horrific human being in the world or the savior of Russia, or if you think that swallowing bleach is an effective way to cure COVID-19, telling others to do so is likely to lead to someone’s death. If Mr. Musk called you, wanted your opinion how best to draw that line, what would you tell him?

Zubin Damania:

This is such a challenge because, yes, there are certain types of disinformation, whether intentional or unintentional, that can lead to havoc. And I think this idea of yelling fire in a crowded theater is a good version of that. Remembering that our right to free speech, that’s government stuff. It does not apply to companies. So companies can do whatever they want to your speech, in theory. What I would tell Elon is, listen, don’t entirely abandon the idea that extremely dangerous and direct disinformation that is clearly outrageously wrong shouldn’t be removed from the platform. There is a certain responsibility, I think, to do that. Where it becomes difficult is where there’s scientific debate or there’s opinion or whatever that is and allowing that to air is very different. And I think who the arbiters are of that truth has become difficult. Dr. Vinay Prasad has looked at who are these sort of filters that some of the companies, the big tech companies, have hired to determine what’s disinformation. And often it’s just the loudest voices on Twitter. So that may stifle scientific debate. You do want to a very vigorous, open debate, especially in a time when we don’t know everything, the time of a pandemic.

Robert Pearl:

How would you set up the panel, the algorithm, the AI application? How would you set up somebody to make this decision?

Zubin Damania:

Oh, man. If I knew that … Honestly, because I am much more on the free speech angle of it, I think it’s really … I don’t know, Robbie. What would you do? I don’t know that it can be done well, honestly.

Robert Pearl:

I think when it comes to healthcare, I tend to be a bit more conservative than I am when it comes to almost any other issue. I’m not so in believing you should censor anyone’s opinion unless there’s an implication for others. I’m worried and bothered by the fact we crossed a million deaths in the United States. I don’t think we should have had anywhere near that number of people perishing from this virus. Yes, in the first year, we didn’t know quite what to do. But the second year, we really should have done a lot better. I don’t know whose responsibility it is, but I know that what whoever’s it was, it’s a failure. Not an easy question, but somehow we had to figure out a better way and be prepared at least the next time to do so. If anyone on Twitter wants to tell the world that you or I or Jeremy or anyone else isn’t very smart, our ideas are wrong, that’s okay. There’s no problem doing that. But I just really worry. When we have a means of being able to advise people positively and the risk is tragedy, not just for themselves, but their family, their kids, their loved ones. I just somehow feel that we need to do a bit more, because it is good public health. And that’s where I separate out medicine from everything else that I can think of.

Zubin Damania:

So this is interesting. I think actually what we find is when these companies did label these things as disinformation or block them or whatever, whether it’s a Marty Makary op-ed in The Wall Street Journal or something more even very much to the fringe like Robert Malone or Peter McCullough, these sort of anti-vaccine activist physicians. What we found is that this is the internet, so people will go somewhere else where they aren’t censored. And the very act of censorship confirms the conspiracy bias of a segment of the population that’s prone to believe these things for whatever reason. And some of that is just having a sense of control. They don’t understand how this could all be happening to us and so they’re looking for meaning. And when these guys say, “Oh, the government’s doing this or Fauci’s doing that,” they’re very receptive to that because they say, “Oh, well that at least makes sense. It’s this nefarious plot.”

Zubin Damania:

And my concern is when we start doing those things, we drive people to those other locations and it doesn’t solve the problem. But where I think we can do better as healthcare professionals is we need to step up and say, “Okay, well …” If we think there’s good things like, say, vaccines or certain interventions to prevent the spread of COVID, then we have to be vocal in a way that isn’t judgmental, that isn’t partisan, that isn’t overtly political because the whole thing’s been so politicized. And that would go a long way, I think. Having a louder voice for science and truth and process than for disinformation is one way to drown out the noise without canceling the noise makers that then confirms the bias of the people who are prone to believe it.

Jeremy Corr:

ZDogg, you bring up a very good point of the whole canceling people from those said platforms. For example, when you saw Trump get removed from Twitter and then he moved over to Truth Social and all these kind of right wing people that get banned from Twitter and then moved over to Truth Social or these other kind of platforms, they’re going to be in these echo chambers of people that only think the exact same way as them and spreading whatever information or misinformation or whatever you want to call it. But when you have Twitter as more of a public square type of thing, for example, when you had the QAnon phenomenon going on. For every person that posted some crazy conspiracy theory, you had 20 people responding, being like, “Look, you’re being dumb. Here’s proof. Look, this doesn’t make any sense. Here’s why.” What are both of your thoughts around that, out of curiosity, about is it better to not censor them and engage with them further versus driving them into those echo chambers?

Zubin Damania:

So my take on the echo chambers is that it’s an existential threat, actually, to all of us, this idea that we are polarized into chambers that just reflect what we already hear. And those chambers don’t connect. They only connect through virtual violence. In other words, this antagonism. They’re almost these hive mind, group minds that form. And you’re right. Whether it’s a Truth Social hive mind or a Twitter hive mind or a Rumble hive mind or wherever it is, they tend to attract like minds and then echo the sentiment. So making that corpus callosum, those fibers that connect those different hive minds, is actually key, which means a dialogue. That’s why I’m … And I get it, Robbie. I totally get that this is healthcare and people’s lives are at stake, so we as physicians really want to intervene. And so the question then is what’s the best, most effective way to do that? I wish I had a direct answer, but it’s quite nuanced.

Robert Pearl:

Yeah. I think what you’re hearing from me is just frustration. I can’t stand to see human life wasted, and we wasted human life. And I’m looking for a better answer and that’s why I thought I would ask you about that. But let’s switch maybe to another topic. Zubin, our discussion of the four existential questions in the last podcast, it stimulated lots and lots of great conversation from our listeners. I heard from quite a number of them. And a physician and former student of mine at the Stanford Graduate School of Business asked if you and I could talk about the difference between transactional and transformational leadership. As you know, transactional leadership is quid pro quo. You increase your screening for colon or breast cancer in patients in the recommended age group from 50 to 60%, you get an extra $1,000 a year. You go from 50 to 70, you get $2,000 more. In contrast, transformational leadership, inspires people and attempts to improve medical outcomes by connecting with their inner motivation as people. You led Turntable Health in Las Vegas. What did you learn about the value and role of financial incentives versus intrinsic motivation?

Zubin Damania:

Ah, what a great question. This is the central piece because how do you motivate people through leadership rather than management, through, like you said, transformation instead of transaction? And what I think, I think the data shows this too, and what I found was that pay for performance just doesn’t really work. Doctors are intrinsically motivated to do the right thing. They’re also a bit competitive. They want to actually do better than their peers on average. They don’t want to be the one that’s the last in their class or whatever it is, or the one that has the lowest scores on whatever. They’ve always been intrinsically motivated. So how do you then lead in that sort of setting? And what it seems is, first of all, you got to just set this culture that we’re trying to do the right thing for patients and for each other. And then you provide the tools, the team, and the trust to actually accomplish that.

Zubin Damania:

And the tools will be the technology that’s actually there to enable what they’re trying to do to make them feel capable to do it. The teams are the support structures, the human support that allow everybody to do the top of their game and support each other too. And then trust is the key thing, which is where you’re saying, “Listen, I’m not going to nickel and dime you and give you an extra $1,000 for this outcome. I am going to actually give you the autonomy to accomplish what we have as goals here together that are partially intrinsically motivated, and then give you those tools and team to actually accomplish it.” And yeah, we may measure it as an outcome in a big sense, like how are we doing here, and then have the discussion as a group and maybe have a healthy competition around it. But pay for performance just is not going to motivate intrinsically motivated people.

Robert Pearl:

If that’s the case, and I concur with you, everything you said, why are financial incentives used so often by leaders across the United States?

Zubin Damania:

I think it’s a currency that they understand, especially non-clinical leadership. And I think they think that humans are motivated by that sort of financial reward. But these are medical professionals. After they reach a certain point, it’s more about that intrinsic motivation. For me, when I was practicing fulltime too, that’s how it felt. It’s like, I wanted to feel valued. I wanted to feel like I was providing value. I wanted to feel like I was part of a team that I felt responsible to, and that felt responsible to me. And I felt that I wanted resources to be able to do my job, meaning technological resources that didn’t suck. And I think when I had those, when everything was firing on all cylinders, giving great care just became the default and you are always striving to be better. But when it became about RVUs and when it became about productivity, when it became about these rewards for clicking the right boxes and getting the things done that way, it really stripped away the intrinsic motivation. And I think it had bad outcomes. But I think our leaders are conditioned that way, many of them, especially non-clinical leaders.

Robert Pearl:

Maybe a theme from today’s conversation, Zubin, is my frustration in how slow our progress is. And I want to figure out how we can make it happen faster. Earlier today, I spoke at Rochester at a really excellent organization that was there. And there was a dinner last night and we were talking about the fact that four miles from we were sitting, life expectancy was 10 years less than the people who were living in the area where we were. And I asked them, I said, “What’s going on to change that?” We know what many of those factors are. And the answer was in a motivated community, not much was occurring. How do we accelerate this change to get the best health for people?

Zubin Damania:

So much of it is all healthcare is local. So actually having members of the team from the community you’re trying to serve, who understand that community, having skin in the game, knowing that every community is different, is motivated differently. Not having a one size fits all platform, but maybe having a central thesis like, “These are the goals we want to accomplish. So how do we do it here, versus here, versus here and making it a priority?” We talk a lot about equity and things like that, but when the rubber hits the road, it’s really about financial outcomes or just playing the same old game. And I’m as frustrated as you are, Robbie. It’s very frustrating.

Zubin Damania:

There’s a female physician at Penn. I’m forgetting her name now, but she was on my show. And she works with health coaches from community areas that are zip codes of tremendously poor outcomes and found that bringing those health coaches that go to homes, that interact with the patients. We did this at Turntable, too. Driving these very empathic, motivated interviewers from the communities they’re going to serve. That was 90% of the battle. And then really tailoring it to how do those patients want to communicate? Maybe they don’t want to do a telehealth thing, but they would love to text. So can we set it up so that they can text us because that’s culturally what they do? Or whatever it is. It’s really being adaptable to the community at hand, and then having the motivation to actually want those disparities to go away.

Robert Pearl:

So let me be a little bit controversial and look at another area related to this, which is how we select medical students. Malcolm Gladwell popularized the 10,000 hour rule, implicit in the idea is that if you want to become, let’s say, a great guitar player, it takes that level of dedication and commitment. And maybe coincidentally 10,000 hours is about the amount of time a resident’s in a three year program like internal medicine spends. As you know, I think Malcolm is one of the most talented non-fiction writers, and he was a guest on a recent Fixing Healthcare podcast. But I’d like to add a second rule, and that I’ll label the three step rule. And just so listeners aren’t confused, unlike the 10,000 hour rule that has deep research background, my three step rule, it’s completely made up. I don’t have the least bit of scientific data, but it comes from my life.

Robert Pearl:

And the rule concept is that we all are born with intrinsic ability in each category, how high we can jump, how good looking we are, how well we do mathematics. And let’s just say we have a number between one and 10. With 10,000 hours of practice, we can go up, this is my hypothesis, three spots. I use my life as an example. One of the greatest gifts I ever got was how terrible I am at singing. I was between a one and a two. Had I been a five or six, I might have deceived myself into becoming a rock professional musician. But no matter how hard I worked, I knew the best I could become was five. So if you, at least for the time being, will agree that talent is equally important to dedication and hard work, let me ask you what are the skills we should screen for in medical students? We both know that traditionally we screened from memorization through Step One tests and MCATs and other pieces. But today with the smartphone, memorization is less crucial. Should we be screening for empathy? Should we be screening for communication ability? Should we be screening for ability to motivate? What do you think we should be screening for picking the next generation of doctors?

Zubin Damania:

Oh, all of those things. All of those things are crucial. And I love that theory. I think that’s fact. I’m going to go further and say for my own life, it’s the same thing. There’s this controversial thing in leadership. It’s like do you work on your weaknesses? Do you spend all this time working on these weaknesses where you’re at a one or a two, try to get it to a three or a four? Or do you really just boost those strengths? And I don’t know. I’m always a fan of boosting the strengths. So if you’re looking in healthcare, the truth is there isn’t a one size fits all because you need surgeons, you need urologists, you need psychiatrists, you need primary care doctors. They all do different things. My neurosurgeon doesn’t necessarily have to be the most empathic person in the world, but they better be a really disciplined technician and highly learned to be able to do what they do.

Zubin Damania:

So maybe you have some latitude for how you’re screening, but I would say the more we screen for things like communication, bedside manner, empathy, compassion, interesting stories that people have overcome adversity, the idea that they would then have real compassion for people who are struggling, those kind of things are … We always give lip service to it, but we’ve never really screened for it. We screen by, like you said, by the tests. And that’s why it’s interesting. A lot of times you’ll get into a school system like a D.O. School system where they screen maybe a little bit differently, and those doctors are trained differently too. And you wonder like, “Oh.” When you’re sitting in the room with them, it’s a different vibe and often in a good way. So it really … And again, I don’t mean to paint it with a single brush, but it really does speak to how we’re even picking people who go through medical school.

Zubin Damania:

Now, the other problem is if you screen based on empathy and those kind of things, and you do underemphasize the testing, then you may set up people for failure in a medical school education system that is designed to continue that process of test taking brilliance and not necessarily all those other factors. I’m curious what you think, Robbie.

Robert Pearl:

Well, I think we need to change not just the acceptance process, but the educational process and the evaluation process. I believe, and I’ve written about it, that rather than banning cell phones from all these exams, you should be required to bring one. We shouldn’t be testing your ability to find the Kreb cycle. For listeners who aren’t doctors, it’s a very famous set of information that’s hard to exactly discern that physicians get tested on in their second year of medical school and never again ever use. So it’s the ultimate metaphor for the problem that we’re talking about. In fact, the entire step one examination is one that’s 16 hours of testing on about 10,000 arcane facts. Medical students spend six to eight weeks, 12 hours a day memorizing all of these, again, 95% of which they’ll never ever use unless they happen to be on the Amazon river somewhere in the jungle encountering some kind of protozoan that they only read about and they, of course, would never have the medication anyway.

Robert Pearl:

No. We’re in the 21st century. Smartphones are with us all the time. I think we should be evaluating people on their ability to take that information that’s readily available now and apply it to difficult situations, to be able to figure out with access to all of that smartphone what really is going on with this patient and this family and how am I going to impact that person’s life. We really don’t measure the change in the patient’s health. We measure simply the advice the doctor gave. And as you well know, we have major problems with patients getting prescribed maybe the right medication but not taking it, sometimes getting prescribed the wrong medication, but getting prescribed the right medication and not taking it. The opportunity to be able to engage in opportunities to improve and prevent chronic disease and treat chronic disease. Diet, nutrition, relaxation. There’s a whole litany of opportunities that exist and we don’t do a very good job of helping patients. Some is the system of medicine. Some is the society around it.

Robert Pearl:

But I personally think that the physician skills going forward in a world where increasingly there are patients with multiple chronic diseases, each of which interact with each other, all of which are overwhelming. The ability of the physician of the future, I think, will be very different than the past. I just wonder how you would screen the 50,000 medical student applicants for the 20,000 physicians that exist every year in the United States?

Zubin Damania:

Yeah. And the screening is one piece, but like you said, how we’re even teaching them medical school is such a … It’s not set up to manage all that chronic disease. It really isn’t. And I almost feel like you should have as part of medical training a week long silent meditation retreat where these students are forced to introspect for a week and come back very sensitive to their environment and very much using nonverbal cues and things like that where they get out of their head and into this space around them with the patient and with each other and with themselves. And I think that would really help open up the motivational aspects of how do you connect with another human being. We don’t teach it very well in medical school. More clinical stuff would be nice, starting very early and really saying, “Hey, this is what it is.” Again, that’s not to lessen if you’re going to be a pathologist or you’re going to do something that’s more research oriented. You want to accommodate for that as well, because that’s important. But man, we’re doing it wrong. Whatever we’re doing now, it’s not right. It’s not working

Robert Pearl:

Well, that’s also why I asked you about this rule of three steps, because unless you’re convinced that everyone who applies to medical school is a seven or eight in the ability to communicate, the ability to empathize, the ability to understand what an individual from a different background is telling you, then we probably do need to figure out the individuals best able to do that, if those are the skills of the future. But I also would agree with you. I think the classes should involve using that technology to be able to now understand, let’s say, the physiology of the heart or the pharmacology of the medications. Why should you have to memorize the dose of a drug when you can look it up with 100% accuracy rather than relying on your memory? But understanding things about lifestyle that affect the drug, that’s a different set of skills that I think we don’t focus on nearly as much.

Zubin Damania:

And I think that that speaks again to mechanical intelligence versus human intuitive connective intelligence, relational intelligence. Why don’t we optimize for that since the computers are going to take everything else and do it better than us? So I agree. I agree a hundred thousand percent. Everyone’s using Up To Date now anyways as a source reference for a lot of stuff. We ought to train how do you use that effectively? How do you overcome bias in it? How do you think from the human side taking that data? Absolutely. But we would just memorize stuff. I mean, that was our thing when I trained.

Robert Pearl:

And the errors in it, not because the science is wrong, but because the application is wrong, as you said, based upon a given population or given set of individuals. So let’s go one more step. I want to talk a little bit with you today about burnout among doctors. I don’t know if you looked at the most recent Medscape survey. It had the information that we would expect. Burnout’s gotten worse in the context of COVID. The two specialties that have been that at the highest level are the two you would predict, ER and critical care. These are the people who have had to deal with the majority of individuals who’ve gone on to die. These are situations where physicians have been overwhelmed by the sense of loss, the inability to change the trajectory of a disease, the frustration of being unable to be effective as doctors. You had the isolation with COVID and families not being there. On and on and on.

Robert Pearl:

But what struck me as being most interesting was the third specialty on the list. The third most burned out specialty today, it wasn’t true two years ago, is OB/GYN. Now OB/GYN physicians don’t have a lot of patients who had COVID. They didn’t see a huge number of deaths. And why did this specialty soar in burnout rates compared to the other specialties? And as I looked at it, my conclusion was it’s one statistical fact, 85% of physicians in OB/GYN are women. And they took on another job, eight to ten hours more work outside the medical office or the hospital because they bore the brunt of child care. And I haven’t heard a whole lot of physicians talking about, and I’ll call it the two-way flow of the world inside medicine and outside. It’s almost like, as you said, the corpus callosum which connects the two sides of the brain was severed. And our minds are, we either have a work environment or our personal environment, and maybe the work environment negatively affects the personal, but not necessarily that the personal affects the work.

Robert Pearl:

I wrote a piece for it on Forbes and I expected about a third of the people would say I was right, a third of the people would say I was a total idiot and I had gotten it completely wrong, and a third would’ve said, “Oh yeah. We knew this all along.” But instead I think there was a pretty good resonance, at least amongst the women responding, that this was the reality of the past two years. How do we have a more broad understanding of burnout to recognize what happens in our practices that we don’t control, what happens in our practices that we can control, and what happens in our life outside of medicine that impacts our satisfaction, our job fulfillment and our level of fatigue?

Zubin Damania:

I read your Forbes piece and I was actually really … I said, “Yeah.” And the thing is, it’s difficult because you and me are mansplaining this thing. But I would say this, I mean, my wife is a female physician and the truth is when you look at burnout, you have to look at it’s not work-life balance. It’s life of which work is an integrated piece and they all resonate together. So for men, they have this, at least in the typical roles that we see, they’re not necessarily always the primary caregiver also of children at home. They’re not caring for elderly loved ones directly. They can be, but it’s not the primary thing. We often see that to be more a female role historically in society. And it’s dragged into current where women are now a huge part of the medical workforce.

Zubin Damania:

So they go to work, they do all the stuff that we have at work that is hard for us, but then they have the extra element, which this is going to be controversial, but if you look at personality tests, women score higher on agreeableness than men. So when asked to do extra stuff, they tend not to say no as often as men do. Men are jerks on personality tests. Again, just trying to stick with the data here, Robbie. I’m editorializing occasionally. And so they get sucked into stuff at work. Then they go home. They’re the caregiver for the kids. They have all that other stress. And even if they’re part-time, it’s like the equivalent of 1.5 FTE full-time equivalent. Duh, it’s going to be harder for them in many ways. And so it’s not surprising to me that that OB/GYN and maybe pediatrics too, which is more female, higher up on the list of people who self-report burnout.

Robert Pearl:

Pediatrics was another specialty that went up quite significantly. But why don’t we talk about it? Why don’t we talk about gender inequality in the context of burnout? Why don’t we talk about the parents who are sick or other environment or personal issues? We just keep separating our work experience and our dissatisfaction, and there’s no question the bureaucratic tasks and the computer systems and all of the problems are very real. But these other pieces, when I look at the data, seem to be quite significant as well. And yet at least I don’t hear it. You talk to far more physicians than I do. Are you hearing this type of outside world impinging on our personal professional satisfaction? Are you hearing that discussed very much?

Zubin Damania:

Absolutely. And when I talk to male physicians who are experiencing high degrees of burnout, often they will report having a child who either has special needs or who is having difficulty through the pandemic and has required a lot more attention from the male parent. And so these things are absolutely intertwined but we reduce it to, well, it’s Epic or it’s an electronic health record problem, or it’s too much insurance interference. All that’s there and that’s been going on, but what is it that really this is about is we try to make doctors try to feel like they’re these invincible, off the grid kind of super humans. And in fact, we codify that in our cultural response to the pandemic and say, “Oh, heroes work here. These are healthcare heroes.”

Zubin Damania:

And so what is calling somebody a hero says, well, then you’re more than human. So you can take on all this stuff. And the truth is, no, we’re absolutely human. And the hero’s journey is the human going on the journey, right? And coming back and returning with new knowledge, new insight, new awakeness. But we’ve taken away the journey and we’ve said, “Oh no, no, no. You’re just going to do inhuman amounts of work and then suffer at home too with all the responsibilities you have.” And we’re not going to talk about it, Robbie, because you asked that. Why don’t we talk about it? Because it’s stigmatized. People are afraid to talk about it. They’re afraid of getting canceled for saying the wrong thing. They’re afraid of … You call this series Unfiltered. You and I will just say what we think, right? But there’s still that subtle fear, like, “Well, I don’t want to come off like I’m mansplaining about what women are going through.” And so everybody’s just all uptight about it. We just need to have these open conversations. You’re very good at that. Your book about physician culture was … I mean, I was like, “This is it right here. And it’s going to generate anger.” But, man, that’s what we need to do.

Jeremy Corr:

All right. So I guess my final question for you both is in 2021, 107,000 people died from a drug overdose in the US, roughly a quarter of the number of deaths attributed to COVID during the same time period. The opioid epidemic is something you hear about in the news significantly less, yet I do not think there’s a single person who has not had a friend or family member that’s been impacted by the opioid epidemic, many of them due to fentanyl. There’s also a massive mental health crisis in this nation that’s been very much exacerbated by the pandemic. I didn’t see the 2021 numbers for suicide, but in 2020, there were over 45,000 deaths by suicide in the US. And a couple days ago, the House overwhelmingly voted to send $40 billion in military aid to Ukraine. This is during a time of record inflation, gas prices, baby formula shortages.

Jeremy Corr:

And I saw one comment on Twitter that I found fascinating that I wanted you both to discuss. I saw someone say that if a member of the House proposed $40 billion to fight the opioid epidemic or mental health crisis here in the United States, they’d be laughed out of the room. I understand that to an extent. This is an apples and oranges comparison. But as healthcare experts, what are your thoughts on this? And why isn’t more being done to address the domestic issues around the mental health crisis and opioid epidemic?

Zubin Damania:

Jeremy, this is what some friends of mine call COVID myopia, for example. We’re so focused on what’s an obvious pandemic, a million dead and so on, that we’ve always ignored actually a very iatrogenic, medically caused epidemic, the opioid epidemic that, like you say, is a significant fraction of the COVID deaths, but it continues year after year after year and only seems to get worse. And the pandemic does not make it better. And so to some degree, our shortsighted responses to one thing tend to either exacerbate, because it’s all connected. During the pandemic, of course, seems like drug use, mental illness has gotten worse because we’ve destabilized society with some of the response to this, which again, gets back to our original discussion of like, well, do you censor people’s discussions when they disagree with our response?

Zubin Damania:

And the answer is no, because some of them may be looking at bigger picture stuff. And sending money to Ukraine, we’re printing that money. It’s not like … We’re just deficit spending. So our children are paying for that and they’re going to pay for the opioid crisis that the Sacklers helped create. And it just becomes a very frustrating stew of not being able to see context and the holistic picture of what’s going on. And I think that really has come to a head here with this.

Robert Pearl:

My take is that in our nation, we do not see all lives the same. And if you are in a group such as someone with mental health illnesses, someone with opioid addiction problems, heroin issues, someone who’s very old with lots of chronic disease, our nation doesn’t value those lives, doesn’t see them as being productive and doesn’t make the investments. Whether they spend the money someplace else, and I personally believe that the war in Ukraine is one that’s vital for our future, because I think the aggression that Russia has shown is only the start. We’ve seen it many times in the past. But that’s my political views. As a physician, my view is that all lives are not the same. I mentioned earlier, the zip code four miles away, people are living. You can run there in 40 minutes. And yet the people dying 10 years earlier are simply not seen as being as important lives worth saving as the people living in the houses surrounding your own home.

Robert Pearl:

This, I think, is a part of the human existence. In particular, we know this from implicit bias that people who look like you, act like you, talk like you, believe like you are ones whose lives you think are more significant. And I think what you’ve pointed out, Jeremy, is the price that we pay, 107,000 people dying now. It was 60,000. We didn’t notice it back then. It could be 125,000 a year from now. And maybe I’m just an idealistic doctor. I just think that every life that is lost unnecessarily and not from a disease we can’t control, but for a problem we could take care of is simply a tragedy. And we have a growing number of tragedies across our nation.

Jeremy Corr:

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