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

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00:00:40.440 I had a similar experience at UCSF when I did a graduation speech that actually launched

00:00:44.200 my whole career as ZDoggMD because I later put it on YouTube. It's in my 1999 UCSF graduation

00:00:49.400 speech. It's there. It's all captioned and everything. And I just went through it as I saw it, and it

00:00:53.460 was all just like, this is bullshit, this is bullshit, this is bullshit, this is why, this 1.00

00:00:56.640 is bullshit. It's about actually connecting with our patients, isn't it? 1.00

00:00:59.180 And the majority of the faculty behind me were just like stone-faced for 90% of it, and then

00:01:04.120 finally start to crack. And you see Michael Bishop, who's like a Nobel Prize winner, finally

00:01:07.260 he's like... And afterwards they were like, that was very well done. But there was one

00:01:12.260 guy who was like, that kid shouldn't be allowed to graduate, and actually was lobbying to have

00:01:17.140 my graduation revoked for giving that speech. I mean, so this is the thing. It's a hierarchy.

00:01:22.740 And I can tell you don't like hierarchies so much.

00:01:25.920 I probably have more respect for it than you, actually.

00:01:28.460 Being a surgeon.

00:01:29.780 Yeah, I don't... I don't know. I feel like I'm not as... I don't bristle as much at it

00:01:35.540 as probably some people. I mean, I would say for a surgical resident, I respected it much

00:01:40.040 less than the other residents, and I definitely got into trouble on a few occasions as a result

00:01:45.220 of it.

00:01:45.780 Yeah, yeah.

00:01:46.300 Yeah, I've met people who completely have absolutely disregard for any hierarchy, and

00:01:50.500 many of them go on to just do the most amazing things. So I always felt like I wish I had

00:01:54.460 less respect for it, but...

00:01:55.660 Well, you know, it's a complex thing because I think certain personality types don't like

00:01:59.120 to be in the middle or bottom of hierarchies. They either want to be on the top or they want

00:02:02.960 to be off the hierarchy. It's hard for them to feel like other people are controlling

00:02:07.340 them or they're beholden to others in the higher hierarchy. And they either have a tendency

00:02:11.960 to dominate those underneath or to treat them as equals inappropriately, in which case the

00:02:16.800 lower down in the hierarchy don't have the competence. And what they need is actually

00:02:20.460 to be trained and lifted and supported. And instead, it's like, why aren't you at the

00:02:25.200 level that I'm asking you to be? And so it's interesting. It becomes tough in the higher

00:02:28.820 echelons of performance and stuff.

00:02:30.320 I think the problem I had in residency was I really loved hierarchy when I could respect

00:02:35.120 the person I was reporting to. So, you know, luckily I did my residency at a hospital

00:02:39.940 where most of the residents were just exceptional. So it, for the most part, was really easy to

00:02:44.940 respect the hierarchy. But the problem was when I encountered somebody and I didn't think

00:02:49.080 that they were good enough or smart enough or knew enough, I wouldn't hesitate to just

00:02:55.220 steamroll them. And that gets you into a lot of trouble.

00:02:58.220 I saw that in you when you were a medical student. I remember it. It was one of your

00:03:01.840 characteristics that I actually respected a lot. Because again, like you said, and you kind

00:03:06.860 of described our team pretty well. And the person at the top was fairly narcissistic.

00:03:10.760 The one in the middle was kind of a non-entity. Then there was me, who was the class clown. 0.90

00:03:14.640 And then there was you. And it speaks to our medical training in general that it really

00:03:21.140 is about kissing the ring of the authority figure. So one day you will be the ring that's

00:03:25.840 kissed. That's the majority of our training. The first two years, we're fed a bunch of information,

00:03:30.200 50% of which is wrong, but they don't tell us which 50%.

00:03:33.180 And then the 50% of the residual will be outdated by the time you finish.

00:03:36.880 Exactly. So it's 100% bullshit. And yet we're expected to kind of suck it all in and regurgitate 0.99

00:03:42.340 it with respect for this hierarchy. And we don't ask questions. We don't step out of that. And

00:03:47.120 you're right. You have to respect your authority figures, which is important when you trust and

00:03:50.760 respect them. But when you're questioning things like, why are we doing this? Why are we giving

00:03:54.760 Lasix to this person? Or what's going on with this renal failure? Actually, what about the root cause of

00:03:59.020 that? You start asking this question. No, no, no, no, no. That's when I was told, hey, you speak,

00:04:02.620 then think you should reverse that. They don't want to hear that from a medical student. And

00:04:07.000 we had the short white coats and everything. You guys had the long white coats. It wasn't as

00:04:10.080 hierarchical.

00:04:10.320 It was very unusual. Yeah. I didn't realize how, quote unquote, special that was until I saw that

00:04:16.400 there were many programs where even the interns were still in short white coats. And I didn't

00:04:21.120 realize what a big deal that was, how much obsessing went into the white coat thing. I feel like an idiot 1.00

00:04:27.860 even just voicing this right now, because I've never thought about this for like 20 years. 0.99

00:04:32.240 But what a big deal that white coat is. And I feel bad. Maybe I should be more respectful of the

00:04:36.380 white coat. You know, when I came from UCSF, nobody wore a long white coat except for fellows and

00:04:41.860 attendings. So even the residents wore short white coats. I think Hopkins was that way. They're just

00:04:46.260 starting to change it. When I came to Stanford, I saw you wearing a long white coat. And my conditioned

00:04:52.720 unconscious wanted to smack you. Like how- I haven't earned it. You haven't earned it. I haven't earned

00:04:57.940 the long white coat I'm wearing as a R1 as an intern. It's such an interesting process. It's almost

00:05:03.620 militaristic. It's a very military hierarchy. And the question is, is that good? Do we need that? I

00:05:08.340 think some degree of organization hierarchy is important when people's lives are on the line. Same

00:05:12.080 within the military, right? Yeah. You're friends with Jocko Willink and these guys. I mean, what would

00:05:15.740 he say about this? I don't know. I'd hate to speak for anybody, especially Jocko. But the challenge

00:05:20.640 comes when you have to make a decision that is probably not the best decision for the patient,

00:05:29.920 but it's the one that's coming down from the person just above you. And I always found the

00:05:33.860 stickiest situations were, and I had an example and I want to be very careful. I don't reveal too much

00:05:39.020 because this was such a vivid example in my residency. But there was a time in my residency when

00:05:43.840 I was an intern and it was a small surgical service. So it was me and a chief resident only.

00:05:49.200 So you didn't have all like the 17 layers. So it was, you know, you basically had attending fellow

00:05:54.620 chief resident intern. So there was only like four people in the chain of command.

00:05:59.420 And there was a situation that was in my mind, clearly a case of someone that needed to go to

00:06:05.000 the operating room. I don't think you even needed to be a physician to know that this person needed

00:06:09.780 to go to the operating room. I think if you walked into McDonald's and just polled a hundred people

00:06:14.800 there, 97 would say, yep, that's a surgical case.

00:06:18.400 Yeah. And the third would be like, I want extra.

00:06:20.380 Right. The other three, they might miss some finer detail. So I called the chief resident and this was

00:06:26.460 a weekend that I was on call. And I said to him, hey, I got this case and you know, blah, blah, blah,

00:06:32.840 blah, blah. It needs to go to the OR. And he was like, just deal with it yourself. And I said,

00:06:38.040 look, I know you're upset at me. I've already called you twice today. This was 8 PM. And I had

00:06:43.400 already called him twice on the Sunday and he had had to come in both times because of the injuries

00:06:47.820 were so severe that I was calling him about that they had to be taken to the OR. So he'd already

00:06:52.020 been to the OR twice that day. It's a Sunday. He's pissed. It's his day off. So now I'm calling

00:06:56.920 him at 8 AM or 8 PM to say, this is a surgical case. He's saying you fix it yourself. I'm saying,

00:07:03.840 look, I technically could address this in the ER, but that's not the best thing to do. 1.00

00:07:10.440 And he was like, stop being such a fucking pussy. 1.00

00:07:14.500 So this- 1.00

00:07:15.520 This was your attending?

00:07:16.300 No, no. This was the chief resident.

00:07:17.380 Chief resident at Hopkins.

00:07:17.800 This was the chief resident. Yes.

00:07:19.300 Yeah.

00:07:19.960 So again, I don't want to get into the details of it because it could kind of give away the

00:07:24.200 identity of any of the people involved. In the end, I did deal with it in the ER. And I dealt with

00:07:30.140 it the best I could, admitted the patient. The next day, everyone's rounding and they see the

00:07:37.060 patient and they're like, God damn, how did this not go to the OR? So what I realized in that moment, 0.92

00:07:44.700 and I was very early in my internship, I mean days into my internship actually, what I realized was

00:07:50.500 the mistake I made was I didn't call the attending directly.

00:07:54.800 Go right above.

00:07:55.600 Yeah. Again, it was so obvious that this chief resident was wrong. It's so obvious he was being

00:08:01.340 a lazy sack of shit. So I should have just called the attending. Now, at the time, that wouldn't 1.00

00:08:07.400 even occur to me. I mean, that's like, you can't break the chain of command. But I look back at that

00:08:12.380 and I view that as probably, certainly one of probably my five biggest failures in residency

00:08:17.240 was the weakness, the inability to break that chain of command and deal with the consequences of

00:08:22.900 it. Because there would have been consequences of that. Even though it was the right thing to do,

00:08:26.260 and even though that patient would have gotten much better care, I would have paid an enormous

00:08:29.600 price for that through the duration of my residency, at least in that era. And I don't know, I feel like

00:08:34.100 in some ways I was just a coward, you know, or deer in headlights. I just didn't know what to do.

00:08:38.460 So I thought, okay, I'll do the best I can.

00:08:40.140 You know what? I want to dig into that because this story is at the center of what we're now calling

00:08:45.560 burnout. And I don't think it's burnout. I think it's moral injury. And Talbot and Dean and others

00:08:51.120 have written about this in STAT and other places. You were in a position where all the system was

00:08:57.240 arrayed to make it very difficult for you to do the right thing for the patient. You knew it was

00:09:01.140 the right thing. You knew the patient needed to have this done. And you knew that it would cause

00:09:06.740 serious consequences to you to have it done. And you erred on the side of, okay, well, maybe the

00:09:12.320 system is this way for a reason and it'll be okay in the morning and it may not have been.

00:09:15.740 And then you had to live with the shame and the guilt of not having done something that was

00:09:20.880 self-destructive, that was not in your best interest to help this other person. And to this

00:09:25.740 day, I can tell sitting across the table from you that this bothers you deeply. You're saying it's

00:09:29.420 one of the five things- This bothered me so much that for at least 12, 15 years after, I would

00:09:39.320 contemplate asking one of my friends who was still at Hopkins. You know, by this point now,

00:09:43.740 a few of my friends who had finished were still attendings at Hopkins. I had contemplated asking

00:09:48.700 them to dig through the medical records to find out what happened to that patient because I couldn't

00:09:52.640 remember the patient's name, but I remembered the date. So I was going to say, hey, go back to this

00:09:56.780 date and look at everyone that came in the ER on that day. And I will be able to figure out which

00:10:02.280 this person is. I want to know what this person is doing today. And I kid you not, this is actually a

00:10:09.420 really funny story. I mean, funny in this one twist. I know you're a huge fan of Dr. Oz, right?

00:10:14.800 Massive. Love him.

00:10:15.800 Yeah.

00:10:15.940 So glad you were on his show, by the way.

00:10:17.240 Right. So I was on that show and a little embarrassed, truthfully, because I felt silly

00:10:22.080 and I didn't think it made sense for me to be on, but nevertheless, I was on. And I didn't know

00:10:26.720 when it actually aired, but when it aired, I heard from the patient's mother who was also there.

00:10:36.280 And to make a very long story short, it reconnected me with the patient who was doing

00:10:39.680 exceptionally well. And it was, you know, in a way, maybe it's wrong that I could alleviate some

00:10:46.100 of the guilt by knowing that the patient turned out okay. But it was unbelievable because even this

00:10:51.460 patient said they'd never watched this show before, this Dr. Oz show. They just happened to be in the

00:10:56.840 waiting room, I don't know, getting their car fixed or something. And they saw it on TV and they're

00:11:00.840 like, hey, I know that dude.

00:11:02.460 That patient recognized you across the years on TV.

00:11:06.160 Yeah. This would have been 15 year Delta. And then connected with me through my blog or

00:11:10.900 something like that.

00:11:11.540 Really, we have to let that sink in. That at the heart of all of this, and you're, you know,

00:11:15.900 listen, you're an amazing scientist. Your podcast is unbelievable. Like I listened to it,

00:11:20.600 I'm enthralled by it because I'm also a huge nerd. But the fact is that was a human connection

00:11:26.080 that you made that also was a victim of a system that was so broken that it caused you moral distress

00:11:33.820 that lasted for years and was only partially ameliorated by reconnecting with that human at

00:11:40.400 the center of that. Now, let's take that, that you suffered, and scale it by a thousand times every

00:11:47.220 single day when we have to take care of patients. We know full well what needs to be done. We know where

00:11:52.020 the fuck-ups are and where things have gone wrong and where our system has failed, and we have 0.86

00:11:55.440 powerless, not only powerless, if we do the right thing, we will lose money, we will lose time with 0.91

00:12:00.900 our family, we'll be charting all night, and it still may not work for the patient.

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The Peter Attia Drive - March 10, 2020

Qualy #125 - Hierarchies in healthcare, physician burnout, and a broken system

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