Mistreated Why We Think We’re Getting Good Health Care And Why We’re Usually Wrong
Robert Pearl, MD
Public Affairs, 2017
Reviewed by Johny Van Aerde
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Robert Pearl is a reconstructive plastic surgeon at Kaiser Permanente, the CEO of the Permanente Medical Group, and a faculty member at the Stanford Medical and Business Schools. Mistreated is about our subconscious misperceptions of health and the health care system.
Although the book deals with the health care system in the United States, the issues also apply in Canada and to ailing systems in other countries. Canada and the US spend more on health care than any other nation in the world, yet, on almost every measure of quality, our outcomes rank in the bottom half among industrialized countries.
We know how to prevent tens of thousands of deaths every year from colon cancer, stroke, and heart disease, but we don’t do it. And despite more than two decades of dialogue about patient safety, too many deaths continue to be a result of medical error, including hospital-acquired infections, medication mistakes, and poor communication among clinicians. Two decades into the 21st century, patients still cannot communicate with their physicians through secure email, make an appointment online, or receive medical care through a video visit within a comprehensive electronic health system. Until we turn our attention to addressing the way medical care is organized, reimbursed, technologically enabled, and led, today’s problems will only become worse.
Pearl uses many narratives and easy-to-understand research studies from psychology, neurobiology, and behavioural economics to support his points. He starts with the existing mental models and context perceptions of physicians and patients. He describes very well where some of these beliefs arose, what they are today, and what the barriers are to changing those models in the future.
He then describes legacy players, the industry and institutional leaders who use their position of dominance to serve their own interests, including maintaining the status quo or generating more of the same. The four major categories of legacy players that benefit from resisting major systemic changes are drug and device companies, physician medical associations, hospitals, and major insurers, which in Canada are represented by government and politicians. Top
Based on his experience at Kaiser Permanente, and having visited other international health systems extensively (he was also in Calgary for six months), Pearl comes up with four pillars of transformation:
Pearl’s four pillars complement Danielle Martin’s six big ideas to improve health care.1 Pearl talks about the need for a comprehensive EHR system and for physician leadership, two elements missing from Martin’s book. Pearl doesn’t address how to deal with the socioeconomic aspect of health care, while Martin covers the need for a basic income well. With only a small amount of overlap, Martin’s six big ideas and Pearl’s four pillars of transformation encompass the ten fundamental elements needed to achieve system transformation for better health and sustainability in Canada.
In summary, Pearl recommends integrating care so that it is coordinated and collaborative; requiring all information and data in patients’ health records to be compiled into a single record as part of a comprehensive electronic system to prevent errors of omission; aligning incentives for doctors and patients through pay for value, not pay for volume or fee-for-service; and investing in physician leadership development. Change can happen, but it won’t until all of us — doctors, patients, and citizens alike — demand it.
1.Martin D. Better now: six big ideas to improve health care for all Canadians. Toronto: Allen Lane; 2017.
Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and past-president of the Canadian Society of Physician Leaders.
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