Our guest this week on the podcast is Robert Pearl, MD, a lifestyle medicine champion and leader. He is the former CEO of The Permanente Medical Group (1999-2017), the largest United States medical group, and the former president of The Mid-Atlantic Permanente Medical Group (2009-2017). In those two roles, he led 10,000 physicians and 38,000 staff. Currently, he cohosts a podcast and is an author, clinical professor, contributor to Forbes, and speaker.

In this podcast episode, we discussed the economics of health care and different payment models that can support preventative care and lifestyle medicine. Dr. Pearl laid out his perspective on the issues with fee-for-service payment models—mainly that it incentivizes disease treatment rather than prevention. He proposed an alternative model known as capitation, which is the model Kaiser Permanente uses. Capitation pays a group of doctors an established, upfront fee to fulfill medical needs for a defined population of patients.

Listen to this fascinating conversation to learn more about the following:

  • Capitation versus fee-for-service models
  • Dr. Pearl’s vision for how clinicians can contribute to building an alternative market for lifestyle medicine
  • The role of artificial intelligence in supporting patient education, compliance and outcomes
  • Using telemedicine and groups to make lifestyle medicine more economical
  • And much more!

Dr. Robert Pearl: As long as physicians get paid on a fee-for-service basis, it’s going to be very hard for the types of things that you know work, that you believe in to get reimbursed. The amount of work that it takes to be able to get someone off of insulin compared to the amount of time that it takes to prescribe a medication is a lot to get them off and a very little to prescribe. That’s why we prescribe so much. The amount of time it takes to refer someone to have a cardiac procedure done to revascularize the heart compared to the amount of time it takes them to avoid that heart attack in the first place, that we know could have been prevented with a high probability of success.

It’s why I do believe that if physicians can move into the place of being paid to keep people healthy, not just take care of disease, that it will move this entire, not just the, and I’ll use the word industry, but I don’t mean a financial industry, I just mean in the magnitude of size that it is, forward and make it be very mainstream very quickly for the reasons that you say. But as long as the system stays in place… And so rather than resisting it, the challenge of capitation is you can’t do it alone, but that goes back to this notion of groups. And every piece of literature that I’ve read tells me that interacting with and working with people is healthy and isolation and being alone as your soul means is unhealthy.

James Maskell: Welcome to the Evolution of Medicine podcast, the place health professionals come to hear from innovators and agitators leading the charge. We cover the latest clinical breakthroughs and health technology, as well as practical tools to help you transform your practice and the health of your community.

This podcast is brought to you by the Lifestyle Matrix Resource Center, who provide a range of options to help you deliver successful, effective, functional, and integrated medicine. To find out more and to get started, go to goevomed.com/lmrc. That’s goevomed.com/lmrc.

Hello and welcome to the podcast. This week, I’m super excited to have what I think of as a legend of healthcare on the podcast. Dr. Robert Pearl was the former CEO of the Permanente Medical Group, Kaiser Permanente. He’s written a number of books. He hosts his own podcast, and he’s a real thinker when it comes to the transformation of healthcare. I saw him speak at a recent American College of Lifestyle Medicine conference and was really enthused by the way that he was talking about the work that our practitioners are doing, whether you call yourself lifestyle, functional, integrative, we talked about empowerment medicine, we talked about capitation, we talked about technology and ChatGPT, so many interesting topics. I highly recommend you follow him on LinkedIn and follow his writing because I think what he shares is that we are in the right place at the right time with the right operating system of care to make a big impact in medicine, we just have to work together.

It was a really powerful half an hour. This session is brought to you by the Functional Forum community. So, if you go to functionalforum.com, you can see that we have communities of doctors in every city or big cities around the world, and particularly in America, and also launching in London in June. And it’s all about bringing practitioners together who want to work together to solve the future of healthcare. Go to functionalforum.com. You can start a group, you can join a group, you can connect with a group. Thanks so much for being part of it and enjoy the podcast.

So, a warm welcome to the podcast, Dr. Robert Pearl. Doc, such a pleasure to have you here on the podcast. Thank you.

Dr. Robert Pearl: My pleasure to be here. Looking forward to our conversation.

James Maskell: So, Doc, I heard you speak at the American College of Lifestyle Medicine where you gave the keynote, and for anyone who was there, they would think that you’d been sort of a longtime advocate for this process, but I don’t really know your history with regard to lifestyle medicine. Is this something that you’ve come to recently or has this been something you’ve been a proponent of throughout your career?

Dr. Robert Pearl: In many ways, it’s a chicken and egg phenomenon. I got to lifestyle medicine through capitation, and I’m sure today we’ll talk about the fact that I believe that people who embrace lifestyle medicine first can get to practicing it by getting to capitation. But when you’re in a capitated system, you’re looking for every way you can to keep people healthy, to prevent disease. And there is no question that lifestyle medicine is part of that.

Throughout my life, I’ve been an avid athlete. I run 30, 40 miles every single week. I run 14 marathons. So, exercise as part of lifestyle has been a big belief of mine. I try to eat a very good diet with a lot of fruits and vegetables. So, from that standpoint, it’s also part. On the other hand, I think that I’ve really come to understand not just the importance of lifestyle medicine, but how important it is and the opportunities to be able to get off medications to eliminate chronic disease. And that, I would say, is more recent than a decade or two in the past.

James Maskell: Absolutely. Yeah. Well, chronic disease reversal is what we’re all about here, and I’m really grateful to hear you say that. I guess I want to start off by sharing one, I really appreciate your writing on LinkedIn. I think as someone who’s interested in the transformation of the healthcare system, I think you identify the problems in the American healthcare system. You obviously are very clear with it from your time in Kaiser and now working in the Bay East ecosystem. I guess I just want to challenge one thing, which is that obviously there are many quirks of the American system. I think you’ve called it like a cottage industry. There’s all these different pieces, and they don’t meld together very well. And you’ve got health systems zigging and pharmaceutical companies zagging, and everyone trying to get the best deal for themselves. And it’s all a mess.

And yet, where I grew up in the UK where you have a single payer system, you still see an exponential increase in costs. Right? Even though it’s a single payer system, ultimately it’s capitated. So, would you agree, my thesis having seen that 20 years ago was yes, there are structural problems, but the bigger problem is that we have an ever-growing exponential increase in the number of people with chronic disease, the cost of treating that chronic disease is growing exponentially higher. And therefore, if we don’t get to into that—how do you actually reverse chronic illness, how do you keep people healthy—we’ll also just be sort of moving deck chairs on the Titanic.

Dr. Robert Pearl: I’d say it’s, “Yes, and…” And I think the “and” is really important. First of all, the word capitation everyone uses, and no one quite knows what it means or uses it the same way. So, I’m very specific. Capitation isn’t a question of how many payers: That’s a single payer versus a multiple payer. That’s a different question. Capitation is whether you are as the clinician—this is at the physician level, at the hospital level, where care is done—whether you are paid a fee upfront for which you do well when patients don’t get sick or whether you’re paid a fee only when they do get sick and you intervene. And that is the piece of capitation that doesn’t happen in Great Britain, that doesn’t happen in Canada, it doesn’t happen very much in the United States because accomplishing that is difficult.

Now in the United States, there are several primary care first organizations that do that. ChenMed’s a really good example, where they take care of the sickest of patients. Often, by the way, in the most difficult communities: people who are relatively poor with lots of chronic diseases. And they are paid on a fully capitated basis. But there’s just not a whole lot of doctors who are being paid that way, which is why increasingly physicians are moving towards concierge-type medical practices because those are, to a large extent, capitated.

So, capitation means your incentives align if your patients never get sick, never need a procedure, never need a day in the hospital. You do great, and that’s your goal, unlike the fee-for-service world. Even in the United States, we call capitation when it’s paid to an insurer, but they pay the doctor’s fee for service. I teach about the Stanford Medical School, the Stanford Business School, and the business school incentives are key. And none of us as physicians think that we do more things, more paid fee for service or do something else simply because of the dollars. But the data says differently.

And more importantly, it’s where you invest your money and take your risk. If you’re going to invest in a lifestyle medicine program—and you’re not going to be paid when people don’t get heart attacks, where they don’t have complications of diabetes—it’s tough to fund it. And it’s just not the same priority as when you are paid to keep people healthy, and you do so. And they get off their insulin. And they don’t need hospitalization. And they don’t need amputation of their extremities. You do really well, and your patients do great.

James Maskell: Yeah, that’s a really good point. What would you say to doctors who have seen the light, have started to learn to practice in a way that keeps people healthy, that reverses chronic disease, that reduces those complications, but they have a lot level of PTSD with being in the system? And they just can’t see themselves going back into any sort of organization because I think they feel like they’ve been failed by the bureaucracy rather than by their calling.

Dr. Robert Pearl: I understand what they’re saying, and, actually, I can concur because most bureaucratic systems are not going to get to this endpoint that I’m talking about. My answer to them is start your own. Find like-minded people in your community. And the beauty of modern medicine is you don’t have to be within a car’s driving distance. You can do it through telemedicine. Now, there are complications and regulations and other pieces that we can talk about if you want, but overall, putting together a huge number of physicians who are all following the same general direction, all using lifestyle medicine, exercise, diet, stress reduction, adequate sleep, we can go through the whole list of things, and obviously the key ones, stopping smoking and not harming your body with various substances. When you start doing all of those things, there will be a market for you. It doesn’t quite exist yet today. I think it’s happening, and it’s coming.

It’s already there in Medicare Advantage. And if you can take the risk, and that’s a bureaucratic process. And I understand why many doctors might not want to do it. That’s one thing. But I think we’re going to see, and I’ve written about this, the retail clinics looking for physicians like that to be able to take care of their patients because the retail clinics will be taking a capitated-type payment and looking for doctors able and willing to do it.

Now you have to take some risk. You can’t just say, “I’m doing the right thing, pay me more.” That’s fee for service, and we’ve seen no one’s really willing to do that. But I think if you put together enough individuals… Because one doctor alone isn’t worth a retail giant’s time, but to have a community with 10 or 15 physicians or across the state a hundred positions or across the United States 500 physicians, that’s a large amount of care delivery. And I think a great alternative and is actually nothing that would stop you then from contracting with other bodies and still taking a capitated payment from your patients for the excellent care and unique personalization that you provide that to them is worth the price and so valuable.

James Maskell: You know, as I’m sitting here, one of the things that we’ve done over the last nine years, Dr. Pearl, is actually introduce doctors locally who practice in this way to each other. Right? That’s one of the things that we’ve been involved with these Functional Forum community groups. And as you’re sitting here, I mean, I think of, there’s a group in St. Louis that’s been going for 14 years. And in that group, there’s family medicine, but there’s also cardiology and pediatrics and all these areas where like-minded physicians have come together and they know, like, and trust each other. And as you you’re saying that, I think I’ve caught a vision for what those groups could be capable of because in some of those more sophisticated groups, there’s hundreds of private physicians that are all practicing in the same way. And that’s very interesting. Well, that’s something I’ll take away from this conversation for sure.

Let me ask you about this sort of post-COVID world that we’re in now because, ultimately, that’s sort of changed the game. I think during COVID, there was this hope that the fact that the outcomes were much worse with people who had chronic illnesses was going to awaken the American population to the need of lifestyle, and you were going to see people really taking care of themselves in a new way. Here we are three years later, and it looks like it’s kind of gone in the opposite direction with loneliness and people gaining weight and just that we haven’t seen that kind of path. Is that your same take. And what do you think are the issues that we have to deal with post-COVID for inspiring patients to want to participate in their care?

Dr. Robert Pearl: Absolutely. COVID was both terrible because of chronic disease and bad for chronic disease. As you said, 88% of the people who died in New York City had two or more chronic diseases, all of which were treatable and many of which were either preventable or reversible. And as a consequence of COVID, as you said, we exercised less, we gained weight, our diet went in the wrong direction, there was increasing stress, all the problems and out of that has come loneliness, a lot of depression, major rise in behavioral health issues. So, you’re absolutely right, that’s where we find ourselves today.

I think though, on the positive side, there are several things happening. One of which I believe that will be crucial is this introduction of generative AI. By that I mean ChatGPT, now GPT-4. Microsoft is doing other advances, particularly using ChatGPT. Google’s using its own PaLM 2. So, there’s a lot of people in this particular area. The problem I think when it comes to chronic disease is that people have it every day, and we treat it every four months in the medical office. That doesn’t make any sense at all. The question we should be asking ourselves is: How do we intervene in the patient’s life every day, but recognize that already doctors are overworked? So, how do we put these pieces together? Hiring people to do… It’s just too expensive. But ChatGPT is remarkable.

If any listeners who haven’t tried it, particularly if you believe in lifestyle medicine, this is a massive opportunity. You can have a patient with a particular diagnosis that would benefit from better nutrition, and they have a particular type of food they like, whatever the ethnicity of the food might be, whatever. They’re vegetarian, they’re pescatarian, whatever they might be. Ask GPT-4 to build a week’s long worth of menu, and you’ll be amazing. And then ask ChatGPT to put that menu into French or Spanish or Chinese, and you’ll have a remarkable tool available. Create an exercise program, and let the person check in with ChatGPT every day.

Yeah, I’m a runner and part of why I’m a lifelong runner is I run with a group. I’m with people. I have an obligation to be there. If I’m a little tired in the morning, I still have to get out of bed. I’m a skier. I have a ski group. Groups of people are particularly effective, and I think we can use some of the generative AI to create those communities, to link together these doctors that you’ve talked about and their patients in ways that they can help each other. And if people exercise every day, if they then diet better every day, if they take the time to get adequate sleep and relaxation and stop some of the habits that are detrimental to their health, when you see them three or four months later, you’re going to be amazed at how much healthier they are.

I don’t know about in your personal experience and that of the listeners, but getting patients to adhere to a lifestyle medicine program is difficult unless they’re really motivated. You take people who are really motivated, it’s easy. All you got to do is help them a little bit. But if maybe they’re motivated intellectually, but it just hasn’t fit their lifestyle, doesn’t fit into their way of organizing their day-to-day activities. It’s really tough. It’s why so many people quit a weight loss program, why they go back to a problematic habit, why they stop exercising. The opportunity to use these technologies. So, that’s one thing that I think is currently available that I’m hoping actually will take off. And I believe that it will be because this technology is doubling in power every six to 12 months. That means it’s going to be 30 times more powerful in five years and a thousand times more powerful in a decade. So, we’re just at the very, very beginning. 2% of where we’re going to be.

James Maskell: Wow. Yeah, I totally agree with you. In the last four years, I’ve become sort of obsessed with that exact question that you asked there is like how do you get people to participate? And you mentioned groups. And so ultimately, I’ve advocated for health care in groups because ultimately, I think that one person’s story, one person’s effort can multiply by 10 or 20 when one person gets inspired by another person. And that’s no more work for the doctor. That’s no more work for the medical system. There’s actually a lot of value that’s added peer to peer that doesn’t cost anyone anything but is actually valuable to both the sort of mentor and the mentee.

One of the things that is… And so, we’ve worked to try and deliver care in groups and seen the power of it. And you mentioned that ChatGPT… I think there’s a great synergy there because it’s much better to have essentially a computer do grunt work of reminding people to do the thing every day. And then the human connection can be the thing that gets you out of bed to go and show up at your runner’s group or skiers group or otherwise. I totally agree on that. While I’ve got you here, I mean, I know Kaiser, in your work there, have you been aware of some of the potential for group medical visits and group care? And what are your thoughts on that in general as a way of organizing efficient care and working in ways that benefit patients?

Dr. Robert Pearl: There are two parts to the question you’re posing. The first part is: Does it benefit patients to be seen in, I’ll say in quotes, “groups?” And the evidence is yes, assuming people want that type of care. Some people would like to be just alone. But they learn a lot about the disease from other people with it. They can share tips and insights into opportunities and places to be able to find exercise or food or find something else that’s going to be positive for their disease. We see that a lot in mental health, where groups could help each other. People going through problems with the pressure or anxiety can be great sources of information, even better than the therapists and often better than the medications and being able to assist other people going through the same stages of life. So, from that standpoint, it’s there.

And I think the second point you’re making is one of cost. Which is: Can you provide care to people in more efficient ways than the traditional doctor’s office visit? And I think the answer to that is also yes. But I would say from that perspective, that’s why I’m splitting the two apart, that technology is going to be even far more powerful than a group visit designed around cost because you have to start factoring in today people’s time. It takes a long time to miss work, drive to a place, get the care, go back. And that opportunity to do it in the convenience of your home, to be able to do it using whether it’s telemedicine or whether it’s going to be some variant to get it, this ChatGPT, or some other even algorithmic form.

How do we empower patients? That hasn’t been something inside the culture of medicine. We’ve asked how do we get patients to be compliant, to do the things we tell them. But how about the idea of being able to figure out tools to empower them to take care of their own health because they also want the same things that we as physicians want for them? They don’t want chronic diseases. They don’t want the complications. It’s just very hard for them to do the lifestyle changes needed to get there. And we, with our encouragement and with technology, I think, can get them there.

And again, you’re adding another piece with groups and with others in a community and that community can be in person or that community can be virtual or that community can just be coordinated by a technology that keeps track. I don’t know if you use any kind of measure when you ride your bike or when you run or when you ski that records how far you went and the routes that are there and share with other people. You feel good about doing that. And so, this technology can be seen as a way of helping individuals to be more consistent, to have a level of pride that’s going to drive them. These are intrinsically human behaviors, and we, as medical professionals, need to figure out how we can help people maximize their health using them.

James Maskell: Doc, obviously, you were involved in a pretty significant and centrally involved in a pretty significant turnaround in Kaiser. What, out of what you just spoke about, were you able to implement in your time? And if you’d carried on, what did you see as the future vision for implementing empowerment medicine? Because I think you really hit on this is something that I think… When I gave my first lecture in 2011 to a group of doctors, I had a slide that said empowerment medicine because I recognized that that’s really what… If you look across all of these different practitioners, lifestyle medicine, functional medicine, integrated medicine, at the core of it was empowering patients to participate in any way. And I’d love to just see if there are lessons from the trenches that were successful in Kaiser because obviously it was a very significant financial turnaround from, I think you mentioned, before having two days of money left when you started to then being in a pretty robust space when you left. But on the clinical side, what were some lessons in empowerment medicine that you learned from that?

Dr. Robert Pearl: You’re absolutely right. When I became the CEO, that was 18 years ago, I inherited an organization that had two days of cash, we had to borrow a day of cash to meet the state regulatory requirements. We were big, we had about 34% market share. By the time we were done, we had a 46% market share. One in two people in Northern California were members of Kaiser Permanente. I’d say the biggest shift started when we changed our strategy. And the strategy that I inherited from my predecessors was one of being a low-cost leader. And I thought at the time that a better strategy would be quality and service differentiation at a competitive price. For I knew that, if we could achieve quality and service differentiation, we actually could be a cost leader, but not by trying to be a cost leader, but by quality and service differentiation.

And within that prevention and avoidance of complications for chronic disease was a major part of that focus. As hypertension, as you know, the number one cause of strokes, major contributor to renal failure, heart failure, controlled in the United States 55% of the time. We controlled it 90% of the time. We had the same medications as anyone else. We had the same excellent physicians as everyone else. The big difference is that we focused on it, so that I’m a specialist. I’m a surgeon. I fix children with cleft lip and cleft palate, but I can recognize hypertension. I know what the numbers are supposed to be. And if I don’t feel comfortable changing the medication, all I have to do is let the doctor who is responsible, the primary care physician, usually, know that the blood pressure today was 160 over 110 or something and that individual will solve the problem for the patient there and then not three months later when the visit is scheduled back in the office.

Colon cancer, we know we can screen and eliminate 20, 30% of colon cancer and find a lot of the other cancers far earlier. Of course, the United States it’s about 60%. We were 90%. We used fit testing. It doesn’t have to be a colonoscopy with bowel preps and anesthesia and possible perforation. Fit testing every year, five minutes, in the safety of one’s bedroom. So, it’s a focused level on all of these opportunities. Interestingly enough, one of the groups that is the largest leader of lifestyle medicine at Kaiser Permanente with an intense focus on diet, particularly diet that eliminates many of the products that we know contribute to heart disease, is the cardiologists, a specialty group. In the rest of the world, the cardiologists, they do best when patients get heart attacks. They do best when patients need to have heart surgery. And here, leading the way at Kaiser Permanente, are the cardiologists. Because they’ve seen the suffering of patients. There’s plenty of people who need to have heart surgery despite everything they do around that.

So, it’s the coordination. We invested. First, on a comprehensive electronic health record. Because how do you know if a patient has had the screening they need? How do you know that the medications they’re on without a comprehensive record? And then we telemedicine. I wrote a paper in Health Affairs eight years ago. At that time, 40% of the care we were providing, over 10 million visits a year, were virtual. And I predicted this would become the norm in the nation, and nothing happened until COVID came. And during COVID, everyone used it, and there weren’t any bad results. I haven’t read a single paper talking about patients being harmed. And yet, we’re back to focusing on office visits in general in the United States. I don’t mean your audience, but this is across the country. Less than 10% of people outside of mental health services are using telemedicine. So, those are some of the examples that are there.

And we created classes. We created food markets where the organic farmers would bring in fresh fruits and vegetables because a lot of the communities we serve, the only place you can get food is a 7-Eleven, and they can’t get the fruits and vegetables that they need. So, we had farmers’ markets with people coming in. We had cooking classes for people with diabetes to teach them the opportunities to better manage their diet. So, it was comprehensive. Probably not as intense as many of the listeners to this show because it was but a piece of the equation. But I see there’s a growing energy to addressing the social determinants of health, and lifestyle medicine is certainly a major piece inside of those social determinants of health.

James Maskell: Absolutely. Absolutely. Well, yeah, I guess while I’ve got you here, it would be amiss for me not to… I guess I kind of want to pitch you a little bit on what our physicians do because I do feel that lifestyle medicine is a common foundation for sure. And getting people to do these healthy behaviors has to be there. But what I believe, what I’ve seen in the last decade and a half is that on top of lifestyle medicine, it is possible to teach physicians a clinical operating system whereby they can bring function back to organs and systems in such a predictable way as to bring people back to baseline health. Some people, possibly the middle of the bell curve of America, will get better with the lifestyle medicine interventions. And that’s why I think lifestyle medicine is really taking off at a system level because it’s sort of the least offensive thing. Doctors know that they want to do it. They want it for their patients. They know it’s helpful. And so, you’ve seen now a hundred health systems say, “Hey, we want lifestyle medicine.”

But there is a sort of level deeper in what I would call functional, integrated medicine where doctors who are armed with a new set of tools, not just clinical tools, but actually taking a deeper history, understanding where historical insults came into the body, looking back at the timeline and really taking time with patients. There is, I have seen in the literature now, but initially in clinics around the country and now starting to permeate into the literature, the potential for autoimmune disease, digestive diseases, other chronic illnesses be taken to a point where people are not only no longer symptomatic, but their function on the organs and systems of back. So, I mean, I’ve seen it. I’m here in service of the popularization of it. It’s not easy because you have to really learn a whole different clinical operating system. And I guess my question to you is: If you knew that was possible, what is the right strategy for that community of physicians to take moving forward to prove their outcomes and then to benefit in wherever medicine is going from your perspective?

Dr. Robert Pearl: The big challenge is getting someone to pay people. I just want to be very blunt about what it is. And that’s where primary care has a tremendous opportunity. And I’m sure a lot of the physicians who listen into your show are involved in some variety, and I want to put air quotes around “concierge medicine” because I’m not talking about the $10,000 a year where a doctor has a hundred patients and can call them 24 hours a day, seven days a week. Now, I’m talking about where a physician is able to have a small enough panel to give the type of personalized care that you’re talking about, if I’m really understanding what you’re describing.

James Maskell: That’s right. Yeah, that is right.

Dr. Robert Pearl: And One Medical has done a very good job at quantifying it. It’s $200 a year, which is affordable for, as you say, the bell-shaped part of the curve can pay $200 a year. That’s one less stop at Starbucks every week. We’re not talking about a massive impact on a family that can’t afford clothes and food and shelter for their well-being. And then you can cut your paddle size in half, and you can start to do the type of investment that you’re talking about. And I believe that not only right now that people will pay it, but I think that ultimately employers will pay it and these retail giants are going to go ahead and pay it. Because what they’re going to see, and people do see it, and Kaiser Permanente, we did this, we had lower paddle sizes, paddle sizes that were, I’d say a third lower than in the community around us, because we recognized the value of primary care. We paid primary care doctors more than it would make in the community for exactly the reasons that you’re saying.

Now, where the lines are within that… Certainly, there’s a lot of data on the relationship of diet and GI problems. And a variety of chronic GI diseases can certainly benefit. And unfortunately, the science has not figured out exactly… Well, some areas we’ve figured out the science, but many areas we know there’s a relationship, we don’t know the exact science. So, it’s experimentation, and you’ve got to be able to help the patient experiment. And again, where I think technology can be supportive of that process. And certainly, we know that an inflammatory problem has to have a source of that problem, and that source can sometimes be just intrinsically in the body, but it certainly can be outside the body as well. And if you can identify that and minimize the impact, you can address it.

So, there’s nothing that you’re saying to me that is different than the way that I think. I recognize that in some areas we have a specific area: gluten. And in other areas, we have not a specific starting factor that’s there, but the opportunity to personalize the care to be able to dive deeper, as you say. A major focus that we had—now this is beyond what you’re talking about—were the ACEs, the problems in childhood, where we know very much that they led to chronic disease, not just in yourself but your kids and your grandkids, in many cases. So, this relationship of the environment and the person, I think that aligns very much with the history of medicine. And we have a lot more learning to do, but I think, as an investment opportunity, it’s a good one.

But I’ll go back to, you’ve got to start with the primary question: Who’s going to pay? Even if it’s the right thing. I’ve stopped telling people what should happen. I want to talk about what can happen. How do you make things that are possible occur? And that’s again why I push your listeners to form these groups because I think, when you create a group, you can sell that service, whether you want to sell it to a group of patients, whether you want to create common ways for them to meet, common application tools for them to use, common cross coverage when people are gone and not available. Those are all the opportunities that communities create. But I think the direction you’re talking about is definitely a direction of the future. And everything I’m seeing in the world right now is going to move in that way once we can figure out some of the economics.

James Maskell: Beautiful. Well, I know you’re right in the middle of teaching the world how to understand those economics. And I guess I just want to give another shout out before we finish this to your writing on LinkedIn. It started off… I read an article, I think, a couple of years ago on telemedicine and access. And that was really starting my process of thinking because I believe that telemedicine creates incredible efficiencies. It really honors the patient’s time in a new way. But can we do a little bit more than just having a very, very basic visit? What else can be done? What else can be done with continuity of care? What else can be done to get people to do things every day? Because ultimately that’s what’s going to be necessary for reversing a chronic illness. And obviously, in the last few months there’s been conversations about the system and about who’s going to win and monopolies and those kind of things. I think it’s really fascinating.

But why I wanted to get you on the podcast is because I think, in our community, there has been a little bit of a historical inferiority complex. Right? Because you almost had to sort of back out of conventional medicine, go and learn this new clinical operating system, work on a smaller group of patients, be outside of the norms. And that’s why these communities are really important. But what I wanted to get across to our practitioners and what you’ve done really well in communicating today is that an ability to keep people well, an ability to reverse chronic disease or reverse symptoms and reverse chronicity and complications is valuable. It’s not just intrinsically valuable. It’s financially valuable. And so now, we just have to find ways to contextualize that and get paid so that in ways it will. And there’ll be more and more people showing up to do that. So, thank you for your time, and thank you for your leadership and your writing, continually inspired by that. And I encourage everyone who’s listening to check out your writing. What’s in the near future for you as far as your vision? For now, obviously now post-Kaiser, wanting to make an impact on the way that you see medicine should be going. And what does the future look like for Dr. Robert Pearl?

Dr. Robert Pearl: Sure. Well first, any listener who wants more information can go to my website, robertpearlmd.com. There’ll be links to my books, Uncaring and Mistreated, links to the LinkedIn articles that you’ve referenced, and my weekly podcast called Fixing Healthcare that takes on a variety of topics both inside of medicine and, actually, increasingly outside of medicine that have lessons for medicine.

What’s next? I’m looking at a world right now that I see as changing rapidly. I wrote my first book, Mistreated, in 2015 about the system. The system is still broken. It hasn’t changed much. The second book, Uncaring, was written and published in 2021. I talked about the culture of medicine as one that has not been very favorable, as you said, to lifestyle medicine and to individuals who understand the need to personalize the care we provide. And that hasn’t changed a whole lot since then, although COVID did get in the way. So, what I’m looking at is where is it all going? And how can I help accelerate that process? And I’ll go back to where I started because I just think it is so important. As long as physicians get paid on a fee-for-service basis, it’s going to be very hard for the types of things that you know work, that you believe in, to get reimbursed.

The amount of work that it takes to be able to get someone off of insulin compared to the amount of time that it takes to prescribe a medication is a lot to get them off and a very little to prescribe. That’s why we prescribe so much. The amount of time it takes to refer someone to have a cardiac procedure done to revascularize the heart compared to the amount of time it takes them to avoid that heart attack in the first place, that we know could have been prevented with a high probability of success.

It’s why I do believe that if physicians can move into the place of being paid to keep people healthy, not just take care of disease, that it will move this entire, not just the, and I’ll use the word industry, but I don’t mean a financial industry, I just mean in the magnitude of size that it is, forward and make it be very mainstream very quickly for the reasons that you say. But as long as the system stays in place… And so rather than resisting it, the challenge of capitation is you can’t do it alone, but that goes back to this notion of groups. And every piece of literature that I’ve read tells me that interacting with and working with people is healthy and isolation and being alone as your soul means is unhealthy.

Yes, we all need to be alone at some times, and it can be a wonderful experience hiking in the mountains for a week at a time by yourself, but you can’t do it for 52 weeks. And so, this opportunity to build community, and I want to commend you for your podcast, that you’re building a community 40,000 strong and growing listeners who are doing it.

So, I’m going to keep pushing at this piece, and I’m hoping that people will recognize sooner than later how different the world is now. And that the way, I’ll say, hospitals and drug companies, this conglomerate monopolies raising prices, it’s just the wrong way to approach medicine. The right way is to keep people healthy, investing in prevention, investing in lifestyle, making it easy to access care where there’s a problem, but reducing like 50% the number of problems. And I’m convinced that if every physician could see half the number of patients per day, they could achieve tremendous benefit for their individuals. It’d be a lot healthier. Costs would drop. The answer isn’t train twice as many doctors. It’s reduce the amount of disease in half.

And I really hope that we’ll get there soon, and I believe that it will happen. I’d like it to be happening inside medicine. I believe that’s best for the profession and best for patients. But if not, every listener should know it’s going to happen. The retail giants are going to do it. And I will be sad if the day comes when the only way clinicians practice medicine is to be as employees of big publicly traded companies because I don’t think that those companies will put the things that we have a 5,000-year history of importance of a doctor-patient relationship on the value of the human life, that they’re going to put that first. And I’m optimistic that clinicians will, particularly the ones listening to your show. So, thank you for having me on today.

James Maskell: Thank you, Dr. Robert Pearl. Well, we’ll check, put all the details in the show notes. Thank you so much for being part of the Evolution of Medicine podcast. I am your host, James Maskell, and we’ll see you next time.

Thanks for listening to the Evolution of Medicine podcast. Please share this with colleagues who need to hear it. Thanks so much to our sponsors, the Lifestyle Matrix Resource Center. This podcast is really possible because of them. Please visit goevomed.com/lmrc to find out more about their clinical tools, like the Group Visit Toolkit. That’s goevomed.com/lmrc. Thanks so much for listening, and we’ll see you next time.


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