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Direct Primary Care Update

Episode 358

Recommended Books:

The Leadership Challenge

The Discipline of Market Leaders

Best Way to Contact Robert:

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Direct Primary Care Update with Dr. Robert Pearl, Author, Healthcare Contributor and Podcast Host | Convert audio-to-text with Sonix

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Saul Marquez:
Welcome back to the podcast. Today I have the privilege of hosting Dr. Robert Pearl. He is the former CEO of the Permanente Medical Group, the nation's largest medical group and former president of the Mid-Atlantic Permanente Medical Group. In these roles, he led ten thousand physicians, 38000 staff and was responsible for the nationally recognized medical care of 5 million Kaiser Permanente members on the West and East coasts recently named one of modern health care's 50 modern most influential physician leaders, Pearl is an advocate for the power of integrated prepaid technologically advanced and physician led health care delivery. He serves as a clinical professor of plastic surgery at Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business where he teaches courses on strategy and leadership and lectures on information technology and health care policy. He's the author of mistreated: Why we think we're getting good health care and why we're usually wrong and offers that it's a not for profit best seller. All the proceeds of that go to doctors without borders. A regular contributor to Forbes among other things that he does such as Fixing Healthcare podcast. I want to open up the microphone to him to fill in any of the gaps of their introduction. It's a true privilege to have you on, Robert, thanks for joining us.

Robert Pearl:
Thanks Saul, it's my pleasure to be here. As you point out the book Mistreated: Why we think we're getting good health care and why we're usually wrong as the Washington Post bestseller with the profits going to doctors without borders and the Forbes blog just past its 5 million reader.

Saul Marquez:
Congratulations

Robert Pearl:
I think we are well on the way to changing American health care for the better, for being able to provide higher quality in more convenient ways at lower cost to patients if we're all willing to embrace the changes that can be.

Saul Marquez:
That is highly impactful Robert and really really appreciate all the work you've done to get rid of the myths and really tackle some of the toughest subjects in our space. Why did you decide to get into health care to begin with?

Robert Pearl:
I've always wanted to improve the health of people. Growing up my father was a dentist, my uncle was a surgeon and I was always in that realm and I've really had three careers. I had a career first as a surgeon, fixing children with birth defects cleft flips and cleft palates and had the opportunity to be the CEO in Kaiser Permanente and take care of 5 million patients not as deep as I used to be. As the personal physician and operating physician for patients and for children but at another level. And since then since I after 18 years of being CEO and publishing the book and speaking I hope it would change the health care of 300 million Americans because I think the current system is broken. We spend more than any of the country. All we know is that our life expectancy is that the last of 11 most industrialized nations. Two hundred thousand patients die every year from medical error. Another hundred thousand could live if they had all the prevention that they needed. If we did one hundred thousand avoiding complications from chronic disease we have tremendous opportunities in this country, Saul. And my hope. Why would two minutes in the first place is to help to improve the health of all.

Saul Marquez:
Love it. It is such a such a great vision and I think of that quote "without a vision people perish". And you know you've done some great things and you think man you know here's Robert, you know Dr. Pearl he's done so many great things as a surgeon as a CEO of Kaiser, you think man this guy's going to hang his hat. He did a great job but now you've come up with an even more just ambitious goal of hey how can I do well for the 300 million Americans?. The people listening to this podcast for their health care so I love to hear what's on your mind as a hot topic that needs to be on health leaders agendas today and how they could best approach these topics that you're thinking about to make it better?

Robert Pearl:
What area is medical errors. I begin mistreated with the story of my dad. He was a remarkable individual. He was the son of two immigrant parents worked his way through college, dental school. Well to break Saudi volunteers one hundred and first heirborn you could have stayed behind American lines but instead he wants to advance the fight and he and his troupe parachute on D-Day. They're captured by the Germans who was a daring escape to the woods at night brings everyone back safely with Tom Brokaw. Would call the greatest generation and one day he became tired. Something he had never experienced before he's asleep four to five hours a night and be basically able to go day and night seven days a week. And now he's tired. His doctors diagnosed him having a hemolytic anemia and take out his spleen. Every physician listening, every nurse listening, everyone listening to this podcast today understands that if you spleens taken out, you're susceptible to infection when a particular bacterium called pneumococcus. Everyone knows that there's a very effective vaccine. But my dad lived half the year New York and half the year in Florida. And his physicians in New York didn't know that the ones in Florida did not give him the vaccine that was in Florida soon New York had done it. Primary care is a specialty care especially care for primary care. Neither never has it done comes out to visit my brother and me brothers chairman of anesthesia at Stanford. It's either my house goes to my brother's house brother wakes up next morning to go to the hospital for rounds at 5 a.m. there's my dad on the floor unresponsive so there's four days in the hospital in the ICU unresponsive another two weeks in the hospital. He doesn't die during that admission but he does die subsequently from its complications and of course the diagnosis pneumococcal septicaemia, one of two hundred thousand people that year and saw more importantly every year including last year to die in the United States from preventable medical error. You know what we know is that one in three times physicians when they go from one patient room to another in a hospital don't wash their hands. And as a result what we know is that hospital acquired infections. Third Leading Cause of death for patients hospitalized. We can do better. We just somehow accept medical errors as part of the process of delivering care rather than seeing them as something that we should be able to eliminate at least 90 percent or more of the time.

Saul Marquez:
Wow. Really really appreciate you sharing that story Robert and definitely a thing that should not be affecting anybody. And I love that you're taking the stance and it isn't just part of a process. It's something that needs to be eliminated. Give us an example of how you think this can happen and then maybe some stories of things that you've done to affect change in other areas.

Robert Pearl:
So if you ask yourself why is it that we tell ourselves the United States the health care is the best that being in hospitals safe from the data says that neither is true. That became the source the first question that drove me to research and write the book Mistreated. Now what I found is that context, shapes, perception and changes behavior let me give you an example. You may remember from college the Stanford Prison Experiment Zimbardo takes regular students technique test them to make sure the psychologically fine after them get these aviator sunglasses they become the jailers half of them get the khakis get the OR Greens with numbers they become the jailees within 48 hours they see and I want to say that we'd see each other differently. The jailers see the jailees as dangerous. The jails to the jailers sadistic within six days the whole experiment ends. Now remember everyone knows that the other people are just students. But the context of being in this jail environment changes that perception, changes the behavior and it's why I believe very strongly that when you change the structure I talk about as the four pillars you make here this integrated so that doctors and doctors and nurses all work together as one. When you pay people on value not on volume, when you give them the technology to provide the leadership. Now things start to change. A great example in Kaiser Permanente when I was the CEO is that we led the nation in preventive care across the rest of the country as an example. Hypertension was control 55 percent of the time we were at 90 percent screening for colon cancer. I don't mean colonoscopy that's one way to do it. If you have a previous polyp or a family history put a fifth test five minutes in the safety of your bathroom without a bowel prep, without any complications, without any risk. Once a year for five minutes has the same outcome. Yet across the country only 65 percent of times have done. We were up over 90 percent. The difference is tens of thousands of lives lost every year unnecessarily. One of the things that I loved was a program that actually I stumbled upon it. Didn't invent it but I can tell you I definitely spread it. I saw one medical center, I walked on this medical center and there is a conference room typical conference room in most hospitals staring of the front is the chief of ophthalmology. I look around and all the doctors and their greens and nurses and their greens and other people sitting there in their white coats and there's this woman sitting there all dressed up with flowers man sitting next to her two little kids next to him and she walks to the stage and the chief of ophthalmology says Sally saved a life. How does Sally save a life? She looked inside the comprehensive electronic health record noticed that a woman had not gotten the mammogram she needed and made sure she had it done. And of course the mammogram found a cancer. Now imagine how that changes perception of everyone in the room rather than doing what we do at hospitals today where we give everyone data and tests we can all score hundred on knowing that the seals the most common bacterium it is carried on the hands you should wash your hands. We know all those things.

Saul Marquez:
Right.

Robert Pearl:
It's changed in that context bring someone in the room whose spouse died from hospital acquired infections because someone didn't wash their hands and now you start to achieve change. Those are the kinds of experiences that I believe leaders have to do to help everyone see what is possible. See what is happening today and make a difference.

Saul Marquez:
Love it. This is a fantastic point that you're making here, Robert. I mean the creation of context you know, a lot of the leaders listening today are probably grappling with their own issues. You know the issues within their own hospitals, within their own companies. And this idea of of changing the context you know the different examples you've provided building experiences. I mean these are some valuable tips that you've provided. I'd love to hear from you a time when maybe something didn't work out, a setback and what you learn from it and maybe maybe how you built the context experience out of that.

Robert Pearl:
So it was a tough question. We always like to think about our successes within our failures. I'll give you one. And I'd call it a personal failure more than an organizational one because I didn't do what I needed to do at the particular time. I was a new leader and I was sitting in a quality meeting and we were looking at the frequency with which we were successful at doing – screening for breast cancer mammograms. At the time we were probably number one in the nation. So it was not there was bad quality. And I'll say our number was 80 percent of the appropriate women were screened and the person stepping forward recommended we moved to 82 percent. So many of the people in the room who would then be accountable for this thought that it was not. Not only was it not possible we should actually lower it down to 78 percent and they had lots of different reasons. Every one of which was true. Following up of potentially abnormal studies is more important than doing new diagnostic screening. The problem is that it's tough to get women to come on in and it's not a question of nothing good to offer the care everyone had the reasons and instead of the meeting ending with what should have happened an 82 percent people adopted the 78 percent. I think the biggest learning that I have is that there's always a good reason to not do the right thing when it comes to health care and that world leaders have to do is to always do the right thing to make sure that they implement the changes that are going to save lives. They're going to improve health and to figure out how to make it happen. To teach you say the Stanford Graduate School business and I tell people that leaders make things happen that otherwise wouldn't administrators make the things happen it should happen all the time. Testing regulatory agencies and submitting data to the states. But leaders have to make things happen that otherwise wouldn't do so in health care on behalf of their patients. That is the five thousand year old legacy of being a medical professional.

Saul Marquez:
What a great example. And a great distinction between an administrator and a leader and something for everybody listening to data to consider. Where do you fall in this and is that where you want to be? Is that what's going to get you the outcomes that you're looking for. Robert what about, I mean you've you've had such a such a tremendous amount of experience and I'd love to hear from you what you believe what you're number one or number two most proud leadership experience in health care has been to date?

Robert Pearl:
Let me give you two if that's OK.

Saul Marquez:
That's perfect.

Robert Pearl:
The first one is the approach we took to hospital utilization as you know hospitalization is the highest component of the cost of health care about 30 percent in the United States today. It's also rising actually very rapidly and the approach we took the hospitalization had two parts to it. Number one how could we prevent disease in the first place. Do the things that are necessary to control blood pressure to reduce strokes, blood lipids to control heart attacks do the things around blood pressure specific to the kidneys do all the things that we could do to reduce the incidence of disease. And number two to move from a five day hospital to a seven day hospital and every hospital is seven days for emergencies. But if you're admitted on Friday night to the typical hospital United States today with the same problem as on Tuesday night we'll spend an extra day exposed to possible infection delaying care, delaying treatment doesn't make any sense it's just the way that we do business today. And by taking both approaches higher quality and more rapid care to patients we lower the hospital utilization to half of the national average. The patients in Medicare as you know it's about fourteen hundred days per thousand Medicare participants. We got it down to under seven hundred through quality and better care. The idea that somehow that we need to ration care is foolish. Well we have so many opportunities to improve efficiency and effectiveness of the care we provide. The other thing and I worked with another leader named Dr. Sharon Levine was we wanted to make certain that our patients could always be trustful in the care we provided. And when we looked at the negative impact of some of the drug companies, the drug reps, the drug programs, the payments to physicians we said enough. This is a decade ago. We said to make it very clear, physicians could take nothing not a coffee cup not a pen – nothing from a drug or device company. At the time we thought that this would be really problematic. We had 6000 physicians. Now we have 10000 but six thousand at the time only two left everyone else stayed. And we were able to do based upon the savings that we achieve by making certain that people did not prescribe simply the drugs that were being hyped by drug companies because they had the greatest profit in the highest cost or buying machinery that would add almost nothing and might have negative consequence for patients. We were able to make many times that investment in excellent physician education. The idea that says if we didn't have the drug company money in the vice company money we could not train people, educate people do all the things that are necessary is just shortsighted. We say invest the savings that we would have by not doing the wrong things on behalf of patients we'd have more than enough money to be able to fund the positive educational and quality improvements that are needed.

Saul Marquez:
Two great examples and the last example you provided Robert fascinating. I feel like a lot of times when you're at the helm and you're you've got a decision to make. It's critical to not see things worse than they are. I mean you said out of 6000 positions, 2 left. What did you think was gonna happen? What happened?.

Robert Pearl:
Everyone talks about well this money is so essential and it's so positive. We heard all the stories we just couldn't find a data around that. But yeah they were all true then people would go someplace else where they could maintain the payments but I think they knew that what they were doing wasn't right.

Saul Marquez:
Yeah.

Robert Pearl:
Wasn't right to take money and let's be very honest about it. When drug companies say we want your advisory board to pay a lot of money because you're so smart. No. They want you on there could you prescribe a lot of it. We think you'll prescribe more of it. All right. So that opportunity to look in the mirror and face reality I think is what that process did. And ten years later it's still the gold standard of course the United States.

Saul Marquez:
Yeah. Now it's the. It is the gold standard when you take a look at practices held accountable by the Department of Justice for both pharma and device. I mean it is the standard. So very interesting to learn that sort of you guys are the ones to spearhead that. Much kudos and and again you know about walking the walk. You talk about administrators make things happen leaders make the difficult things happen. What a great example of that. And then I do want to spend a little bit of time a couple of minutes on the hospital utilization piece. Tremendous work there as well. I mean going from 1400 days to 700 days per 1000 patients. Unbelievable work. What would you say the most difficult thing in achieving that was?

Robert Pearl:
The most difficult thing was going through the five day to a seven day hospital because it would mean that people would have to practice differently and when I say a seven day hospital it doesn't mean you do the same thing you do today Monday to Friday. All seven days the week is there no more patients to take care of means have to shift some of the care you provide during the week. The elective care, the routine care onto the weekend so that your team is already in place and adding on a patient who's not emergent. We always do the emergent things on the weekends, urgent who can wait till Monday. But are you better to do it today or at least more satisfying. Deal with the anxiety the patient's going to have. Well it's a interventional radiology procedure, OR procedure or colonoscopy in the suite to have a team of people available now allows you to efficiently with minimal added cost. Add on that other patients. But of course we all like our weekends.

Saul Marquez:
Yeah.

Robert Pearl:
And the idea was terrifying. And it took a lot of conversation a lot of scheduling a lot of what I call the A to G. That's the mnemonic that I used to talk about hey you make leadership change happen. Had to do that in order to quell the fears that were there. Now that it's in place it's just the way we do business in fact this may not even be that bad. You maybe you have an extra day on Saturday you like to ski you can ski when the slopes are empty. You want to visit your child at school and see how they're doing. You can do them on a Tuesday or Wednesday. Change is just difficult and we know psychologically is that short term loss is over feared and the long term benefits are under appreciated.

Saul Marquez:
Love that. And you mentioned a to G. What do you mean.

Robert Pearl:
So it's actually a model that I teach the Stanford Graduate School business and the process of writing a chapter for a book on it.

Saul Marquez:
OK.

Robert Pearl:
Looks at the question how do leaders make difficult changes happen or as we said earlier. How do leaders make things happen that otherwise wouldn't. And I used in a monarch eight G because it's easy to remember a b c d e f g.

Saul Marquez:
Yeah.

Robert Pearl:
But it includes all of the steps that I believe leaders need to do to get people comfortable with the change process.You have to start with the first question which is why do people not want to change. And it's something they don't want to change. Every physician every nurse is very dedicated to the patients but sometimes these ideas generate fear generate the fear that it's just a bad idea. Going to harm patients to generate the fear that too much is going to get estimate generate the fear that people will laugh at me because I'm going to go along and they won't. People fear I can't trust the leaders if you start looking at all the fears you need a plan to address them and I don't mean it any way to deceive them, manipulate them you can't do that in health care used car salesmen can do it at least to you once in their life. Leaders in health care see people every single day throughout their career where they have to do is be able to help people get over the short term problem to the better long term solution. Think about that is in chemistry the activation energy gotta get over that hump to get to the other side. So a is aspirational vision a combination of something that's very inspiring but also realistic. I think about Martin Luther King who talked in his I Have A Dream speech you said get rid of all negative racial thoughts that would be impossible. He said I dream that on the hills of Tennessee they'll be the former slave owners and the children of former slaves dancing together go to a soccer field the United States. You'll see that it was difficult but it was there and you've got to win the hearts of people I think if we can deal with their mind the B is the behaviors what are the specific things you can have to do. You know people are afraid you don't ask them on a seven day hospital to be there 30 days a month give up all the weekends and never see their kids. No. Yes exactly when in one day a month that's starts to become doable. The C is the context that we understand why we're doing this. Physicians are very very smart people. They're intellectually want to know exactly what's going on. They see the context does that. D is the data. How are we going to know what's going on. How are we going to evaluate this and one of the worries I give to leaders is if you're going to distribute data you better know what you're going to do if your data doesn't show the change you want because then all you'd be telling people is it doesn't really matter that we did this if it turned out that nothing changes around patient a late the stay or utilization we are unable to lower the infection rate or do something positive for patients that we better have a backup plan to make that happen. E is the engagement of the leader, nothing happens unless people trusted individuals. Why I often speak about physician leadership. It's not that I undervalue nurses or technicians or hospital administrators or anyone else but my experience has been that doctors will follow colleagues whom they respect and know and they have to trust them and trust is often built up through clinical practice. But then it has to be built up by one on one engagement. You can't send that emails. You can't have these these big broad meetings you got to sit down with people and deal with their fears and help them understand why in the end patients are going to benefit as a consequence of what you're doing. The F is for the faculty. No one does this alone. You've got other people working with you. Some of them are going to be analytic, people some of them going to be other clinicians helping to lead the effort. And then finally G is the governance I bring governance into three parts. There's the formal structure. Most leaders have a board they have to report to or someone else they have to get the approval that's important but it's not the most important. The second is the informal or the real leaders your facility. Who are the clinicians that everyone relies on for the toughest the patients because if they don't think it's a good idea no one's going to go along with that. You make you better make sure that you engage them. If we begin the change process and finally incentives. I wrote a Forbes piece recently about how financial incentives always create change just almost never the change that you expect. You may have seen the recent report from Medicare as a consequence of some of the approaches they used to diminish readmissions. The consequence was that patients were not getting readmitted who needed to be and as many as maybe twenty thousand people could have died over the past two years for a program that was well intended but simply financial incentives are not how you make change happen. It's the full A – G model that makes it a reality.

Saul Marquez:
Love that love the model and I'm glad I asked. At first I thought you said Z. I'm like wait a minute, Z? I'm so glad you asked. What a great playbook that any leader could take a look at to inspire change in a way that is acceptable but also exciting. So appreciate it walking us through that Robert. How about today? I mean you do a lot of things. What are you most excited about today?

Robert Pearl:
What I'm most excited about today is that I think that our country is on the verge of making this shift that needs to happen for us to move American healthcare from the 20th into the 21st century. I write about in Mistreated while we think we're getting good health care while usually wrong – four pillars. But I believe the road to the future need to be built and I think we're moving towards those. The first one is integration both horizontally within departments and vertically between departments. When you horizontally integrated as you can have people in the same department working collaboratively, cooperatively you can have greater specialization you can come up with ways together to be able to be more efficient and effective than any one person alone and vertically between primary care and specialty care. The opportunity to be able to take care of the patient's problem sooner even when the patients in the primary care physician is a great example of that to me is that we used digital photography to be able for patients seeing a primary care physician who had a rash that an individual, a physician wanted assistance for to use a digital picture to have it looked at by a dermatologist and I joked in the community it's about six weeks often to see a dermatologist. We did it in six minutes before the patient left the room. They had a diagnosis and a treatment plan put in place by the dermatologist. Now sometimes they can't resolve it but it works in that particular way. Number two capitation I think you know we talk a lot about moving for volume to value the rest of our lives we never imagined that we would bring a contractor into work on our house and just simply pay them time and materials. And yet that's what we do in so much of American health care today. It doesn't matter whether the intervention makes a positive improvement, we simply pay for it and we know from the New England Journal of Medicine is that 30 percent what physicians do has been shown to not add any value what you looking arthroscopy with cartilage trimming against physical therapy alone, single vessel angiography and angioplasty for patients with stable heart disease a lot of the back surgery we do we know this the data has shown it and yet we continue to do that as soon as you move to a capitated arrangement of changes technology, video, artificial intelligence, data analytics. A great example to me of the potential of all of this is video in the E.D.. We had a stroke trained neurologist still have a stroke trained neurologist who actually looks at the 20 E.D. Northern California when anyone comes in or maybe having stroke symptoms. That physician takes over the care. What's the difference. Door to needle time drops to under 30 minutes rather than hour elsewhere. Saving lives saving brain function. And then finally the fourth pillar is simply leadership and ability to take what today is a truly fragmented and let system and put in place the kind of operational movements through integration opportunities through prevention avoid some medical error relative to capitated payments the opportunity to use technology to put it in place and to create a true integrated care delivery system that is what is necessary for the 21st century. You know last century Saul, we had acute disease we didn't have very many treatments available the system we had worked. Today it can't. When the average person over the age of sixty five has at least two chronic diseases, sees multiple physicians, is on numerous medications that kind of system creates risk for patients unless that care is fully integrated listed as a technological support behind it. And unless everyone is organized in ways to avoid complications to prevent disease we can do those things today they excite me but we still have to make that happen as the norm across all of the United States.

Saul Marquez:
Outstanding. Some great pillars to think about. I'm definitely going to take some a little journaling session after today Robert, our time together. aAn folks I encourage you to do the same. Think about these topics but also invite you to go to Dr. Robert Pearl's website. It's robertpearlmd.com. There you'll be able to see all the things that he's done including his Forbes blog, his podcast, links to his book. This is just the tip of the iceberg and I definitely encourage everybody listening to dive in and learn some more robertpearlmd.com definitely take a dive in and learn some more. Robert getting close to the end of our time together here, really have enjoyed this. This part of the podcast is a lightning round so I've got a couple of questions for you that you'll answer with brief responses and then we'll we'll finish it up with a book that you recommend to the listeners. You ready?

Robert Pearl:
Ready.

Saul Marquez:
All right what's the best way to improve health care outcomes?

Robert Pearl:
The best way to improve health care outcomes is through the four pillars.

Saul Marquez:
What's the biggest mistake or pitfall to avoid?

Robert Pearl:
Relying on financial incentives to drive change and improve performance.

Saul Marquez:
How do you stay relevant despite constant change?

Robert Pearl:
Go to robertpearlmd.ccom and see all the articles that are there. I personally do is I spend a lot of my time looking at the literature looking at what's being written and published and learning from others.

Saul Marquez:
Love it. What's one area of focus that drives everything in your work?

Robert Pearl:
The patient higher quality care that's more rapid and convenient at lower cost. It's got to be affordable. It's got to be high quality. We can do better. We should do better.

Saul Marquez:
What's your number one health habit?

Robert Pearl:
I run about 30 to 35 miles a week.

Saul Marquez:
Nice and what is your number one success habit?

Robert Pearl:
I take the time to think about the past the present and the future. To learn from the past, to enjoy the present, and plan for the future.

Saul Marquez:
Love it. And what book would you recommend to the listeners?

Robert Pearl:
I'd recommend two books one book is the leadership challenge by Posner and Kouzes. It's the first book actually I read on leadership it's still I think possibly the best single book that's out there right now even though it's probably on their tenth edition and then another book that I find very useful to understand healthcare in specific the business in general is the three disciplines of market leaders. The notion of operational excellence a notion of customer intimacy and the idea of product differentiation and what I would tell the listeners who do read the book is that although in the first edition the writers of that talked about how you can only be great in one. Overtime, they've evolved and I believe that not only can you be good and to actually need to be extremely good in all three. I saw a sign Saul on the wall of a health organization big letters the topics and quality service and cost down below it said Pick any two. We can't pick any two anymore Saul. We've got to do all three.

Saul Marquez:
Strong message there Robert and I totally agree with you. The choosing is gone, we have to do all of them. Listeners, some great books here provided by Robert including his own. But for all of these resources go to outcomesrocket.health in the search bar type in Robert Pearl and you'll find this entire podcast transcript, links as well as just the short hand shownotes for you. outcomesrocket.health type in Robert Pearl but also visit robertpearlmd.com to dive in to some of Robert's thoughts. It's definitely a site that you'll enjoy spending time on. Robert, before we conclude I love if you could just share a closing thought with the listeners and then the best place where they could continue following your work.

Robert Pearl:
The thought I'd give to the listeners is what I wrote Mistreated. I wrote it for the patient and all of us and that's how I view it. We can't think of ourselves simply the providers of care or the insurers of care we're actually all ultimately the receivers of that care. And I do believe that together all of us can once again make American healthcare great. That's the underlying theme of the podcast. Fixing health care podcast that I do. I encourage listeners to listen into the one they just completed with Dr. Debbie Shetty the heart surgeon from India. Mother Teresa's personal physician and the founder of a hospital on the Grand Cayman Islands one hour from Miami Beach. That's a large hospital on a small island that's not aiming only to take care of the local people who are there and anyone who wants to communicate with me they can reach me through LinkedIn.

Saul Marquez:
Outstanding Robert. This has been such a tremendous podcast really appreciate your insights, your passion, your stories. I know that the listeners have enjoyed it as much as I have so a big thank you to you.

Robert Pearl:
Thank you Saul. It's been fun and keep up your great work. I think through your podcast together all of us can change American healthcare for the better. And I really support all the things that you're trying to do to educate people and to drive change in American health care today.

Thanks for listening to the outcomes rocket podcast. Be sure to visit us on the web at www.outcomesrocket.com for the show notes, resources, inspiration and so much more.

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