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

**Peter Attia** (0:11)
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Without further delay, I hope you enjoy today's Qualy.

**Zubin Damania** (0:40)
I had a similar experience at UCSF when I did a graduation speech that actually launched my whole career as ZDoggMD because I later put it on YouTube. It's in my 1999 UCSF graduation speech. It's there, it's all captioned and everything. And it was, I just went through it as I saw it. And it was all just like, this is bullshit, this is bullshit, this is bullshit, this is why. This is bullshit, it's about actually connecting with our patients, isn't that? And the majority of the faculty behind me were just like stone-faced for 90% of it. And then finally start to crack. And you see Michael Bishop, who's like a Nobel Prize winner, finally he's like, rrrr, rrrr, rrrr, rrrr, rrrr, rrrr, rrrr, rrrr, rrrr.
And afterwards they were like, that was very well done. But there was one guy who was like, that kid shouldn't be allowed to graduate. And actually was lobbying to have my graduation revoked for giving that speech.
I mean, so this is the thing, it's a hierarchy. And I can tell you don't like hierarchies so much.

**Peter Attia** (1:26)
I probably have more respect for it than you actually.

**Zubin Damania** (1:28)
Being a surgeon.

**Peter Attia** (1:29)
Yeah, I don't, I don't know. I feel like I'm not as, I don't bristle as much at it as probably some people. I mean, I would say for a surgical resident, I respected it much less than the other residents, and I definitely got into trouble on a few occasions as a result of it.

**Zubin Damania** (1:45)
Yeah, yeah.

**Peter Attia** (1:46)
Yeah, I've met people who completely have absolutely disregard for any hierarchy, and many of them go on to just do the most amazing things. So I always felt like I wish I had less respect for it.

**Zubin Damania** (1:55)
Well, you know, it's a complex thing, because I think certain personality types don't like to be in the middle or bottom of hierarchies. They either want to be on the top or they want to be off the hierarchy. It's hard for them to feel like other people are controlling them or they're beholden to others in the higher hierarchy. And they either have a tendency to dominate those underneath or to treat them as equals inappropriately, in which case the lower down in the hierarchy don't have the competence. And what they need is actually to be trained and lifted and supported. And instead it's like, why aren't you at the level that I'm asking you to be?
And so it's interesting. It becomes tough in the higher echelons of performance and stuff.

**Peter Attia** (2:30)
I think the problem I had in residency was I really loved hierarchy when I could respect the person I was reporting to. So, luckily I did my residency at a hospital where most of the residents were just exceptional. So it, for the most part, was really easy to respect the hierarchy.
But the problem was when I encountered somebody and I didn't think that they were good enough or smart enough or knew enough, I wouldn't hesitate to just steamroll them. And that gets you into a lot of trouble.

**Zubin Damania** (2:58)
I saw that in you when you were a medical student. I remember it. It was one of your characteristics that I actually respected a lot. Because again, like you said, and you kind of described our team pretty well.
The person at the top was fairly narcissistic. The one in the middle was kind of a non-entity. Then there was me, who was the class clown. And then there was you.
And it speaks to our medical training in general that it really is about kissing the ring of the authority figure. So one day you will be the ring that's kissed. That's the majority of our training. The first two years were fed a bunch of information, 50% of which is wrong, but they don't tell us which 50% is.

**Peter Attia** (3:33)
And then 50% of the residual will be outdated by the time you finish.

**Zubin Damania** (3:36)
Exactly, so it's 100% bullshit.
And yet we're expected to kind of suck it all in and regurgitate it with respect for this hierarchy. And we don't ask questions, we don't step out of that. And you're right, you have to respect your authority figures, which is important when you trust and respect them. But when you're questioning things, like, why are we doing this? Why are we giving Lasix to this person? Or what's going on with this renal failure? Actually, what about the root cause of that? You start asking this question, no. That's when I was told, hey, you speak, then think, you should reverse that.