The Truth About Integrated Healthcare with Dr. Robert Pearl and Managing Remote Workers with Liam McIvor Martin

Dr. Robert Pearl is a physician leader and a healthcare innovator who specializes in children with birth defects before he moved into a leadership role and saw how mission driven it was. He has worked with integrated healthcare since 2009 and was recently named one of modern healthcare’s 50 Most Influential Physicians. He shares that as a surgeon, he had the opportunity to change the lives of thousands of people, but in the leadership role, he is able to impact the lives of over five million healthcare members across the United States. In his book called Mistreated, Dr. Pearl educates us on how to tell good health care from bad health care, and provides a roadmap for how healthcare could radically improve. Liam McIvor Martin helped develop Time Doctor, one of the world’s leading time tracking software for remote teams, as a way for companies to manage remote workers and maintain a high level of productivity. The core adage of his company is to empower people to work wherever they want, whenever they want, to make them happier and more efficient.

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We’ve got Dr. Robert Pearl and Liam McIvor Martin here. Dr. Pearl is the author of Mistreated: Why We Think We’re Getting Good Healthcare—And Why We’re Usually Wrong. He is very well-known and this book is very exciting and the proceeds go to a very good cause. Liam McIvor Martin is the Co-Founder of Time Doctor and He is a speaker, writer and metrics-based marketer and he’s going to discuss about what they’re doing to get companies to track time and remain more productive.

Listen to the podcast here

The Truth About Integrated Healthcare with Dr. Robert Pearl

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Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong

I’m here with Dr. Robert Pearl, who’s the former CEO of The Permanente Medical Group from 1999 through 2017, the nation’s largest medical group, and former President of The Mid-Atlantic Permanente Medical Group from 2009 to 2017. In these roles, he led 10,000 physicians, 38,000 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 Healthcare’s 50 Most Influential Physician Leaders, Pearl is an advocate for the power of integrated, prepaid, technologically-advanced, and physician-led healthcare delivery. He’s the author of Mistreated: Why We Think We’re Getting Good Healthcare—And We’re Why Usually Wrong. The book is a so interesting because all profits are going to Doctors Without Borders. Dr. Pearl, welcome.

Diane, it’s good to be on your show.

I worked as a pharmaceutical rep for fifteen years and saw a lot of crazy things out there of how people were treated. From having my background with that and my husband being a plastic surgeon and you’re a plastic surgeon as your background, it interests me how a plastic surgeon got into wanting to be a CEO and more business-oriented. Can you give me a little background on how that came to be?

I went to medical school, Yale, and then I came to Stanford University for my residency. I specialize in children with birth defects, cleft lip and cleft palate, but I’m trained in all the aspects of plastic surgery for facial fractures, head and neck cancer, and hand surgery. When an opening happened at the end of my residency at Kaiser Permanente, I thought it’d be a very interesting place to work. I was very excited about how it was changing the approach to American healthcare, how mission-driven it was, and how the people there were in health care for the right reasons. I went there without any sense that I was going to be moving into a leadership role, but people started to ask me to do things. They asked me to become the Chairman of the Operating Room Committee. I said, “Sure, why not? I’ll try almost anything.” I found that I enjoyed it. The opportunity as a surgeon is to change the lives of thousands of people, but the leadership changed the lives of hundreds of thousands and ultimately 5 million Kaiser Permanente members across the United States.

When I was in pharmaceutical sales, I heard so much about Kaiser Permanente. They were so huge in California and all of the different HMOs were getting very popular back then. It’s been a long time since I’ve been in that industry. It’s obviously a big part of how we treat patients now, to have these big organizations handle treatment. I saw that your background, and some of the reasons that motivated you, was something that happened to your father. Do you want to share that story?

My father was an amazing man. He was the son of two urban parents. He paid his way through college and dental school. When World War II broke out, he could’ve stayed behind American lines safely, but instead he joined the 101st First Airborne. He parachuted on D-Day. He was a trooper and he was captured by the Germans for two nights. He led them through a daring escape through a dark forest, where everyone were back safely. It’s truly what Tom Brokaw called a member of the greatest generation. My father was a tireless man. He had tremendous energy. He slept more than four or five hours a night, and then one day he became tired. We didn’t know what it was. We went to the doctor. My brother, who was Chairman of Anesthesia at Stanford, and myself handpicked his doctors, and they were excellent. The one who saw him made the right diagnosis. He establishes that it was hemolytic anemia, probably from one of the medications he was taking. He recommended the right surgery, which was taking his spleen, and in doing so restored his red blood count, which was lowered, the reason for his tiredness. My father recovered well.

The problem was that my father living on the East Coast, with half the year in New York and half the year in Florida, and they didn’t share a common electronic health record. They didn’t necessarily work together in a collaborative way. The doctors in New York were sure that the ones in Florida have given him an essential vaccine after your spleen is taken out, called the pneumococcal vaccine, because you’re in a tremendous risk without having that filtering organ in your body. The ones in Florida were sure New York had done it. Primary Care, specialty care, in the end he never got it. A couple of years later, he’s out visiting my brother and me in California. He was at my brother’s house and at 5:00 AM, my brother gets up and sees my dad on the floor, unresponsive. He takes him to the hospital and for four days, he was unresponsive in the ICU. Two weeks in the hospital and he is finally discharged. He doesn’t die during that admission, but ultimately he’s going to succumb from complications. The diagnosis was pneumococcal septicemia. Dad was one of 200,000 people that year and every year since to die from medical error. When you add on top of that, hundreds of thousands of deaths from patients who didn’t get the prevention they need from complications of chronic disease that could have been avoided. We’re looking at half a million deaths every year. When the Commonwealth Fund looked at the American healthcare system, they ranked eleven industrialized nations. We were last in life expectancy and childhood mortality. The only area we lead in was cost.

When I looked at that data, that’s mistreat. Hundreds of thousands of people are dying unnecessarily every year. Yet when you ask Americans, 76% of them will tell you the American healthcare system is the best in the world. There’s not a shred of evidence that that’s true. It was this conflict between an objective reality between the numbers that are published by third-party independent organizations and what we see. That led me to research Mistreated: Why We Think We’re Getting Good Healthcare—And We’re Why Usually Wrong, and to try to understand and in the end to conclude why it is that what we should understand the objective information readily available is not the way we see the world. We behave not based upon logic but based upon perception.

I’ve gone to Mayo and some of the places where they’re more connected and all the doctors share information in a database. A lot of them were very slow to even get their records online. The hospitals were telling them they can’t come in anymore unless they learned how to do this. Why do you think they were so slow in general to embrace technology as compared to other industries?

I get that question when I speak as a keynote speaker or while speaking at conferences about health technology. What I tell people is doctors actually love technology. What they don’t like is technology that slows them down and makes their life more difficult. The electronic health records available now are very cumbersome. They were designed 30 years in the past. They are designed around billing, not around any physician who provides care. One of the things I tell technology companies is that if you want to be successful, you better create a product that solves a problem.

The classic example that I like to talk about are these exercises devices, the so-called Fitbits that a lot of people wear. They’re the most commonly-used individually-bought product. When you actually look at what they do, they do two things. They tell you how well you slept last night, and they tell you how far you traveled or how far you ran or walked. I carry an iPhone. It tells me exactly the same information. If you think it’s too heavy, you can carry a little plastic pedometer. Why are these devices the number one-selling product in healthcare in the United States today? The answer is they solve a problem. The problem though is not medical. The problem is called the December Dilemma. You’ll want to buy someone a product or a present that is attractive, that they’re going to carry all the time, that they’re going to think about you, and it’s got to cost between a hundred and $150 and $200. They solved it. In the 1990s, there was Inline Skates. Half the people who got them never took them out of the box after December 25th, and yet they solved the problem.

The electronic health record has not yet solved the problems for the physician to allow them to provide greater care. There is no interconnectivity and interoperability. They essentially are like calculators, but used for billing, rather than from direct care. That’s why doctors don’t like it. It slows them down. If the manufacturers opened up the so-called APIs, the Application Processing Interfaces, third party developers could come in and make them interoperable. Why are they not done? Because the companies that sell them know that it would reduce the barriers to switching and people could go to a competitor, and so they don’t do it. The American healthcare system is broken, and as a result, people are mistreated.

When you say broken, what do you think of movies like Michael Moore’s where they focus on how we compare to other countries like Canada or France or the different areas? Do you agree with what he says about how we compare? What’s your input on that?

The Commonwealth Fund has looked at a variety of measures year after year, and the answers were very expensive and the outcomes are not very good. A girl born today in South Korea has a life expectancy of 90 years. In the United States, it’s 83 years. You look at the medical errors, that’s hundreds of thousands of people every year. I was the CEO of Kaiser Permanente and in doing that role, I was very focused on quality outcomes. If you look at a measure like hypertension or high blood pressure, 90% of the people inside Kaiser Permanente with a diagnosis of high blood pressure had it well-controlled. Across the rest of the country, it’s 55%. What’s the difference? 40% of people who get a stroke could have avoided it.

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Integrated Healthcare: With information technology this 21st century and excellent physician leadership, we can save hundreds of thousands of lives.

For colon cancer, there are tests out there right now. I don’t necessarily mean colonoscopy. That’s one thing. It should be used in people with a family history of people with polyps but for most people it’s called the FIT test. Five minutes once a year in the comfort of your bathroom, no risks, no bowel prep, and yet across the United States its 60%. In an organization like Kaiser Permanente, its 90%. When you look at the outcome, the National Committee for Quality Assurance know the fact that The Permanente Medical Group have achieved a 30% lower chance of dying from heart disease or cardiovascular disease and patients in the community around us. 40% lower chance of dying from sepsis, systemic infection. All we have to do is look within the United States and everyone could match the performance of the best, the top 10%, and these are not individual physicians. It’s a systems approach to care that integrated and doctors are working together as one. It’s prepaid so the incentives line up to prevent the disease, not treat them. With information technology this 21st century and excellent physician leadership, we can save hundreds of thousands of lives every year and lower the cost of American healthcare by 10%, 15%, or even 20%.

I remember talking to a doctor about a migraine drug I was selling and how you’re painting a picture of how if you gave them the drug, there’s maybe be a less chance of them having to go the ER and they wouldn’t be calling you in the middle of the night. We were discussing and he goes, “I don’t care. That’s somebody else’s budget. I’d rather him go to the ER to prevent him from having this problem.”We need to work on preventative care, but we have issues with some of the doctors worrying about their bottom line, but you also have people that want to take a pill, so they can eat whatever they want. How do you get past that?

A lot of the research for the book and then ultimately the focus of Mistreated: Why We Think We’re Getting Good Healthcare—And We’re Why Usually Wrong is around this sequence, where context shapes perception and changes behavior. I talk in the book about Philip Zimbardo. Zimbardo, was from Stanford University. He did the Stanford prison experiment. He takes normal students and he squeezed them psychologically to make sure they don’t have any problems. Half of them become the jailers. They get these aviator sunglasses. Half of them become the jailees. They get Ørgreen and just a number. He puts them together in a simulated jail to try to figure out a better way to handle the penal problems of the United States. Within 48 hours, the jailers see the jailees as dangerous criminals. They make them do the basic things, like clean toilet bowls with their bare hands, and the jailers see the jailees as statistic. They board the doors up. Everyone there knows that the other people are students. The context of being in a jail environment with either aviator sunglasses or Ørgreens makes you see this other person differently and makes you then act differently.

Let’s look at medicine. They’ve done 80 studies and every study, when a physician goes from a patient’s room in a hospital to another patient’s room, one out of three times, they don’t wash their hands. In order to get hospital privileges, they had to pass that exam on hospital-acquired infections, which is now the third leading cause of death in the United States. They all know that the most problematic bacterium called the C.difficile, Clostridium difficile, is carried on the hands of people. It doesn’t travel through the air. Yet in the context of being late to the office late or they skip that step and patients suffer. They get mistreated. They get an infection they did not need to have because of that.

We’ve got to change this context of American medicine. When you integrate care within a specialty, now you start to get systems that improve greater specialization and higher quality. When you link and integrate primary care to specialty care, you find ways to get better things for patients. That kind of experience you described with that doctor wouldn’t happen if he could see the world through the eyes of a colleague who is in the same organization, but he doesn’t. Integration and pre-payment. You focus on prevention. Now, individuals start to understand that importance and how it comes back in not only better quality outcomes but lower cost. Now you invest in the technology, you learn how to use it, and now you’re willing to have leadership that can effectively make change happen. I don’t believe we’re going to solve the issues you described, until we fundamentally change the American context for how our care is delivered, and get away from what today’s the nineteenth century college industry. It’s fragmented.

Doctors scattered across the community. Hospitals in every town are paid on a piecemeal basis we call fee for service. The information technology we have today is literally 30 years old. If you could only access information to your checking account or your financial investments nine to five, Monday to Friday, or if you had to make a phone call and stay on the phone in order to get your airplane ticket rather than being able to go online, or if you couldn’t do retail, all the things that we demand, we simply accept in the healthcare we get today, and that is why we are mistreated in the medical care received in the United States.

You bring up an important point. Doctors don’t get paid unless patients come in, so they can’t treat them virtually. The way things have changed in terms of managed care, they didn’t have hospitalists when I was in the hospital a long time ago, and the now they have hospitalists handling. You get doctors assigned to you sometimes, where you used to have a lot more choice in the matter, and that’s the thing that I found was problematic with the managed care because somebody had to graduate at the bottom of the class. I’d like to be able to know I could pick my doctor. How much are we taking away our options? How much are people relying on doctors just because they like them and they don’t know anything more than that?

You’re describing a very important issue. I teach at Stanford Graduate School of Business. I teach a class on healthcare and technology. The first thing I ask the students is, “How many of you get great medical care?” These students are very smart. They can tell you how to do an analysis of a business down to the third decimal place and they’re certain, so all the hands go up. Then I say to them, “How do you know?” All the hands come down because there’s no way that the individual can pick a physician or a surgeon. Even if you get a referral from another physician, how do they know? In an integrated organization you have doctors reviewing each other and seeing each other all the time.

To me, a great example was from Bill Clinton. After he was president, his wife run for president, became the senator from New York, and he developed symptoms consistent with coronary artery disease. The state of New York publishes data on 35 hospitals in terms of the cardiac outcomes. President Clinton chose the second worst out of all 35 hospitals to have his workup done in, and when he had completed, he then chose the worst hospital to get his surgery, by the surgery with the highest rate of complications, and he had a complication. The problem to me is not a choice. The problem is figuring out how we get the performance of every one to be as good as the best, and how we then help people to make decisions not based upon who they like or what a friend says, but based upon objective information. That happens better in integrated organizations with physician leadership than it has in the community at large.

I’m curious what you think of now with all the advertising going to the consumer and the consumer is coming in and telling doctors what they want. They come in and they want medications to solve all their problems. We have a society where we want to eat, and we want to have a pill to fix it. We don’t want to exercise. How do you get past all that? Are doctors doing enough to educate people and to make them more proactive with their health?

I believe that we have not put the right emphasis in our healthcare system along the lines that you’re talking about. Much of that comes out of economics. We train far too many specialists and not enough primary care physicians. We then take our primary care physicians and we rush them through the day and I’m speaking now about the nation as a whole. They don’t have the time to establish the relationships. You’ve got to earn the patients’ trust, and that takes time. I believe that if we could re-vamp the system, when you look at the integrated and prepaid organizations like Kaiser Permanente, that’s what they do. They hire more people in primary care. They give them more time to interact with the patients, and they evaluate them based upon the kinds of outcomes you’re describing. None of that happens in the traditional community-based fee for service world.

You say we need less specialists, but the specialist makes more money and doctors are making less money. My husband probably went through the same seven years of residency after medical school. If you’re not a specialist, how are we going to make it worth it to them to want to be doctors?

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Integrated Healthcare: There are too many residents with specialties and not enough in primary care.

We have to re-balance everything. When I say fewer specialists, I don’t mean that we’re going to do less. We’re going to do it far more efficiently. As an example, between San Jose and San Francisco, because I live in Silicon Valley, there are ten hospitals doing heart surgery. Three of them do fewer than 300 cases a year. That means that at least 65 days of the year, you’re paying a team to be there because you need a team for emergencies, and you have no patients. Try to imagine having high quality when you do one case a day on average on your cardiovascular team. Everyone understands what should happen. Three hospitals to come together, close two other services, raised the volume, improve the quality, and lower the cost. It doesn’t happen in a fee for service world. What I’m saying is you want to have greater volume, more centers of excellence and people with higher specialization, but the system today generates more people. There are too many residents with specialties and not enough in primary care. As soon as you’re able to shift the equation, you can pay primary care physicians more. Today students come out of medical school with a $200,000 debt is simply wrong. We need to find a way to make the system work. What you’re describing are the consequences of a broken system, where at the end of that four years and a tremendous debt, they may have no choice but to pick an area based upon remuneration. That’s a 5,000-year history of being mission driven, but we’ve got to make sure that financially they can be successful, and they can be rewarded for the decade of time they had.

I’ve gone around talking about mistreated. A lot of the times I put on TV and radio shows like yours, and people call in and they ask questions. I expected a lot of physicians we’re unhappy because I’m talking about a radical disruptive change in American healthcare system. Most of them are saying, “Do you know what you’re describing, Dr. Pearl? That’s exactly what we want. We want to work together on a team with our colleagues. We can’t in the competitive Doctor Y Doctor world in American medicine today. We want to be paid for preventing disease, not intervening, not doing things that are marginal or no benefit at all. We want that information-sending in place. What’s good for patients is good for physicians.” One-third of physicians today report being depressed. There are 400 suicides a year. Burnout is a major issue and I believe it’s like a hamster in a cage, spinning that wheel faster and faster, but not making any progress.

There’s a big problem with trying to keep up, especially it’s a business. I don’t think they teach doctors enough about it being a business. When they get out there, they’re great at being a doctor but also they’re entrepreneurs.

I wrote a piece for the New England Journal of Medicine about why I believe that in the fourth year of medical school as one of the elective rotations. Every student should go to business school for a month to learn these skills. It’s not the business skills. How do you build a team? How do you motivate people? Medicine is no longer the single doctor working alone, and diseases are far more complex. Patients have multiple chronic illnesses. Physicians have to work together as a team, and that’s very hard when there’s certainly a lot of ego in some of the areas of medicine today and in getting people to collaborate and coordinate, to put the patient at the center and to have everyone realize it’s a privilege to be able to provide that care. That’s a 5,000-year history of medicine. We’ve got to re-embrace that.

My father ultimately needed to have a procedure done because of the problems that he still had and the complications for his first hospitalization. He had to have his anticoagulation stopped, because he had a medication being taken for atrial fibrillation. As a result of that, he developed a stroke. My brother and I were in California. We took a ride back to Florida where he’s being hospitalized at the time. We got there and he was tied down in the bed, intubated, and a line of doctors out the door. The otolaryngologist wanted to do the tracheostomy. The gastroenterologist wanted to put in the feeding tube. The neurosurgeon wanted to take out parts of the skull to allow the brain to swell. My brother and I looked at the X-Ray, and he wasn’t going to get better. My father was not going to get better. We thanked the doctors for the care they provided, but we also said we wouldn’t like anything else done. For the next two and a half days my dad was in the hospital, we never saw another physician. There’s no ICD-9 and there’s no CPT code for compassion in American healthcare today. You don’t get paid for being with a family in this time of greatest need, and yet I believe that’s exactly why physicians went into medicine in the first place. The American healthcare system is broken. Patients are being mistreated. We think we’re getting good healthcare, but we’re usually wrong. We can change it. There’s a roadmap to the future. If we embrace is together, we can make things better in the near future. I hope all of us together are going to be able to accomplish that and to force the American healthcare system to change for the better.

What you’ve done in this book is important. Thank you. If people want to get Mistreated: Why We Think We’re Getting Good Healthcare—And We’re Why Usually Wrong, remember that all the proceeds from the book benefit Doctors Without Borders. That’s amazing that you’re doing that. Can you tell people how they can get the book and find out more about you?

They can get the book at almost any bookstore. They can get it on Amazon, or they can get it on Barnes &Noble. Type in Robert Pearl, Mistreated, and you can find out lots of places to get the book. It was a Washington Post bestseller and it was number seven on the list. All people have to do is go online and get Mistreated: Why We Think We’re Getting Good Healthcare—And We’re Why Usually Wrong.

Thank you so much, Robert. This is so interesting. I appreciate it.

Thank you, Diane. It has been a lot of fun.


Managing Remote Workers with Liam McIvor Martin

I am here with Liam McIvor Martin, who is the Co-Founder of Time Doctor and Staff.Com. He’s a speaker, writer, and metrics-based marketer. Time Doctor is one of the world’s leading time tracking software for remote teams. They help companies to be able to manage remote workers as if they were in the same office, maintaining a high level of productivity. His goal is to help individuals and organizations be more productive, to help stop people wasting time on distractions, and instead finish what’s important to them. Liam is from Montreal, Canada, and he likes to swim with mermaids. Welcome, Liam.

My girlfriend runs a chain of mermaid schools. She has about fifteen locations throughout North America and Europe, and she teaches women how to swim like a mermaid. You put on a mermaid tail and you jump in the pool. That’s something that I’m intimately interested in because I like working on different entrepreneurial projects. I thought to myself that this is the polar opposite of everything that I do. It’s been fun working on it.

I’ve worked virtually for so many years. I’ve been an online professor for a dozen different online universities. I’ve worked in pharmaceuticals and different things where I always had my own days to be self-motivated and not necessarily tied to an office, and that can be challenging for some people. I’m curious what you do to help make people remain productive and reduce the time that they spend on distractions. Can you tell me about what you do?

I’m currently working on podcasts right now. I’ve been working on podcasts for seven minutes and 42 seconds, and at the end of this particular podcast, I’ll be able to compare that to all the other podcasts that I do and measure what I did. What websites was I on? What applications were I using? To what degree? Then I can start to figure out signals and figure out trend lines to see what is a successful podcast for me, and what’s an unsuccessful podcast for me? I can also measure these results directly to how many viewers or what’s the level of engagement if I had that type of data. We use that as an example to extrapolate on deploying this on a grander scale. We don’t necessarily measure how long someone works, most time-tracking tools do that, we measure what you did while you were working. That’s the big difference between us. Someone who comes in at 8:00 in the morning and leaves the office at 9:00 PM and you think, “This guy’s working thirteen to fourteen hours a day, what a hard worker.” Then if I compare that to someone that comes in at 10:00 AM and leaves at 1:00 PM, we can compare those two workers together. The guy that came in at 10:00 AM and left at 1:00 PM got more physical work done. He was spending more time in his terminal. He was putting more work hours. The average work day, and what I mean by this is people working at a computer in an office environment, the average amount of time people spends working on that computer, is a little under three hours per day.

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Integrated Healthcare: The average amount of time people spends working on that computer is a little under three hours per day.

My perspective is, “Why don’t we focus on work and not focus on being in the office or putting in time because putting in time doesn’t equal productivity?”In reality, putting in time maybe a complete counter to productivity. Just because you’re sitting at a computer doesn’t necessarily mean you’re getting anything done, and you might actually be getting less done. That’s one big variable that we take on, is focusing on trying to bring the people in an organization forward that are doing a lot of work, but you may not see it, because the Fortune 500 managers will say, “I don’t measure anything other than how long they spend in the office. I can’t measure anything past that.”

The second thing that we do is we measure distraction. My personal perspective is that we live in the distraction economy. Whoever can distract you more usually wins. It usually makes more money. Facebook is a perfect example of this. I’m sure that you probably heard recently about all of the Cambridge Analytica data that was grabbed in the ability to be able to predict someone’s political actions by producing three or four small movements on social media. The exact piece of content to communicate to somebody to be able to change their political sphere is changing in all aspects of life. In essence, there are these companies that make billions and trillions of dollars trying to pull your attention and trying to win over your attention. What we do is we are a tool against that.

As an example, if I’m currently doing podcast right now. It’s my task. If I went to Facebook right now, you would say, “Are you still working on the podcast?” I would say, “No, I’m not,” and then it leaves me alone and it takes me off work and I do my Facebook stuff. If I say, “Yes, I was,” then it keeps tracking time, but it says Facebook is part of my work day. That’s how I personally have it set up. You can set it up however you’d like, but it gives you that last opportunity to say, “I’m leaving productivity village and entering distraction towns.” I need to make sure that I’m going to give you that last little out to say, “Is this part of your workday, or did you just get a notification from somebody talking about what movies are they going to see on Tuesday?”

Can you multitask and do them? Will it allow that?

Will it allow you to multi-task different activities? If you’re going between Facebook and your email, you’re probably not getting anything done, unfortunately. Even though you feel like you are, you’re not, and I have a lot of quantitative data to back that up. I’ve got hundreds of thousands of people that use the system every single month and the real way to stay focused and productive is to break down a task list of what you’re going to do, go out and accomplish those particular tasks, and don’t get distracted by the tools that are designed to distract you. It’s becoming more and more problematic because these tools are getting better and they’re getting slick. Facebook would probably be defined as a drug at this point, if we are able to redefine it. They’re getting powerful at this point in and it’s very important to keep yourself protected against these types of tools that are there to distract you.

There might be some subjectivity. I had a professor who didn’t like how quickly I turned in my paper. He thought I needed to take more time and he said, “That was too fast. You should take more time.” I can’t work slow, so I would write it and then hold onto it for a couple weeks after I wrote it in the same amount of time as I took, and then I’d send it to him and he go, “See how much better that is?” It was because he liked to work slow and that’s how he thought. I’m thinking the way I work will probably mess up the software. I worked for seven universities all at the same time, and I’ll have all seven tabs of all universities open and I’ll grade a paper in one. I might jump to the other, then jump to the other. It’s processing because the software takes so long sometimes to catch up with me with the little spinning. I jump from task to task, which makes me work fast. Would that explode your system?

I don’t think it would because we would define it as a productive action for you. The thing that you want to focus on is distraction tools, like video games, Twitter, and Facebook. I got an interesting data set in from some of our Dev teams just recently. There are these games, Clash of Clans and Clash Royale and probably some of your listeners have actually played these games before. They have entered a new level of distraction. They’re doing billions and billions of dollars a month with these games, and they are designed to distract you. They are perfectly engineered to distract you. When you look at that, you realize that your medulla oblongata brain is defenseless against these types of distractions. If there’s a little beeping button that pops up, I want to push it, and I get a little adrenaline every time I do. This creates negative feedback loops that generally don’t make you happy.

In comparison too if you’re marking a whole bunch of examinations and maybe you get bored with marking one type of exam and you switch to another, that’s not necessarily a problem. The problem is if you are marking one exam and then you get a pop up on Facebook and then you go look at that pop up and that leads to looking at some funny cat videos, and then you are going to pull down YouTube and Twitter and all of these types of media platforms that are designed for distraction. My girlfriend, she runs a YouTube channel as well, and there is a new AI algorithm that YouTube has implemented. They don’t care about commenting. They don’t care about liking a video. They don’t care about any of those metrics, safe for one, which is time on site, which is watch time. If your video makes that individual that’s watching your video watch more videos, then they reward you in the algorithm and they put that video up everywhere. If it doesn’t then they don’t and it’s an AI that’s doing it. It’s looking at tens of thousands of variables. It may be looking at saying, “People that were read tops in videos seem to actually have a higher watch time, and therefore we’re automatically going to reward people that were red tops on videos.” This is moving at a breakneck speed that even humans can’t even understand how fast it’s moving, but it’s moving, and it’s moving at a breakneck pace. We need to be able to build some defense against it.

For me, I have to get onto Twitter and Facebook and different things as part of marketing my company. If you’re in marketing, you have to check how things are going on Twitter. How do you differentiate whether they’re spending good time or bad time?

We can slice that out deeper. If you want to say, “I believe that going on the Messenger app inside of Facebook is a distraction, but going onto the Facebook pages is not,” you can slice down. You can say, “The Messenger app is a distraction, and I’m going to try to make sure that you don’t end up in the Messenger app, but I have no problem with you being on a different Facebook pages distributing your podcast.” You can slice it even deeper based off of the URL structure to deeply get into where people are putting their time.

How much of this gets to be where you’re being tracked so much that you’re worrying about tracking, that you start to play the game. Is there any worry about that? If it looks good that I’m in a certain class for certain times a day, I make sure that that is signed on. I keep hitting the mouse button over here on this computer, but I’m on the other computer doing Facebook?

TTL 179 | Integrated Healthcare
Integrated Healthcare: Just because you are more efficient at your job than someone else, that means you should be rewarded for that and not necessarily told to work longer hours.

We do have those people that play that game. It’s a tiring game. The amount of time that you can keep that up is low, and I personally have never done that. We have employees in 27 different countries all over the world and everyone uses our tool. For us, the biggest use case has been deploying the software across remote teams because then we can get that type of granularity that we would’ve gotten in a brick and mortar office but we have it online. We’ve had maybe two or three people over the six-year history of the company that have had some type of issue where we’ve shown them clicking around in the same spot every single time to run up the amount of time that they work, but we also have a perspective which is we don’t care how long you work. There is no impact whatsoever on whether or not you’re going to be successful. We do care whether you get your work done, so we have an adage inside of the company, which is we want to empower people to work wherever they want, whenever they want. We feel like empowering people to work remotely is going to make them happier people. Just because you are more efficient at your job than someone else, that means you should be rewarded for that, and not necessarily told to work longer hours.

How do you go with subjectivity, like with my professor? In his mind, short time working equals bad work, because that’s what it is for him. He looks at your work and think, “This isn’t as good as it could be if she had done this.” How do you factor that in?

He’s stupid. I don’t know what discipline he was in, but he doesn’t understand any of the social sciences. He doesn’t understand that the amount of time that you have to complete a task, the size of the task expands in the time that you have to do to complete it. If I told you I need a 10,000-word paper done by the end of tonight on the Crimean War and I’ve got a gun to your head, you’re going to deliver that paper. If I said I need a 10,000-word paper done on the Crimean War for next month, you are probably going to screw around. Maybe you’re going to work on it a little bit today, but not really. It’s going to be pulled out into that entire time period. Even by restricting the amount of time that you have to complete a task improves the relative productivity of that task, but there is a whole bunch of variables to that.

I’m thinking about people I’ve worked with who are good at what they do, and they tend to do a lot more work than everybody else. Somebody I worked with my last company, she’s super motivated, works hard, but then the more she’d work, the more they’d give her, and she didn’t get paid any more for it. How do you avoid that?

There are two variables to that. Number one, you should have an organization that rewards productivity and not necessarily how long you’re working. If your output is ten units per hour and everyone else’s output is five units per hour, I personally believe that you should be able to work half as long and produce the same reward. The second variable, which is a major issue inside of the workspace now and is an advantage inside the remote work, is the gender gap, the gender neutrality connected to how work is accomplished. She might have been a lot more successful working completely remotely, because there is some bias towards women in the workplace, how they get work dumped on top of them constantly, whereas sometimes men will speak up for themselves and say, “I don’t want to do this type of work,” but women sometimes they’ll accept that work.

That frustrates me quite a bit, because usually those women are working just as hard, if not harder, than most of the men inside of the business and they’re not getting the same type of reward. We’ve been doing a little bit of study into this because we have such a large dataset, that working remotely as a woman sometimes actually has you rising through the organization faster than if you were in a brick and mortar environment. It’s because the concept of gender to a degree disappears inside those types of organizations. Those would be my two suggestions to her. If you are producing ten units of output per hour and everyone is producing five, you should go find another job that’s going to reward you for those ten units of output. You’re selling your labor just like anyone else.

She worked remotely, but she’s one of those people that wanted to fix everything and work hard. With her, I would reward her based on how much she worked, if she wanted to work so many hours. The salary thing hurt her. The reason I found you is that somebody contacted me about this Running Remote Conference.

Yes, that’s in Ubud, Bali. If you wanted to define the absolute nucleus of remote work, I would probably say in Ubud. The venue is this beautiful network of tree houses made out of bamboo and they can hold 500 people in these tree houses. It’s going to be in the jungle, bamboo tree houses, some great collection of speakers, and we’re going to be talking about how to build the next billion-dollar remote business. There probably isn’t one right now even though there’s probably some that could argue that they’re close, but I do believe the next billion-dollar business will be coming out in the next year or two. What we realized was there was no real playbook on how to build large remote teams, so we wanted to basically learn how to get there. We are 80 plus people now, and we want to get to 200 within the next year. How do we do that? How does HR work remotely? Marketing all these other different variables. How does education work? Which is something that you’re probably intimately connected with. How does that work on a massive scale? A lot of these massive online education programs, they’ve had varying degrees of success. Why is that? Because it’s all new. There’s no playbook. There are no best practices. If we could put all of the smartest people you can find in a single in a cool bamboo tree house for two days and have them talk about all of these issues, we might be able to come up with a playbook that could help us in building our businesses. We’ve decided to invite 500 other people to come and listen in on those topics.

I hope that people take a look at They’ve got companies like Buffer and FlexJobs and TimeDoctor. A lot of other top companies are going to this thing. That isn’t unique location. It’s good to find out more about working remotely. I have a lot of people who would like to work remotely, but if you go searching for remote jobs, you get those scams work at home things. How would you go about getting a good, serious and maybe not entry level, but executive jobs? Is there an easy way to find jobs like that?

Unfortunately, no. It’s relatively new. Remote work is a relatively new discipline, and we have not been doing the utmost to move it to where we want to get it. Probably within the next two to three years, you will start to see massive shifts, and there are tools that are starting to do that. A tool like Time Doctor, Slack and a bunch of project management tools are making that type of communication a lot easier. I just recently ended up learning about the new Starlink Program, which is a SpaceX project that is going to give every man, woman and child 30 mbps internet on their SIM card. You’ll be able to be in the middle of the jungle and be able to do 4k Netflix streaming. That’s going to completely change remote work. The opportunities there will be absolutely huge. Once that occurs, you will start to see more of the executive level. The reason that we’re not seeing that right now is because most of the executives are probably the founders of the businesses that are starting out remotely. Those companies need to cook for another five years before those founders are probably going to leave, and then you need to put in chief level CMOs, CEOs, CTOs into those spots. Once you do, you’re probably going to see huge changes.

TTL 179 | Integrated Healthcare
Integrated Healthcare: Remote work is a relatively new discipline.

I would personally look at, that’s a great one that has a lot of higher-end job postings on it. FlexJobs is another one. They’re great for getting high-end job postings. There are a couple sites that are pretty good. Toptal is another one. They have fantastic job portal for remote workers more specifically. They have a remote toggle that you can switch, so they’re finding a place for remote work. These platforms are out there, but the Fortune 500 executives are not interested in remote work, because they don’t believe in the core measurement of productivity, which is how many units you put out per day and per hour. They don’t recognize that as the measurement. They recognize the measurement of productivity as how many hours can you put in the office. Until that changes then it’s not going to change.

I’ve taught remotely online for twelve years now and so I’ve seen quite a bit of changes in that. I love to work remotely, and so I hope all that does change. What you’re doing is fascinating to me, and a lot of people would like to know more about how they find out about your products and reach you. Can you share all that information?

Go to If you want to check out those cool bamboo tree houses in the sky, go to

It was so nice to have you on the show, Liam. Thank you so much.

Thanks a lot.

You are welcome. My thanks go out to Robert Pearl and Liam Martin. I want to make sure you have Dr. Pearl’s website. It is RobertPearlMd.Com. Thank you so much to all my past guests.


About Robert Pearl


TTL 179 | Integrated HealthcareDr. Robert Pearl is the former CEO of The Permanente Medical Group (1999-2017), the nation’s largest medical group, and former president of The Mid-Atlantic Permanente Medical Group (2009-2017). In these roles he led 10,000 physicians, 38,000 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 Healthcare’s 50 most influential physician leaders, Pearl is an advocate for the power of integrated, prepaid, technologically advanced and physician-led healthcare delivery. He is the author of Mistreated: Why We Think We’re Getting Good Healthcare—And Why We’re Usually Wrong.

About Liam Martin

TTL 179 | Integrated HealthcareLiam McIvor Martin is the Co-Founder of TimeDoctor and, speaker, writer, and metrics-based marketer. is one of the world’s leading time tracking software for remote teams. They help companies to be able to manage remote workers just as if they were in the same office, maintaining a high level of productivity. His goal is to help individuals and organizations to be more productive, to help stop people wasting time on distractions and instead finish what is important to them. Liam is from Montreal Canada and likes to swim with mermaids.


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