Week after week I read with great interest the viewpoints, perspectives, analysis & commentary, blog posts and other dispatches from my healthcare professional peers and colleagues who are seeking to understand and influence the current and future state of both our profession and our systems of care.
With each reading, I am reminded of the published words of my late mentor Dr. Carleton Chapman, a former Dean of Dartmouth Medical School and one-time President of the Commonwealth Fund “…. our present scheme…for medicine is intellectually deficient, wasteful of money and time, and in urgent need of overhaul”.
Because, for all the decades of deep academic, economic, clinical and governmental expertise and intellectual rigor of healthcare subject-matter and policy experts, the vast majority of the disciplined analysis and insights ring remarkably hollow.
Healthcare is at war and it’s time the healthcare community realizes that our historical approach of using the realm of ideas to shape our future is a failure. The passivity and genteelism illustrated in our approach reflects the weakness of our tools and techniques. Our enemies do not respect any rules of engagement; they are laughing at us.
Over the last few decades, the healthcare provider community has been buffeted by many forces of change, none so powerfully as the competition for our economic and social capital.
We have largely been destabilized and rendered vulnerable to those with less selfless and less generous agendas: commercial and political communities unimpeded by the cultural and academic mores that have been the historical underpinnings of the medical profession.
What Dr. Arnold Relman, former Editor-in-Chief of the New England Journal of Medicine called the ‘medical-industrial complex” has disintermediated and dehumanized the traditional doctor-patient relationship, undermined professionalism and offloaded administrative responsibilities and costs to the healthcare delivery system without proportionate compensation.
We have tried to fight the battle, but the rules of engagement of the free market and politics are largely foreign to our professional culture and skills set.
The effort ended driving more of a wedge into the professional community itself. Physicians organized around specialty identities and entering a zero-sum game, with primary care and specialist physicians bickering over how dollars are divided among themselves while payers doled them out like parents deciding if they earned their allowance.
This fragmentation, pitting physician-against-physician, only served to weaken the profession even more — with the patients losing trust as physicians were distracted and reduced in their capacity to share the work of worry about their health.
Physician-poet William Carlos Williams wrote “no ideas but in things”, the connotation being that meaning is in the tangible; objects over concepts. I can tell you that the enemy has mastered the power of Williams insight. They are not shaping the world with words, but with pervasive action. They have, and use with aplomb, skills and competencies that actively shape the knowledge, attitudes and behavior of key target audiences toward their oft-hidden ‘prime directive’ of protecting (and growing) their money and power. They are master manipulators and use every systemic weakness to their advantage.
The academics, researchers and policy wonks fall right into the trap they set: knowing our reductionist tendencies, they get us head-down in the details, trying to find the flaws, trying to understand language and codes, modeling scenarios; with us distracted, they remove all our furniture without even the need for stealth. Behind the curve and forced to react to an aggressively played hand, we waste valuable brain power analyzing what ends up simply being a distraction.
We’ve seen this happen for decades, with the hospital and physician communities reacting by trying to fight the battle of professional devaluation on economic terms. Unfortunately trying to fight on other people’s terms is almost always a losing proposition.
What is missing is any sense of strategy-towards goal. For all the experience and opinions out there, there are few insights as to how to wrest control of healthcare to the benefit of the health status of Americans, independent of partisan politics and lobbyists, in the same way the taxi industry was forever changed; not with an app, but with a strategy that uncoupled tradition and organized collective action.
It’s time to embrace and master the very same weapons that I watched, and helped, them use against us: strategic thinking, communications discipline, audience targeting, message segmentation, strategic thinking and economic leverage.
However, before this is possible, we need to organize and rally around a singular decisive infection point: redefining the foundational identity of the physician, independent but inclusive of all specialty perspectives or competencies — medical, surgical, behavioral — and reclaiming the profession.
Confirming our commitment to excellence and human service beyond economics will revitalize the experience of care for patients and professionals and garner the affinity and loyalty necessary to assert our social and political will.
Two forces are in our favor. The first is the evolutionary principle, as described by Edmund O. Wilson that “within groups, selfish individuals beat altruistic individuals, but groups of altruists beat groups of selfish individuals”.
This means that if physicians organize around and commit to their fundamentally altruistic professional mission, they will have a better chance of winning the battle for professional identity than if they keep trying to compete on goals of specialty-based self-preservation.
This shift away from primary defense of economic status will be offset by the second force in our favor: the free market. It is also well established that people will pay a premium for the value; the Ford Taurus you rent from Avis is exactly the same car you can get from Budget, yet people show preferences and are willing to pay a premium for one over the other.
By regaining control over professional identity, physicians will have the opportunity to wrest control of the definition of value, and in doing so, reevalue themselves in society and the ‘marketplace’.
One of the tenets of public relations is “define yourself before others define you”. However, in many ways we are own own enemy, as clear definitions are impeded by our own tendency to asymptotically studying issues without ever reaching a consensus upon which to build actionable insight; in this we squander our own time, energy and knowledge-as-power.
“Needs further study” is not a strategy, but a platform from which to watch others overrunning our territory (note well: the ascendance of urgent care is a failure of mainstream medicine to recognize the changing dynamics of work and family life; would it have been so hard to have office hours til 9pm?). How many times do we need to study how mental health diagnoses are associated with increased resource utilization before we declare that relationship validated and act on it on our own to deliver integrated care?
Such collective action could flip our subordinate position in the figure/ground relationship of power in healthcare; we adopted SOAP notes on our own, why not a universal framework for care planning would allow us to determine the requirements, and value, of investments to ensure that every member of society has the same opportunity to optimize their health status? We don’t need to ask permission to do so.
Many disciplines and industries outside of healthcare have demonstrably powerful knowledge and tools that might productively contribute to the healthcare community’s goals for improving the quality of care delivered to individuals and the quality of health of populations. Despite our capacity to master complex science and make life-changing (and potentially life-taking) decisions and actions, we may not necessarily be competent to evaluate the value and power of concepts from outside of healthcare, resulting in unconscious, but significant bias in their selection, approval and support; this phenomenon may be equally true for peer review, influencing what see, and don’t see, in our professional publications.
You can’t see the whole picture with blinders on.
Species with limited genetic variation are less able to adapt to changing environmental conditions. Looking at healthcare as a species, we would benefit considerable if we diversify our conceptual DNA.
This will require a critical look at our own biases, flexibility in our process of understanding and assessing capabilities and competencies outside our own expertise and a willingness to evolve — not just our organizational processes and system workflows, but what my colleague Dr, Sam Bierstock calls our “thoughtflow’ — in ways we may not envision today and may be uncomfortable.
Our survival as a species may depend on it.
The big question is whether we, as a society, want people to be sick or well. The healthcare war is over who is best suited to educate around and influence that decision and, if we chose well, who is best suited to determine the framework by which such a social imperative is achieved.