Some Big Things That Keep A Physician Awake At Night …

The essence of Torah: “Do unto others as you would have them do unto you.” Rabbi Hillel explains that “all the rest is merely clarification.”  Hence, moral actions assume primacy in important human endeavors such as the practice of medicine. Agency, discernment, caring and healing relationships—those are elemental to “medicine befitting free men” (Plato, the Laws, ca. 350 BCE).

And the wisdom of a West Texas cotton farmer covers most of the rest: “I invest in people and land, because that which God creates appreciates, and that which man creates depreciates.” See what follows about engineering, monetization, and rhetoric of control; there are consequences when transactions (exchanges) replace or subordinate medical relationships.

The importance of a child’s developing brain to the future of the world cannot be overstated. The child’s brain is the perfect example of and laboratory for a complex adaptive system. From it will emerge the two determinants dominating the future of mankind: 1) healthy brains, which 2) can think. From these two fonts will pour innovation, productivity, and demand freeing humans to craft a humane society through caring and healing.  It will never be free of risk and fear, but it will be more fulfilling. No greater good exists than getting this right.

A funny thing happened on my journey as a physician… healthcare. Forty years ago, the word did not exist, nor did its assumptions, metaphors, and conceits. It assumes disorder and chaos can be controlled, that variation is bad, and that experts can take charge of and fix all of that. In my fewest possible words: “Tell it to the disease; tell it to that patient.” Then ask yourself: What is the intellectual discipline of healthcare? Healthology? Does it function like an ecosystem or a social construction? What is its core competence? Transaction management or consolidation (deal making)? Did anyone ever go to Provider School? How about Stakeholder School (and what is the nature of the “stake” they hold)? Who and what gives these words their power? Or has it been assumed…? Is anyone concerned that ecosystems have predators and parasites as well as symbiots? Is anyone asking if and how the conceits and complicated mechanics of command and control are helpful? Do they ever work in complex adaptive systems? Do they almost always cause more harm than good, if only because they amplify entropy? What is really going on here, and why? One answer: healthcare concerns itself almost exclusively with structure and process for gain, because it never seems to influence outcomes (i.e., actual medical ones).  Another: “Healing is an art, medicine is a profession, and healthcare is a business.”

In the past 50 years, there have been major culture shifts in America, from: opportunity to entitlement; liberty to security; individual responsibility to institutional rights; virtue to protocol; productivity to distribution; relationships to transactions; competence to conformity; message to medium; and good to fair. So, American citizen, consider John F. Kennedy’s phrase from his inaugural address, January 20, 1961: “Ask not what your country can do for you, ask what you can do for your country” Now ask yourself how are we doing in American “healthcare” some fifty years later?

Why does quality in healthcare resemble an industrial plan? Why are “science” and “results” presented like Kabuki theatre? Why do we not insist on ‘Metrics of the Moment”, including narrative (the actual experience of being ill, chronicled by the person)? Other than family and physician who can help guide, who else’s opinion has relevance? Somebody needed to create a Medical Model for Quality… and somebody did.  Now some others need to field test it for some important medical conditions… and somebody wants to do just that… for children.

The value of health is enormous, and financiers, industrialists, and politicians (FIPs) know this. And patients know it as well. Consider a dilemma put this way: If you were to receive news that you will die tomorrow but for the application of a “perfect technology” that will extend your life for one year of perfect health (at which time you then will die), what would you pay for that? Answer: for most persons, the number in dollars represents a fair approximation of their net worth. (And by the way, the same answer often applies for loved-ones as well.) The value of extending life is reasonably well established. Quality of life (utility) is an additional bonus. The productive value of raising the quality of life of all Americans by 5% would likely wipe out in excess of $100 trillion of debt in a decade through demand side economic growth.

The universe of humanity lives in a loop of complexity (as in an ecology), quality (as primary empirical reality), and communication (our “oaths” by which we represent, reflect, organize, plan, respond, and adapt). We often are shunted to more simplistic and complicated mechanical places through programs to engineer disorder, monetize precious things, and pre-format acceptable responses (political correctness comes to medicine, retarding civilization). These structures and processes are large consumers of resources, with little if any value added. No debtor ever gets better by taking on more debt. Productivity is the ultimate medical outcome, and without it no social construction is sustainable. Stein’s Law—“If something cannot go on forever, it won’t”—applies.  When (not if) intermediations result in waste, dependency, and debt, “we have a problem Houston.” A good place to start with disintermediation would be with children; we are not doing right by them, as dependency and debt will crush their future.

The outcomes of disease—across the full spectrum of all disease in all people—may be represented in the 40/30/20/10 approximation. Forty percent of the outcome is determined by patient behaviors, 30 percent by patient genetics, 20% by environment, and 10% by medical interventions (Brent James, MD, Intermountain Healthcare; and the Institute of Medicine). So, if we want to cut the healthcare budget, we should first trim the “stakehold”of “providers,” right? My universal epiphany (there is one and only one constant to every problem I have ever had…and it is I) comes to mind. By that standard (to use a phrase common in Texas): “That ain’t right!”

About the cost of things: Canadian citizens receiving care at U.S. facilities will pay about 40% of what insured Americans will pay for the same service in the same places. They come to America, for example, to have knee replacement surgery and pay cash (presumably because they are intelligent enough to understand the value of time and utility). This is an example of the understanding that in America at least 60% of the money is spent before anybody sees a patient. The system feeds itself first (and “every system is perfectly designed to get the results it gets” [Deming]). So assume you are sick and you have $1,000 to spend, which “stakeholder”/ intermediary would you hire first? In such a system, the most vulnerable (including children) are at high risk. As before, perhaps it will be a child who sees through the new clothes of today’s Healthcare Emperors.

Finally, Aristotle distinguished between goods of primary intention—family, faith, health, and community included—from those of secondary intention—power, money, prestige, and property, for example. The challenge of a life well lived is to form connections for the goods of secondary intention to primary ones. Fulfillment will only be achieved when we do so. The ship we call healthcare is lost at sea, so that some now call it the “Brigantine Hellthcare.”

George R. Beauchamp, MD

July 4, 2012

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