Thursday, January 29, 2009

Physician mindsets - Mindsets about Physicians

Judgments in almost every area are driven by mindsets, from worldviews to personal relationships. If a wife’s mindset is that she has a faithful husband, she receives all information as fitting into that picture. It defines what she hears beyond words and her reaction to it. If a wife’s mindset is that she has a faithful husband, she views the world differently. That’s at the micro level.
At the macro level, there are those whose mindset is that the world is in a “clash of civilizations,” and they see everything within this frame.
Of course we all have mindsets, like politicians are a bunch of crooks, outsourcing to India is stealing American jobs, cats are the cleanest animals you have, global warming is a threat to the sustainability of mankind.

John Naisbitt, Mind Set!, Collins, 2006

Two Doctor Mindsets

Why should mindsets about American physicians be any different?

• One prevalent mindset in this age of reform is reflected in the views of the Dartmouth Institute. It says doctors don’t heed evidence-based care and go their merry way, doing what they want to do. The Institute is most famous for its work on “unwarranted practice variation” which they have shown exists among doctors, especially between specialists, hospitals, and academic institutions. Consequently, costs and outcomes vary enormously in individual cities, contiguous states, and different urban and rural regions. The Institute claims this wide variability comes at the cost of quality, outcomes, rationality, and price without rhyme or reason, other than padding one’s pocketbook and charging what the traffic will bear. Variability also reigns because of lack of monitoring so measure amd subdue it. Overall, says Dartmouth, these variations produce a 30% “waste” in the system. If only one could reduce variation, one could boost quality, make care more uniform , and reduce waste. For this insight, John Wennberg and his Dartmouth colleagues have received honorary degrees and a string of kudos from the health reform establishment, including some who think Wennberg should receive a Noble Prize for Medicine or for Economics.

• Another less visible mindset is that health care is a vast, individualistic, entrepreneurial, innovative , unmanageable, ungovernable enterprise known as the health care industry.. This industry, it is said, is the product of unhampered choices made by patients and physicians in free markets. Leave the markets alone, say its advocates, and the checks and balances and reasoned judgments of everybody participating will work themselves out. This is the view of the market-driven crowd who believe Americans should be left to their own devices, wishes, and choices. It is not the view of third parties who pay for care – Medicare, Medicaid, and health plans.

Mindset of Policy Reform Sector

The mindset of the reform sector staunchly advocate accumulating and applying “data” to more tightly manage care and to bring rationality to the table. This sector tends to push their agenda in certain publications and media outlets. The New York Times, Health Affairs, other health policy journals, the New England Journal of Medicine, growing numbers of liberal blogs, think tanks like the Commonwealth Fund, the Robert Wood Johnson Foundation, the Urban Institute come to mind. The leading lights of this mindset are sometimes called “Policy Works, “ defined as persons who develop strategies and policies , especially those who have a keen interest in and an aptitude for technical details and a rapt attention to data supporting their point of view.

Mindset of Free Market Sector

On the other side of mindset aisle are free-market supporters, who tend to be politically conservative and capitalistic in their world views. They believe health care market details will work themselves out in the push and pull, tug and counter-tug, competitive battles of the marketplace. In the end, society will squelch the outliers. In this group are think tanks like the Manhattan Institute, the Cato Institute, the Hudson Institute , the Heartland Institute, the Heritage Foundation, the Hoover Institute, the Galen Institute, the American Enterprise Foundation, Consumers for Health Care Choice, Fox News, the Wall Street Journal, and, of course, Talk Radio. Champions of this sector may look upon their ideological opponents as eccentrics, “kooks”who are paving the way to socialism through data-mongering.

Mindset Actions and Reactions

Those enraptured with these respective mindsets tend to ridicule their ideological adversaries, to gather data to support preconceived notions, to exclude dissenting points of view from their news and information outlets. They often practice a form of censorship by muting the opposition by being dismissive or not airing opposing points of view, and by filtering and editing material to match their mindset.

The mindset is both cases is not what the news is or what the facts are. It is how you receive and process the information, how you view the world through your respective lens. Each mindset sector, if you will pardon a pun, “doctors” the data and supporting information to fit their world view. In America, we call this “Debating the issues, “ “We win, You lose,” “Our Guy is smarter than your Guy,” or “Democracy in action. ”

Politically, mindset differences have manifested themselves in calls for bipartisanship, in why we can’t just get along for the common good. Yesterday’s vote on the $819 billion economic stimulus in the House of Representatives – “Yes,” 244 Democrats, “No, ” 178 Republicans – though not focused on physician issues other than calling for $20 billion for electronic medical recors, shows the power of partisan mindsets.

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