Sunday, May 29, 2016

Saving Soul of Medicine
I owe my soul to the company store.
Lyrics of song,  Sixteen Tons, most memorably sung by Tennessee  Ernie Ford in 1955
Physicians are struggling to save the soul of medicine.  They feel they owe their allegiance and  skills  to  patients, not to the corporations  or hospitals,  not to CMS (Centers of Medicare, Medicaid, and ObamaCare),  not to the VA,   and not to insurers, all of whom set the rules of payment for roughly half of all Americans and dictates the rules of patient engagement.
For physicians this struggle poses problems of the soul, defined as the principles of life, feeling, thought, and action in man, the spiritual and moral part of man as distinct from the physical part.
Serving Three Masters
How do you serve three masters, your employer, your government, and your patients?  How do you serve as the prime deliverer of these services without sacrificing your soul? 
At What Point
At what point, does the profit of your employer or payer become more important than your desire to give patients the best medicine has to offer? 
At what point, does servicing your own debt (the average debt of physicians entering practice is about $200,000) become the force that drives you and compels you to follow the wishes of those who employ you and pay your bills? 
At what point is enough enough?  And you feel you must go on my own to serve yourself, your family,  and your patients better? 
At what point, do you heed the words of Matthew 16: 26, “What is a man profited, if he shall gain the whole world and lose his soul.”
Daunting Dilemmas
These are daunting dilemmas. 
The dilemmas involve choices between morals and markets,   socialism and capitalism, economic prosperity and  economic stagnation, government control and individual liberty, idealism and  reality.   Physicians find themselves between a rock and hard place, tormented by tortuous ambiguities and convoluted  contradictions.
Do you owe your soul to a government health law, designed to cut your fees to below Medicare, which is 80% below private fees? 
Do you owe your soul to your employer, usually an integrated hospital system or a large medical group, whose profit may depend on how well you perform and follow directives?
Past Writings
I have thought about these dilemmas for years, first in a 1988 book And Who Shall Care for the Sick?  The Corporate Transformation of Medicine in Minnesota,   in 2005 in Voices of Health Reform- Interviews with Health Care Stakeholders at Work: Options for Repackaging American Health Care, in a 2009 book Obama, Doctor, and Health Reform: A Doctor Assesses Odds for Success,   in 2011 in The Health Reform Maze: A Blueprint for Physician Practices, and finally in 4300 blogs and tweets in Med innovation and Health Reform. Com (2006 to the present).  
No Easy Answers
The answers are not easy.  Universal coverage is noble, but it is proving to be unaffordable when superimposed on the current entrenched system.   Given the nature of the federal bureaucracy, government care is inherently inefficient and interferes with the doctor-patient relationship. 
Anytime government undertakes anything on a massive scale, it becomes entrenched permanent, and dependent on its constituents.  
If you defy the government, elected by popular vote, you are labeled as unpatriotic or immoral.  
If you act in your own self-interest, you are considered  greedy and ignoring the collective interests of the nation. 

If you do not accept Medicare, Medicaid, or ObamaCare exchange patients because   you cannot afford their reimbursements levels and stay in practice, you are said to be inhumane and self-serving.
Saving the Soul of Medicine, the Whyte Way
In 2007, I interviewed David Whyte, an English poet then living in Washington State.    Whyte earned his living by serving as a consultant to health care corporations, using poetry as physician soul-saving tool. 

Whyte believed physicians were losing their souls to business matters, and he sought to help corporations help physicians regain their souls.     In his heart and soul, Whyte believed government health care, as practiced in Britain and Canada, was the answer in physician-soul saving.
Here was his reasoning:
The health service in Britain, just as in Canada, has lots of difficulties, but it is astonishingly cohesive glue for the whole of society. Neither country would ever swap it for the system we have in the U.S. “

“The National Health Service gives you the sense of being part of a greater society, that you are not just part of an anthill with people climbing over one another. There is a social contract that admits to a greater bond with one another than our ability to pay up. If things go wrong, there is a safety net. “

“Society has made a contract whereby you will be taken care of no matter what your financial background or particular circumstances; that is an immensely powerful idea. I'm not sure the conditions would ever be right in the United States for that to come to pass, because the mindset, the vested powers and the individual expectations are so different. “
As   consultant to major health care corporations, David believed poetry was a potent humanistic weapon for saving souls.  By hiring David, corporations sought to escape fetters of an overly managed and rigid hierarchal pyramid. Corporate leaders sought to bring humanity to employees and caregivers to render them more creative, adaptable, and dedicated.  Corporate leaders sought  feedback and ideas from people on care frontlines, for they were  true arbiters of quality coupled with humanity.
When Whyte used that word soul” in the workplace, he was encouraging physicians to have a sense of participation in the particular work or the organization, a sense of texture, color, intrigue, and surprise. For most human beings, that was  an important question to ask and an important journey to follow.
American physicians, particularly those in heavy managed care areas, he felt,  were losing their souls in the name of profit. How do they regain their souls?  He did not mention the soul of corporations or their need for profit.
Whyte said the soul of medicine was on trial.  There was no coherent voice speaking up for the spirit of medicine, and the spirit of what doctors stand for. The American Medical Association had not spoken to the soul of medicine.

Doctors, he added, were trained in a hierarchical way. Because people's lives were at stake, there were always people who know better how to deal with those vulnerable thresholds of health. Doctors were therefore constantly deferring to someone else or to the great hierarchy of knowledge throughout the system.
Something Had to Change
Something, he thought,   had to change. No one was happy with the system.  He quoted Oscar Wilde who  said of a certain person, 'He has no enemies but is intensely disliked by all his friends." It applied, unfortunately, to American health care. It was hard to find anyone who will speak up for the U.S. health system with any enthusiasm.

Whyte noted we had almost 45 million uninsured people.  No society could afford to disenfranchise so many of its members. We were surely approaching a bridge that we would  have to cross, where everyone sould  have to give up something, somewhere, and that bridge was  probably not too far ahead of us.
Not Convinced
I am not convinced that the answer to moral problem of the uninsured lies in universal government  coverage.    A government system breeds bureaucracy, is inherently inefficient, discourages innovation, and inevitably involves rationing with long waiting lists, as exemplified by today’s VA waiting lists.
For these  reasons, and because of the impersonal nature and  higher costs of any government  system,  a dual system is emerging. 
One will be an impersonal  government-related and run system, like Medicare, Medicaid, the VA, and ObamaCare.  The other will be for patients and physicians, who seek affordable liberty and choice, personal care, and efficiencies and amenities , beyond the reach of government.

Or there may be a cross-over between systems.    Pete Sessions (R) and Dr. Bill Cassidy (R) have just introduced a House bill that allows patients to stay in or leave  ObamaCare  health exchanges.  As premiums and deductibles rise, they can go to a market based system with $2500 in tax credits (plus $1500 for each child) to purchase private insurance or to put their money into health savings accounts.
Perhaps poetry, with its capacity to make the complex simple  and its power  to evoke the best in the human  soul and spirit ,  is the answer.   Perhaps computers and the Internet and social websites will breed efficiencies , promote individual choice, and  give every patient a portable medical record to carry from doctor to doctor.
 But perhaps not.   Government and health care corporations  have turned to algorithms and data and artificial intelligence to manage doctor-patient relationships,   but  there is nothing poetic about data. Government and managed care are  not poetry,   but bureaucratic  prose (regulations and  mandates)  and  prose run mad.

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