Sunday, June 19, 2016
In Medicine, Politics Is All Local
All politics is local.
Tip O’Neil (1912-1994), Democratic politician and Speaker of House of Representatives
I have spent much of my medical career trying to unify doctors and to get them to speak with one voice. I have written 12 books on the subject, composed countless blogs, spoken at many conferences, tried to form organizations like the Integrated Health Organization , worked with the Physicians Foundation, brought my message to audiences in Minnesota, Oklahoma, Connecticut, and Boston – all to no avail.
The problem? Medicine is not perceived as a national enterprise with a single voice. The AMA has not done the job, perhaps because it has tried to do too many things for too many people and because it has become an impenetrable and distrusted bureaucracy. A new organization, Unified Physicians and Surgeons, is seeking to fill the void, but it is too early to say if it will have any impact.
Why have doctors failed to create a single unifying vision of the profession?
There are many reasons.
Here are a few of them.
· By training and inclination . doctors are fiercely independent and prefer to be their own bosses free of outside influences. In a business sense, we are our own worst enemies.
· Most doctors are non-hierarchical . Doctors do not like structured organizations with one leader calling the shots; they prefer doctor democracies with equal voices for all.
· Sad to say, but doctors tend to be jealous of one another. Perhaps this evolves from competition to get into medical school or into training programs or competition with each other. Quality to many is how I do things. Doctors do not reward their star performers.
· Doctors have had little need to be unified. They have done very well on their own – with incomes in the $200,000 to $400,000 range.
· For the most part, most doctors are not business or politically minded on issues requiring organizational or management skills and self-sacrifice.
· Doctors have a latent and deep distrust of government or large organization who presume to manage medical affairs from a distance.
· Doctors have little training or inclination to form overarching management structures – with enough capital, specialist resources, and marketing reach – to get the job done.
Organizing doctors and beseeching them to act in an organized way, to use that tired cliché, is like herding cats. Cats are fiercely independent, even to their owners, except when the cats are being fed and petted by owners and are being protected from competitive predators.
There are exceptions, of course - the Mayo Clinic, Kaiser, Geisinger, the Cleveland Clinic, other large group practices, big academic centers, and affiliated medical-academic complexes like the Harvard complex of hospitals and groups – that have able to unify doctors within their walls or jurisdictions.
Each region of the country has its characteristics – the Minnesota and West Coast formation of huge group practices and integrated hospital systems, Oklahoma City’s free-standing surgical center manned by 40 surgeons offering bundled services for cash, and the New England tendency to be dominated by large integrated hospital systems featuring salaried physicians.
But, by and large, medicine has not gone national, nor does it have a national vision across primary care and specialties. That remains a local or regional matter. Outside of national clinical laboratory companies, we have few national medical franchises, national physician companies offering specific products or procedures, national corporations led by multimillion dollar CEOs.
Doctors perceive medicine as a profession, not a business. A profession, by definition, is an occupation requiring extensive education in a branch of science or the liberal arts and designed for service to the public. It does not require education in business or politics.