Thursday, October 13, 2011

The Great Finesse in Health Reform- Changing The Language

One man’s words are another man’s poison.


We were reasonably calculating in our approach. We consciously began using the language of the marketplace, rather than the language of medicine. We began talking in terms of “providers and consumers” instead of “doctors and patients,” for example. This, of course, was and still is highly offensive to many people in medicine, and we felt the old language was almost like the language of religion, and, thus, harder to use when trying to affect widespread change.

Paul Ellwood, MD, 1985, “Life on the Cutting Edge,“ Twin Cities Magazine, 1985

1n 1988 in Who Shall Care for The Sick: The Corporate Transformation of Medicine in Minnesota, I said that words matter in health reform, that use of “providers and consumers” signaled a transformation in American medicine, and that these words werea “Grand Finesse” of American physicians, effectively distracting them from what was really happening.

I predicted physicians would become serfs of payers, physicians would be disillusioned , and ultimately, a doctor shortage would ensue.

In my book, I quoted a passage from Alice in Wonderland,

“ ‘ The question is,‘ said Alice,‘ whether we can make words mean so many things.”
‘The question is,’ said Humpty Dumpty, ‘ which is to be the master – that’s all.”

The master has become the marketplace and payers – whether they be private plans or Medicare. If you give the matter any thought at all, you will realize changing the language from “doctor and patient” to “provider and customer” changes everything.

Money becomes King. The new words reduces doctors to just another “provider,” or “vendor,” or “seller,” along with other “providers” – chiropractor, naturopath, social worker, psychologist, physical or respiratory therapist, hospital, or any other care facility.

And these words transmute patients into “buyers,” “consumers,” or “consumers.” It opens the doors for converting medicine is just another business sector that can be industrialized and standardized - the main thrust of Obamacare and its cadre of government experts.

As my 1988 book indicates, thee is nothing “new” about this conversion of medicine into just another industry. It has its real beginning with wholesale introduction of managed care into the medical mainstream in the 1970s and 1980s and continues to this day.

In an essay “The New Language of Medicine, “ in the October 13 issue of the New England Journal of Medicine, Pamela Hartzband, MD, and Jerome Groopman, MD, wife and husband and Harvard faculty members, capture the essence of the impact of the language change means.

Prominent health policy and even physicians contend that clinical care should essentially be a matter of following operating manuals, like factor blueprints, written by experts.”

They go on,

The guidelines for care are touted as strictly scientific and objective, In contrast, clinical judgment is cast as subjective, unreliable, and unscientific.

And they conclude,

The specific cutoffs for treatment or no treatment, testing or no testing, the weighing of risk versus benefits – all necessarily reflect the values and preferences of the experts who wrote the recommendations. And their values and preferences are subjective not scientific.

Medicine, by its very nature, because it involves the permutations and combinations of variable human beings and their variable relationships with different values and expectations, is inherently subjective most of the time.

Yet I have not seen a comprehensive study of large series of consecutive patients going through primary care offices showing how many of these patients have conditions to which “objective guidelines” apply.

There is another motive, seldom mentioned, behind the widespread use of guidelines – reining in physician economic behavior, particularly “clinical judgment” that benefits doctors financially.

Supposedly guidelines, by rationalizing what should or should not be done, and what should or should not be paid for, would cut the physician “greed” factor. This so-called greed may be partly unconscious. Yes, doctors profit from procedures or tests they are trained to do or order. These is what colleagues and patients expect them to do.

The guidelines may miss another critical point – doctors deeply believe what they do helps people and shows they care about patients as people, not just “paying customers.”

The words, “patient doctor,” are serious words. Human relationships matter. They are a national and human resource and should be preserved and cherished over mere “provider and consumers.”

Tweet: Changing the language from "doctor and patient" to "provider and customer" changes the fundamental nature of medical practice.

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