Tuesday, April 23, 2013

Doctors: Out with the Old and Realistic, In with the New and Idealistic
What is morality at any time or place? It is what the majority then and there happen to like, and immorality is what they dislike.
Alfred North Whitehead (1861-1947), Dialogues of Alfred North Whitehead
Reading the health reform tea leaves is a little like reading a morality play.   A morality play’s main theme is this: We begin in innocence.We falls into temptation. We repent and are savedl  We struggle against the seven deadly sins of greed and self-interest.  
Some argue that fee-for-service impels doctors to become specialists, to master a narrow discipline, to do as many procedures as possible out of greed, and to do everything to pursue their own interests rather than those of patients.  

The answer to reforming these misdireactions,  believe, medical school educators,  is to reform how doctors think by picking a different kind of medical student and reeducating them to meet society's interests and those  patients rather than their own needs.
This point of view is expressed in three articles in the April 25 New England Journal of Medicine.  The articles, by medical school academics from Boston University, Icahn School of Medicine at Mount Sinai in New York, and University of California in Los Angeles, accurately reflect their content.
·         “Holistic Review- Shaping the Medical Profession One Applicant at a Time.”

·         “Reforming Premedical Education – Out with the Old, In with the New”

·         “The Opportunities and Challenges of a Lifelong Health System.”
The gist of these articles is that we need to create a new kind of doctor and to minimize producing the old kind of doctors - those overly structured, driven individuals who sought to master medical and specialized subject matter – and to select a new kind of doctor – a holistic generalist team who works well on a salary within organizations and who knows as much about humankind than his or her own self-interest and discipline.
The result, say the various authors,  is “that medical school admissions  is not merely about selecting new year’s class, but also about selecting the physicians who will successfully lead a rapidly evolving 21st-century health care workforce… we have allowed premedical curricula to ossify despite advances in science , clinical practice and technology…The main challenge it to create a lifelong health system lies in moving from a fee-for-service model with  short time frames in paying for value and better outcomes over the long term. Innovation in care delivery, integration of services, and development and adaption to new fiscal tools can all contribute to strategies for improving health.””
I’m reminded of comments by Phillip Miller of Merritt Hawkins, a national physician recruiting firm.
“Students still go into medicine for the right reasons - to take care of people and to create the bond of the physician-patient relationship.  ...The difficulty arises once they have gone through all those years of training and begin practice.  They find the medical practice environment interrupts their dreams and disrupts patient relationships. At that point, physicians become disaffected, more so than they have in the past.”
Which brings me to what many older doctors think?   Jeffrey Singer, MD, a Phoenix based surgeon, writes in the current issue of Reason magazine
“Government interventions over the past four decades have yielded a cascade of perverse incentives, bureaucratic diktats, and economic pressures that together are forcing doctors to sacrifice their independent professional medical judgment, and their integrity. The consequence is clear: Many doctors from my generation are exiting the field. Others are seeing their private practices threatened with bankruptcy, or are giving up their autonomy for the life of a shift-working hospital employee. Governments and hospital administrators hold all the power, while doctors—and worse still, patients—hold none.”

Tweet: Medical schools are now selecting and creating a new kind of doctor- team-based, less-structured physician intent of improving outcomes.

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