How many times a day do I hear fellow providers of health care ask themselves the title question? A dozen? A hundred? How many times have I asked myself the same question? We all mean it seriously. We all wish someone would give us back our calling.
People who provide health care – nurses, doctors, respiratory technicians, pharmacists, etc. – believe that we were called to do what we do. When we chose to enter health care, we were answering a call to nobility, not doing a job simply to pay the bills.
What has caused health care to go from noble calling to painful job?
Practice of health care
Over the past century, dramatic advances in medical knowledge and technology have profoundly altered the role and capabilities of health care providers as well as their relationships with patients.
My grandfather graduated University of Pennsylvania Medical School in 1912. In his day, there were two kinds of doctors: surgeons and physicians. That was all. Today, doctors are specialists and super-specialists. Orthopedic surgeons operate on one joint only. Care is now delivered by teams, rather than by a single physician.
Using modern capabilities such as CAT or PET scanners, both the structure and the function of all internal organs, even the brain, can be evaluated. No invasion of the body. No doctor hands on the patient at all.
Between the super-specialization, care by teams, and the interposition of technology, the doctor is increasingly separated from the patient.
Finally, there is the public perception of healthcare’s broken promise. Modern health care has oversold itself. Without meaning to, doctors have left patients with the impression that health care can fix anything. You and I know there are many, many medical conditions for which there are no good treatments. Intellectually, patients know this is but as soon as sickness strikes, emotion takes over. Provider becomes God. God will save me.
When the patient does not recover fully, has an adverse outcome, or succumbs, obviously it is God’s fault. Doctor-God has become Satan. Patients expect health care providers to be what they can never be: perfect. When providers demonstrate their humanity including limitations in what we can do or when our imperfection is manifest in a error, the bubble bursts and the trust relationship inverts to adversarial. Fiduciary becomes agent-of-my-distress.
Now comes the med-mal lawyer and the healthcare bureaucrat.
Administration and Litigation of healthcare
As a small child, I watched patients reach in to their wallets to pay their doctor, my grandfather. They had a fiduciary relationship in both financial as well as ethical meanings. As a doctor myself for 35 years, I have never had a patient pay me out-of-pocket, ever.
Financial separation of the doctor from the patient, termed micro-economic disconnection, prevents the free market from functioning in healthcare. Consider the phrase third party payer. By definition, the third party separates the two parts – the two halves – that constitute a functional free market: supply and demand.
When you go to McDonald’s, you choose the meal, you pay for it, you eat it, and you evaluate it. McDonald’s is the supplier and you are the demander, the consumer. There is no third-party. It is just supplier and consumer, who balance each other through price competition (among suppliers) followed by exchange of money for product or service.
In healthcare, the patient-consumer does not pay the doctor-supplier. They are ‘disconnected’ financially by a third party – the insurance carrier – who pays a predetermined amount to doctor and/or hospital. Supply and demand cannot balance because: a) there is no direct financial connection between consumer and supplier; b) both price and reimbursement are fixed: they cannot vary; and c) the one who consumes is not the one who determines the value and worse, the suppliers do not compete on either price or quality.
Each rule or regulation puts another small wedge between doctor and patient. Rather than protecting the patient, each additional regulation further constrains what the provider can do in the service of his or her patient. Rules and regulations are the government coming between you and your patient.
Instead of the patient or innate altruism calling the provider to service, it is now government calling the shots, expanding the power of its bureaucracy, and generating huge expenses that the Public does not see but must pay.
A final intrusion in a provider’s previously satisfying life is the tort system. While its financial expense is substantial – multibillions of dollars per year – the cost is much greater to the soul of healthcare.
The medical malpractice system is intended to deal with adverse health care outcomes and errors. Based on the tort (civil wrong) legal model, medical malpractice requires that a cause-effect link be identified, and that action or inaction by one person is the cause or agent of harm to another person.
Direct cause-effect links are occasionally can be identified in health care such as the surgeon who operated on the wrong (unobstructed) coronary artery in comedian Dana Carvey. However, most of the time, the cause of bad patient outcomes is not known.
Our current medical malpractice (tort) system requires that a wrongdoer be identified before it can “make the victim whole.” Without fingering some perpetrator, the injured patient cannot be compensated. Since such identification is impossible in the majority of cases, most injured patients cannot be made whole.
Because it is based on the tort model, the medical malpractice system, by its nature, inverts the fiduciary doctor-patient relationship instantly turning them into adversaries.
You cannot “adjust” such a system to make it work because the fundamental concept on which it is based – tort law – is not applicable to healthcare.
When health care providers are considered guilty until proven innocent and treated like ‘perps’, their noble calling has completed its conversion to painful job.
How did my calling turn into a job?
The answer to the title question is simple. People and providers live in the 21st century. Healthcare is still back in the 19th. Each part of healthcare (the system) and health care (the service) has changed, radically and independently, while the system itself has remained static. The system did not adjust because it cannot. Healthcare is not a complex adaptive system. It is a system in name only, a system without system-ness, a non-systematic system.
The root cause or primary etiology is the lack of system-ness. That is what we need to cure and will do so in Part IV.
Deane Waldman, MD MBA, author of “Uproot U.S. Healthcare,” your personal guide to curing Patient Healthcare.