MedCanto

In “Inside Out”, Pixar Animations 2015 blockbuster movie, we watch as 11-year old Riley, whose life to-date has been largely driven by Joy, learns the value of Sadness as she comes to grips with a life changing event.  In so doing she has to let go of a piece of her childhood self but ends up a better balanced person and closer to her family.

What most movie-goers don’t know is that the story has an academic foundation in the work of, among others, Dacher Kelter, a psychology professor at the University of California Berkeley and an expert in the social functions of emotion, whose insights also have reflective implications on the practice of medicine and delivery of care. 

 In a 1993 paper¹, Dr. Keltner and his colleagues added valuable detail to our understanding of how emotional states affect cognitive processing, specifically our appraisal of others, clarifying that “when we are angry…(others) seem lazy, manipulative, and intentionally obtuse; when we are sad we may see the very same behaviors as signs of overwork, real need, or genuine misunderstanding”

 The frustration, dissatisfaction and anger of the medical community, and their perception of their well-being as threatened by system-level factors, has been the subject of much attention recently².  Considering Dr. Keltner’s research, we can see how a physician’s underlying emotional state may have adverse effects on their capacity for clinical appraisal and potentially interfere with their ability to meet societal expectations for quality of care and clinical outcomes.

 In my role as Chief Medical Officer of primary care network serving exclusively complex/fragile patients, I regularly observed the “Keltner effect” in action; physicians with with the most complaints were generally angry, bitter and disappointed in their careers and the changing role and place of physicians in society.  In many of these cases, a genuine listener is all that was necessary to re-orient the patient relationship and improve quality and patient satisfaction.

 But what about those doctors?  In truth, the foundation of successful medical practice is not the scientific method, but the willingness to truly shoulder the work of worry about another, unrelated, human being. Making space in your heart and taking on the extraordinary depth of responsibility for life-changing (and potentially life-taking) decisions for other people’s lives requires energized focus, discipline, concentration and confidence, all of which must be nurtured and cannot survive in a vacuum.  Our society seems to understand the importance of this dynamic when it comes to protecting and supporting the performance of elite athletes and movie actors, but we can’t seem to make the same respectful accommodations to the critical performance of those we entrust with our health and our lives.   Given our ambitious goals for healthcare quality improvement, it may be in the best interest of society to provide some level of emotional security for physicians to support their inherently intrinsic motivations to positively change people’s lives.

 A recent editorial lamented the increasing prevalence of process improvement methodologies in clinical operations⁴. While it has been well established that evidence-based process measures can have a significant effect on utilization patterns and costs in a defined population⁵, we do not yet understand the variables that may amplify that performance to the next level.  The question then becomes:  what makes the difference between achieving a 20% reduction in hospitalizations and $68 PMPM savings based on process measures alone, and achieving 60% reduction in hospitalizations and $800 PMPM savings (all things being equal in patient complexity and fragility)?  At some point, it is factors beyond evidence and engineering that will influence patient outcomes.

 Keltner has also established that emotions influence interactions in relationships, where they serve to a) “help individuals know others…beliefs and intentions, b) evoke complementary and reciprocal emotions in others and c) serve as incentives or deterrents for other individuals…behavior.”³   Given the power of emotions to influence knowledge, attitudes and behavior in relationships, we need to consider how human connection and depth of patient-provider relationships may be important drivers of the Triple Aim.  While we typically seek to keep emotions in check in medicine, we may want to consider a more active role for them in the design of our care delivery and value-based payment systems.

 In an internal study designed to define priorities for value-based care, we discovered that more care is not necessarily better when too many different providers are involved.  Our analysis revealed that when a patient is ‘connected’ to a specific primary care team at the threshold of providing 75% or more care, line item costs for primary care, testing and medications may increase, but there is a dramatic drop in overall costs, specifically around inpatient care and use of other outpatient and specialty services.

 Our assessment, reinforced by Keltner’s findings, is that our capacity to achieve dramatic levels of Triple Aim performance is driven by our commitment to continuity of patient-provider relationship and some associated consequences of relationship continuity which have been referred to as “professional intimacy”.

 Our model of home-based primary care makes it almost impossible to maintain traditional “professional distance” and, as such, increases the likelihood of personal connection and accountability, creating a space where patient and provider find meaning and value from each other, and, in doing so, also within themselves.  Professional intimacy becomes the power driving improved regimen compliance, information sharing, collaborative care planning and the desire and motivation to achieve more in one’s life. 

 Professional intimacy uses the power of human connection to help us better understand each other, share emotional experiences together and “serve as incentives or deterrent for …behavior.”   Under it, providers and patients remain present in each other’s lives even when they are absent from our daily schedule, and, as such, the influence of the relationship extends beyond the immediate encounter.

 Professional intimacy is not the same as empathy, nor is does it necessarily require blurring of professional boundaries, but is based on both parties being fully present for each other, generating a level of closeness, confidence, and affection (a’ la Carl Rogers unconditional positive regard), and generating a new level of affinity and loyalty based on mutuality, respect and acceptance (even in the face of imperfection).

 At the end of “Inside Out”, Riley and her parents each have to break through their respective defenses – for Riley, anger to the point that her feelings shut down completely; for her parents, it is the faux enthusiasm they engender to help get the family through a tough transition.  Only then do they find themselves on the same side, as they embrace the sadness they share, albeit for different reasons.  

 Perhaps the medical community needs to have a similar catharsis.   Much of the situation physicians find themselves in has been shaped by outside forces wielding their influence without any values prevailing towards their well-being.  With this history in mind, resistance to change on the part of physicians may, in fact, be simply a desperate attempt to achieve some level of equilibrium, when prior trends have proven to have adverse professional risks or never sustained enough traction to warrant personal investment. 

 However, just like Riley, maybe it’s time healthcare professionals acknowledge to themselves their sense of loss and the sadness about how the healthcare system has changed, feelings we seem to share with our patients (albeit for different reasons); by letting go of our past expectations and embracing the shared humanity of our professional relationship, it may just allow us to find a better balance and connect in ways that revitalize our relationship and our experience of giving, and receiving, care.

1.    Keltner, D, Ellsworth PC, Edwards K. Beyond Simple Pessimism: Effect of Sadness and Anger on Social Perception. J Personality and Social Psychology 1993; 64: 740-752.

2.     Ariely D, Lanier WL. Disturbing Trends in Physician Burnout and Satisfaction With Work-Life Balance: Dealing With Malady Among the Nation’s Healers.  Mayo Clin Proc 2015; 90: 1593-1596.

3.     Keltner D, Haight J.  Social Functions of Emotions at Four Levels of Analysis.  Cognition and Emotion 1999; 13: 505-521.

4.     Hartzband P, Goopman J.  Medical Taylorism.  N Engl J Med 2016; 374:106-108.

5.     Javitt JC, Steinberg G, Locke T, et al.  Using a Claims Data–Based Sentinel System
to Improve Compliance With Clinical Guidelines: Results of a Randomized Prospective Study Am J Manag Care. 2005; 11:93-102.

One of the greatest strengths and most vulnerable weaknesses of the American medical system is our commitment to subject matter expertise as the dominant criteria for authority and career advancement.

Healthcare has traditionally taken this approach to recruiting talent, largely based on peer-review of credentials. This served the medical community well when departmental identity and membership (driven by specific education and training criteria) were the core organizing principles of healthcare delivery; it continues to be the critical when seeking specific clinical skills or vertical subject matter expertise.

However, more often than not when healthcare organizations need ‘enterprise-level’ leadership, they mine their departmental talent pool or recruit from outside an institution based on a model of ‘similarity’ of title or organization type.

It is well established that species cannot evolve without diversity in their gene pool. If healthcare is to advance and thrive in the coming millennium, there will be a need to reconsider the entire process of recruiting and evaluating leadership talent.

Medicine is not the only realm where there is a delicate balance between talent and management in service of real-time world-class performance, yet remains one of the only industries organized in domain-based verticals. In equally complex and mission-critical non-healthcare organizations – Apple, Google, GE, Boeing, Dodge – there are horizontally organized teams that are dangerously nonexistent in healthcare organizations of similar size and complexity. 

The fact is that the "credentialing" approach to healthcare leadership recruitment is major barrier to healthcare reaching its full potential. Sometimes there are non-obvious, but easily transferable and critically valuable skills and experience embedded in a non-traditional professional resume. However, experts in healthcare verticals may not have the depth of professional experience to adequately understand and evaluate ‘outside-domain’ candidates.

First, there is the issue of title parity (or lack of it). A corporate vice president may have substantially more, and far broader responsibilities than a hospital vice president. A corporate VP may be a division leader, with oversight over multiple domains (e.g., sales, technology, marketing, product management), rather than the domain specific responsibilities of most hospital VPs (e.g., service line or service domain [e.g., dietary services]).

Second, there is the risk of ‘fallacy of comprehension’, when we believe we understand something, or its value, but in reality we do not. This phenomenon is especially common in healthcare, where professional success is often based on the capacity to comprehend and assess complex situations. 

However, the capacity to analyze and assess skills in one domain is not always transferable to others. Unconscious, but significant bias in candidate selection may come into play when evaluating the ‘credentials’ of non-traditional candidates. 

Leadership experience in ‘operations management’, ‘product management’ and ‘business development’ are three areas in which the corporate competencies are virtually unrecognizable – but may far deeper and more valuable – than the equivalent functions in healthcare system labels. More important, healthcare executives may be completely unfamiliar with the full depth and scope of positions such a ‘general manager’, or disciplines such as ‘behavioral economics’. Entrepreneurial experience, even transitional, may have provided experiences with team leadership and corporate development that are not fully understood – and therefore devalued – by many healthcare organizations. 

Many academic and professional disciplines outside of healthcare have knowledge and tools that might productively contribute to the healthcare community's goals for improving the quality of care delivered to individuals and the quality of health of populations. However, this might be done in ways that are not native to healthcare thinking or operations. The "fallacy of comprehension' then becomes a barrier to knowledge and skills transfer from outside of healthcare because they are not necessarily recognized during the candidate assessment process.

An interesting analogy can be made between healthcare leadership and orchestral performance. The world-renowned conductor and pianist Daniel Barenboim once said:

“To be a great conductor requires the ability to make people want to play, it requires the ability to animate the orchestra, to teach, to cajole, and at the same time, to learn from what you hear from good players in the orchestra. In every orchestra there is somebody that always shows you something that you haven’t quite thought of before.”

Extraordinary healthcare is symphonic – each instrument being played perfectly by a “subject matter” expert, each player playing a different line of music that, in total, creates a concordant experience for the patient. The conductor does not need to be able to play every instrument, nor even ‘lead’ the orchestra, but to envision the performance as a whole and serve an essential integrating, coordinating role. Even the most virtuoso players understand they cannot conduct and sit first chair; they respect, trust and defer to the conductor because they understand that their solo may be in their hands, but the symphony only exists in the collective effort.

Achieving consistent world-class performance in healthcare – especially for emerging operating models such as population health management – will requires a diversity of skills and experience beyond what is necessarily innate to the healthcare professional community. This will require the talent identification and recruitment process to be less about assessment of ‘credentials’ and more about being open to “something you haven’t thought of before” and exploring the potential of skills and experience from outside of healthcare to contribute to clinical, operational and financial objectives of healthcare delivery organization.

Species with limited genetic variation are less able to adapt to changing environmental conditions. Looking at healthcare are a species, we would benefit considerable if we diversify our professional and conceptual leadership DNA. This will require a critical look at our own biases in the talent acquisition process, flexibility in our process of understanding and assessing the competencies of candidates beyond formal credentials or equivalent titles and a willingness to allow our organizations and systems evolve in ways we may not envision today

For a very long time, one of the most valuable business assets in New York City was a yellow cab taxi medallion. With recent value in the $1 million dollar range, ownership of the medallion was a virtual cash annuity, combined with equity growth (in 2004 medallion prices were in the mid $200,000 range and have increased in value 15% year over year in the 9 years since). As one owner once put it “it even makes money for me while I sleep”, since the cars can be ‘rented’ when the owner is off shift.

Medallion owners tend to fall into two categories: Private Practitioners and Fleet Owners. Private Practitioners own their own car, have responsibility for maintenance, gas and insurance, and tend to use the cash flow to live while allowing the medallion to appreciate over the course of their career. They then cash out as part of their retirement plan.

Fleet Owners have dozens of medallions; they lease or buy fleets of automobiles and often have their own mechanics, car washes and gas pumps. They either hire drivers as employees or, more often, ‘rent’ their cars to licensed taxi drivers who get to keep the balance of their earnings after their car and gas payments.

In London, taxi drivers have to invest 2-4 years of apprenticeship before they can take and pass a test called “The Knowledge”. However, like NY, finally getting that a licence to operate a Black Cab in London is a hard-working but stable way to earn a living.

Now imagine that someone comes along that can offer all the services of the NYC yellow cab or the London Black Cab directly to the general public, but does not have to own the medallion, own the car or employ the driver. With as much as 70% lower overhead, they provide the same service to the consumer; in fact they are so consumer friendly that they become the virtual gatekeeper for all the taxi and car service business in the community.

How, you ask? Outsourcing the overhead and just-in-time inventory management; they convince thousands of people to drive around in their own cars with the promise of a potential payment for services driving someone from point A to point B. All these drivers have to do is meet certain standards of quality and safety. This new company does all the marketing and uses technology to make the connection between the currently active drivers and those in need of a ride; they provide simple and transparent access to a host of cars circulating in your neighborhood, let you know the price and send a picture and customer rating of the driver, all before he or she arrives, and they process the payment so no money ever changes hands.

This is the premise behind Uber, a very disruptive take on the ‘taxi’ business. As a recent article in Bloomberg News noted, the slower rate of growth in medallion value is already attribute to the very young company; a recent protest by Black Cab drivers in London resulting in an eight-fold increase in Uber registrations.

Now imagine that a new healthcare services company comes to your community offering population health management services on a bundled payment or risk-basis. They guarantee otherwise inaccessible metrics of quality and safety to both large employers and individual consumers. They employ only a handful of doctors, but do not own any hospitals, imaging centers or ambulatory care facilities.

However, they are masters at consumer engagement, creating levels of affinity and loyalty usually found with consumer products and soft drinks. They use a ‘don't make me think” approach to their technology, seamlessly integrating analytics and communications platforms into their customers lives, and offer consumers without a digital footprint a host of options for communications, including access to information and services via their land lines or their cable TV box. They leverage high-level marketing analytics to determine who will be responsive to non-personal tools for engagement, like digital coaching, and who requires a human touch.

Care Planning is done based on clinical stratification and evidence; population specific data is used to determine the actual resources required to achieve clinical, quality and financial goals (a mid-West ACO has more problems with underweight than obesity, do they need to maintain their bariatric surgery center?). Physicians serve as ‘clinical intelligence officers’, creating standing orders across the entire population, implemented by non-clinical personnel; they also create criteria for escalation and de-escalation of services and resource allocation based on individual patients progress towards goals. They employ former actors and actresses as health coaches and navigators, invest heavily in home care and nurse care managers and use dieticians in local supermarkets to support lifestyle changes (while accessing and analyzing the patients point-of-purchase data to see what they are really buying).

The ‘primary relationship' between patients and their health systems is with a low cost, personal health concierge: primary care physicians who agree to standards of quality and accountability get a guarantee of traffic based on predetermined eligibility criteria and are spared administrative burdens. Multi-tiered scenario planning for emergencies is built into the system. For professional resources only required on an 'as-needed' basis, such as hospital beds, surgeons and medical specialists, access is negotiated in advance based on a formula of quality standards and best pricing but only used on a just-in-time basis (Alert: ICU bed required in 6 minutes, who wants the job?).

They are not a payer, although a professional relationship with them is on a business-to-business basis. They are a completely new type of health system, guaranteeing health and well being, transparent in their operations and choosing their 'vendors' based on their willingness and ability to achieve those goals. In doing so, they significantly reduce the resources necessary to achieve goals for quality of care and quality of health across the entire population; they treat quality achievement as an operational challenge and manage their supply chain accordingly.

Am I suggesting this a new model of care? No, I am personally an advocate for physician-driven systems of care. But this kind of system is very possible, and there are companies working on models of “national ACOs” using many of these principles.

The Uber of healthcare will have much less to do with the “mobile app”; and far more to do with creating value by minimizing overhead, designing flexible operations, supporting goal-directed innovation and bringing supply-chain discipline to the idea of resource-managed care delivery. It will involve embracing models of care delivery that leverage emerging evidence on non-clinical approaches to health status and quality improvement, and focusing on designing goal-directed interactions between people, platforms, programs and partners.

I can hear more than a few of you creating very good reasons why it wont work (“you can’t put an ICU bed out to bid!”), but these scenarios are very do-able. If we want to revitalize the experience of care for patients and professionals, we must be willing to acknowledge and embrace dramatically different, often counter-intuitive, operating models for care that will require new competencies, forms of collaboration and reengineering the roles and responsibilities of those who comprise a patients ‘health-resource community’

In 1950, business life looked good for the US Railroad system. With almost 100 years of dominance of the American transportation system, the US railroad system had 7 times the intercity passenger-mile traffic of the then-30-year-oldcommercial airline industry. 



However, by 1970 the tables had turned, with airline service carrying passengers then 9 miles for every mile traveled by rail services, which ended up bankrupt and nationalized. (Interestingly, the proportion of passenger traffic maintained by inner city buses during this time changed very little).

While many forces drove this change – the Interstate Highway System, the familiarity and comfort of returning WWII veterans with airplane travel, and shifts in mail sorting technology were all factors -- one of the biggest failures of the railroad industry itself was the way they defined themselves.



By not envisioning themselves as being in the transportation business, railroad executives created an artificial isolating barrier where airplanes were outside their operational frame of reference, and, in fact, ignored as a potential threat to their survival. If the railroads had decided to categorize themselves as being in the ‘transportation industry’, they could have invested in airlines and modified their rail service strategies based on market forces, allowing a more productive evolution, but hubris and legacy blinded them to the reality of social dynamics.



This phenomenon was largely repeated when the Internet emerged as a competitor to the print publishing industry and looms prominently in the future of the inpatient hospital industry.



As one historical reference on rail transformation notes: “An entire generation of rail managers had been trained to operate under (a restrictive) regulatory regime…Labor and their work rules were likewise a formidable barrier to change.”



Which could be rewritten thus: “An entire generation of healthcare administrators had been trained to operate under an increasingly restrictive fee-for-service model. Physicians and the existing operating model for care delivery were likewise formidable barriers to change” 



Reducing preventable primary and secondary hospitalization rates in a defined population is a well-proven competency for health plans (and their “Plan Sponsors”, usually self-insured employers); their financial incentives are aligned to do so (they get to keep any unspent money), and by and large, their success is driven by

• Improvements in the quality of care delivered to covered patient-employees (e.g., closing evidence-based gaps in care and focusing on clinical risk-reduction strategies) and
• Targeted shifts in patterns of resource utilization and patient engagement (introducing Care Management for example).

While the absolute levels of engagement and quality improvement by Health Plans is quite low (only closing 26% of identified gaps in care in one study; only reaching 13% of patients eligible for Care Management in another), the results still have been quite dramatic; a 9% reduction in hospitalization rates can save (tens of) millions of dollars; shifting emergency department utilization via telephonic and urgent care is both financially and operationally valuable under risk- or bundled payments models.



“Accountable care” shifts in the locus of control (and costs) of these care delivery strategies from the employer to the provider. However, as the health plans know very well, when the patients physician recommends care management, engagement and compliance levels rise, raising the potential for successful prevention of the ‘most impactable hospitalizations’ under the population health model. Combine this with “bundled payments” or "capitation+ bonus”, or full risk, there is an incentive for more intensive resource (cost) management by providers by sourcing and using lower cost/high efficacy tools and interventions.



When in the business life of a value-based health system does it stop making sense to own an inpatient facility? What happens when the costs of inpatient services are ‘out of its own pocket’ and do not have any direct associated revenue? How do value-based health systems make the determination as to which resources to own and which to contract for on an “as-needed” basis?

Another problem with the railroad industry (and the print publishers as well) is that even when there was a recognition that things were changing, there was a concerted effort to shape the change to retain the status quo. I once heard a publisher whose magazine was getting thinner and thinner every month, say “We’ll give away web banner ads in order to sell more print pages”. On the surface, 15 full-page ads at $20,000 does not have the same value as 3,000,000 ad impressions at $25 per 1000. The real problem was that his P&L had to pay for the print production infrastructure. The print margins were 15%, leaving $45,000 in profit on $300,000 in revenue; the web margins were 45%, leaving $33,750 profit on $75,000 in revenue. Divesting the print production infrastructure and leveraging the subscriber list to build web traffic would have resulted in lower revenue, but much higher profit venture -- as many newspapers and magazines eventually figured out often too late to maintain their market share.

With the gradual decline in healthcare fee-for-service revenue will come an associated sea change in the concept of “return on investment” (ROI). First, the administrative infrastructure for coding and billing will no longer be necessary, although some of the coding functions can be repurposed for clinical and operational analytics. No longer will the value of an infrastructure or resource-related expense be assessed on its dollar-for-dollar return. In value-based care, ROI calculations will have to be determined under an operational efficiency model. Performance consistency, flexible operations, clinical supply chain management and customer value will become new standards of health system operations.

The questions a CFO will have to ask are:

1. What is the cost/efficiency value of a resource to my ability to meet my contractual goals for quality, efficiency and patient experience management?
2. What is the portfolio of resources I need to deploy in order to meet those goals in the most efficient (highest effect/lowest cost) way possible?
3. What are the criteria I need to escalate and de-escalate resource allocation with any individual patient (taking into account individual patient attributes, preferences, and goals)?
4. When I must deploy significant or complex portfolios of resources against a patient (e.g., emergencies, exacerbations of existing conditions), do I need to own them, or can I use a ‘just-in-time’ inventory construct and contract for them “on-demand”?
5. When I do contract for on-demand care delivery services, how can I assure those vendors (which may include inpatient services, imaging and medical and surgical specialists) will be accountable for their contribution to my contractual goals for quality, efficiency and patient experience management?

Today's hybrid fee-for-service + gainshare or 'pay for performance' models are offering a transition window of economic comfort to health systems. But as cost-shifting gets more traction, eventually there will be a tipping point where, even with a successful effort at “steerage” – assuring patients stay within the ‘network of accountability’, it will take great economies of scale – tens or hundred of thousands of patients – to generate enough inpatient volume to justify a health system retaining its hospital. The likelihood of any one ACO succeeding with the cost of an inpatient infrastructure on the books is very low. Why keep the building and staff on the books when you can divest it and competitively negotiate terms and rates?

The same is true, by the way, for specialty services; the only ones an ACO might want to invest in will be driven by the population analytics. One ACO I work with has no need for a bariatric obesity program because the vast majority of their population is underweight; while analytics may justify primary care and certain specialties 'on staff' there will be an entirely new forms of private practice for specialties where services are provided to system-attributed populations, not geographic communities.

The economics of ‘accountable care’ will naturally lead to a divesture (or abandonment) of the infrastructure and overhead costs associated with running inpatient services, some high cost imaging services whose success was based on fee-for-service ROI models, and some specialty services with limited 'need' in an attributed population. Since the population health model is also based on keeping patients in the ‘network’, hospitals (and some specialists) will not compete for share of mind of patients, but share of market from ACO’s.

The future of the inpatient hospital will be as a freestanding ‘on-demand’ service competing for business-to-business contract with value-based system of care under a population health management model (interestingly this is similar to what health plans do today). Even when an inpatient hospital and an ACO are under part of the same corporate parent, it will increasingly be a zero-sum game to have the profitable ACO offset the losses or required investment of the inpatient service; the hospital will have to become ‘market competitive’, wooing and negotiating with a all the local “ACO’s” to provide value-driven services at competitive levels of quality and cost

I read with dismay a recent announcement that as many as 34% of American physicians are considering leaving the profession in the next 10 years, and 16% will make some transition away from clinical practice in the next 12 months; remarkably similar data were also published in 2010 in the New England Journal of Medicine.

Both surveys came to the same conclusions: physicians are unhappy about their professional lives, and are extremely pessimistic about their futures. While economic burdens – costs more than income – are cited as a top reason, the bulk of their concerns related to their sense of control – or lack of it – over their professional identity and the role and place of physicians in emerging systems of care. 

However, we are now at a moment in history where there is an extraordinary opportunity for physicians to recapture their leadership roles in patient care and the systems of care in which it takes place.  If the operational systems and technology that are being imposed on us are flawed and less than optimal in design and functionality, that means there is an opportunity to actively determine the fate of what is likely to be an ‘intermediate species’ in the evolution of modern healthcare, and the professional of medicine has an incredibly powerful tool that we can, and must, employ to wrest control and drive the evolution of these systems:  science.  

So, please friends and colleagues: don’t go yet, the biggest opportunity of our careers is just opening up.

Medicine is the science of solving human problems, and success requires mastery of science, problem solving and humanness.  We trusted in this model to give us the power to care for patients and we must trust in it to help us revitalize our roles as leaders in the healthcare system.   A recent report issued by The Physicians Foundation spelled out our value very clearly:  “Physicians and their relationship with patients constitute the animating principle of the US healthcare system”

Unfortunately, for most physicians today, the environments in which they work, whether in independent private practice or as organizational employees, are killing this vital spirit and undermining the very contribution physicians are expected to make to the success of the system.  One of the fundamental requirements of the successful practice of medicine is the sense that your efforts – your studies, your discipline, your mastery, and your work of worry -- will be channeled to achieve some form of positive results for your patient and be valued by the community. 

Health professionals take on an extraordinary depth of responsibility for other people’s lives;  as such, their confidence, optimism and professionalism must be nurtured and cannot survive in a vacuum.  Our society seems to understand the importance of this dynamic when it comes to the performance of elite athletes, but we can’t seem to make the same respectful accommodations to the critical performance of those we entrust with our health and our lives.  But while “the system” today may not adequately support the role of physician as central figure, an emerging set of critical issues will place physicians, if we are organized enough to take advantage of it, in a position of not only controlling our own destiny, but driving the fundamental framework for “the system” itself.

Once upon a time, there were well defined, socially accepted modes of interaction between patients, health care professionals, and healthcare institutions.  At a superficial level, patients accepted physician authority without question and in exchange, physicians would shoulder the whole work of worry about a patient’s health; while this model had its own flaws, it left the social structure of healthcare more certain. It was from this social compact – a balance of singular authority and mutual commitment — that patients felt they were able to move through difficult times with confidence. 

While the paternalism of the old model is largely unacceptable in modern society, the model had a sense of wholeness and integrity that was comfortable and comforting to patients and community, providing a central figure — the physician — who accepted us in the face of imperfection, offering a professional form of unconditional love and its associated commitments. 

Patients and the community are now confronted with increasingly complex systems that are iterations of adaptations to situations and circumstances – many of which began outside the realm of the healthcare system – and often find themselves stranded without credible social constructs for healthcare, often with fluctuating authority. The deconstruction of the culturally standardized healthcare structure has left us with a system that has no rational base. The system has no evolutionary logic, nor could it pass even the most superficial test of ‘evidence-based’.

As a result, most people face major healthcare events with doubt and confusion.

Deconstruction of physician authority may have brought about broader individual awareness, but also systemic weaknesses; the physician community, vulnerable to competition for our social capital from forces who were unimpeded by the mores of academic and professional fairness that underlie our profession, fell victim to those with less selfless and less generous agendas, resulting in devaluation of our role.

Physicians started out the 21^st century in a position of weakness; our leadership position was weakened, our professional judgment and competence questioned and our autonomy was under threat. The “health system” showed little interest in improving medical practice and took advantage of our vulnerability by offloading administrative responsibilities and offsetting costs to the physician community. 

 Over time, the ‘medical-business’ complex became a superficially dominant force, and we responded by organizing around our specialty identities and entering into a zero-sum game, where we bickered over how dollars are divided among ourselves while third-parties doled them out like parents deciding if we earned our allowance; this fragmentation, pitting physician-against-physician only served to weaken the profession even more as we tried to play a game whose rules were largely foreign to our professional culture, leaving us both unprepared and ambivalent.

Professional devaluation takes place on two levels:  economic and social.  For decades, physicians have reacted by been trying to fight the battle on someone else’s terms – economics –  and trying to fight on other peoples terms is almost always a losing proposition. The key to our success is to shift the battlefield to one in which we dominate:  the science of solving human problems.   

Why go into battle at all?  Why not just quit; take our toys and go home or give up on autonomy and become salaried employees?   Well, first because of why we became physicians in the first place:  our commitment to excellence and human service, and second, because, actually, have a good chance of winning, both socially and economically.   Society needs us, and we can do well by doing good.

Two forces are in our favor.  The first is the evolutionary principle, as described by Nobel laureate Edmund O. Wilson that “while within groups, selfish individuals beat altruistic individuals, groups of altruists (consistently) beat groups of selfish individuals”[1].  This means that if we organize around and commit to our fundamentally altruistic professional mission, we will have a better chance of winning the battle for our professional identity than if we keep trying to compete on relatively selfish goals – like money.

The second force in our favor is the free market.  It is well established that people will pay a premium for the delivery (and sometimes just the perception) of value; the Ford Taurus you rent from Avis is exactly the same car you can get from Budget, yet people show preferences and are willing to pay a premium for one over the other.  By regaining control over our professional identity, we also revalue ourselves in the marketplace.

This defines our mission: revitalizing the value of the physician in the healthcare system. Rather than deploy our resources across multiple battlefields, we as a profession need to rally around a singular decisive infection point:  redefining the foundational role of the physician, independent but inclusive of any and all specialty perspectives or competencies – medical, surgical, behavioral -- and reclaiming our profession.

Future of physicians is actually in a modern reclamation of three traditional roles:

• The determination of the value and significance of available information and how it should be applied to or removed from decisions – and actions -- that can affect the lives of human beings
• Serving as the orchestration point for plans of care by members of a patients’ professional and personal resource-communitie
• Take responsibility and shoulder the “work of worry” for the health and well being of our entire practice population, not just those who self-select for care but those who may have been in our waiting room recently.

There was a time when physicians shouldered all the risk for patient care; we took care of the patient and they either paid or they did not; if not, sometimes we took a chicken.  There was also a time when physicians were the primary employers of nurses, who served critical roles as care coordinators and care managers.  Physicians with better reputations garnered higher fees -- of course in those days, patient satisfaction was not scored by Federal survey, but by how neighbors talked about you in the supermarket.  This is not a call to recover the past, but to remember that our profession is familiar with some of these principles seemingly being imposed on us.

So, at a moment in the history of medicine when we are needed most to achieve the broadest improvements in the health of our nation, it is time to activate ourselves. Let us: 

• Take a critical look at boundaries to a cohesive professional identity across medicine -- the things that evolved as defensive reactions to outside threats and, if they do not serve our vision for the future, bravely eliminate them.   
• Adopt the emerging roles that suit our profession – knowledge manager, population view and conductor, and find the most relevant science to support our success in these roles.
• Wrest control of the strategies and frameworks for care delivery and determinations of quality that are infiltrating our professional lives, and set the standards against which products and systems are designed and operated.

Let us reclaim our professional identity; let's lead with craftsmanship and relentless intellectual energy and the vigorous commitment to research and discovery that is the foundation of the profession to which we aspired.  The opportunity exists for us to rewrite the script for our future and, in doing so, define our leadership position and value to society.