Every week, I explore with great interest the commentaries, viewpoints, perspectives, podcasts, social media posts, and other dispatches from my peers and colleagues who are seeking to explain and influence the state of both the health care professions and our systems of care.
With each reading, I find modern parallels to the published words of my late mentor, Dr. Carleton Chapman, a former dean of Dartmouth Medical School and one-time president of the Commonwealth Fund regarding medical education: “… our present scheme… is intellectually deficient, wasteful of money and time, and in urgent need of overhaul.”
Because, despite decades of academic, economic, clinical, and governmental expertise, as well as the intellectual rigor of health care subject matter by policy experts, the vast majority of these disciplined analyses and insights are remarkably ineffective.
Health care is at war, and it’s time the health care community realizes that our historical approach to using the realm of ideas to shape our future is a failure. The passivity and genteelism illustrated in our approach reflect the weakness of our tools and techniques. Our enemies do not respect the rules of engagement; they are laughing at us.
Over the last few decades, the health care professional community has been battered by many forces of change, though none so powerful as the competition for our economic and social capital.
We have been largely destabilized and rendered vulnerable to those with selfish agendas: commercial and political communities unimpeded by the cultural and academic mores that comprise the historical underpinnings of the medical profession.
Dr. Arnold Relman, former editor-in-chief of the New England Journal of Medicine, called it the “medical-industrial complex,” which has disintermediated and dehumanized the traditional doctor-patient relationship, undermined professionalism, and offloaded administrative responsibilities and costs to the health care delivery system without proportionate compensation.
We have tried to fight the battle, but the rules of engagement of politics and the free market are largely foreign to our professional culture and skill set.
The effort ended up driving a bigger wedge into the professional community. Physicians organized around specialty identities and entered a zero-sum game, with primary care and specialist physicians bickering over how dollars are divided among themselves as payers doled them out like parents deciding if they earned their allowance.
This fragmentation, pitting health care professionals against one another, only served to weaken us more, with patients losing trust as we were distracted and suffering reductions in our capacity to share the work of worrying about their health.
Physician-poet William Carlos Williams wrote, “No ideas but in things”; allegorically reflecting that meaning is in the tangible. I can tell you that the opposition has mastered the power of Williams’ insight. They are not shaping the world with words but with pervasive action. They have, and use with aplomb, skills and competencies that actively shape the knowledge, attitudes, and behavior of key target audiences toward their oft-hidden “prime directive” of protecting and growing their money and power. They are master manipulators that use every systemic weakness to their advantage.
Academics, researchers, and policy wonks fall right into the trap they set. Knowing our reductionist tendencies, they get us head-down in the details, trying to find the flaws, trying to understand the language, codes, and modeling scenarios. While we’re distracted, they remove all our furniture without the need for stealth. Behind the curve and forced to react to an aggressive hand, we waste valuable brain power analyzing smokescreens.
We’ve seen this happen for decades, with health care communities reacting by trying to fight the battle of professional devaluation on economic terms. Unfortunately, trying to fight on other people’s terms is almost always a losing proposition.
What is missing is any sense of goal-directed strategy. For all the experience and opinions out there, there are few insights as to how to tangibly wrest control of health care to the benefit of the health status of Americans, independent of partisan politics and lobbyists, in the same way, the taxi industry was forever changed: not with an app, but with a strategy that uncoupled tradition and organized collective action.
It’s time to embrace and master the very same weapons that the opposition use against us: strategic thinking, communications discipline, audience targeting, message segmentation, value proposition, and economic leverage.
However, before this is possible, we need to organize and rally around a singular decisive inflection point: redefining the foundational identity of health care professionals, independent but inclusive of all disciplines and competencies – medicine, nursing, pharmacy, psychology, social work, therapists – and reclaiming these professions.
Confirming our commitment to excellence and human service beyond economics will revitalize the experience of care for patients and professionals and garner the affinity and loyalty necessary to assert our social and political will.
Two forces are in our favor. The first is the evolutionary principle, as described by Edmund O. Wilson, that “within groups, selfish individuals beat altruistic individuals, but groups of altruists beat groups of selfish individuals.
This means that if health care professionals organize around and commit to their fundamentally altruistic professional mission, we will have a better chance of winning the battle for professional identity than if we keep trying to compete on goals of discipline-based self-preservation.
This shift away from primary defense of economic status will be offset by the second force in our favor: the free market. It is also well established that people will pay a premium for what they perceive as value; the Ford Taurus you rent from Avis is exactly the same car you can get from Budget, yet people will pay a premium for Avis because they add value by reducing the “friction” — standing in line, dealing with customer staff, and other administrative burdens — associated with a car rental.
By regaining control over professional identity, health care professionals will have the opportunity to wrest control of the definition of value, and in doing so, revalue themselves in society and the marketplace.
One of the tenets of public relations is “define yourself before others define you.” However, in many ways we are our own enemy, as clear definitions are impeded by our own tendency to asymptotically study issues without ever reaching a consensus upon which to build actionable insight; in this we squander our own time, energy, and knowledge as power.
“Needs further study” is not a strategy but a platform from which to watch others overrunning our territory (note well: the ascendance of urgent care is a failure of mainstream medicine to recognize the changing dynamics of work and family life; would it have been so hard to have office hours till 9 p.m.?). True leadership is about results, not notions, concepts, or designs; the bar for measurable accomplishment must be set well above a conference presentation, published position paper, or a well-crafted webinar. If we truly are committed to the mission, we can no longer be cautious or courteous to those who, by commission or omission, try and marginalize or oppose us. It also means that some social structures, principles, and practices, may not survive.
Collective action could flip the subordinate position of professionals in the power structure of health care and wrest control of its evolution.
Why not adopt a model of collective care and a universal framework for care planning that would allow us to determine the requirements and value of investments to ensure that every member of society has the same opportunity to optimize their health status? We don’t need to ask permission to do so.
The big question is whether we, as a society, want people to be sick or well. The health care war is fought over who is best suited to educate about and influence that decision.
We are in a battle for control of the health of our communities at the system, societal, and individual levels. However, we cannot allow traditional academic mores to impede our progress if we truly wish to shift the balance of power over the distribution (and control) of economic and other resources to those whose values prevail towards patient and community. We must be unified in message and aggressive in our strategies to enlist support, engage, and activate the individuals and communities we serve.
Steven Merahn is a physician and health care executive.
