(From Physician Executive, September/October 2008)
The answer to that question is undergoing a rapid, thorough, and historic shift. The very existence of a group with the hyphenated title “physician-executive” hints at the depth of the change.
When people around the world ask for more from healthcare – easier and less expensive access, higher quality, better care – at the core they are talking about their relationship to a physician. The demands are emotionally conservative, even nostalgic. They express a longing for a return to a perceived lost golden era (in which the relationship with a physician was deeply personal and permanent) melded with the modern panoply of technology. But the results of the demands, combined with modern technology, will in fact not be a return to any mythical “good old days,” but something entirely new, different, and probably better – both more efficient and more effective.
All that must be sacrificed are some habits of mind.
The legal and professional definition of a “medical doctor” or “physician” is not likely to change: a person who has earned a medical degree in medical school, then rounded out their education as a medical resident at a teaching hospital. Yet around this definition are a series of ideas and images that come to us as givens, an ancient and immutable parts of the human situation. But though the notion of the physician has ancient roots, the ideas that we grew up with actually crystallized relatively recently, and are no less mutable than the boundaries of any other profession.
Round out the basic question (What is a “doctor?”) by asking yourself a few other practical, everyday questions, such as, What does the doctor do? How is the doctor paid? How does the doctor work? Within broad outlines, applied to most physicians in Western, developed countries, the answers are largely clear and consistent.
What a physician “does” is Western allopathic medicine and surgery based on germ theory, using scientifically-derived pharmaceuticals and imaging technologies. The broad range of therapies outside the physician’s purview include massage, manipulation (except for osteopaths), herbs, infusions, poultices, muscle testing, acupuncture, and hypnosis, among many others.
The physician is paid by the patient (or the patient’s financial representative, the health plan or the government) for each medical act, as “fee for service,” in which the “service” is defined not as “being your doctor,” but as a particular office visit, examination, test, or therapy.
How the physician works is, at its essence, alone – perhaps consulting with other physicians, assisting at a surgery, or handing off parts of the care to specialists, but depending on his or her own judgment and training to diagnose and treat the malady, one-on-one with the patient. The physician classically does not depend for diagnosis on outside algorithms, computer programs, or probabilistic analysis. Instead, the physician classically uses his or her own interpretation of the patient’s history, the physical examination, the images, and the results of chemical tests. This judgment is classically held to be independent of even the latest and best-supported medical studies reported in peer-reviewed journals. (I can remember my late father’s doctor as recently as the 1980s telling him that people like him, with the beginnings of heart disease, should avoid any kind of exercise, no matter how mild. And my father avoided it, because his doctor told him to.).
It is the absoluteness of this independence of judgment that causes people to attach the term “god-like” to the image of the physician. And this absolute independence sets physicians apart from any other profession. Lawyers, accountants, indeed all other professionals, are part of structures that constantly question their judgment and holds it up against the accepted standards and precedents of the profession, as an ordinary, daily part of their professional practice. Within broad boundaries, this is not true of physicians. As long as their practice is not provably, criminally fraudulent or negligent, physicians are free to operate as their training, experience, and personal bent move them – and as their financial motives encourage them.
This classic image of the physician is actually not all that old. It only came together toward the end of the 19th century. At the beginning of the 19th century, doctors had almost no tools: few pharmaceuticals beyond emetics and purgatives, no antibiotics, only laudanum to kill pain, no theory of infection, no way to see inside the body. Most medical theorizing was based on the four humours. The most common therapy for almost everything was bleeding. All discussion between doctors was in Latin. Antisepsis was an unknown idea. Inoculation was a new and not fully accepted idea. Surgery was something done by barbers and military surgeons.
The modern role of the physician only gained some of its major tools (such as antibiotics and the regular use of X-rays) and achieved its full status (as allopathy separated from other forms, for instance, as physicians achieved a monopoly on prescribing in most cultures, and as the modern medical school took shape) well into the 20th century. Many major specialties (such as cardiology) only date to the middle of the century, and quite a few are even younger.
Little about the image is ancient or immutable, and much of the image is undergoing deep change right now. The principal change is this: for reasons of efficiency and effectiveness, the “physician of the future” is far more likely to be a team player. This plays out in several ways. The “physician of the future” will be far more likely to:
- Be paid by a larger institution, rather than to be in sole or group practice, making the physician part of the “team” trying to bring healthcare to a population at top quality for a reasonable price
- Use “evidence-based medicine,” submitting their independent judgment at least in part to the discipline of the judgment of their profession for like cases
- Use computer algorithms to assist in diagnosis, in part to speed the process, in part to keep the physician aware of the latest published information, and in part to standardize the process so that it can be documented and measured
- Work in teams whose membership stays relatively constant over time, and which focus on a single problem with a multi-disciplinary approach. For instance, a diabetes management team might include not only an internist or family doctor and an endocrinologist, but also a nephrologist, a podiatrist, a dentist, a nutritionist, a diabetes educator, a social worker, a home health nurse or physician assistant, and a psychologist.
- Work with this team to try new things; measure everything (the particulars of the case, the attempted therapies, the outcomes) in standardized comparable ways; compare results (with other attempts, other teams, other institutions); improve by adopting the best practices, and document the results, reporting them freely both within and outside the organization.
Trying things, measuring results, comparing them: This is called “science.” We are used to thinking of this as something we do in “studies” that are isolated from everyday healthcare. In the meantime, we are leaving hundreds of millions of datapoints lying on the table for lack of the effort to record them, add them up, and compare them. It never would have been possible before, but now it is: Today’s medical data technologies allow us, if we so choose, to measure and compare everything we do in every case. They allow us to discover what actually works and what doesn’t, what is effective and efficient.
Many people are underserved by healthcare, having no access to treatment (or effectively none, due to assorted costs) in the United States, or delayed or diminished treatment in many other countries. But at the same time, many people are overtreated, subjected to expensive and invasive treatments that are inappropriate, unhelpful, and sometimes painful and dangerous, especially toward the end of life. In a context in which one can get paid for doing any treatment that is reasonably medically justified, one repeatedly hears (from healthcare providers) of knee and hip replacements foisted on bed-ridden nonagenarians, cataract surgeries performed on frail elderly people deep in dementia, and valve replacements of doubtful outcome performed on people whose hearts are too enlarged and weak to support the new valve. We are told repeatedly to respect the doctor’s judgment. Yet clearly this is a picture of a system without appropriate feedback loops that help focus our medical efforts where they are needed and effective.
I think of the doctor, trained probably in the 1920s or 1930s, giving my father information about exercise that was at the time widely known and clinically proven to be wrong. Only after that doctor retired and Dad got a new family physician did he begin his daily walks, which probably prolonged his life many years. If that doctor had been part of a team focused on elder care, he would at least have had someone to argue with him about the advice he was handing out so freely.
These changes are already in train, especially in the United States. Healthcare systems began hiring physician-executives decades ago to try to close the gap between physicians and the larger systems. Now increasingly healthcare systems are hiring physicians as physicians, both family practitioners and specialists, and increasingly building teams focused on specific problems. The dichotomy of purpose between the “suits” and the “docs” is, I believe, beginning to dissolve. Evidence-based medicine is becoming more accepted. The new transparency spreading across healthcare is increasingly holding up institutions and individual physicians for scrutiny of both their methods and their outcomes. Inherent in that scrutiny is the need and desire to determine what actually works. It will no longer be sufficient to rely on a loose-knit team of doctors with “privileges,” coming in to deal with whatever nurse happens to be on that shift, or a nurse working out of the registry, possibly even from another city, communicating with other specialists (if at all) only through a not-all-that-rigorous medical record. That old model fails every test of 21st century medicine. The new scrutiny, the new tools, and the new teamwork, constitute together a shift in medicine from an art into something approaching a true science, the beginning of a whole new era in healthcare.