Health Care Becomes an Industry

First I want to congratulate Dr. Rastegar on his clear, objective expression of the realities of the healthcare industry. There is indeed a danger to be dealt with. To make the danger more visible, I would like to set his observations against the backdrop of the history of the Universe. From its beginning 13.7 billion years ago, the Universe has been guided by the three principles of Diversity, Subjectivity, and Communion. Diversity is development of new forms and processes (ie. atoms then molecules, inorganic then organic). Subjectivity is individual identity for each form with its unique gifts. Communion is the existence of all forms and processes in one interdependent whole. Any system that limits diversity, ignores the unique identity or gifts of individuals, or interferes with wholesome interactions between them, defies the universal principles that have operated for 13.7 billion years. These principles will not cease to operate. A discordant system is itself unhealthy, and because of the interdependence of the community of life. It becomes in itself a health risk. A stressful and unhealthy environment is created when the creativity of so many individuals is stifled. The creativity of the system is thus stifled, and what cannot grow dies. The time is right for a health care model that honors the gifts, talents, and creativity of all genuine practitioners of healing arts and of patients. This model recognizes the need for diversity, individual identity, and the interdependence of all beings on each other.

Competing interests:   None declared

"I have heard the fear expressed that in this country the sphere of the physician is becoming more and more restricted, and perhaps this is true; but I maintain (and I hope to convince you) that the opportunities are still great, the harvest truly is plenteous, and the labourers scarecely sufficient to meet the demand"

-- Sir William Osler

In this thought provoking essay Rastegar reflects on how ongoing changes in the organization and delivery of healthcare in the United States not only threaten the autonomy and professional satisfaction of physicians, but perhaps paradoxically, even quality of care itself. He identifies several trends that exemplify the process of “industrialization”. These include the continued march towards specialization, highlighted by the development of location-based specialties such as Emergency Medicine, Critical Care, and most recently Hospital Medicine; ongoing efforts to reduce medical practice variation through clinical practice guidelines, order sets, and computerized decision support tools; and finally, the rise of a managerial class of physicians to oversee the process of standardization and to monitor productivity and quality of care. Like the craftsmen of the early 20th century, Rastegar believes that physician roles are becoming increasingly limited, their judgment challenged or supplanted, and as a result, their professionalism threatened. While acknowledging that the “goal of health care should be to provide patients with the best and most cost-effective care possible, not to provide physicians with fulfilling professional lives”, Rastegar fears that these organizational changes, made in the name of quality and efficiency, may leave patients feeling like “a product on an assembly line” cared for by disengaged physicians who are simply cogs in a giant health care machine. He voices concern that such systems of care may be particularly ill-suited for patients with complex, multi- system disease, whose experiences and outcomes have not been adequately studied.

That health care in the United States is beset by high cost, unacceptable rates of injury, inferior quality, poor service, and inequality is in little doubt. The status quo is indefensible, and the system in need of revolutionary change if we are going to achieve the vision of Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable care as spelled out by the Institute of Medicine in their report Crossing the Quality Chasm: A New Health System for the 21st Century. Yet not only did these problems predate the changes described by Rastegar, but instead, provided the rationale for many of the efforts that he characterizes as industrialization. That we have begun to address such problems offers reason to be hopeful; however the process of transforming our health care system is in its early stages, and clearly, a great deal remains to be learned about how to achieve these lofty goals.

While Rastegar can be commended for focusing on the risks to professionalism, it seems to me that he ought to be more willing to view guidelines, checklists and other decision support methods as tools intended to assist but not replace the judgment of professionals. I doubt that he would choose to fly on an airline whose pilot decided not to run through a pre-flight checklist because he perceived this as a threat to his own autonomy and professionalism. Similarly, I suspect that he would be thankful to the anesthesiologist whose preoperative checklist identified a patient as being eligible for perioperative beta blockade prior to major surgery. I wonder too, whether the patient whose monthly, office-based physician visit is supplemented by regular telephone or home visits by a case manager feels concerned that they are being treated on an assembly line or are instead grateful to have the extra service and attention. Finally, Rasteger rightfully notes the need for greater research demonstrating the value of traditional primary care models in caring for patients with multi-system and complex illnesses. This is especially apropos in light of an expanding body of research demonstrating a positive correlation between volume, specialization and outcome. Without further evidence supporting its value the traditional model should be subject to the same skepticism reserved for any other innovation.

Competing interests:   None declared