The Playbook for Tomorrow’s Leaders
Hey Reader,
No industry failing more than healthcare. No field is more urgent than medicine.
The doctor is the most conflicted professional in modern life. We are committed to contradictory ideals.
These two strands represent the pressing obstacles for today’s physicians. We are experts operating in dysfunctional systems.
This leaves doctors riven by existential discord (who am I?), professional dubiety (what is my role?), and personal burnout (why am I not fulfilled?) as we adapt to paradigm changes in culture, technology, and the economy.
The humanistic ethos of medicine is well known and it is deeply embedded in the narratives we tell ourselves of why we do what we do.
We took an oath to do no harm. I came from a school of thought that trained us to be “attorneys for the poor,” the famous dictum by physiologist Rudolph Virchow. The patient’s well-being came before our own. Ours is the noblest of professions.
This messianic description of medicine is both empowering and limiting. It gives us purpose to accomplish great and difficult things, but it is a burden no doctor can bear.
If we are going to claim credit for saving lives, then we must own that we lose them as well. That is a painful legacy that contributes to burnout.
Then there is the uniquely painful emotional collision that occurs when a young doctor, steeped in humanism, confronts a medical system that is explicitly transactional in nature. “Just deal with it Doc because, after all, what did you expect?”
Like many of you, I experienced this culture shock firsthand.
Culture is not the only driver of physician unrest. By the arrival of the first half of the 20th century, we saw an explosion in biological insight. Germ theory, development of antibiotics, the use of ether in surgery and more had culminated in taking medicine from a quasi-religious practice to a professional one grounded in science. Ironically, science allowed MD to become perceived as God. We finally had the tools to alter the course of people’s lives.
Prior this, doctors were closer to faith healers, shamans, and men (only, alas) of wisdom.
This paternalistic model of care disenfranchised patients, but had the small benefit of clear professional roles and obligations. Everyone – doctors, patients, society – knew and played their part in the health of the nation.
Things were simpler, if not poorer back then.
That knowledge soon became a curse. As bio-medical information progressed, it became obvious that no individual doctor could know it all and do it all. As The Economist noted “As the stock of human knowledge increases, the time needed to move oneself to the knowledge frontier grows.” The idea of a sole doctor, white coat billowing like a cape, and curing patients on the wards entirely by himself was becoming a thing of the past.
So a plethora of allied health professionals emerged to siphon off responsibilities once attributed to doctors – phlebotomist, respiratory technician, ultrasonographer, and more.
The result, was that doctors went from deity to team leader.
As those fields multiplied, unionized, and professionalized, they took on the imprimatur of medicine (often with their own white coat ceremonies and such). Doctors became respected but de-valued, transitioning from team leader to team member.
Rapport, collaboration and influence have become the soft skills required of doctors.
This in sharp contrast to our militaristic training, which emphasizes hierarchy and top down orders. Medicine was becoming horizontal not vertical. Case in point, advanced practice practitioners (APPs) such as NPs have argued for independent licenses. Doctors have not always kindly responded to such changes.
Patients for their part went from merely receiving care to collaborating with doctors in a model of shared decision making. Questioning and challenging a doctor went from taboo to socially expected for the empowered patient. Health coaches, functional providers, and other non traditional providers filled the gaps especially in areas like nutrition, fitness, and lifestyle considerations. Online research can now allow patients to acquire knowledge on any one condition that can rival ours at times.
Many of these changes were needed and helpful. All, however, have been notably disruptive and left doctors confused about how to act in society. Professionalism is defined by its duty and obligations to others, so these changes became existential in nature.
The aggregate effect is that the clinic, lab and operating room is no longer solely ours.
Dramatic era bio-medical innovation is created a new, unexpected archetype of this physician: that of body technician. In this frame, we are fancy journeyman, but ultimately don’t have a special connection to the patients we serve. We fix, mend, and occasionally cure, but we don’t heal, salve, or hold solace. That era is done. No medical school dean would ever say this, of course, but just ask any hospital executive in private (as I have).
The era of AI in medicine is emerging now, and prompting even greater questions of our professional value. The bedside is now webside and with it a new plethora of professional changes.
AI is now co pilot, but will eventually become auto-pilot.
In much of our work, we will give orders to computers or take orders from them.
This is the brave new world of algorithmic healthcare and doctor as data synthesizer.
The modern era of managed care tasks us with a very different challenge – to be stewards of resources. As the argument goes, doctors, not patients, are the real “consumers” of healthcare since our prescription power is what initiates a plan of care and its attendant costs. Therefore, the burgeoning medical budget, now 4.5 trillion dollars, is now our responsibility.
In an insurance run health system, medicine is a contract not a covenant.
The market has, thus, rebelled against the idea that medicine is qualitatively different than any other service industry. Therefore, it can be managed like a bank. The dramatic rise of private equity in hospital and clinic acquisition speaks to this reality.
This manifests most insidiously in the subtle lexicon creep of the financialization of healthcare – and it should not go unnoticed. We are no longer doctors. We are “providers”. Apparently I went to provider school not medical school. We don’t have patients rather “consumers” of care. We don’t have clinic appointments but “encounters.”
The only people who have “encounters” are government spies and commercial sex workers.
The only time administrators regularly talk to doctors is when they are behind in their billing submissions or haven’t hit their RVU (productivity quota) target. We stress about ICD 10 and CPT codes. This is doctor as small claims and billing accountant.
This is nothing less than a wholesale redefinition of what it means to doctor. And it is being foisted on us by an army of non medically trained professionals who took no oath, have done no overnight call, and have obligations to different stakeholders.
Physicians have been, at times, complicit in their undoing. The American Medical Association has long fought meaningful healthcare reform by invoking the spectre of “socialized medicine.” Creating a moat around our skills, status and income paradoxically helped invite the rise of managed care during the Nixon administration and put patients at risk who are dying because of poor health access.
Eric Topol, erudite cardiologist, notes that physicians have organized, just not necessarily for patients. This absence of physician leadership comes at a time when the public needs our support deeply. In doing so, we have lost the trust of the public in some meaningful and undeniable ways.
When I talk to physicians today about the state of healthcare, I sense their frustration. Despite their extensive and extended training, they feel ill-equipped to serve our patients and be effective in the contemporary environment. The goalposts keep moving.
We have devolved from being proficient to feeling deficient.
Look at all the major stakeholders in healthcare – patients; hospitals; device manufacturers; Big Pharma; PBMs; venture capital and digital health; health insurance; the federal government; and providers. Doctors are the weakest politically, the least organized, and direct the smallest share of capital and investments.
Systems can become shackles.
We have limited agenda setting capacity. We respond to the agendas of others.
Our success are rarely celebrated. And because we are supposed to morally righteous (unlike insurers), our failures are more apparent by contrast.
We live in difficult and unusual times. People are sicker than ever, science ever continues to leap forward asking more from us, and costs of care are at a breaking point.
The only response is for doctors to become innovators both within systems and outside of them. In other words, as intra-preneurs and entrepreneurs.
We need to become politically organized.
We have to have a seat in the boardrooms, a place at Sandhill Road, and elected toCongress.
Physician leadership is no panacea, of course, and sometimes can be quite troubling (eg Dr Oz nominated to head CMS).
But to anyone who think otherwise I say – who are you kidding? You can’t do this without us. Those who have tried have already failed.
It is one of the reasons medical education is undergoing a needed reform with the introduction of the third pillar of training: basic science, clinical science and now health systems science.
Whenever a country fails in some regard, the first to suffer are the health of its citizens. These are the sentinel events for a society.
By this measure, the US has been profoundly failing for a long time. Our work is needed.
Let’s get heal together.
Tomorrow can’t wait,
