Enough with the nailing doctrines to doors which are supposed to have some significance in righting what’s wrong with health care in the United States. Public policy, health or otherwise, is always difficult to visualize. Lots of intangible things are talked about as if they could be made tangible. So the way-too-big picture of Luther nailing his theses on the door is not only a good analogy, but also gives readers a solid visual image to ground the notions presented as readers struggle with intangible concepts.
Good PR, but the nailing of the theses to the door does not necessarily guarantee that the policies themselves are good.
When the topic of health care reform comes up, we hear a lot of lip service paid to the nostalgic Dr. Welby days, with a condescending sadness that gee, these days in health care are long gone. What these spokespersons refrain from discussing is that perhaps the Dr. Welbys of the world actually provided better patient care than we are providing today. Horrified at the thought? Would that health care policy gurus were more realistic about the quality of that old fashioned care they are trying to replace. All our frenzied efforts to “improve” health care has really accomplished is the destruction of what was largely patient-centered health care. In Spanish Inquisition style, in the dogged pursuit of health care modeled after John Locke’s representation of man as a machine.
In William Arntz et al., What the Bleep Do We Know, the authors clearly define the problem with what I have many times called checklist medicine:
“The materialist model of reality moved long ago from the ranks of “theory” to become set in stone as the implicit basis of all thought and research. It has governed scientific inquiry, and the scientific world’s openness to what is possible or impossible, for 400 years. It tells us that the universe is a mechanical system composed of solid, material, elementary “building blocks.” It asserts that what is real is what is measurable….In this view, nature becomes “resources” to control and exploit rather than an organic living system to care for and sustain.” (pp. 28-29)
Forget “evidence-based” medicine. It regards patients as a Lockian machine. Unfortunately, because government IS a machine, it can only SEE other machines. Medicare and those creating Medicare policies literally can’t SEE the quantum physics operating between physician and patient in a genuinely patient-centered encounter. The human beings on the policy boards could choose to see the difference, but for some reason they have failed miserably to incorporate this understanding in their policies.
Those regulating health care and reimbursement can’t see when a physician spends time with a patient, the physician can diagnose the exception to the human machine viewpoint. That is, provide real health care to a patient in need of something more than what’s on a checklist. Marcus Welby medicine. This may involve recalling a similar incident the physician observed 30 years ago, as likely as not an observation missing from standard medical texts. This is the difference in behavior between a novice and an expert. Since this kind of physician knowledge cannot be categorized, to Medicare policymakers, this valuable physician knowledge does not exist.
“Evidence-based” medicine is little different. Those doing materialistic research scornfully delete the “outliers” from their research and pretend their subjects are all the same, just like machines. The 30-year ago incident would be labeled “anecdotal.” Anecdotal, yes. But no less real.
Value-based reimbursement does not and cannot exist and can never exist in reality (oh, there will be some construction labeled value-based, but that doesn’t make it so) because there is no way to measure real value in health care. There are too many variables. Narrow the number of variables and the “value” is diminished. The “value-based” reimbursement becomes a means of control, nothing more. The nurturing part of the care disappears from the formula.
Furthermore, a lot of patients don’t always get well with “value-based” care, and a lot of others get well by avoiding “evidence-based” medicine. But to the clockwork mentality, if it doesn’t fit the measurement checklist, it doesn’t exist. Patients have been denied care because “evidence-based” medicine shows their problem, which is real, doesn’t exist. This is nonsense in every sense of Arno Gruen’s The Insanity of Normality.
So, it’s time to let go of the health care model fashioned upon “man-as-machine.”
Physicists abandoned the materialistic model years ago. It’s time those trying to fix health care let go of the destructive clockwork model. But to do so they would have to understand why they have failed with their clockwork and will continue to fail until the train barreling down the misguided track wrecks.
Pounding a few more theses on the door won’t cut it. Get rid of the delusion that health care can be controlled by anyone other than a dedicated physician with a personal, longstanding relationship with a patient. Then let physicians do their job without demanding clockwork, materialistic results.
Patients leave physicians perceived as poor providers and go elsewhere fairly regularly. The care they received may well have been stellar, but the patients for whatever reason do not perceive it as such. In reality, patients sometimes can’t tell a good physician from a poor one, or good advice from bad. But the checklist mavens are busy trying to rate the value of physician care based upon how patients rate the care they receive. No “evidence-based” medicine or “value-based” reimbursement will have one iota of effect on changing this pattern of patient behavior.
Those insisting otherwise are deluding themselves. That includes policymakers and those in government trying to control health care costs by controlling the clockworks when they think they are controlling the clock. Serious, serious delusion.
Enough with theses nailed to doors and policymakers sitting around a table with no idea what goes on in the trenches when the interest is, quite frankly, controlling health care, and secondarily, controlling it’s costs. Every single person with a stake in creating policy and mechanisms to supposedly better our health care system needs to start reading up on quantum physics and energy systems constantly in flux (Brian Greene’s The Fabric of the Cosmos is a possible starting place). Such systems are essentially uncontrollable by clockwork rules.
The relationship between physicians and patients cannot be regulated like the gears of a clock. The flow of information between the physician and the patient contains far more knowledge than the clockwork mind can assimilate, much less control.
It’s time for a new paradigm, all right, but not a new paradigm in wolf’s clothing. Nothing new about this paradigm. It’s been around for 400 years.
Time for the health care policymakers to nail a thesis on the door that really is new, one based on the what we now know and are still learning about about complex systems, implicate and explicate order, and energy constantly in flux.