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The Myth of the Marketplace

There is no competition in the clinical relationship, nor should there be in the health-care system.
(Commercialization, corporization, regulation, standardization each and all eclipse the patient-clinician relationship.)

Summary:  There is no "competition" in the patient-clinician relationship, nor should there be competition in the over-all health care system.  We Americans have accomplished little coherence in health care.  Now our policy is to cut "expenditures" at any cost, but costs rise because of the many massive new non-clinical industries bureaucracy engenders.  Self-serving commercial enterprises distract us from meeting real needs of real patients.  The outmoded AMA myth of private practice differs radically from personal medicine grounded in the clinical relationship.  A "bureaucratic" model which prohibits input from the patient or the clinician is opposed to interpersonal sharing of information and responsibility.  The clinician’s habit of caring is a fading residual, but it brings whatever “care” we have today.  There will be no care tomorrow.

Competition is Prevalent:  Competition in the marketing of health care is not new, but its new intensification has changed the quality of relationships and phenomena.  We have been habituated blindly to rely on "my doctor" (my personal relationship with a clinician––physician, nurse, chiropractor, psychotherapist, et alii), that I pay or someone pays in my behalf and the clinician pays attention to me, uses expertise to help me.  There is no such relationship any longer, nor will there be in the foreseeable future.  There will be no more “my doctor.”  All health care relationships are now between institutions, not persons, and whether those institutions are named so or not they are payors and providers.  All physicians, even modest solo practitioners, are providers--not persons, but institutions.  There is great danger for all of us--patients, clinicians and institutions alike--in current myths of "competition," "free enterprise" and "cost containment" in the provision of health care.  What we considered health care has already been destroyed by hoaxes which professed to save it.

The reliable traditional model within which diagnosis and treatment have occurred is a simple relationship between clinician and patient.  "Competition" does not fit between a clinician and a patient, nor is there "freedom of choice" for the person who is ill or injured.  We could not tolerate the avarice of some doctors and hospitals, but programs which pretend to improve the economy or quality of clinical care by emphasis on competition are already disastrous failures, bringing on immense new bureaucracies and "services" costing us not only billions of dollars but immeasurable human suffering and neglect.  We have changed some of our expectations and all of our clinical relationships drastically á la "the myth of consumerism" (discussed later), but it will not work soon for anyone, nor will it ever benefit the poor.  The basic processes of diagnosis and treatment depend on communication from and to the patient which must be for that patient only (for he or she is as unique as any of the rest of us).  Marketplace packages and regulatory protocols cannot well enough fill individuals' clinical needs.  We may consciously choose impersonal and mechanical health care for seemingly valid fiscal and cultural reasons, but we are thereby foolish as consumers, and as public policy-makers a good deal worse than foolish--destructive, diseconomic and self-serving, for we have professed to help when we have indeed harmed.

There are plausible reasons for the confusion we now suffer.  The American Medical Association promoted a myth that personal health care, solo private practice and fee-for-service were integrally identified with each other.  The motivation for this myth was self-serving, an attempt for doctors to maintain control over health care.  The elements of the myth were themselves valid--it is the motivation which was duplicitous.  Most physicians (not all of whom were members of the AMA) colluded to oppose the “Red Menace” (socialized medicine), feared bureaucratic intrusion into processes of diagnosis and treatment (and physician income).

Health care can take place only in a personal relationship between clinician and patient.  There may be more than one clinician in relation to the patient, but when there is a team it must be integrated so that each member of the team can care about this patient, not just about self, others on the team, the institution or the bureaucracy.
The patient should know the cost of his care whether he pays it or not, and he should know the data, the thinking and the techniques before they are applied to him, in terms he can understand.  There is nothing inherently wrong with solo practice, private practice or fee-for-service; nor is there anything inherently wrong with group practice, public practice or third party payment.  There are immense problems when care becomes impersonal, uncommunicative, competitive in the market.  It is unkind and wrong that the clinician is ignored thereby, but it is disastrous that the patient is lost and never missed.

The hospital was seen traditionally as a setting within which care can take place, a furnished haven in which the clinician and the patient could do the work of diagnosis and treatment.  That has not been so since hospitals as institutions have used their size and power to dictate what happens, a result of their grab for power and dollars.  They saw governmental policy changes coming and wanted to be first in line for government-controlled dollars, especially wanted to be ahead of the other hospitals.

The insurance industry has always been able to raise premiums to exceed costs, virtually guaranteed big profits.  It sat salivating as government policies which applied to Medicare and Medicaid set the standards for all health care, and just as the government had, the insurance institutions wholesale demanded discounts from physicians and hospitals and other "providers" of health care, declined payment for no particular reason (except to keep the money).

By the time these powerful institutions (government, insurance and hospital) had taken control of the dollars, they had taken control of the "standards" of medical practice.  General resentment in the population against upper-class white male physicians (and especially intense resentment from poorly paid predominantly female nurses) synergized with lust for power from previously nonexistent bureaucrats (e.g., Health Care Finance Administration) to bulldoze physicians' influence in health care.  Not all doctors were rich and self-serving, but only those who were aggressively greedy could survive now.  Any physician who ignored the political and economic changes in order naïvely to focus on the welfare of patients was bound to be swept away.

So institutions took over as soon as the Reagan administration got rolling, but even today many persons can't see it (the Emperor's new clothes phenomenon), and without exception every patient in America continues to wish to be cared for personally--and it will not happen.

A few years ago Edmund Pellegrino said, "An increasing number of patients now enter  the same relationship with a hospital which formerly was obtained solely with physicians...a moral relationship between the patient and the hospital...can be very similar to the patient/physician relationship..."1  Usually I am reluctant to disagree with Doctor Pellegrino, but I guess even he would disagree with those statements today.  The relationship of an individual to an institution cannot be the same as her or his relationship to another individual or a group of individuals.  When a person must be a patient it is from a very down, a weak position.  A patient is in no condition to contend in the marketplace with various strong and greedy institutions.

Federal policies are the obvious real power behind current drastic changes in clinical relations and increases in costs, but those policies are ours, generated from our biases and blindnesses through legislative processes, ballooned by political and bureaucratic greed which have become our way of life as a nation.

The AMA Myth:  If organized medicine was self-serving in previous decades, why should we trust its protests today?  The person who becomes a physician is not a saint, nor is there any guarantee that her (or his) training and credentials protect against motivations of greed.  None the less, there is likely no other professional group in our society whose individual members are more consistently motivated by altruistic purposes, whose formal constraints on misbehavior are more stringent, whose competence is more reliable.  (This statement raises eyebrows because it contradicts prejudices about self-centered, powerful rich doctors.)

I never met Michael Shadid or Morris Fishbein.  I don’t know that they met each other.  The history of health care in the Twentieth Century cannot be typified by the experiences of any one or two individuals, but the conflict between these two men characterizes much of the set of issues we have come to face.  Morris Fishbein was a powerful policy maker of the American Medical Association for most of fifty years, especially as editor of the Journal of the AMA2.  Michael Shadid was a tough and dedicated individual physician who organized one of the first pre-paid health care plans3.  The two were enemies.  Fishbein assured Shadid of failure4, and through his own success Fishbein failed.

The AMA myth is simple.  Succinctly stated it is this:  Good medical care is individual medical care rendered to a patient by his own doctor who is equipped with the latest scientific knowledge and technique; the patient freely chooses a doctor from the many in the community and pays him for his protective care.  The underlying assumptions imply a structure of medical care with which we have become so familiar we rarely scrutinize what it means.

The AMA model defines the clinical relationship very clearly.  The patient is dependent on the doctor because of his mysterious power, without which the patient is threatened with disease and death.  The loyalty of the physician to the patient is a fiscal loyalty.  The doctor will care for the patient when the patient pays.  The doctor cares for the patient when he is sick and must pay.  “Pay or die” doesn’t work on people who are well––they stay away from doctors.  The power of the doctor so carefully protected and preserved by the AMA goes in other directions as well.  Consultants and hospitals can pay attention to a person as a patient only if that person is referred or admitted by the doctor.  The loyalty of the hospital or consultant to the patient is a fiscal loyalty mediated through the control of the referring physician.

In 1928 in Elk City, Oklahoma, Michael Shadid developed a plan of pre-paid health care in cooperation with the Farmers’ Union.  The plan was to have broad support and managerial participation from the whole community in order to meet the health care needs of that community, a sharing of fiscal and managerial responsibility aimed to provide health care without unnecessary procedures or duplications churning out revenue from fees for service.  The physician did not need to drum up business to support himself, but could count on a fair fixed salary.  He was free to attend to clinical tasks, to pay personal attention to patients out of professional rather than fiscal loyalty.

In his several books Doctor Shadid made clear his awareness of clinical principles of personal responsibility to individual patients and families, demystification of clinical information, straightforward provision of sensible health care, avoidance of unnecessary reduplication or risk in processes of diagnosis and treatment.  Doctor Fishbein had access to the same simple principles but remained preoccupied with the political struggle to retain power in the hands of the AMA, predominantly white, predominantly male, entirely MD’s, but (despite representations) not all the MD’s or all the doctors.

Third Parties Emerge:  Early health care insurance plans were aimed at preventing unnecessary disability and death, to make available to all working members of the community life-saving medical diagnosis and treatment.  (Care for the indigent who could pay no premiums developed with Medicare and Medicaid in the 1960’s, but has not been made economically feasible so far.)  The basic concept was to have a community-wide sharing of the heftiest financial medical costs, “major medical  coverage”––similar to insurance against catastrophic illness expenses we have recently discussed.  As special groups with limited risks began to identify themselves they managed to withdraw from community-wide sharing of risks and sought more detailed coverage.  Commercial health insurance plans were promoted which offered increasingly detailed benefits to those who could pay or negotiate them into their labor contracts.  The distortion of expectations which thereby mushroomed altered perceptions and expectations throughout our culture.5  Poor people knew they could get care only at the deficient public hospital, access to which was the emergency room, the ticket into which was interminable obsequious waiting.  The privileged expected bright, clean, pleasant high-tech doctors’ offices and promptly-met appointments (but their hidden expectation was that nothing bad would ever happen to them).  Everyone came to expect high technology would save every threatened life.  Everyone single one believed––there was no Cassandra left to warn us.  But worse, there was no one willing to listen to such a warning.

By the time we had come to commit ourselves to the decent and plausible proposition that it was economic and right that each individual have basic health care available despite inability to pay (with Medicare and Medicaid), our expectations of health care had already completely outstripped reality.  Here is my summary of the myth each of us silently subscribed to:  Once I took responsibility for my own life, trusting doctors only a bit when serious injury or disease took the situation beyond my control.  If I relied on a doctor or went to a hospital I knew I might perish.  Doctors and the AMA, hospitals6 and American entrepreneurs began to promise amazing miracles which I could have if I could pay for them (just as I could have other high-tech miracles if I were wealthy, hard-working or lucky).  Health insurances promised I could get help in a desperate situation, but as they promised more and more I expected more and more, until I expected health and happiness as long as I paid the premiums.  I believed my annual examination guaranteed me another year of health, or if something was wrong it would be detected and immediately eradicated by the newest machine.  I would not become sick, I could not die.

This myth, this unstated underlying belief upon which I have acted, is a contradiction of the one ancient truth of humankind, that we are mortal.  Through this myth we have lost not only immense wealth wasted, not only the pain of realizing our false hopes are false, but we have been severed from our own basic understandings and the freedom to make tough choices in our own lives.

The textures of recent and contemporary American culture all fit to show us how and why we are in such an unstable situation with health care.  We have abandoned reliable basic principles no less in consumer production, energy utilization, environmental deterioration, education, economics et cetera.  Our way of life is characterized by short-sighted short-range individual interests unrelated to any basic good––chrome, fins and nineteen-cent gasoline.

The Clinical Relationship and the Personality of the Clinician:  Even though the patient may not have adequate data, judgement or “objectivity” to decide which will be the best diagnostic tests or medical or surgical treatments, the patient may have some choice in the selection of the physician.  Even in extreme circumstances the patient may sense the humanness and authenticity the physician offers, but the patient rarely takes time or energy to “shop” for a hospital or a team of health care providers.  There is little real choice anyhow among the purposeful lies in billboards, TV commercials and other such hype.  The lowest, highest or middle premium may be as good a criterion as any, although there is no correlation between health care dollars and health care goods.

The patient can (with difficulty) meet the persons who are clinicians to make a personal human choice, but there is too much chaos, too many unrealistic expectations, too many lies and not enough truth to make a market choice in health care.  Recent years have ripped away all but the last vestiges of human choice in health care, once the most human of arts and sciences.  The subtle change is drastic.

The reality of clinical experience is most clearly seen as taking place in the relationship between clinician and patient, rather than only in the patient’s experience or only in the clinician’s observations and actions.  (The phenomena of the clinical team have yet to be understood and used, and the effects of bureaucratization of processes of diagnosis and treatment will never be examined because that would threaten the politically and economically powerful, who as such are neither patients nor clinicians.)

We use the abstractions “subjective” and “objective” to describe the statuses of patient and clinician.  Perhaps “intersubjective” represents a more productive idea.  A model for clinical interaction should allow both patient and clinician to function and comprehend at several levels, and to exchange much as persons, not as inert objects or flashy programmed machines.  Distortions result in what we describe as “impersonal,” “fragmented,” “dependent” et alii.

For over thirty years I have tried to elaborate the personal clinical relationship, what I consider the only basic and powerful tool of diagnosis and treatment.   I am busy implying to you some of my convictions now and through the rest of this writing, but on the surface I will emphasize our group and cultural problems.  I will teach you to be a good clinician later, if you are willing and if I have enough energy.

The clinical relationship and its parts are:  a patient or sufferer who is asking for and willing to have help (or she or he would be elsewhere doing elsewise); a clinician (literally “at the bedside”) who is fearlessly willing to understand and assist; and what transpires between them (clinical phenomena), which neither could do without the other.  It is a lop-sided relationship because only the welfare of the patient is primary.  The patient necessarily is dependent and unable to decide in the beginning, and rapidly or slowly comes to an understanding and a decision, for the ultimate goal (rather than his immortality) is the patient’s autonomy. (The labels are quite old enough: “patient” means “sufferer” from Latin, the opposite of which would be “agent” or “actor” [or “agonist” or “protagonist”, but let us not stretch these terms even in jest to “victim” and “victor”]; clinician is literally “the one at the bedside”, from the Greek klinein “to lean or recline” which comes to be kline “bed”, whence also the English word “client” [or “dependent one”] now used often instead of “patient”.)

There are some dangerous clinicians who act in the fashion known as “sociopathic” or “antisocial.”  These may not be common, but we hear of them.  All clinicians are subject to some of their faults, which consist essentially in self-centered, callous, negligent and even exploitative attitudes and behaviors.  When you have power over another you run the risk of stepping on his toes.

I consider there is a type of personality opposite to the sociopath which often allows a clinician to be successful in helping a patient.  It might be called the “altruistic” type, oriented to the welfare of the other.  It can be distorted into the “pathologic altruism”7 which can be self-destructive and can promote disabling dependence in the patient.

It is not merely the underlying personality and upbringing of the clinician which determines what happens in the clinical relationship.  The matrix of health care has a massive effect on the outcome.  The clinician must be aware, take these effects into account and inform the patient of them.

Training in clinical professions has never taken into account the core of clinical science, which is the clinical relationship and its components:  the persons and what transpires between them.  We can hardly anticipate any coherence in health care in our culture if basic principles are purposely avoided by us all.  The only reliable safeguard against confusion, waste and destruction is the direct communication of clinician and patient, or the patient will be confused, overpowered by an impersonal system, and necessarily victimized.

The Structure of the Clinical Setting:  If the clinician should be a “normal” person, shouldn’t the setting, the matrix, be “normal” also?  But I fear sociology has not given us a clear view of “normal” human organization or institutions.

The usual structure of a health care organization, large or small, includes a complex of relationships and interactions which is not coherent.  We carry with us the model of “medical authority” (“the AMA myth”) in which it is the physician who makes the decisions and takes the responsibility.  If we pause to think a moment, every one of us knows this is not so.  Doctors’ signatures (or rubber stamps) are used for the dispensing of drugs, documentation of diagnoses, authorization of payment for services, certification of disability, use and payment for technical facilities, et cetera, but no physician comprehends or controls what happens to a patient.  The “pyramid” model does not apply to health care organizations as we know them today, hasn’t since the physician was dethroned (though the physician still unfairly bears the brunt of liability through weight of legal tradition).

The most common tool to fragment understanding and responsibility in clinical care is the time-honored “specialization” (long-since superseded by “sub- specialization” and “super-sub-specialization”).  The patient’s parts and problems are parceled out to several departments who have no reliable way of bringing them back together again.  (Poor Humpty!)

A veritable passel of disruptions comes from the intrusion of third parties.  Independent of any clinical criterion they determine eligibility for care, diagnoses, procedures and costs which will be honored (any others don’t have existence in the marketplace), and even what penalties will be imposed on anyone who doesn’t follow their rules (based entirely on their own self-interests, whether insurance industry or government).

If there were clarity despite all such non-clinical confusions we would still have to make sense of the parts, workings and relationships of the clinical team, a worthy but difficult task.

Under the best conditions the patient brings with him or her confusions and resistances, and certainly mistrust of the health care system.

If all these parties are to do their things (third party payors, regulators, institutional administrators, many teams of clinicians, many teams of diagnostic technicians, many support and clerical teams, family and friends, and the patient) and all are to somehow be coordinated, can it be done?  Can it ever be done for the patient’s sake rather than for the various self-interests of the others?  I doubt it.  I doubt a “parallel compartment” model will ever work for understanding or operating health care.

We used to coordinate health care by having every party focus on the welfare of the patient.  It seemed easier to work as a clinician myopically focused on the unique individual who was doing the suffering (and the next patient, and the next).  It seemed possible to develop structure for a health care team, coordination with specialists when the focus was the patient.  Meeting the demands of the arbitrary bureaucrats, countering the greed of the third parties seems impossible and distracting.

The two-party model of clinical relationship seems the simplest and most practical.  That each person relating to a patient directly or indirectly do so as if it were a personal relationship between herself or himself and the patient engages purpose and expertise.  When any party focuses on a selfish purpose (the greed of the physician, the continuity of the institution, the coherence of the team, the power of the bureaucracy, et cetera) the patient must either take distance or be victimized.  When clinical persons and entities are acting from their self-interests they are acting like the sociopathic clinician.

If it is difficult to achieve good focusing on the patient’s welfare in a small clinical team, it must be much more difficult to accomplish such coherence in a large institution where authority issues and budgets overwhelm concern for the real individual patient.  If it is difficult to accomplish coherence in a complex institution, it must be impossible to accomplish cooperation between clinicians and third party payors whose contracts with the patient are in terms of dollars rather than health, whose motivations (whether commercial or “non-profit”) are to take money, keep money, and refuse to pay out money.

The assumption in consumerism is that the patient can make the central judgements for her or his own diagnosis and treatment.  There may be feasible models of health care delivery which do not center on the patient-clinician relationship (like VD clinics where patients are identified by number, blood pressure monitoring in grocery stores, a court-approved list of Antabuse monitoring programs) but the very narrowness of these impersonal processes illustrates by contrast the value of personal clinical relationships.

The most remarkable burgeoning of the consumerist cultural wave is “alternative” modalities, especially called “holistic” (a term which had meaning a quarter of a century ago), in which the patient-consumer chooses (instead of professionals and substances incompletely understood but licensed) exotic diagnoses and treatments which are completely incomprehensible and utterly unregulated.

It is not my ignorance which keeps me from being able reliably to perceive and judge, but my very being-the-patient.  I learned a long time ago that I cannot safely diagnose or treat myself or my own children.  “Objective” and “subjective” are not adequate terms to lead us to understand the blindness we experience as patients.  Perhaps “intersubjective” gets us a little closer to what can be productive of good for the patient in the personal clinical relationship.  One fact is clear: the sick person is in no condition to run the show.

Politicians (especially since the Reagan administration) have exploited “health consumerism” as a part of justifying their programs of “free market competition” in health care, while exponentially increasing government regulation.  I hope I have so far clearly indicated that none of these three (consumerism, competition and regulation) is likely to produce any health goods, that each of them is immensely expensive, and that the unsurprising result of such programs is that again we have been badly had.

Commercialization and corporization of health care for profit have made it necessary for us to give up personal health care (the traditional two-party patient-clinician relationship).  The Reagan administration accomplished in a few months what the Red Menace of socialized medicine could not begin in decades, the destruction of all traditional clinical relations.

Two Models of “Private Practice”

I distinguish two models of medical practice which superficially appear to be similar.  One was promoted by the American Medical Association as a model of solo private practice from the nineteen-twenties (when alternatives first reared their heads) to 1981 (when the Reagan administration dismantled health care as we had known it).  The second is a model of personal (rather than impersonal) health care which can provide what we want and need as patients and is what is most gratifying to the professional clinician.  These two models appear similar because each can be described in some loose definitions of those three components as “solo, private practice, fee for service.”

The AMA model of solo private practice, fee for service was used for decades to oppose any kind of group practice, to oppose “socialized medicine” which might take control out of the hands of (white male) physicians.  An underlying fear was that some party (administrator, government agency) might interfere not only in dollars but in the physician’s pure understanding and control of the patient’s care.  There really was a measure of concern to keep the relation with the patient very direct.

As long as the basic unit of medical care was the doctor’s office all power resided in the doctor and most revenues came to him.  Even in the hospitals nothing was done without the doctor’s order.  There was an ethic of medical practice which focused on the welfare of the patient, but there was no expectation that the patient understand what was happening.  The patient was to trust, obey and pay.  If the patient had bought insurance the insurance company would pay what the doctor claimed was due.  There were few malpractice complaints.

Changes have occurred in the motivations of clinicians.  The monolithic model of medical authority has given way to rationality, autonomy and responsibility on the part of the patient.  These are gradual cultural changes in which we have all participated, clinician and patient alike.  Even though megalomania and greed have sometimes been motivations for physicians, greed is no longer so predominant.  I have never seen a clinician succeed on greed alone, but now that we have recommercialized medicine, perhaps it will be so.  I have never seen a clinician who had not, at least a little in the beginning, been motivated by altruism, the sincere desire to attend to the needs of another.  Unfortunately, altruism is now punishable because it leads to the individualization of the patient, does not disallow the uniqueness of the patient’s needs as the health care system requires.

The model of personal health care resembles the AMA model in that it seems to imply solo private practice, fee for service.  Physicians who struggle to remain in the clinical relation with their patients seem solo, alone, because we have not yet reliably developed ways for a team to relate to an individual patient.  If a small team cannot easily relate to a patient, then the large organization of a hospital or institution cannot do it.  So, some physicians tend to be the proprietor and the clinical professional.  Fee for service hardly exists any longer, but it fits in the personal reciprocity of personal health care, and is more recognizable in the doctor’s office than in the institution.

We don’t need the old AMA model to have personal health care, as its underlying motivations to retain power and wealth (despite Doctor Fishbein’s protests) do not promote health care.  The failure of institutions to provide reliable personal health care is not an issue of “socialized medicine.”  Excellent work can as easily be done in institutions, public and private, as elsewhere.  The failure is that we have not understood what health care can be, what it cannot be.

Current public policy is openly oriented to reestablishing “free enterprise” and “competition” in health care.  There is absolutely no inherent value in such an approach.  Health care cannot reside in regulatory or fiscal relationships, only in fiduciary ones (justifying faith and trust).  As a patient you cannot respond positively to the instructions of authority or to the dictates of the market.  You can only respond within the relationship in which you are cared for and communicated with as an individual.  You must in some sense be loved, not bought, sold, catalogued or instructed.

We argue about scarce resources in health care while we waste unaccounted-for billions to establish massive marketing, bookkeeping and regulation.  Paper, paper, paper!  And what we need are persons­­––clinicians and patients.  Each of us must sometime be a patient.  Where are the clinicians?  We are killing them rapidly, driving out the ones who are competent, training the rest to be impersonal.

Two Styles of Relationship

There are two styles of relationship, defined in terms of how data are treated.  One, for which the paradigm is the ethical clinical relationship, is characterized by the orderly sharing of information for a purpose which is discretely contracted on between two parties.  The second style, typical of political interaction, is characterized by withholding of information or creation of confusion.

Those with some power tend to perpetuate their power by withholding information.  The clinical paradigm, and some models of teaching, parenting and management, enhance the specific availability of data, disperse power, render reliable decision-making within the grasp of many.

When clinical administration is constructed by the power-hoarding, data-withholding model, clinical relationship and responsibility  are changed, goals not merely altered but perverted.  The antithesis of personal care is established under the guise of benevolence.  This happens increasingly throughout our health care system, especially in hospitals public and private, underfunded public programs and health maintenance organizations.  Obedient clinical professionals who want to keep their jobs are indoctrinated to believe limitation or withholding of care is good or necessary, but the persons who are patients cannot afford to fall for the trap of macroallocation applied to unique individual cases.  We must treat real persons, not “the system.”

Economy of health care delivery will never take the form of withholding of information or care.  Economy means to accomplish the task “quickly and neatly,”8 not ever to evade the task.  Macro-allocation (community-wide budgeting) may enhance economy, but it must never be the clinician’s consideration in any individual case.  The question is not what we cannot afford to do, but what we can do here and now, immediately for you.

Bureaucracy is Ubiquitous

Bureaucracy is ubiquitous.  It is not what some have said, the self-perpetuating inertia of public officials and civil servants.  Such ineffectiveness and recalcitrance as we see in their behavior are real, but more a result than a cause of our problem.

Bureaucracy also is not the machinery by which public policy meets public needs.  Our bureaucracy tends to deny or freeze real needs, more likely selling favors to “interest groups.”  It has been a poor tool in our and other societies, costly and rarely productive of effective programs.

Bureaucrats often are serious, even dedicated public servants.  They more often than not wish to respond to real needs of the people.  Public servants, ironically, often oppose each other in public fora, consuming public resources as they represent “conflicting” public interests.

What bureaucracy is, is a system for which no one party is to blame, which accomplishes one simple thing:  it fragments each task so completely that no discrete action can ever be effected.

For the devastations of bureaucracy the cure is correspondingly simple:  to assign each significant task to only one party, to allow no diffusion of purpose, to identify discrete needs and maintain their discreteness until they have been met.

We have learned these maneuvers in caring for each patient because we have acted to empower and to inform on a direct personal level.  We are not distracted from our myopic loyalty to the patient, our shared goals unified in relation to the patient’s uniqueness.  There is no excuse for mystifying technical mumbo-jumbo, no time for self-aggrandizement. 

There is no difference between “public” and “private” bureaucracies.  In health care they both look to nonclinical purposes, that is they haven’t the slightest concern with health care, only the dollars and power which surround health care.  No good is to be had from bureaucracy in health care until it recognizes the clinical relationship and enhances and supports it.  Bureaucrats who address myths like “larger need,” “public good” or “potential market” should get out of the hospitals, HMO’s and public agencies, back to Madison Avenue and Washington where they belong.  They don’t understand health care.  They don’t care about patients.

All health care now takes place in a setting of massive enmeshed bureaucracy which is structured to withhold information and power of choice from each patient and from the clinical professional who might attend that patient.  Clinicians respond to “the system” instead of to the patient.  Most clinicians have inadvertently fallen for the overturning of the clinical relationship because they never consciously understood what they were already doing well.  But they do understand at some deep level, or they would never have begun their altruistic work.  I encourage clinicians to become aware and to unstintingly oppose the directions our culture has taken in these regards, actively to take on the role of advocate for the patient.

It is important to see that even when current embryonic efforts to turn the profitdriven juggernaut to care for the frail or dependent, the public power-driven agents of regulatory agencies will again veer us away from care into an essentially identical machine to break the clinical relationship, to ignore the real needs of real patients and to punish clinicians who don’t follow all protocols and instructions exactly as trained and told. There are attempts to integrate interest in truly effective patient care9 and welfare on the one hand, at the same time to promote the health needs of the community (beyond the sole individual) and to conserve the resources that are necessary for health care itself and for the economy as a whole (the "triple aim").10

***

I thank you for your attention to these abbreviated thoughts.  If any statement seems extreme, please do not assume it is polemic.  I say only what seems important and true, and I trust anyone who may disagree to engage with me in productive dialogue, where there is sharing of mutual concern, community, not antagonism.

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1Edmund Pellegrino, “Hospitals as Moral Agents” in Humanism and the Physician, (Knoxville:  the University of Tennessee Press, 1981), pages 146-148.

2Some of Doctor Fishbein’s editorials against pre-paid health care can be found at www.thenation.com in Archives: The Healthcare Debate. His self-inflation and chicanery are documented in Michael Lerner’s Choices in Healing, MIT Press, 1994

3Especially Doctors of Today and Tomorrow (Cooperative Publishing Company, no date) in which he outlines his conflicts with Fishbein (pages 83-102). Also see his other works including Principles of Cooperative Medicine, A Doctor for the People and Crusading Doctor.

4Paul Starr, Social Transformations in American Medicine, Basic Books, New York, 1982. He is one of a very few authors I know (other than Doctor Shadid himself) who refers to Doctor Shadid’s pioneering work and the ordeals he suffered from the American Medical Association, including the wholesale drafting of his sons and all the other physicians at the Elk City Community Hospital during the Second World War, leaving the aging Doctor Shadid alone to do the work of twenty.

5A detailed analysis applied to hospitals can be found in George Ross Fisher’s The Hospital that Ate Chicago, (Saunders, 1980), especially “Moral Hazards of Third and Fourth Parties” (Chapter 14).

6A detailed analysis applied to hospitals can be found in George Ross Fisher’s The Hospital that Ate Chicago, (Saunders, 1980), especially “Moral Hazards of Third and Fourth Parties” (Chapter 14).

7Although she does not name it as such, and describes it explicitly for psychoanalysts only, Alice Miller recognizes this type in The Drama of the Gifted Child (previously Prisoners of Childhood), (New York:  Basic Books, Inc., 1981).  The psychiatrists who formulated the standard list of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (perhaps because they were a committee and because they were psychotherapists) as a group could not acknowledge what applied to themselves and omitted any consideration of this personality disorder which characterizes most every clinician, what I call “pathological altruism”.

8Hippocrates, Regimen in Acute Diseases (as previously cited in the chapter on The Oath), still my oldest and most reliable teacher (even if he was a committee).

9As in “evidence-based medicine”.

10As promoted by Donald Berwick, MD and the Institute for Healthcare Improvement (ihi.org)

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