How to Make Things Better

Don Berwick is the influential “physician” businessman (not clinician), whose righteous indignation over his own travails in the maze of medicine so impressed reporters of the Wall Street Journal and Boston Globe, that his personal opinions have been given elevated status and circulation. And this fame may have led President Obama to think his judgment is what we should follow. Meanwhile, while touting returning to “primary care” the Maze of Medicine today is wiping out us “real doctors”, the generalists: the Family Physicians, General Internists and General Pediatricians.

Complaining about his wife’s poor treatment when she was lost medically and emotionally in the maze of a large, impersonal organization, Berwick — from his lofty perch in his own large organization — recommends that we all subject ourselves to even larger and more impersonal organizational schemes, in the name of efficiency, cost-saving and “quality”.

Could not the reverse be true? We have become disconnected from our real doctors, our family/generalist physicians, by subspecialists doing not only their own jobs but preempting the generalists’ purview. The patient needs coordination of care, hiring and firing these very subspecialists by someone qualified to oversee their performance close at hand. Insurance companies (“health plans”) and hospitals have wrested power away from all but the most tenacious personal physicians to develop systems that effectively disincentivize them by excluding them systematically from the care of the sickest patients and interrupting continuity of care. This takes away the patients’ most important link and advocate. Our graduating residents are acculturated to accept fragmented care and handing their sickest patients over to hospitalists. In fact, it has been “systems” that have “done us in.”

Had this physician’s wife been my patient (or my like-minded colleagues), our name would have been on her hospital bracelet, from admission to discharge. We would have willingly taken responsibility for her total care, including negotiating the puzzling patchwork that is today’s mega-hospital.

The bowel of a large hospital system is no place for sick people. The makeup of such systems guarantees that there will be snafus right and left. If one wanted to design systems where errors would multiply, they couldn’t do better than our megahospitals or even our large medical groups — unless there is personal oversight & priceless continuity, not by PR people but real doctors.

Bigger is not better. Small and personal is good: one doctor, one patient, one at a time, with specialists coming and going as needed. It is not the lack of systems, but of individuals imbued with concerted efforts to revert to the first principles of Medicine. The concept of small and personal assuages completely patients’ dissatisfactions, and leads to fewer errors, better communication and more real caring & curing. That’s how to make things better. A practicing, up-to-date generalist should run things. He/she can acquire knowledge necessary regarding regulation & business milieus to keep the sick (& well) patient central to any “system” change.

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