Meet the Expert: Brian White
For our next feature, we are
interviewing Brian F. White, DO my co-author on the article "Patient Satisfaction Surverys: Tools to Enhance Care or Flawed Outcome Measures?"
in the December, 2013 issue of PM&R the journal of injury, function, and
rehabilitation.
Gary:
First off Brian, thanks for participating in this
Q&A session. It's a privilege to have you here. From a standpoint of
introduction, can you tell us about your background, and your journey in
becoming a physician.
Brian:
Thanks Gary, it is a real
pleasure to be involved in the fantastic work that you and Garret are doing at
Lake Washington Sports and Spine. In
regards to my own background, when I graduated from high school a career in
Medicine was pretty far from my mind. I
attended the University of New Hampshire, initially as Mechanical Engineering major,
but during my junior year decided to complete my degree in Business
Administration. At that time, I was not
thinking of pursuing a career in engineering, or medicine for that matter.
I had been an alpine ski
racer in high school and when I began my studies at UNH I envisioned competing on
the UHN alpine ski team, unfortunately, as a ski racer I was not competitive at
the Division 1 level and stopped ski racing after my sophomore year. As part of training for the ski team, I
became involved with the UNH cycling team which at the time was a regional and
national collegiate cycling powerhouse. I
ended up living at the US Olympic training center in Colorado Springs as part
of the National Team Development program for three different winters and while
I competed for UNH we won the US National Cycling Championship title.
Gary:
I know that you were involved in both skiing and
cycling. How did you make the transition
from skiing to cycling?
Brian:
Once I stopped skiing during
my sophomore year of college, I transitioned to cycling fulltime and for the
next several years hardly ever got on snow.
In order to take my cycling to the next level, I moved to Boulder
Colorado, initially in 1992 to train for Olympic trials, and then on a
permanent basis in 1994.
For various reasons cycling
was a good fit for me as an athlete, a much better fit than alpine skiing had
been. I competed at Olympic trials in
1992 and 1996 as well as more than a score of National championship events,
finishing in the top 20 on multiple occasions.
I also represented the US National Team in many International events and
wore leader’s jerseys in the Tour of Venezuela as well as the Tour of Panama.
Gary:
I also know that you have had some success with
coaching, both skiers and cyclists, I believe your former athletes were
National Champions and even an Olympian.
How did you move from athlete to coach?
Brian:
One of my main cycling training
partners in Boulder, Peter Davis, had been a ski racer at the storied Burke
mountain academy. Given my background in
alpine racing, he suggested that I get involved with coaching youth ski racing
as an off season activity. He introduced
me to a friend of his Matt Lyons, who was the Program Director at the local ski
team. We met and discussed my
involvement in the program and I began coaching 9 and 10 year olds the winter
1994. Although an unplanned diversion in
my life, I took to coaching and was able to combine the understanding of elite
athletics I had learned as a cyclist with my prior knowledge of ski
racing. This combination of skills
proved quite useful as a ski coach and I ended up coaching full time, six days
per week, for the next seven years.
Ultimately I developed a
cycling team in association with the Eldora ski racing program, one of my
athletes, Ian MacGregor, went on to win the US national road championship in
2004 and 2005, and another, Timmy Duggan, won the US professional national road
championship in 2012 and was also a member of the 2012 US Olympic cycling team
that competed in London. Ian has retired
from cycling and since has gone on to co-found Skratch labs with physiologist
Alan Lim. In another selfless act that
continues to make me swell with pride, Timmy and Ian developed a non-profit
organization to help young athletes get funded to further their own Olympic
dreams; Just Go Harder.org, check out their web page, and more importantly,
make a donation.
During my time in Boulder, even
more important than success as an athlete and a coach, was the meeting of the
Head ability coach at Eldora, Susan Holes, who eventually agreed to become my
wife in 1998 and then the mother of our two sons. As fate would have it, we were first introduced
to each other by the same training partner who suggested that I get involved
with coaching young kids. I suppose that
sometimes it is better to be lucky than good.
Related
media:
Gary:
So you went to UNH and obtained a business degree, competed as
a cyclist at the Olympic Trials level both domestically and
internationally. Then you coached skiing
and cycling with some success, how did this pathway during the 1990’s lead to
your current career as a Physician?
Brian:
Susan and I were married in
1998 and decided that developing a more long term profession was in order to
facilitate building a life together and planning for a family. To that end I enrolled at the University of
Colorado and pursued a second degree in Biochemistry. I considered a few alternative professional
pathways, but given my history in athletics and coaching, Medicine was really
the best fit and best way to use my prior skill set to give back
I ultimately began
Osteopathic medical school at Midwestern University – AZCOM in the late summer
of 2000. I continued to coach skiing during
the first year of medical school and continued to compete as a cyclist into the
second year of medical school. Medical
school was very challenging, but I found that leaving the life of an athlete
was an even more challenging; it was very difficult to give up that way of life
and the intensity and singularity of mind it provided after so many years.
Gary:
More specifically, how did you decide on Physiatry?
Brian:
During medical school, like
most medical students I struggled with the decision of which specialty to
pursue. I eventually narrowed it down to
orthopedic surgery and Physiatry. In the
end I chose Physiatry, in many ways guided by my beliefs and the experiences I
had as an athlete. I experienced several
significant injuries as a cyclist, in fact in 1997 I missed the entire
competitive season due to a recalcitrant Achilles tendionopathy; this lost
season was especially disappointing given the success I had during the 1996
season.
When I was injured, surgical
debridement of the tendon was offered as a treatment option, an option I
ultimately chose not to pursue. This
desire to avoid surgical intervention drove my recovery process as an athlete for
this as well as other chronic musculoskeletal injuries I suffered over the
years. Given the non-surgical pathway I
had mapped out for myself as an athlete I thought that pursuing a
musculoskeletal care pathway that minimized surgical options as much as
possible would be the best pathway for me advise to my patients; to this end I
choose Physiatry over Orthopedic surgery.
Gary:
I had a similar experience, though at a lower level
of competition. When I graduated from
the University of Wisconsin in 1995, I was training for an Ironman, and tore my
right PCL in my knee. I ended up spending the
summer between college and medical school rehabilitating my knee. My personal experience with rehabilitating
this injury is what led me to choose PM&R as a career as opposed to
Orthopedics.
Brian:
It is very interesting to
hear you describe a similar early story and tying your personal desire to avoid
surgery if possible with your ultimate decision to pursue Physiatry over
Orthopedics. I know many Physiatrists
who were would be Orthopedists but ultimately choose Physiatry as their life
pathway. This includes several of our mutual friends such as Ethan Colliver,
Marla Kaufman, and a host of other notable physicians.
Gary:
Getting back to the line of thought regarding the
pathway that brought you to where you are today. We initially met in Cooperstown when you were
an Intern. I had completed the Internship
at Bassett two years prior. We met again at Kessler where we were both
residents. Tell me a bit about your experience with Bassett as well as at
Kessler.
Brian:
Sure, as you note we had a
similar training pathway with me following two years behind you at the Bassett
Internship program and then again at the Kessler PM&R residency
program. After graduating from medical
school in 2004, I completed a Columbia University associated Rotating
Internship at Bassett Medical Center in Cooperstown, NY. It was a challenging but wonderful year in
Cooperstown. I learned a lot about medicine, made many friends, and continued
to train along side one of my medical school classmates, Ethan Colliver. My wife and children made many friends and
despite the long hours and stress involved in Internship, we had a great year,
it was good for me as a growing physician but more importantly it was a very
good year for our family.
I left Cooperstown and again
followed you to engage in the rigorous, academic residency at the Kessler PM&R
program in NJ. While at Kessler I was
exposed to many great musculoskeletal attending physicians such as Gerry
Malanga, Greg Mulford, Jeff Cole, Todd Stitik, Gautam Malhotra, and Pat Foye
among others. I also had the benefit of
excellent mentors such as Steve Kirshblum and Susan Garstang. Further, the Kessler program also afforded me
the good fortune of meeting like minded and very gifted musculoskeletal
colleagues in residency such as yourself, Jim McLean, Casey O’Donnel, and Chris
Visco. Chris and I were residency
classmates and two of our other Kessler class of 2008 classmates, Rich Dentico
and Ron Karnaugh, also did post residency fellowships and chose to pursue a
career as musculoskeletal Physiatrists; it was a great bunch of talented
individuals to be mixed together with during our formative training years. All of these individual provided direction to
my education and career pathway, and more importantly remain my close friends
to this day.
I left Kessler to pursue a
Fellowship year at the University of Massachusetts in Worcester, MA where I
furthered my knowledge of EMG and musculoskeletal medicine as well as
developing an interventional skill base.
Your question regarding
Cooperstown and my time at Bassett I think can be best answered by where I live
and practice now. When it came time to select a job post fellowship, I gave my
wife the choice of pursuing a position in San Francisco or returning to Bassett
Medical Center in Cooperstown; she chose Cooperstown as the place to grow our
lives together and to raise our sons. We
have been here ever since and so far have been quite happy with our
choice.
Gary:
You describe a bit of a convoluted pathway toward you
current career as a musculoskeletal physiatrist, given my personal pursuit of a
PhD in Anatomy as part of my own medical pathway, I can see value your unique
process. Is there anything special you
think that you bring to the table in treating patients that you might not have
in your bag of tricks had you pursued a more traditional pathway to Medicine?
Brian:
Yeah, it was a bit of a road
getting here, but life is about the journey much more so than the
destination. I believe that this unique
and protracted pathway to Medicine has afforded me many unique tools to bring
to bear in the treatment of my patients.
Graduating with a business degree provides an insight into the business
aspect of Medicine and the requirements to run a successful business. Competing at an elite level has given me an
understanding of what it takes to be successful at a high level and of how hard
I can push my body and mind in the pursuit of excellence. Coaching high level athletes helped me to
develop the capacity to teach and nurture individuals to push themselves to
attain goals that they once did not think possible. All these are qualities I use on a daily basis
in the course of providing care to my patients.
I had the good fortune of
recently being featured in the quarterly edition of CORE which may be an
interesting read for your readers.
Gary:
Let’s switch gears a bit. Tell us more about patient satisfaction
surveys. For those who don't know much about these surveys, they sound like a
great idea, but you argued that they may actually be harmful for patients.
While I obviously agree with you (since I was your co-author), that may not be
apparent to most people. Why are patient satisfaction surveys harmful?
Brian:
As you mention, you and I
wrote an in-depth opinion piece on the subject published in the December issue
of the PM&R Journal. I would
encourage your readers to review the article for themselves and get a more informed
perspective. (Gary's Note: full access to article only available for PM&R Journal subscribers. Please contact Gary if interested)
There are many problems with
patient satisfaction surveys. These
surveys are marketed as a tool to grade healthcare quality but are deeply
flawed. First, they are not particularly
accurate measures of what they purport to evaluate. Second, the measures these surveys do
evaluate do not equate to improved healthcare.
So in the end these surveys are a poor measurement of data that is not
relate to the quality of healthcare provided.
A big flaw is that patient
satisfaction surveys ask the wrong question.
The goal of medical care is not to engender satisfaction, but rather to
improve health and function of our patients; satisfaction surveys miss the
point. What we should be doing is
looking at how we can better engage our patients to further their personal
goals for health and function rather than look to see if they are satisfied with
us or not.
There are not a lot of
scientific studies on the topic, but those studies that do exist actually
demonstrate that high patient satisfaction correlates with poor patient
outcomes. This may, at first glance,
seem counter intuitive but this unexpected result is likely related to what
physician behaviors and activities engender patient satisfaction and what
physician behaviors foster better patient health; these two sets of behavior
are often in direct opposition to each other.
As we noted in the article we
co-authored, the best study to date on clinical outcomes and patient
satisfaction scores demonstrated that the patients who were most satisfied with
their physicians died at a much higher rate than those patients who were
relatively unsatisfied. A further point
we made in our article was to note the moral inappropriateness of using satisfaction
scores to evaluate physicians, as is well described in the article we
referenced by Labig.
Unfortunately these surveys
aren’t just a benign waste of time, but rather are misguided tools. In their
application, they are often used to manipulate physician behavior, often in
ways that might not be best for either the patients or the doctors. The unintended consequences of these surveys
are potentially great and argue against their use.
The patient-physician
relationship is not a symmetric one. The
physician brings to the table a set of knowledge and insight that the patient
does not possess and then uses this insight for the benefit of the patient
rather than leveraging the inequality in the relationship for personal
gains. As physicians, we use our skills
for our patients benefit rather than for our own good despite the frequent
sacrifice on our part required to do so.
Our role in the relationship is
not to engender a fondness for us, nor to get our patients to like us or feel a
high degree of ‘satisfaction’. Rather
our role is to selflessly care for and guide patients on their road to improved
health and function. However, if we were
to focus on getting patients to ‘like’ us, we would often make decisions
counter to the real goal of helping patients improve.
So this brings us back to the
prior thought that measuring a patients’ satisfaction with their physician is
looking at the wrong factor and in doing so could very likely alter the
relationship in a manner that is harmful to the patient. As improving patient welfare is the goal of
physicians, engaging in satisfaction scores is the wrong thing to do.
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Gary:
For a small private practice like what Garrett Hyman
and I run here at Lake Washington Sports & Spine, how would you advise we
improve the patient experience? Are there methods that would work better than
using commercial survey tools? For example, would simply asking patients
directly for their feedback be more helpful?
Brian:
I think that there is a
cluster of features that help define the patient experience in regards to
clinical quality. The first two aspects directly
tie to the physician, in this case Garrett and yourself, and what you bring to
the table. The second two aspects apply
to the patients and what they bring to the table. The quality of the clinical experience lies
in the interplay between theses facets of this relationship and both parties
need to have responsibilities to, and expectations of, that relationship.
Gary:
So part of the relationship is the responsibility of
the physician and part is the responsibility of the patient?
Brian:
Exactly, the first set of
features in this relationship puzzle relate directly to the physician. I see two big items that the physician
controls. The first is development and fostering
of a caring relationship and the second is striving to continue ongoing
development of clinical excellence.
At the heart of the patient
physician relationship is the relationship itself; this is often the key to
clinical excellence. In order to care
for patients, you must first ‘care’ about them, and directly engaging them is a
fundamental component of the process of caring.
To that end physicians need, as your question suggests, to directly engage
their patients and discuss their needs in a proactive manner as a starting
place for maximizing patient care.
However, although fostering a
relationship based on compassion and caring provides a starting point, this is
not enough. You and Garrett need to continue to expand on your already considerably
clinical skills. Pursuit of clinical
excellence needs to be the second step in this relationship pathway.
When you and I were in
residency, one of our mentors, Dr. Kirshblum, often talked about the three
‘A’s’: Affability, Availability, and Ability as the key to excellence as
physicians. The two components I am
discussing here as the province of the physician within the relationship is
really another way of stating the three ‘A’s’ to excellence as Dr. Kirshblum
taught us years ago.
The second set of features
comes from the patient, but as physicians you can help teach and mentor the
patients in these components. The first
is management of expectations, and the second is embracing personal accountable
for health and outcomes by the patients themselves.
I think that appropriate
expectation management is especially important.
As we care for an ever aging patient population there are real, as well
as perceived, limitations on what people can do. The limits of human ability is always
expanding, but that said, there are limits and sometimes what a patient desires
for their healthcare outcomes may not be realistic; we need to counsel and
educate them about what is reasonable, we just need to do so in an optimistic and
positive manner.
For example, I often counsel
my patients with back pain, that their desire for complete, permanent
eradication of their lumbar pain while engaging in any activity they desire may
be unrealistic. However, addressing
underlying factors effecting the development of their pain and having a goal of
increased function in an age appropriate fashion is usually very
realistic.
People tend to be
disappointed, complain, and have reduced satisfaction when their expectations
are not met. As such, if their
expectations are not obtainable in 99% of the circumstance, they will end up
disappointed 99% of the time. We need to
set high goals, but obtainable one that can be achieved with discipline, hard
work, and the patient’s full engagement in the process of achieving health and
improving function.
This brings me to the next patient
driven aspect. Patients need to be
accountable for their ultimate health and outcomes. As an athlete, if I didn’t train, I was the
one who did not succeed; I was responsible, there was no one else to blame. We can control our efforts, the time we put
into our training and the attitude we bring to the training environment, but we
can not control the outcomes; control of outcomes is an illusion. In this vein, we need to teach our patients to
focus on what they can personally address, the controllable factors, and try
not to get hung up on what they can not address, the uncontrollable factors. As a coach, and with my own children, I teach
that your personally controllable factors are: the time you put in; the effort
you are making; and the attitude you bring to the task. This perspective has wide spread utility in
healthcare, especially healthcare intimately directed by small practice
physicians such as Garrett and yourself.
Gary:
That sounds great, be realistic and take
responsibility in your own healthcare, do you have an example?
Brian:
Sure, let’s look at a patient
that would be common in both your practice as well as my own. Let’s look at low back pain. When we look at a clinical issue such as back
pain we know that there are many factors that are involved in a complex
interplay of genetics, phenotype, environment, injury, etc. For back pain we know that obesity and
smoking play a large role as does age and gender. We also know that strength, flexibility, and
neuromuscular patterning also play a role as does daily activity, personal
biomechanics, and ergonomics.
Some of these factors, for
example genetics, gender, and age, are not modifiable, so we need to teach
patients to try not to get too caught up in worrying about these issues; they
can’t change them anyways. Other factors
are modifiable and patients need to be counseled to fully engage these factors. Are the patients aggressively trying to get
their weight down to a BMI <25? Have
they stopped smoking? Are they doing a daily home exercise plan? Are they avidly addressing their deconditioning? Are they engaging in activity that requires
inappropriate duration or intensity of activity for their body and age? Have they modified their expectations to
include reasonable goals? And so
forth.
In all of these examples, you
and Garrett can directly improve the quality of patient care by keeping the
patients focus on modifiable, controllable factors, the time that the patients
are putting into these issues, the effort they are applying to make changes,
and the attitude that they bring to the process. This effort on your part will potentially
have a much more lasting impact that any particular intervention or
medication.
----------------------
Gary:
For you or your family, which would you prefer for a
better patient experience- a small independent practice, or a large practice
that is part of a system or Accountable Care Organization?
Brian:
For my family, my primary
concern would be excellence of care. To that end, I would prefer to see the
components discussed above brought to bear for the benefit of my family
member. I would like to see care
provided by a physician with demonstrated excellent clinical skills and
academic knowledge and an obvious desire to continue to develop and improve
their knowledge base and acumen. I would
like to see this physician provide care within a compassionate, concerned
relationship with an eye toward an end point of great care for my family
member.
Care such as this could be
provided in many settings, this would include small independent practices as
well as larger organizations. However, I
think that a small independent practice is better positioned to give this type
of care. In the small setting, the
patient typically has direct access to their physician and the goals of the
practice are more in line with the goals of the individual patient. In larger organizations, even with the best
intentions by individual physicians, often the organizational goals are more
aligned with the overall care of a patient population rather than an individual
patient. This bigger picture, population
driven focus of healthcare in a large organization works well for the
management of demographic data but not necessarily for any given individual
patient.
When caring for an individual,
we get back to the keystone word ‘caring’; I think that the small physician centric
independent practice is better positioned to provide that ‘care’. This focus on direct patient relationships
and ‘caring’ can happen in larger organizations, but I think it is more
difficult. In a small practice such
yours, because you have both direct authority over care and direct
responsibility for the patient relationship, I think that you can be more responsive
to individual patient needs and in most cases provide better care.
At the end of the day,
healthcare is about two people in a closed room having a private, intimate conversation. One of those two people brings a deep
knowledge about medicine to the discussion and the other person brings a deep
knowledge of their personal problem.
After a private discussion and evaluation, the two people come up with a
plan and then leave the room. What
happened inside this room is ‘healthcare’. Everything else in the system exists
to support that private conversation and patient-physician relationship. The closer we can get to this idealized
situation the better it is for patients.
In general, I think that at this point in time, the small independent practice
is best positioned to provide for and support this private interaction.
----------------------
Gary:
Do you think physician ownership of a medical
practice, as opposed to a medical practice run by an administrator, makes a
difference in a quality patient experience?
Brian:
I think that in general medical
care should be directed by physicians, both for the individual patient as well
as for organizations and policy. This need
for physician control and direction holds true at a local level for a small
practice such as yours but also expands upward to control and direction of
larger healthcare organizations and even to state and national healthcare
policy objectives.
To use a sports metaphor,
many great coaches were not great athletes themselves, but they were nearly
always good athletes. How can you coach
and direct a team or an individual athlete if you do not ‘know’ the game. When I coached alpine skiing, I was a better
coach than I was a ski racer. But I had
ski raced at a high enough level to have some insight into the ‘game’ and by
competing at a much higher level as a cyclist, I knew what it took to compete
on a National level and beyond. By
combining those two skills along with some other personal skills, I developed
into a good coach, much better than my personal history of ski racing would
have suggested. But the important point
is that I had been a ski racer.
I think that it would be very
tough to coach any sport that you had not played yourself and it would be very
hard to help an athlete be successful at a high level if you hadn’t been at a
high level yourself; how could you understand the process or mindset without
the experiences yourself? Extending this
metaphor, the direction and management of medical care must be via physicians. How can non-physicians directly lead or direct
healthcare without the background that the process of becoming a physician and
obtaining Board certification affords?
I think that a natural career
pipeline for physicians is to practice for 15 – 20 years and be mentored in
leadership during that clinical phase of their careers. Following this phase they can have a
leadership / administrative role for 10 – 15 years leading into
retirement. This is a natural flow that
allows for development of a deep understanding of patient care, healthcare
process and delivery, as well as development of leadership skills. All while directly engaged in the
relationship and pursuit of clinical excellence that we discussed above.
To have non-physicians in a
role of supervising, directing, or controlling physicians is a mistake. Non-physicians’, that includes mid-level
providers and nurses, do not have the same ‘buck stops here’ experience with
medical care that physicians do, as such, they are not positioned to evaluate
or direct physicians in the execution of patient care. This is much the point of our point-counter
point article on patient satisfaction scores.
I make a strong point on the
importance of physician control and leadership of healthcare, but we must also
remember that other players perform unique and useful tasks within the patient
care pipeline and we need to respect and support them in the course of their
filling those support roles. The
non-physician colleagues can play a very important and much needed role as our
allies, but not as our leaders, ‘owners’, or ‘bosses’.
Gary:
What does your vision for better health care in 5
years look like?
Brian:
I think that the tea leaves
on this issue are in really muddy water at this point in time. The current trials and tribulations of the
ACA and the obvious public distain for much (but admittedly not all) of the
contents make any forecasting very difficult.
Further obscuring the future pathway is that the pendulum has swung very
far towards the business / administrative side of healthcare. It is crazy that people with business degrees
are in positions to tell physicians how to run their clinics, that
administration is having a say in the schedules of residents and fellows during
their training, that in many large healthcare organizations there is one
administrator for every 3 or 4 physicians.
The inappropriateness of these and many other things are being noticed
by those outside the ranks of physicians and I believe that the pendulum will
swing back toward physician drive patient care as the cornerstone of health
care, the question is when.
As a nation we are also going
broke providing healthcare in the manner that we currently do, so things must
change. We have an annual GDP of about
$15 trillion in the US and medical care expenditures of more than $2.2
trillion. That can’t keep happening; we
simply can not afford this amount of cost over the next 15 or 20 years. It is a fact that this expanding expenditure
will get cut, but the question is where to cut?
A large part of the problem
is the almost complete lack of national discussion on the real source of these
runaway costs. Physician salaries make
up only 8% of the total healthcare costs, so even if every physician in America
worked for free we would still spend nearly $2 trillion per year on healthcare
in the US. So, obviously targeting
physicians is the wrong way to go, even if only for pragmatic reasons that
chopping doctors will have minimal to no effect on the cost problem.
So where to address
things? My personal belief stems back to
the above mentioned patient centered aspect of care; personal
responsibility. Modifiable factors are
the biggest cost in healthcare in America.
Obesity and smoking combine to directly tie to >50% of all healthcare
costs in America. In other words, if everyone in the US had a BMI <25 and no
one smoked, we could move toward a future with healthcare costs <$1trillion
per year; now that is a significant difference.
The escalation of healthcare
costs is really a demand side economic problem and as a nation we continue to
attempt to address the issue by making supply side regulations and attempting
to change payments in order to change the slope of the supply curve. But supply is not the problem, demand is the
problem. In most large hospital systems
the top 100 utilizers of emergency department services (the 100 patients who
use the ER the most) spend a wildly disproportionate amount of the healthcare
dollars in those systems. I do not have
an article to cite, but I have heard it stated that overall 10% of the patients
spend 90% of the healthcare dollars.
Until we address the demand
curve for healthcare, the US healthcare expenditures as a percentage of GDP
will never get ‘fixed’. The great news
is that if we can get politicians on board and decrease the disproportionate
input that ‘big’ medicine has on the system, and focus on the quality of care
issues you and I discussed above, then we can find a solution. But there is almost no discussion on a
national level regarding this issue; instead our national and state leaders
continue to throw regulatory requirements into the marketplace that make
healthcare more expensive all the while ignoring patient responsibility for
cost control and their own personal health.
We must move on a national scale toward the above noted components for
excellence, with a national focus on excellence in physician directed care and on
patients having realistic expectations and taking personal responsibility for
their healthcare and outcomes.
There are several well known
national voices that have espoused a future of medicine in the model of
Wal-Mart or the Cheesecake factory. They
envision large corporate entities providing homogenized, albeit acceptable (but
not excellent), healthcare to the masses.
This vision is deeply flawed because of it continues to focus on the
supply side of the healthcare equation while lacking in the much more
financially salient demand side of healthcare in the US.
Further, is shopping at
Wal-mart a better retail experience than shopping at a local merchant? Is it better for the community at large? Is it better for the workers? I would ask what community has seen its local
population benefit from the invasion by Wal-Mart and the subsequent decimation
of local retailers. Does eating at Cheesecake factory offer a better meal or
quality of product than could be provided by local chefs using local or
regional products in a small to medium volume format? If you are looking for a quality dinning experience
would you rather eat at Cheesecake factory or at The French Laundry or Blue
Hill at Stone Barns (look them up)? Or,
if you are looking for less financial challenging quality food, I would suggest
that the Panini sandwich at your local deli is both higher quality and lower
cost than a similar lunch at the Cheesecake factory. What community has seen an expansion in the
quality of local food when a Cheesecake factory opens up in the local shopping
center?
These giant organizations
offload their profits away from the local community, pay relatively lower wages
than would be making by the owners of local establishments, and degrade the
quality of product in terms of both product and the quality of relationship
available. This corporate homogenization
does not improve the retail experience or the dinning experience, and I do not
think corporatization will benefit the healthcare experience.
So the future is murky, but I
think that there will always be a role for small physicians groups providing
outstanding clinical care and forming lasting and quality relationships with
their patients and communities.
Excellence never goes out of style, so I think that you and Garrett have
a bright future.
