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On Being a Doctor |

Recycling

James H. King, MD
[+] Article and Author Information

From OSF Galesburg Clinic, Galesburg, Illinois.

Requests for Single Reprints: James H. King, MD, OSF Galesburg Clinic, 3315 North Seminary Street, Galesburg, IL 61401; e-mail, james.h.king@comcast.net.


Ann Intern Med. 2014;160(1):68. doi:10.7326/M13-1051
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I must admit to a certain admiration for the chutzpah of those who simply recycle an old idea and then take credit for inventing it, and I stand amazed that the medical establishment applauds them for it.

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Recycling or Transformation?
Posted on January 10, 2014
Richard Blakely MD
Memorial Hermann MHMD, Houston
Conflict of Interest: None Declared
Dr. King, in his “On Being a Doctor” contribution in the January 7, 2014 edition of the Annals, is “bemused” by what he calls a new career field in renaming traditional models of health care. He believes that the concepts of a medical home, patient-centered care, evidence-based medicine and the accountable care organization are merely the renaming of the multispecialty group practice, patient-directed care, decision making based on evidence, the HMO, and notes that care has always been patient-centered.
It is emblematic of the problem of medicine in this country that Dr. King finds this all bewildering. The fact is that vastly more money is being spent per capita on health care in the U.S than in any other industrialized country but our outcomes are no better. We talk about care of the “highest quality”, but what we mean is that we are providing excellent care in our practices rather than ensuring that our patients (and communities of people) are receiving the best possible care. The differences are huge: a patient may go from doctor to doctor getting high quality care in each setting, and yet face the difficult task of trying to coordinate the care being given and having to deal with a health system that is rewarded by illness rather than wellness.
So the concepts of the “medical home” and of “patient-centered care”, rather than simply being a bureaucratic exercise in renaming old concepts, actually describe physician-led initiatives that do focus on care as received by the patients and communities of people we serve. Built into the ACO is the word “accountable”, meaning that all health care providers in the organization are held accountable by each other and by a payment system that incentivizes not volume, but wellness, coordination of care, avoidance of unnecessary and duplicative interventions, and a strong commitment to practice in a manner consistent with current scientific evidence. Moreover, inherent in the ACO are data, analytics, and transparency of outcomes reporting so that physicians are kept informed regarding opportunities to keep doing better.
While I agree with Dr. King that these “renamed” terms are all too often being used as marketing tools, the underlying principle is far more than “renaming”. It is health care transformation. It offers the promise of restoring us to world leadership in cost-effective health care. We physicians need to lead it. It is the right thing to do.
Complaint against Recycling
Posted on January 28, 2014
Edward Volpintesta MD
Danbury Hospital
Conflict of Interest: None Declared
To the Editor,

I appreciate Dr.James H. King’s concise criticism of those forces that have undermined the integrity and the peace of mind and the very soul of medicine (“Recycling”, Ann Intern Med 2014; 160-68).

Clearly, the control of medicine has been usurped by MBAs. Like him, I find that the “medical home” and “patient centered care” and “accountable care organizations” are just buzz words meant mostly to be used by policy makers in their relentless efforts to extend their control over the practice of medicine.

And for all the theoretical good that electronic medical records may have, they have not made me a more capable physician.

With all due respect however I was disappointed that Dr. King said that he “shall offer no complaint” to the policymakers that push these changes.

It seem that too many of us physicians are too accepting and too tolerant toward the forces that that are too eager to define medicine in their terms. Clearly, “complaint” is exactly what is needed in the new world of medicine.

Ever since the early 1990s medicine has suffered a slow and steady erosion of professionalism. And effective and sustained complaint has been shamefully missing from our medical leadership and from physicians in general. Until physicians are ready to complain and to complain in a loud collective voice the light in medicine will eventually be extinguished.
Physicians would do well, in the words of poet Dylan Thomas to: “rage, rage against the dying of the light”.
Author's Response
Posted on February 20, 2014
James H. King, MD
Galesburg Clinic
Conflict of Interest: None Declared
Dr. Blakely appears not to realize that my article was ironic. For example, I don’t really think that the Patient-centered Medical Home is synonymous with a multispecialty group practice. It is the definition of the Medical Home as given by its proponents that is synonymous with a multispecialty practice. In point of actual fact, the Patient Centered Medical home is an inadequate attempt to deliver primary care by committee without benefit of primary care physicians. This is certainly transformative, but the question is: “What is being transformed and to what is it being transformed?”
As for “patient-centered care, “the definition varies from “the customer is always right” to a vague suggestion that we should listen more to our patients. As described in some articles, it is in direct opposition to evidence-based medicine. Bensing defines it in Patient Education and Counseling [39(2000) 17-25] as “a humanistic, biopsychosocial perspective, combining ethical values on the ideal physician, with psychotherapeutic theories on facilitating patients’ disclosure of real worries, and negotiation theories on decision making.” I suggest that a phrase that means whatever the author chooses it to mean in fact means nothing.
The concept of the ACO is essentially economic, not clinical. It is concerned with “population management “reduced ALOS and preventing hospital readmissions rather than the individual care of every patient every time. Dr. Blakely’s incentivizing of wellness, “date, analytics, and transparency of outcomes reporting” are what we in the fly-over part of the country call “lipstick on a pig.”
I certainly agree with Dr. Volpintesta that “Until physicians are ready to complain…in a loud collective voice, the light in medicine will eventually be extinguished” I’ve been waiting to hear that loud collective voice for over 40 years. How’s that working for us? Physicians would indeed do will to rage against the dying of the light, but that light is already very dim-likely too dim to be revived.
Comment
Posted on April 14, 2014
Omega C. Silva, MD, MACP
Professor Emeritus, George Washington Universtiy
Conflict of Interest: None Declared
I read Dr. King's contribution to the On Being a Doctor with much shaking of my head to agree. I did, however, think we could add that the Recycling occurs with the modern physician seeing many more patients in a much shorter time slot. We're supposed to be the old fashioned family doctor who knows the family and is relaxed and thorough during our time with the patient while we also see much more technical data (MRI, genetic data, lab values, etc) on the patient that we should explain. IMPOSSIBLE!
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