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Ideas and Opinions |

Medicine as Ecoculture

Muriel R. Gillick, MD
[+] Article, Author, and Disclosure Information

From Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.

Potential Conflicts of Interest: None disclosed.

Requests for Single Reprints: Muriel R. Gillick, MD, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215; e-mail, mgillick@partners.org.

Ann Intern Med. 2009;151(8):577-580. doi:10.7326/0003-4819-151-8-200910200-00012
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The use of diagnostic tests, especially imaging studies, varies markedly across the United States—with higher costs but no better patient outcomes associated with the highest-use regions. A proposed new model of the health care system draws on an analogy with the ecosystem to explain the geographic variations in physician test ordering. This framework emphasizes the adaptability and interdependence of the components of the system. Patients and physicians are influenced by the health care organizations in their community, including the practice site in which the physician works, local hospitals, malpractice lawyers, and imaging centers. These are in turn influenced by institutions in society at large, including the media, health care plans, and the government. Further adaptations to the explanatory model account for the psychologic and sociologic aspects of physician behavior. Understanding the medical ecoculture is essential for effective health care reform because widely touted changes, such as the introduction of an electronic medical record or comparative effectiveness studies, do not address the adaptability and interdependence that characterize the medical ecoculture.




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Medicine as Ecoculture
Posted on October 26, 2009
James Webster
Northwestern University, School of Medicine
Conflict of Interest: None Declared

Dr Gillick's brilliant analysis (1) resolves many of the enigmas that physicians observe in their practice environments, but the conclusions simply discuss possible measures for reform in very general terms. Only by initiating a physician led, "bottoms up", total restructuring of how care is organized, delivered and most importantly, reimbursed, can the culture be significantly changed. An initiative to establish integrated, transparent, multispecialty groups as the national standard for practice, promoting Accountable Care Organizations with closed end budgets and a focus on Patient Centered Medical Homes would be an excellent start that the ACP should lead. This would eventually end the fee for service mentality that is destroying the integrity of the profession, and bankrupting health care. Now that would really improve the ecosystem!


1. Gillick MR. Medicine as ecoculture. Ann Inern Med. 2009;151:577- 580

Conflict of Interest:

None declared

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