Seasons
Seasons are part of our physical world, but I am convinced metaphorical seasons occur not only in our personal lives, but in our collective ones as well. Lately, there has been much written and said about nominees for leadership of the Federal health care apparatus and also about public reaction to the murder of a healthcare insurance company executive. “The modern right wing…feels dispossessed: America has been largely taken away from them and their kind, though they are determined to try to repossess it and to prevent the final destructive act of subversion…” 1 This quotation, though, was written in 1963, not 2025, and was part of an essay published in book form in 1966 noting the “paranoid style” was a recurring theme in American history. He was clear that the paranoid style was not the sole province of one side in political disputes, a point evident in our recent presidential election. The author also noted: “But the fact that movements employing the paranoid style are not constant but come in successive episodic waves suggests that the paranoid disposition is mobilized into action chiefly by social conflicts that involve ultimate schemes of values and that being fundamental fears and hatreds, rather than negotiable interests, into political action. Catastrophe or the fear of catastrophe is most likely to elicit the syndrome of paranoid rhetoric.” 2 I present these points not to take sides in that dispute, but to point out that as a society we are not only in astronomic winter, but sociological winter. So, beyond the headlines, what should we in healthcare be doing to adjust to this season of stress? I contend our challenge in medicine is more than personalities or particular positions, and reflects a fundamental crack in the social contract with which we have operated in the 80 years since the end of World War II. What do I consider that contract to have been? The first forty years were characterized by a belief that large organizations and collective action would improve lives and control diseases much as they had led us to victory in combat. The NIH was established and money was invested in both basic and applied research, a medical Manhattan Project if you will, hospitals were built in every county seat, and the medical-industrial complex came into being. This phase probably ended with the “War on Cancer” of the 1970’s. The second forty years can be marked with introduction of the Prospective Payment System by which Medicare instituted something 1 Hofstadter, Richard. The Paranoid Style in American Politics and Other Essays. (New York, Alfred A. Knopf, 1966,) p. 23. Richard Hofstadter (1916-1970) was DeWitt Clinton Professor of American History at Columbia University, New York City. He was a member of the Communist Party in 1938, but quit prior to WWII. He moved from a historiographic stance that history was driven by economic conflict to a more conservative position that was characterized as “consensus.” [https://en.wikipedia.org/wiki/Richard_Hofstadter, 23 January 2025. 2 Ibid., p. 39. akin to price controls for hospitals, and has been characterized by increasingly specific regulatory intrusions designed to control what is seen as exponential, unsustainable costs. In other words, the notion society would write a blank check was abandoned, but there was still some hope that medical advances would improve lives. I would argue that the pandemic marked the collapse in the second part of the contract. It seems large segments of the population no longer believe “big medicine” is helping them improve their lives, and we see declining childhood vaccination rates, freezes on meeting for extramural funding of research at NIH, and controversial nominations for leadership positions. I noted during the pandemic that our public health officials often attempted to brace their recommendations by saying “Science says…” (pun on Simon Says intended,) or the “data show…” but the public did not find these phrases persuasive compared to other sources of input, social media for example. Paradoxically, demand for health care services has gone up and stayed persistently high even though we appear to have taken care of the backlog generated during the COVID crisis. But as also noted, this increase in demand has taken place in the face of a decreased supply of clinicians to provide the care. This has had a negative effect on clinician morale, patient satisfaction, and probably quality of care, although the latter is harder to gauge. The problem with social contracts is they are implicit and/or tacit, not stated, so I don’t think we can create a plan to “fix” the old contract or negotiate a new one. But it would help if we asked ourselves a couple of seriously difficult questions. First, what do we currently do that represents a real improvement in the lives of our people? Second, how can we make these items available to everyone at a cost that is sustainable? Third, how do we expand our and the public’s understanding that healthcare is more than what occurs inside the walls of the hospital or clinic? While we work out answers to these questions, I suggest we recognize it is winter, so wear layers of warm clothing and don’t be surprised if it driving a car is hazardous. |
Further Reading
A Season for Everything Maybe it is time to rediscover the art of medicine. Agility "Agile managment" is a business term akin to what I have called resilience. Are we at the point of a conversion experience? Asking the Right Questions Solutions for problems in health care abound, but are we asking the right questions? Cathedral Thinking What lessons does building cathedrals have for healthcare reform? Necessary Conversations Conversation is an essential step if we are to overcome the problems with our current dysfunctional health care system. Swimming Upstream Our current cultural norms make following traditional medical advice, like eating less and exercising more, difficult for most people to do. Improving health may have more to do with modifying these forces, which is beyond the competence of health care providers and organizations. |