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May 14, 2007
Who can change the Future
Back in March, business professors from Harvard and UVA wrote a special communication in JAMA (March 14, 2007) basically summarizing their book, Redefining Health Care, which I am hoping to obtain so I can examine their thesis more closely. The article was entitled, How Physicians Can Change the Future of Health Care. They are very thoughtful and well-spoken professors who make the point that health care is not only a poor value for the money, but the system is fatally flawed, preventing any increase in value. They address the increasing value in telecommunications, for instance. No one complains about the cost of a cellphone because of the ever-increasing value purchased. Medicine is a zero-sum, cost-shifting competition. Their criticism is right on the mark. But their solution is reorganizing practice around medical conditions and care cycles, with risk-adjusted outcomes and costs carefully measured for comparison.
So their solution appears to be more of the same social iatrogenesis, compounded and re-organized. Any solution based on increased data will certainly improve results on an individual level, if the data is more accurate and applicable. But as clinical iatrogenesis improves, unless there is increased focus on the individual person's autonomy (according to Illich), social iatrogenesis will increase. And I would add to Illich that not only must the patient's autonomy increase, but the relationship between the doctor (teacher/advisor) and the patient must intensify. Porter's proposal speaks of value for "patients" but the focus shifts from the individual patient to "conditions and care cycles," the very shift started by Sydenham and intensified by Descartes. And the shift from individual to "disease" must be a shift of decreasing value for the patient, ultimately.
Social iatrogenesis | By Robert Maddox | 11:55 AM