Relational Medicine, Transactional Industrial Healthcare

Dishabituation Conversation, Part 3 of 3

Shaman at Erratic Rock
*Photograph by Phil Newman, MD 2024*

In the last newsletter, I emphasized again how I think Medicine and industrial healthcare are two very different entities that are actually in opposition. Yes, of course, there are intersections, ways we need each other, but the reason I believe it's important to be crystal clear about how they're different is primarily to help doctors. When medicine, healthcare, the healthcare industry, and corporate medicine or healthcare providers and doctors are muddled together, I think doctors, in particular, also get muddled in ways that healthcare business administrators don't. It becomes difficult for us to reflect on our struggle and discern what's us, what's the profession, and what's the system we're functioning in. For now, let me just say I think our confusion partly concerns the nature of our promise. The physician's covenant expresses some form of not allowing our interests to supersede the interests of our patients. This is critical for building trust, but it's also thorny, not an intention that can be navigated without ongoing, conscious reappraisal of and recommitment to it. The more we can explore and claim the relational nature of medicine and know that we don't feel very good when that dimension is bypassed, the better equipped we are to assess what industrial healthcare proposes and to decide what we're willing to participate in and where we draw the line. In other words, we become able to negotiate individually and collectively because the positions are clearer. We can also stop giving our power away by depending on industrial healthcare to solve our physician dilemmas because it was never equipped to do so anyway.

Maybe an example of doctor thinking versus business thinking would help here. My ex-husband was a nuclear engineer with an MBA who was a strategic planning consultant. He made a lot more money than I did and started at an earlier age, which meant it was hard for me to catch up. He often made suggestions for sweeping reforms of businesses that involved things like changing production processes or firing a lot of people or changing industries altogether. I asked him if he had any idea how his plans—many of which he helped implement, not just propose—worked out. Did the companies get more efficient, more competitive, or wealthier? Or did his proposals backfire? He had liability insurance, but he'd never been sued. It seemed like there was pitifully little accountability. I told him I thought surgeons (since I'm a surgeon) got paid for the responsibility we assume, the length and complexity of our training, and how hard we work. Maybe there's a little basis for this in the RVU formulation, but I'm not sure I even understood that at the time. "Salaries," he informed me, "are a function of the revenue generated by the person or role." I was dumbfounded.

This was a long time ago, and many doctors have a clearer perception of this principle now. Even so, it's hard to calculate our interconnectedness, especially given the vast inefficiencies in the delivery of care. Oddly, surgeons—so much more strongly identified as providing episodic rather than longitudinal care—now often provide greater continuity between inpatient and outpatient settings than primary care specialties. That's why I was asked if I would manage TPN orders after discharge for a medicine service patient for whom I had been a consultant. As a medical student, I would never have imagined that day. By the way, the doctor who asked me to do this was the same doctor who told me when I shared my assessment of this patient earlier during the hospital stay, "I think I'll get a cognitive opinion about that." He wasn't a bit ashamed to say this directly to me despite later finding me intelligent and reliable enough to manage TPN. Or maybe he just saw me as a tool.

This week is the tenth and final week of an MBA Essentials online course I have been taking at the London School of Economics. I have never handled my own money well or taken very good care of myself. Even the act of enrolling in medical school with no concept of how much money doctors make and how or if I would be able to repay my loans was one of many occasions of essentially throwing myself out of an airplane and trusting that if I did the "right" things and was a good person, my parachute would open. Along the way, once I was in practice, I paid for all kinds of help to keep my life afloat: an accountant, lawyers, a trainer to be sure I showed up at the gym, a therapist, housekeepers, dog walkers, gardeners, and for a short time, a personal chef who cooked once a week for me. I spent an awful lot of money to have people do the things I enjoy most in life so that I could work longer and harder, which became more essential to maintain the help I engaged. I was both grateful for help with personal matters and ungrateful because most things didn't get done the way I would do them myself. It was a jumble. In one of my current responsibilities as an executive director of a small surgical research foundation, I wasn't getting the responsiveness I needed from our accountant, and I wasn't sure whether it was his failure or mine. Was I not asking for the right things? Was my ignorance causing this? I decided it was time for me to understand, among other things, what a financial compilation is and what reports constitute it.

What a revelation this has been! I have loved it, and I don't know whether it's my act of choosing to take this course (I've always been secretly fascinated by the London School of Economics) or what I'm learning, but strange things have been happening in my life during these few months, tweaking my financial dial in interesting ways that are creating huge shifts. It feels like fluid coincidence more than one-to-one correspondence, but who knows? Is something about this allowing me to finally find the time to repair the pockets of three of my coats so that I stop losing things out of them and take care of them, understanding how important they are?

Last weekend, I was also fortunate to be invited to speak at the amazing Auburn University Physician Executive MBA (PEMBA) Program's 25th Jubilee Alumni Reunion. My topic was Rebalancing the Three Priorities of Medicine. What an outstanding group of people I met: faculty and staff as well as the alumni. My talk wasn't recorded, but because it explains a lot about the framework the Three Priorities provides for monitoring our situation in practice and a structured approach to reconsidering our uniquely personal formulas for thriving as doctors, I recorded it myself when I got home. It's potentially diagnostic and prescriptive. You can watch it here. I think every resident should take the LSE Business Essentials course—not so much for dealing with industrial healthcare as for self-care, insight, and confidence, for appreciating our "pockets" and keeping them in secure repair. The PEMBA program is a gem, too. There are links to both in the text and below. I also need to thank my friend and colleague Dr. Andy Mohan for organizing my invitation. Andy is a PEMBA (2012) grad himself who works closely with the board and is an IT wizard and consultant with a doctor’s heart who has been trying for years to translate EPIC so it makes sense to doctors who want to know how things work, not just what buttons to push.

Maybe you're intrigued by some of the ideas I present in these email newsletters but not quite sure where all this is heading or whether Metamorphosis Medicine has more to offer you. You can explore those questions in conversation with me (schedule time here) or nose around on the website. I've also been creating some swag that functions like medicine. This thermal cup carries the message "The healing starts here," meaning with each one of us, that the healing we offer to others begins with the healing, the restoration, the equilibrium we make or discover for ourselves. I like the notion that you can fill your cup as you drink from this one. I've also made some vinyl stickers and a warm hoodie to wrap yourself up in the message Medicine (over) Healthcare. Here's one of my longest-running surgeon mentors (the venerable John R. Benfield, MD) wearing his. Could this get you fired? Perhaps not yet. These aren’t priced to make much money for Metamorphosis Medicine. They’re really to help you and help change our thinking and to help overcome obstacles to better Medicine and better practice and better lives.