Physicians on the Sidelines: How Can Healthcare Be Reinvented Without the People Who Actually Care for Patients?

H. Jack West, MD


March 14, 2018

In an attempt to learn more about how the people trying to develop the future of healthcare see the world, I attended the influential JP Morgan Healthcare Conference in San Francisco earlier this year. Though distinct in its flavor and focus from several prior conferences I've participated in that focus on identifying and overcoming the grave shortcomings of the US medical system, including TEDMED and the South by Southwest Interactive Health Care track, I noted one disturbing universal feature of all of them: None of these self-appointed saviors of medicine actually cares for patients. And I don't think any viable new system can be developed without meaningfully engaging the people on the front lines.

None of these self-appointed saviors of medicine actually cares for patients.

I don't mean to say that there are no physicians who attend these meetings, or that they literally don't ever care for patients. However, in all of these meetings that purport to disrupt healthcare, where I met hundreds of participants, not a single one sees patients more than 1 day per week, and nearly always in an academic setting.

Of course, these individuals provide helpful insight and some understanding of the practical issues around patient care, but it's no exaggeration to say that the issues and challenges of the community-based physicians who care for 20 or more patients 4-5 days every week are fundamentally different from those of the narrow subset who have such titles as "Chief Innovator" at their academic center and see a handful of patients every week, often supported by residents and fellows. But even that subgroup is far outnumbered by people who have a background in business and no pretense of any practical experience in the actual execution of delivering the care they presume to disrupt.

Much of the reason the healthcare system is in such dire need of overhaul is that control has been ceded to business interests. This graph clearly illustrates the sad fact that whereas the number of physicians has grown only minimally over the past several decades, the number of managers in healthcare has grown remarkably faster. Those of us working in the US medical system, as well as our patients, directly experience the myriad harmful effects of relinquishing the industry to businesspeople devoid of any experience or insight into the actual care of patients. As documented by the excellent and brutally accurate book by Elisabeth Rosenthal, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, (Penguin, 2018) we now deliver staggeringly inefficient and low-quality care despite the resources dedicated to our medical system.

One of the biggest changes in healthcare over the past decade has been the introduction of electronic medical record (EMR) systems, with Epic being the overwhelmingly most commonly adopted platform. Although widespread adoption of EMRs has conferred some real benefits—especially for everyone who has struggled to decipher the chicken scratch of our colleagues' notes and orders—clinicians widely recognize the sober reality that they are most effective as a financial tool to maximize billing, with a broadly held perception that Epic was designed with complete indifference to, if not a sadistic malevolence toward, the clinicians who have the misfortune to struggle with its user interface every hour of every day.

Unfortunately, too many of those who seek to disrupt healthcare have dollar signs in their eyes, making it impossible for them to see and acknowledge their ignorance—their lack of any real insight in the daily practice of healthcare. Those with the practical experience to help shape a better system that integrates the potential efficiencies of telemedicine, machine learning, and big data with current practice patterns in order to provide efficient and high-quality care are too often relegated to the sidelines; changes are imposed upon them from above by people with no understanding of the potential unintended consequences of their unilateral decisions.

I believe the US healthcare system is poised for significant change in the coming years. This may be rudderless navigation directed overwhelmingly by profiteering individuals from a business and technology background, merely seeking a short-term exit strategy to maximize their wealth rather than a true transformation of healthcare in a meaningful, beneficial way. But there are new entrants in the healthcare arena who may have the more noble goal of creating a US healthcare system that truly works, rather than being dragged down by colossal inefficiencies and the deliberate foot-dragging of the incumbent stakeholders who benefit from this. The recently announced collaboration among Amazon, Berkshire Hathaway, and JP Morgan to create and demonstrate a path to efficient medical care in America[1] may have the needed power and, possibly, the long-term vision to execute on this promise.

To do so, it will be critical to welcome the participation not only of the medical dilettantes who consider themselves experts because they technically still see a few stray patients as a small fraction of their workweek, but the vast majority of working doctors who unfortunately remain an afterthought of far too many who expect to redefine how healthcare is delivered. At the same time, physicians who fit that bill and care for patients day to day should strive to play a more active role in these initiatives. We only have the right to not be shepherded around by those outside healthcare if we, as practicing physicians, are not complacent enough to act like sheep.


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