COMMENTARY

'The Providers': A 21st-Century Healthcare Fantasy

Michael V. Orlov, MD, PhD

Disclosures

September 16, 2019

I sit in my study, surrounded by books from my father's library; a collection of paintings; and all kinds of artifacts reminding me of the wonderful places that I have visited, remarkable people for whom I have cared as a medical doctor, and generations of my relatives spanning the past hundred years.

I have been working to update the medical manual written by my father. Frequently, sleep overtakes me while I type, imagining a fantastic time in the future.

I fall asleep and dream, wakening in the Paradise of Providers and transformed into a medical provider (MP) in a medical home (formerly known as a hospital). The President of Providers (POP)—a former manager of a large hotel chain, as I later find out—is entertaining me as we tour the medical home.

The first stop on our tour is the emergency department. We witness a wartime triage in an overcrowded room filled with very sick, destitute patients waiting for treatment, lying on the floor, on stretchers, on beds, or simply on the floor, prostrate. MPs do the best they can and are doing very well in the initial stages of triage and simple procedures (eg, suturing and treatment of lacerations).

Our second stop is the clinic, where I see an MP examining a patient who complains of shortness of breath. Somehow, from the bottom of my memory being a medical doctor in the past, I masterfully dig out my capacity for differential diagnosis and, based on just a few physical findings, see that the most likely problem is exacerbation of heart failure. However, the MP smiles and tells the patient that he will do an extensive battery of tests and then treat every possibility: pneumonia, exacerbation of COPD, leukemia, and heart failure, at the same time administering antibiotics, steroids, blood transfusion, and diuretics.

Perplexed, I look at the POP and ask why. He proudly replies that after an abbreviated schooling of MPs, which only takes 2 years (and includes afternoons off to prevent "burnout"), they excel in treating every possibility simultaneously, achieving excellent results.

I meekly ask whether any problems are ever encountered from instituting the wrong or inappropriate medications, or all possible meds at the same time. The immediate answer is that yes, problems do occur every now and then, but they are quickly taken care of by checking (or unchecking) all the appropriate boxes in the Perfect Electronic Medical Record (PEMR), thus achieving a 100% success rate by meaningful use criteria (MUC) as reported to HIPPA (the High Intelligence Provider-Perfect Authority).

We continue on and visit next the operating theater. It reminds me of a large room in a big factory: There is a conveyor belt where many different operations are done in succession. Somebody is getting a leg amputated, followed by a cataract surgery and coronary stent implantation.

Each MP is doing a very small step of each procedure, acting as a small cog in the wheel of a grand scheme. This was the revolution in automobile-making, allowing rapid production of large quantities of "ready to drive" basic cars to satisfy the growing public demand.

Is this principle applicable to the human body? Would a new digit smelling of fresh automobile paint be acceptable to the old owner of the hand? I notice that at the end, the conveyor belt splits. One half goes to the left and the other to the right. I ask what this means, and the POP replies that excellent work of MPs goes to the right and the MUC failures go to the left, but recycling is possible.

Again, perplexed and digging back into my memory of surgical rotations during my medical school, I ask whether the surgeons themselves are ever involved in the process. The POP answers that in the old days, surgeons had designed the conveyor belt using experience gained from Cheesecake Factory operations. Subsequently, after demonstrating superior results compared with old-style surgery by MUC outcomes reported directly to HIPPA, the surgeons have all been retired. Their high salaries were bankrupting the operation of the modern healthcare delivery system.

Next, the POP exhorts, "You should know about the provider teams that we have!" What is this, I ask? What do they consist of? The POP responds, "Naturally, we have all kinds of providers: medical doctor providers (MDPs), nurse practitioner providers (NPPs), medical assistant providers (MAPs), medical secretary providers (MSPs)."

But who is responsible for the patient? I ask. "What? Everybody, at the same time!"

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