"When you have your health, you have everything."
–Augusten Burroughs
How does society measure the success of the US medical profession? Number of physicians, their wealth, power, and prestige? Their homes, automobiles, and boats? Their dedication to work, family, and community? The degree of respect by their neighbors?
My view is that the medical profession, and that of other healthcare professions, should be judged by the quality, length, and happiness of the lives of the people they serve.
Way back in my career in academic medicine, we used to describe a three-legged stool for success: service, teaching, and research. As an entity, we were expected to succeed in all three.
As individuals, we were expected to make serious efforts in all three. Those super-achievers among us who did, were promoted to what became the fourth leg: administration, often then succumbing to the Peter Principle, getting stuck at their highest level of incompetence.
Once American medicine became predominantly "money-driven medicine" after the triumph of capitalism and the MBAs, many of those who excelled in medicine were rewarded (often richly) by an appointment or promotion to senior administrators/managers. This was all about alignment.
Proper successful management requires a different three-legged stool: authority, responsibility, and accountability. If these are aligned appropriately and properly managed, success is likely.
Roughly 20% of the health of individuals and the length of their lives is determined by actual medical care and 80% by numerous social determinants. But who gets the blame for the dismal actual US scores and comparisons with other "developed" countries? Obviously, we in the medical and other health professions become the ready scapegoats. We generate/consume nearly 20% of the total American economy and deliver dismally inefficient total health-lifespan-happiness outcomes.
Consider the existing US misalignment of authority, responsibility, and accountability in medicine. Clear and clean alignment could produce effective and efficient, internationally competitive health-lifespan-happiness outcomes. It would be difficult to imagine a more dysfunctional alignment than ours. We represent an albatross of misalignments.
Our national credo is Thomas Jefferson's "life, liberty, and the pursuit of happiness." Canada is our nearest counterpart nation by geography, history, climate, natural resources, culture, education, and ethnic-racial diversity. Its national credo is "peace, order, and good government." Really different.
For the United States to achieve national competitiveness in health-lifespan-happiness outcomes, we must more successfully address that 80% of the controlling factors that are the social determinants of health. The list includes income (poverty), job opportunities, education (language and literacy skills), safe neighborhoods, housing, transportation, nutritious food, physical activity, freedom from violence, clean air and water, freedom from addiction, and underlying systemic racism. In short, to be a "healthy culture," we need a nearly total US societal makeover.
Impossible to achieve in any short run? Yes. Worthy of effort from all of us? Absolutely. So, how might our highly successful American medical-industrial complex (AMIC) expand its sphere of influence into this 80% opportunity gap to measurably improve national outcomes in lifespan, health, and the "pursuit of happiness" without threatening our liberty?
In fact, the AMIC is incentivized the opposite way from the public interest. It thrives on sickness rather than the pursuit of health. Why prevent diabetes when the AMIC makes so much money off its complications? Why prevent coronary artery disease when revenue is so high for cardiac surgery and invasive cardiology? Why prevent tobacco addiction when its multiple related cancers can now be treated increasingly as chronic diseases maintained by hugely expensive drugs? Why enact a diet-and-exercise norm to prevent obesity when orthopedists get rich from joint replacements and various other interventions? Why establish palliative care and hospices when in-hospital and ICU care are such large revenue producers?
My proposal to convert a problem (the AMIC) into an opportunity relies on activating the fundamental goodness of human beings who choose to enter the healing professions. It further relies on the eternal driving force of such people to be learned professionals in every sense of the word; to reassert their innate professionalism to place the health, lifespan, and happiness of their fellow human beings and their profession above themselves as individuals. Long-term history provides hope; short-term history provides opportunity.
Some will push back on this notion with rebukes such as "Doctors, stay in your lane." Health outcomes such as length of life and quality of health are as germane to mainstream lanes of the medical professions as anything could be.
It took the United States hundreds of years (think 1619) to achieve and sustain its current level of social/societal inequity that lies at the root of our abysmal comparative national scores on length and quality of life/health and happiness. So, major improvements could take a long time to realize.
But why now? What is different? The vast success of the AMIC is what is different, taking only about 40 years to reach dominance, a tribute to the powerful aligned incentives of a culture fundamentally organized around wealth. The AMIC, taken as a whole, has the smarts, the size, the clout; the national, regional, and local political positioning; and the people to make the difference. What it lacks is aligned incentive, motivation, and leadership to address health.
I am proposing that we now harness some of that enormous power and redirect it toward establishing a society organized more around health than around wealth. Even a modest movement in that direction could get us thinking about how to add a dose of wisdom to the mix. That would be real progress.
I intend to work with you readers to explore these healthy opportunities over the next several months. Stay tuned.
George Lundberg, MD, is editor-in-chief at Cancer Commons, president of the Lundberg Institute, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.
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Cite this: Let's Value Health Instead of Wealth - Medscape - May 15, 2023.
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