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barbara-smaller-it-s-fine-to-discover-cures-but-remember-chronic-conditions-are-our-br-new-yorker-cartoon (1)Forever there has been a power struggle between the medical school faculty and physicians in the community. For those of you who are versed in House of God, the book about medical care in the early 1970s, attendings and residents at the House as well as the students who went to BMS (Best Medical School) would reference care delivered by LMDs. This term referred to “Local Medical Doctors,” known uniformly for taking crappy care of patients who were then transferred to the “House”  where life-saving intervention would occur. The protagonist soon realized that there was more to medical care then doing stuff to people, culminating in realizing the truth in Fat Man’s Rule 13 (THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE). In the 1970s, the reality is that physicians on medical school faculty tended to earn less, a LOT less, that the LMDs, may have adding to the tension.

Somewhere about 20 years ago, LMDs traded their label for another that was even more pejorative – PCP. The Primary Care Provider concept was created in part to reduce the confusion around training requirements of physicians (Family Medicine, Internal Medicine, Pediatrics) and non-physicians (Physicians Assistant, Advanced Practice Nurse) who might provide primary care to a given patient. Patients don’t use the term, PCPs find the term demeaning, and the term doesn’t really reflect the complexity of care delivery that happens in the primary care office. Teaching hospitals, though, became Academic Health Centers and were distinguished in part by their lack of PCPs as well as their lack of desire to train them. The Academic Health Center was home to Specialists.

It is now almost 40 years since House of God was published. Obamacare is the law of the land and  the law encourages the use of primary care. This is in part because the work of Barbara Starfield demonstrated that health care is just better when people have access to primary care, and in part because a lot of work was done to demonstrate that specific models which incorporate primary care lead to better health outcomes. Programs like the Massachusetts Blue Cross Alternative Quality Contract and truly integrated systems like Kaiser and Health Partners  led to better outcomes. The work on Patient Centered Medical Home initiatives led to this specific type of primary care being incorporated in the law as well. Good primary care, so the saying goes, will keep you healthy. If you happen to get sick, it will help keep your costs down by keeping you out of the hospital. If you happen to go to the hospital, it’ll keep you from being harmed and help maintain quality care.

This week, the Houses of God are fighting back against the LMDs. The University Healthsystem Consortium (the trade organization for Academic Health Centers) put out a video entitled Through the looking glass: a new perspective on population management. Their video tells us the following in convenient cartoon form: 1) Most people just randomly become ill so don’t need a specific LMDs but instead need access to a CVS with a nameless Pee Cee Peee (their pronunciation) sitting and waiting for you to show up (and perhaps willing to give you a Z-pak “to prevent pneumonia”).  Oh, yeah, and prevention is too expensive so let’s blow off trying to get people Pap smears and mammograms and focus on treatment. 2) If you are chronically ill or sick with a serious illness, you don’t need a Pee Cee Pee at all but a House of God led team of folks. According to the video, they are sitting on the steps of the House just waiting for you to show up. 3) If you suffer from an early chronic illness you might want a Pee Cee Pee, but only get one who has the number to a specialty hotline, just in case you need one of the specialists at the House. You know how those Pee Cee Pees are.

The UHC’s vision is a dystopian one where patients are taking ambulances to the Academic Health Center for their not-well-controlled diabetes because the local House of God is 2 hours away and the Pee Cee Pee is unqualified to administer insulin. The evidence they cite for the effectiveness of this model is dated and incorrect. I can only hope that the Academic Medical Centers and their research arm, UHC Research Institute (TM), have a better plan for survival before the next “House of God” is written without them.

I was given a copy the movie version of “House of God” which I watched the other night. I read the book in 1984 before I started my clinical rotations and reread it in 1990, so it has been a while since I have been exposed to it.As I watched it, it struck me that there are aspects of the movie (and by extension the book) that are extremely relevant 30 years later.

The emphasis in the movie was placed on the construction of the new “Wing of Zock.” In the movie, the Wing denoted progress. It was going to be a modern setting to provide access to technological advances in health care, financed by grateful and wealthy benefactors.However, in the movie as well as in medicine today, there is a tension. The adminstration realized that having such a Wing meant paying for the care delivered in the Wing. The Interns in the movie were encouraged to “Putzelize” patients. This was a term for admitting a patients with no known medical illness to the hospital solely for attention and their ability to pay for the care rendered. Although it was unnecessary and expensive, it was clear that these patients were an important part of the business plan to pay for the new wing.

The other overarching theme was the replacement of a caring doctor with technological intervention. The Fat Man, kind of a Zen Master for the Interns, instructs the Interns on the importance of doing less rather than more at the beginning of their training. So important is this, in fact, that the last of the Fat Man’s Rules is “THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.” Unfortunately, as in medicine today, the Fat Man loses to the sterile, technologically driven world of modern health care. To bring home the point, Wayne Potts, who is an Intern from Charleston, South Carolina, does not perform the technologically correct (at the time) therapy of giving steroids to a patient dying of fulminate hepatitis and the patient eventually does die. Wayne has a very touching scene where he and Roy (the main character and also an Intern) discuss why they went into medicine. Wayne poignantly discusses how “All I wanted to be was a country doctor.” Ultimately, the hierarchy at the House of God are unable to forgive him for making their numbers look bad, he is unable to forgive himself for the patient’s death, and he commits suicide by jumping off the Wing of Zock.

In a new blog named “Wing of Zock,” the LCME, the organization of medical schools, identifies the needs for medical education in the new era:

Academic medical centers and teaching hospitals are at a crossroads in redesigning our health care system and examining how they educate medical professionals. They are experiencing tremendous discontinuity: Current payments, incentives, and value systems don’t reward excellence in care delivery and medical education. They are constantly engaged in building the next Wing of Zock as they seek to define a future that signifies hope.

In creating the next Wing of Zock, I hope we can avoid “putzelizing” America in hopes that it will pay for the education of medical students and residents. In addition, we in medical education need to support the Wayne Potts of this world. We need to nurture those who want to be “someone’s doctor.” Turns out that steroids in the case of the “yellow man” would really not have made a difference in his survival. Putting a Wayne Potts in a country town for 40 years makes a huge difference. Now more than ever we need to figure out how to teach the right people to deliver exceptional care and hopefully the money will follow.