Population Health: the New Medicine

Below is a modified copy of my response to an informational article that was recently sent by the CEO of our hospital to our medical staff. Many suggested that I make this letter available publicly. Little do they know that I do so on a regular basis!

“I want to thank our CEO for forwarding this article to us while simultaneously pointing out its significance to any of you who might have merely glanced at it casually. For this article is illustrative of the subterfuge of changes taking place in medicine, changes that have created a paradigm shift in how we understand medicine—how we understand ourselves as physicians, ourselves as professionals, and the medical care we render.

Central to our understanding of medicine has been the physician-patient relationship, a relationship that has been considered sacred and inviolable, that has been determinative of our responsibilities, and has been a limiting factor in keeping governmental intrusion at bay. While responsible medical care has always provided for the good of the individual while keeping the good of the society in our peripheral vision, it was the care and needs of the patient before us that was our primary concern. But over the last decade, forces foisted upon us largely from outside of the profession have been driving a wedge into that relationship, with the apparent intent of severing it. Those forces have taken many forms: the EMR which forces us to turn our backs to the patient; the “medical home” which has been surreptitiously substituted for the relationship with “my doctor;” the increasing loss of the independent physician (who now, by virtue of her employed status, have a primary obligation to an employer rather the patient, and is now subject to the governmental regulations that dominate that employer); and now this deceptively subtle utilitarian shift in focus from “patient” to “population.”

A utilitarian ethic can be effectively summarized as “the greatest good for the greatest number,” but patients are neither numbers nor statistics, they are persons–idiosyncratic beings that possess histories and exist in contexts that are not reflected in mere “data.” Moreover, as I am fond of saying, flesh and bones do not fit into algorithm boxes without remainder. We have failed to realize or acknowledge that a profusion of data (not always readily accessible) is no substitute for personal knowledge that grows out of relationship.

What we are being expected to do is to shift our focus. But the human eye, not to mention human attention, was created to be able to focus on only one entity at a time (as evidenced by my road-hunting husband who often misses the game in front of him on the road as he is searching for it in the fields!). And this is not a zero-sum game: attending to the horizon—population health—detracts from our ability to focus on that which is before our eyes—the individual person.

Furthermore, such a shift involves is a category mistake: it is an attempt to substitute apples for oranges; it confuses the distinction between medical care and public health, which are separate entities–we received degrees in medicine, not public health. Furthermore, one has only to look at the effectiveness other governmental initiatives, well-intentioned as they may be—initiatives such as the “Food Pyramid,” “MyPlate,” etc.—in changing America’s dietary habits and impacting obesity to see what potential influence a “population health” initiative and focus will have on the health of our population.

A shift to population health will have disastrous consequences for many of our patients. Take for instance, L.B. who has probably made a significant contribution to my income over that past few years as I have seen her regularly for her chronic vulvodynia which I am unable to cure: often I do nothing more than listen which is at times, for her, therapeutic; but “therapeutic listening” is not quantifiable and does not compute in the system focused on population health. One of the principles of medical care, dating back to Hippocrates, has been “To cure sometimes, to treat often, to care always.” But in today’s outcome based management, “care” has been replaced by “cure,” because “care” can’t be quantified and measured. But how will L.B. and so many others like her be cared for in a system that is only interested in quantifiable, documentable changes, in measuring outcomes and cures?

So beware! Population health has a nice ring to it; it looks like a nice bandwagon onto which we should all be willing to jump. But it is taking a detour off the main road, onto a bureaucratized, industrialized one–a detour which appears smooth and streamlined and efficient, but one which will leave the persons we are called to care for lying in the dust…”

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