So inadvertently, while it took medical schools in the direction of even better science
and even better treatments and even cures in some cases, it also tended, without anyone’s
intention, to sometimes put students a bit out to the margins….
But then something else happened. Added to the legacy of Abraham Flexner
and the NIH is the legacy of Lyndon B. Johnson…. [W]hat most of us actually
remember him for is Medicare. Lyndon Johnson understood that we had WAY
too many elderly people in this country with no health insurance coverage whatsoever.
He felt it was a national tragedy. And with the help of some like-minded
members of Congress, he established Medicare as a health insurance program for
the elderly…. [T]hey established a way of paying for those services in Medicare
that was firmly based in traditional fee-for-service medicine. Now what that
meant was Medicare, like those growing employee insurance plans at the time,
would pay me as a doctor piece by piece for every visit, every procedure I did.
Think about it for a second. If I’m in academic medicine, and I’m a faculty member,
it’s all about me as an independent expert. If I also am a researcher, it’s all
about me as an independent investigator. And suddenly, as a clinician, it became
all about me as an independent biller for physician services.
Get a sense of the kind of confluence here? … There are a lot of problems
associated with that traditional fee-for-service reimbursement that rear their ugly
head at times. But for us in medical schools, in the now 45 years since Medicare
passed, it created an additional trend, which was we got bigger and bigger clinically.
So … you had a small core medical school … in the middle of enormous
research laboratories and institutes, side-by-side with an even more enormous
health system complex. In the last 50 years in the United States, the number
of medical students has doubled; the number of clinical faculty has increased
14-fold! That wasn’t because medical students became harder to teach. It was
because we became very focused, working in the world of fee-for-service medicine,
on building large clinical systems. And we did good things in those systems.
I’m not debating that…. For me, the question that was generated out of all of
that was, “What was the culture we created, what did it mean for medical students,
what did it mean for American health care?”
… The more I, as an aging baby boomer, become a patient, the more I know
that I want a different culture. I want a culture that isn’t centered on the expert
but is centered on me as a patient. I don’t want a bunch of specialists each acting
like an independent agent. I want a team taking care of me. I want that team
to communicate with each other. I want that team --regardless of who they are,
what degree they have, what specialty they have – I want them all to feel that they
are equally accountable for my health and my outcomes in this system. That’s the
culture we want. And this was our failing in academic medicine. We had drifted
and reinforced the culture that wasn’t meeting the basic needs of patients….
But then there are two other huge forces out there today, this year, that make
me feel a real sense of urgency.
The first one is … [the] health-care bill passed in Washington this year….
The presidential candidates, many of the candidates for Congress and Senate
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