The largest barrier to achieving humanistic nirvana in medical care

The dictionary defines humanism as “a system of thought that centers on humans and their values, capacities, and worth.” No sector of the economy comprehends this definition better than a small business. In a sea of competition, the small business whose primary focus strays from its customer’s best interests will surely sink. Those with business experience will undoubtedly attest that, whether in a hair salon or restaurant, a happy customer is a paying customer. In other words, the incentives driving a hair salon to profit from its services are in direct concordance with its desire to make its customer happy. In this scenario, the customer is the ultimate arbiter of quality regardless of race, creed, or social class, and the businesses above all else seek to satisfy.

Of course each hair salon is operating in a saturated market filled with hair salons competing on price, clientele, shampoo brands and customer service. This model of service delivery provides the consumer with a multitude of options. Each hair salon competing on price must find ways to lower its prices while maintaining or improving quality, creating an innovative impetus that radiates upstream throughout the entire supply chain of hair salon products. Scissor and blow dryer producers will seek new methods of product development that appease their customer’s new cost-cutting strategy, resulting in a slow but steady decrease in cost carefully coupled with an increase in quality, a trend that’s conspicuously apparent in the prices and capabilities of any electronic good produced today as compared to a few years previous.

This voracious appetite to please the customer and constantly innovate lays the foundation for vibrant and satisfied consumers driving successful business growth, and it is undermined when consumers no longer maintain their important role of paying customer. And in medical care, this disconnect is the largest barrier to achieving humanistic nirvana in the context of the physician-patient relationship.

If we awoke tomorrow to a world in which all hair stylists were equally reimbursed, based only on which style of haircut they perform, what would happen to these innovative stimuli? What would happen to our power as ultimate arbiter of quality if our post-hoc payment capacity were replaced by compensation from a surrogate who was not involved in your care?

We would find ourselves in an altered universe where artificially created incentives, not traditional market forces or noble intentions, determine human behavior. Barbers’ and hair stylists’ salaries are now determined solely by the quantity of cuts, independent of quality. Each stylist’s ability to increase income in a progressively expensive world can only be achieved by working more hours, shortening haircut times, or both. Young trainees would adapt to these conceived incentives and predictably flock to specialties that perform more profitable cuts.

Because the customer would no longer be concerned with the cost of a haircut, each hair salon would suddenly operate in a cloaked environment, devoid of necessary transparency and unaffected by the competitive forces normally applied by other salons; forces that, in an otherwise healthy market, would serve the indirect role of maintaining accountability and keeping prices low. When determining the cause of the hair salon industry dysfunction in this imaginary world, certainly the payment model would be on our differential diagnosis.

For the vast majority of medical care today, we as the consumer have surrendered the reins of paying customer over to a notorious third party whose role in any other realm of society is strictly to fund rare, unexpected, expensive events. This role of insurance in protecting us from medical and financial tragedy is critically important, yet it has somehow crept so far from its intended function into the method of payment for all medical care that most of us don’t realize how strange this actually is.

This seemingly minor deviation to our normal method of payment has had dire consequences on our subsequent care, exploding costs, and most importantly, patient safety. The insurance-for-all-care model has created an isolated microcosm of surrogate-controlled disincentives and bureaucratic frustrations that divert our efforts from our primary focus of patient care.

Once insurance assumes the role of reimbursing physicians for all services administered to a patient, the concordance between satisfied patient and paying customer suddenly splits along two diverging paths, creating a series of perverse incentives that even the most altruistic individual cannot ignore. The physician’s reimbursement is suddenly independent of the patient’s fulfillment or safety, removing the major determinant of livelihood and prosperity all other industries cherish – customer satisfaction – from the success equation. Insurance coverage of all planned and routine care has diluted the patient-first philosophy with a system that encourages an assembly line style patient-per-hour reimbursement scheme all physicians increasingly need to adopt.

This remuneration method also creates a wage-fixed environment that discourages innovation and sterilizes creativity, paying a charismatic, flawless clinician with 30 years of experience the identical amount for a given procedure or visit as a physician who is young, careless, or error-prone. Whether it be personal trainers, hair stylists or surgeons, surely the hardest working, most experienced professionals should be able to use prices as an objective measure of their skills if they choose to do so, providing the patient with an essential evaluation tool required for a functioning market everywhere else in the world.

As an entrepreneur turned medical student, I have experienced first hand the tremendous innovation and customer service that arises from a series of competing businesses that focus their first, second, and third priorities on customer satisfaction. In this sense, the start-up world is the epitome of humanism. It is a magical place where the only person atop the pedestal of quality control is the consumer, a land where wide-eyed inventors and effervescent visionaries work tirelessly, compete viciously, and create new technologies at an exponential pace, all for the opportunity to make your life better and put a smile on your face.

I entered medical school ultimately for the same reason I was so enamored with starting my own company: for the chance to improve someone else’s life. The opportunity to equip someone with a technology or dispense a medication that could literally cure their disease or mitigate their symptoms is the purest and most important expression of customer satisfaction, one that many entrepreneurs could only dream of. The miraculous developments in medical care have morphed what were once death sentences and acute medical emergencies just a decade ago into manageable chronic diseases of today. These chronic diseases now overwhelm our medical system, a system that yearns for new ideas in the treatment of obesity, diabetes, and other lifestyle related diseases, arguably the most threatening maladies to our public health.

This is precisely the time to unleash, not restrict, the creativity and innovative capacities all physicians can offer; a time when medical students should not be suffocated by massive debt that systematically funnels them away from primary care toward specialties that insurance companies deem more lucrative. As soon as we empower our patients to regain their essential role of quality-assessing consumer and free our physicians to prove their societal worth instead of being assigned it, the humanistic ideals of the Hippocratic oath we enthusiastically recited upon donning our white coats for the first time will finally be realized.

Larry Istrail is a medical student. He is also the co-founder of PhotoCalorie and the founder of the Ancestral Weight Loss Registry.

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