Dr Alper is a practicing internist in Burlingame, Calif, and a Robert Wesson Fellow in Scientific Philosophy and Public Policy, Hoover Institution, Stanford University, Palo Alto, Calif.
You might think the terms in the title refer to didgeridoos, the wind musical instruments played by Australian aborigines. But I'm actually thinking of people rather than things, and they're located much closer to home. "Udoos" are those who say "you do this and you do that." "Udids" chidingly remind us that "you did this and you did that." Both types are familiar to physicians, because authority figures and critics with whom we interact characteristically speak this language.
Furthermore, because "we" did this or that (or allowed this or that to happen), it is only right that our failures must be redressed. Enter the "udidoos," who offer "because"-based pre?scrip?tions for doing better in the future. Udidoos simultaneously create guilt and the promise of expiation. Consequent anxiety pushes us to accept the controls of managed care, for example, no matter what doubts we may privately harbor about their utility or effectiveness.
In that unsettled spirit I read through a recent issue of Newsweek that featured multiple articles on the "future of medicine." These articles offered a fascinating look at the ways in which new science will revolutionize medical technology and create a host of new treatments. Only by the end did I realize that the articles told us nothing about the future of health care, leaving the impression that technology will somehow administer itself. This bothered me, because I wasn't clear on whether I would be part of the problem or part of the solution.
A new book, titled The Future of Primary Care, added to my discomfort. Edited by Jonathan Showstack, PhD, MPH, Arlyss Anderson Rothman, PhD, MHS, FNP, both of the University of California, San Francisco, and Susan Hassmiller, PhD, RN, of the Robert Wood Johnson Foundation, Princeton, NJ, it discusses everything but the economics of primary care. One would never know that imposed inefficiency is rendering most primary doctors noncompetitive. Or that the current legal and regulatory structures prevent noninstitutional physicians from banding together to offer useful services at affordable prices. Were my concerns as a primary physician beneath mention or of no relevance to the future of medicine?
Perhaps so. In the same book, Mary O'Neil Mundinger, RN, DrPH, dean of the Columbia University School of Nursing, contributed a chapter titled, "Advanced Practice Nurses: The Pre?ferred Primary Care Providers for the 21st Cen?tury." The under??lying notion is that nurses are better suited than physicians to be primary care pro?viders. There is no attempt at collegiality here. Dr Mundinger has previously written about why nurses should be paid the same as doctors (they get equal results). Now she wants to not only replace the primary physician but also commandeer their title.
Columbia now has the nation's first doctorate of nursing program that will literally turn its nurses into doctors. As for their not going to medical school, why would they want to do that if they are already the preferred providers?
So, I wonder, should primary care physicians shape up or get lost? Between medical futurology, managed care, and doctors of nursing, it's hard to know. Maybe the best thing to do is to just laugh. Even gallows humor certainly beats crying?or going crazy.
Once before, incomprehensible ab?strac?tions and a sense of unreality motivated me to write. I wrote an article entitled "Learning to Accentuate the Positive in Managed Care" (N Engl J Med. 1997; 336:508-509), which satirized the absurd features of managed care. (Yes, the New England Journal of Medicine does rarely publish satire.) Borrowing from Voltaire's Candide, an affected faith that this is the best of all possible worlds allowed me to ignore all the clouds in favor of the silver linings. And to assign any meaning I chose familiar words.
Medicine hasn't changed much since then. Only now it is the terms "networks" and "teams" that increasingly evoke cognitive dissonance in me. Consider that, owing to preferred provider organizations, we belong to all kinds of networks. But how many of us know the names of other doctors who are also in them? I suppose I could read the manuals to find out, except that they are usually out of date?and that's assuming I could locate them in the first place. Besides, what would be the point? I prefer to choose consultants first for quality and only then for network status. Usually, a quick phone call by the staff re?solves that question.
The most reliable way to learn the network status of another physician occurs serendipitously, when the doctor drops out of the plan and new patients suddenly show up on your doorstep to tell you about it because, cut adrift, they've found your name in the plan roster. As for memorizing any portion of the books preemptively, no thanks! I may not be the sharpest tack in town, but an idiot savant I'm not.
Networks like these are more virtual than real, and are unlikely to ever become teams in more than name only. But lately, even teams are not teams. I can understand the intravenous team. Or the operating department team. And maybe, by a stretch, the pain team. But the cobbling together of professionals into teams that exist on paper rather than in spirit is rampant.
Nurse practitioners refer over the heads of their physician-employers directly to specialists (rather than consult internally) because they are all busy. Social work referrals are made to unload problems, not to create new and deeper levels of shared understanding. Clinical compartmentalization rather than collaboration results and fragmentation are accentuated when financial incentives are at odds.
Still, the language of teamwork continues to grow, indifferent to the pressured situation in the trenches. At health policy meetings, buzzwords flow in torrents. Words like "health consumerism, empowerment, and information" spread like contagious diseases. For disbelievers, I recommend the Web segment, "Con?necting Patients to Care Teams: Getting Serious about Advanced Medical Communications," by Mike Magee, MD (www.healthpolitics.com).
Dr Magee is a nice man (we've spoken) and very smart. He is the director of Pfizer's Medical Humanities Initiative. Yet I have trouble processing his conclu?d?ing paragraph, which may be the ultimate udidoo: "Every physician today, whether we are aware of it or not, is a medical communications network executive. Now is the time to stop blaming the nightly news for bad stories, and to start producing some good ones of our own."
Of the many tasks laid out for us (and which, we are told, will pass us by if we don't promptly get moving), the idea of becoming an impresario for my own personal network of patients, competing with the major communications networks (who don't, incidentally, have to practice medicine on the side) makes any previous inclination to play God a mere warm-up for Dr Magee's real thing.
Builders of today's plethora of medical castles in the sky pay little attention to basic principles concerning the incorporation of technology into the workplace and the consequences for teamwork (the subject of the latest class at Stanford University School of Medicine that I am auditing). The classic article in the field was written by E. L. Trist and K. W. Bamforth (Human Relations. 1951;4:3-38) and is based on a study of British coal miners undertaken for the Tavistock Institute of Human Relations. There is now a vast literature that confirms that new technology always has a social impact on the people who work with it and that understanding and implementing new ways in which people work together (more than the technology itself) determines the success of what-ever venture is under consideration. It takes great insight to put successful teams together.
This should be obvious, but medicine remains in the Stone Age when it comes to understanding the doctors, teams, and networks that will be needed to implement new technology. The practical people at Stanford's School of Management Science and Engineering who deal with these considerations might therefore do more to help constructively shape medicine in the future than all the planning in a vacuum that benefits expensive meetings more than medicine.
As for the udidoos, they have their place, but only when they reflect more than big talk?ways for medical hangers-on to make money or ill-considered schemes.