Let’s Renegotiate the “Social Contract” in a Way that Promotes Human Flourishing

From the 2/26/2021 newsletter

Director’s Corner

Let’s Renegotiate the “Social Contract” in a Way that Promotes Human Flourishing 

Adina Kalet, MD MPH

This week Dr. Kalet wonders how we might reimagine the relationships among society, the profession, and healthcare systems to ensure the ability to pursue human flourishing for us all …

Toward the end of his life, my father-in-law needed a generalist physician to provide real primary care, but he had neither an engaged, attentive physician, nor a system that was prepared to enable this type of attentive oversight. 

A couple of years before his death, a hurricane hit the region where he lived on the east coast of Florida. Unable to contact him and knowing that the area had lost electricity, my husband flew down from New York the next day. Mark found his father sitting in a dark, warm, damp apartment struggling for breath. Mark’s dad had experienced a significant myocardial infarction and was in florid heart failure. 

Over the next few months, my father-in-law’s physician-son and nurse-daughter scrambled to manage his health care needs as he deteriorated. He required prolonged hospitalizations in a cardiac rehab facility utilizing resources up to the full limit of what Medicare would allow. When he returned home, none of Dad’s specialist physicians offered to take responsibility for coordinating his care or arranging for homecare. Luckily for Dad, his son and daughter-in-law were physicians, and his daughter and son-in-law were nurses. My husband attempted to manage things from a thousand miles away by phone, fax, and email, and eventually was able to hire a wonderful aide who stopped by for a few hours each day to help with the activities of daily life and a private care coordinator. Despite the fact that he could hardly walk or drive, Dad’s local physicians insisted that he come to their offices for regular weight checks and refills. He missed many appointments, was confused about his medications, and was disgusted with the whole thing. We would have paid dearly to offer Dad the level of medical care coordination my husband is able to provide his own patients through the VA System, our largest publicly financed, national health care model.

We REALLY need more primary care physicians and compassionate teams

Last week in this space, I outlined why and how medical schools need to train more primary care physicians. Data have shown that access to good primary care in accessible, coordinated, integrated, and globally funded systems is associated with the best outcomes and lower costs; these paradigms offer benefits to communities and to patients like my father-in-law who have chronic medical conditions. Without a solid primary care physician, even patients like my father-in-law with excellent insurance and attentive social support, have less-than-ideal outcomes. 

I think we need to come together to make things better for us all. I am convinced that if my father-in-law had had a generalist physician practicing in a coordinated and supportive healthcare system, he would have received more competent, coordinated, and compassionate care.  Dad and his family would have had a better quality of life over those final couple of years, less confusion and stress, fewer days in high-cost care, and a “better death.” No doubt, there would have been significant cost savings. While many systems strive to do this and many medical schools work toward preparing students to enter competent health care systems, this is not the reality for most of the country.

Rethinking how care is provided by reviewing an imperfect model

Recently, a friend shared an email she received from the primary care physician to whom I had referred her many years ago. This well-established physician was transforming her practice from an insurance-based to a “membership” model. In exchange for an annual retainer (relatively modest compared with similar arrangements), she offered herself to be personally accessible 24/7 for telehealth visits, promised next day appointments, and provided office visits that were three times the length of what she had been able to schedule before (thirty v. eleven minutes). For patients like my father-in-law, she offered to proactively oversee home care, ensure medications are delivered and taken appropriately, and stay in touch with the patient, healthcare team members, and family. She would serve as the team’s quarterback, providing the leadership that winning teams need. 

At first, I was critical of this Executive Model - what some call “concierge” medicine - where wealthier patients with health insurance pay for the kind of consistent, high quality access I believe everyone deserves. But, as I thought about what this change in practice model said about the physician’s well-being, my heart broke. This wonderful woman had always practiced “cognitive” medicine in a fee-for-service model where the only way she could generate revenue was by seeing office patients. In her old system, her “success” was measured by seeing more-and-more patients for shorter-and-shorter visits.  By embracing the new model, she would likely enhance her income while practicing medicine the way she knew it should be done. 

Numbers matter though. One serious problem with this type of “tiered” model of care is that, unless there is a dramatic increase in the number of primary care physicians, even fewer people and communities will have access to quality primary care. This shift will have the greatest impact on those who live in poverty, are disproportionately affected by the social determinants of health, have increased rates of comorbidities, and have little or no insurance. Yet, this is exactly the population that stands to benefit most from ready access to compassionate, attentive, and highly coordinated primary care.  

The divide between cognitive and procedural physicians is making the situation worse 

Part of the problem with workforce distribution and balance is the widening income differential between cognitive and procedural physicians. Since 1980, the median salary of cognitivists has increased at the rate of inflation, while the median salary of physicians who perform procedures has doubled. This gap translates into a $3-$5 million lifetime advantage for proceduralists. This economic power allows proceduralists to benefit more readily from modern practice management (e.g., partnering with advanced practice nurses or physician assistants, medical scribes, and other documentation technology), thereby gaining efficiency, further widening the gap, and increasing their personal salaries. Meanwhile, cognitivist physicians can only increase their efficiency by giving up what is most meaningful and valuable in their work: communicating with patients in the context of strong relationships, taking time to figure out complex problems, and committing to longitudinal care. Under the current models, cognitivists cannot optimize their practices without trading off what is most satisfying in their work. 

We need to rethink the social contract between physicians and society

Many (including me) have pointed out that medical professionalism is the basis of medicine’s social contract. But as things change, we see that this simplistic view of the contract is a poor metaphor for the complex physician-patient relationship. The COVID-19 pandemic has given the medical profession a reprieve from decades of society’s eroding trust as we move from a predominately solo practice model to a more systems-based model. Physicians around the world have demonstrated that we will serve, run toward disaster, and care for the sick even when our own health is threatened. It is time that the old, implicit sets of agreements between society and the profession be aired out and reimagined. The moment to reexamine the details of the social contract is here. 

As a country, we spend enormous amounts of money for healthcare, yet the outcomes, both for physicians and society, are far from optimal. Taxpayers provide $20 Billion annually to support graduate medical education, and support all aspects of medical education through public insurance, yet the average physician and their family sacrifices for years in order to join the profession and accumulates significant debt. We need real, granular conversations about the cost of medical school (of all school), effective practice models that balance outcomes with efficiencies in care, and ways to enable physicians and patients to spend more time together, engaged in doing the meaningful work that promotes wellness. If we don’t put our heads together and find a better way to improve public health while creating a healthy, physician workforce, both society and physicians will continue to suffer.

Human Flourishing 

In a perfect medical world, healthy physicians would expect to learn and work at the highest intellectual and technical levels while they spend their careers doing both what they ought to be doing but also what they want to do for its own sake. The environment would allow them to perform their callings at the level of the “highest human good,” what Aristotle called εὐδαιμονία or Eudemonia, translated as human flourishing. Ensuring these kinds of environments should be goals for both physicians and society as we renegotiate the social contract. 

I suspect many of you have similar tales to the one I shared about my father-in-law. Many people shake their heads talking about care lapses for elderly loved ones or other family members. These all-too-common stories reflect the perverse incentives, inefficiency, waste, burnout, and lack of attention that can emerge from our current bureaucratic models of care. Sometimes, it feels as though character-driven, compassionate care is the exception, not the rule. 

At the Kern Institute, we are committed to transformation, and today’s issue explores how we hope to promote human flourishing. If things are to change for the coming generations, physicians, who - as a group - have always demonstrated the willingness to be there, must be given the moral agency to do their work in safe and well-equipped environments while pursuing professional fulfillment, well-being, joy, and collaboration with other healers. We must commit to exploring new approaches where society can expect a healthy workforce, and every family knows who to call when that time comes for a prepared, highly competent, and compassionate hand on the wheel.

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.