Health Care's New Social and Structural Transformation

Roy Smythe–(Forbes)–In 334 B.C., Alexander the Great, having triumphed in Macedonia and Greece, visited Troy en route to his Asian campaign. Although we know he visited the tomb of Achilles (whom he had admired, like no other, since reading Homer as a child) with his trusted general and friend, Hephaestion, there is no significant recorded detail about his time there. However, knowing what we do about Alexander and his sense of predestination, it might well have gone something like this:

Alexander purposefully strode into the ruins of Achille’s tomb, then suddenly stopped. He slowly turned his head from side to side, and then upward – examining the eroding columns surrounding him, most no longer supporting any structures above. He then looked down at the rubble that the fallen stone lintels had become. 

“Strange,” he uttered under his breath, then spoke audibly, “strange… this impermanence. It matters not what one’s exploits, or what civilizations one might conquer. This was Achilles, the greatest warrior the world has ever known – before now.”

He looked up and over at Hephaestion, then back at one of the pillars, running his hand over the once polished, but now uneven and pitted surface “one always has the sense that his physical form is impermanent, but it is obvious that the monuments erected in his favor, no matter how grand, or how sound… are no different – all goes to dust in time.”

He patted one of two pillars still intact and sharing a supported structure above. He looked up again and smiled, “my master Aristotle was a great admirer of trabeation – this post and lintel form – it was for millennia the strongest known structure, prior to the arch.”

His brow then furrowed, and his countenance darkened. He leaned forward, placing his forehead onto his hand resting upon the stone, and no longer smiling, he whispered, “you too; however, will fall.”  

Sure, I could have just said, “nothing lasts forever,” but it just seemed more powerful and dramatic to put the words into the mouth of someone who once conquered the world…

Paul Starr, professor of sociology and public affairs at Princeton University, and co-Editor of The American Prospect, wrote the book “The Social Transformation of American Medicine” in 1984 – one that deservedly won the Pulitzer Prize for General Non-Fiction that year.

Starr described in great detail the pathway that the enterprise of health care had taken from the early nineteenth century up to that time – from an informal home- and community-based undertaking, to a huge and powerful industry. Although written more than a quarter of a century ago, revisiting Starr’s framework is helpful when one considers the massive sociologic change that is in process at this moment, and one that will change the health care delivery system like nothing that has come before – even when one weighs against it things such as the accumulated mass of biomedical scientific discovery.

Starr suggests that the medical-industrial enterprise has been built, on another “trabeative” (pillar and lintel) structure. Consider two solid columns, holding up a large monolithic rectangular stone. One column represents “Dependence,” and the other, “Legitimacy.” The large lintel stone on top is “Authority.”

In this context, dependence implies “you have proprietary technology I cannot have or use,” and legitimacy implies “you have proprietary knowledge that I cannot have or use.” What Starr suggested in his analysis was the medical-industrial enterprise has been built thusly: the establishment of authority over the users of the industry, by way of these two supporting ideas.

He suggests that this was perhaps the most important organizing and catalyzing force in the development of the health care industry in America, and other industries as well here since the mid nineteenth century…

“The acceptance of professional authority was, in a sense, America’s cultural revolution, and like other revolutions, it threw new groups into power – in this case, power over experience as much as power over work and institutions.”

The sociologic change I refer to earlier? The two columns of dependence and legitimacy are eroding – right before our eyes.

In the case of dependence, the digital revolution is putting technology into our hands that was only recently the stuff of dreams. Eric Topol, an ardent health care technology evangelist, describes many of these in his new book, “The Patient Will See You Now” – hand held ultrasounds, as well as lab tests, oral and aural (ear) examinations performed on yourself, by your smart phone, etc. The success of platforms such as “The Quantified Self” proves that people are willing to use any number of personal technologies to gain insights about their health and wellness. Medical technology is certainly no longer totally “proprietary.”

What about legitimacy? When I was in medical school, the only way to get the information that I received was to be sitting in class next to me, or to have a pass the the medical library, and some idea of which books to read. Now WebMd gets an average of 156 million unique visitors each month. I was quoted during a panel discussion at the 2013 Forbes Healthcare Summit, saying that the “only difference between WebMD and what I learned in medical school is that the online pictures are better than the ones I saw in class.”

These realities considered, there will likely always be a role for authority in health care. Yves Rene Marie Simon, the French philosopher that finished his distinguished career at the University of Notre Dame and The Committee on Social Thought at The University of Chicago, stated that:

“The most essential function of authority is the issuance and the carrying out of rules expressing the requirements of the common good, considered materially.”

There will always be a need for the common good – the carrying out of biomedical research and the discernment and sharing of its findings, the repository of information regarding populations, the financial stewardship for the management of health and wellness, and many other activities.

In addition, there is only so far that those two pillars can erode – it is one thing to have a hand held ultrasound that images your gallbladder and tells you that it is inflamed, and quite another to remove it. I am not proposing that we drain the ocean, I am just suggesting that the interface between the sand (what “lay people” know and do, pursuant to health care) and the water (what organized health care knows and does) should move to a more logical place – and will.

Perhaps the more logical structure is the arch – referred to above by the fictional Alexander – that replaced the post and lintel as an even stronger, more durable supporting system. Here, the weight of responsibility would be borne across a continuum – patients, non-physician providers, physicians and others. The mortar for the stones in this arch would be the knowledge and technologies all have access to and utilize, in different ways, to minimize suffering, and extend meaningful life.

Do we have to allow the lintels of medical authority to actually fall and shatter? I suggest that large, consolidating health systems are best positioned to create a more thoughtful transition – by embracing the fact that dependence and legitimacy, in the previous context of health care delivery, are indeed eroding. Might it be that actively lowering those monoliths of authority down off of their pillars, and shaping the stones carefully to fit into the arch I refer to is better than digging through the rubble to find those that might fit?

After all, “nothing lasts forever.”

Dr. Roy Smythe is a Forbes contributor and the Chief Medical Officer for Valence Health, a Chicago-based health care consulting, services and operating company that seeks to facilitate the ability of providers of care to manage medical and financial risk.

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