Tuesday, September 23, 2008

Reflecting on a Reflection

It took a while to upload my slides, but I finally got my Grand Rounds  on the blog.  You could stop reading this, and drop down three posts to check it out.  Posting it made me think more about what I said- I think that it is mostly accurate (and of course, I would love it if folks would send me corrections), but I think that I spent too little time on the final reflections.  What has my modest participation in this fantastic process taught me?  My "lessons learned" seems a bit lean, and I wanted to think on this a bit, especially in the context of a talk I heard today by Michael Fine, a family doc from Rhode Island.  Michael has written a book, The Nature of Health in which he laws out a strong argument that our current healthcare mess (high cost, poor outcomes) is rooted in our social fabric, that has defined health in measurable terms (delay of death, alleviation of pain, personal function) that encourages us to think about medicine as a business, and that focusing our remedies on the payment system (national health insurance) will do little to change that unless we change the system from one focused on procedures and specialists to one focused on primary care and prevention.  All of which I agree with.  He points out that neither Obama or McCain want to fix this fundamental problem.  What he didn't do today was give us the blueprint for change;  how do we make this change happen?  
That's what was missing from my lessons learned slides:  What I have been learning for the last year or so (actually for the last 50 years, but I am a slow learner) is that actually bringing change to a system is really hard.  It requires a careful analysis of the forces holding the old system in place, a keen sense of timing to understand when the "Time is Now", incredible attention to details- an ear to ground, contacts at every level of the government, knowledge about how the levers of power are actually pushed, and finally a recognition that, in order to counter any political force, you need another political force to knock it sideways.  These are not things that one learns in medical school.  The are people- politicians and their aides- who have a keen sense of how this work.  When us medical people want something to change, we need to ally ourselves with these political chessplayers and let them show us how our knowledge can become political clout.  Sobering lesson, but really important if one wants to change actually systems.
Michael's talk, however, was right on target and brilliant.  He just needs to tell us more about the steps that we should take to make it all happen.
Bill signing tomorrow.  I'm looking forward to it.  I'll try to blog live.

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