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What are the biggest changes in the practice and delivery of health care in
the last decade?
He is Chief of the Division of General Medicine and Primary Care at Beth
Israel Deaconess Medical Center. He is a well-known leader in the field of
patient-centered care, and, when he arrived at the Beth Israel Hospital in
1971, created one of the first nationally recognized hospital-based primary
care practice and teaching programs, called health care Associates. Currently,
he is a Professor of Medicine at Harvard Medical School and chairs the Picker
Institute. Dr. Delbanco is a practicing internist.
The biggest change I've seen is the fact that my colleagues are getting
angrier. I'm seeing a lot of angry, upset, frustrated doctors, and patients
are confused about what we're all about. There seems to be a real
transformation in the way we relate to patients, relate to one another, and
relate to ourselves as colleagues in our hospital.... There's a real sea
change in the way doctors are facing the world, and in the way patients are
facing the world. It's a change that holds a lot of opportunity and a lot of
What's the sea change? From what to what?
Doctors thought of themselves as independent, self-possessed, self-controlled
characters who ran the world and didn't work for people, particularly. Now
they're part of large bureaucracies and being told what to do, and they don't
like it. Patients have been much more passive than they are today. They're
learning to be more aggressive about their own health care. They're learning to
really take us on. They're learning to use us as expert consultants, rather
than people who tell them what to do. That transition is a real fundamental
change in the clinician/patient relationship.
What's happened to quality of care in this sea change?
While there's a lot of moaning going on, the quality of care is improving.
We're much better at doing things than we used to. When I was training, I had
many patients who I would give comfort to, and hold their hands, and hope
they'd do well. Now I see many people like that walking around feeling very
healthy. The problem with our new technology that everyone yells about is that
it actually works--that's why things are so expensive these days. That's why
it's so hard to really get the economics right. But I actually think we're
taking better care of patients than we used to, in spite all the rhetoric to
There was a period, four or five years ago, when all the sense of anger and
animosity and frustration was directed at HMOs. There was a decision here to
take on a fair amount of that health management, and that involved taking on
financial risk. Do you think that's been a smart move?
Doctors were taught to take care of people, not to figure out economics and to
run things. We're really caught in the middle, with a new set of
responsibilities, so we flail around, and we're angry at everybody. We're
angry at the people who control the money. We're angry when we're told that we
have to think about money, and not patient care. We're angry when we're told
we have to think about the whole picture in the country, rather than that
individual patient standing right in front of us. We don't quite yet know how
to deal with it.
But actually, it's teaching us to be different--to take on different kind of
sets of responsibilities. The younger doctors today are going to handle it
just fine. The older people are having a lot of trouble with that transition.
We weren't trained to do that. We weren't educated to do it. We resent it a
bit, but in the long run, I can take better of a patient if I have the right
resources when I need them for the given patient. And I won't have those
resources unless I think about money once in a while, or more often than I used
to. It's not wrong for us to do that. It makes us more responsible, and we
should be doing that.
That's a big transition, and it's hard to make. But we're not going to have
enough to take care of everything for everyone all the time. It just doesn't
work that way. It doesn't add up.
What are doctors saying to each other about their relationship to
One of the saddest things about doctors right now is that, when I came here 25
years ago and I saw two doctors standing in the hall, they would usually be
talking about a patient who is a problem--what could they do to help this
patient. Now they're talking about managed care. They're talking about
economics. They're talking about the government. They're talking about the
press. They're talking about everything but their patients, and that's a
tragedy. We have to get beyond that.
Do doctors here worry about the survival of the institution that gives them
a chance to practice medicine?
Doctors are worried, not just about themselves, but also the places in which
they work. When they hear about the millions of dollars that are in the red
for institutions such as ours, of course they're worried about it. I'm quite
impressed by how they're slowly getting over the fear and the anger about
everything, and actually getting to work to try and fix things, and come up
with solutions to some of the problems a hospital like this faces. People who
have been here a long time and love this place are kind of exsanguinating,
bleeding with it, and they'd like to stop bleeding. So we're all working
together, and it's going to work better in the future. But it's a very scary
time in medicine. Anyone who says it's not is hallucinating.
Why is it scary?
It's scary because at least we perceive that we don't have the resources we
used to have. We perceive that there are times when we can't do the best thing
for the patient. We perceive that friends of ours are giving up and leaving
the profession. We perceive now that medical students may not be as talented
in the future as they have been in recent years, as we learn about the drop off
in applications to medical school. And we worry about that.
But the debate goes on today. They're meeting weekly, monthly, and asking,
"What elements in our business are paying off, and are not paying off? What
should we spin off?"
It is fair to talk in undoctorly terms about segmenting our market. It's fair
to say we will focus in this area, and not be all things to all people. In a
rational world, Boston, which has a doctor every square inch, one hospital
would do well to take care of certain types of patients, and another one would
take care of other patients.
The trouble is that we're not all that rational and human emotions get in the
way. You and PBS want to fight with CBS and ABC, and so you don't always make
rational decisions either. If we could get over that very human way of
thinking, we could rationally parse out the care of patients in this
town--which is so privileged anyway--in a way that would be good for the
patients, that would not break the bank, and would keep us all still very
Are you suggesting that breaking the market up into groups that compete is
When we started in medicine, we were taught by all our professors that
economics don't apply to medicine, that the marketplace doesn't apply. Now
we've learned that we were wrong, and competitive forces are jiggling us around
I actually think that's been a wake-up call for us. Over time, the only way
we'll be able to afford and build a rational system is if we again leave the
marketplace--and work together in a rather centralized, heaven help us,
nationalized way--all of us working on the same thing, and that's taking the
best possible care of individual patients.
What do you say to people who say, "Yes, of course, you've got to focus on
the patients. But the way you're talking is old school, old-fashioned."
This business of saying that when you focus on the patient, that's passe,
that's gone, and that here's a new century coming on. That's nonsense. The
basic principles of health care . . . are still the same basic principles of
taking care of someone, of the basic human interactions. . . . We still
basically think about --what will it take to manage you, help you, and care for
you when you're sick? Those things don't change. They haven't changed for
hundreds of years. We have new tools, new technologies, and new strategies.
Ideally, we want you much more involved in that than you used to be, and we're
going to try and teach you over time to do that. But the basic principles
don't change, and it's utter nonsense when people say that.
If those are distractions, should doctors have taken on the financial risk
as well as the responsibility of managing care? That's where the distractions
Doctors are not trained to be economists or businesspeople, and I'd be very sad
if that were the principal part of our training in the future. You would get
much worse care than you get now. But this transition, this kind of pressure
we're under, is very difficult, and there's no easy answer. . . . When I was
young, if I did more and more things to you, I got paid more. Now, as I'm
older, if I do less and less things for you, I may get paid more. Both of
those extremes are crazy.
I should do what's right for you. I should probably be paid a salary. I
should be rewarded if I give better quality of care to you. I should be
rewarded if I work harder and longer hours, but I should basically be thinking
of your needs, not my pocketbook, as it applies to the number of patients I see
per session, the number of tests I order or don't order, or my hope that you
don't call me, because I was paid in advance to take care of you, and if you
don't show up, I make a lot of money. That's a crazy way of living.
And that's what you're doing now.
We're in a crazy transition. The country is in a big muddle.
How do you describe the incentives that are at work on doctors today? Are
The incentives that we work under are crazy, and we've never gotten the
pendulum to swing right. Fifteen years ago, if I did a cardiogram on you every
week, and drew as much blood out of you as possible, I was paid more and more
money. Now, if I never do a cardiogram on you, and never got any blood out of
you, I'll be paid more and more money. Both extremes are nuts. We have to get
it right, get in the middle. . . . I personally think there are solutions.
The trouble is that my solution may be different from someone else's, and in
the end, you get into a political game that gets played out in the Congress, or
on TV, or what have you. We've got to get that right. It is a crucial
One of the things that we've learned is that we were too scared of the managed
care companies. We didn't push back hard enough. We didn't really negotiate.
We thought that if we weren't good boys and girls, they would just take
patients away from us, push them somewhere else and we'd go bust. That's nuts.
We have to push back and work with them, as a team in collaboration, to make
the thing work. You're beginning to see glimmers of that happening, because
the managed care companies themselves aren't so happy these days, in case no
one has noticed. They're in trouble also. Their salvation may be not to do us
in, but to work with us more closely. And you're going to begin to see that
happening in this country soon.
inside the dilemma ·
financial incentives ·
cost v. care
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