Contemporary Western physicians uniquely are recognized for their high analytic academic achievement, ability to delay gratification, diligence, perseverance, self-abnegation, the capacity to work while being exposed to the corporeal aspects of human disease without manifesting repugnance, and the willingness to undergo a very prolonged apprenticeship. By the end of training, the physician is expected to effectively communicate with patients, be empathetic and discrete, and have flawless technical diagnostic and treatment skills. From a cultural perspective, a very prolonged adolescent developmental stage is necessary for these professional expectations to be fulfilled.
The developmental stage of adolescence is a social construct that is dependent upon the culture in which an individual lives. Developmental psychologists delineate stages of life from infancy through adulthood that must be successfully navigated, one after another, in order to ready one for the challenges of the next stages of life. Physicians cannot successfully fill their ultimate professional roles and meet such challenges until completion of their prolonged training. Jean Piaget focused upon adolescence as a time of mastering concrete operations. Contemporary medical education requires the mastering of technical skill through many years of training, whether the skills are procedural, diagnostic, or therapeutic.
The professional identity of a physician as a fully licensed interventional cardiologist, for example, requires four years of college, four years of medical school, three years of an internal medicine residency, and four years of cardiology fellowship training. With no breaks in training, an eighteen-year-old high school graduate would be thirty-three years old before he or she had established an identity as an interventional cardiologist, at least from a professional standpoint within the American medical education system and culture. Subsequently, the steps of passing boards and credentialing exams, and becoming an employed physician for two or more years prior to becoming a full practice partner means the cardiologist would undergo further initiation into the profession in order to enter medical practice and become a partner. Perhaps by age thirty-five the long dependency of his or her medical training would finally be over. What are the consequences for the physician and for his or her society that require such a prolonged period of training in order to achieve full professional status?
Among the most schooled, physicians achieve their full professional authority later than all the other professionals. The impact that this delay has on physicians personally, as well as its impact on patients and on the society that he or she serves and is supported by, needs to be carefully analyzed, because much of the success or failure of health care reform will be influenced, although not necessarily determined by, physician behavior. Physicians, who have delayed their full entry into adult professional roles longer than most of their contemporaries, have definite expectations about what this delay should ultimately bring to them. When these expectations are not met, the implicit dysfunction in physician behavior may be very disruptive to attempts to improve the health care delivery system, as physician buy-in will be more difficult to achieve.
The previously anticipated secure financial compensation at the end of their training is no longer certain for physicians who are experiencing declining reimbursements, loss of status, patients identifying alternative medications or non-traditional practitioners as equally qualified or valued, and consumerist pressures for improved access, results, and transparency. Physician-to-physician comparative data publicly accessible on the Web adds competitive pressures that make compensation more dependent upon performance than on licensure in and of itself.
Despite its length, physician training does not include enough substantive work on running a business, nor does it fully equip today’s physicians for the evolution of health care that is occurring around them. Statistical process analysis, team-focused approaches to patient safety, and results-based, information-driven infrastructures upon which 21st century health care systems will be based is not part of the skill set of the current physician workforce, nor is it part of the implicit bargain physicians thought they made with American society when they chose to spend their young adult years in the prolonged apprenticeship of medicine. Cumulatively these inherent challenges in the American medical education system, to some extent, stifle the opportunities for physicians to engage in leading the changes necessary to permit optimal patient care.
Paradigm-Shifting Elements
The medical community has faced a tremendous array of paradigm-shifting points leading up to the current ambiguous position. The positive and negative transformative effects of financial constraints, disruptive technology, and culture change have impacted the practice of medicine, its operating models, and its future needs for innovation in the delivery system. Over the past two decades a number of landmark reports, books, and legislation have been issued that have pushed the agenda for many initiatives that are altering rapidly the health care industry. As we focus on the need for transformative physician leadership in the current environment, we identify a few of the paradigm-shifting elements in American medicine for reflective thought as we consider the impact of these areas on current and future physician leaders in daily patient care and strategic management activities.
• Integrative Medicine — The field of integrative medicine (IM) may be considered either complementary to or challenging of conventional academic medicine and can involve a number of types of treatments such as psycho-oncology, massage therapy, naturopathic medicine, acupuncture, Chinese/herbal medicine, biofeedback, nutriceuticals, and nutritional supplements/ counseling. Many IM methods have been or are in the process of being evaluated for their efficacy and safety while care providers who prescribe and utilize such interventions typically claim beneficial psychological and/ or physical condition improvement.18 Patients who experience adverse side effects that result from some conventional medicine treatments, especially in the case of some cancer therapies and other chronic diseases, often turn to the field of IM for alternative approaches to help lessen such side effects or in some cases to explore alternative interventions. In 1998 the National Institute of Health (NIH) established the National Center for Complementary and Alternative Medicine (NCCAM).19 This organization focuses on research on complementary and alternative medicine (CAM) to provide evidence as to the safety and efficacy of interventions that are adopted and used by practitioners, patients, and the general public for these types of treatments. As the evidence base has grown, several academic medical centers20 and hospital organizations have established centers and treatment services focused on IM and CAM, including Yale Integrative Medicine, Duke Integrative Medicine, Johns Hopkins Center for Complementary and Alternative Medicine, University of California San Francisco (UCSF) Osher Center for Integrative Medicine, and the Mayo Clinic. This paradigm shift alters the very core of traditional physician authority that is based upon 18th Century rational thought, and brings all the uncertainty, but also the possible power, of the traditional shamanistic healer role in intervening with the spiritual world. In Western culture, it is the “art” rather than the science of medicine these alternative therapies emphasize, but for physicians trained in empirical methodology, the juxtaposition of medical science with such “healing arts” is unfamiliar, and not comfortable territory in which to practice one’s craft.
• Cost of Care — The cost of health care services in America has grown exponentially over the past three decades. This issue has led to legislative reform initiatives at both federal and state levels as consumers, employers, and government attempt to exert control over the cost of care escalation. While cost increases are partially fueled by advancements in medical technologies, pharmacotherapy, and research, they are partially a result of waste, fraud, and misuse of medical therapies incentivized by the volume-based fee-for-service systems. At the federal level the Department of Health and Human Services (DHHS) Office of the Inspector General (OIG), Center for Medicare and Medicaid Services (CMS), and the Department of Justice are escalating enforcement of fraud and abuse21 and anti-trust laws,