The Vanishing Center

By

Leonard Zwelling

         This is not a blog about basketball—college or professional.

         I have returned again and again to the striking similarities
between the challenges I face at Legacy and the ones I used to face at Anderson
and with which those who have succeeded me in the Anderson administration have
to contend to this day. There seems to be a vacuum in the middle. It threatens
to cause the collapse of the entire system upon itself due to a lack of
reasonable free energy that could keep the system from dissolving to chaos.

         When I was younger, there seemed to be a host of politicians
who lived in the middle. There were Democrats who were more hawkish than some
Republicans. There were Republicans who did not think that every program to aid
the poor and disenfranchised was another hand out to Americans unwilling to
work or a welfare program for immigrants. There were real giants in both
parties who understood that the country required them to compromise away from
the extreme positions occasionally expressed by fellow party members in order
to have an efficient running country that would maintain its place as a beacon
of freedom and prosperity in a post-WW II world dominated by the Cold War and,
in particular, the threat of Communist totalitarianism following on the heels
of the defeat of fascist totalitarianism. They realized that the best defense
against the Soviet threat was an America that was both prosperous and
inclusive. They took the responsibility to act like adults, insist on getting
some but not all of what they wanted and to not bathe in the luxury of self
aggrandizement a la the junior senator from Texas.

Little
by little, we thought we were getting there as the civil rights movement,
Medicare, Medicaid and a Supreme Court that actually respected the rights of
individuals, including women, moved the country, albeit slowly, to the center.
There was even a public education system that gave birth to a middle class of
first and second generation Americans who got to college and maybe even beyond.
Oh yes. It got us to the moon, too.

         When did this change?

         I think that Barry Goldwater’s claim that “extremism in the
defense of liberty is no vice” began the ball rolling in the wrong direction if
McCarthyism hadn’t already. But Goldwater was just a trickle as Lyndon Johnson
defeated him in a landslide in 1964. (What is so humorous is that Barry
Goldwater would probably be considered inadequately conservative for today’s
GOP).

Rather
than extremists making gains, it was the failure of the center to keep the wolf
of corruption and factionalism at bay that really led to today’s crisis. Acting badly became mainstream. 

It was
mainstream centrist thinking that enabled Johnson and then Nixon in Vietnam, Nixon through
Watergate, Carter through the Iranian hostage crisis, Reagan through
Iran-Contra, Clinton through Monica and W. through Iraq and the financial
crisis on Wall Street. It took a very long time for the establishment center to say these were
all mistakes with grave consequences to the soul of the nation.

Now
we have a President whose signature piece of legislation is up for constant
debate and daily revision away from the tenets of the very law that same
president signed four years ago. Why trust the central government that is no
longer centrist? The center is gone, replaced by the presumption of government
criminality and the gravitation of wealth to the few. If there is an American
center, it is as likely to contain criminals and politicians, as statesmen and women if you can tell
the difference.

         As Vinnie Daniel is quoted as saying in Michael Lewis’ The
Big Short: “They were more morons than crooks, but the crooks were higher up”.

         To the chagrin of many of us, the same is true in medicine.

         Medicine was the last vestige of the guild system. Doctors
were small businessmen (and some women) who were well compensated for their
work, but understood that their work never ended. Doctors were always on call,
always there for their patients first and their families second, and
represented both intellectual and social order even when assisting those who
were dying, an activity that used to take place quietly at home and not among
alarms, tubes and ventilators let alone MRIs, antibiotics and chemotherapy that
spun the ATMs at the ICU’s sliding glass portals.

         My first therapist said when I asked her why psychiatrists
needed to be doctors:

         “Doctors bring people into this world and doctors help them
out. They can handle most of what happens in between”.

         This too changed. Mostly due to money.

         Doctors began to understand that there were ways to convert
their healing power into earning power and did so. But then those doctors and
civilians in the insurance and hospital industries learned how to really up the
ante by creating an industry of paying for health care where none existed
before and for care that was both unneeded and iatrogenic. The insurers
manipulated risk management into profit by becoming intermediaries between
suppliers (doctors) and demanders (patients) negating the market forces exerted
by either and owning the revenue streams in all directions, leaving the
hospitals to scramble for the rest. And they did.  

Just
as the political center vanished, so did the center where doctor and patient
joined in the common goals of disease eradication, health maintenance and
prevention. Today it’s all about billing, coding, coverage, deductibles,
bundled payments, capitation, fee-for-service and a host of other principles
none of which are described in Harrison’s Textbook of Medicine, but rather
constitute a seminar’s worth of study in the business schools that are turning
out the real leaders in medicine, the administrators who own the processes that
govern care and run both the hospitals and the third-party payment systems.

         Just as I saw transpiring at Anderson, at Legacy there is a
tug of war between the “providers” (you know I hate that word) and the
operations folks. I find my day filled with trying to drag the discussion back
to the center so that the doctors can have a say in the manner in which patients
are cared for. It is a full-time job to engage in this war, but nothing is more
important for me, or for you.

         Either you as physicians and other mid-level providers are
going to do what is best for your patients as only you know what that is or the
accountants, lawyers, administrators, and other assorted wannbes around the
sites of medical care will do it for you, or rather, to you. You need to drag
them back to the center. They need to negotiate with you and you with them on
behalf of your patients.

         It ain’t called a cancer CENTER for nothing. For your
patients’ sake, “get back to where you once belonged”—the center.

Leonard Zwelling