Arizona Advanced Medicine Clinic

Changing the Paradigm of Medicine

by Martha M. Grout, MD, MD(H)

In the October 13, 2011 edition of the New England Journal of Medicine appears an editorial in which the writers lament that “Patients are no longer patients, but rather “customers” or “consumers.” Doctors and nurses have been transmuted into “providers.”[1]

Words are indeed powerful. By reducing the physician to a “provider” of “health care”, the time-honored paradigm of medicine as a healing art is reduced to little more than commodity fulfillment.

Which came first, the words or the facts? Have we brought this paradigm shift upon ourselves by agreeing to be employees of Insurance and by utilizing only prescription drugs? Or is the language in some sense an attempt to bring health care practitioners into line - a subtle way of down-playing the importance of the individual practitioner in favor of the relative security and ill-conceived assumption that one size fits all?

There is, of course, some value in algorhythms - it’s a roadmap leading to the correct diagnosis for which the correct pharmaceutical drug has already been determined. Notice that the point is not treating the patient who carries the diagnosis. Nor is the point to look for underlying causes - inflammation, nutritional deficiency, dysfunctional thinking, etc. The point in the current paradigm of medicine is arriving at a diagnosis and finding the appropriate drug.

The entire medical profession - the “doctor” or “teacher” aspect - becomes more or less irrelevant in the “delivery” of healthcare, perhaps better described as disease management. If we have the right algorhythm, there is no need to think, or to use our intuition (otherwise known as clinical experience). All we have to do is connect the dots - and surely it is not necessary to go to school for 24 years in order to learn how to connect the dots.

To call our nurses “physician extenders” makes them sound like collapsible poles used for changing light bulbs. The word nurse comes from the Latin word “nutrire” meaning to “nurture” or care for, as for a child or small creature that cannot care for itself. Our patients are not “consumers” of health care. They are individual human beings who suffer, and who come to the office in an effort to learn how to extricate themselves from their suffering.

The language that we use does indeed set expectations.

In a shop, the customer is always right, and can demand service from the clerk behind the counter. Thus if we have sagging eyelids and want them surgically lifted so that they no longer sag, we can pretend to ourselves that we are still young - even if only in body. In a “provider’s” office, care is standardized on the assumption that we are all alike, and that if we just follow the rules, we really don’t need to go to graduate level school. Just as with the “barefoot doctors” in Mao Tse Dong’s China, lesser degrees of training will serve just as well, and the consumers will receive adequate care in the shortest possible time.

In a “doctor’s” office a relationship is established. The doctor’s responsibility is to teach the patient behaviors and lifestyle information that they may not have discovered on their own.

The relationship does, of course, have similarities to the shopkeeper and customer relationship - one does try to find a treating physician who has experience in the area with which we are concerned.

For example, one would probably go to a urologist to get advice about a sluggish stream of urine due to swelling of the prostate gland. One would not expect to get information relating to the co-existing condition of cognitive impairment or memory loss - for those issues, one sees a neurologist. And yet... if we think about it, the function of the prostate is almost certainly affected by inflammation in the system which may be caused by sensitivity to wheat resulting in brain dysfunction (cognitive impairment, inattention, lack of focus) as well as prostate swelling.

We could choose to see a urologist who has embraced the new paradigm of functional medicine, who cares enough to take a complete history, and who is looking for underlying cause of dysfunction, because we would also learn the underlying cause of the memory impairment, as well as figuring out the prostate issue.

Are we, as doctors, willing to accept the limitations imposed upon us by our medical associations with their “practice parameters”, by the insurance companies which may pay us 30 cents on the dollar, by the hospital administrators who need to put us into a predictable box and who reward us for doing the least amount of testing possible?

Or shall we decline to be forced into that box so that we may continue to exercise our clinical judgment, even at the risk of becoming the black sheep of the profession?

The choice is ours. It begins with an idea, translated into the language that we choose to use.

We are not “providers”, we are doctors, or nurse practitioners, or chiropractors, or naturopaths, or acupuncturists. We never went to “provider” school. We went to professional school, and spent many years beginning to learn our professions. We do not employ “physician extenders”. We work with physicians, nurses, medical assistants, physician assistants, clerical staff, and so on.

Our patients are not “customers” or “consumers”. They are human beings, many of them friends. We are honored to assist in their journey toward health and growth.

Whatever our paths, we are all headed toward the same highway that leads to fulfillment. Sometimes we need to change directions, take a new road, in order to continue our journey. We are the travel guides, illuminating the path.

It is our responsibility as teachers to learn everything that we can learn, so that we can offer our patients more options. It is our patients’ responsibility to take in all the information available, and make the choices which resonate with them. As teachers, we have enormous freedom. As “providers” we are very much limited by the rules of those who write our paychecks. There is an element of choice and free will for both teacher and student.

We could choose to be victims - “Oh, the doctor told me to take this pill/have this surgery.” We simply chose to ignore the part where we were (presumably) told about nasty side effects. It is a real shame that we have no more immune system, or hair, or strength to move around, but at least we followed the rules, and what happens to us is not our fault, we did all the “right” things. We could also choose to be active in our own behalf. This particular path is more narrow and rocky than we might wish. But we have the opportunity to examine the rocks, and to find beauty in the path.

For physicians, this narrow rocky path involves swimming against the stream of convention, and attending many conferences and seminars to learn the latest information. Our responsibility is to be discriminating in what we choose to apply with our own patients, to ensure that whatever we do does no harm, and is in accordance with the best evidence available to us. This sometimes brings us into conflict with our medical boards. We may have to defend ourselves against those who think that “detoxification” is a bad word, invented to fleece the public of their hard-earned dollars; that there is no problem with genetically- modified foods; that a calorie is a calorie, no matter what the source.

For patients, the requirement is to weigh the evidence, and go with what makes the most sense to us. There are no absolute rules. This sometimes brings us into conflict with both families and other doctors.

There is no growth without conflict, no strength without resistance.

The hardest part for many of us is simply becoming aware that there are other legitimate paths. It is far easier to scoff - after all, the vitamin studies that have been done show that taking Vitamin E is worse for your health than not taking it - that you die of heart disease or lung cancer sooner than if you don’t take Vitamin E.[2] Never mind the fact that taking a single vitamin to excess can create significant imbalance in a system which is already teetering on the verge of collapse.

If we truly admit that there might be another way to practice the care of health, then we are required to re-examine everything we have been taught, everything we learned in our professional school.

For physicians, this means stepping outside the box, going beyond practice parameters, taking more time with our patients. We may no longer be paid even a survival wage by our patients’ insurance companies because we cannot possibly fit the 6-minute patient visit into this model. We may be brought before our medical boards to defend our treatments to a group of physicians who are firmly committed to the symptom - diagnosis - drug paradigm.

The choice is ours.


[1] Hartzband P, Groopman J. The New Language of Medicine. NEJM 2011; 365:1372-1373 ( October 13, 2011)

Words are indeed powerful. By reducing the physician to a “provider” of “health care”, the time-honored paradigm of medicine as a healing art is reduced to little more than commodity fulfillment.

Which came first, the words or the facts? Have we brought this paradigm shift upon ourselves by agreeing to be employees of Insurance and by utilizing only prescription drugs? Or is the language in some sense an attempt to bring health care practitioners into line - a subtle way of down-playing the importance of the individual practitioner in favor of the relative security and ill-conceived assumption that one size fits all?

There is, of course, some value in algorhythms - it’s a roadmap leading to the correct diagnosis for which the correct pharmaceutical drug has already been determined. Notice that the point is not treating the patient who carries the diagnosis. Nor is the point to look for underlying causes - inflammation, nutritional deficiency, dysfunctional thinking, etc. The point in the current paradigm of medicine is arriving at a diagnosis and finding the appropriate drug.

The entire medical profession - the “doctor” or “teacher” aspect - becomes more or less irrelevant in the “delivery” of healthcare, perhaps better described as disease management. If we have the right algorhythm, there is no need to think, or to use our intuition (otherwise known as clinical experience). All we have to do is connect the dots - and surely it is not necessary to go to school for 24 years in order to learn how to connect the dots.

To call our nurses “physician extenders” makes them sound like collapsible poles used for changing light bulbs. The word nurse comes from the Latin word “nutrire” meaning to “nurture” or care for, as for a child or small creature that cannot care for itself. Our patients are not “consumers” of health care. They are individual human beings who suffer, and who come to the office in an effort to learn how to extricate themselves from their suffering.

The language that we use does indeed set expectations.

In a shop, the customer is always right, and can demand service from the clerk behind the counter. Thus if we have sagging eyelids and want them surgically lifted so that they no longer sag, we can pretend to ourselves that we are still young - even if only in body. In a “provider’s” office, care is standardized on the assumption that we are all alike, and that if we just follow the rules, we really don’t need to go to graduate level school. Just as with the “barefoot doctors” in Mao Tse Dong’s China, lesser degrees of training will serve just as well, and the consumers will receive adequate care in the shortest possible time.

In a “doctor’s” office a relationship is established. The doctor’s responsibility is to teach the patient behaviors and lifestyle information that they may not have discovered on their own.

The relationship does, of course, have similarities to the shopkeeper and customer relationship - one does try to find a treating physician who has experience in the area with which we are concerned.

For example, one would probably go to a urologist to get advice about a sluggish stream of urine due to swelling of the prostate gland. One would not expect to get information relating to the co-existing condition of cognitive impairment or memory loss - for those issues, one sees a neurologist. And yet... if we think about it, the function of the prostate is almost certainly affected by inflammation in the system which may be caused by sensitivity to wheat resulting in brain dysfunction (cognitive impairment, inattention, lack of focus) as well as prostate swelling.

We could choose to see a urologist who has embraced the new paradigm of functional medicine, who cares enough to take a complete history, and who is looking for underlying cause of dysfunction, because we would also learn the underlying cause of the memory impairment, as well as figuring out the prostate issue.

Are we, as doctors, willing to accept the limitations imposed upon us by our medical associations with their “practice parameters”, by the insurance companies which may pay us 30 cents on the dollar, by the hospital administrators who need to put us into a predictable box and who reward us for doing the least amount of testing possible?

Or shall we decline to be forced into that box so that we may continue to exercise our clinical judgment, even at the risk of becoming the black sheep of the profession?

The choice is ours. It begins with an idea, translated into the language that we choose to use.

We are not “providers”, we are doctors, or nurse practitioners, or chiropractors, or naturopaths, or acupuncturists. We never went to “provider” school. We went to professional school, and spent many years beginning to learn our professions. We do not employ “physician extenders”. We work with physicians, nurses, medical assistants, physician assistants, clerical staff, and so on.

Our patients are not “customers” or “consumers”. They are human beings, many of them friends. We are honored to assist in their journey toward health and growth.

Whatever our paths, we are all headed toward the same highway that leads to fulfillment. Sometimes we need to change directions, take a new road, in order to continue our journey. We are the travel guides, illuminating the path.

It is our responsibility as teachers to learn everything that we can learn, so that we can offer our patients more options. It is our patients’ responsibility to take in all the information available, and make the choices which resonate with them. As teachers, we have enormous freedom. As “providers” we are very much limited by the rules of those who write our paychecks. There is an element of choice and free will for both teacher and student.

We could choose to be victims - “Oh, the doctor told me to take this pill/have this surgery.” We simply chose to ignore the part where we were (presumably) told about nasty side effects. It is a real shame that we have no more immune system, or hair, or strength to move around, but at least we followed the rules, and what happens to us is not our fault, we did all the “right” things. We could also choose to be active in our own behalf. This particular path is more narrow and rocky than we might wish. But we have the opportunity to examine the rocks, and to find beauty in the path.

For physicians, this narrow rocky path involves swimming against the stream of convention, and attending many conferences and seminars to learn the latest information. Our responsibility is to be discriminating in what we choose to apply with our own patients, to ensure that whatever we do does no harm, and is in accordance with the best evidence available to us. This sometimes brings us into conflict with our medical boards. We may have to defend ourselves against those who think that “detoxification” is a bad word, invented to fleece the public of their hard-earned dollars; that there is no problem with genetically- modified foods; that a calorie is a calorie, no matter what the source.

For patients, the requirement is to weigh the evidence, and go with what makes the most sense to us. There are no absolute rules. This sometimes brings us into conflict with both families and other doctors.

There is no growth without conflict, no strength without resistance.

The hardest part for many of us is simply becoming aware that there are other legitimate paths. It is far easier to scoff - after all, the vitamin studies that have been done show that taking Vitamin E is worse for your health than not taking it - that you die of heart disease or lung cancer sooner than if you don’t take Vitamin E.[2] Never mind the fact that taking a single vitamin to excess can create significant imbalance in a system which is already teetering on the verge of collapse.

If we truly admit that there might be another way to practice the care of health, then we are required to re-examine everything we have been taught, everything we learned in our professional school.

For physicians, this means stepping outside the box, going beyond practice parameters, taking more time with our patients. We may no longer be paid even a survival wage by our patients’ insurance companies because we cannot possibly fit the 6-minute patient visit into this model. We may be brought before our medical boards to defend our treatments to a group of physicians who are firmly committed to the symptom - diagnosis - drug paradigm.

The choice is ours.

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