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Escape Fire: The View from Cleveland

By Dr. Arthur Lavin

Dear Fellow Doctors,

Last night, 4 of our Doctors for Health Care Solutions (our Cleveland group of 600 progressive docs) were able to conduct a panel discussion after the screening of Escape Fire thanks to the collaboration of the filmmakers and Doctors for America.
It was especially powerful watching the movie in Cleveland, with all the references to our community, with Steve Nissen (a member of our Steering Committee and a real force in DOHCS), with the Cleveland Clinic all so prominent in the movie.
The four panelists from DOHCS were Drs. Peter DeGolia (geriatrician), Dr. Dena Magoulis (family practice), Dr. Eric Schreier (interventional radiologist), and myself  (pediatrician).  Of our three major medical centers in town, each of the first three docs were from one of each of the systems, and I represented private practice.
Here are some impressions from watching the movie and what I learned from the audience.  Let me first say about 100 people were there, and the discussion revealed a quite powerful and deep level of concern and caring about health care today.

The Movie
This movie made me really weep for our profession.
I weep because, as Steve Nissen and Don Berwick, et al,  remind us, what we need to do as a profession is profoundly simple and obvious, care for each other.  And yet the health care industry has evolved into something other than that, into something that does extraordinary harm.  Yes it does great things every day, and saves countless lives, and will likely do that for me someday.  But it also hurts many people.  What makes us all weep is that anyone can take a step back and see both facts clearly- the need and the reality.
Wag Dodge lit one match, and created a space where the flames would not consume him.  I actually hold out little hope that anyone can do that for the system.  There will be many isolated instances of caring doctors and people who get good care, but the system has a life of its own.  It really is parallel to Wag's situation.  He can save himself, but could not stop the massive fire.
At the end of the film, we held a panel discussion for the roughly 100 people present.   They stayed for 30 minutes to talk, and the feeling in the room was deep and very powerful.    The first question from the audience, and one repeated in many ways, was surprising since it tapped an issue not talked about directly in the film at all.  That was, "Why can't I have a doctor, someone who knows me, present when I am in need, when I get sick, when I get in trouble?"
We talk about EMR's, and teams of care, and responding to the importance of prevention and healthy lifestyle, each of which are critically important.  But underneath the whole picture, and all the approaches to understanding our crazy health care industry, is the oldest and most important question people ask when they get sick- Where is my doctor?
For my money, there are essentially two types of medical care- procedural and relational.  Procedural care is highly transient, episodic, and unrelated to the people involved.  Examples include appendectomies for appendicitis.  Really, who cares who the surgeon is as long as she or he is very good?   You will meet the surgeon when you have appendicitis and likely never see them again once you heal.   My point is not to devalue this line of work.  It is as important as the relational approach to practice.  If we stop doing procedures, great harm will follow.  It is critical, it is important, but it is not the only thing.
Relational care is just the opposite, in this mode you want to know a person, who cares for you, knows you, and will be there for you, for many decades.
Whether we point our priorities towards prevention or not, these two modes of care are the only two choices I know of.
For procedural care, teams and large systems work great.  For relational care, you need some system that allows and supports one person caring for one person over many decades.  I am extremely lucky to have that.  I work in a company that only does relational care.  It is small, and we know everyone in the practice, and most of them quite well.  And so, when anything goes wrong, we are there for that family.  We are at the hospital, we are on the phone, we will meet them at the office, and we will go to their home, anytime, any day, and respond directly within minutes of their call.
This was the most powerful yearning I heard from the 100 people in the audience.  They want a doctor.  They want a doctor like  people have had for the last 10,000 years.  They are bewildered that they can't have one now.  Why can't my doctor take care of me when I go to the hospital was a plaintive question asked in many ways.  When I responded, "It sounds like what you are asking for is a doctor who knows you, will care for you, and will be there for you, especially when you get sick,"  a palpable sigh went up from the audience.   The single most heartfelt request from the discussion was, where can we find doctors like  you?
So yes, there is a crying need for our suicidal system to stop killing and hurting people.  The train needs to be directed away from hitting people.  But even if this very unlikely goal can be met, a whole other challenge waits- fashioning a system based on one person caring for another, rather than on any of a whole host of people randomly being selected to do a procedure on another.
We need both, the procedure and the doctor, but the ancient most central role of a doctor in people's lives is rapidly vanishing, and the people are not pleased.
That's the view from Cleveland.

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