It began almost imperceptibly with a small regulation here, a comment there. Slowly at first and then with relentless speed and force it grew, and like a tsunami overwhelms anything in its path. By now, every physician who has practiced for more than a few years has noticed the dramatic shifts in the relationship of doctors to the society in which we practice our profession. From relative independence, we are being forced further into group think.
Hardly a day goes by without some new directive from above instructing what and how to perform a task to benefit our patient. Examples abound: The Surgical Care Improvement Project (SCIP) commands us to give a β-blocker and an antibiotic. Woe to the anesthesiologist who misses the magic hour before incision or without explanation holds metoprolol in a bradycardic patient.
Then there is the mandatory computer-based education that instructs us to be caring, do the right thing and dump garbage in the appropriate color-coded bins—followed by a test. Why bother with medical school and residency? You can’t make this stuff up!
Some centuries ago, Alexis de Tocqueville (or was it Machiavelli) explained how control of a population can be simply achieved by forcing compliance with many relatively small and innocuous requirements. Sounds a lot like the multiplicity of rules and expected behaviors coming down daily from the hospital, insurers, the government and even our own colleagues. A doctor could once choose from multiple diagnostic and therapeutic pathways, like a driver motoring down a wide interstate picking a lane. Now that same physician must navigate a narrowing European cobblestone alley.
In a recent issue of The New Yorker magazine, Atul Gawande, a Harvard surgeon, wrote about the efficiencies, quality and cost control of the Cheesecake Factory restaurant chain as a model for improvements in medical care delivery. Airline pilots no longer, our new role models deliver crab cakes and teriyaki chicken … but, oh so efficiently.
A Postmodern Infection
We have all heard about the advantages of replacing the individualistic physician making clinical decisions based on his judgment, education and experience with uniform algorithm-driven medicine. Minimizing variation and increasing predictability, we are told, will improve care and decrease costs. But, in addition to those practical reasons, I believe deep structural changes must have occurred to allow this viewpoint, unthinkable a generation ago, to become an everyday reality.
I believe the answer lies in the migration of postmodern continental philosophy to the elite bastions of American education. Today’s medico-political-educational opinion leaders, Boomers and Gen Xers, alumni of Ivy League schools—the best of the “best of the best”—came of age in an atmosphere steeped in the words of Derrida, Lyotard, Foucault, Baudrillard and other intellectuals whose thoughts and writings were in vogue in the 1970s. These ideas subsequently penetrated state universities and community colleges, became part of the standard curriculum and spread mimetically throughout the culture. Today art, architecture, critical theory, science, medicine, psychiatry and in many ways life in general are viewed through the postmodern lens.
A cornerstone concept of postmodern philosophy is the importance of the collective over the individual. (Incidentally, this is curious since postmodernism developed out of existentialism, in which individual responsibility was paramount). As reported by Roger Kimball in his book, “Tenured Radicals: How Politics Has Corrupted Our Higher Education” (Ivan R. Dee), a 1984 Stanford University conference of “formidable scholars” essentially declared the death of the concept of the individual as defined by classic liberal Enlightenment thinking, the American Declaration of Independence and the U.S. Constitution. In its place was an ill-defined “reconstructed post-cultural entity,” whatever that means.
The postmodern generation is obsessed with the idea that we are all in this together. This is so obvious a truism as to be banal, but do they take it too far? Does this approach translate to remote control of medical decision making by anonymous experts, far removed from a particular doctor–patient interaction? In Dr. Gawande’s view, at least, such a system deserves a chance—indeed, he argues, it’s the future for many hospitals.
Our leaders may not deliberately have decided to deconstruct Marcus Welby, M.D. and his weekly TV struggles against medical conformity. But trapped in their postmodern Weltanschauung, they simply could not help themselves.
Dr. Kron is a semiretired anesthesiologist in Hartford, Conn.