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Chapter 1

State of Affairs

The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty. As our case is new, so we must think anew and act anew. We must disenthrall ourselves, and then we shall save our country.1

President Abraham Lincoln

1862 Address to Congress

The Beginning

The time is now. We are at the beginning of what we expect will be the single fastest transformation of any industry in U.S. history. In this tidal wave of change demographic and socioeconomic forces colliding with the status quo will radically alter the landscape of the health care delivery system in ways that were inconceivable a decade ago.2 Our nation is addressing a number of critical issues, including recovery from the Great Recession with its housing and mortgage crisis and the near-collapse of the world’s financial system, a polarized political leadership, rapid demographic changes brought on by the aging of the population and immigration, terrorism, and health care financial reform. Among these competing national priorities, no individual issue in America has posed as pressing of a concern and heightened importance for the public as those that directly impact their personal well-being and health. The election of President Barack Obama in 2008 brought landmark reform efforts for our nation’s health care system, while the subsequent national elections of 2010 brought to office a new set of legislators who ran their campaigns on the promise to repeal this legislation. While political debate continues on the funding, necessity, and timing of many aspects of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), it is currently the law of the land, and the underlying focus on the rapidly accelerating health care costs in the current fee-for-service system will continue to drive the health care market to more cost-efficient delivery models regardless of the partisan political debate in Washington.

In 1960, U.S. federal government spending for education as a percentage of gross domestic product (GDP) was 3.7%; for defense it was 10.1%, and for health care it was 0.3%. In 2008, federal government education spending as a percentage of GDP increased to 4.6%, defense spending had decreased 5.1%, and health care spending had increased to 4.6%.3 Since 1960 the federal, state, and private expenditures for health care services and goods in the U.S. haves accelerated from 5.2% in 1960 to 17.6% in 2009 (Figure 1, below). Factoring in the impact of the Affordable Care Act, national health expenditures (NHE) as a percentage of GDP are expected to reach 19.6% by 2019.4

While the uninsured segment of the American population stood at 49.7 million in 2010 and the projected impact of insurance market reform will bring this number down to 24.4 million by 2019,5 this population segment will continue to challenge health care providers when their lack of access to basic health care services inevitably leads them to the emergency departments of our overburdened hospitals.

More than a decade has passed since the release of the Institute of Medicine’s (IOM) landmark report, To Err Is Human6 in 1999 that cited the high number of medical errors occurring throughout our health system. Even today with significant resources having been dedicated by health care organizations, government agencies, not-for-profit organizations, and physician practices across the country to launch and conduct major quality improvement initiatives, our nation’s health system still faces significant challenges with eliminating medical errors.7

The economic incentives of a fee-for-service health care system drives overutilization of profitable services by health care providers, which the private payers respond to through managed care, and the governmental payers respond to through regulation. These counter measures to overutilization lead to increasing frustration on the part of physicians and other health care providers, who perceive less freedom to practice medicine unfiltered by externally imposed constraints. Along with the anxieties provoked in providers by the current punitive tort-based malpractice system, physicians face very low professional morale. The current self-reported professional morale among physicians is dismal, with only 23.1% reporting professional satisfaction in the current practice environment.8 Regardless of professional morale, demographic and socioeconomic changes will continue to drive the health care delivery system reform an serves as justification for continued innovation and our need for strong, diplomatic and collaborative leaders among physicians to improve the health of our current and future patients.

The Impact of a Generation

No generation has made such a significant impact on the focus of medicine in America as the baby boomers. In 2011, the first wave of baby began to start hitting age 65 and become eligible for Medicare benefits at a rate of 7,000 per day. As the 80 million boomers continue to age and consume greater portions of health care, American society will focus its attention on the needs of the boomers at this stage of their lives, as we have necessarily focused on this portion of our population since their disproportionate demographic impact began in the post-war births in 1946.

The baby boomers are growing old. When this population segment was in the 1950s and 1960s, America was focused on the “youth culture.” In the 1970s-2000s, the culture has been focused on the socioeconomic issues of marriage, child rearing, and work-life productivity. In 2011 the tides turned again as the largest segment of American society began to grapple with the issues of retirement and physical decline. We should not expect the baby boomers to “go gently into that still night” any more than we should have expected them to acquiesce to the draft during the Vietnam War. This portion of the American population, with demographic strength in numbers, coupled with buying power and political strength, will be reaching that point in their life cycle with increasing health care needs.

The aging of the baby boomers will lead to inevitable health care reform. One could argue that the Clinton health care reform attempt of the early 1990s failed because the baby boomers were too young, healthy, and productive at that point in their lives for health care to rise to the top of federal political policy concerns. Boomers were far more concerned in 1990 with competing for good jobs and having a thriving economy than health care concerns, as long as the cost of health care did not interfere with more pressing economic concerns.

However, as this population segment moves into its golden years, the 40 million generation X workers cannot replace the 80 million boomers in the workforce without radical structural changes or liberal immigration policy. Although it became apparent decades ago that inefficiencies in the health care system would make a daunting challenge to meet the health care needs for this group, it was not until the boomers approached the years in which their Medicare entitlements kicked in that we began experiencing intensified focus on wellness and longevity research, changes in political agendas, renewed efforts in innovation across the gamut of care delivery, new technologies, and most importantly, transitions in our approach to payment models away from the volume-driven care delivery system that emerged with the managed care era (when the boomers were productively employed and the problems associated with health care costs were thus focused upon employee benefits) toward one that is working toward being more focused through delivery of high-value and high-quality services.

The Medical Profession in America

The earliest archeological evidence reveals that humankind has always worked through cultural evolution to change the environment in ways perceived to meet our needs. Whether through the development of rudimentary stone tools, transformation from hunter-gatherer methods of food acquisition to agricultural methods, the development of densely populated settlements, or the development of modern technology and scientific methodology, humankind has sought to improve our lives by changing our physical and social environment. However, the consequences of our actions also lead to unanticipated adverse environmental changes. With the advent of animal domestication and the rise of dense populations of relatively sedentary groups of people, disease patterns changed as rich niches for rodents, parasites, and insects developed. Exposure to new bacteria, molds, and toxins occurred with the new dependence on a grain-based diet subject to putrefaction due to the need for storage. The more narrowed nutritional spectrum of the agriculturally-derived grain-based diet also led to nutritional deficiencies in vitamins, proteins, and minerals, and in times of poor crop yield, starvation.9 Whereas evidence of treatment of trauma has been found in the earliest Paleolithic records, the advent of cities over the past five thousand years has furthered the spread of epidemic infectious diseases derived from viruses, bacteria, and parasites. In the modern era, civilization has wrought exposures to chemical and industrial toxins, radiation, alcohol and drug addiction, and an increase in the prevalence of other lifestyle-influenced diseases such as diabetes, cardiovascular disease, and cancer.

As long as human cultures have evolved and adapted to their physical and social environment, humankind has sought to maintain some control over disease. Anthropologists have identified the healer role across cultural boundaries as one-way cultures attempt to understand, influence, and control human disease. The earliest historical records of Egypt and Mesopotamia document an understanding of illness as a divine punishment for sins committed by the patient.10 The healer in cultures as diverse as those in native New World populations, Asia, Africa, Europe, and Oceania can be described as a shaman, whose cultural purpose is to serve as a mediator with the spirit world for purposes of relieving the physical distress of a suffering individual. The shaman holds cultural power by bridging the natural world and the spiritual world for the benefit of the community.11

In modern Western culture, the scientific revolution led to a rationalist approach to physical disease, and, as Paul Starr articulates in his introduction in The Social Transformation of American Medicine:

Though the works of reason have lifted innumerable burdens of hunger and sorrow, they have also cast up a new world of power. In that world, some people stand above others in knowledge and authority and in control of the vast institutions that have arisen to manage and finance the rationalized forms of human labor.12

Starr’s Pulitzer Prize-winning work analyzes the role of the physician in American society from the colonial period until the advent of managed care in the 1980s. Starr describes the rise in status of physicians that resulted from their control and exploitation of emerging innovations in technologies and practices grounded in research, scientific evidence, and medical education. The resulting improvement in medical treatment accelerated the perceived value of the medical profession over the past hundred years in America. Starr discussed the important role of medical education in the United States and the historical significance of the Flexner Report of 1910, which led to national physician curriculum standardization emphasizing the scientific method as critical to ethical high-quality patient care. While we shall discuss the significance of medical education from the perspective of physician leader development, here we wish to note that the standardization of curricula emphasizing scientific inquiry helped improve the abilities of our nation’s physicians to continually improve patient care through the development of evidence-based orders, guidelines, and practices.

Starr analyzed the complexities of how the physician profession rose to the level of power and authority in the United States that we see today.13 He argues that modern medicine has developed “an elaborate system of specialized knowledge, technical procedures, and rules of behavior” granting to the medical profession an especially persuasive claim to authority.

Even among the sciences, medicine occupies a special position. Its practitioners come into direct and intimate contact with people in their daily lives; they are present at the critical transitional moments of existence. They serve as intermediaries between science and private experiences, interpreting personal troubles in the abstract language of scientific knowledge.14

Starr’s analysis is focused upon the sources of power in the medical profession leading to cultural authority and occupational control, economic power, and professional autonomy that was at its peak at the time of his publication in 1982. He accurately predicted the current threats to professional sovereignty through “competition and control” as “hospitals and other organizations merge into larger and more powerful corporate systems…and beyond private bureaucratic organizations looms the regulatory power of the state and federal governments.”15

Of course, Starr did not predict the impact of the Internet on patient access to information sources for helping them make personal health care decisions without yielding to the authority of physicians and other health care service providers. This issue has accelerated the threats to professional authority embedded in regulation and economic management models.

Starr’s analysis can be applied today in the context of understanding the contemporary health care industry landscape with its various economic and societal factors our nation’s physician leaders must address and consider in critical decision making for their own organizations and patient care decisions. While the industry has been transformed organizationally through waves of both vertical and horizontal integrations and mergers, even today a large percentage of the nation’s physicians still operate as small business entrepreneurs. In this transitional state, both the complex structures of large organizations and smaller entrepreneurial ventures are better understood with their historical context. Starr’s analysis demonstrates the application of market dynamics in health care as a force for evolutional change within complex adaptive systems.

This implication that historically physicians have always faced the market dynamics of their time permits a larger insight into the tension present between the professional obligations of patient care and the economics of the community in which care is rendered. Today, the market dynamics regulated through the Federal Trade Commission and the Department of Justice create an environment for medical practice in which physicians must adjust their objectives to improve access to care, affordability and the quality of care with the need to meet co-occurring interests of cooperation and competition as they occur within the financial market.16 The individual professional decisions made to achieve these objectives will involve economic impact issues (e.g., number of health care professionals to employ to meet consumer demand for services; impact of various supplier relations, etc) and social relation issues (e.g., determining associations and advocacy agendas to support), some of which occur simultaneously and are collectively influenced by the actions taken by various stakeholders in our nation’s health care community.

The “subtle loss of autonomy for the (medical) profession” resulting from the rise of corporations controlling the economics of the healthcare industry through “increasing corporate influence over the rules and standards of medical work” predicted by Starr in 1982 is old news now. He accurately foreshadowed that “the new generation of women physicians may find the new corporate organizations willing to allow more part-time and intermittent work than is possible in solo practice” and had the foresight to recognize that:

There will be more regulation of the pace and routines of work. And the corporation is likely to require some standard of performance, whether measured in revenues generated or patients treated per hour.17

Paul Starr did not predict the advent of the hospitalist movement, the rise of physician executives as a hybrid clinician/management role, or the regulation of resident physician work hours. However, these developments led to value-based health care that challenges the economic status quo in the health care delivery system. The rise of managed care in the 1980s and 1990s is now under siege as the result of legislative insurance reform and the demographics of the aging population. The Affordable Care Act, Health Information Technology for Economic and Clinical Health (HITECH) Act), widespread consolidation of the industry through mergers and acquisitions, the development of patient-centered medical homes, and clinical integration among complementary provider organizations will result in innovations in care delivery models. For the physicians and care providers in the medical profession, delivery system reform will accelerate organizational change and provide an opportunity to improve the continuity of care and result in a revitalized health care system going forward.

Alongside this potential renaissance, the information-system technology revolution offers us the opportunity for improvement in evidence-based medicine practices, communications, and stronger opportunities to deliver high-value care to patients. The necessity of keeping pace with continuous clinical advancement, new technologies, and increased reporting requirements will accelerate the rate of change in the health care delivery system. Physicians must both adapt and continue to provide the leadership and social authority to make these changes patient-centric, or our special position in American health care will erode and become increasingly irrelevant.

The Individual Physician

The shamanistic healing role is a powerful one across many cultures, but the special authority physicians occupy in our culture still to a large extent is dependent upon the prolonged years of medical training, where professional competencies develop that permit physicians to assert their shamanistic authority within our own cultural context. Physicians (and other health care workers) push beyond the genetic and social aversions to disease and decay and social taboos in order to restore health or relieve suffering. In doing so physicians are allowed to probe the most intimate aspects of a patient’s life for the purpose of healing or relieving pain to a far larger extent than other health care workers. Within the confines of the professional relationship, physicians ask about a patient’s bowel habits, sexual history, and the most private aspects of life. A surgeon open the body to excise an infected appendix or breast malignancy within the proper clinical context of diagnosis and treatment without presumed boundary violation.

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, employing new methods such as the CMS Recovery Audit Contractor program, adoption of the Correct Coding Initiative in CMS programs, and intensifying the bundling of codes for previously separately reimbursed services.

• State of Mental Health Services — In light of the prevalence of mental illnesses across all segments of the population and the interconnectedness with physical health, there is great interest in integrating mental health services with primary care services and especially with evolving efforts to expand adoption of the patient-centered medical home model across the nation.22 In 2006 the IOM’s Committee on Crossing the Quality Chasm addressed mental/ substance use (M/SU) issues identifying four critical problems with the quality of M/SU care, which included:

— Failure to provide care consistent with existing scientific evidence,

— Variations in care that occur when clear evidence on effective care is lacking,

— Failure to provide any treatment for an M/SU illness or to address the risk factors associated with the development of these illnesses, and

— Unsafe care.23

In addition to intensifying human suffering, the failure to provide an adequate safety net and infrastructure to treat M/SU issues experienced by certain patients has resulted in increased overall health care costs to payers, both private and governmental.

For those seeking care for mental illness, limited access and insurance coverage for services, stigma and discrimination is embedded in the overall infrastructure on a national level.24 In order to improve outcomes from those in the current fragmented system, physician leaders must drive strategic agendas forward to mitigate risks associated with the current bifurcated system, and continue to develop and implement integrated care models that equally meet patient population needs for both general health and M/SU care programs as recommended by the IOM.

• Emerging Models and Innovations — A number of changes regarding new models of care and innovation are addressed throughout this book. The most pressing initiatives involve new models for care delivery along with innovative changes in medical education and the accelerated pace of technological advancements. Some of the care delivery model initiatives include patient- centered medical homes, accountable care organizations, and clinical integration programs. Payment reforms will transition the industry away from volume-driven are delivery to a pay-for-performance and value-driven model such as bundled and global payment structures.

These paradigm-shifting areas and others will have tremendous impact on the strategic initiatives and patient care activities for physicians. Many interconnected health reform initiatives will have long-term effects on the U.S. health care system, and failure of the physician community to responsibly lead and champion health care reform and make effective decisions on how best to address these paradigm shifts will result in the de-professionalism of physicians. Physicians must support patient-centric advocacy efforts by maintaining an awareness of changes regarding privacy laws, patient rights, reporting requirements for increased transparency in quality of services delivered, along with reforms such as new regulations for accountable care organizations and the CMS Meaningful Use of Electronic Health Records (EHR). Without maintaining a strategic leadership presence physicians will lose their centuries-old high social status that is based upon a powerful relationship with patients as their advocates and healers along with a level of societal authority that has grown to transcend the boundaries of health care and move into economic and political domains.25

Continued physician professional sovereignty will require a renewed focus on national policy initiatives as they pertain to patient care. The countless analyses published on the problems with the current health care system with various proposed remedies contributed to the language of the federal health care legislation of 2009 and 2010. However, the call of the IOM in Crossing the Quality Chasm in 2001 for the development of a 21st Century health care system was one that asserted a new system can improve, not just alter, health care by refocusing on the patient. The IOM declared that our health care system should aim to be safe, timely, efficient, effective, equitable, and patient-centered.26 These six aims have served as the underpinning foundation for many care delivery reform initiatives, research programs, and other transformational initiatives that have occurred or are under way across the country over the past decade. Sadly, the majority of physicians in American have read neither Crossing the Quality Chasm nor the IOM’s 1999 report To Err Is Human that focused on improving patient safety. The 2011 IOM report calling for leadership in nursing in the new health system ironically challenges physicians to intensify their leadership role in order to appropriately remain relevant in the national agenda.27

The proposed agenda from the IOM Committee on Quality of Health Care in America calls on health care leaders to:

• Design and implement more effective organizational support processes;

• Create a national environment that fosters and rewards improvement;

• Commit to a national statement of purpose and the six aims for improvement;

• Adopt principles to guide design of care processes; and

• Identify priority conditions to provide resources to stimulate innovation.

The key tenets of this agenda have influenced much of the policy decisions of private and governmental payers over the past decade, and are radically changing the culture of American medicine.28

As it was proposed a decade ago, this agenda led to the commitment to a national statement of purpose that is apparent through the multi-year effort that brought about the Affordable Care Act in 2010 and prioritized the conditions to be focused upon in national health care redesign. The IOM’s generation of a national dialogue endorsing an environment that rewards improvement, has catalyzed the move away from a volume-driven reimbursement system to one that is driven by and pays for performance and delivery of value-added services. A decade after the IOM publication, the health care community is still working to implement initiatives to meet the IOM’s goals. What will it take for physician leaders to achieve these objectives fully in the 21st Century?

Setting the Stage

Many people believe the nation’s physicians are ill equipped to manage the tsunami of change engulfing the health care system. Physicians must be prepared to collaboratively lead the multitude of health care reform initiatives, or succumb to becoming its victims. America will be worse off if physicians fail to take on the real leadership role required to improve health care delivery. The high position of respect and honor will be lost if others take up this important challenge in their place. Physicians face challenges that range from the individual practice level to the national landscape and by their very nature cannot be adequately addressed within the context of the traditional authoritarian, paternalistic role. Twenty-first Century health care should be physician-led, but patient-centered. In the paradigm shift, effective leadership will be collaborative rather than authoritarian and proactive rather than reactive.

The original title of our book was From Hero to Duyukdv. The Cherokee language defines duyukdv (pronounced du-yu-(yo)-dv) as a way of living a healthy life by balancing the proper role of the individual with obligations to the good of the whole community. Duyukdv is a way of living within a culture with truth and dignity. As physicians struggle with the changes in power and authority in their current cultural role, duyukdv offers an alternative concept to the traditional heroic model of medical professionalism. The Cherokee believe that health is achieved by living a life of balance within society, in which one fulfills one’s social roles in a manner that is respectful of the meaning of that role for others, while taking care of one’s personal spiritual health as well. We believe duyukdv is an appropriate metaphor for what medical professionalism must embody in a healthy 21st Century health care delivery system. In Western literature, the traditional story of a hero is one of a journey. The 18th-Century bildungsroman specifically tells the story of a hero’s journey to his proper adult role. In our book, we use the duyukdv concept as an alternative metaphor in which the journey to professional maturity is a different path. Having personal freedom (within the role of physician) only through the context of responsibility to patients and others has always been part of professional obligation. However, in this new era of professionalism, the old traditional physician value of autonomy, greatly associated with the heroic metaphor, is subsumed in a culture of professional balance and obligation.

Chapter 2 deals with the topic of power shifts occurring across the industry and their impact on the physician culture and leadership. In chapter three leadership theory and its practical application in today’s environment is articulated in order to develop an understanding of the implications of these theories for physician leaders within shifting organizational structures and various industry clusters (e.g., academic medicine, private practice, corporate medicine, managed care, research, and government agencies). A conceptual model is introduced for consideration of the implications for leadership in a population health management focused health care system that is the emerging strategy for a value-based delivery system.

It is crucial to understand the barriers, both clinical and administrative, that physicians face on a daily basis in their careers, many of which are overlapping. Chapter 4 will address these barriers in detail as we provide examples of technical, financial and regulatory, systemic, and especially the psychosocial barriers and factors that impede progress and impact organizational effectiveness of collaborative physician and clinician efforts throughout the U.S. health care system. The remaining chapters will address facets of medical education, technological advancement, medical professionalism, and, in the final chapter, a conceptual path to leadership for physicians.

At the end of several chapters we provide a set of summary insights for reflective thinking. Physicians in leadership or working toward leadership positions in their careers are engaged in myriad clinical and strategic business issues. Our summaries focus on two principal areas based on material covered in each chapter: leadership implications in today’s environment and health policy considerations. We believe that physician leadership is critical to setting appropriate direction in the creation and implementation of health care policy. Through advocacy, participation in government, and community outreach efforts, physicians will all play an active role in shaping the future. Our objective will be to draw attention to pertinent policy issues and their potential impact upon physicians and patients. We will survey the economic, social, political, and health-centric landscape to create a platform to address stakeholder concerns and provide options for action (Figure 2).

This model, modified from the work of Teitelbaum and Wilensky, does not include problem statement development, and, for illustration purposes, one can assume that both development and analysis of options are collectively considered within the “Options for Action” section.

MD 2.0: Physician Leadership for the Information Age is about a transformative journey for contemporary physicians that will strengthen the ability to lead. For today’s physician leaders and for those who are aspiring to become future physician leaders, it is a journey that must be embraced and recognized as critical if we are to succeed in advancing the quality of care delivered to our patients.

If the virtue of medicine could be enforced by the benevolence of the prescriber, how soon I should be well.

Samuel Johnson, 1784

References

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2. Glen Tullman, Allscripts CEO. Public remarks on the future of health care.

3. Historical U.S. government spending data compilation. Accessed online February 24, 2011 at http://www.usgovernmentspending.com/downchart_gs.php?year=1960_2016&view=1&expand=20&units=b&fy=fy12&chart=10-fed_20-total_30-total&bar=1&stack=1&size=m&title=&state=US&color=c&local=s

4. CMS National Health Expenditure Projections 2009-2019 (September 2010) Accessed online February 24, 2011 at http://www.cms.gov/NationalHealthExpendData/downloads/NHEProjections2009to2019.pdf.

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8. The Physicians’ Foundation. The Physicians’ Perspective: Medical Practice in 2008. Accessed September 15, 2010 online at http://www.physiciansfoundation.org/uploadedFiles/PF_Survey_Report_Nov08.pdf.

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