Health 1.0: The Not-So-Golden Age

We stand at a crossroads in healthcare today. Behind us lies a nostalgia-tinged world of unfettered physician autonomy, sacred doctor-patient relationships, and a laser-like focus on the art and humanity of medicine. This was Health 1.0 — the world of my father, an immigrant and primary care physician with a solo practice in rural Central California.

While many still pine for the “good old days” of medicine, we easily forget that those days weren’t really all that good. With unfettered clinician autonomy and authority came sky-high costs derived from misaligned incentives. Outcomes were variable and quality inconsistent, and fragmented delivery meant an utter lack of systems thinking and population health management. Evidence-based medicine wasn’t really a thing yet; it was all about consensus and intuition and prior experience and whatever that one drug rep or med device salesperson was pushing that week when they brought lunch for the office staff.

Volume-based fee-for-service payments incentivized doing things to people, instead of for them. Escalating costs and unnecessary interventions along with straight-up corruption led to cracks in the facade of the “guild” of medicine. Rampant medical errors, massive waste, and a lack of focus on outcomes began to provoke serious backlash, especially with the advent of the internet and its democratization of information. The human relationship in 1.0 was elevated to the sacred, but the physician remained the undisputed high priest of the Church of Health Care. The rest of the “team” — including patients — were subordinate, and usually voiceless. To maintain the 1.0 status quo, our medical education system remained mired in an ancient hierarchical, tradition-bound Greek paralysis, valuing deference to authority above all else.

Health 2.0: Medicine As Machine

In response to the real and perceived failures of the fragmented medical cottage industry, a new paradigm emerged: Health 2.0 — the era of Big Medicine. Folks asked, “Why can’t healthcare behave like other industries where the rules of business and economics — carrots and sticks and metrics and mid-level managers — apply in force?” A focus on value over volume meant looking at populations and systems design, and so Big Data, randomized controlled trials, and quality improvement science became the new religion of the realm.

But somewhere in the mix of good intentions, the human heart of the thing — the piece that really matters — was lost. Large corporate groups gobbled up solo practices and hospital systems. Managed care, government regulation, evidence-based “guidelines,” HIPAA, PQRS, HCAHPS, MACRA, MIPS, Press Ganey, Lean, Six-Sigma — these ushered in the era of Medicine as Assembly Line. All of us — clinicians, patients, and administrators — became mere cogs in this glorious, insanely mundane production machine.

Instead of ceding authority to the guild of paternalistic physicians, we now cede to endless bureaucracy — the swelling ranks of the administrative technocracy, with its faceless protocols and algorithmic click-boxes codified in that glorified cash register, the electronic health record. We now treat a computer screen while our patients are reduced to 0’s and 1’s in the Medical Matrix. The doctor doesn’t hold power anymore, but neither does the rest of the healthcare team — and certainly not the patient. We are ALL commodities…raw materials in the human factory farm of Health 2.0.

And now the very calling that first drew us into medicine is itself in crisis. 60% of physicians wouldn’t recommend the career to their children, while our nurses are exhausted and our patients turn to Dr. Google and Gwyneth Paltrow in despair. Suicide is epidemic among our healers. Why? Because although many of the principles of quality, efficiency, and systems-thinking espoused by Health 2.0 are crucial to moving us forward into the 21st century, we’ve lost the heart and soul of medicine along the way — that distinctly analog human relationship that elevated medicine from career to calling.

Health 3.0: Repersonalized & Transcendent

A new paradigm is emerging at last — one that treats both Health 1.0 and 2.0 as partially true, but incomplete. A paradigm that transcends both, preserving their strengths while allowing for the emergence of something far greater: repersonalized care that honors both the unique individual and the larger whole.

Health 3.0 is about connections and the primacy of human relationships, but it’s no longer simply paternalistic (Health 1.0) or strictly commoditized and informational (Health 2.0). It’s a partnership with our patients and each other that can only emerge when clinicians are given the time, space, and tools to understand the unique hopes, dreams, and fears of the human in front of them, while also recognizing that no person exists in a vacuum — including the caregivers, who are now part of a seamless team where every member is allowed and expected to practice at the top of their license.

Actual outcomes matter in Health 3.0, not click-box “quality measures” that don’t actually measure quality. Clinicians are given the tools and autonomy to achieve the outcomes that matter to their patients; do the right thing, and let technology work in the background to enable and empower the relationship. This allows the emergence of real value, where cost, quality, and patient experience intersect. We’re paid to create this value, not to do more tests or withhold needed care or click through checklists on a computer screen. Our administrators seek not to greedily grab more of a shrinking pie, but to grow the entire pie for everyone.

In Health 3.0 we are evidence-empowered but never evidence-enslaved. We find a nerdy kind of joy in process improvement science that allows us to better achieve the outcomes that actually matter to our patients. We hold patients accountable to take control of their health, and they hold us accountable to be their shepherds. We recognize that interiors matter as much as exteriors: the mind-body connection and the conscious experience of human beings is no longer discounted. Each member of the healthcare team supports one another while bringing their unique gifts to bear, and clinician-leaders guide our organizations with compassion and wisdom.

This is medicine as a living, evolving, beautifully complex organism where every cell is unique and autonomous yet an integral part of the larger whole. And here we find the joy of caring restored.

Welcome to Health 3.0.

 

Listen to ZDoggMD’s podcast about it.

Read more about it in Forbes.

Read Dr. Venu Julapalli’s article about it.

Read ZDoggMD’s interview about it, and his take on medical culture shift in primary care.

Watch ZDoggMD’s TED talk.

Join the conversation nightly on our live show.

 

Contribute YOUR voice and let’s build Health 3.0 together!

  • Oldretirednurse

    I’ll soon be 76 years old and I look back on 40 years of my calling. What I remember are my patients, their families and their gratitude. What I remember is the compassion, the love, the tears of my fellow nurses. I think very little about the system anymore. I leave that to you and your colleagues, ZDoc. Fix it.

    • Thank you for all you have done and for your comment!

  • Gia Daniel

    There’s something very comforting at times to just be told what is wrong and what to do to fix it; this is usually when one is most afraid, when one no longer has the physical and emotional strength to continue independently and needs to surrender in hopes of salvation.
    Of course, while understandable, it is also dangerous. The initials “MD” do not stand for “Mighty Deity”! But it can’t all be laid at the feet of the healthcare system, because the nurses and patients and techs and others turned over our autonomy, wanting salvation at the expense of dignity and acknowledging that the very human practitioners could err. It’s scary. Who wants to entrust their health or their loved one’s health to another mere human? We all know the ish that we put out, and now you’re saying that physicians and other practitioners are just as fallible? *gasps and swoons*

  • Bert Walker

    I’ve been in healthcare for 39 years. 34 as an RN. I remember healthcare 1.0 and I’ve unfortunately lived through all of healthcare 2.0. I did OR trauma ASA well as other OR specialties. I’ve left and went to Hospice in 2004. Best decision I’ve ever made. I live hospice nursing because it’s the one place I’ve found in healthcare with the people, pts and families, are the focus. That analog human heart of which you speak. It’s about quality of life, human connections, spirituality. I’ve found it’s where I can practice the art of nursing, not just the science of nursing. It’s what the Big Machine of healthcare is missing. I hope you are successful in restoring this focus on patients, and people in general, to healthcare. I support your efforts.
    Bert Walker

    • Heard on all points, Bert.

    • Epador

      Bert, I hear you. Remember most hospices survive 50% on reimbursement which is capitated and 50% on charity/fundraising. Imagine if ALL local healthcare had that kind of support and backing. I’m getting <50% reimbursement for my fee for service and that sucks. I've been an MD for 40+ years and been through DOS2.1 to current OS 3.0 to use Zdogg speak.

  • Lauren Surrock

    “Lose Yourself” could not be any more spot on, hit the nail on the head for me. I AM that girl in the video…. dreams shot, wishing I had gone to business school instead. THIS is not what I went to school for. Our patients deserve better, WE deserve better. How do I join your movement!? Are you hiring for your campaign? 3.0 is my goal and I can’t wait to see it happen.

    • You are already part of the Movement just by being here. Stay tuned!

      • dcooper

        Well Dogg what’s the plan? The rest of us have to work for a living.
        No time to make videos.

  • uuberdude .

    The greatest evil lies in regarding people not as ends in themselves, but as means to ends.

  • Doug Davies

    Thank you for bringing this to the frontlines. I’ve worked in healthcare for 8 years now and I am saddened as each year ticks by. The current ‘Big Buisness’ approach to healthcare has ruined the true spirit and soul of our healthcare system. And it only gets worse. I hope for everyone’s health and well being that 3.0 becomes the new way. Thank you for all you do! Your voice is reaching many!
    Doug D.

  • Patrick Cox

    Hell buddy. that video ‘7 years old’ was pretty Dramatic. I love it but now i have to ask you. YOU ok buddy. Life is not so bad. It sure beats the other side of the coin. I wish you do so well with this 3.0 that it doesn’t make their heads spin, I hope that light bulb goes off in their heads and they look at you and say, “wow, i got it now, Thanks ZDogg”…….

  • Shane Sanders

    Hey ZDogg, you absoluyely nail it on yhe problems with “modern” medicine and these things are exactly what myself and colleagues discuss constantly. You’re doing an awesome thing and your vids are great. Need a daily new DocVader though haha. BTW, you need an in house eye doctor at TurnTable? Haha, no harm in askin 😉

  • MS

    As a psychologist who practiced at a naval primary care clinic I witnessed potential of integrating behavioral health with IM and FM-we actually planned and ran Mindfulness Based Stress Reduction groups, helped patients lose weight, utilize motivational interviewing to improve medication adherence in addition to treating anxiety and depression… this is the future!

  • Judy Christine Thomas

    Mental health treatment is in a similar state of transition. Glad I am to see all forms of health care transforming into being more human centered.

  • Katy Benjamin

    Thank you for what you are doing. I love the nursing industry and would be heading to nursing school if it wasn’t for patient to staff ratio’s. I want a career in management so maybe I can make a difference and make things better. Please keep up Health 3.0 maybe we can make a difference together and bring chance. God bless you

  • Esparkee

    I think the CMS-mandated interdisciplinary group care planning meetings that occur in hospice and LTACH’s (probably LTC and elsewhere, too but not to my direct knowledge) should be expanded in H3.0. I’ve not attended IDT meetings in my LTACH, but in hospice ones the dying patients’ own goals received prominence, not just analysis of disease trajectories and continued qualification for services and treatment/care plans. Wouldn’t it be great and ultimately efficient to have everyone (especially patient and supports) on the same page for more of our patients throughout their chronic diseases’ progression? Maybe expand some of the concept of the stroke team to COPD, CAD, cardiomyopathies, CKD, etc., where there is a discrete team with specialized knowledge meeting regularly to review cases. The team members in smaller medical centers still practice more generally (eg, RNs still staff all med/surg patients and PT/OT still treat all patients but they maintain specialized expertise in a couple of diseases to actively participate in those IDT’s–a specialist/generalist hybrid). It might sound extravagant on the surface to pay for these meetings, but the expenses might be justified in a combination of reduced waste of substandard care, improved patient satisfaction with their progress, shorter LOCs and fewer read missions, reduced emergency services utilization, enhanced risk management/lessened liabilities, and reduced staff turnover costs secondary to improved satisfaction from enhanced prestige.

  • Elle

    I’m a physician, too, and I love that you are getting out there and meeting with groups and trying to educate…but I have a request: is there any possible way you to get yourself out in front of the Senate asap and talk with them? I know you said on your show that the bill is all politics —and it is — but maybe there is a way to wrap something good into the bill they are proposing; maybe they could even roll some health 3.0 ideals into the bill. I feel really strongly that one of the key reasons there is so much that is wrong in healthcare is because the government has never involved doctors and other health care providers in the process, and we as don’t have a real voice. It has always bugged me that the political world goes around saying that the AMA backs or doesn’t back something — and then they (and the public) act as whatever the AMA says is automatically what all doctors say. But the AMA has become so distant from what real doctors do and feel these days. I don’t feel the AMA represents me, and that is what I’ve heard from so many doctors.

    BUT – what if
    we had some sort of conduit, some sort of public forum, that could be used to allow all of us to voice how we feel, in real time, and be heard. I’m not sure how to do that, but I am 100% sure that if anyone can do it, that would be you. You have the “star power” and the creativity and the charisma to think up a way to form a conduit for our ideas. And it would then take you, and your message on health 3.0,, as well as the voices of so many of us real doctors, and get them out and heard by politicians and by the public.