Health-Care Reform, the Future of Medicine, and the Return of Power to the Community
Krauser, John, Humane Health Care International
* Former Associate Director of Health Policy, Ontario Medical Association.
Correspondence and reprint requests to: J. Krauser, 2340 Truscott Drive, Mississauga, Ontario L5J 2B2.
The medical profession has excelled in providing clinical care for individuals and has fought hard for the economic rewards regarded as responsible payment for these services. It has achieved great sophistication in both areas. The profession also can achieve excellence in working directly with the community, but this goal needs its own model of medical leadership. At this point, health care has few senior role models of such collaborative work and scant medical recognition and documentation of the process. Under these conditions, it is possible that the profession will lose these important social skills and the "social capital" they represent. To have energy and direction, health-care reform requires this powerful social dimension in medicine and accompanying it, a return of power and responsibility to the community. These vital elements come together in a model of collaborative medical leadership to improve specific health outcomes that, after giving some background, I will briefly describe.
This is a work in progress. Physicians, senior program managers in health care, and community organizations should try to improve a specific health outcome important to the whole community, use this collaborative model, and report on the results. I think we will see what more can be done to advance excellence in collaborative leadership--at least in health care--by paying close attention to, and helping, these deliberations.
For many years, the Ontario Medical Association's (OMA) health-policy committees were the object of much professional pride and attracted physicians of the highest quality to serve the people of this province. Many of the Chairs and members of these committees have been outstanding examples of "grassroots" medical leadership. Once they are identified, put into position, and supported, "grassroots" leaders are unique in bringing with them an extensive network of colleagues. This is the way they create the critical mass of talent so necessary to improve a health outcome.
These committees were oriented to broad social fields, or focused on specific clinical topics, or they undertook collaborative work with direct community participation. Table I illustrates the range of these activities.
Increasingly, as the medical community concentrated its energies on preserving global funding and defending the fee schedule, this service philosophy was undermined by a growing feeling of cynicism. If they knew of these committees at all, the general public, the government, and physicians in general perceived them only as producers of "good works," contributing little to the overall government relations strategy, and no longer an anchor of professional unity. By the mid-1990s, the number of health-policy committees had been reduced considerably and the OMA no longer could focus the strength of the entire profession on a wide range of co-ordinated efforts to improve health care.
Ironically, over the same period, the physicians on OMA health-policy committees had become skilled at listening to community perspectives, defining mutually desirable goals, identifying the changes required in medical practice, devising the necessary interventions, and then enlisting diverse elements of the profession to achieve the desired outcome. They could see for themselves that such collaboration improved health-care outcomes in the community. These physician leaders were doing something right. They were building bridges in a polarized health-care
[Part 1 of 2] Table I Some Examples of Health Policy Initiatives of the Ontario Medical
Broad Social Fields Clinical Topics - Child Welfare - Breast Screening - - Reproductive Care - Cervical Screening - Hospitals - HIV/AIDS - - Accidental Injuries - Drugs and Pharmacotherapy - Work and Health - IVF Guidelines - Public Health - Emergency Health Services - - Wife Assault - Acupuncture - - Medical Bioethics - Spinal Manipulation - Medical Care and Practice - Maternal Mortality - - Education - Implementation of Midwifery - Women's Issues - - Rehabilitation - Mental Health - - Nuclear Fuel Waste Management - - [Part 2 of 2] Table I Some Examples of Health Policy Initiatives of the Ontario Medical
Broad Social Fields Collaborative Groups - Child Welfare Coalition on Comprehensive School - Reproductive Care Health Education - Hospitals Task Force on the Hazards Associ- - Accidental Injuries ated with Nuclear Energy and the - Work and Health Handling of Nuclear Products - Public Health Colloquium on Care of the Dying - Wife Assault Medical Needs of Children in the - Medical Bioethics Care of Social Agencies - Medical Care and Practice Ontario Cervical Screening - Education Collaborative Group - Women's Issues OMA Confidential Telephone Help- - Rehabilitation line - Mental Health OMA /Insurance Rehabilitation - Nuclear Fuel Waste Management Liaison Committee Undergraduate Curriculum Guide- lines for the Medical Management of Wife Assault Coalition on Children, Families and Communities