Thread by @ePatientDave

Hands down, this is the most amazing and transformational thing I've ever seen in my ten years of wondering about healthcare. Unbuckle your "safety belts" and see if you can hear what's described here.

And it's in Lancet.

Can you?

https://twitter.com/EricTopol/status/1149709737455263744

I'm going to post several tweets in a slow-mo thread here, responding to @PHEski's 10 responses last night. (I'm trying to be organized here, amid a rich discussion that's already turned into forks & branches.)

Please see his, which start here

https://twitter.com/ePatientDave/status/1149872936511246336

1/n

@pheski 2/n
First, I couldn't see mention in the Lancet article of the original paper they cite on "the scarcity loop" by Arthur Frank. It seems to be this, from 2012: onlinelibrary.wiley.com/doi/full/10.11…

Open access, yay!

Fascinating title: "From sick role to practices of health and illness"!

@pheski Also fascinating is that it's in _Medical Education_, the journal of @ASMEofficial - Assn for Study of Medical Education, from undergrad to C.E.

So, this aligns with those of us who have a hankerin' to weave this into clinicians' thinking from the git-go.

3/n

That paper's probably too abstract & philosophical for most people, but even browsing for "scarcity loop" is intriguing. I did what I could to absorb it, and I think the Lancet article does a really good job of harvesting the relevant ideas & putting them in context.

4/n

I agree with @HeartSisters, this seems strongly aligned with what @VMontori wrote about in Why We Revolt, and does in @PatientRev.

And now I find myself drawn to an unpleasant aspect, especially in the US system:
5/n

The Lancet authors ask this (I hope the screen grab works).

In the US system, the answer is all too certain: the money people would say (under cover of pretty press releases) "SCREW you. Protect my damn money!" (Links in next tweets)

We must fight back.

6/n

Two recent posts, originally 8 years apart, illustrate why I say the US system's executives would say "SCREW you - protect my money."

First, originally 2009, US healthcare's Gordian knot. This was BEFORE I began my advocacy & travels.
tincture.io/a-thousand-poi…
7/n

Then 8 years later, after 500 speaking events in a dozen countries & US policy meetings, the realization that stopped me in my tracks:
tincture.io/american-healt…
"American healthcare is a malignant tumor that can’t stop killing its host"

8/n

So yeah, I believe the US system IS structured as a scarcity loop.

Time & again I hear HCPs & patients reporting that their insurer basically said "We'd love to do what you want, but we need to keep the money."

I believe this is close to Satanic in its evil.

9/n

The @JohnLauner Lancet article continues, citing how Frank questions the assumption that capitalism is the only way to organize society. I'm a capitalist (I like money) but I profoundly question it as the foundation for treating people in trouble.

10/n

I'm also gravely concerned about breakdown of capitalism's best mechanisms (e.g. incentive to develop improvements) when too much power gets too concentrated, as has happened w FAANG (FB / Amazon etc), to the point where upstarts can't steal share. Same now w US hospitals.

11/n

Another example, not limited to the US, is the reprehensible behavior of pharma companies regarding prices of long-established medicines (and new) ... a reaction to *their own* scarcity issue: "Protect my damn money!"

12/n

And now at last I'll turn to @PHEski's 10-part reply this morning, which is what I came here to tweet about :-)

13/n

@pheski Wait, first a question: @EricTopol you say "We need to be carers, not providers" - given these structural issues, how can we get there?

And everyone, the Lancet author is in the UK system, so what he writes about is not just US. How can we get there?

14/n

@pheski @EricTopol (Speaking of scarcity, now comes @HMKYale (with response from @VMontori) with an apt NYTimes piece on shared decision making, showing a doctor rushing away, out of time.)

https://twitter.com/hmkyale/status/1150026254575460355

15/n

@pheski @EricTopol @hmkyale @vmontori So now: having re-read @PHEski's 10-tweet comment 3 hours ago, & studying more closely the Lancet piece, particularly looking at the 2012 Arthur Frank piece on "scarcity loop" -

- I agree with Peter that the values in the first part of the Lancet article aren't new; and -
16/n

- OTOH, he had the *great* advantage of being trained by a super-visionary physician dad (You really should essay-publish that, @PHEski); and -

- I agree that the second half is "just" aspiration (my word), nothing practical.

So now:
17/n

I guess that leaves us with, from my first tweet:

- IS the Lancet piece amazing? Yes, to me, in clarity of its vision & its questioning of scarcity as a principal factor in managing care ... but now I see it's not as new as I thought - just "in my 10 years," as I said...

18/n

- IS it transformational? Now I'd say yes & no. For those who already think that way, not at all. For those who don't (= most?), yes, it could be.

What is transformation? --

19/n

In years of courses w Landmark Educn they defined it as "genesis of a new realm of possibility." I'm guessing that's the sense in my heart when I read it, and from the strength of the response to my tweet, I'm guessing it's true for some others: "new realm of possibility"

20/n

All this discussion gives me new clarity: yes, there are other ways to think abt things; the system may be structured to resist (esp in US), including "Protect my damn money!"; & as both Peter & @VMontori said, ultimate lesson may be "Know what's possible & move toward it"

/end

@vmontori /ps #1:
Anyone who doubts "malignant tumor" / "Protect my damn money!" is harsh, life-crushing reality in US HC should read the recent @ProPublica series on non-profit hospitals SUING POOR PEOPLE - including in this case their own underpaid employees. mlk50.com/9-times-method…

@vmontori /ps #2: Returning to the question in my original tweet: "Can you hear what's described in this article?"

Some replied "Yes, we've been SAYING that!" perhaps w implied "(Glad someone's finally listening!!)"

Others evidently haven't: all those likes & RTs. Hope all CAN hear it.

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