Law and Medicine, Part 3: The Hospital and The Shadow

I get weary of the debates over how America should deal with its intractable healthcare problem.  People need to get real.  But reality is actually changing.

The illustration above is a self-portrait with a pipe.  I haven’t taken up smoking again.  The pipe serves a purely symbolic function, to show the act of remembrance, a device to conjure the foggy, smoky convention of movies and comic books.  This pipe is not a pipe, which is part of the point I am trying to make.

I had once imagined having a long and successful career in the comic book industry.  Yeah, that would have been my fantasy job.  Instead, I got sidetracked by the need to earn a livelihood.  Now that I’ve reached the end of a long career in healthcare law, I set out to write a piece of non-fiction, with the goal of offering practical advice on legal issues affecting the healthcare industry, only to find fiction invading my efforts.  As I grapple with the challenges of serious nonfiction, it seems my goal lies in the realm of fantasy.  A dream harasses me—a dream of an ideal version of this essay, something crystal clear and lucid, ordered and compelling.  But when I strive to capture it in material form, the dream keeps evaporating, as dreams are wont to do.  Out of my literary comfort zone, I couldn’t tackle the truth without resort to things that appeal to, or are produced by, the imagination. 

The tension between the imaginary and the actual in my own life are part of the point I was trying to make about the nature of medical and legal problems.  The same kind of tension exists between the conflicting disciplines of law and medicine themselves, a tension that reveals something about the nature of reality, which continually interacts with unreality, the two being part of one another, unifying to make the world comprehensible.

Does this sound like the prelude to an unserious, frivolous, comic book, fantasy, or science fiction version of a prelude to discussing the American healthcare industry– something that should be very serious? 

Well, I learned a lot about reality by running away from it.

There are all sorts of serious and telling lessons that can be gleaned from comic books, fantasy, and science fiction.  I found an interesting exchange in the most unlikely place—a pulp magazine published in 1934, Charg, Monster, an adventure story, featuring a prototype superhero known as The Shadow.  The passage (very real, but lightly edited) lays bare two of America’s competing myths about the purpose of business organizations: 

 

“Five Million Dollars.”

“…I’m not interested.”

“You are a fool… One simple word of agreement—you will become a millionaire.”

“You want to make me like yourself—another plutocrat.  You want me to grind my share of the profit from the weary and oppressed.  …You have met the wrong man.”

“Let us consider the matter less tensely,” suggested the banker.  “You and I should be friends. Our views may be more similar than one might suppose.  We are both creatures of an existing economic system.  Modern conditions have brought you tribulation and misfortune; to me they have meant acquisition of tremendous wealth.  That is all… I have gained the ultimate in money.  You have reached the zenith of creative effort…  Both of us held the same ambition.  We have gained it… Success!  Under the existing conditions– which we must recognize as real– your invention can be transformed to wealth.”

Perhaps it was banker’s tinge of satisfaction; perhaps it was his reference to money as the final basis—whatever the cause, the effect upon the inventor was instant. 

     “Wealth!” the inventor’s words came with a sneer.  “You judge all by that one term. You are the fool, not I. … I shall do better—I have already done better.”  The inventor seemed to gloat over his ability to pass up the chance for fortune.

     “Why do you want my invention?  I can answer.  You see a chance to make more millions.  You see new masses of wealth for your bulging coffers.  Through my invention, you can drive other corporations out of business.  Power plants will be idle.  Present machines will become obsolete.  Small capitalists will be ruined.”

     “What of it?” interposed the banker with a hard smile.  “You do not like capitalists.  You will kill a budding crop of them if you sell me your invention.”

     “Kill them for your benefit!”  retorted inventor.  “Turn them into fodder that you may fatten.  Let you control a greater aggregate of wealth—you alone—than they all possess together. 

      “They are not the ones whom I would consider.  I am thinking of the workers.  Thousands upon thousands of jobs if you gain my invention.  That is why you will never have it.”

      “The world must progress.”  The banker was rising as he made his final insistence.  “The misfortune that the masses suffer cannot be avoided.  Economic conditions are adjusting themselves to meet the world’s advance.”

–by Walter Gibson (under the pseudonym Maxwell Grant)

 

*

     Should the organization serve the interests of the its owners?  Or its workers, or its customers, or its community, or its innovators or other dynamic contributors (like superstar performers or executives) responsible for performance?  We find variations of this debate in many of our culture’s iconic myths.  The principles take personified form as Scrooge and Fezziweg in Charles Dickens’ Christmas Carole, and in George Bailey and Hiram Potter in Frank Capra’s It’s a Wonderful Life.  The scene has echoes in The Fountainhead, when Howard Roarke refuses to compromise his artistic standards for mere money, though Ayn Rand’s sympathies for economic systems and social goals are diametrically opposed to the two previous examples.

In the cauldron of this conflict, the notion of an ideal keeps bubbling up to the surface—a commercial enterprise where the customers are pleased with products and services because they were provided by a workforce committed to excellence, and the enterprise itself is a boon to its community.  The workforce might be paid somewhat less than the most generous of what is available in the market, and the customers might pay somewhat more.  The owners might collect less on their investment.  The overall quality of the enterprise keeps it vital, stable, with a rich promise for the future.  It was heartening to see the recent statement by the Business Roundtable redefining its view of the purposes of a corporation, shifting away from using the price of stock as a polestar.  Such an ideal thrills the imagination– but also smacks of romantic unreality, or mere marketing.  It sounds like a fantasy.

 

Consider “New Amsterdam”, a popular television series about a public health system in New York City.  The series showcases a pulp adventure version of modern medicine, with stories and characters as fantastic as anything found in Doc Savage or The Shadow magazines.  With penknife, a prima ballerina performs a successful emergency tracheostomy in the field on the basis of transmitted verbal instructions.  A cardiac surgeon frees a full-grown man impaled through the chest upon an iron post, then carries him atop his shoulders through a freezing blizzard, then successfully performs surgery upon the man’s heart in a powerless operating room without the use of a by-pass device.  The medical director brilliantly performs his endlessly demanding duties while recovering from an anoxic coma, caring for his pregnant wife, and undergoing chemotherapy for life-threatening throat cancer.  Every selfless act and decision made in furtherance of the communal good somehow yields a result that saves lives and bestows benefits to all, making for an emotionally satisfying and uplifting fantasy, if the hard-left bias doesn’t bother you. 

New Amsterdam surely is a fantasy, but it was derived from a non-fiction book, Twelve Patients: Life and Death at Bellevue Hospital by Eric Manheimer.  This mixture of testimonial autobiography with unbridled pulp convention resonates in curious ways, which I am trying to emulate here, but from a different angle.

I used to work for an organization that approximated an ideal.  Locally, my former employer was viewed as a community treasure, winning countless awards.  It provided healthcare on a charity basis, and also on a fee-for-service basis.  It was famed for employee satisfaction and outstanding care.  Its balanced approach towards management created a workforce able to shrug off recruitment efforts by labor unions.  Employees would stay on for decades.  I certainly did.  It was a public institution, a unit of local government.  It had the ability to collect taxes, but through efficient management, it made enough money so that tax rates could be slashed year after year.  Making money was important, but it was only one of multiple interdependent and competing priorities.  It was balanced against other aspects of its mission. It was a state political subdivision, but it wasn’t about Democrats or Republicans.  The enabling legislation provided that the governing body would be appointed by the Governor of Florida, so the political affiliation of the leadership would from time to time.  Regardless of which political party was in control, the corporate culture didn’t change.  In my experience, the organization would more likely change the values of the people who worked for it than vice versa.  I saw how individuals fell under the influence of the corporate values, amending their priorities, biases, their ideologies, philosophies of governance, at least to the extent necessary to work together to achieve the organization’s goals. 

Sound like a fantasy?

Could my former employer serve as a structural model for other healthcare organizations?  Actually, no.  Curiously, my former organization had a kind of corporate identical twin sister.  The two organizations were created by special legislation that used the same language and shared the same structure.  Members of both governing bodies were appointed by the same Florida governors.  Both were bound by the same laws and had to follow the same legal procedures.  And yet the resulting organizations proved startlingly different. 

If nothing else, this sister organization had a tendency to generate more bad press than we did.  Sometimes this bad press tempted me to oversimplify, talking about them as if they were a shadowy cabal from a pulp novel, joking that they only existed to make us look good.  The reality is more complicated.

People used to ask me, what’s the magic sauce that makes my organization different.  And I would say, the culture—the extraordinary corporate culture.  It is a culture that could balance competing, conflicting priorities, with the awareness that all of the complex components had to interact in a way that resulted in good care at the bedside, knowing the effects would be profound– literally matters of life and death.  The organization embraced diversity—not simply in the sense of employing people of varying ethnic, racial, and national backgrounds (it did that, too), but also in the sense of embracing a diversity of thought.

A friend cut me short when I was trying to explain this essay.  He asked, “So, are you talking about something real or aren’t you?”

“It isn’t that simple.  Part of the problem, these days, is the nature of reality is actually changing.  I’ll talk more about that later…”

“You know what pisses me off?  Lawyers only have one of three answers to every single question.  On the one hand, it is one thing, and on the other hand it is something else.  Or yes and no.  Or it depends.”

“That’s not exactly true…”

“OK.  Only one of four answers.”

“Yeah.  No.  Both at once.  It depends.”

“Are you talking about something real?  Tell the truth.”

In his own way, my friend was objecting to the kind of distortions of New Amsterdam that I found provocative.

So I replied, “What pisses me off is when people trying to push my emotional buttons by using charged trigger words like ‘capitalism’ and ‘socialism’ or ‘free enterprise’ or ‘common good’.  And especially high sounding phrases that used to mean something, but don’t anymore, like  ‘real’ and ‘truth’.  What quaint notions.”

Over the course of decades, in the context of legal problems affecting the healthcare industry, I could see the way our culture was becoming less and less based on tangible and material things.  Those changes were impacting the very notion of truth.  Medical records used to be preserved on old-fashioned paper.  When there was a suspicion of forgery, you could test the ink as a measure of whether the record had been truly written on the time and date indicated.  You could examine the pages beneath for impressions left by a pen.  The information was grounded in something with substance, something very material. 

These days, medical records are no longer fixed upon paper.  Large portions of the narratives are pre-authored or constrained within the intellectual straight-jackets of dropdown menus. Truth and falseness have to be tested by resort to immaterial algorithms.    

Not only have we moved away from paper medical records, we no longer need paper contracts signed by a hand holding a pen to prove our promises or to cement our obligations.  We no longer have to leave our chairs to make purchases.  We don’t need to interact with human beings to obtain goods, or even to search for mates.  We have stopped looking each one another in the eye.  Even medical exams can be performed at distances.  Even surgery.  Patients are devolving into data sets, and care is transforming into data driven transactions that take place in the ether.  The material becomes confused with the ideal.  Even our states of mind can be altered with drugs.  We are becoming less entangled with the bodily substance that encumbers our souls.  We can alter our genders as well as our noses.  Our genes are next.  It seems inevitable, inescapable.  But the backlash against the inevitable is also inevitable.

The boundaries are shifting between the material world and the ideal.  The concrete world is dissolving into bits.  The very nature of reality is changing.  Human consciousness is becoming increasingly digitized, intermingled with mechanical functions, and operating in binary code.

Every culture has its own dynamics for determining the truth.  These social dynamics involve some level of armistice in the old materialism vs. idealism debate that has gone on for centuries with no clear winner.  A culture remains stable as long as it maintains an equilibrium between that which can be verified by the senses and that which lies beyond the senses but is none the less recognized as true.  That which exists is informed by that which does not.  Our waking life is informed by our dreams.  Our realities are continually shaped by what we imagine, even when our imaginations produce things that seem to come out of nowhere.  Our present, which contains approximate certainties, vanishes from instant to instant, and is sandwiched between a fleeting debatable past and an unformed future.  That which is real is infused with that which is not.

You might say that each of us is continually bombarded with concrete bricks, and the only way to make sense of the ordeal is to gather up the scattered bricks and build them into solid structures using a reliable mortar of fabrication.  Imagination, dreams and intuition might serve as this kind of mortar.  But the most common, flexible, adaptive, ubiquitous, abundant form of this mortar—the form most readily and cheaply available for multipurpose use— might just be pure unadulterated bullshit. These days you find it everywhere.  It is the Zeitgeist.  This is the Age of Bullshit.

How many of you think me guilty of cementing this essay with that kind of mortar? 

So, here’s something real in the objective, journalistic, honest and academic sense of the word.  I’m going to make this personal.  I spent most of my life immersed in the healthcare industry.  I was born into it, and not just in the sense I was born in a hospital.

My father was an eye surgeon who loved the practice of medicine.  He wanted to share what he perceived as its rich rewards with me.  My childhood was full of lessons about becoming a physician, with surgical instruments brought into the home as toys.  Lift a pea from a tiny bowl, he would tell me, and pretend it is a cataract.  A paintbrush in my hand while I experimented with watercolors was to be regarded as a scalpel making an incision. 

As soon as I was old enough to fully appreciate the implications, I began to fight it tooth and nail. 

In my early teens, I announced that I had found my true calling, and I proposed to dedicate myself to the creative arts, predominantly fiction and illustration, with the comic book industry as my main target.  My father reacted as if confronted with a surgical crisis in the operating room, something dire, on the order of an eye leaking vitreous, an example he frequently invoked to convey a sense of imminent disaster—vitreous being a type of humor, he would joke, that was no laughing matter.  And I would joke back that his joke was no laughing matter either, which he didn’t find funny at all.  He got very calm, very rational, recognizing that he was dealing with a fanatic. 

Eventually the two of us worked out a compromise, based on the premise that I would find a reasonable trade, one that would at least enable me to earn a living, without letting go of my artistic aspirations. 

“Do both,” my father said.

Do both.  It turned out to be good advice for me.  The ideal and the practical.  Fiction and reality.  Do both. 

My father and I both viewed the compromise as if it were a fiction, but we functioned as it were reality.  I fully expected my artistic career to blossom at some point.  He fully expected that I would outgrow my grandiose delusions once the demands of adulthood caught up to me.  He continued to urge me to go to medical school. 

I did the opposite.  I went to law school.  Not that I wanted to be a lawyer.  Law school was a hedge, a fallback position.  I pursued a career in the comic book industry the entire time, not really believing I’d have to actually practice law for a living.

Despite my best efforts, I ended up in medicine anyway.

At the age of 27, fresh out of law school, I was hired to establish a legal department for a community hospital in my hometown.  An in-house hospital lawyer was something of a novelty at the time; an arrangement not entirely unknown, but not as common as it is today.    

I already had a history with the hospital.  The first service I ever performed for that hospital was going from door to door, when I was six years old, collecting signatures on a petition for a voter referendum to build twin towers for patient care.  What better way to promote the referendum than through two cute little kids, my younger brother and I.  About three years later, those twin towers were complete, raising the hospital’s bed count from 100 to 680.  I grew up two blocks away, with those twin towers looming large in my bedroom window.

At age fifteen, I volunteered in the patient transportation department, jockeying wheelchairs and stretchers.  My father wanted me exposed to the reality of dealing with patients as soon as possible, part of his plan to turn me into a doctor.  By my senior in high school, the volunteer transportation escort position became a part-time job.  After starting college, I continued to work for the hospital during the summers, first as a nurse’s aide in the med/surg wards, the psychiatric unit, and the operating room, then as an emergency room Patient Relations Representative. 

By the time I had graduated from Law School, I took the inhouse legal position thinking it would be a short-term gig, simply a means of putting food on the table until my creative work paid off.  But my writing and my drawing never really found any sizable audience.  The fictional compromise I reached with my father then became a defining point of my life.

 

Even though neither my art nor my writing ever yielded enough money to live on, I never let go of them.

I turned into a prime example of how the organization made constructive use of diverse and opposing viewpoints.  I found myself, a failed comic book writer and artist who managed to eke out a law degree, trying to find a place in a deeply conservative organization.  When I first started, the administrative positions were held largely by men who had military backgrounds, and who carried the formality and rigors of military life into the workplace.  The organization never really strayed very far from that orientation.  Yet somehow, in this setting, I was able to make valuable contributions.  Maybe it was because I was already deeply immersed in the hospital’s corporate culture, listening to my father’s tales of the inner workings of the medical staff as I was growing up, then directly experiencing the workplace, starting in adolescence.  I had decent writing skills, though meant for other purposes.  And I had a wild, sometimes untamed creativity, which I used to offer the organization surprising solutions to some of their problems.  I got caught up in the service of an enterprise larger than myself. 

At the outset of my law career, dealing with only one hospital and no employed physicians, the organization’s operations were small enough so that I could be directly involved with all of its legal matters, including, (without limitation as they say in contracts) risk management, contracting, medical staff, tax, billing, human resources, privacy, and insurance.

Over the course of decades, the organization slowly grew.  It began to employ physicians.  It added facilities— more hospitals, a nursing home, a series of clinics.  By the time I retired, 37 years later, the organization that started with a modest community hospital had blossomed into the third largest public health system in America.

During my tenure, I saw this organization outperform all of its local competitors, regardless of their structure, whether for-profit, not for profit, or governmental. 

 I already set forth the proposition that the magic sauce was the organization’s corporate culture.  And I gave an example of the way you can’t conjure a corporate culture using the legal structure alone. 

So what kind of magic does it take to create the magic sauce? 

You can start with a dream, which implies magic, or a hypothesis to be tested, which implies science.  There’s a formula for the magic sauce, but it involves science as well as magic, which is to say, confronting and resolving contradiction and paradox.  It involves alchemy and chemistry, not unlike the warring disciplines of law and medicine.

Whatever the nature of a business organization, be it governmental or private, it has to confront the same turbulent cross currents of competing and conflicting demands, for the cornerstones of ideal practices are in a state of constant opposition with one another.  There’s an unrelenting tug between the prices charged to customers and the salaries paid to employees, between the costs of benefiting the community and the return of investment on the part of the owners.  The enterprise must keep its workers satisfied and loyal without their becoming complacent and unmotivated.  The enterprise has to weigh the value of individual contributions within the context of supporting the larger team effort.  It must maintain quality while remaining cost competitive.  It must maintain a healthy margin between the amount of money it pays out and the amount of money it brings in, whether we label the term profit or excess of revenue over expense.  The enterprise has to recognize the center of gravity shifts constantly, and emphasis on one or more the competing, contradictory values has to shift as well. Even the value of diversity of thought has to be balanced against a contradictory opposing force.  An organization—a culture– can’t diversify in a way that threatens cohesion.

A great corporate culture requires great leaders.  But it also requires teamwork so aligned, the team can act on its own.  Leaders are important.  And not.     

I worked with many gifted leaders.  But there are limits to what even the most exceptional of individuals can achieve, and greatness comes from the organization itself, collectively, being able to recognize what it takes to be a great leader, picking the right kind of leader—one who is aligned with the corporate culture— and then reaching an appropriate balance between the contributions of the leader and the contributions of the rest of the organization.

Over the years, I watched many of the leaders come and go, with praises being sung over way the organization flourished under the guidance of each one.  But much of that guidance owed as deep a debt to the way the organization nourished them and shaped them as the way they nourished and shaped the organization.  The best of them would acknowledge their debts to other team members every time anyone ever offered praise or bestowed yet another accolade.  That’s the hallmark of a great leader. 

Strangely, paradoxically, even the very notion of what is real and what isn’t, what is truth and what is fantasy, even these contradictions have to be balanced against one another.  The very notion of the fantasy ideal must continually test itself against what can actually be achieved in the turbulence of opposing forces in the real world.  That’s not unlike the basic scientific model of hypothesis and experimentation—but there’s a funny thing about cultures.  Collective beliefs and values alter behaviors and results.  You can’t avoid the paradoxes of science interacting with magic. 

It’s mystical.

   

Maintaining a balance of opposing forces goes to the very nature of life.  Think of the factors that continually harass every single cell in our own bodies.  Each cell must maintain a proper chemical balance of acid and base.   It must gain nutrition and expel waste in proper measures.  Each cell must maintain the proper temperature and salinity during energy use and recovery.  The pressure of contents within its fine membrane must approximate the pressure of its surroundings.  The activities of every cell must compliment the routines of surrounding tissues, remaining vital, and fecund, but not so fecund as to overwhelm the grander design and murder the host.  Life lies in that sweet spot where all of these competing and conflicting demands achieve a steady balance.

What you need is an organization that truly maintains a correct and appropriate balance between all of the contradictory and competing imperatives. 

I’m not claiming that it is easy to find, or create an appropriately balanced organization.  To the contrary, it is extraordinarily difficult.  It takes genius, inspiration, vision, objectivity, judgement, temperament, discipline, persistence, faith, principles and ideals, and exhaustive, exhausting labor.  It takes imagination.  And luck.  And it requires the continual maintenance of all the above.  The task doesn’t end.

The way to find balance is to look at the particular moment before you, and the task that needs to be done.  All of human experience is a mix of the material and the ideal, sifted and sorted in different proportions.  The right mixture in the correct proportions, depends on whatever task lies before us.  There’s another paradox.  What is true may not matter, but no matter what is true, we must do the right thing.  What we identify as “truths” are simply usable sets of information, collections of reduced materials, analogous to mathematical sets.  One can find an example of a very concrete and understandable truth in the set of even whole numbers between one and ten, but one has to ignore the imponderable vistas of infinity that lie between them.  The number Pi also represents a concrete and understandable truth, though it has an additional layer of complexity.

Even life itself, which we tend to regard in absolute terms—like a living cell with all its attributes in balance, both within and without; the great personal cosmic certainty—Life or Death.  Something is either alive, or not.  But in a hospital, one sees constant permutations and variations on these simple absolutes.  Life endures, sometimes miraculously, against all odds, or ends shockingly, abruptly, tragically.  You see it up close when you work in a hospital.  There are many permutations of what seems the most absolute of absolutes— life and death.  You see the questions played out in medical ethical and legal controversies, such as those involving brain death and termination of pregnancy.

Information comes at us in torrents, constantly, and there is only one way to make it useful.   One must have specific criteria for deciding what to select and what to delete.  Every intellectual discipline has its own criteria for sorting and filtering information.  Law, Medicine, Art, Science, Philosophy, Mathematics, Logic, Theology, History, and the like—each one works as a filter.  The results might differ radically, depending on which filter is used.  What might be scientifically true for medical purposes might be found to be false for legal purposes—it commonly happens in medical malpractice cases.  What might represent absolute truths to a theologian frequently violate principles of scientific method.  Works that are artistic triumphs might violate principles of math, logic, and common sense.  What we leave out is as important as what we leave in. 

So, the only usable information is necessarily incomplete, and necessarily false.  This isn’t a new concept, but one that doesn’t stay in the forefront of awareness because it tends to confuse, and it hampers our ability to make quick decisions—and it doesn’t matter what is actually true, as long as we do the right thing.  The Earth might not be the gravitational center of our solar system, but it needs to be treated as the celestial center of everything that matters to humanity.  The Earth might as well be as flat as the map of your state, for purposes of all your local healthcare needs.   

Consider a hypothetical American community that wants to build a hospital.  There are many options available. The community might try to recruit a private corporation to do the job. Or it might seek funds from the state.  Or the funds might come from a local government—a city or a county might build the hospital on its own for the benefit of its residents, using tax funds or revenue bonds. 

Public and private corporate models each offer their own potential advantages and their own potential risks for abuse and waste.  Self-interest is a great motivating force, but so is being part of an enterprise with the right goals and values that serves a larger community.  These two basic motivations tug against one another, sometimes under the labels of competition and cooperation, sometimes under the labels of capitalism and socialism. 

Under a governmental model, the entity might fall prey to the sins of crony capitalism, with elected or appointed officials depleting the organization’s resources by rewarding the people who made contributions to their political campaigns, with the rewards taking the form of fattened fees for services or goods.  Under a for-profit corporate model, the abuses may take the form of overcompensation to stockholders or executives. There’s no practical difference between a public organization undertaking the enterprise itself using tax dollars directly, and a private organization leaching off public subsidies, which could take the form of grants, or relocation incentives, or tax exemptions, or inflated contracts, or subsidized street improvements that only benefit the private organization, any of which eventually impacts the tax burdens for everyone else.  If the corporate culture is corrupt or inept, it won’t matter under what guise or label or ideology the money is being diverted from the goal of providing high quality services or the goal of providing appropriately benefits to the owners, the employees, and the community.  Greed abounds in both the private and public sectors.  As does incompetence.  As does excellence.  You can find For-Profit, Not-for-Profit, and Governmental providers all listed among the best providers in America.  And the worst.

The labels of socialistic, capitalistic, for-profit, not-for-profit, or governmental may not adequately describe how healthcare is delivered in America in any specific instance, for the various components may differ and intertwine, and can be assembled in a wide variety of configurations.  It is possible to link up the governmental and for-profit components, and lawyers play with these components like tinker toys.  There might be a for-profit hospital that contracts for indigent care with a government, like a city or a county.  Funding for certain aspects of care might come from a not-for-profit foundation.  A governmental provider might contract with a for profit corporation to provide management services, or specialized care.   Healthcare payors can be for profit, not for profit, or governmental, and almost all providers receive payments from all three varieties.  Physician services are almost exclusively provided by for-profit entities, and even when they are not, the level of compensation that physicians receive for their services is more likely to be determined by market forces than by the corporate nature of their employers.

It is tempting to offer up specifics of my own experience, 37 years as a hospital attorney, in much the same way.  I can’t fully do that.  I am bound by the confidentiality rules governing two secretive professions.  In the interest of full disclosure, I can’t hold up my former organization as a real-life role model because I know, all too well, of its many imperfections.  There were far too many failures, some profound and horrific, interspersed with its many successes.  In medicine, the smallest of mistakes can lead to the direst of consequences.  That was part of my job, really– to deal with the mistakes and the aftermath—the horrific and heartbreaking results when systems break down, when the organization failed to live up to its ideals.  It was part of my job to prevent the mistakes as well, to look at everything that was going on, and to anticipate disasters that might occur, but hadn’t.  It was my job to look at the way things actually are, while considering how they might be, and how they should be.  Finding the right balance between the real and the unreal. 

Is my former organization real?  Yeah, but in ways this essay doesn’t fully capture.  There is too much to tell.  Every truth contains the weaknesses of its omitted elements, an embedded contradiction, a shadow opposite, that is equally true.  All fiction contains elements of autobiography, and vice versa.  And the reader should maintain a healthy skepticism about the way I view my former employer, which I have taken care not to name because I’ve reduced it to an ideal, a shadow unreality.  I don’t have it in me to be fully objective.  The organization played an enormous role in my life.  From early childhood, those twin hospital towers dominated the view from my bedroom window.  That hospital shaped me and nurtured me, gave me a livelihood, was there when I was sick or injured, and when those I loved most were sick or injured.  It was the place where I met my wife, where my youngest brother was born, and my own children were born, where my grandmother, my father, and my mother died.  Don’t expect objectivity.

I said this was going to be personal   Purely personal.  The best I can offer here is unabashed subjectivity, which may be the highest kind of truth, since it cleaves to honest, personal perspective– irrefutable as a statement of opinion, but uncertain as to its usefulness outside of the context of one individual.  Another blend of the real and the unreal.  What happens when the glare of the spotlight penetrates into the darkest and most secluded of realms?  The inner workings of the mind, full of light, and shadow.

So, the hospital where I used to work might not been quite so ideal as I previously claimed.  Was it real?  Does it even matter?  It yet might be real.

I get weary of the debates over how America should deal with its intractable healthcare problem.  People need to get real.  But reality is actually changing. 

Effectively, what I have done so far – in general terms– is to allude to a model for an effective corporate culture, holding up my credentials of decades of experience with a highly successful, prestigious organization with a verifiable track record, while disclaiming the reliability of any of my claims.  It seems I am trying to have it both ways, with an essay that puts on the respectable airs of non-fiction, while indulging in the flamboyance of a fantasist, spouting idealistic sounding banter.

.  You might insist that I can’t have it both ways.  But that is the part of the point I was trying to make.