As anyone who has spent time looking at different types of providers and integrating them into a common system knows, each health care profession has its own culture. The word “culture” stems from the Latin culturare, ‘to tend, cultivate.’ It is a way of acknowledging, appreciating, respecting–or changing–the ‘customs, arts…institutions and achievements of a particular…people or social group.” It’s also a type of container within which a profession can manage its own growth and maturation. Does this matter in health care? It may be more important in the new health care marketplace than we first think.How is professional culture created? In a variety of ways. Culture can be engineered: the American medical system as we know it was a very intentional construct that grew out of problems identified in Abraham Flexner’s 1910 report. Culture can grow organically: chiropractic’s rough-and-tumble start, early philosophical schism and partial attempts to emulate aspects of medicine’s educational culture have produced an often wildly-divergent set of professional norms and morés–and cohesion remains elusive.
Culture can be co-opted and revised by dominant hosts: osteopathy’s assimilation into medicine through political blunt force is a prime example. Culture can be co-opted and subsumed through grace: nursing’s alignment with medicine has sought to preserve the original principled independence of its founders with the value of patient service as physician extenders. And culture can be designed: naturopathy very intentionally sought to establish its culture and accredited education through careful selection of elements of its historical ‘alt-medicine’ origins and variants of selected allopathic medical strengths. Starting while the profession was fairly small, it has been able to create a unique niche role.
Once created, what does a professional culture confer, make possible, or prevent?
If culture is thoughtfully managed, it can confer important, shared values and experiences that can serve as a basis for maturation and growth. Dentistry very intentionally sought to change itself, managed its culture with perhaps thorough controls and design, and as a result enjoys a degree of coherence, unchallenged social acceptance and business success few can match. If culture is not managed or incompletely managed (as with chiropractic), it can result in public confusion and internal discord. Used as a kind of container for growth, defining a professional culture offers a metric to use as a way of ensuring coherence and continuity. And if culture is disparaged or only partly revered, those who do not share the value of developing and maturing can prevent its growth–and a profession’s success.
Integrative health care efforts have sought to solve existential and developmental challenges in three areas. The first has been cultural authority; with allopathic medicine’s dominance, other professional cultures have had to fight to establish and defend their self-described basis for clinical authority and autonomy. The second has been economic: in a fee-for-service model efforts to calibrate clinical time, outcomes and compensation in an overall understanding of value have been limited by the often-misleading paradigm of symptom-based care. And the third has been education: presumed efficiencies in the delivery of professional education by sharing curricula and training have been difficult to achieve given profession-specific national accreditation limits. Many have tried to avoid codifying the siloing of providers; having to settle and adapt for profession-specific education has often been viewed as a shortcoming. What we may have missed is the opportunity to create greater distinction and esteem for profession-specific cultures and to explore and understand potential benefits.
Considering this from the ‘supply side’ is one thing. Viewed from the perspective of the marketplace, a different set of questions may need to be asked: what matters to consumers?
With health care moving inexorably toward a retail model (increasing consumer independence, purchasing authority, financial responsibility, market-side innovation, evaporating network constraints, defined benefits, etc.), does a profession’s culture have value? Is it more or less important to emphasize and clarify distinction or commonality? Does it matter if a MD, a DC, ND or a LAc drops a needle on LI4? Providers are going to have their opinions. What does a consumer think?
The short answer is, we don’t know; no one I’m aware of has formally asked the question.
And the context for the question matters a lot, because unless something drastically changes, the opportunity for integration into mainstream delivery systems is only likely to benefit a portion of each provider population. For a number of reasons, system-side solutions to the clinical need for integration that assimilate these professions are only going to absorb a limited number of people.
Demand-side solutions are potentially very different. We don’t know yet whether or not consumers in whole or in part are going to favor an acupuncturist who is part of a delivery system (e.g., offering palliative care in a cancer program) or an independent practitioner who is free to operate within the full extent of their clinical paradigm and autonomy.
From a retail dynamic standpoint, it’s likely that the answer will be ‘both, under certain conditions.’ That is probably going to be the asterisk for any single clinical option or provider-specific solution in retail health care.
If that’s true, the degree to which schools and systems care about supporting, developing, rewarding–or revising–professional cultures will have effect on their graduates, and by extension, graduates’ professions. Ultimately, those choices will be vetted by the marketplace–likely with winners and losers. We just don’t know yet.
What I submit should be remembered as these questions are considered is consumers’ preference for brands. ‘Brands’ aren’t what the person, product or business wants to be known for, they are what their users or consumers know them as. So chiropractic as a brand in consumers’ minds has certain qualities; will those qualities change–for better or worse–if doctors of chiropractic are integrated into a delivery system? And what are the implications for those who are practicing outside the system? Consumers segment themselves in the retail world, normally with a degree of congruence in the products and services they seek out from a pricing and value perspective. Should we expect health care to be any different?
It’s hard to imagine consumers separating cultural denominators from providers’ brands. And in a marketplace where more and more ‘consumption decisions’ are being made independently because consumers are paying largely out of pocket for elective services, it’s hard to imagine that the emotional component of those decisions won’t depend largely on brand awareness. So if this vision of the future holds up, it may be important that health care professions begin reconsidering the importance of more careful examination and stewardship of culture. It may make a critical difference in professions’ viability in a few short years.