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Your Life Your Health - Citadel - A 1937 Introduction to the Spirit of Patient-Centered Medical Home
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James L. Holly,M.D.
September 26, 2013
Your Life Your Health - The Examiner

There is nothing new under the sun, we are told; and, new models of healthcare reinforce the truth of that statement.   As we discussed in 2011, the concept of medical home was demonstrated in the 1951 movie, People Will Talk (see  And now, we come to an older movie which addresses the issue of professionalism and entrepreneurism.  In the 1937 movie, Citadel, we see concierge and subscription models of care illustrated as a doctor abandons his passion for medicine for a commitment to wealth.  One summary describes the doctor as being “seduced by the thought of easy money from wealthy clients, rather than the principles he started out with.  (He) becomes involved with pampered private patients and fashionable surgeons.”  

The doctor’s pilgrimage has three stages. The first occurs when he miraculously saves the life of a new-born baby.  Leaving the family home with a live and healthy mother and baby, he exclaims to himself, “Thank God that I am a doctor.”  He labors to help the poor and to do clinical research to improve the care of those he treats.  His wife is content and happy even though his wages are meager.  They live and prosper on their passion not upon their possessions.

After moving to the city, the young doctor is influence by affluent physicians who refer him patients who pay handsomely for unneeded attention from a medical doctor.  At first he is shocked at the amount of money which can be made in this turnstile referral system which maximizes reimbursement.  Then he enjoys the clothes, the home, the cars and all the other things he can buy. But, his wife laments his loss of passion for medicine even though she has many “things.” 

Rich, our young doctor is now insensitive to innovative efforts to improve healthcare, brought to him by his friend, many of which innovative opportunities would require him to contribute his own funds to the new efforts.  His friend’s vision was rejected.  Ultimately, the friend was injured in an accident caused by our young doctor’s callousness.  His friend dies because, while the elegantly dressed specialist has made him wealthy, he incompetently causes the death of the friend at surgery.  It is then that our doctor looks around him and sees the suffering and the need and his heart is soften and he returns to his roots. 

The Moral Test

At the heart of patient-centered medical home is The Moral Test of a government; Hubert H. Humphrey said:  “The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.”  This same test can be applied to healthcare organizations and to health care providers. 

In SETMA’s September, 2013 Provider training, we watched small parts of Citadel and each SETMA provider was give a copy of the DVD.  The snippet from the first stage of the doctor’s career shows him  thanking God that he a physician; the second shows his declaration that he has the right to make money; the last shows recovery of his professional soul as he begins to see the suffering around him.  As they played in our meeting, there was a hush over the room.  The gripping heartache, as our young physician sees the suffering around him and as he realizes that he in part was responsible for the death of his friend, caused us all to be silent.

Patient-centered medical home does have a structure and the final steps to being a medical home includes effective structure, the heart and soul of PC-MH is a dynamic born of a passion and a commitment to caring for others and particularly for those who cannot afford the care they need.

Medical Home - Caring for those for whom we Care

As this article is being prepared, I received this note from one of SETMA’s healthcare providers.  He said:

 “I wish we could take money out of healthcare.  I know we can’t and that’s the way the world is now but it just tarnishes something that is so great.  I wish the movie would have continued.  If he lost his medical license for saving that girl’s life then I would say it was well worth it and I would hope I could do the same if I had to.  I have to provide for my son and have to base all my decisions off of how it will affect him.  There are times I wish I could just do like he did when he first became a doctor.  Life was simple, he knew everyone in a small town, when they needed him he was there, they appreciated him and he received great satisfaction from helping people.  No HIPAA, regulations, corporate greed, ungrateful patients, just helping people.  No documentation (laugh out loud) just treated them and sent them on their way.  I am sad that life will never be that way again but like the voice at the end said, “we must press on.”  It’s what God called us to do.  I hope I make you proud by the way I treat my patients and if I ever don’t you can slap me twice like he did the rich girl(smile).” 

My response to his note:

“Well said; our task now is to revolutionize the modern practice of health care (“care” is used as a noun) so that we have the time and the energy to care (“care” is used as a verb) for others.  We do not address healthcare, but caring as we “feel concern, or interest in others and as we; attach importance to others.” 

We must return a degree of objective so that our “feeling,” caring” and ”interest in others” does not disable us, but we also must share empathy and compassion with and for others such that to a degree our wellbeing is dependent upon their wellbeing.   Caring brings joy and pain; it is impossible to eliminate either from the patient-centered medical home.

None of us are asked to take a “vow of poverty,” and there is nothing inherently evil about profit.  It is however the case that because we are called to the profession of healthcare delivery, we must make sure that we never put aside the interest of the individual or the group and that as Mayo Clinic declares, “When confronted with a problem always do what is best for the patient.”  It is their choice but several May Clinics have stopped seeing Medicare patients.  Therefore, I would add here that we must never lose fact of SETMA’s motto, “Healthcare Where Your Health is our Only Care.”

SETMA’s partners are fulfilling this motto and are balancing their interests and the patients’ interests by maintaining the SETMA Foundation and by giving $500,000 a year to the Foundation.   We are further encouraged that SETMA is progressing in pursuit of the true dynamic of PC-MH  as one healthcare executive recently said of SETMA:

“Your work in costing out the implementation of these measures is very unusual and creates a logical interface between NQF and CMS/CMMI. With the strong emphasis on moving to value-based purchasing, you may be one of the few places they can get a grip on what the costs and savings could be. Your philosophy, outlined below, is also very important to doing this right. I really do hope we can make that more visible and create a conversation with SETMA as the seed.”

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