In one of the most profound lectures that I have heard in my life, Dr. Eric Cassell, New York City internist and author, discussed at a Harvard conference on hospice the “Nature of Healing.” His concept regarding spirituality moved me. He said, “Function reaches from the cellular to the spiritual. Something is spiritual when it transcends the individual. Relationships are spiritual. Religion is spiritual. Spirituality is a human function.” As a family physician, I fully subscribe to this spiritual aspect of my relationship with my patients.

Dr. Cassell further discussed the role of the physician by quoting Dr. Donald Boudreau of McGill University’s Centre for Medical Education, who said, “All the therapeutic interventions of physicians are exercises in healing. There are some impairments of function where the technologies of medicine are most appropriate and some where the skill of healing is best employed; virtually always, however, both are in play, and proper balance is the issue,” which Dr. Cassell then further described by saying in part, “healing is personal” and “healing is individual.” As I have I said in previous blog posts, I strongly believe in the concept of patient-centered medical homes, which fits this description of a physician as a healer. Treating a strep-throat infection probably does not require this type of individual, personal care (although if the visit prompts an annual exam, mammogram, or preventative colonoscopy, then even this visit may be made better within the context of a medical home); but I guarantee you that, in the areas of mental health, chronic disease, and most importantly palliative care, having a continuous relationship that allows for individual, personal care can make all the difference in the world.

This is further true when viewed in the context of family dynamics. A quick example: The day I wrote this blog post, I saw a 40-some-year-old woman and her 15- and 17-year-old daughters, both of whom I had delivered. In every one of these clinical visits, the family situation played a role in my evaluation and treatment of their various medical conditions.

I reference Dr. Cassell’s lecture to illustrate my views regarding not only the proper way to be a family physician but also as the way health reform should proceed in order to promote quality and cost efficiency. (See previous blog posts for documentation.)

In contrast, I share a quotation from Adam Zamoyski’s book, Rites of Peace. This book details the 1814 Congress of Vienna that divided up Europe after Napoleon’s exile. The victors — Britain, Austria, Prussia, and Russia — gathered for about nine months. The resultant negotiating, bargaining, and horse-trading led to this analysis: “One thing that had offended many …  was the way in which ‘souls’ were counted, bundled into units and traded across the negotiating table like cattle. This was widely regarded as ‘a violation of the dignity of man and of the rights of nations’ … .”

À la the Congress of Vienna, I fear the current division of the state of Iowa by entities such as the Mercy and UnityPoint hospital systems, with their respective accountable-care organizations (ACOs). This approach is currently being promoted by payers such as Medicare, private insurers such as Wellmark, and ultimately Medicaid. I say this due to my current experience with these ACOs and these payers, which does not show to me an emphasis on treating patients as individuals. If these ACOs use the tenets of patient-centered medical homes, then I believe in the ACO concept. If not, I agree with this Dominique Dufour de Pradt quotation from Zamoyski’s book: “The Congress of Vienna has demonstrated that it is easier to be awarded souls than to conquer hearts, yet the former are worth little without the latter.”

At a very personal, individual, and dare I say spiritual level, patients in this new health-reform world need physician relationships that provide quality and efficient health care. I believe patient-centered medical homes provide this care; ACOs will have to convince me that they, too, can provide this type of care. Without quality and efficient health care, health reform will fail.