Elección de lengua en relación con el interlocutor

It is the best of times and the worst of times to be a health care professional. The opportunities to be a healer are growing. The opportunity to provide consumer-friendly services that optimize health gains is growing. The definition of health is likely to broaden to include community as well as individual health, opening up new avenues for contribution. Yet cost pressures are making it difficult, especially for allopathic

physicians, to provide as much personal contact as their patients want. For

chiropractors, meanwhile, demand is growing in most regionsbut perhaps not quickly enough to keep up with the looming oversupply of practitioners. And will the economics of health care allow chiropractors to retain the high level of integrity most have brought to their practice?

We will explore these prospects in more detail in Chapter 4. However, given the forecasts for expert systems and other tools, and the pressures of managed care for better cost-effectiveness, it is safe to say that some health professionals will likely be replaced by less-expensive providers. For example, 60-70% of primary care contacts can be handled more cost-effectively by a nurse or nurse practitioner than by a physician. In the years ahead, expert systems will let nurses or nurse practitioners handle an even greater percentage of primary care visits, as well as provide some services now performed by specialists.43 _{In this setting, many physicians will need to}

continually reinvent their “value-added” role.

It takes vision and courage to imagine and to create enhanced roles. It also takes vision and a strong identity for a professional to be able to accept as appropriate the

displacement of some of his or her functions by a less-trained person or a computer. There were probably many bank tellers whose employers could not discover new “value-added” roles for them when ATMs pervaded America. Many lost their jobs or

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suffered from depression. Today many physicians are similarly depressed about the environment they find themselves in. Physicians are taking disability in higher numbers than ever before, arguably because of lower levels of satisfaction with their jobs.44

Physicians need to explore their opportunities to provide value in relation to their personal visions.

Chiropractors will face parallel challenges. Generally those who choose to become chiropractors were committed strongly enough to the chiropractic approach to healing that they could face the attendant difficulties. It will be even more important for chiropractors to have a clear and strong vision for their role in the larger health care system.

Vision is an important personal and organizational tool that establishes both personal and organizational identity. Vision is a shared commitment to creating a preferred future. Vision is also a powerful way to identify one’s value-added contribution, and it gives the owners of the vision the courage to let go of roles that are no longer defensible.

Vision has been used in many industries to determine where the contribution of an organization or the field should head. Vision is both a skill and a shared commitment. Table 3-4 identifies trends in value-added visions across sectors as diverse as major local newspapers, quality consulting, health care and military medicine. Table 3-4 is drawn from IAF’s work in these fields and reveals consistent patterns of adding value. The implications are that health care will increasingly pursue larger outcomes— ultimately, syndrome prevention, health design and social values such as equity.

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Table 3-4: Trends in Value Added

Wisdom, Co-Creation, Vision:

Trends in Value Added/Visionary Directions

Value-

Added Journalism Corporate Activities Messaging Electronic Consulting Quality Health Care Medicine Military

Civic journalism

Visioning, co-creation

Wisdom Vision Syndrome prevention, design, equity Anti-war, health/ sustainability Providing what is significant Knowledge Community health Community health Providing what is news Community services, collaboration Information Strategies Disease prevention Personal prevention, fitness Accurate facts Profits, efficiency operations Data Operations Disease treatment Disease and combat casualty treatment Source: IAF, 1997

In terms of marketplace challenges for chiropractors, the situation is likely to be riskiest where core aspects of their work are amenable to incorporation into an expert system (e.g., some of the diagnostics). Where touch is necessary, as in manipulation, expert systems will be less of a threat.

The point is that each health care professional needs to have a strong vision, a "North Star," so to speak, to serve as guidance. Each health profession needs to do the same. Professional groups could inadvertently turn their guns on themselves by neglecting to forge a shared set of goals. Health professional groups that become self-serving (as, many would argue, the American Medical Association did in the past in the name of “protecting” physicians) can fail to rouse their members to threats oreven more importantto opportunities for enhanced service and moving up the value-added ladder. In either case, in the absence of strong shared vision the organization leaves its members more vulnerable to becoming “victims” of their circumstances and

environment.

As chiropractic develops and pursues a shared vision, its practitioners should start by studying the influential health care visions already on the table: WHO’s Health For All; visions for US health care like the Belmont Vision Project; and the localized visions developed by communities and health care providers around the United States. From

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visions like these, they can both draw inspiration and creatively explore the value added the profession can provide.45

MANAGED CARE