This posting continues the story started HERE and continued HERE. This third installment of my investigation of Managementism, the profoundly popular theology influencing everything from food production to health care, looks at one example of one practitioner who choose to step "Off The Grid."

In the last installment, I introduced a doctor, Bob Ironside, who, dissatisfied with the management of the health care system he was a part of, took personal agency to make his part work much better. I was sitting in an extremely comfortable room—I would not call it a waiting room, because it was clearly not designed for any activity as wasteful as waiting—for a chat with Bob about his life off the grid.

...I spent the few minutes after the receptionist left checking out the room. My chair was extremely comfortable. Three other matched chairs were, like mine, set around a large, low table, which held a bouquet of fresh flowers. Just behind me, on a sideboard, a Bose Wave Radio softly bled classical music. The windows to my right overlooked the mansions and forest just above NW Portland. I sipped my water, wondering where this conversation would start. And where it might lead.

Bob quietly opened the sliding panel and slipped into the room. I stood, and we shook hands like old friends before settling back into those comfortable chairs. I asked, "Bob, why don't I feel like a cow in a cattle car waiting for the conductor to call my stop?"

He explained that people don't open up when you treat them like cattle. He'd designed this clinic to not feel very much like a clinic because the traditional design shuts people down, and he needs people to speak freely there.

He went on to explain how his clinic works. "If Tim Russert had been our client, I'm convinced that he wouldn't be dead," he asserted. Bob's clients do not suffer catastrophic illness. Sure, they get sick, but in every case, he's seen the trouble coming and caught it in the earliest, most treatable stages. He helped one client, an ex-Olympic athlete, avoid a heart attack by carefully listening to his family's health history. Though he was in excellent health and showed no symptoms of heart disease, he ordered a battery of tests which showed that he did, indeed have heart disease, which he's treating before it became a catastrophe.

He shared several examples of clients who came to him dissatisfied with the diagnoses (and mis-diagnoses) they'd received (or not received) from their harried managed care physicians. Bob's great skill, I knew from my earlier relationship with him, was his exceptional ability to create rapport and really get to know his clients. He gets to know their story and can weave the intricate threads together. Perhaps just as importantly, his clients get to know Bob's story, too. He discloses a lot of his personal stuff as a part of his work.

This, it seems to me, is one hallmark of the self-manager. They do not aspire to an emotionally or intellectually or politically-neutral professional presence, but a disarmingly personal one. He is a very skilled and deeply respected practitioner, but he doesn't present himself as a Mr. Know-It-All. Instead, he creates a sense of joint inquiry, fueled by deep personal interest and, as I already knew but was about to learn even more profoundly, an uncommon advocacy.

His practice is now all about advocacy. When he refers a client to a specialist, he visits the specialist WITH them. He doesn't second-guess or upstage the specialist, and rarely says a word during these visits. If the client has questions, he lets the specialist answer unless explicitly invited into the conversation. Too many times, Bob noted, clients have questions after a specialist visit or don't understand that they don't fully understand what the specialist tells them. Bob forwards extensive patient history to each specialist beforehand, but admitted that specialists do not always make time to review them before the client arrives. Having been there, Bob can help position the puzzle pieces so the whole portrait makes sense to his clients, their specialists, and himself, too, making for much better-informed choices.

I was astounded! I wondered how he could possibly schedule those visits. (He also visits any client who's hospitalized.) Bob explained that client load has a lot to do with disabling a doctor's ability to fully advocate. Under managed care, he needed to carry a client load of about 3000 to make the numbers work, and even then, the numbers didn't work very well. Fully three-quarters of his staff then worked on billing and collections, and his performance was hampered by the normal intrigues that come with any large staff. Now he has a client load of about a hundred.

Incredulous again, I wondered, "So, you can do more with less, but what about the bottom line."

"It's much healthier than it ever was before," he smiled."

How does this work? People subscribe to Bob's service, paying an annual flat fee in advance. In exchange, Bob provides exceptional internist attention and health care advocacy. One of his clients, the Board Chair of a local hospital, was dissatisfied with the specialist Bob had referred him to at that hospital. "He was brusk, and 'all-knowing,' and we didn't feel like he'd delved deeply enough before diagnosing. So, I looked nation-wide, and ended up referring him to a colleague at the Mayo Clinic in Minnesota, who found a potentially life-threatening condition before it could threaten. Did Bob accompany his client there, too? You betcha!

This is an admittedly small-scale operation, but it's getting noticed by the HMOs. Bob's clients are healthy because they proactively attend to their health, rather than retroactively respond to often avoidable illness. The reimbursement for treating a single modest health crisis could pay for a lot of pro-active advocacy. Bob's practice doesn't replace the need for personal insurance coverage, but it quite effectively reduces the need to resort to it in crisis.

I asked Bob if he'd become a pariah in the local medical community, and he recounted a conversation with a local cardiologist at a recent meeting. "You're the envy of everyone practicing medicine in this town," his colleague confided. To those who might criticize Bob for taking an admittedly top-tier clientele, he responds that he's always treated the indigent and still does. Some of his clients pay noithing. Under the 'put on your own oxygen mask first' principle, Bob claims to be much more interested in volunteering his time now that he has time to volunteer. And now that his practice is supporting him well, rather than struggling to make ends meet. What was once mostly obligation has become a welcomed and more frequently engaged in opportunity.

I'm afraid that this posting has grown much larger than I intended, so I'll sign off here. There's more story to come. To be continued. ... ...