— BOOK AND MEDIA REVIEWS —

The Long Fix

Daniel Jason Frasca, DO

Fam Med. 2022;54(4):311-312.

DOI: 10.22454/FamMed.2022.112208

Book Title: The Long Fix

Author: Vivian S. Lee, MD

Publication Information: New York, W.W. Norton & Company, 2020, 302 pp., $17.88 hardback, $14.95 paperback

 

“The maddening paradox. By a few measures, the US health care system is one of the best in the world and, by some measures, it is one of the worst.” (p. 6)

Such a compelling quote demonstrates the bottom-line message of this motivational, call-to-action book about the state of US health care. The Long Fix is a constructive read, distilling the challenges and frustrations of the system to distinct, actionable steps, with specific guidance for physicians, patients, administrators, health insurers, and policy makers throughout. It is a refreshing read written by a clinician-turned-hospital CEO, describing her experience as health care has evolved. She motivates the reader to improve costs, quality of care, and efficiency of the medical system, and by extension, improve the overall health of the nation and its constituents.

The author, Dr Vivian Lee, presents her personal journey, sharing her calling to medicine, and instantly connecting with readers. She shares her introduction to medicine with “Dr B,” an internal medicine physician she met as a young community leader who shared the seemingly magical art of patient care. She fast-forwards through her residency and fellowship training until she becomes an MRI fellowship-trained radiologist. She discusses the changes over those years, from her introduction in her teens, through her journey to become board certified and in practice.

After laying the groundwork, Dr Lee dives into detailed discussions of the tug of war between hospitals and physicians with pay-for-action models, opposed by insurance companies who limit payments to increase profits. She demonstrates the demands placed on physicians and patients, such as the average primary care provider manager being empaneled with over 2,000 patients (p. 20), and an average of 86 minutes daily outside patient care to catch up on documentation (p. 142). She reflects the overall concern of quantity versus quality, advising a shift to pay for results, instead of actions. She gives specific examples such as how the University of Utah has implemented the “Exceptional Patient Experience,” centering on patient satisfaction. Within several years of starting, one-quarter of University of Utah physicians were within the top 10% of national patient satisfaction (p. 103).

Dr Lee demonstrates extensive research, sharing mind-boggling, hard-to-digest data for readers regarding the irony and waste our medical system creates. Examples include health care wasting 30 cents for every dollar spent, 20% of all medical care being deemed unnecessary upon review, 8% of spending solely on bureaucratic entities, and American hospitals spending more on administration than nurses. She compares this to less wasteful models, such as the military health system and the veteran health system, as well as international examples such as Britain, Sweden, and Australia, reflecting the intricacies, benefits on access, and ultimately patient care.

“Every one of us has a role in the Long Fix—we are all soldiers in the war against disease.” (p. 203).

This book should motivate readers of all backgrounds to work toward reforming the current modus operandi, focusing on standardization, coproducing with the patients and their families, and focusing on individualized goals. Dr Lee gives concrete examples of ways to refocus on preventive medicine, rather centering on lifestyle management over disease management. Examples include effectively using the electronic medical record as a “health plan” to remind of pertinent health maintenance, improving integration of mental health into primary care more (with the understanding chronic conditions would secondarily be better managed), and “coproducing” with the patient, teaming together toward shared goals (p. 198, p. 202).

The book’s intended audience is broad, with small subsections throughout the book targeting specific groups of readers including physicians, health care workers, health care administrators, health care policy makers, insurance companies, employers, employees, and health care consumers. This book does not specifically target the specialty of family medicine, however, it speaks to the many tenets of family medicine, including prevention, the significance of primary care, and connecting with patients toward individualized, longitudinal care.

I consider this a refreshing read describing the bottom-line issues the health care system faces, with direct, practical guidance for the future. The references the author uses are relevant and up to date, and she has clearly researched the data well. The price for this book seems appropriate and manageable. This is not a relaxing vacation read for those considering it. However, for potential readers looking to better understand the challenges of health care and ways to improve moving forward, it is worth the cost of purchase, and a productive investment of time to read.

Lead Author

Daniel Jason Frasca, DO

Affiliations: Grovetown, GA

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