From The Editor

Lately, I have been thinking about some of the observations that Alexis de Tocqueville made in the mid-1800s regarding the still very young experiment in democracy known as the United States of America. A French diplomat, political scientist, and historian who traveled widely in the U.S. and Europe, Tocqueville’s keen observations of people and governments were published in several books, but he’s best known for Democracy in America, the first volume of which published in 1835. Tocqueville wrote about the New World and the new democratic order that was transforming American life. He was trying to understand why the U.S. was so different from Europe, which was experiencing upheaval as it cast off its aristocracy. He was fascinated by the way that, in American society, hard work and money-making were the dominant ethics and the “common man” enjoyed a level of dignity that was unprecedented anywhere else in the world. Commoners never deferred to elites in America. Individualism and market capitalism had taken root as the dominant ethic, a situation completely different from Europe, where a hereditary upper class maintained a sense of entitlement. Tocqueville saw that, in a democratic country where there was no hereditary wealth, every man must work to earn a living, and therefore labor was held in honor. These observations were entirely new ideas to the people of France, and it helped them understand the nature of the democratic world they were creating as they cast off their Old World aristocracy after a messy revolution. Tocqueville’s observations about our country have an eerie prophetic quality, in large part because he understood human nature. He observed that, “There is no country in the world in which everything can be provided for by laws, or in which political institutions can prove a substitute for common sense and public morality.” It was he who said that society was not endangered “by the great profligacy of a few, but by laxity of morals among all.” I think Tocqueville would have correctly predicted the outcome of the most recent presidential election. We live in a country that despises elitism and entitlement while valuing hard work and the free market since the Mayflower let down her anchor. And that takes me to the topic of healthcare reform. Our healthcare system is a business. We’ve advanced the frontiers of medical science and built the greatest medical institutions in the world. However, we have a problem, perhaps not with the “great profligacy of a few,” but more by the “laxity of morals amongst all.” It’s estimated that 30% of Medicare billing is inappropriate. We are not parsimonious with our resources. We don’t provide care to our patients as if we were spending our own money on them. It’s starting to bring down the entire healthcare system. As a result, the government is left with no option other than to try to handle the excess spending with increasingly draconian laws. Unfortunately, these are not a substitute for common sense and the public morality of providers. Medicare’s instruments are blunt. The Centers for Medicare & Medicaid Services’ method of rationing can hurt patients. However, every time we overtreat or overutilize, or do the opposite by failing to provide the standard of care, we are part of the problem. If we don’t police ourselves, we will end up with even more draconian rules attempting to impose standards on our behavior.

There are alternatives, however. We can decide to engage in transparent quality reporting. We can have national benchmarking. We can commit to “honest outcomes reporting.” Does anyone want to sign a pledge for that? No more fantasy healing rates? We can decide to be clinicians who “Do The Right Thing” with registry reporting. There is enormous pressure to keep the economic engine running at full throttle, but it’s a short-term strategy that is doomed to fail. As a result, doing the “right thing” takes tremendous courage. But, as Tocqueville once said, “Life is to be entered upon with courage.” Let’s courageously change the field of wound care.