The next battles of the sick care revolutions have started. Battle lines are drawn. Forces are gathering. Militias are recruiting foot soldiers. But, like all revolutions, the attack on the perceived injustices of US Sickcare, Inc, could fade with a whimper or create real change for the better. Permutations of M4A (Medicare for All) are now part of the political conversation, not just a quirky idea.

Then, there is the battle to win the sick care part of the 4th industrial revolution with all its ferocious impact.

A third revolution sees doctors trying to gain their independence from BIG MEDICINE

According to one author, the result of the next phase of the sick care revolution will depend on four things.

Successful movements do things that failed ones don’t. Namely, they create clarity of purpose, forge shared values, plan effectively, and connect to the mainstream.

Clarity of purpose. One such outcome is the Triple Aim of improved outcomes, reduced per capita costs and a better user experience. Throw in making the doctor experience better and you have the Quadruple Aim.The purpose of healthcare reform is to optimize scarce resources while solving the Rubick’s Cube of quality, cost and access. Some feel that the goal is not achievable, and that you only get, at best, 2/3. Others claim that the purpose of reform is to make care more affordable, patient driven and transparent and that will improve access and qualiity. Simply shifting the costs to patients with high deductable plans is not successful.

Forge shared values. The multiple healthcare sytems around the world are, in large part, a reflection of the values of the society. American values include personal freedom, independence, equity, fairness, a suspicion of centralized government, personal responsibility and a meritocracy that rewards individual initiative. Of course, there are many examples of trends and actions that don’t reflect those values. Fundamentally, however, the basic ethical precepts of medicine have not changed over many centuries and include :

• Autonomy: People have the right to control what happens to their bodies. This principle simply means that an informed, competent adult patient can refuse or accept treatments, drugs, and surgeries according to their wishes. People have the right to control what happens to their bodies because they are free and rational. And these decisions must be respected by everyone, even if those decisions aren’t in the best interest of the patient.
• Beneficence: All healthcare providers must strive to improve their patient’s health, to do the most good for the patient in every situation. But what is good for one patient may not be good for another, so each situation should be considered individually. And other values that might conflict with beneficence may need to be considered.
• Nonmaleficence: “First, do no harm” is the bedrock of medical ethics. In every situation, healthcare providers should avoid causing harm to their patients. You should also be aware of the doctrine of double effect, where a treatment intended for good unintentionally causes harm. This doctrine helps you make difficult decisions about whether actions with double effects can be undertaken.
• Justice: The fourth principle demands that you should try to be as fair as possible when offering treatments to patients and allocating scarce medical resources. You should be able to justify your actions in every situation.

Plan effectively.  Each special interest has a plan. Some have more money, power and influence, but, as history has shown many times, that is not the deciding factor. While, as we all know, no battle plan survives the first shot, successful revolutionaries have well thought out strategies and tactics to achieve their objectives. They use infomation, logistics, media, recruitment tools and the charisma of their leaders to achieve success.

Connect to the mainstream. No revolution lasts without winning the hearts and minds of the mainstream. Fringes don’t last and often create counter-revolutions. Most importantly, change does not happen from inside. It must come from and be sustained from outside and be engrafted into the new culture to prevent relapses.

US sick care is a system of systems. In addition, each system is composed of various subgroups vying for influence. They include doctors, non-doctors, payers, health service organizations, patients,policy makers and regulators to name a few.

Doctors are part of the “fed ups” and want to #takebackmedicine.

Americans have a core suspicion, resentment and hostility towards institutionalized central power. The Founding Fathers, however, also understood the impact of the tyranny of the majority and our Constitution is a testament to compromise, including why we have an electoral college instead a a direct popular vote, something, for the fifth time in presidential election politics, has been in the headlines.

It seems we have some work to do as revolutionaries. Our purpose is not clear and convincing. Our actions are not reflective of our core values. Plans are at cross purposes. The 99% feel disenfranchised. In addition, doctors are badly underfunded, outgunned and out-manned in the halls of Congress. Previous allies, like patients, are suspicious of self-serving motives.

Once again, pundits are identifying trends that portend, seriously, a sick care revolution. No , I mean it this time. However, there are always headwinds:

1. Patients are lousy consumers of sick care resources and don’t do a good job preventing illness. Did you get your flu shot? How about that new and improved shingles shots that Medicare refuses to pay for?
2. Sick care players have gone from taking care of patients using data to data companies that happen to take care of patients.
3. Price transparency will be vehemently resisted by vested interests who want to see the sick care spend , now at $3.5 trillion,increase, not decrease
4. Doctors and nurses won’t sit idly by as they are increasingly disintermediated by technology, investors and managers
5. Consolidation will erode both the doctor and patient experience and make innovation harder. Have you called Amedzon customer service lately?
6. Data might be the new oil, but OPEC is in trouble and so is digital health. Telemedicine adoption is meager by practicing physicians, blockchain has solved few medical system problems and there are significant issues about how the 4th industrial revolution impact sick care.
7. The regulators ignore cost-effectiveness so there is no Moore’s law in medical care.
8. None of the sick care stakeholders want to say no
9. Medical educators refuse to change their unsustainable model that creates a medium of over $200,000 in debt while creating a product that does not address the needs of the communities they serve
10. The GME bottleneck and immigration politics feeds the so called physician shortage.

Physician entrepreneurs live in a world of rules. Understanding how healthcare policy is shaped,influenced and enacted is part of the core curriculum. Ignoring that is like doing surgery without knowing the anatomy and physiology. Change will happen from both bottom up and top down and the latter happens in hearing rooms, not examining rooms.

We also have to fight a two front war, since the battles are being waged not just in sick care, but in the 4th industrial revolution as well.

Every revolution is followed by a counter revolution. Those that see driving change as merely a series of benchmarks often find their efforts thwarted. Those that build a plan to survive victory based on the forging of shared values, are much more likely to prevail. Transformation is always a journey, never a destination.

Winning the revolution will take extraordinary leadership and organizational skills. Perhaps combat fatigues are more appropriate than white coats and scrub suits. They might even spread less infections.