“We must not allow a mineshaft gap!” famously spoken by George C. Scott as General Turgidson in Dr. Strangelove as the post-nuclear holocaust planning begins in earnest. For some reason, this quote goes through my mind as I sit through meetings, assemblages and retreats that talk about the future state of medicine in a large gobble-gobble network that has aspirations to provide population health as an Accountable Care Organization to millions of “lives” at higher quality and lower cost. What is the medical equivalent of a mineshaft gap?

The “mother ship” of any health care unit is run by a very powerful administrative structure these days. The days of a potent medical executive committee or a powerful board running a hospital are gone. The people with the keys are the “C” suite, who may or may not be physicians. The Chief Executive Officer (CEO) and their armada of other Chiefs (Medical Officer, Nursing Officer, and Operating Officer) always begs the obligatory “too many chiefs and not enough Indians” comment. These are not bad people with evil intentions, although I’m reminded of Ghostbusters and “choose the form of the destructor” and the Stay Puft Marshmallow Man. At some place and time, physicians were given an opportunity to take medicine into the next millennium and were too startled by all the changes occurring around them to imagine a different form of the transition. So, it fell to capable and earnest people to don the pin stripe suits and suspenders and carry health care forward into its uncertain future. Practicing physicians passively chose the form of their agent of change — the administrative equivalent of the Stay Puft marshmallow man.

So, as each satellite facility is pulled into the gravitational orbit of Megacorp Hospital Incorporated, and each sign is changed to the perfunctory Megacorp logo, the masses expect the same health care to be delivered.

A perfect example of this is Johns Hopkins, Saudi Arabia. (I am not picking on Johns Hopkins – I am a Johns Hopkins University graduate, but think that if you are consistently ranked as the best, then you can certainly tolerate a mention in a health care blog.)

Here is the text from their website:

“Johns Hopkins Aramco Healthcare brings together Saudi Aramco’s long-established health care delivery system and its approximately 360,000 beneficiaries and the world-renowned clinical, education and research expertise of Johns Hopkins Medicine.”

Are we under the illusion that I could walk in the door of the Saudi facility and expect the “same care” as I would if I walked into the Emergency Department in East Baltimore? To lend administrative machinery to the Saudi health care enterprise and to put the name Johns Hopkins on the door seems like a noble pursuit, but are we forgetting something? Who is staffing the hospital? I would love to give my wife a diamond bracelet from Zales, but putting it in a Tiffany box may be misconstrued as false advertising. I certainly would not want to be on the receiving end of that wrath and fury.

But let’s look at this more closely:

One may argue that a Big Mac eaten at a Mcdonald’s in Los Angeles tastes the same as a Big Mac eaten in London or that my 2006 Toyota Sienna can get the exact excellent level of servicing at my local Toyota dealer as it might, say, in Dubai. Although, somehow I think there are not too many 2006 Toyota Sienna’s with 130,000 miles driving around the streets of Dubai — even the police drive Lamborghinis there.

If I needed an elective knee replacement, it might be argued that with all the appropriate administrative machinery in place, I could get the exact same value and quality in Saudi Arabia as I might in Baltimore. Or perhaps cataract surgery, or a kidney transplant? Why stop there?

Certainly, Johns Hopkins is an iconic entity with a storied tradition of groundbreaking medical advances. William Osler, William Halstead and Alfred Blalock, all giants in their time and we stand on their shoulders in all that is righteous and noble in medicine. Funny how when an institution is named, it is the rugged individualism of the founding fathers of that institution that first come to our lips. Heroes, as many would call them, who pulled themselves up by their bootstraps, overcame adversity and championed patient care beyond all else. I wonder, who was the CEO/trustee equivalent of Johns Hopkins Hospital in 1889 and how did he manage to get Osler to drink the 19th Century equivalent of Kool-Aid (perhaps it was a cocaine-laced Coca Cola?) and align himself with the interests of the new School of Medicine.

It’s interesting to note as a tangent that Johns Hopkins himself started his fortune shipping whiskey which ultimately led to warehouses, railroads and the considerable fortune that started the Johns Hopkins institutions. So where are the modern day equivalents of these giants? Is the CEO of Johns Hopkins Medicine a household name, a folk hero of significant stature who has brought Johns Hopkins branded medicine to the masses of a Saudi Arabian oil company, a visionary who we will all seek to emulate in our long-term behaviors?

So the real “hurt” in all of this is the marginalization of the physician — or is it? Big networks like to talk about physician alignment — their doctors are “clinically integrated,” happily toeing the line for all the quality and value that the Megacorp Incorporated is farming out to all the satellites.

What are the conceivable shortfalls that may occur in producing this “mineshaft gap.” In other words, what do I not get out of my experience when I experience care at a branded facility?

Maybe this is a new era where a physician is not emblematic of health care. Perhaps we have let our image deteriorate to the point where Average Joe wants to see Johns Hopkins Medicine on the marquee at the strip mall and does not care what his doctor’s name is, as long as it is “aligned” correctly with high quality and value that is promulgated by the parent corporation.

I do not have an answer to this dilemma. I go back into the clinical fray, set my teeth and stretch the nostril wide, for the game’s afoot and there is another gangrenous limb on the fourth floor in need of an ID consult.

Jaan Peter Naktin is an infectious disease physician.

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