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Expectations of leadership

By Robert Poole, M.D.

As a recently retired physician, I am desperately proud of the medical marvels of the past fifty years. At the same time, I am also desperately concerned about the health care direction threatening these accomplishments. It is difficult to address a reading audience of physicians in 1996, for “survival” issues overshadow matters of ideals and quality. However, Jim Giuliano, West Chester, PA Daily Local News columnist, set the stage on August 8, 1996 for what I’d like to say. Let me excerpt his well-written article, “Physician Heal Thyself, Along With Us”:

“If you went to high school in this country, you know who I’m talking about. They were the kids who always get the best grades, the academic honors, the sparkling SAT’s. They were the kids who became physicians. Just about every really smart kid I went to school with became a doctor. Oh, there was the stray nuclear physicist here and there, but most of the top students eventually went to medical school.

“So, I have a question for all those guys and gals who became doctors: How did you get so dumb? In the eyes of this former straight-C-student, politicians and accountants have foisted upon us an array of medical-care mumbo-jumbo that no one seems to like or understand.

“We have a system in which a woman enters the hospital to deliver a baby and the hospital administration determines her length of recuperation with an egg timer. We have all this nonsense, and at the base of this mess we have, incredibly, the smartest kids in the class, the doctors, who do nothing but complain like assembly-line piece workers whose rate has been cut.

“You guys and gals who became doctors, c’mon willya. Pretend this health-care thing is the chemistry final. Ace it. Get a grip on your own industry. And don’t tell us that there are forces out there that have unfairly overpowered you. We used to say that about Mr. McKeon, our chemistry teacher.

“Get on it. Do your homework. And just like the old days, the rest of us will be looking over your shoulders for the answers.”

Jim’s humor is entertaining, but, buried in it are truths deserving attention by the medical profession. I sincerely believe that among professionals, physicians are still among the most trusted; and to us, the general public looks for guidance and advocacy. Let us review the roots of this strength.

There is a normal, instinctual desire within each human being to live long and to live well. This driving human value, common to all cultures, is prompted by the joy of living, the unpleasantness of illness and the profundity of human relationships.

The 20th century initiative to address this human value by the medical profession was taken by Abraham Flexner in the early 1900’s. He designed a systematic approach to the human body and its afflictions that produced the excellence in medical education, medical research and health care delivery that is known today. Indeed, our stringent credentialing process assuring quality is the envy of most other professions.

The consequences of Dr. Flexner’s approach broke through in the middle of this century and the technological impact on life expectancy in the past fifty years is now a matter of record. It has been aptly stated that more has been done to cure disease, eradicate disease and prolong life in this century than had been accomplished in the previous 2000 years.

But the force of this human value has consequential economic and political implications. Because it is shared by the masses, the gift of health care and the promise to financially penalize those who deliver it can be used by enterprising parties as a pathway to power and/or wealth. Even within the health care family there are those few who will take economic advantage of the unwell.

Social Security and Medicare are proving to be just as expensive as was predicted by the medical profession fifty years ago. Outrageous malpractice insurance premiums and defensive medical practices prompted by society’s litigious inclinations have made their contribution to the cost of health care. And now, the business community has predictably decided to participate in the process.

Health care costs were least when physicians looked patients in the eye while stating charges. An overlay of self-serving, economic ventures in the insurance, legal, government and business communities have profoundly affected the environment first addressed by Dr. Flexner.

The managed care overlay is really an experiment without apparent precedent or plan. By virtue of its profit motive and transfer of financial risk to health care providers, it has created a conflict of interest for both payer and provider. That conflict is between financial gain and quality patient care.

The commendable emphasis of managed health care has been on the prevention of illness—the elimination of unhealthy habits, the attainment of physical fitness and the promotion of our preventive medical practices. But, the real test of this experiment will rest on its approach to the diagnostic and therapeutic management of illness when it does occur. Already, as indicated by Jim Giuliano, there are some perceived, and many real, anecdotal complaints by patients and providers about sacrificed quality.

But beyond the development of a high quality system for delivering health care, Dr. Flexner designed an approach to medical education and research responsible for the excellence of the former. Managed health care has demonstrated an unwillingness to invest in research and education, and essentially, for profit, is marketing the product of these two important legs on the stool. Further, government is threatening reduced support for both research and medical education. Medical student tuitions and faculty practice plans cannot bear these costs alone, and without sustained investment in our premier biomedical centers, we are doomed to “kill the goose that laid the golden egg.”

We must remind ourselves that the golden egg is the consequence of curious, bright, hard-working students of the science, laboring in an inspiring free enterprise environment. In my view, the present reactive scramble among medical centers for bigness and survival has great counter-productive risk.

Physicians, we are the one profession that is committed to the elimination of the reason for our own existence. The fact that we need fewer doctors and fewer hospital beds is a credit to our accomplishments. But to allow the business world to use those accomplishments for personal economic gain is shameful! The health care industry will always be dependent on us for the delivery of patient care, and we should have a prominent say about any proposed delivery scheme.

Above all, we must respond to the trust of our patients with a brand of leadership and advocacy that guarantees quality care. There is no place for contractual conflicts of interest and “gag” clauses that compromise our integrity. Medical decisions are clinical decisions with economic implications, not vice versa. Above all, we have a Hippocratic obligation to the medical education, research and the Flexner heritage that has made us what we are.

There is a great need for an excellent health care system that covers everyone regardless of income, employment or health. A physician’s response to this serious challenge should logically be led by organized medicine. A proposed solution must be fair but not self-serving, clinically oriented and economically feasible. As Jim says, the general public is worried and is looking over our shoulders. And, as he suggests, I know that “we’re smart enough to stop whining and get a grip on our own industry.”

Robert Poole, M.D., a retired family practice physician and past president of the Chester County Medical Society, was Pennsylvania Family Physician of the Year in 1992. He is on the medical staff of Chester County Hospital.

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