Everyone seems convinced that regard for the professional of medicine has been eroded both from without and within. The constant pounding by the media about the bad things that have been discovered about hospitals and doctors has had a corrosive effect. The insistence by the community that we are rude, rich, selfish and uncaring has also taken its toll. The dissension from within has been destructive more to the sensibility of physicians because their confidence, entitled arrogance, and their altruism—renamed foolishness—has begun a re-socialization process which is now in full bloom.
Doctors are under attack. Their income has been continually eroded by managed care companies, intense competition, the purchase of practices, as well as the government’s attempts to control health care costs. Their role has become more confused by the growth of a profusion of other professionals and paraprofessionals, all of whom are looking for a piece of the pie. Their confidence has been eroded by the commodification of health care in which the responsibility for the patient’s care has been divided among a number of caretakers, case managers, and family members who believe, rightly or wrongly, that their input has the same value as the clinical opinion of the physician. The common belief that physicians are only out for the money and are fraudulent and unscrupulous until proven otherwise is becoming a self-fulfilling prophecy because the doctor says to himself, “Why bother?” or “Why not?—no one believes me anyway.”
The effect of all this on medical ethics and medical education has been devastating. Practicing medicine from the position of covering one’s back is now a way of life. The ethical physician is challenged every day by a payment system that says if you give patients more time than you “should” you’ll go broke. Or, if I resent participating in an HMO that pays one-third to one-half of my fee, I’ll lose my patients and my practice. Or, if I insist on an expensive treatment when the hospital has a per case payment rate, I’ll be eliminated from the medical staff or I’ll be character assassinated within the hospital community as a non-conformist. There is also the problem of situational ethics which says there are no ethical absolutes, doctor-patient barriers can be stretched, and it is okay to misuse patients because everyone is misusing me.
The reaction to the downgrading of the doctor has been interesting. Cries for a single voice, unionization, tougher laws, organizational sanctions and “drum them out of the corps” have become cacophonous. A plethora of projections and rationalizations has also arisen. “Managed care made me do it,” “Nobody cares about us anyway,” “The profession is dead,” “Who cares,” “Why bother” have attempted to excuse or explain egregious behavior accompanied by lots of mea culpas.
The changes in the practice of medicine have been very challenging but also discouraging to most physicians. As hard as practice is, there was always the joy of doing good, saving lives and being appreciated that more than compensated for the continual pressure and drudgery of every day work as a doctor. Recently someone said, “The pleasure has been divested from the experience.” This accounts for the smoldering anger that has recently been manifest among physicians. It isn’t the money, it isn’t the hard work—it is the unrelenting sense that it isn’t worth it.
In addition to anger, there is also guilt. Doctors are fed up with selling out, giving in, cheating patients, cheating themselves and not living up to the promises they made and the oath they recited at graduation. Once pillars of the community, they feel little responsibility for the community. Whether burned out or burned up, the picture is not pretty. Younger doctors are socialized to feel that there is no special role or place for physicians nor do they have a social responsibility. I’ve been told that the doctor-patient relationship is a contract—the patient comes to the doctor, receives a service, pays for the service, leaves. Older physicians have felt that the doctor-patient relationship is a covenant, a promise of continued responsibility not only for the visit, but for the course of the illness, if not a lifetime. Oliver Cope, a famous Harvard surgeon in “Man, Mind, and Medicine” tells the story of a woman on whom he operated six times in her lifetime. After 40 years he finally realized that she was his patient and he had been her doctor throughout his career and her entire life.
The erosion of significance is now built into the education of medical students and the socialization of residents. You can hear the discouragement and the painful reaction of young physicians to the daily undermining of their decision making and judgement. Non-physician “service managers” must approve the diagnosis and treatment plan. Gatekeepers can countermand an order. Formularies are designed to avoid more expensive drugs and when decisions are controversial, one must appeal to a peer who talks more like an insurance man than a physician. Then, if everyone gets up in arms, the legislature begins to make medical decisions on such items as hospital care for delivery of children or the appropriateness of “drive through” mastectomies.
Can the medical profession survive through all of these extraordinary changes? Will the pleasure of helping someone get well return? Will students ever get over the cynicism of our society and be awed by professors with great clinical acumen? Will society ever again feel proud of its doctors who in turn will be proud of themselves? There are lots of sick people in need of quality medical care. That will never stop. In some way that is the answer to the questions just posed. We must sustain our Hippocratic foundation and rally around the extraordinary service, art, skill and compassion that is the sum and substance of a “good” doctor.
Paul Jay Fink, M.D. is a professor of psychiatry at Temple University School of Medicine and senior consultant for Charter Fairmount Behavioral Health System.