Physician empowerment

By Paul J. Fink, M.D.

The recent tenth anniversary symposium sponsored by Physician’s News Digest called “Unionize, Corporatize, Socialize: Visions of Change for Delaware Valley Physicians” raises to a very high level some of the most critical problems facing medicine today. There are good reasons for physicians to consider coming together in some manner to create greater leverage and to recapture greater control over their professional lives. Whether the right direction to go is unionization or corporatization, whether doctors should become the insurer, or whether contracts made with insurers by doctors should be better developed to serve the interests of both doctors and patients are important questions that need to be resolved. Barlett has coined the term “comodification”—that is creating medical care as a commodity which I think has become more apt in the last five years. The fiscally driven care systems in which all physicians participate present several challenges, not the least of which is finding the right way to combine giving patients the best care you can and making a living simultaneously.

Although many physicians complain that they are making less money and working harder, my impression is that the average physician is doing better but feeling worse, that is, doing better financially but feeling emotionally drained and suffering under the yoke of disrespect and disregard. Thus, the generic issue that is being tested is empowerment. Whether it is unionization or corporatization, the effort to become powerful enough to make one’s own career determinations and be responsible for medical decisions are powerful motivators no matter what the mechanism by which such organization takes place.

The AMA is looking for a way to do collective bargaining without calling itself a union. Tricky euphemistic wordsmithing has been used for years to try to resolve a problem while saving face. It obviously doesn’t look good for physicians to unionize because that takes physicians out of the professional class and puts them into the worker class. Unfortunately, many young physicians now see themselves as having a job rather than being in a profession and regard the doctor/patient relationship as a contract rather than a covenant. Once you sit down at the bargaining table and start talking price, you are a union no matter what you call it—at least you are a group of executives taking the responsibility for hammering out the details of the contract with a paying entity whether it’s the boss, the insurance company or some variation or hybrid.

There’s something to be said for empowering the body-politic of medicine and finding the terms by which one would negotiate fees, working conditions, levels of control and how one practices one’s area of special skill. Years ago a group of psychiatrists and I locked ourselves in a room trying to figure out how to design a benefit package that would truly take into consideration the needs of patients as well as appropriate payment for the physicians. As soon as we determined that we had a finite amount of money, we began to bicker both about benefit levels (how many inpatient days, how many outpatient visits) and the inclusion of non-physicians in the patient care system. After several hours, one of us who was concentrating and working very hard searching for a solution, said “Wow! We sound more like insurance men than we do like doctors.” It is easy to get trapped into counting shekels, it is easy to be cynical about the over-utilization by doctors, it is just as easy to talk about the under-utilization by insurers and pointing a finger is much easier than solving a problem.

Corporatization is another idealized method that, I think, has tremendous power. Physicians Care, the HMO created by Gary Brown and other physicians to wrest control of the insurance activity from the “profiteers” and put it back into the hands of the physicians is another idea that has enormous merit. Once again, the decision-making about insurability risk and appropriate benefits looks a lot more like the high level corporate board room of an insurance company than it does like a doctor’s office for finalizing those decisions. Physicians Care in their rush to do good for all doctors made some of the same mistakes that other HMO’s have made. For example, when it came to psychiatric services the decision to carve it out to one of the existing behavioral health companies seemed easier than solving the problem within their corporation by working out a method for including psychiatry as a sister specialty. Fortunately, or unfortunately, physicians are human first and physicians second and their tendency to believe basic prejudices and go with the basic socially held ideas is much stronger than facing up to the task of becoming an HMO with the doctor, for the doctor and by the doctor.

Dr. Coletta’s idea of bringing everyone into a multi-specialty group with the benefit of economy of scale and the eye of the organization on the patient, and only the patient, seems to be one that is being successfully applied around the United States. It is useful for physicians to band together in order to practice the best brand of medicine possible and not to be totally submerged in the details of practice which burden the solo practitioner. Unfortunately, this type of collectivization does not provide much leverage or power. One or two hundred physicians in a community of 15,000 is nice but could easily become negligible.

In all of these models, there are both benefits and liabilities. The biggest problem is one of perception. Can the public allow doctors to become “stronger”? Can the doctors tolerate further abuse from the general public? Are we able to take over control and manage HMO’s where doctors truly have input into the nature and quality of the caregiving and where care is improved because there are doctors running it? Can we somehow avoid the label “profiteer” which is so easily put on the backs of the major HMOs whose unconscionable profits are sometimes publicized in the newspaper? And, from the other end, can we collectively have enough leverage and power in our practice system that we will not tolerate the abuse of patients or the misuse of doctors? Recent articles demonstrate that there may be legal problems to physicians actually behaving like a union and the whole question of unionization does raise the specter of the doctor having greater loyalty to the union than to the patient. The basic ethic of Hippocrates “primo non nocere” is abrogated daily throughout the United States and perhaps the world. We cannot help but do harm when programs are dominated by money, controlled by accountants and reviewed and assessed constantly by non-physicians. Perhaps the bottom line is: “Who makes medical decisions?”

The recent flap over drive-through pregnancies and one-day mastectomies illustrates better than one can say the enormous complexity of the problem. Initially the insurers tried to take away the medical decision-making from the doctors and determine when and how discharge of patients from hospitals should be done. In an act of enormous courage and under pressure from the physicians, we moved the decision-making from them to the legislature. Neither the insurer nor the legislature is appropriate to be the medical decision- maker. Neither of them has gone to medical school. Neither of them has the capacity to make serious clinical judgment. And neither of them should appropriate that role in doing their own job. Nevertheless, that’s the way it works and we could have seen that become a slippery slope in which the legislature made decisions about almost every illness. In Oregon, when they outlined the 700+ illnesses and drew a line under 575 as the bottom condition for which Medicaid would pay, they essentially made serious legislative decisions with very few caveats and no consideration of individual patients.

The future of medicine appears to be somewhat rocky. Medical decision-making must stay in the hands of the physicians and, hopefully, the era of a fiscally driven, quasi-profession will pass and we can get back to the practice of the profession of medicine.

The models for collective action presented by the authors all have merit and should be seriously considered. Hopefully none of them will undermine the professional nature of medical practice.