It's still not cooked

By Richard J. Baron, M.D., FACP

Reading the four essays in the Physician’s News Digest supplement “Unionize, Corporatize, Socialize: Visions of Change for Delaware Valley Physicians,” one is forced to the conclusion that we just aren’t there yet in terms of envisioning our way out of the problems confronting our profession. Each proposal seems to have identified something importantly wrong with the way things are changing now, and each seems to build itself from the foundation of defect upward. One can perhaps characterize each of them as having the form: “Here’s the most important problem, and since we have identified that, let’s build a solution that would address that problem and restore us to the productive path.” I found myself agreeing that important problems had indeed been identified, but I wasn’t comfortable that the important problem was the starting point for any of the essays, except perhaps Dr. Tsou. I think the difficulty arises because the problems are being located outside of medicine itself, and they all have the character of responding to a hostile world that has imposed something awful upon us. I think we will be better served starting from our essence and purpose as a profession-a positive foundation-rather than being in what seems to me to be a reactionary mode.

Let me consider the proposals one at a time. Drs. Coletta and Brown’s proposals to corporatize operate under the assumption that power has shifted to the corporations, and that we need to emulate that form of organization to forward our aims in the new world. Dr. Tsou observes (rightly, I think) that we cannot use “a thousand dollar slingshot to bring down a multibillion dollar Goliath.” But my objection goes deeper. The foundation of corporate power is capital. Nothing about us as physicians particularly equips us to have any privileged position with respect to the amassing and deployment of large amounts of money. It isn’t that we can’t do it: I have no doubt physicians can be trained effectively to become capitalists. My concern is that the corporate enterprise is not the medical enterprise in a fundamental way, and physicians who become corporators are in an important sense no longer physicians. I don’t mean this as a “loyalty” question or an “us versus them” question; I mean rather that there isn’t anything “medical” about running a corporation. I don’t have much confidence that people running corporations will behave differently just because they have an MD after their name. The route to corporate power is the accumulation of capital; I would hope that doctors could find a different route.

Drs. Sklaroff and Lodise’s proposal to unionize seems to me to raise the same issue from the opposite side. I would argue that the union paradigm concedes too much. It says that we are labor and someone else is management. As labor has discovered, the biggest weapon they have is to collectively withhold their efforts on behalf of management. The “protection” these authors seek from the NLRB is merely an administrative code of rules defining “fair” uses of the respective power of labor and of management. Definitions of “labor” typically involve the admission that someone else has control over all of your work environment; the dilemma faced by our colleagues in New Jersey has to do with whether they will meet that legal definition. I don’t think we should want to. Besides, I’m not sure that knowing we couldn’t be fired for striking is the critical issue we should be thinking about as we confront corporate power. We shouldn’t have to choose sides in the labor-management war; we are clearly both labor and management, and casting our lot unequivocally with the labor camp seems precisely to give away any claim we might have to actually running things or having a significant overall impact by exercising (rather that withholding) the skills of our profession.

Dr. Tsou seeks a political solution, arguing that we should throw our collective might behind universal coverage under a single payer system. To my mind, those are separable issues: Clinton Reform would have offered universal coverage, but not under a single payer system. I see advocacy for universal coverage as being absolutely central to who we are as a profession, and I totally agree with Dr. Tsou that we should be behind anything that achieves universal coverage. I am less sanguine that either the “right” or the “only” way to get there is through a Single Payer approach. I believe we speak most powerfully and effectively as a profession when we speak on “medical” subjects. That everyone should be cared for is a basic tenet of our profession going back to antiquity. Who signs the checks is not.

It isn’t fair to criticize what five accomplished and successful physician leaders have put forth without at least indicating some direction of my own, so I’ll take a stab at the broad outlines, or at least the principles that I think should be guiding us as we participate collectively in a very complex set of social and political interactions that will define health care in the future America.

First, we are well advised to remember that no one is going to get to design and build our future health care system. President Clinton couldn’t do it, Len Abramson couldn’t do it and none of the proposals offered would or could survive the American process in a form that looked anything like their current incarnation. What is happening is that the institutions of health care are up for grabs with a variety of national stakeholders (government, business, insurance companies, drug companies, the list goes on) at the table reshaping the way things are going to be done. Our goal should be to participate responsibly in what we acknowledge from the beginning to be a diverse partnership. The louder we proclaim our privileged position with respect to the whole re-design, the less seriously we will be taken, especially as we take upon ourselves expertise not uniquely medical.

I believe our efforts should be focused on defining clearly the areas where we do bring unique expertise to the table, and seeking positions within evolving organizations-government, corporate, advocate-where we can bring that to bear. A health care business simply will not and does not run effectively without physician input on a variety of critical issues. An HMO medical director doesn’t tell the chief financial officer where to invest the company’s cash reserves, and the CFO doesn’t tell the medical director whether a hospital day is medically necessary. There is great need for physician direction within all of the evolving power structures; we can lose our credibility by overselling our expertise outside of what we know best. Ours is a profession dedicated to service and the welfare of the patient. The Managed Care enterprise (which I define as “Improving the health of a defined population within a fixed budget”) takes up beyond the welfare of the individual patient in front of us and makes us think about the health of the population as well. How to protect both is the fundamental task of the new medical enterprise.

I believe our major task is to develop a viable medical paradigm for the new medical enterprise. For a generation, we have functioned in a wonderland characterized by ignorance of and lack of concern for the resource implications of our “medical” decisions. We need to change that, and we need to coalesce around a vision of medical excellence that incorporates resource accountability, not for the protection of our own incomes but for the responsible stewardship demanded of a sovereign profession. If we focus on that, we will derive the most legitimate power and authority we can. This will come neither from being effective laborers, corporators or politicians, but from being the best doctors we can be.

Richard J. Baron, M.D., F.A.C.P., is medical director for provider education at Health Partners.