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The Medicalist (or, Looking for the Pony) No. 4
ON THE DIMINISHED STATE OF THE MEDICAL PROFESSION
Note to fellow Ricochet members: I have had to take my Ricochet account back from Dr. Publius at this time. As it happens this post (Number 4 of Dr. P’s Medicalist papers), was inadvertently leaked, prior to publication, to a physician colleague, who took umbrage. Regrettable words were subsequently exchanged between Dr. P and this unnamed colleague (obviously, on a site with a less restrictive CoC than one finds here), and as a result the two have agreed to settle the matter in the way of gentlemen, on the Field of Honor.
I am hopeful Dr. P. will conclude this matter satisfactorily, despite the fact that his old eyes are perhaps not the precise instruments they once were. I have agreed to post this, and the remaining Numbers of his Medicalist papers (which he has fortunately completed), in case the outcome should be unsatisfactory. (Due to my own infirmities of age, I was obligated to pass up his offer to serve as his second.)
The irony is that, in a later Number, Dr. P takes a much more charitable and sanguine view of his fellow physicians than he does here, and had his antagonist read the entire tract (or had Dr. P not been too stubborn to say as much), this gentlemanly discussion they have undertaken might not have been necessary. There is a useful lesson here for those Ricochet members who count themselves among the Whippersnappers: When you become an Old Fart, try not to be too cranky.
Finally, in my role as Dr. P’s amanuensis, I have taken the liberty of revising the title of the Medicalist, to more accurately describe its intent; namely, to explore whether there’s something about the healthcare plan being considered in Congress that makes it worthy of the support of most conservatives.
To the People of Ricochet:
BEING a physician himself, DR PUBLIUS considers it an obligation, in advancing this tract on the healthcare plan being proposed in Congress, to say something about his own profession’s role in healthcare reform. After all, doctors are among the primary actors in the healthcare system, and their professional recommendations go a long way toward determining how much money is spent on healthcare. What doctors believe about the proposed reforms, one might assume, should carry substantial weight.
This will be a relatively brief Number, because as it turns out there is little to say.
For the medical profession, there is one ethical obligation that surpasses all others. It is the very obligation that defines a classic profession, and once it is abandoned, members of that so-called profession no longer have any claim whatsoever to any of the special regard, respect, perquisites, or considerations that commonly accrue to true professionals in our society.
Physicians have referred to this obligation as the doctor-patient relationship. Like the lawyer-client relationship and the clergy-parishioner relationship, the doctor-patient relationship is supposed to be a sacred, protected, fiduciary one, in which the patient can feel safe in disclosing private information they may not even willingly tell their spouses, and in return the doctor agrees not only to keep that information private, but also to act on that information in such a way that furthers and optimizes the individual patient’s own best medical interests, without regard to which actions or recommendations might be to the doctor’s interests — or to society’s.
The abandonment of this sacred, fiduciary obligation (honored by physicians for over 2000 years) cannot be blamed on Obamacare. It was formally abandoned years before most of us had ever heard of Mr. Obama. The doctor-patient relationship, never as pure in practice as it was in concept, began to significantly erode in the 1990s. This, of course, was the heyday of for-profit HMOs, when the insurers used extreme coercion to make certain that doctors learned who their real customers were. Doctors who did not place the payers first had their reimbursements slashed, and often found themselves excluded from panels, and therefore from access to patients. In a surprisingly short time doctors by the thousands were signing “gag clauses,” in which they agreed to withhold from patients certain information that might be adverse to the interests of the HMOs.
It would be wrong to say that doctors did not mind these things. It troubled many of them deeply. Indeed, by the turn of the millennium many members of the profession were feeling, and occasionally publicly expressing, tremendous guilt for having had to abandon their chief ethical obligation to their patients, in order to continue practicing medicine.
Faced with an ethical dilemma which was increasingly difficult for them to tolerate, an outcry arose from within the medical profession demanding that their leadership take up the problem, and do something about it. Most doctors had in mind some sort of organized action by which the profession would attempt to reclaim its ethical grounding. And so, conferences were convened, debates (of a sort) engaged in, and at last, action taken.
What doctors in the trenches failed to realize was that the physicians who dedicate their careers to leading professional organizations are almost always Progressives, because this is what Progressives do. So the action that was finally taken was the official adoption of a new set of medical ethics, which was published in 2002: “Medical Professionalism in the New Millennium: A Physician Charter. “(Annals of Internal Medicine, February 5, 2002). This document described a new ethical precept which was to be formally adopted by the medical profession. That new precept was, of course, “Social Justice.” Under the precept of social justice, doctors, in making medical decisions at the bedside, suddenly became obligated to take the equitable distribution of healthcare resources into account. Covert rationing at the bedside at the behest of payers (who presumably knew more about equitable distribution of resources than individual physicians did), was not only acceptable, and not only a positive good, but an ethical requirement.
During the intervening years this new charter of medical ethics was indeed formally adopted by virtually every medical professional organization in the world.
Adding social justice to the ethical obligations of physicians or course did nothing to ease the discrepancy between the needs the patient and the needs of the payer. But its addition at least assuaged some of the guilt of some of the doctors who chose not to think too deeply about it.
This modernized, progressive version of medical ethics was not the result of Obamacare, but it has served Obamacare well. It was a matter of mere moments before doctors noticed that it would behoove them to shift their efforts from making the insurers happy to making the government happy.
Today, when a doctor makes a medical recommendation to a patient, that patient can no longer be confident that the recommendation is truly the one the doctor believes is best for him or her. For it may instead simply represent what the doctor has decided the patient deserves, given his/her needs in relation to the needs of all the other patients in the Accountable Care Organization, the state, the country, or the world. (The range of patients encompassed by the directive to “fairly distribute” resources turns out to be quite fluid.)
If we Americans ever do regain control of our healthcare system, and are successful in redirecting its efforts away from the benefit of the herd and back to the benefit of individual patients where it belongs, our physicians (most of whom, by this time, have been trained in the New Ethics from the beginning of their careers), will need to attend some type of re-education camp. (Our Progressive friends can probably help us in setting these up.)
In the meantime, having abandoned their defining ethical obligation, doctors and their opinions on healthcare reform, or on any other matter of public importance, can be listened to politely if we are feeling generous. But we should feel no real obligation to take them seriously, and we are free to proceed without them.
DR PUBLIUS
For anyone interested, here are links to all seven Numbers of Dr. Publius’ Medicalist papers:
The Medicalist No. 1 – ON WHY WE SHOULD CONSIDER A DISAPPOINTING PLAN
The Medicalist No. 2 – ON THE THREAT POSED BY THE COST OF HEALTHCARE
The Medicalist No. 3 – ON THE RELUCTANCE OF THE HEALTH INSURANCE INDUSTRY
The Medicalist No. 4 – ON THE DIMINISHED STATE OF THE MEDICAL PROFESSION
The Medicalist No. 5 – ON THE REQUISITE FEATURES OF AN ACCEPTABLE PLAN, PART 1
The Medicalist No. 6 – ON THE REQUISITE FEATURES OF AN ACCEPTABLE PLAN, PART 2
The Medicalist No. 7 – ON WHY CONSERVATIVES SHOULD, AFTER ALL, SUPPORT THIS PLAN
Published in Domestic Policy
Yup. Paranoia can serve us well these days. (I am not being sarcastic.)
You have been accurately describing the frustrations of my life between 1992 and the present.
That’s interesting. Thanks for the tip.
I noticed in last years annual check up the nurse took more time taking my blood pressure than the doctor did in the whole visit. He just chatted pleasantries and never even listened to my heart or lungs. I was so startled being shown the door that I didn’t object. This year I will make a note to be more demanding.
I suppose most older docs were in it for being part of a healing art. When we changed from artists to business people our profession lost something.
The history of medical care over the past fifty years is of a system that has evolved to have confused allegiances and priorities. The result is a declining quality of care. No one assumes responsibility anymore because moral responsibility has been replaced by financial responsibility, and that is actually harder to work with.
I wouldn’t mind the change to putting people to sleep the way we do our pets if we were paying a lot less for that type of care. The care veterinarians provide at a relatively low cost would make sense to me at this point. My daughter is veterinarian, and when she was in vet school, she had to have a complete blood count (CBC) test for herself for some reason, and when she got the bill, she called me to say that it was $500. She said that veterinarians run the same test on exactly the same machine, and it costs $20. She could understand that it would cost more for a test for a human being, but not that much more. What creates that differential in price? Layers and layers of useless liability insurances.
I want to go back in time to when it was just me and a doctor and the lab down the street. And when it made financial sense.
And just to add to my note in comment 5:
I saw the change to “managed care” happen. I had a fantastic pediatrician for my kids, and a “sick visit” used to cost $14. There was in the office one doctor and one nurse/receptionist. There was another doctor on call on some weekends, but I mostly only saw Dr. Dankner. My kids and I adored her. Managed care came in and with it, a second nurse and two people out in the office. Almost overnight, a sick child visit went up to $48 dollars. It was dramatic. And it was the beginning of the end of health care as I had always known it. My kids grew out of the pediatrician’s care (not until she threw my last kid out at 18! because he refused to see anyone else), and two years later I ran into Ellie at the grocery store one night. She tearfully told me she had closed her practice. She just couldn’t practice the “new way” anymore. (We both looked after our mothers–that’s what we had in common and why we were such good friends.) She was the best doctor on planet earth.
The system is sick. It needs a team of doctors to look it over, make a diagnosis and fix it.
It needs that, and more. What individual patients can best do to protect themselves, in my opinion, is to find a doctor they pay themselves — someone like DocJay, who you pay yourself, and who answers to your individual needs.
Unfortunately, in order to discourage this practice, current regulations generally prohibit docs from accepting direct-pay patients, if they also accept any insurance or Medicare payments from any other patients.
It is very scary for docs to do what DocJay has done, and hence there are relatively few of him. But if you want a classic dr-pt relationship you should strongly consider finding his like.
We could adopt the Soviet system. They had the best health care system in the world. (If you don’t believe it, go back in time and ask them.) And it was free. If you or your kids needed any important treatment in a timely manner, you’d slip the doctor an envelope with money in it. They’d somehow manage to let you know how much.
Maybe it was more of a free market system than we have here in the U.S.
I had a friend make a trip to Cuba before the Obama reopening, and her tour guide was a doctor. He made more money as a tour guide, because he could collect and hide tips from the Castro regime.
Another good post from Dr. Rich.
If we get single payer health care, I think the medical profession will get what it deserves. While there are many doctors that oppose government run health care, all the medical interests (which are mainly run by M.D.s) were for Obamacare. Do they really want to be government employees?
This is no joke. If a Soviet official found you accepting such a “gift,” he might demand a cut of the proceeds. If a U.S. regulator discovered such a thing you would lose your career, your life savings, and you would go to jail.
The younger ones mostly do. Some out of complacency and others out of immense frustration.
It’s strange to me that so many of the liberal docs I know still place all the blame only on “greedy insurance companies” and are unwilling to confront the real array of distortions and corruptions that have led us to this current mess.
Blaming the problems on the greedy companies is the default position of Progressives with all issues of controversy, since it justifies more government control as the solution to the problem. And in most cases (and certainly in healthcare) it is government regulations that created (or encouraged) most of the distortions and corruptions in the first place.
This, again, is one reason why the historical tendency toward ever more Progressivism tends to be a great, ponderous, one-way, gear-and-cog mechanism.
There’s a heap of blame for every aspect involved.
The problem dates back to the foundation of the American Medical Association in 1847. It was founded in reaction to the economic threat posed by the homeopaths, who had formed a national medical association two years previously. At this time, there was no reason known to what we would today consider valid in the science of the day to prefer “regular” medicine to homeopathy.
The regular profession struggled. The most garish advertising permitted by professional journals of the day were “tombstone” ads, which were a framed announcement something along the lines of “Eli Lilley proudly announces the release of the finest laudanum available to the profession” or “After a shortage, we are happy to announce new supplied of xxx.” Another “ethical” stricture was the AMA’s ban on professional association with “sectarian” practitioners such as homeopaths.
This resulted in some very bad publicity when an AMA affiliated local medical society expelled a physician for discussing a patient with a colleague, who was a homeopathic physician – and his wife. (Since one had to be a member in good standing of the local society to have hospital privileges, this was a serious penalty.)
It was considered to be unethical to advertise “patent” medicines through most of the 1800s. The financial incentive was too great, and in about 1897 (the records of the discussion were lost in a fire at the AMA headquarters) patent medicines were permitted to be advertised, provided that the patentholder submitted the formula to a committee of the AMA
JAMA’s revenues began to climb, which in turn financed new political activity. This included a long, ultimately unsuccessful attempt to prevent first chiropractors and then acupuncturists from gaining state licensure, and an ongoing campaign to deny licensure to naturopathic physicians wherever possible.
Having failed at the state level, the AMA undertook a campaign to “contain and eliminate” chiropractic. This came out in a lawsuit, Wilk v AMA et al. The leaked documents in which this goal was stated featured prominently in the plaintiffs’ case and also made it clear that whatever the public rhetoric might be, the primary motive was to eliminate an economic competitor. (One charge the AMA leveled at chiropractors was that they advertised. The AMA came out with its own practice promotion materials and advertising guidelines starting around 1990.)
This led to the Appeals Court ruling, on which the Supreme Court refused certiorari, finding that the AMA had engaged in illegal restraint of trade.
Among the things that led the plaintiffs to sue:
•Refusal of MDs and hospitals to release X-rays and other medical records to a chiropractor despite a signed release from the patient; such refusals, enen in violation of state law, were common well into the 1990s and only began to stop when the ruling went against the AMA.
•A hospital threatening a neurologist with loss of privileges if he continued to evaluate multiply handicapped children as part of a multidisciplinary medical/chiropractic/rehab/educational charity started by a Kentucky chiropractor.
Since its founding the AMA was promoting the economic interests of its members even to the detriment of patient care.
The problem actually dates back to the Fall of Adam.
What’s new is that that, in the past, the profession of medicine at least “professed” to hold itself to a certain standard of behavior, regarding the relationship between doctors and their patients. That standard is now gone.
Americans. of all people, should know how important standards are. The Declaration of Independence asserted a standard that was manifestly unmet at the time but which, over a few generations, ultimately produced a Big Fight that removed the major impediment to that standard.
Even when unmet, standards create a certain check on behaviors, and may create a tendency, over time, toward their actual fulfillment. That is now gone for the medical profession, and that’s what is new here.
If your point is that the AMA sucks and does things against the public interest, you will not get an argument from me. You will also not likely get an argument from the more than 75% of American physicians who have refused to join, and who largely disdain the organization.
Hypocrisy may be the homage vice owes to virtue, but it’s one thing to aspire to virtue and another to use it in a con – as the AMA did from its inception. True, there were many, many dedicated physicians who were proud members of the AMA; one of whom was my grandfather, A”H. The CPUSA did, of which at least one of my grandfather’s sisters-in-law was a proud member did the same. (His mother-in-law was a follower of Emma Goldman.)
I wonder what it would take to just change that particular prohibition …
Ah, but this prohibition is the SJW’s work. They want a single payer system whose main feature is not quality but egalitarianism: if everyone can’t have it at government expense, you may not buy it with your own money. This rule is but a way-station en route to the finished product.
The AMA’s declining membership and power is one of the few positive developments in the politics of American medicine in the last several decades.
ON the other hand, the CPUSA is a shadow of its former self yet one of its protegés occupied the White House and its ideology now dominates education and the media. The government’s trend is for a monopoly in medical care… which is pretty much what the AMA was pushing, though it wrongly assumed the perpetuity of private practice.
This is the key. And this is a main reason why (Dr. Publius argues) we should consider supporting Ryans’s plan. (See Number 5.) The plan resurrects HSAs, which will assure that patients are allowed to, and encouraged to, pay their own way, to at least some extent. Re-establishing the principle that individuals have a right to use their own resources for their own healthcare is critical. Doing so and making it stick would ultimately be fatal to the Progressive program.
To quote from the Medicalist No. 5: HSAs are to Progressives as the crucifix is to vampires.
Agreed: Monopolies are a bad thing, no matter who runs them. It was the rise of monopolies, after all, that originally gave rise to the Progressive era.
I want HSA.
I’m not sure I agree with this. As a small business owner, I paid more attention to the details of the doctor patient relationship (actually a course in medical school) than most of the young physicians I know. Recently, my wife who has COPD developed pneumonia and the pulmonary specialist I have known for 30 years sent her to the hospital ER where the ER docs, who are in a contractual relationship with the hospital ownership, decide if she should be admitted. When I asked him about this detour, he told me, “These are not the days we knew. I cannot admit a patient without their approval.” We have not been back to him or that hospital.
Actually, I would modify this to state the AMA was promoting the interests of its Board of Trustees. The story of the RVS code and its morphing into the CPT code is an example. Another is the birth of the RBRVS.
Patients did their part in this too, when they demanded to be treated as “customers”.
What they didn’t realize is the customer pays the bills, be he individual, insurer or government. What they want and what the patient needs may be very very different…