Like many Americans, I enjoy taking my children and grandchildren to baseball games. I look forward to seeing a live game up close and eating stadium food. I buy a limited season pass, allowing me to pick certain games in certain seats well in advance. I select a home game against our team’s most exciting opponents on a day when family can attend.
Let’s say that several weeks before the game, I receive a phone call. A voice says, “Is this Henry?” I hesitate at this greeting without identification, but I respond, “Yes.” The Voice continues: “Well, Henry, we are going to have to move your game a month into the future.” I respond, “Why?” The Voice: “We’ve changed the day you were scheduled for a game between two different teams.” Me: “But I don’t want that. Give me my money back.” The Voice: “We can’t do that. Your contract entitles you to a game, but not to a date or to choosing the teams that are playing. Have a good day.”
This scenario could never take place. Major league baseball would go out of business; there would be a great public outcry. Government would step in and pass laws to forbid such shenanigans. Yet, our healthcare system currently “plays” such a game with impunity. The big business of healthcare does not suffer; indeed, it flourishes and is encouraged to place additional impositions on its customers to enhance profits for its administration and stockholders. There is no public outcry. Government does not step in but rather facilitates the subjugation of all of us by paying, in one way or another, for 60% of national healthcare expenses from taxes collected from us, the ill-served populace.
This month, my book titled “Healthcare Upside Down: A Critical Examination of Policy and Practice,” is being published. This book demonstrates the Orwellian use of language to depersonalize medical care and to denigrate the integrity of the doctor–patient relationship. I trace this transformation through the medical school, the clinic, the hospital and the practice, as well as through the contributions and profiteering of private healthcare insurers, hospital conglomerates, the pharmaceutical industry and medical instrument companies. I discuss the particulars of why in the standard eight global statistics of healthcare performance—such as life expectancy and infant mortality, and six others—the United States is markedly inferior to all comparable industrial nations even though we pay more per capita and in percentage (17%) of our gross national product for healthcare than any other country in the world.
As a nation, we have accepted the current state of affairs, not demanding something better. Most of us have consented to receiving inferior medical care, except for the well-to-do who can afford and are willing to pay for concierge medicine, that is, a personal doctor on call. Medicine’s big business is booming—a safe and profitable investment, providing 20% of the highest CEO incomes in our country and represented by five of the top 10 Fortune 500 companies. In contrast, the average healthcare recipient—all of us who are the customers of this system—are not getting our money’s worth for the dollars we pay in taxes, for private insurance policies with additional copayments, deductibles and exemptions, and the costs for pharmaceuticals and medical devices. We are being cheated. We, the recipients of healthcare, are victims of this system.
The focus of this column, and what I don’t discuss in my book, is that our cadre of medical professionals, including those of us who are surgeons, also are victims of the “brave new world” of monetized medicine.
I believe that the foundation of being a doctor rests on the one-to-one doctor–patient relationship, which allows the patient to say, “My doctor,” a designation of trust, and for the doctor to say, “My patient,” thereby accepting responsibility for the well-being of the patient. In such a relationship, the physician has direct involvement in the outcome of the patient’s care and the patient has confidence in the therapy recommended and provided. This relationship is embodied in the personal interactions of the doctor and the patient, including office and virtual visits, and telephone conversations. It cannot be replaced by a telephone call with a succession of gatekeepers, starting with a robot, followed by an interrogator who violates HIPAA standards, and subsequently schedulers trained to obfuscate, defer appointments, spout pablum, and conclude by wishing the patient a good day.
In emphasizing the one-to-one doctor–patient relationship, I do not mean to denigrate the advantages of the group approach for the management of certain situations, such as the expertise of a service line of surgeons, radiologists and oncologists in treating breast cancer. A service line, however, should designate one physician to interact with the patient, a communicator of recommendations, someone who actually listens to patient concerns.
In my opinion, the status quo of depersonalized healthcare corrupts our tenets of professionalism and infringes on the concept of medicine as a personal calling. The definition of professionalism, a doctor’s precepts of behavior, was delineated in Greco-Roman times by Hippocrates and the Roman physician Scribonius Largus. The Charaka Samhita, an ancient Indian code of conduct, states, “He that practices not for money or for caprice but out of compassion for living beings, is the best among physicians.” The seventh-century Chinese ethicist Sun Simiao stressed that the physician must exhibit compassion and practice equal treatment for patients. In 1803, the English physician Thomas Percival published a code of conduct for physicians that was adopted by the American Medical Association in 1847. The American Board of Medicine journal subsequently defined six standards of medical professionalism: altruism, accountability, excellence, duty, honor/integrity and respect. A 1903 dictum by William Osler accurately reflects the essence of professionalism: “The practice of medicine is not a business and can never be one. Our fellow creatures cannot be dealt with as a man deals in corn and coal; the human heart by which we live must control our professional relations.”
A critical examination of current medical practice has to conclude that these principles of professionalism are not being met. Medicine has become synonymous with business. The idea of medicine as a calling that involves patients as fellow creatures has been shunted aside.
I never really knew what I wanted my calling in life to be until my third-year medical school surgical rotation. The life of a surgeon seemed to fit me like a glove: It was my calling. I imagine that a comparable revelation motivates my fellow medical and surgical practitioners. With that sense of commitment, professionalism becomes an everyday reality. A good friend, a monsignor of the Catholic Church who propelled a college into a great university, an educator, an advocate for inclusion and community cohesiveness, responded to my question of how he would like to be remembered by commenting, “I would like people to say, he was a good priest.” In that same spirit, we as physicians would want people to say, “He/she was a good doctor.” Can this statement be reconciled with the lack of a personal calling in today’s physicians?
Some of my fellow physicians may disagree with me. They may believe in and support the current state of healthcare delivery. They may prefer to have a job that provides a steady income without the need to run a business. They may prefer regular daily, weekly and yearly hours; specified times for night and weekend call; patients (clients) covered by hospitalists when they are not on duty; regular, paid vacations; paid maternity/paternity leaves; and other perks. For some surgeons, a system that offers set operating room hours and the ability to leave a case and be replaced by another surgeon is preferable to the time-honored tradition of one surgeon in charge from the beginning to the end of the case. These new norms represent a dilution of responsibility for the care of individual patients, changing the practice of medicine to a group effort, thereby eliminating personal triumph or personal guilt for an individual patient’s therapeutic outcomes.
When the practice of medicine is viewed merely as a job that offers a satisfactory income and personal life for the physician, a tranquil home and family life, with more time for leisure pursuits, the patient in the relationship loses relevance and is sacrificed to the welfare of the physician. National statistics, however, indicate an ever-increasing rate of burnout among physicians, starting as early as medical school. This rise in burnout does not present the life of today’s doctor as a contented one. Neither does the decreasing age of retirement, exhibited not only by those of “the old school” but by the new generations as well.
I believe that the structure of healthcare in the United States today is not only askew but upside down, so that the administrators of patient care and services are on top, supported by a compliant middle layer of doctors, all resting on the ultimate payor base of patients, the sick, the needy, the trusting. To turn healthcare right side up, the patient—a designation that refers to all of us at one time or another—must be at the top of the healthcare edifice. Patients should not be treated as pawns for the convenience and for the profits of this system. Patients should be served by the system they pay for. Today, patients are not the beneficiaries but the victims of this healthcare inversion. We, as doctors, the purveyors of healthcare, are also pawns in the current healthcare structure.
Continuing discussions at the personal, state and national levels about healthcare need to focus on who and what is primary for those involved. Stated affirmatively, healthcare should be for patients, conducted by physicians, and facilitated—not dominated—by or for the benefit of the administration.
Dr. Buchwald is emeritus professor of surgery and biomedical engineering, and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery, at the University of Minnesota, in Minneapolis. His articles appear every other month.
This article is from the August 2022 print issue.
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This is a great review of the collapse of the practice of medicine, and I look forward to reading Dr
Buchwald's book. The current practice of surgery often violates the principles put forth by the College of Surgeons. Pre and post op surgical care. No longer exist. I am 67 yo and I have transitioned to wound care from a very busy Gen Surg practice. I frequently call surgeon's offices to discuss or alert them to post op wound problems. I often get no return call, or the "staff" tell me the surgeon only operates and I need to send the patient to the "post-op clinic". I used to feel that from the moment my knife created an incision, I was responsible for everything with the patients care, and made every effort to achieve the best possible result. This level of "patient ownership" is non-existent in the Big Box medicine world I work in. The MBAs have taken over the practice of medicine and the CEOs make obscene salaries while nurses strike to achieve safe nurse to patient ratios. Medicine is in trouble, but the advertisements tell us it is better than ever.
I tried to fit the base ball game analogy to my experience as both a practitioner and a patient and cannot find any such fit. I agree there has been a change in practice as compared to previous times but it is difficult to say that current practice mode is worse than previous both using outcome and satisfaction as a measure of better. I do not have data to compare both time periods even if there id a certain identified time period. since the delivery of medicine has never been perfect the struggle is how to improve on what was before now. With regards to outcomes here compared to other industrialized nations the reasons cannot be placed on how medicine is practiced now compared to previously but rather on the social processes through which medical care is provided and shows particularly in the spheres in which we are lagging "I discuss the particulars of why in the standard eight global statistics of healthcare performance—such as life expectancy and infant mortality, and six others", are areas that are particularly influenced by the social environment. I am sure that in areas of healthcare that require sophisticated equipment, high technical skill and acute intensive care we will not lag.
"There is no public outcry. Government does not step in but rather facilitates the subjugation of all of us by paying, in one way or another, for 60% of national healthcare expenses from taxes collected from us, the ill-served populace."
Yes there is a public outcry, however speech is money and the people who have money (corporations and the moneyed elite) have cornered speech (outcry) and also government to their own benefit and the detriment of all of us. That is why Elizabeth Warren and Bernie Sanders are not heard or heard but ignored or passed over while those who ensure continuing the current financially abusive system run rampant. When we as doctors are not patients and are strong and making some money these issues are not that important to us but what goes around comes around.
Fact is there has been some immprovement from the days of John Steinbeck's "The Pearl".
Definitely people are living longer, more complex surgery is being carried out on much sicker patients with better success rates than previously and we cannot deny those facts but of cause using the global health outcome rsults we are under perfoming compared to ther equally industrialised nations but what I think we should look at is the main difference between how we deliver health care and other social benefits that impact health compared to those countries.
When I started my career as a new medical student, I never imagined that the dominant emotion I would feel at the end of my career would be sadness. But, even in that earlier time, I watched my father go from triumphant to a beaten-down, disheartened older physician who would speak with sadness about how things once were, but no longer in the earliest days of "managed care". Had I any idea that my professional life's trajectory would mirror his, I would have been better advised to choose a different career altogether. I enjoyed some truly amazing, life transforming experiences during my career. I wouldn't trade those experiences for anything I can imagine. How I wish that those were the dominant memories, rather than the slow motion pile-up that was the experience of my last several years in the saddle. I am the poster child for the descent from triumph into burnout, depression, unwilling and unanticipated disability and termination of my beloved career and vocation in surgery. I own my part in it. I am not a victim, per se. But, I see the causes and effects of an environment that systematically dis-empowered the professional at the expense of the managerial class, the imperial "c-suite", the consultants and other interested parties who do not share the sacred trust between patient and physician. And now, the very foundation of that trust is being eroded by systems of care that divorce the patient from the person of their physician/surgeon and replace that relationship with systems, algorithms, allied health practitioners and the like. It is just cause to weep, and when the weeping is done, to remain in a state of enduring sadness.
Go to the case of Libby Zion and the Bell Commission. Politicians mandated hour restrictions on residents, which had the effect of putting political derived policy above the doctor patient relationship. When your shift is over, you must leave. Patients, well, someone else will take over. That's the moment it started. Academic surgeons protested to no avail. The bad effects on medical practice and surgical training are evident.