While they were mindful of and grateful for the powerful advances in medicine, they believed that social and economic conditions which influenced the life of a person and a community had a greater impact on a person’s life and health than did the power and might of all of medicine.
They believed that medicine was a profession that involved more than a technical set of skills and a high income. They accepted the responsibility of caring for the whole person; mind, body and soul.
Literature, fine art, poetry, music serve to remind overworked clinicians that they are part of a timeless tradition of healing whole human beings, who present in all their magnificence and complexity. Also, that physicians themselves participate in the tradition of physicians as humanists. Perhaps that’s why a liberal arts education – in my opinion – makes an important contribution to the practice of medicine today.
A modern version of the Hippocratic Oath, the Physician Charter, commits physicians to work toward “the wise and cost-effective management of limited clinical resources.” But there’s little physicians – or anyone else – can do to change the behavior of politicians, insurance companies, pharmaceutical companies, or other entrenched stakeholders. It would indeed be heartening to see a visionary, public-minded physician emerge as a leader of the medical profession in the fight to solve this important and extremely difficult dilemma.
Medical science’s individual servants are crushed under the weight of its promises, becoming commonplace and losing their authority; they are simple service providers who can be sued – often justifiably, moreover – if they commit an error. While the medical researcher, the scientist, and some surgeons whose skill amounts to genuine artistic genius retain immense prestige, in many cases the doctor is now seen only as a repairman who gets the machine running again until the next breakdown.
The bureaucratization of medicine with increasingly complex rules, codes, algorithms, prompts, bylaws, schedules, and administrative structure is leaving its mark, but medicine at its fundamental is still about suffering, healing, and comforting; it is about individuals; it is about relationships and trust; it is about stories.
How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction?
To be fair, many of these experts may be true believers, people who want to do everything they can not to miss anyone who could possibly benefit from diagnosis. But the fact that there is so much money on the table may lead them to overestimate the benefits and ignore the harms of overdiagnosis. These decisions affect too many people to let them be tainted by the businesses that stand to gain from them.
She goes on to discuss some of the issues involved in getting pharmaceutical companies to develop desparately needed new antibiotics. In particular, she explains the need to create a stockpile of new antibiotics that everyone will agree not to use for many years. (If we did use them, resistance would develop almost immediately.) This will mean some people (thousands? tens of thousand?) will die during the waiting period, when they could have lived. (Good luck on that one.) Someone (the government? foundations?) must agree to pay the pharmaceutical companies for all those years of waiting. And the US – for various reasons – will have to do this first.
In a perfect world, doctors would not prescribe – and patients would not take – drugs that do more harm than good. But it’s complicated. The benefits and harms of drugs are determined in randomized, controlled clinical trials. For many reasons, the outcomes of such trials may not provide doctors with the information they need to decide who should take what.
In 1911 the medical profession complained of the “commercialization” of medicine, contending that this led to abuses in pharmacology and the practice of medicine. The Romans failed to check these abuses, which increased as Rome declined. “[I]f we are to avoid such unfortunate deterioration in our own time, we must not shrink from recognizing and resisting the evils which do so easily beset commercialized ages like those of the first and twentieth centuries A. D.”
The real beauty of direct-pay primary care is not only that it’s attractive to patients. It can be a way for struggling primary care physicians to maintain a financially viable practice. The average patient pays $700 to $800 a year for membership. According to a report from Kaiser Health News, this is three times more than a doctor makes for each patient in an insurance-based practice. Not to mention the extra time and the absence of aggravation that comes when doctors eliminate insurance companies.
Medicine is a profession. Economically, it’s sufficiently different from other marketplace transactions that it shouldn’t be run as a for-profit business. When I made that argument in a recent post, I mentioned: “The health care market is basically not price competitive – a patient contemplating brain surgery is not going to be tempted by a surgeon offering a deep discount.” That may still be true of brain surgery, but it’s obviously not true of plastic surgery.
The public may not readily appreciate the adverse financial consequences of a health care system in which the majority of doctors become specialists. But it would understand the story of a primary care physician who chose to end her practice because she was undervalued, overworked, frustrated, and underpaid.
JAMA is much more stodgy than NEJM, at least in my opinion. During the presidential election and then during the debate over health care reform, NEJM published timely commentaries on the issues and made them available online to non-subscribers. It continues to cover topics such as the legal challenges to the health care bill. Not only does JAMA give less space to these issues. Articles in JAMA are not available online without a subscription ($165 for 48 issues).
In part one of this post I explained how a new anatomical understanding of disease in the 19th century changed the practice of medicine. Prior to this insight, there was no need to expose the body to observation or to touch parts of the body that were normally clothed. The anatomical theory sent doctors on a search to discover what was happening inside the body. The new physical exam required much greater exposure and invasion of the body, a significant change for the patient experience.
Well, one reason is that primary care physicians are being financially squeezed out of practicing their profession. There’s a good post at KevinMD on how physicians are responding, along with an acknowledgment of this sad truth in the comments. The post is called “Primary care physicians are rebelling against the system.”
