The business of medicine: hospitals, 3rd party payers, politicians, drug & technology companies, doctors’ practices, and others in our healthcare system are driven by the dollar bill. It is understandable; this is America. However, in my view, the practice of medicine is one arena in which the dollar bill should not be the primary driving force. Rather, sound, ongoing, non-conflicted doctorpatient relationships, supported by not supplanted by the dollar bill, should be the goal, which we pursue. Why? Because that’s where clinical decisions are made. These relationships are the proximal source of the work of health care. Dollar thinking should not be allowed to compromise the thinking that occurs within the mutual trust developed between the doctor and the patient. Is it possible to remove the dollar bill from doctors’ thinking? I think it is and I think this has to occur, if we are to have healthcare reform. Doctors themselves must acquire the discipline to put their own dollar earnings out of their thinking when they see patients. They also must possess the courage to say NO! NO! NO! to administrators of hospitals, 3rd party payers, politicians, and any others, who try to bring the poison of their business rhetoric to bear upon the functioning of the doctorpatient relationship. Let’s look at just one of a myriad of examples of this subtle business pressure which sounds oh so good but which is in reality poison for the trust, which must be developed between doctors and patients if sound, ongoing, non-conflicted health care is to be our norm: Physician Compacts with the medical centers, which hire them and pay their salary.
Here is the link to one of these: The Virginia Mason Medical Center Physician Compact:
Perhaps print a copy of this compact and then focus on the following sections under Physician’s Responsibilities:
- Collaborate on Care Delivery— Behave in a manner consistent with group goals. NO! The goals are decided within the context of a sound, ongoing, non-conflicted doctorpatient relationship. If the doctor wants/ needs help, it will be available. It’s called Consultation with other doctors, who are specialized in other areas of medical knowledge. Teams of professionals are assembled within medical centers to help bring the medical work, the decision making of the doctorpatient relationship, to fruition but not to assert group goals on this decision making.
- Listen and Communicate— Request information, resources needed to provide care consistent with VM goals. NO! Doctors listen and communicate within the context of sound, ongoing, non-conflicted doctorpatient relationships. Medical centers exist to enable that communication to occur but not to insert their own goals on top of it.
- Take Ownership— Focus on the economic aspects of our practice. NO! The doctors are not responsible for the medical center’s economic welfare. When this happens, clinical decision making becomes conflicted by those economics.
Let me ask a commonsense question. When you go to the doctor for a medical problem, do you want the doctor to base his/her decision making on their own dollar earnings, their own economic welfare? Of Course Not! This superimposes dollar conflict on top of clinical decision making. It’s the same conflict if the doctor has the medical center’s economic well being on his/her mind during the course of clinical decision making. And yet doesn’t this business rhetoric in this physician compact sound OH SO GOOD! ( Focus on Patients, Collaborate, Group Goals, Economics etc., etc.)
This business rhetoric is poison. It is one of the techniques socialists use to try to assert their authority and beliefs. (F.A. Hayek: The Fatal Conceit The Errors of Socialism Chapter 7). The business of medicine is socializing our health care by using the techniques of Socialism in partnership with 3rd party payers and politicians for their own end: Efficiency in Spending. That is to say, spend as little as you can to make it look like you’re delivering great medical care to everyone in your community while concomitantly lining the pockets of hospital administrators, helping to maintain the mega-profits of insurance carriers, and, of course, keeping the politicians happy! (R. Garth Kirkwood, MD: Socialized Health Care Reform). If you don’t believe this, try looking up the salary of some non profit medical centers’ CEOs, then decide if you think what I’m saying has any merit. This doesn’t conform to the strict definition of Socialized Medicine only because the government doesn’t own and operate both the financing of health care and its delivery in all of these institutions. http://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a-taxonomy-of-health-care-systems/ But the end result is the same as that evolving from the pejorative context of the term, Socialized Medicine, i.e, fear of and fact of clinical decision making within the context of doctorpatient relationships being manipulated and controlled by someone else other than the doctor and patient to accomplish an agenda, which is not part of clinical medicine despite the best efforts of these someone elses to make us believe that it is.
WAKE UP TO THE WONDERFUL WORLD OF SOCIALIZED MEDICINE IN THE LAND OF THE CAPITALISTS!
Is there a solution to this? Yes, of course there is. Perhaps the most important part of the solution is for doctors and patients to just say NO! to the business of medicine. Doctors and their patients need to make it known to hospitals, 3rd party payers–private and public, and to politicians that the patient employs the doctor not them. The doctorpatient relationship is an employee-employer relationship. It is an unusual one, to be sure, because, although the ultimate power in the relationship belongs to the patient, the employer, (the patient has the choice of doing what the doctor recommends or not) this employer (patient) does not tell the doctor (employee) what to do. The doctor, based on his/her medical training and experience coupled with information from the patient, decides what is best to do for that individual circumstance. The patient can accept or reject the proposed plan of diagnosis and treatment but that does not put him/her in the position of guiding the relationship. The patient participates in the relationship, which is guided by the doctor. This is why TRUST is so important. For many reasons, some of which are doctor-generated, this trust has been lost in America. It needs to be resurrected. But I state this clearly and emphatically: Medical centers and others, who pay the doctors’ salaries, imposing their own business rhetoric on the clinical decision making of the doctorpatient relationship will not restore this trust. It will simply conflict the clinical decision making with dollar signs, $$$, and we will eventually wind up drowning in the green swamp called, The Big Dollar Pie. (R. Garth Kirkwood, MD Equal Health Care For All)
One other thought: Don’t let the medical centers’ hiring of physicians fool you. Medical centers have evolved for one reason: To enable the clinical decision making within doctorpatient relationships to occur. And their administrators’ proposals, MDs or not, do not supersede that individual decision making, which occurs within the context of sound, ongoing, non-conflicted doctorpatient relationships. Even though these medical centers pay the doctors’ salaries, patients and the American people in general are the original source of the money within the American health care system. Thus, they are the doctors’ employers.
I believe the following is a good and reasonable ethical position for doctors to follow: Put the needs of the patient above your own needs and above the needs of any group for whom or with whom you work. I believe physician compacts like the one discussed in this essay tear this ethical concept asunder. This business rhetoric is widespread across the USA in many forms and disguises:
- Managed Care
- High Value-Cost Conscious Care
- Evidence-Based Medicine
- Shared Decision Making
- Medical Homes
- Bronze, Silver, Gold, Platinum Insurance
Virginia Mason Medical Center prints their agenda for everyone to see. Their administrators want to be in charge of health care in their institution. It’s a big mistake, but they make it sound so good! I wonder if they have any understanding of the fatal flaws of their own conceit.
R. Garth Kirkwood, MD