PerspectivesAre you interested in submitting a Perspective Article? Be sure to read The Science Advisory Board's Editorial Guides for Perspective Articles. Click here. Values in Medicine: How Will We Keep Hold of Our Oath? by Faith T. Fitzgerlad, M.D. A survey of my 2003 medical school class at the University of California, Davis, showed that about three-quarters had been discouraged by physicians from entering medicine. This is usual among residents and students. Why? Are doctors in such despair that they advise their young not to follow in what was once the dream of their own youth? They are, and they do. Our generation of physicians did well by doing good. We worked hard but we were "in charge." We were held in high regard, trusted and well paid. By following the advice of our teachers in academic medicine and our mentors in practice, we reaped the rewards to which we felt entitled. And it was not just venality, for among the greatest of those rewards were the confidence and affection of our patients and the exhilaration of discovery. We became embittered when, having created the most remarkable period of scientific progress in the history of medicine, and generated an age where the words "medical miracle" became commonplace, we were suddenly stripped of our authority and stewardship by, as it seemed to us, profiteers holding crass mercantile values. Other types of practitioners—from New Age gurus to well-trained nurses—claimed equal, or even greater, value to us. And people who had never practiced medicine, who couldn’t spell the conditions for which they rejected coverage, were telling us what to do. Enraging! Some doctors quit, and others decided that this, like so many other challenges in medical science, could be mastered by study and hard work. We underwent a series of curricular multifocal myoclonic jerks. We tried to regain dominance of our own patch. Some physicians decided to study business but, like wrestling with Proteus, the god who could continually change shape, we haven’t quite pinned it down. We thought we could master business as we did medicine—how arrogant we were! Worse than anything, perhaps, was the mutation of the doctor-patient relationship; "Provider-consumer" just wasn’t the same. Patients weren’t certain whether we worked for them or for the system. In truth, this estrangement from patients had come sometime before the advent of health care reform, as diagnostic technology replaced the touch of the physical exam, and subspecialty medicine fractured continuity of care. The science no longer complemented, but now often replaced, the art of medicine. We forgot that the doctor him or herself is a therapeutic instrument. We were fearful of the non-quantifiable, anecdotal fuzziness of influences—religion, culture, hope, dread, and the primal need of the suffering for magical thought—on the patients’ illnesses. We shunned the shamanistic side of medicine, and alternative practitioners very quickly wiggled into the gap. And over the past three decades, "wellness" replaced sickness in the public mind as the preferred focus of medicine, and this "wellness" encompassed emotional and social well-being as well as perpetual youthful vigor. Now everybody—not just sick people—needed a doctor—and we doctors said: "We can do that!" Once again we were arrogant. So—we had advanced science, developed miraculous technologic diagnostic and therapeutic machines and potions, fractionated patient care among multiple experts, neglected (in fact avoided) our priestly tradition in shame of its intellectual weakness and we also tried to expand our hegemony to cover social and emotional disquietude. Costs soared. Those who paid the bills complained: We were in trouble. Since health was cheaper than sickness, health maintenance was emphasized. Since doctors were trained to care for the sick, others—non-physicians—could often "do" health cheaper and better. Fearful of the competition, we quickly altered housestaff and medical school curricula to cover socioeconomic, political, psychological, cultural, and ethical aspects of prevention, screening, nutrition, and population medicine; many schools even threw in courses on alternative medicine. All of these new curricular efforts were at the expense of core curricular "sickness" subjects, but achieved no increase in patient contact since, in the more crowded curriculum and the growing need to generate clinical income, teachers had even less time available to listen to and be with students and their patients. The most efficient and more reliable "virtual" patient, on CD-ROM or via actor simulation, was used to teach and examine students, while real patients in nursing homes and ward beds complained that doctors spent too little time with them. Sometimes patients were forgotten entirely: About three years ago the then Dean of my medical school issued a directive to all faculty, residents and students. We would all present ourselves at a two-day seminar given by a traveling troupe of for-hire managed-care experts. Attendance was mandatory. True, 80% of our insured were in managed care. True, increased costs and decreased reimbursements were threatening research, teaching and patient care as faculty were driven to a frenetic pace of clinical work. True, the jumble of acronyms, payment plans, multiple and mutable regulations, documentation requirements ("magic words," we called them), pharmacy restrictions, and care algorithms were stupefying. True, we were sending graduating students and residents into the world of mercantile managed care; were we not obliged to prepare them for it? I phoned the Dean. "Mandatory?", I asked. "Absolutely. Vital to us all!" "Everybody? Two days? All faculty? All housestaff? All students?" "No exception. No excuses. Must do!" "But who will look after the patients?" So some of us didn’t go. Now what shall we teach medical students and housestaff? Certainly not how to be the best employees of managed care. Granted, many of the things in the variably proposed new curricula are important, but, frankly, counseling on diet, smoking, and seat belt use, questionnaires on domestic violence and gun control, advice on sexual continence, and most screening and immunizations can all be done without a medical school education. Think: nurses, physician assistants, and technologists can follow protocols; our previously arcane knowledge is now available on the Internet to whomever may seek it; many non-physicians can and do support the patient in his or her search for "wellness." What is so special about doctors? It is a question the managers of for-profit health care plans often ask, and—answering it themselves—believe that we may be more trouble than we’re worth. Why should they pay to create more of us by subsidizing medical education? Even our own accountants at UC Davis referred to the Dean of Students Affairs Office as a "deficit department." So what can we do that non-physicians can't? * We can take care of really sick people; only we physicians can do that. * We can translate knowledge from bench to clinic, from general to particular patients, and questions from clinic back to bench better than anyone else. * We can generate enormous patient trust if it is clearly the case that our physician's oath—that the care of the sick is our principal purpose—is perceived as real and binding. We have eroded the public confidence in that physician’s oath by concentrating too hard on the evils of managed care as they affect doctors. We speak with deep feeling of the "uninsured," not the "uncared for," as if insurance were the only obstacle to our care; we'll give it if we are paid. And we complain about the 7 to 10-minute visit with complex patients, but we "go along" with it because if we don't we will be fired or our salaries will be cut. The patients, rushed through their short appointments, wonder whether we are making a choice between their well-being and ours. And the students are watching, and learning ... this? We talk a lot about "surviving" as professionals in these troubled times, but if in order to survive, we have become what we do not want to be, we may rightly be said not to have survived at all. Managed-care curricula and seminars we attend are replete with advice on coding, organizational structures, efficiency measurements, and the like. In fact, doctors are now advised to become MBAs to succeed in managed care—or to organize into unions to function in it. We have accepted the business model, labor and management, when we should have rejected it from the first. We were not good at it. In my opinion, teaching health care maintenance and managed care is easy medically and nothing new: (1) know the patient population served and what they need in the way of screening and prevention, always asking whether it does any good and if it is worth the cost; (2) diagnose and treat the patients using the best means available and pay as little as possible for the best; and (3) keep the patient's interest superior to your own. All the rest is business. Young doctors, like the class of 2003, came into medicine when many warned them against it. But they persisted because they had a sense of vocation. They need to be doctors in spite of the absence of our "privileges." We can assassinate their inspiration and enthusiasm with our cynicism, or—worse—our visible compliance with what we concurrently tell them is bad care and bad science. We do have power and only physicians have the skills and knowledge to care for sick people and to create new knowledge, and that is what we must teach. Since students learn by imitation, we must not only insist on caring for real patients in time enough to really care for them, but also actively refuse to go along with any system that forces us to do otherwise. Our job as teachers is to teach our students to create a better future for our patients, not how to adjust to a bad one... and that is what we must teach. Managed care for profit as it is now structured must fail. It is not only dehumanizing (people as "work-units," human tragedy as "medical loss ratio"—its Orwellian!), but a pyramid scheme economically as well. Preventive medicine succeeds, but does so by increasing the burden later: It should more properly be called postponative medicine. And when today’s pernicious experiment crumbles as it is already beginning to, it will be the job of the young doctors whom we have taught to create—with their patients, colleagues and society—a new structure of health care, free of profligacy and entitlements, and, most importantly, patient-centered as well as concentrating on the sick. Environments of practice change, economic "realities" change, demographics and social expectations change, even scientific and clinical "truths" change, but the core value of physicians—to serve their individual patients as best they can with the resources available and to seek for better ways to do so—that is the enduring and essential lesson of medical education: If we are denied the opportunity to teach that, then we are no longer teaching medicine. Because such students as I would have us teach are taught to care for their patients with professional devotion, they will be unpopular with management, who sees them as not fully productive and practicing a time-consuming art. Further, their role models—us—are disruptive to efficient systems when we sustain the weak and disabled, support the socially unvalued patient, and advocate for the disenfranchised patient. Moreover, we must engage in curiosity at the bedside and the bench to set our students a good example as well as to advance the work—and this, too, is regarded as a drain on the commonwealth as it is a "no-profit" activity. Why can’t we serve both the sick and society? Simply because their interests conflict, in most cases, and by trying to serve both we would be distrusted by each. Without trust, the doctor is impotent. Business or the state must supplement medical education because businessmen and citizens get sick, and need us to defend them. But they will only believe we are essential if we act as if we are: So please, let us not be rump economists, nor nurse-practitioners, nor allow ourselves to be lumped together with naturopaths or chiropractors—all "providers" together. We are physicians and should teach physicians, requiring that necessary privilege of teaching as a non-negotiable condition of employment. Our young are the best thing we have. What is the future of Medicine? They are. Let us, today’s doctors, not sacrifice them in trying to save ourselves. Faith T. Fitzgerald, M.D. Department of Internal Medicine University of California at Davis Medical Center Sacramento, CA ### Relevant Links: This essay was excerpted from “Medical Education Meets the Marketplace,” which was published by the New York Academy of Sciences. The complete text can be accessed at www.nyas.org/books/medicaled/ The New York Academy of Sciences homepage is www.nyas.org The Annals of the New York Academy of Sciences is now available online at www.annalsnyas.org. Patrons of libraries that subscribe to the Annals in print have unrestricted access to full text of Annals Online articles, as do members of the New York Academy of Sciences. ### << Previous Next >> [ View All Perspectives ] |
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