Andrew Coates: Medicine As A Beleaguered Profession

Aug 3, 2013

A young friend and keen analyst of social change made the observation that it seems that physicians, when it comes to the contemporary state of our profession, seem a bit in shock, as if suffering a grief reaction. She referenced the stages of grief elucidated by Elisabeth Kubler-Ross -- denial, anger, bargaining, depression and acceptance.*

Last week I mentioned an anecdote from a recent essay in the Journal of the American Medical Association in which a medical school Dean asked the incoming class for a show of hands by those who had been advised by at least one physician not to go into medicine -- and 4 out of 5 hands went up across the room. I can attest to the veracity of this anecdote from my own experiences with medical students and colleagues.

Physicians find the profession of medicine in a beleaguered state as the environment and framework in which we practice has shifted around us. The solo practice physician worthy of a Normal Rockwell painting has become a fossil of the past. Physician-run group practices are now also on the endangered species list, as hospitals, corporations, insurance companies and Wall Street investors purchase or develop physician groups.

For example, at the end of April this year Forbes magazine reported "in the [United States] where healthcare faces sweeping changes accelerated by the Affordable Care Act," private equity investors have been "making serial acquisitions of smaller medical practices that they roll up into larger, more efficient groups. In particular, [private equity] funds are assembling groups of practitioners, both in traditional hospital-centered specialties in such areas as radiology and neonatology as well as in emerging fields of hospital-focused specialization like neurology and general surgery."

Once upon a time physicians commanded almost total control over who we worked with, what kind of equipment we needed, how we wanted to spend our day. Now doctors are among the employees, not just of hospitals and non-profit organizations, and not only for-profit entities, but finance capital itself. As physicians experience these changes -- and weigh what it means to care for our patients within these new environs designed to serve the interests of private equity -- we find the potential for conflict between the loyalty owed to our patients and their interests, and the loyalty demanded by our employer.

The American Medical Association last November emphasized the impact of these changes upon physicians by adopting a set of guiding principles for physicians entering into contractual and employment agreements in order to protect the paramount responsibility to patients and the best interests of patients. That the American Medical Association took the time to "address some of the unique challenges to professionalism and the practice of medicine arising in the face of physician employment," seems to me a fair gauge of the pressures upon physicians brought by the "sweeping changes" like the ones Forbes magazine describes.

These pressures will likely intensify unless profit-seeking itself is removed from healthcare, removed from caregiving. What's more, to throw the sweeping changes toward the "profitization" of caregiving into full reverse is entirely practical. A bill before Congress, the Expanded and Improved Medicare For All Act, would ban for-profit medicine.

This week Professor Gerald Friedman, economist of the University of Massachusetts, presented the findings of his analysis of the legislation at a Congressional briefing.  Not only would profiteering be removed from our healthcare system, upgrading the nation’s Medicare program and expanding it to cover people of all ages would yield more than a half-trillion dollars in efficiency savings in its first year of operation, enough to pay for high-quality, comprehensive health benefits for all residents of the United States at a lower cost to most individuals, families and businesses.

With a solution at hand perhaps it is not too much to invoke Kubler- Ross's paradigm of denial, anger, bargaining, depression and acceptance as an analogy, for the societal moment seems to me precipitous. Yet for medicine as a profession although the diagnosis is grave and life-altering, I believe the prognosis is excellent. How we will carry on in the interests of our patients will ultimately win out.

Four out of five of our students may have been warned to stay away from medicine, yet the chose our profession anyway. Physicians and physicians-to-be remain profoundly motivated by the service we perform to our fellow human beings. That spirit will help us lead our system to the kind of real reform we need.

Dr. Andrew Coates practices internal medicine in upstate New York. He is President of Physicians for a National Health Program.

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