The Changing Character of Medicine: Are We Headed in the Right Direction?

Vigorous work and determined dedication are minimum requirements for excellence in medicine. Being the best doctors we can be means working long hours on a daily basis, in addition to covering nights, weekends, and holidays on call. It means constant studying to keep up with the latest scientific advances. On top of that, add the tasks of running our own small business as the majority of physicians have done in the past. The work is demanding, but when we can be our own boss, and know we are providing a valuable, and valued, service, it's well worth our time and financial risk. The honor of sharing the intimate, intensely human experiences of our patients' lives is immeasurable.

Now pile on reams of government regulations and paper work which add to overhead costs and subtract from time with patients. Toss in threats of felony charges for billing errors and ever-shifting carrots and sticks to get us to practice the way the politicians think we should practice medicine, instead of the treatment we and our patients determine to be in their best interest. Top it off with the rising risk of litigation and malpractice premiums, and is it any wonder that more and more physicians are choosing the path of employee?

Working as an employee is a reasonable and legitimate option. But when political manipulations of the business of medicine drive this choice, we need to look closely at what is going on. Is it really a move in the right direction to have physicians less independent?

Dr. Donald Berwick, head of the Centers for Medicare and Medicaid Services, definitely thinks so:

The primary function of regulation in healthcare...is to constrain decentralized, individualized decision making....No longer is the physician, paternalistically committed to the patient, the driving force in medical care.

Today, this isolated relationship is no longer tenable or possible....The traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of delivery of healthcare.

A recent article in the New York Times relates how the shift from small business owner to employee affects a physician's politics. But that is far from the most important change that will occur because of this shift. What we really need to pay attention to is how it will affect the practice of medicine itself.

When you are ill, do you go to your physician to receive a government (or industry) derived practice guideline? Or do you want your physician to be able to apply his independent judgment to your individual situation? Which kind of doctor is more likely to be willing to rely on his own judgment in service of your individual best interests? One steeped in the ethics of social justice, beholden to a third-party for payment? Or a physician whose livelihood is directly related to and primarily dependent upon the quality of care he provides to you, the patient?

What if you have an unusual illness, or even a common illness for which a new but not yet thoroughly tested and approved treatment is available? Which physician would be more likely to suggest and/or support an innovative treatment? A doctor whose job depends on keeping the politicians or administrators happy, or the physician whose primary loyalty is to you?

Not only will individual patients suffer from the lack of courageous doctors and patients pushing the envelope of medical knowledge and experience, but society, too, will miss out on innovations and advances. Drs. Jonas SalkLouis Pasteur, Thomas J. FogartyAlfred Blalock, and Vivian Thomas, to name a scant few of the many heroic pioneers in medicine, did not achieve their breakthroughs by following standard practice.

Another point to consider: How much of the professional pride and independence which employed physicians currently maintain is the result of the pre-existing professional culture of physicians as independent businessmen? What will happen when the field is no longer dominated by these entrepreneurial individuals? What will happen when young men and women who want to be their own boss no longer apply to medical school because the standard practice of medicine is that of a salaried employee? Or when the over-regulation of medicine has destroyed the satisfaction and profitability of private practice? Is this a cultural change we wish to encourage?

A significant aim of ObamaCare is to set up structures and mechanisms for monitoring and controlling physician behavior using ACOs designed to corral physicians into centrally controlled payment plans. The ACOs are also configured to use electronic medical records as a quality control and payment device, as well as comparative effectiveness research along with “best practices” guidelines -- all of which are helpful when employed in an advisory role, but which suffocate innovation and prevent customization when variance is punished.

If we are to preserve medical excellence, in quality, efficiency, and innovation, we must not simply preserve independent thinking; we must actively promote and nurture it. A physician's primary orientation must be to the reality of his patients and their specific medical conditions. In a free country, working as or seeking medical care from an employed physician is one of many important alternatives. But using government to give legislative and regulatory preference to this mode of health care delivery over that of private practice is not only an anathema to freedom, it is an anathema to the independent minds of doctors and patients.