The Battle for the Souls of American Doctors

We physicians like to think that we are really different from other workers.

We physicians, perhaps thinking back to that medical school application essay we all wrote, really believe that we went into this career to simply help others.  We physicians truly believe that we always put our patients first.Because we sincerely believe all of the above, we are shocked when someone like Uwe Reinhardt points out that collectively we act just like any other worker in the economy.

The classic 1986 letters between the Princeton professor Reinhardt and former New England Journal of Medicine editor Arnold Relman highlight the tension between how we think of ourselves and how we act.

Relman thinks physicians are special and he asks Reinhardt the following question:

“Do you really see no difference between physicians and hospitals on the one hand, and ‘purveyors of other goods and services,’ on the other?”

Reinhardt is ready with a long answer that should be read in its entirety.  The short answer is that doctors act like any other human beings. A portion of his answer includes the following:

“Surely you will agree that it has been one of American medicine’s more hallowed tenets that piece-rate compensation is the sine qua non of high quality medical care.  Think about this tenet, We have here a profession that openly professes that its members are unlikely to do their best unless they are rewarded in cold cash for every little ministration rendered their patients.  If an economist made that assertion, one might write it off as one more of that profession’s kooky beliefs.  But physicians are saying it.”

I have recently written about the inevitable transition from fee for service payment to global, value-based payment systems, and I was surprised when a primary care physician whom I admire tweeted that he thought the end of fee for service would be the end of primary care.

This tension between the ideal of medicine and the economic reality of how medicine is practiced in the United States is perhaps best summarized by Atul Gawande in his famous New Yorker article about McAllen, Texas:

“Here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community has come to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.”

This morning I was reminded of this battle for the soul of American medicine when I read two articles in the New York Times. On the front page an article titled “Quiet Doctor, Lavish Insider: A Parallel Life” describes how a well-respected neurologist at the University of Michigan capped off his successful academic career by cooperating with federal prosecutors to avoid charges in a Wall Street insider stock trading scandal.

“The riddle for Dr. Gilman’s longtime friends and colleagues is why a nationally respected neurologist was pulled into the high-rolling life of a consultant to financiers and how he, by his own admission, crossed the line into criminal behavior.”

The other article in the Times published on the same day was the obituary of Dr. William F. House who invented the cochlear implant.

“Neither the institute nor Dr. House made any money on the implant. He never sought a patent on any of his inventions, he said, because he did not want to restrict other researchers. A nephew, Dr. John House, the current president of the House institute, said his uncle had made the deal to license it to the 3M Company not for profit but simply to get it built by a reputable manufacturer.

Reflecting on his business decisions in his memoir, Dr. House acknowledged, ‘I might be a little richer today.’”

A major challenge for 21st century American medicine is to cultivate the culture epitomized by Dr. House and avoid the mistakes of Dr. Gilman.

Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billionhealth care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his blog, Kent Bottles Private Views.

19 replies »

  1. DeterminedMD sounds like an angry, bitter individual. I would not want to be his patient, because there’s no way his hatred of the president and Democrats in general, and his general negative attitude and closed mind do not bleed into his interactions with his patients.

  2. Rajesh, let’s stick with primary-care before making sweeping statements regarding how “medicine, as a profession, has lost its way”.

    FFS is accused of driving increasing volumes of expensive tests and procedures to benefit those who provide those expensive tests and procedures.
    Primary-care does perform and does not benefit financially from ordering more tests and procedures (nobody gets rich from performing urine dipsticks and US doctor visits are below OECD averages).
    So how will eliminating FFS from primary care reduce “volume” and costs of health care?

    We can make up imaginary problems and then try to solve them, but I suspect that this won’t help us solve the real problems, and it may actually exacerbate them.

  3. First, the demise of FFS is FAR from certain.

    It’s not as if primary care isn’t really thriving in the world of FFS.

    The root of the issue, in my perspective, is that medicine, as a profession, has lost its way.

    Fixing this will require nothing short of a cultural revolution. The kind of revolution that “To Err is Human” should have caused (among members of the profession) but didn’t.

    A good place to start is medical education. If the people we are training to be tomorrow’s physicians expect to make a ton of money, work autonomously and be able to largely shun accountability, then we’ll have more of the same.


  4. The demise of FFS won’t save a penny, but it will definitely be used to push down doctor pay and reallocate all possible profit to the ACO or whatever you want to call it.

  5. What a loser you are. “Aha moment ” on someone you don’t know, oh, and anyone who files a 1040 is making profit. Thanks for your projection, because such baseless and over generalizations expose you as the profiteer and example A of what I note are the usual suspects here: antiphysicians and/or profit driven business people who just want to corrupt medicine.

    Nice try though. Hopefully some readers see the BS in your rebuttal. I know I do. But hey, take solace, more colleagues than not have sold themselves out. Hey, all for the sake of a buck.

    WHEN physicians like myself bail on the health care “industry”, and then the truth to what PPACA will do for the country without sizeable input from physician leadership, well, good luck defending that situation.

    Oh, here’s an opinion, Obama, Pelosi, and Reid will be gone and hiding from accountability when the feces hits. Enjoy the spoils of blind loyalty!!!

  6. Thank you Margalit. It still amazes me how otherwise smart people are so easily confused by such simple terms. The only system that truly eliminates “fee for service” is the same system that eventually leads to that famous quip, “They pretend to pay us, and we pretend to work.”
    It is also amazing to me the extraordinary lengths and expense to which we as a society are willing to go to compensate for the elimination of the most powerful cost and quality controlling measure ever known to modern health care – the concept of letting the patient control how money is spent on their health care services. (Insurance is NOT a health care service)

  7. And how exactly is the demise of fee for service going to change this?

    Will salaried doctors be exempt from filling out 1040 forms?
    Will doctors paid capitation (as in “I’ll give you $500 per head”) be exempt from filling a 1040?

    And by the way, payment for labor does not meet the definition of “profit”.
    Profit is what’s left after labor payments and other expenses incurred in providing a service or product are deducted from the payment received.

    If folks are concerned about profiteering, than I suggest we stop herding doctors into employment at often self-described profiteering corporations, including those who don’t fill 1040 forms, and who unlike independent primary-care docs, have every incentive to “do more”, and on top of that, insist on charging multiples of what independent physicians do for the same service.

  8. “A major challenge for 21st century American medicine is to cultivate the culture epitomized by Dr. House and avoid the mistakes of Dr. Gilman.”

    @MD: Not sure why you’re so quick to attack with such scathing commentary. Kent is simply providing some perspectives to be taken into consideration for the modern physician. He’s not casting aside strife.

  9. What was YOUR 2012 income, Dr. Bottles?

    I love these corporate management types who just love to hear themselves talking, while being completely dettached of the realities and struggles of the private physician.

  10. One of my aha moments in life happened when a physician friend said to me “Life becomes a lot easier when you understand and accept that we all have something to sell.”

    Actually I’m trying to synthesize, not polarize and make things black and white.

    Your statement that “I’m a physician, not a profiteer” implies inherent inconsistency between the two. If you file a tax return, you report income (profit). You ARE a profiteer, and there’s nothing wrong with that.

    That’s where the world is NOT black and white — you can be a good doctor (and I sense you do care about your patients a lot) and be profitable .

  11. It is amazing how two groups in this argument want to vilify doctors. One group, the antiphysician lobby, will look for anything to make doctors out as villains, we’re just out to screw society for a buck. Well , “buck” that lobby!

    The other, the obscene profit oriented group who just wants to validate that doctors are as compassionless and money grubbing as this group, who practice the defense of projection as an art form. Yeah, well buck you too.

    Nothing said here will change my perspective, there are losers who have MD after their names who tarnish the profession, but these lame efforts to generalize physicians as money grubbing assholes only serves these fraud lobby efforts to disingenuous places.

  12. Yeah, I’ve been filing 1040s all my life. Nice try to make a debate black and white to serve your interests. I’m a physician, not a profiteer.

    Some of us adhere to what we committed to in training. Must piss you off you just can’ t lump me into generalizations!

  13. As a practice consultant I’ve watched good, honest, hard working physicians struggle daily with the challenge of being a physician and being a provider. It’s hard for professionals to wear two hats– running a modestly profitable small business and caring for his/her neighbors.

    Non profit hospitals for the most part behave like their for profit hospital competitors.

    When we treat medical care like any other service or commodity this is what we get. Why are we surprised? Health care is a public good that should be available to all through the care of professional and we ought to use good business practices to assure that health care is delivered to patients at an affordable price.

    Health care can’t be both a public and private good, either it is fish or fowl. We’ve chosen in America to make it a private market good available to those who can afford it or are lucky. I don’t think we can go back.

  14. Doctor,

    Do you and your physician colleagues file a 1040 form with the IRS? Unless your answer is “No”, that makes you “for-profit”.

  15. I don’t think that there is a physician today who would say that they provide suboptimal work even when they are being ripped off by managed care companies. Reinhardt’s views of physicians as being like any other worker are overly simplistic and don’t reconcile at all with views of management experts like Drucker who make clear distinctions between knowledge workers and production workers. Unfortunately physicians are now being treated almost uniformly like production workers and that is the real issue here. Who controls the lives of professionals? Are they semi-autonomous or manipulated on a ridiculous productivity scale by managers and bureaucrats who know nothing about the practice of medicine. How economically efficient is that in Reinhardt’s world?

  16. I appreciate what Dr House did. But the idea that physicians are somehow above it all and don’t care about money is incorrect and simplistic. The idea that they shouldn’t care about money is unfair and reductive.

    That being said, I don’t know any physician that didn’t have some level of altruism, perfectionism, or intellectual engagement that drove their pursuit of a medical career – much moreso than their goal of money, which could have been attained more easily in finance, entertainment, or entrepreneurship. But these goals don’t have to be incompatible with money.

    There is a tyranny of the OR when we should be pursuing AND. Political leaders don’t chase high level offices simply out of altruism, nor do they do it purely for their egos. They do it for both and find a way to channel their dual desires into a productive goal for society. The challenge for the medical profession is in finding the right balance point.

  17. Atal “Why did I go all the way to McAllen when I could have found rip-off fee schedules down the hall at B&WH” Gawande?

    You lost me there.

  18. What debate is being proposed here, medicine as a profession is already forever altered in negative ways since it accepted business model intrusions, and did NOTHING to negate the disruptive intrusions by managed care and the pharmaceutical industry, at least as a stat. Mentors said to me over and over when I was in med school when doctors allowed others to dictate health care matters who were not themselves providers or patients, as those two parts to the relationship remained only with sincere interests in promoting changes, the health care process would be disrupted and ruined.

    So many commenters here have been dishonest and disingenuous in either dismissing or demeaning my perspective that profit margins have no place in providing care. Oh, how ironic the loudest and rudest in fact ONLY have an interest in profit margin matters, just take advantage of the empathetic and caring roles of providers.

    Well, welcome to 25-30 years later and now we as a collective have just sat back and let Obama and ilk screw us completely. I have no faith in my profession as a whole, Dr Bottles notes it fairly accurately above in noting doctors are just worried about financial bottom lines, and let advocacy go down the toilet like an annoyed constipated stool.

    Tomorrow is 12-21-12, will things matter the next day? Personally, I could care less whether the world actually ends tomorrow, I’ve been living on it like it has for the past 10 or more years, just no actual physical decay to ram it home.

    Happy Holidays.