Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD

November 11, 2010: The State of the Medical Profession

By Rob Tenery, MD on November 11, 2010

By most criteria, the medical profession has come far, evolving into an increasingly, complex science that prolongs and saves countless lives everyday. The future holds nothing but promise that more is to come. When the profession first evolved, it was only about two people---the patient and the doctor. As the science grew, so did the influence of other parties. What initially was almost an act of beneficence has by necessity involved into a contractual union between the involved parties. Not that this evolution is bad, or even unexpected, but different.

Costs of delivery and allocation of available resources dominate discussions on health care. Below the surface are subtle changes in our society that have had just as great an effect on health care delivery. Because the public is better informed and the use of marketing by virtually all sectors of the delivery system, the patients base their expectations increasingly on outcomes rather than efforts. As a consequence, the patient/doctor relationship has moved from personal to adversarial all too often.

A less obvious, but just as important, change is occurring in the makeup and attitude of the physician population. The majority of physicians through the ages have been males, who, in some form or another, worked for themselves. It might have been as a solo practitioner in a small rural community, or a specialist in a large group in a city. The major charge in their lives was the practice of their chosen profession. To them, the forty-hour workweek was virtually non-existent. Time commitment to medicine has changed dramatically. Most physicians still consider what they do a ‘calling,’ but it is not their life. They may be just as committed as their forefathers, but are not willing to give up everything for their profession.

A look at the institutions of higher learning reveals one of society’s most significant changes---the increasing role of the female professional. Their medical school enrollment has risen to around fifty percent. Specialties such as pediatrics and obstetrics are areas where many patients now specifically seek out the female physician in growing numbers. This change from male domination not only includes the delivery of care but as spokespersons for the organizations that represent the profession and professors in medical schools. Many of our female colleagues have time commitments to their practices that exceed some of their hardest working male counterparts. Others have obligations outside of medicine that are of equal importance. One of the most obvious would be having and raising children and the unique situations when ‘only the mother will do.’

What do these demographic changes mean? With diversity comes unpredictability. How long will physicians practice? Will they be fulltime or part-time? Which areas of health care will attract the physicians of tomorrow?

The pool of future physicians will have more broad based interests, bringing their own sensitivities and unique approaches to the practice of medicine. Patients will have more choices based on their own individual desires and personalities. With the projected increased need for more physicians, the opening up of the profession could not have come at a better time. The changing priorities of the physician population, the diversification into specialty interests and the growing presence of non-physician providers have created a decentralization of the health care delivery system. In the larger perspective, the physician is no longer the ‘captain-of-the-ship.’ With the ‘moral rudders,’ upon which the medical profession was established, being bashed from all directions, this noble profession finds itself adrift in many areas.

Chaos begins to rein when there is no control or governance. Is our health care system to that point? Almost. The passage of the Patient Protection and Affordable Care Act of 2010 is the most demonstrable evidence that not only is the physician community divided, but relatively ineffective in influencing the course this county takes into the 21st century. Not that the American Medical Association (AMA) and several other medical organizations weren’t asked to the table in the early stages of putting this legislation together. Figuratively, they were. But, how much real input were they able to exert into the crafting the final legislation? The proof lies in the outcome which has yet to be determined. Granted, the legislation does not have a public option, but leaves that alternative open if no affordable insurance packages are available. The recent legislation does little to rectify the out-of-control costs of undocumented individuals in this country who fill the emergency rooms, labor and delivery suites and subsidized out-patient clinics. It only gives faint interest to the inordinate costs expended for defensive medicine. It potentially shifts funds from the Medicare program by creating ‘efficiencies’ that supplement new bureaucracies that monitor and instill even more control over the practice of medicine.

Why has this happened? Because the physicians in this country let it happen. They are not alone or didn't try. An observer only has look at many other organizations and religions to see the almost epidemic apathy for anything that does not create a direct benefit to the participating individual. As a nation, the ‘greater good’ is being subjugated to individual benefit. It is a concept that first came into prominence with the 1960’s ‘me now’ mindset.

When voids in leadership occur there will always be someone or something to fill them. In health care, it is the federal government, the third party payers and the current administration.

Societal changes are and will always be in flux. The U. S. health care delivery system will trend in one of two ways: Either in the direction of a single-payer, capitated system or toward major insurance reforms with supplementation for those who can’t afford adequate coverage. Currently, the trend is in the direction of the former option, because the medical community is no longer in control of its future. On one thing everyone seems to agree---the current system is not viable.

Unless the physician community wakes up and comes together in a more appropriate organizational way, the battle for the future of the profession will eventually be won by others. How can that be accomplished? In two areas. First is by instilling in physicians and future physicians that when they became a part of this profession, they not only took on responsibilities for their own patients, but to the other patients as well. In the broader sense, that means getting involved. Not just with one’s own practice, or specialty, or locality. Just like the ministry, medicine was never meant to be an ‘eight-to-five job.'

Some alarming trends are occurring in physician participation in activities other than their individual practices. There is an increasing recalcitrant attitude by the leadership of many of medical organizations that claim to represent the medical profession. For many who are in charge, it is ‘business as usual’, even when the AMA barely can claim less than one in four practicing physicians as members, and the best state associations are ‘holding steady’ while their penetration into the market decreases with each new crop of physicians. The national and state specialty associations, in a different way, are not doing any better. Although they claim a very high membership penetration, mostly because of their association with board certification and CME, their influence in the political process in Washington and the state legislatures pales beside the potential of the state societies and the AMA.

Government 101, all politics are local. Our leadership in Washington and in the state capitols are beholding to their electorate, not just to one special interest group over another. That is unless that special interest has more resources to perpetuate the individual’s stay in office. When special interests come together, they derive exponentially more influence. The elected leadership is concerned primarily with solving the problem of providing the best care to the most citizens with the funds that are available. Doesn’t that sound similar to what physicians want? The elected representatives are not as concerned with how the funds and resources are allocated as long as their goals are accomplished. They will, and currently are taking over the role of allocation, if the physician community continues to abrogate that responsibility.

The other area that is necessary to restore the physicians’ ability to control the direction of this country’s health care delivery system is a restructuring of the organizations that represent them to reflect political reality and physician perception. Will that happen? To what membership percentage does the AMA and the state associations have to fall before they no longer exert a viable voice in the political arena? How many more pieces of legislation will be passed, that take away the physicians right of free choice before the specialties realize that it is not just about them? How much longer, until the patient/doctor relationship is a thing of the past??

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