No other vocation—not even the sacred ministration of religion itself—requires a more constant exercise of the higher faculties of the human mind, or a more earnest devotion of the purer and nobler attributes of the human soul. … Never suffer yourselves to be betrayed into anything that can degrade your [humanity] or cast the slightest stain upon the bright escutcheon of your honorable profession. - Doctoral Address of Gov. J. Proctor Knott, KY School of Medicine to class of 1890.
Oh, these sweet, noble lies
Those who train future physicians love graduations for the opportunity to repeat exaltations about our sacred calling. Of course, in the middle of a 36-hour call shift, a speech like this can be a lifeline of validation. That speech echoing in your head reminds of the purpose of sacrifice.
Yet, the phrase “Healing is an art, medicine is a profession, health care is a business”* continues to be re-quoted. These articles usually discuss the “reality” of healthcare being a business. They comment on how doctors are increasingly seeking out business training in order to succeed in private practice or leadership settings.
On the one hand, training programs still hammer the importance of self-sacrifice, humility, and service into young physicians. Then, they graduate residency directly into a “business system” which, by definition, is trying to get as much profit out of our “sacred art” for the lowest cost.
Sometimes, it feels that training groomed us for exploitation.
Externality (n) - a side effect or consequence of an industrial or commercial activity that affects other parties without this being reflected in the cost of the goods or services involved.
doctor and patient outcomes: externalities of the “business of medicine”
As much as “value based payment” is in the news, it is far from mainstream and even farther from delivering its promise. The healthcare system makes money from providing a large volume of services, not healing or treating.
In the business of providing a high volume medical services, the outcomes of patients only matter if they sue. The satisfaction of physicians only matter if they leave. Otherwise, they remain externalities.
Healthcare companies prefer greedy physicians, greed is a value they understand and can exploit to their benefit. The noble and principled physicians are a nuisance – disruptive. Those values have no value in the marketplace of American Medicine.
If you can’t bill Medicare for it, it doesn’t exist.
We graduate residency totally unprepared to compete in the arena of business, we don’t even know the rules. As such, we are also unprepared to protect our own humanity from it, let alone our sacred art. The current generation of graduating physicians are inheriting a system that has collected a century worth of stains.
The old Catholic hospital saying is, “No margin, no mission.” It seems now that the margin has become the mission. Medicine has lost its way at the crossroads of the sacred and the commercial.
The healthcare machine has replaced our once bright escutcheon, bearing the symbols of healing and humanity, with the Madison Avenue designed brands of healthcare delivery.
The moneychangers now own the temple.
“It is easy, when you are young, to believe that what you desire is no less than what you deserve, to assume that if you want something badly enough, it is your God-given right to have it.... I thought climbing the Devils Thumb would fix all that was wrong with my life. In the end, of course, it changed almost nothing. But I came to appreciate that mountains make poor receptacles for dreams. - Jon Krakauer, Into the wild
is medicine too, a poor receptacle for dreams?
I had thought medicine would provide a meaningful, useful vocation in life. My teachers taught me I should guard my humanity and the sacredness of my profession.
How can you guard these things when the majority have already sold them before you step foot into practice? Has being a physician become just trading pieces of your soul until you have enough money to FIRE? Is that the best medicine has to offer?
If losing my daughter and my first job taught me one thing, it is no one deserves anything. It seems I have to fight for the kind of medicine I envision, no organization will provide it for me. Is that the lesson?
Maybe my noble profession is not the direct laying of hands on the sick, but struggling for a new world. Is a future where the layers of hands and the sick are once again on the same side possible?
[* Dr. John E. Prescott, chief academic officer, Association of American Medical Colleges, quoted in The New York Times, Sept. 6, 2011]