Jan 12

In Feuchtblog, I will be publishing several articles regarding healthcare and medicine. This article, as well as several to follow, will be short reflections of mine regarding the status of medicine in our country.

Following my heart procedure and then subsequent Sabbatical, I’ve had time to think about medicine and what is different about my profession from when I began as a private surgeon in 1992. The opportunity of being away from medicine for a year has been especially helpful in delineating what seems to bother me about the “New” Medicine.

1. The feminization/effeminization of medicine: The percentage of physicians that are female have sharply increased, so that in many medical schools in this country, there are now a majority of females. This is especially true in surgery, where the shift toward female doctors have taken a sharp upward turn. As a female, different expectations are held toward the profession. It is often the activity that conflicts, rather than supports family life. The female psyche of being more a nurturing person changes the approach to the patient. Oddly, this feminizing effect on medicine has affected even males. They are no longer supposed to be aggressive. They must be gentle and never lose their temper or raise their voice. They must now approach their patient as an advocate, friend, sympathizer, rather than as the authority and aggressor against their illness. As we have seen the effeminization of male movie stars, who previously were masculine and tough, Clint Eastwood types, but are now boyish girly men, male doctors have had a tendency to become girly men in the ways mentioned above.

2. The foreign-ication of medicine: I will be the first to comment on my absence of objection for foreign doctors. I believe that foreign physicians stimulate thought and provide wonderful new perspectives to American medicine. My favorite doctor of all time ever, Dr. Das Gupta remains a role model and mentor, though he was born outside of the USA. Yet, I can’t help but think that there is a problem when greater than 50% of our physicians are foreign medical graduates, and not necessarily assimilating into the American cultural belief systems. Besides religion, they differ in such drastic things as how they view the nature of science, medicine, and life itself. Many come here, assuming that wealth and lifestyle will be an automatic given, and often end up frustrated or disappointed when that doesn’t happen.

3. The accelerated gentrification of physicians: we see both an effect on the older physician, and a response that older physicians are giving to their profession in this gentrification. First, modern technology demands rapidly changing practice patterns in order to keep up on the latest-greatest. This often results in ping-ponging of management, that is, certain techniques or management methods are forbidden, then encouraged, and then later forbidden again. Otherwise, newer technologies or treatment plans come in that are often demanded by the patient, but offer no distinct advantage, are far more expensive, but take seemingly forever to discover the errors in their thinking. We see physicians retiring early, or, as soon as possible. They simply don’t wish to put up with the arrogance of younger doctors and competing technologies that seem to be more hot air than distinct helps to the physician or patient. We also see a loss of respect for the older physician. They tend to be out-dated, not with it, hopelessly lost in the past. It takes years to make the best physician judgements, yet these older physicians are no longer respected. A most functional medical community would allow the older physicians to slow down, and work with younger physicians to help them develop skills. This is not happening, and an increasing generational gap happens between younger and older doctors. In times past, the older doctors were able to hone their practice to allow for their decreased ability to be as physically agile or supple as the younger doc. It is more difficult to stay up at night, to have great physical strain in caring for sick patients, yet, there is no reprieve for the aging physician. Thus, for an aging physician, it only makes sense to get out asap.

4. Economic and legal dis-incentivation of physicians– The cost of medicine continues to rise. Prices on medical commodities continue to inflate at standard or accelerated rates, rent and employee costs continue to rise, taxes fail to go down, all of this eating away at physician profitability. Meanwhile, reimbursements continue to fall. When one subtracts costs from reimbursements, you get a number that is essentially your profit. If you divide that profit by the hours that you work, you get an essential pay rate. Currently, when accounting for inflation, I made more as an apprentice typographer than I am currently earning as a physician. Ultimately, physicians will deem the effort not worth it, and consider an employed situation, volunteering, or switching professions. Worst of all, many physicians will remain in their trade, while playing other trades such as gambling with the stock market or real estate investments in order to make a reasonable income commensurate with ones’ education and overall “sweat factor” to get where one is. Remember, most physicians started as quite competitive throughout high school, college, and even competed seriously in medical school, if one desired a more challenging specialty. Residency could be quite variable, but usually seriously limited ones’ lifestyle in years past. As an example, I spent essentially 16 years in “school” past high school to get to a point of being able to earn a living, and all the while accrued hefty school loans. Meanwhile, friends who started to work after high school were able to establish families, purchase homes, and become quite established. Others, who enlisted in the military or worked government jobs immediately after high school were 4 years from retirement by the time I was able to earn my first dime. I don’t pull out too many Kleenex when people complain about doctors’ earnings. But, what about legal dis-incentivation? It is not infrequent nowadays to see articles in surgical journals lamenting that certain surgeries are safer at high volume centers, and even though one may examine their own track records and see competitive  morbidity and mortality rates, the pressure is still extreme to transfer those patients on. When deciding to tackle a more complicated case, the reimbursement is no higher than a simpler case, yet the amount of time spent could be quadruple to ten-fold. At the same time, one is not legally protected for medical “heroics”, but could always be faulted for assuming care of certain patients. Thus, there is every reason to stick with simple cases, and transfer off more complicated, high risk cases. This does a terrible service to many patients, where travel away from families and known surroundings and a known medical community makes life more difficult, and often increases the risks to the patient. I have often seen where patients go off to these “centers of excellence” only to receive vastly inferior care to what would have been provided back home in a smaller hospital. The legal climate offers me no incentive to attempt to retain these patients.

5. The rise of public medical pseudo-professionalism with de-professionalization of physicians–Patient empowerment is a good and a bad thing. It is good when a patient comes to a true specialist and then gets a more complete picture of their current illness or situation. It can be bad when patients determine that they are more knowledgeable than the physician. I wish to add one caveat here. Patients always know themselves best, so that a decision for or against a medication or a surgical procedure is something that they need to choose in their own mind, and it is not good for a physician to force a treatment plan on a patient against the patients’ better sense, no matter how wrong it may seem to the physician. Contrary, when a patient attempts to force the hand of a physician for a treatment that the physician feels to be wrong, you could expect only trouble if the physician gives in. Much public pseudo-professionism is a result of a combination of the internet and big Pharma direct patient marketing. Another way in which pseudo-professionalism manifests itself is with the “2nd opinion”. In the past, a second opinion was often required by an insurance company. Now, many websites encourage seeking a second opinion. The problem with the second opinion is that a patient will never be able to adequately and critically choose between two doctors without a large amount of personal health care experience. Rarely is second opinion thinking correct. I have had patients turn me down because their second opinion physician gave them a kinder hug at the end of the session, or had a slicker office, or had better name recognition from advertising. When I discover that I’ve just wasted an hour or more with a highly anxious patient who just saw me as a second opinion and now is even more anxious in needing to decide between physicians, I will ask them for what criteria they would be using to determine who would be the best physician for them–typically, their answer betrays the other physician promising false security or over-rated expectations of what is physically or humanly possible. Therefore, I refuse to see second opinions, and will immediately cut off a second opinion visit unless the patient swears that they intend to stay under my service. I am not an entertainment committee to amuse the curiosity of needy patients. They can watch a medical soap on television for that.  Meanwhile, while patients become the “professionals”, physicians are rapidly loosing their concept of “professionalism”. I already railed about physician advertising, the loss of a true moral creed for physicians, and increasing dishonesty with physicians. Since the advent of the 80 hour residency workweek, personal time and comfort has taken a strong priority over the care of the patient. I was taught that one always sacrificed personal time when a patient needed your care. Residency meant almost never planning an event, since your primary responsibility was for your patients, and not the movie or restaurant you would be attending that evening. It was considered immoral to be an employed physician, as that meant confused loyalties. All of that is gone, and physicians have become nothing more than highly intensively trained plumbers or electricians. We are no longer professionals, but sophisticated and highly educated blue-collar workers. In return, we no longer have the right to expect to be treated like professionals.

Concomitant with these changes among health care professionals and patients, are changes that are occurring throughout our society, which influence medicine and the attitude of physicians.

1. Loss of personal integrity. I am called by the chart reviewer and asked to up-grade a person’s admission for no reason other than increased reimbursement by Medicare, and Medicare would allow it. The whole idea seemed quite dishonest to me, or at least encouraged serious inconsistencies, that would leave us physicians always wondering from moment to moment whether we were being “honest” rather than violating some crazy medicare rule. Physicians no longer desire integrity as a supreme quality. Efficiency and profitability come first.

2. De-personalization of others. While walking home one day recently, I passed a number of people, and would usually smile at them and either nod my head or say hello to them. The typical response was for the passerby to walk on, head slightly turned away from me, and not even acknowledge the presence of another person. De-personalization has affected medicine in many similar ways, so that people have become more and more fragmented, consisting of lungs and livers and intestines. This attitude has been true of the past, but distinctively truer now, and more obvious on the wards.

So, where does that leave me? In a sense, I dread being back in the bathtub of medicine, since the water now has become quite filthy. The next feuchtblog will talk about who is responsible for breaking medicine. I might eventually write a blog about my thoughts regarding what could be done to fix the healthcare crisis that we are in.

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2 Responses to “Changes in Medicine”

  1. Uncle Dennis says:

    Ken, your comments about “professionalism” strike a resonant chordwith me. My comments are in an article on the topic at:

    http://www.en-genius.net/site/zones/designDEN/design_den/col_071309

    What is happening in health care is but a vignette of what is happening to American society generally. It is in an accelerating collapse. It is time to re-examine long-held assumptions about it and one’s relationship to it and begin to think outside the box.

    Human law affects human behavior. If the law did not promote dishonesty and constrain honest alternatives, health care could be given in a different context and tradition. No wonder alternative health care is on the rise. It is not that the alternatives are always better than what is offered in the allopathic tradition; they simply provide a way of being free of some of the pathologies of “establishment medicine”.

  2. Eliza says:

    Dr. F: Speaking of feminization, I could quote some greats of the faith at length, but I think you’ll accept my word–Luther, Calvin, and even Machen would not be elected elders, or even deacons in certain Reformed churches today. They were too “strong-minded”–they didn’t shed tears (except for tears of repentance). I’m indebted to John Piper’s article on Machen for the bit on him. With Calvin and Luther, you can see their masculinity all over the place.

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