Published in February, 2006
God is dead, and we have killed Him. Nietzsche
Medicine is dead, and we have killed it. Feucht
Gustav Mahler, in his 9th symphony, detailed in musical terms the arrhythmia which would eventually lead to his demise. According to Leonard Bernstein, who stands as one of the great Mahler interpreters of the twentieth century, the 9th symphony remains the greatest musical testimony to death ever written. Bernstein claims that it is within the 9th symphony that Mahler prophesied and depicted not only his own death, but also the death of tonality in music, as well as the death of society. Mahler’s musical prediction about the death of tonality in music proved to be correct. The remainder of the twentieth century bore witness to the correctness of Mahler’s prediction about the death of society, when the world twice attempted wholesale suicide in the space of two world wars, leaving a culture which more resembles a zombie than a living person.
Mahler’s 9th symphony needs to be the official theme song of Medicine. We are currently observing medicine in its peri-mortem state, experiencing the pain and irregular heartbeat that portends the demise of the entire system. We look in horror as we see arising from the ashes the twentieth century reinvention of medicine, and find it to be not a beautiful and majestic Phoenix that takes lofty flight, but rather a horrid behemoth that neither man nor creator can control.
Who killed medicine? We did. We have only ourselves to blame. I attribute the death of medicine to three factors. First, we abandoned our oaths. The time honored Oath of Hippocrates, though written by a “pagan” Pythagorean mystic in ancient Greece, was immediately adopted by Christian caretakers of the ill, revised by the Jewish physician Moses Maimonides, and adopted in similar form by Muslim practitioners of the healing arts. While having a superficial resemblance to these ancient oaths, modern oaths, such as the Oath of Geneva and AMA Oath, possess an entirely different flavor and intention. Modern oaths fail to adequately protect the rights of the physician or the rights of the patient, including the unborn or infirm elderly patient. The ancient oaths realize that a covenant exists between the physician, the patient, and God or gods. In modern oaths, God is replaced with government, society or third party payors. The new oaths hold us equally responsible to society as to our patient, causing unease when the good of the patient and the good of society seem to conflict. The Hippocratic Oath defines moral standards; the AMA Oath only suggests what may be inappropriate behavior. Na und? Hospitals now tell us to call our patients “customers”. When I complained to the Customer Relations person at my hospital about the inappropriateness of her title, I was soundly rebuked for thinking poorly of my patients by not considering them customers. We arbitrarily and frequently change the standards of behavior that define the good and moral physician. This week, if I fail to date AND TIME my notes and orders, I will be considered an immoral physician worthy of sanction. Last week, I could have been sanctioned for writing q.d. as an abbreviation (I actually wrote instead the latin equivalent “quaque dium” on an order in order to avoid writing the dangerous and forbidden abbreviation, and almost had my privileges revoked for that sin). Who knows what moral standards I will be held to tomorrow?
Secondly, we rolled over dead when ordered to allow physician advertising. The AMA held strong statements forbidding physician advertising (AMA Code of Ethics, 1847) until ordered in 1975 by the federal trade commission to allow this. Poof! Ethic by government edict. There are few physicians or hospitals nowadays that do not advertise. As a result, medicine has become a business and not a profession. Pharmaceutical firms have found that they can outdo physicians, and have inundated not only medical journals, but popular press and television with promises of cures, health, happiness, and vitality that resemble the traveling miracle man in his stage coach pawning off his snake oil to a desperate but wantonly gullible audience.
Thirdly, we have failed by allowing administrators into our relationship between the patient and ourselves. These are the government and third party payors. The Great Society notion of Medicare was hailed as the cure for the elderly lack of access to care, yet has done the opposite, making it more likely that a Medicare-aged person will not be able to find a physician. With third party payors, I am given no reason to contain costs. I want what’s best for my patient. My patients want what’s best for them-self, and will go elsewhere if I don’t provide what’s best. Spare no cost, the insurance company will provide. As a result, the costs of healthcare have gone from reasonable to ridiculous. The current economic system of healthcare is unsustainable, and will soon collapse. The replacement healthcare system will not likely be better.
We all abound with thoughts about the cure to the wounds that will not heal in medicine. We no longer possess the elixir vitae, nor the salve of Isolde that healed Tristan. So, let’s sue somebody. Let’s sue the hospital. Let’s sue the insurance companies. Let’s petition our legislators. Let’s march on Olympia. Let’s beg and plead and polish some legislator’s shoes. Let’s get more laws. Let’s get counter-laws. Let’s remove laws. We need safer hospitals, so let’s regulate them more. Let’s regulate the regulators of the regulators. Let’s devise programs that measure and influence public (customer) sentiment. Let’s pump even more money into the problem. Let’s eliminate (terminate) the inconvenient or the expensive patient from the system. We need a single-payor system. We need to eliminate third parties. We need medical savings accounts. We need rationing of care. Medical courts. Tort reform! Nuke the lawyers! Let’s force patients not to smoke or drink or get sick, and force them to exercise and eat only organic grains. Then, let’s force patients to love us!
So, this week, I will listen to Mahler’s 9th symphony. Solti and Karajan offer superlative recordings of that symphony. So does Bruno Walter, who was Mahler’s student. Bernstein’s recording is transcendental and a must-hear. Mahler’s music, while focusing on death, seems to be more cheerful than thoughts about the future prospects of medicine. Next week, I’ll listen to Korngold’s Die Tote Stadt (The Dead City), the official opera of medicine. If you haven’t heard or seen it, Eric Korngold achieves as a twentieth century composer a mastery of atonal music and stage so sublime as to bring tears to the eyes of even the most amateur musical dilettante. Rummy stuff, that music about death; how can it cheer ole’ doc Feucht?
“The harvest is past, the summer is ended…the wound of my people is my own heart wounded; I mourn and dismay has taken hold on me. It there no balm in Gilead? Is there no physician there? Why then has the health of my people not been restored?” –taken from Jeremiah 8:20-2