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The Politicization of the Physician

2004; Lippincott Williams & Wilkins; Volume: 114; Issue: Supplement Linguagem: Inglês

10.1097/00006534-200410001-00064

1529-4242

Robert M. Goldwyn,

Pharmaceutical industry and healthcare

Anyone preparing and delivering a presidential address would do well to keep in mind that, of the 42 presidents that America has had, and of the thousands and thousands of speeches they have given, fewer than fourscore and seven items have lasted long enough to amuse or instruct us. In short, I have no illusions that what I say today will alter the course of plastic surgery or of your lives. Nevertheless, I admit my frailty: I could not forego the occasion of trying to act presidential. The longer one lives, the more reality resembles fiction and the more fiction, reality. The older one becomes, the more one is surprised by not being surprised, by accommodating almost too easily to changes that a few decades ago would have been unimaginable. When I was a medical student (in paleolithic times), I would never have predicted what books a recent issue of The New England Journal of Medicine would review1: Prescription for Profit: How Doctors Defraud Medicaid Medicine, Money and Morals: Physicians as Conflicts of Interest Inside the New Temple: The High Cost of Mis taking Medicine for Religion Enemies of Patients Although for centuries writers and satirists from Molière to Shaw have railed against doctors—their ignorance, avarice, and charlatanism—nothing before has approached the sustained level of open hostility from the public, the media, the politicians, and even from patients toward physicians—the supposed guardians of their health. Never before, and only in the United States, have doctors been so vulnerable to legal harassment, including possible jailing for negligence, as a recent article2 almost gleefully reports. All of this has occurred at a time when the United States stands preeminent in world medicine and when patients, theoretically, can have the best care human beings have ever known. Admittedly, a large number do not have insurance coverage, but this is not necessarily synonymous with their not being able to get medical attention. Gone from within our borders are smallpox, polio, certain death from leukemia, assured amputation from vascular disease, and the enormous morbidity and mortality associated with infections in the past when antibiotics were not available. One could cite many more cogent examples. Paradoxically, the public today has more but wants more—a well-recognized human trait that we doctors also share. Unlike the situation in previous centuries, medicine is no longer the purview of physicians. It belongs more to patients than to doctors. No longer can we, like those in the Middle Ages, speak in Latin to one another to restrict knowledge and demonstrate our superiority and control over the patient. Medicine is a right, not a service to be dispensed because of noblesse oblige on our part. The physician on the pedestal has gone the way of the wooden stethoscope. Not only have we lost our pedestal, but we seem to be losing our perch. Small comfort to us that other authority figures, such as teachers and clergy, have also become lilliputian. These changes in the structure of power have moved with remarkable velocity, making the world we knew as children, not to mention the world of our parents and grandparents, seem antediluvian. We are able to adapt to the scientific and technical changes with apparently less difficulty than to social changes. As dramatic as it was viewing the first man walking on the moon, it was more astonishing to see an angry horde of parents marching in front of a junior high school to urge that their children be given condoms. Jackie Mason, the humorist, once commented that New York City’s schools, which lack teachers and books, have an ample supply of condoms. (He went on to say that kids are doing “homework” when they never did it before!) Although laughter is salubrious, the current social situation in America is not comical. I recognize that every generation likes to flatter itself by believing that it faces a crisis or crises of historic proportions. The reality is that it probably does. Our planet has never enjoyed long periods of peace or freedom from hunger and fear. We seem always to be at the crossroads of something. In his autobiography,3 Pirogov, the celebrated nineteenth-century Russian surgeon, said that in Berlin in the 1830s he had witnessed medicine at the crossroads. The issue then was whether the future was to be based on anatomy and physiology and not “pure observation and experience.” Today our medical crossroads relate not to science but to society, less to the nature of medicine but more to its distribution and its cost. Our concepts of disease, diagnosis, and treatment and its daily practice cannot be considered or understood apart from the larger context of society and its subcultures. Economic fluctuations and social attitudes and values as well as scientific advances all impinge upon how we think and what we do as doctors. At the risk of sounding simplistic, my analysis is that we are presently witnessing in America a democratization that has gone far beyond what our founders envisioned. Much of this good. There is considerably less discrimination now than previously with respect to gender, race, religion, and age. The problem as I see it is the inability of the masses, to use a Marxist term—something probably never previously uttered before this association—to accept the fact that even if we were to have a utopia without any discrimination, we would still have differentiation on the basis of innate ability and acquired skill. Like it or not, we are born with different strengths and weaknesses. This inescapable fact leads inevitably to some stratification. At the top, there are the elite, whether they be opera singers, athletes, politicians, rock stars, professors, judges, or doctors. And within each group, there is further stratification. People resent the rewards and higher status that others with specialized knowledge and talents enjoy. Ostensibly, American society is having a problem in accepting a hierarchy based on talent and skill in areas other then athletics and entertainment. Thomas Jefferson of “created equal” fame, wrote in a letter to John Adams, “I agree with you that there is a natural aristocracy among men. The grounds of this are virtue and talents. Formerly, bodily powers gave place among the aristoi. But since the invention of gunpowder has armed the weak as well as the strong with missile death, bodily strength, like beauty, good humor, politeness and other accomplishments, has become but an auxiliary ground of distinction. There is also an artificial aristocracy, founded on wealth and birth, without either virtue or talent; for with these it would belong to the first class. A natural aristocracy I consider as the most precious gift of nature, for the instruction, the trust, and government of society. … May we not even say, that the form of government is the best, which provides the most effectually for a pure selection of these naturally aristoi into the offices of government?… .”4 Brann, from whose talk I have just quoted, observed that “to excel” comes from the Latin “to rise above the rest” and that Jefferson, and we, by extrapolation, would not be wrong in considering valid “the theory of justifiable elitism.”5 In an interview that I recall but unfortunately cannot locate, Libowitz, the writer, remarked that in America it is almost impossible to state that someone is smarter than anybody else; whereas it is not that difficult to stratify people according to athletic prowess. She went on to say that when she takes a plane, she wants the best pilot, someone chosen on the basis of skills alone and not politics. Along these lines, Madonna, who I am sure has never been quoted at a meeting of this association, said something pertinent to what I am talking about today. She remarked that many women would like to have what she has, but they would never want to work for it. The public is far less disposed to criticize the position and financial standing of athletes and entertainers than they are of physicians. The reasons are several: health care is now a right, but not so a game or a concert, which are luxuries and unessential for the public’s health. There is volition involved in seeking entertainment, whereas most people do not seek illness. Patients resent having a sickness that they never wanted, and they protest even more having to pay for it directly or indirectly. The physician is associated with disintegration, death, pain, and loss. Not so a Broadway musical or even a Shakespearian tragedy, where all that goes wrong is on the stage but not in the house of each person in the audience. Although baseball fans can voice their opinion, and they certainly do, the manager does not have to heed their advice. This is true even though the spectators, whether actually at the game or in a living room watching it on television, have paid the salaries of the players and the incomes of the owners. In contrast, although the public—our patients, and their elected representatives, the politicians—cannot control disease, they certainly can determine the conditions under which we work. Medicine today is public property. Let me remind you that the United States has about 700,000 physicians; we are far outnumbered by a population of 255 million. The doctor is not a free agent; neither is the hospital and soon, if not already, neither will be the insurance companies. Fast disappearing is the autonomy of everyone in the medical food chain. This is true also with other groups: pilots, teachers, and sanitation workers, to name a few. The essential fact is that any group or any institution deemed indispensable for the public good cannot for long escape supervision by the public. For many doctors, perhaps most, especially if they are surgical specialists, the combination of loss of control, decrease in income, and the prospect of uncertainty has created a disconcerting milieu in which to work. A major consequence has been to make most physicians, including plastic surgeons, spend increasingly more time processing patients rather than treating them. This is admittedly less true if the plastic surgical treatment involves aesthetic procedures. Nevertheless, the physician—the plastic surgeon—and his or her staff must run the gauntlet of bureaucratic hurdles and abuse. Added to this sorry scene is the attorney often waiting in the wings. I have become increasingly displeased with what I must do each day that relates less to the patient than to the matrix in which I am trying to care for that patient. Although I may be efficient, I am not a perfect machine insensitive to annoying demands from the noncombatant bureaucrats, whose ranks have been joined by many self-serving physicians—whose ingenuity for creating paperwork is apparently limitless—until that time when complete deforestation has occurred. The computer, however, will be there to take over. What we do with our time is not only interesting to contemplate but should be mandatory; yet most of us avoid doing so. Let me force the issue on you. Calculations of reasonable validity tell us that an average American lives to be 74.9 years of age, which means 27,339 days, 656,136 hours, and 39,368,160 minutes.6 During this time, the average American will spend 70,696 hours working, 3 years attending business meetings, 10 months commuting to and from work, 31 months watching commercials, 8 months opening junk mail, 7 years in the bathroom, and 5 years waiting in lines, and will visit the dentist 104 times, be sick 1,086 days, catch 304 colds, have the so-called flu 17 times, take 8,891 aspirins, submit to 10 rectal exams, and have 463 prescriptions filled. An incredible but unsurprising statistic is that the average American male will have spent 126 hours crying compared with 476 hours for the average American woman. For all concerned, it would be better if the figures were reversed. For those of you interested in numbers regarding carnal activities, please see me afterward for the appropriate reference. I realize, of course, that this audience might find more entertaining a discussion of sexual mores, but I am hardly qualified and the occasion is not appropriate. If we assume that the average plastic surgeon will finish his or her training at age 32 and will have a career of 38 years, this means that he or she will have worked 416 months (I have allowed 1 month of annual vacation) or 1,824 weeks of work (again a 4-week vacation each year). This means 10,032 working days (5½-day work week). At 15 operations per week, that physician would have performed 27,360 operations; if that same surgeon saw 20 new patients per week, the figure would be 36,580 during a career—enough to populate a town. I realize that not all procedures are major and that not all plastic surgeons will be doing the same number or type of operations, nor will they see the same number of new patients every year throughout their careers, either by choice or by circumstance. If we calculate that each of us will likely spend 10 hours a week in paperwork, by the time we hang up our scalpel, we will have spent more than 2 years scribbling, or barking into a dictaphone, or playing with the computer. Has there ever been a society so obsessed with documentation? We seem to be recording more than we are thinking. The patient sometimes receives too much inconsequential data and too little meaningful treatment. So much a part of the routine of being a physician has this compulsive record keeping become that we have ceased to question its value. Is the time approaching when we will be having specific days to see patients, and special days to document that we will be seeing them, and then another day after that to document that we have seen them? Actually examining a patient will become a curious activity, perhaps something akin to donning a Victorian corset. The so-called “paper rounds” in which medical house staff and their attendings engage have become also a ritual in surgery, and increasingly so in our offices. It is really unfortunate that we seem to be getting inconvenienced by the presence of live patients. Sometimes, as I am dictating furiously, I wonder how medicine has come so far with having to do so much work that I consider unnecessary and extraneous to the patient, but not unnecessary and not extraneous to the processing of the patient and to the intricate legalistic defensive maneuvers that we execute each working day. We have become an electronically advanced culture that approaches in its obsession with paperwork the Hapsburg Empire, which died almost of its own weight in government officials and their paperwork. Future archaeologists might even have trouble figuring out what happened to our civilization. They might conclude that it crumbled from an overdose of cellulose, a possibility that even the most astute archaeologist in the future would likely miss. It will be interesting someday to learn what those who are beginning their surgical careers today will be doing in a couple of decades. What sort of procedures, how many, how many patients, what kind of patients? Will one be judged more by quantity than quality? Will anyone get any kudos for originality? At present, 63 percent of plastic surgeons who are members of the American Society of Plastic and Reconstructive Surgeons are in solo practice. I should imagine that this number will decrease as physicians combine and join Health Maintenance Organizations. They will do this, of course, to get patients in order to make a living. The solo, free-standing, individual plastic surgeon, as indeed I thought I was and tried desperately to continue to be, may be going the way of the 10-cent ice cream cone. In the past, the needs of patients determined how a surgeon would spend his or her time; now, this is dictated by other external agencies and factors—hospitals, insurance companies, state and federal governments. We who are older can remember the days when the hospital was a focus of our activity and served a supportive role. In decades gone by, the chiefs of each service were the most important people in the hospital. Then it was hard to remember who the director of the hospital was. Now it is just the opposite. The hospital has become dominant and the directors of the hospital powerful in their influence and in their money-making capacity, far exceeding in salary and perquisites what is allotted to heads of the various departments.6 Although there may be an occasional doctor on the Board of Trustees, power within the hospital is not in the hands of the physicians. Perhaps that is the way it should be, but it is a difficult reality. Physicians increasingly feel their powerlessness and their disenfranchisement. I realize that only an older physician would be giving this kind of talk. After all, eventually, one attains an age at which it is possible to look back. I confess that I find it hard to accept with a cheerful countenance the blame for the cost of medical care, as if preventing disease and restoring health are minor concerns. What else should demand more attention from a society? Perhaps I am stubborn, but I do not accept the blame for all of the ills of America—for broken families; for teenage pregnancies with lowbirth-weight babies whose care requires enormous expenditures of personnel and finance and whose ultimate cerebral functioning may be less than satisfactory; for violence, rape, and gunshot wounds; for lung cancer from smoking, heart attacks from poor diet and obesity, and injury and death from drunken driving; for drug and alcohol addiction, the appearance of AIDS, and the improper planning for the enormous costs associated with that plague. Perhaps it is that I am getting older also; I have not accepted a cut-off time for the elderly. As I look out of an intensive care unit when I visit a patient in her 80s who is dying from cancer, I somehow lack the courage or the arrogance to consign her to death because of the so-called bottom-line thinking—the costs to the public of taking care of her seeming so extravagant when the same people crowd the streets on their way to spectator sports and shopping malls. I now have more sympathy for and empathy with teachers who are blamed for the poor performance of children in their charge—children who arrive in the classroom neglected, underfed, and often from families that not only are poor but abusive. I do realize, of course, that a physician, like all authority figures, is a convenient target, but I refuse willingly to be one. If then, we do not find emotional sustenance from a grateful society or community or from a thankful hospital or medical school, where will be its source? I hope that the answer, quite simply, is what it has always been—the patient. Ernest Hemingway put it this way: “The thing about yaws is to cure them.” Indeed, the thing about medicine is the patient. Patients, in general, tend to respond positively when the physician is caring, concerned, committed, and (one hopes) competent. Unlike a medication or an anesthetic agent, which have comparatively short half-lives, the effect on the patient by a good physician is long term, even lifelong. The effect goes far beyond even the patient; it extends to family and friends. Presidents come and go; bureaucrats have their moment and then fade away like the paper that they grind out for us to grind back; information on computers may never get retrieved; data once considered important are forever discarded. However, what has lasted, what will always last, is that bond between the patient and physician. I do not know what future term will be used for the person who is ill and the person who is trying to relieve that illness, that pain, that suffering, that deformity. The relationship between two people is as old as human life, and the relationship between a patient and a physician duplicates in many ways the special interaction between two people who care about and need one another. When the music is no longer heard, it is the inner tune that counts, that endures and transcends in time and in memory the articles that we read, the presentations that we hear, the techniques that we learn and think are so important but that comparatively soon become obsolete; even the concepts or so-called principles of what we do end up as outmoded, even humorous, footnotes in the history of medicine. It is a fact that those who pursue happiness seldom find it because their vision as well as their objective can be lost in the heat and the dust of the race. And so the paradox is also true that those who expect less come to receive more because what they get back is more than they had anticipated. I believe that in recent years the practice of medicine has somehow gone astray; its mission has become lost in the process. The trick, if there is one, is to keep the eye on the patient, just as Ted Williams kept his eye on the ball, despite the taunts or even the cheers of the crowd. Does this mean that we should ignore what is occurring? No, but it does mean that we should not become paralyzed by it. The threat of nuclear war has been ominous for decades but we became doctors, raised our families, and took care of patients. In short, we must develop a transcendental philosophy, a state of thinking that permits us to rise above the petty, even the disagreeable. My mother used to say that there are some who when given roses, see only the thorns. I hope that we doctors do not become “thorn birds.” Although it is comforting in the short term to gripe, to have a catharsis, it is not productive in the long term. Pity generates pity, not progress. Let us not forget that, every day, people in teaching, in business, in the ministry, must face change and adapt to it. Think of our patients not just in their role of being ill but in what they do as spouses, parents, children, workers, and bosses. Then add in all the pain, the uncertainty, and the fear that being a patient entails, especially being a patient whom only a miracle can save. If one pauses for a moment to consider the alternatives to what you and I have now, to where we could have been born, to what could have happened to us, as has happened to so many throughout the world and as it happens to our patients, do we really have a legitimate complaint that fate has dealt with us cruelly? I realize this is not a popular kind of talk, that I shall be accused of not being sympathetic to your problems and, perhaps, even to be at the other end of a career and to have no understanding of what young people go through. Yet, I assure you that I am not oblivious to what besets us all. But I can tell you that bitterness is not the way to fight back if one perceives life or a medical career to be a battle. Just as George Herbert said that living well is the best revenge—taking the best care of the patient is the only revenge for us. Let us retaliate against disease and not against our patients—against what ails them, not what ails us. Let us save our energies for what we chose to do with our lives, for what we were trained to do, and for what sets us apart from those who are not physicians. With each new patient lies the opportunity to enlarge ourselves as well as to help others. For me, the words of Thoreau provide a pertinent simile: “In each dew drop of the morning lies the promise of a day. … Only that day dawns to which we are awake. There is more day to dawn. The sun is but a morning star.”7