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American medicine: A profession or a business?

Medical ethics has long been associated with the investigation of moral questions arising at the two boundaries of human existence. We have long studied end-of-life dilemmas as well as issues in neonatal intensive care units. A very small portion of the human lifespan is spent in the birthing and dying process, yet medical ethicists and educators continue to focus much of their attention there. What lies in between is ripe territory for further ethical attention and deliberation.

Becoming an American doctor
Medical ethics curriculum has traditionally focused on moral issues affecting the lives of patients, with the goal of improving patients’ quality of life. Patient autonomy has been elevated to a sacred state. This is all well and good, but the quality of life and autonomy of doctors and nurses has deteriorated to the point of a massive nursing shortage and increasing early retirements or mid-life career changes for doctors—as well as declining medical and nursing school applications. As a practicing academic physician for twenty years, I increasingly witness the disillusionment, despair, and discontent of my colleagues. Wounded and ill healers will not be able to sustain the high quality of healthcare previously known to Americans.

A physician completes four years of college, followed by four years of medical school, followed by three to four years of residency—often followed by a two to three year fellowship before he or she begins practice. That is a total of twelve to fifteen years of training after high school—magnitudes longer than any other profession. By the time the young doctor begins practice, he or she is thirty to thirty-five years of age and may be over $100,000 in debt. He or she has to pay tuition for college and medical school and receives a minimum wage salary as a resident and fellow, while working unparalleled hours performing many unpleasant tasks—often in the middle of the night.

Contrast this to the business student who completes four years of college and a one or two year MBA and earns a salary by the age of twenty-five. Or the lawyer who completes four years of college followed by three years of law school (during which he or she may command a substantial salary during summer clerkships) and begins practice by the age of twenty-six. Little known is the fact that doctors do not make vast sums of money compared to comparably successful businessmen or lawyers. And increasingly doctors are making much less.

So what is the issue? Doctors should not—and most do not—enter their profession with monetary rewards primarily in mind. They should, however, expect to make a reasonable salary commensurate with their education. This year Medicare reimbursements to physicians decreased across the board by 5.4% and are slated to decrease at least that much each year for the next three years. Some physicians are now refusing to take on new Medicare patients in their practice; some mammography centers have been forced to close since Medicare payments do not cover their costs. Compounding the problem is the increasingly burdensome documentation and paper work required for collection and, indeed, for preventing criminal prosecution for fraud. Medical malpractice premiums are reaching all-time highs. We are in a medical malpractice crisis with physicians forced to eliminate certain high-risk services to patients or move to locations where premiums are tolerable. Large medical malpractice carriers are opting out of the business, leaving doctors to scramble for coverage from other companies.

During my training in medical school and residency I was taught that the medical record of a patient was to be a clear, concise, and relevant communication tool to aid in the care of the patient. Today, the very way in which a doctor writes notes in a chart is dictated by Medicare and insurance regulations, which require the inclusion of irrelevant, repetitive and distracting items, that impair communication of crucial medical information. The medical chart has become a documentation tool for reimbursement purposes rather than a communication tool for medical management.

Productivity vs. patient care
Newer diagnostic and treatment regimens grow increasingly complex. The time it takes to explain these to a well-educated patient population also grows, aided by media and internet exposure. While a ten to fifteen minute office visit may have sufficed twenty years ago (when diagnostic and treatment options were much more limited), this traditional time segment is totally inadequate to provide care commensurate with our professional code of ethics mandating informed consent and patient autonomy in treatment choices.

More and more emphasis is being placed on “physician productivity,” defined simply as the number of patients one can churn through the office and bill per hour. To comply with productivity requirements, many physicians are employing nurses or other assistants to do many of the “routine” tasks associated with patient care. These include doing a history and physical, discussing social and family issues with patients, explaining treatment choices and side effects, and following up on the progress of chronic diseases. This trend is dramatically altering the patient-physician relationship and making the practice of medicine much more intense for the physician. The physician is responsible for a much larger pool of patients which he personally knows less well, and is often merely left making the demanding technical decisions of diagnostic and treatment regimens at an ever increasing number per hour.

The increasing stresses of medical practice are being felt even more strongly in our academic medical centers. In addition to the mission of good patient care, academic physicians are also committed to medical research and medical education. The balance between these three goals is hard to achieve when the demands of patient care escalate beyond the manpower and reimbursement available.

Traditionally, academic physicians received less monetary compensation than their counterparts in private practice, but, in exchange, they saw fewer patients and were afforded the opportunity to have more time available for academic endeavors and education. This balance has been grossly violated as reimbursement for patient care decreased and increased patient loads became necessary to support the infrastructure of academic medical centers. Currently, the volume of patients seen by an academic physician may meet or exceed that of a private practitioner, while the academic physician has significantly less monetary compensation and is still expected to fulfill research and educational missions of the institution.

Ironically, it is at this very time that the hours worked and the number of patients seen by residents and fellows is being regulated by the Association of American Medical Colleges. Residents and fellows traditionally performed some of the work involved in caring for hospitalized patients, freeing some time for the attending physician to perform research and teaching duties. While limiting the number of hours worked by physicians in training is a noble and long overdue action, its unilateral implementation leaves the academic attending physician in an impossible situation. The intent of the regulations was to ensure that patients were not being cared for by overly fatigued and stressed young house staff, but its current implementation only ensures that patients will be increasingly cared for by older, more fatigued and more stressed attending physicians. It is also instilling in our physician trainees the perception that the job of a doctor can somehow be limited to set hours and set numbers of patients with disregard for ever-changing patient needs.

The perfect storm
Current conditions are such that we are precariously perched at the onset of the “perfect storm.” The amazing increase in the complexity of medical treatments available is coupled with a decreasing morale and decreasing number of doctors and nurses, declining reimbursements for patient care, increasing demands of an aging population, increasing frivolous medical malpractice claims and expenses, and an incessant push to transform medicine from a professional to a business model, in which the expense of medical care is to be minimized and physician productivity maximized at all costs.

In some respects, it would be easier for physicians to practice in a business model. In a business model of medical care, physicians would be allowed to refuse to care for Medicare patients if reimbursement did not cover their costs or leave them with some profit; in a professional model, they cannot. In a business model, physicians could cut “customer services” and quality of the product to maintain a profit; in a professional model they cannot. In a business model, physicians could close their practices without notice, and move on to some more profitable endeavor; in a professional model they cannot. Perhaps then, when human welfare is at stake–as in medicine–any business model must be government regulated. With the recent wide-reaching scandals in regulated industries such as Enron and WorldCom coming to light, one must think seriously about the government’s ability to impose professional ethical standards on a business model. Turning medicine into a business, and then imposing governmental regulations to protect patients, is unlikely to be successful.

Restoring patients to good health or alleviating their suffering is a whole different league of work than producing consumer goods like automobiles or tennis shoes or energy. Medical professional ethics have dictated that physicians place their patient’s welfare as their primary responsibility. Physicians are required to care for their patients even if that means risk of injury to themselves.

We have traditionally cared for patients with infectious diseases that could harm us and worked longer hours than reasonable for our health or family responsibilities. Doctors will continue to do this, but autonomy, respect, and reasonable, comparative compensation are not unrealistic expectations for highly trained professionals to receive. The professional status and respect of doctors and nurses needs to be as staunchly defended and promoted by the medical ethics community as patient autonomy. If not, our healthcare system will deteriorate into a cadre of “healthcare providers” working in a business model for the bottom line, rather than doctors and nurses working as professionals for the patient’s good.

Robin Lynn Miller, MD is associate professor of Hematology/Oncology in the Winship Cancer Institute of Emory University. She also serves as vice-chair of the Center for Ethics’ faculty advisory board.

[ Posted by Robin Lynn Miller at September 1, 2002 09:09 AM | More Health Science Ethics articles ]

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