Tuesday, October 02, 2007

Are physicians no longer "proud" and "Ethical"

The Covert Rationing Blog's author DrRick uses the phrase "Once-proud,once ethical" to refer to the medical profession. I certainly do not want to believe that the modifier "once" is correct.
However, there seems to be much awash in the land to push the vectors in the direction of less pride and less ethical behavior.

When a doc has to depend on a clerk in some distant place to tell her if she can order a certain test or prescribe a certain drug or perform a certain operation, obviously pride will suffer. What does it do to the ethical framework when a doc in tempted to game the system to make it possible that that test or that drug can be ordered or that operation be perform? How much pride can you feel when you rush through a 7 1/2 minute patient encounter when you realize there are issues that the patients brought up that you can only brush off and move on to the next overly-hurried,doomed to be incomplete patient encounter?

What happens to pride when your medical group agrees to mandate 32 patient encounters per day rather than the leisurely 30 you now plow through? Does your spider-sense ethics tingle
annoyingly when you realize you are setting the stage for even more inadequate medical practice solely because of the perceived need to increase volume? Does your pride titer decrease when you agree to no longer attend patients in the hospital, even though a major part of your internal medical training and to date professional experience has been caring for seriously ill,complicated patients in the hospital and you know that you can do a better job than the recently hired internist-self proclaimed hospitalist who is one year out of training solely because it appears to be economically advantageous to do so?

Does your pride suffer when you see the latest survey of professional compensation that illustrate that your years of training as a internist or psychiatrist or pediatrician or family physician earns you about the same as a CRNA?

What is the effect on your pride when you are labeled a "disruptive" physician because you repeatedly pointed out that the four-hour rule for treatment of pneumonia is wrong headed and likely to cause more harm than good?

I personally am not proud of the-what I consider to be a sea change-in the stated principles of medical training for internists? I refer to the deletion of what was the touchstone of an internist's training- "... in no case should the resident go off duty until the proper care and welfare of the patient is ensured."

I personally am not the proud of the concepts slithered into the new medical professionalism.I have written about this before .I refer to an attempt to substitute for the time honored and pride generating fiduciary duty to the patient a collectivist view of conserving society's resources.

Having said all of that, the really big elephant in the room derives from the fact that much of medical care is paid for with other people's money and as expected those other people want to spend less money and much of their concern seems manifest -as DrRich has eloquently explicated-by covert rationing. With those economic forces at work pride and traditional medical ethics are not likely to enjoy any resurgence any time soon.

3 comments:

rlbates said...

Very nice post. I like to think I am still proud (and ethical) in my profession. Still, the public's image of us does not seem to be the same as when I was a kid. Sad..

Andrew Schamess said...

Yes I have to agree with all you've said. I prefer to practice medicine the way it ought to be practiced. I've started a solo practice so that no one else can tell me how many patients I need to see in a day. But I've also had to accept that I will work very hard, and make very little money. How long I will keep this up, I don't know.

A low moment was when a patient told me his daughter just finished an associates degree as a pathology technician - and was making, as a starting salary, 30% more than I make after 12 years in practice.

Anonymous said...

Another great post. Too many people in medicine and the AMA have too much at stake in the current system that they're unable or unwilling to make the changes needed to fix the system.

I agree wholeheartedly with everything except for the limits on training. These came through after I trained but I remember well the 30 hour ICU shifts and the frequent car accidents by exhausted residents on the way home. I don't doubt that the new is probably a lousy compromise between hospital economics and proper training but the old system was more dangerous than we care to admit.