Wednesday, January 06, 2010

Why Aren't Doctors Asking "Why the Secrecy?"

With the turn of the calendar to the new decade, the reality of health care reform has set in for doctors and patients. Already cuts to physician salaries and patient access to care are becoming starkly apparent to those of us on the front lines of health care.

I wonder why doctors have been so ineffectual relative to the other special interests “at the table,” in the health care debate? One would think that those with the knowledge base and skill to manage their patients would be the ultimate power brokers in the efforts of health care reform. Yet here we are, watching the commoditization of our profession at the hands of lawyers and politicians in Washington, eager to avoid being perceived as the spoiler.

There appears to be a curious dichotomy, neither very effective, in physicians reactions to the current health care reform plan before our legislature.

One is an almost incredulous, trusting, beneficent universe position of denial – if I work hard and try to help people, they won’t hurt me, right? Altruism is denial’s cousin in this sense: we need to help everyone and our very beneficence will protect us from harm. I will not suffer, my patients will not suffer, and my family will not suffer because anyone can see that I ask nothing. Selfless quality doctors by definition have no interest in protection of income, of time, of the profession – just appeasement glorified as humanitarianism.

We see this as our professional membership leaders failed to ask about the details of the health bills before them nor inquired about the potential flaws inherent to comparative effectiveness research promulgated on large, unfiltered populations. Rather, our representatives capitulated and mollified themselves with platitudes: “I’m sure it will all work out, after all, 30 million more people will have insurance.” No thought about the 23 million who still won't receive insurance nor the impact that these policies to save money will have for the majority of patients that currently have coverage.

The very idea that adult professionals are normally called upon to defend and define the boundaries of their profession is an anathema to these purists. We are scientists and technicians and humanitarians after all. And so, we wash our hands of the debate in the public yard. But none of this is in fact true. Underneath is the trusting assumption that if one works hard, if one hurts no one and sacrifices one’ life for the greater good, then the world will protect us. What a lovely simple position to cling to in the remaining months or years before the reform bill is implemented. It’s a stubborn adolescent holding on to a fair universe.

The other popular position appears to be one of extreme passivity and martyrdom. The chief marker of this syndrome appears to be comments about seemingly catastrophic events in a tone of voice normally reserved for the weather. Our pay is set to be cut 21% while 30 million more people will expect to be seen. Pay for performance measures will be the norm, despite no proof of their utility at improving care. Gosh, doctor, it looks you’ll just have to be employees now. Never mind that the majority of doctors serving patients are not employees of large hospital systems. "Yep, we lost the farm in ’23, as your mother got sick and of course they repossessed the truck…”; the resigned laconic language of hard times. “Nothing I can do about it” has become doctors’ new tag line.

Passivity or denial. As if doctors have no power.

Sadly, as a political force perhaps we don’t. Harnessed with guilt about harming our patients if we set any reasonable boundary whatsoever, perhaps we are hogtied. We are the ones with the skills. We are the ones with the lifesaving relationships. And yet, as a profession, we feel powerless in this debate.

It is interesting to wonder about the source of this empowerment paradox.

To reinforce this observation, in the midst of the final negotiations that will affect every American's health care, a lonely voice in the sea of rhetoric came forth to insist on transparency to the negotiations to consolidate the most important piece of legislation that will affect every one of our patients' lives. Sadly, it was not the AMA or a collective of physicians voices like SERMO, but C-SPAN.

If we as professionals have any gonads or interest in what will ultimately affect the health care of every American across our country, then we ALL should join C-SPAN in their insistence that “all important negotiations” affecting the reconciliation of the final health care bill be televised publicly.

Mr. President, are you listening?



Classof65 said...

Join the club -- our "representatives" aren't representing the patients either. Obviously the Senators and Congresspeople have such wonderful health insurance and such great salaries that they feel no need to talk with constituents about the current healthcare system.

The "representatives" seem to believe that the health insurance companies have all the answers and that there is no need to talk to medical professionals or patients. They intend to present us with a fait accompli and then to wait for the applause... I hope they're not too disappointed when all they hear is complete silence -- or weeping and gnashing of teeth!

doc said...

There IS a petition out there to demand openness in the health bill.
For what it is worth, I did sign it

Steve Parker, M.D. said...

The President and other politicians are listening to the people who brought money, lots of money, to the table.

I love hearing the sound bites of candidate Obama promising "transparency" in the process.

Anonymous said...

We, as physicians, have only ourselves to blame for the mess that awaits us. After all, we are the one's who have been wasting billions of taxpayer $$ each year by prescribing over-priced, unnecessary pills to millions of our patients just to get them out of our offices (purple pill, blue pill, or the one the drug co. is paying us to speak in favor of to our colleagues even though we know the extra cost isnt worth it)

We're the ones wasting Billions of $$ ordering unnecessary tests and procedures that lead to more tests that lead to unnecessary serious morbidity/mortality. (CXR "screening" on asymptomatic pt- read by Rad as suspicious-"suggest CT" -read as possible mass. Thoracic surgeon consult gets you a lung bx, a nosocomial infection etc, etc,etc. We've all seen it, and it continues to happen even at the "best" institutions.

Sure we can blame the lawyers, politicians, insurance companies, but it's time for us to look in the mirror. We killed the Golden Goose.

Keith said...


Doctors do tend to be a passive bunch in my experience. But there is some truth to the anonymous posters comments regarding physician culpabilty in the health care mess. If we were not wasting money on unproven and untested techniques and medications, we probably would not have such a great need to drastically change the current system.

As to the lack of transparency, I am not at all clear how televising the proceedings will change things. Most of this compromise will be hammered out in back room discussions anyways and if you teleevise the discussions, you will only get politicians playing to the cameras.

Anonymous said...

How transparent was AMA all these years when doing it's shady RUC> RVU which killed primary care at the expense of proceduralist? Doctors never explain to patients how much their medications cost, how much they charge for their procedure etc etc. I know exactly how much my car mechanic charged when I pick my car, everything else except health care( maybe wall street deals) seem transparent enough.