It Was Never ‘Just a Job’

We must never let the business of medicine rob us of our identity as physicians. 

The residents and I were stressing on a recent shift about who would take our injured patient to the OR. Hand is the logical service, but if Plastics is covering, they may not want this obvious open fracture. And technically, with an injury starting above the wrist and extending to the proximal dorsum of the hand, maybe it doesn’t actually meet the criteria for a hand case.

“You know,” one of my residents sighs, “My dad was a family practice doc in our small rural community, and he did everything. He took care of CHF and diabetes, he delivered babies, took out appendixes and tonsils, and put patients on the dialysis machine. He never tried to punt a patient. And he loved his work. And his patients loved him.”

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I thought back to my own training, to the surgeon who, prior to entering academic practice, spent the first 20 years of his career as a part time cattle farmer and full time local doctor. We were doing pre-operative rounds one evening, and a patient got out of bed and kissed him, exclaiming to the resident and student team how Dr. Rush had delivered her and her siblings—as well as her own children, cared for her diabetic daddy, done her brother’s cancer surgery, and would be taking out her gallbladder in the morning. And I recalled a surgery rotation at a rural academic hospital when I questioned my chief about a call to see one of the oncology patients who had walked into the office complaining of an earache at 5 p.m. on a Friday. “That’s how we do it here,” the chief said. “You operate on them, you own them. They trust us, so we do everything for them. We only call a consult if it’s something that needs specialty involvement.”

It’s clear that in the twenty years since I graduated from medical school, the fact base of medicine has become far too broad and the skill set far too complex for any one physician to take care of all of any patient’s needs and do it well. But why has our attitude towards our professional self-image and our patients also changed?

Hippocrates referred to his relationship with his profession, even his vocation, as a covenant between him and his patients, and him and his gods. He took full responsibility for his patients, attributing his ability to do so to his skills and medical knowledge, acknowledging that a physician also has social responsibilities to those who she treats.

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“Whatever homes I visit, I will come for the benefit of the sick” means we should practice not because it’s a job, not as a source of income, but for the benefit of the patients. “What I may see or hear in the course of the treatment, or even outside of the treatment in regard to the lives of men, which on no account one must spread abroad, I will keep to myself,” means we should not post about them on Facebook, not laugh about them as soon we leave the patient’s room, not text their stories to our BFFs. While medicine has developed to the degree that portions of the Hippocratic Oath may not be relevant to 21st century practice, why have we tossed it all, when only some of it is irrelevant?

In his book, When Breath Becomes Air, Dr. Paul Kalanithi ascribed his choice of specialty partly to his perception of neurosurgery as one of the only specialties in which you can give everything that you are and everything that you have to your patients. He lamented classmate choices that were based not on what they loved or excelled at but which residencies were shorter and which specialties paid the most. He was dismayed when some at Yale debated whether the statement, “I will place the needs of my patients above my own” should be included in the modern version of the Hippocratic Oath.

A few years ago, I listened to a research project presented at CORD. When residents at five EM residency programs were asked to rank 25 qualities in order of importance, “honesty” was ranked number one, but “putting the needs of my patients above my need to sleep” and “putting the needs of my patients above my own needs” ranked number 24 and 25.

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I believe it is no coincidence that the most noticeable changes in physician attitudes have come as medical practice has increasingly changed from a covenant between doctor and patient to a for-profit industry. Moreover, with the USA being possibly the only country on the planet that regards health care not as a human right but as a business, it should not surprise us that the cost of health care in America is the highest on the planet—and most of that money is not going to doctors, but rather to those who manage us and the business we are being asked to serve. Only 20% of the healthcare dollar goes to physicians and clinicians (Source: Kaiser Family Foundation) and an estimated half of that is paid out by the physician for malpractice insurance and the expenses incurred in running her practice, so physicians ourselves accrue only 10% of the healthcare dollar (Source: Economix).

As corporate medical groups take over the management of emergency departments, who gets admitted and who gets a CT scan becomes a business decision, rather than a clinical judgment. When agencies run by non-physicians determine that patient satisfaction is tied to prompt pain relief, opioid epidemics are created, so that those same agencies can now monitor physicians for over-prescribing.

Unfortunately, while the benefit of regarding physicians as a source of revenue for corporations might be a healthy bottom line, it is not a healthy population. According to the WHO, in 2014 our per capita health care expenditure was a full 29% higher than the second top spender, Switzerland, and 11.5 times the per capita expenditure of Cuba. Our life expectancy ranks 43rd in the world, exceeding Cuba by only a year and two months (Source: WHO), and our infant mortality rate (6.2 per 1,000 live births) falls between that of Croatia and Cuba (Source: US Census Bureau International Data Base).

While much of Cuba’s low per capita expenditure can be attributed to low financial compensation to physicians, doctors there enjoy their work and the relationships that they share with patients. As a taxi driver told me quite emphatically as we barreled down the streets of Havana in his magnificently preserved 1967 Ford Fairlaine, “Cubans become doctors with the passion and dedication that other people become priests or rabbis, and the public treats them with the identical respect and veneration. In America, a doctor earning what a Cuban doctor makes would starve to death! But in Cuba, we bring our doctors eggs and meat, vegetables and fruit from our gardens; we take in their washing; we fix their cars, because they care for us from their souls, and we honor that.”

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Of his own relationship to his profession, Dr. Kalanithi said, “People often ask if it is a calling, and my answer is ‘Yes.’ You can’t see it as a job, because if it’s a job, it’s the worst one there is.”

Too many of us are finding ourselves in the worst job there is. The hours are long, and the pay is comparatively poor. We are judged on throughput time rather than the accuracy of our diagnosis. Corporations track our ordering and admitting patterns and balance the costs we generate against the dividends they can pay to their stockholders. Years of education and training may result in good medical decision making, but insurance companies and big box drug chains control whether or not we are able to give our patients what we know they need. Too often our residents memorize what’s on the Walmart Four Dollar List rather than learn what the best drug is for a given condition. Burnout is high, especially in emergency medicine, and the suicide rate among physicians is twice that of the general population.

We are the experts in what our patients need. Not only were we trained and educated, but we actively learned and practiced in what is arguably the best medical training system in the world. Thus, it would seem ironic that we have the worst health outcomes in the first world. Except that it’s not. Bad results happen when physicians are not making the decisions.

Unfortunately, I don’t believe that the corporatization of medicine in the US is going away anytime soon. But I do believe that we can take back our identity as physicians. We can remember why we chose to go to medical school in the first place. We can reclaim some of the joy of the vocation of medicine. And as we move forward in knowledge, evidence, and skill, let us not lose sight of the fact that our patients entrust us with their most precious earthly possession, their bodies, and we are answerable first to ourselves and our gods for the care that we give them. The admonition to love our patients does not make us eccentric; it makes us physicians.