Medicine Is Not a Business

The practice of medicine in America is undergoing a major upheaval. As a patient and a physician, I have watched how the practice of medicine has been taken away from clinicians and placed into the hands of politicians and business administrators, at the expense of the doctor-patient relationship. From my perspective, it is clear that the commodification of medicine is destroying this ancient art and critically important profession. 

Commodification, as described by Douglas Rushkoff, happens when market values replace social values. For example, a patient came to me with a burning sensation when she urinated and said, “Give me that purple antibiotic that I only take for five days.” The patient approached the situation as a business transaction: she has burning, I give her antibiotics in exchange for money. 

But as a physician, it is my responsibility to understand more about the symptoms before I prescribe antibiotics, and I may determine that antibiotics would do more harm than good. I provide a service based on my education and training. I have taken an oath to do no harm. 

In modern medical practice, however, it has become routine and acceptable for patients to lodge online complaints when their physician doesn’t provide a specific treatment the patient deems necessary. There is an inherent threat in this market shift, when public opinion, no matter how ill-informed, trumps medical professionalism. I am seen as a dispenser for antibiotics rather than a trained professional, and my livelihood depends how many stars I have next to my name in an online search. 

But the fact remains that the practice of medicine is not a business, and patients are not just customers. In an excellent article on the blog site, KevinMD.com, Shirie Leng points out that patients cannot demand positive outcomes. The outcome of my care for a patient may mean that the patient dies, but that doesn’t mean the service provided to the patient and family was poor. 

Patient satisfaction, then, does not necessarily correlate with the quality of the product. In fact, it may do more harm than good.

The link between patient-driven medical care and poor outcomes is supported by research. In a large study published in the Annals of Internal Medicine in 2012, higher death rates were associated with higher patient satisfaction. More aggressive care to improve patient satisfaction can create instability in a couple of ways: patients perceive they are receiving better care, physicians make more money, get better ratings and face fewer lawsuits. All while delivering potentially harmful services. If I were running a business, I would be thrilled. But as a physician, the fact that providing more care to make everyone happy misses the point that we are causing harm.

I’ve discussed the potential harm that is caused by the assumption that medical expertise is a commodity. In following section, I will discuss how regulation of medicine as a business is leading to increasing administrative burden and burnout. Lastly, I will present some thoughts on how to restore the profession of medicine. 

Even before graduation from medical school, young doctors-to-be are bound by a professional code of ethics. Once they graduate and begin medical practice, the regulation of almost everything they do piles on: there are federal, state, and practice-based rules and regulations, as well as guidelines proposed by each subspecialty professional group. And every one of these requirements and guidelines adds administrative burden, reduce doctor-patient time and doctor job satisfaction. 

For example, I may spend 30 minutes in a difficult conversation with my patient about end-of-life issues. As a cardiologist, many of my patients’ illnesses will significantly reduce their lifespan, and I need to make sure they understand the impact of their heart disease and what we can do about it. But, in order to get full compensation for those 30 minutes, I first have to do a complete assessment, including asking about their eyes, ears, joints, skin and so much more, just to comply with the Centers for Medicare and Medicaid Services guidelines. 

While I do care very much about all of these things, how do those questions improve my patients’ health care in this particular visit? I went to school to be able to learn when I need to ask about hair loss or skin changes. I should not be required to check a box at every visit to prove that I am providing excellent care. 

What started, no doubt, as a good idea, has morphed into a misery-inducing, time-wasting task. One way doctors have gotten around this is to hire more nurses and mid-level healthcare providers to check the boxes. But this also further bloats our current healthcare system. 

If I owned my own practice, I might choose to forego this time-wasting practice and find a different way to support my patients and their health. But more and more small practices are being bought by hospital systems and must now comply with their rules and regulations as well. 

In fact, hospitals own more of the medical delivery pie than ever before. Many physicians were happy to sell their practices, hoping that this would mitigate the costly overhead and bureaucracy of running a practice. But the reality is the opposite. 

Physicians’ income today must pay more than their own salaries and overhead. It also contributes to hospital administrators and CEOs. In a May 2014 piece for the New York Times, Elizabeth Rosenthal summarized a Compdata Survey which showed that an average insurance CEO earned $584,000, a hospital CEO $386,000, and a hospital administrator $237,000. Note that these jobs may or may not require a four-year college degree. Compare that to $306,000 for a surgeon and $185,000 for a general medical doctor, both of whom are required to have at minimum seven years of education after a four-year college degree. 

Particularly egregious salaries include Mark T. Bertolini, the CEO of Aetna, who earned $977,000 in 2012 but had a total compensation package of $36 million. And hold on to your hats, fellow MDs – the U. S. Department of Labor website says that the employment of hospital administrators is expected to grow 23 percent from 2012 to 2022, “much faster than the average for all occupations.” 

We are told that we need high-dollar administrative leaders because running a hospital is complex, that it requires business as well as relational acumen. If we don’t pay them high salaries, we are told, we will lose the high-quality healthcare to which we are now accustomed. 

But despite these dire warnings, a systematic review of the literature published in 2014 showed no correlation between hospital CEO income and variables such as financial performance, organization size, job difficulty and nonfinancial performance. 

So why were hospital CEOs being paid such outlandish sums of money? The authors concluded that “the question of what factors determine health care executive compensation remains unsettled according to the extant empirical literature.” In short, they are earning millions of dollars because they can, not because it provides Americans with better health care. 

As a physician trying to deliver excellent and timely care, I feel I am no longer working for my patients, but rather to provide income for hospital and insurance company CEOs. Not only does this haunt me in my cynical moments, but it intrudes on my peaceful moments, too. 

All this sounds like whining, you may say. To do a complete review of systems may take only 10 minutes. But 10 minutes may be all I have to spend with my patient. And those are 10 minutes I would rather spend helping my patient understand their medications, finding out about the impact of their health problems on their family and work life or answering their questions. After all, that is what I was trained to do. 

On a larger scale, all of these minutes add up. A recent study by Woolhandler and Himmelstein showed that U. S. physicians spend on average one-sixth of their work week on administrative duties, and the more the administrative effort, the less satisfaction experienced by that physician. 

They found that the presence of electronic medical record systems increases administrative hours, and that hospitals rather than small practices come with a greater administrative burden. And doctors are burning out in record numbers. 

In a Medscape survey, burnout rates increased from 40 percent in 2013 to 46 percent in 2015, the highest rates in younger (35 or younger) physicians in small specialties (urology – 63 percent, infectious disease – 61 percent), but also in docs on the front lines: young ob/gyns and internists (53 percent), and pediatricians (47 percent). The top causes for burnout were “too many bureaucratic tasks” and “too many hours at work.” 

Many medical professional societies hold legislative conferences where we can speak to legislators directly and tell them how legislation may improve our ability to provide excellent medical care. 

I have been to these conferences, and they really do mean well. Physicians are given a list of topics considered important to the professional society. We practice our speeches in groups and then meet our legislators. 

In the past, this process was how our legislators learned about problems among their constituents, and it felt good to be part of it. 

But physicians who attend have to pay for their own travel, accommodations and food. We often have to attend on our own time since we are not generally given time off for these kinds of events – the meetings are neither educational nor academic, and they can’t be considered sick time. So when we are not working and catching up with the endless stream of paperwork, we are out trying to defend our lives at legislative conferences that may or may not have impact, at a cost to our families, our personal time and our finances. 

I discouraged my children from becoming physicians years ago, but not because of the administrative burden. I didn’t want my children to have to experience the long years of grueling, often cruel and expensive training. Now I wouldn’t want my grandchildren to become physicians because we are being forced into a business model of health care delivery that is less and less satisfying for the physician, but more importantly, less effective in actually providing care. 

How can we re-create the profession of medicine in a way that improves the doctor-patient relationship and patient health, but also acknowledges the high cost of complex delivery and regulation? We can start with addressing the cost of creating physicians, reframing the incentives that drive our practices and reducing the administrative burdens that diminish our time and experience with patients. 

If we remember that the practice of medicine has social value, then training to become a medical practitioner is a societal responsibility. The average medical school debt in 2014 was $176,000. 

If we decide that medical school should be tuition-free, graduates would be less pressured to seek high-paying specialties in order to pay back loans, and it would be more likely that graduates could practice in underserved areas of medicine, or follow their dream of going into research. Tuition-free medical school has been offered at the Cleveland Clinic for about 7 years now, paid for through general hospital funds. Most students are still in residencies, but they appear to be favoring research or rural medical practices as predicted. Having more physicians in primary care will assist with prevention of major health problems, and having more physician-scientists will create an efficient pathway for investigating our current treatments and creating new ones. 

We also need to asses the value of high-level administrators in complex healthcare systems. Do their high salaries result in better outcomes for our nation or not? This has to be addressed systematically and in an evidence-based way, since there is a great pressure on individual hospital systems to have “the best” leadership. 

Regulations on physicians are oppressive, yet regulations are necessary to prevent destabilization of our complex healthcare system. Physicians are bound by a professional code of conduct, but also by federal regulations, state laws, rules within their own practice, and limitations imposed by each individual insurance company. 

The most administratively burdensome regulations are those imposed by our third-party insurance system, those required for reimbursement. We must abolish the third-party insurance bureaucracy, eliminate the need for preauthorization of testing and unify prescription guidelines, to name a few. This will be the most difficult to accomplish since there is great financial benefit for those at the top of these bloated systems. 

We must collectively decide whether we believe good health is a right or a privilege. If we decide that good health benefits everyone – rich and poor – then good health is a right. It is easily forgotten that we pay as a country no matter which path we take – either we pay for the catastrophic strokes and heart attacks that happen when we fail to prevent them, or we pay for the preventative care up front. If good health is a right available to all Americans, we must invest in a system that provides the same excellent care to the poor as well as the wealthy. It won’t be free, and it won’t be cheap. 

We will have to accept this and manage it together. The Affordable Care Act, regardless of the emotions it inspires, is designed to provide healthcare to those who cannot afford it. It is not yet clear how the Affordable Care Act has impacted the profession of medicine. The main goal – to reduce the number of the uninsured – is certainly being achieved. Whether it is a burden or boon to the practice of medicine remains unknown. 

Ultimately, we must return the dignity of the profession to the practice of medicine. As physicians, we enthusiastically and willingly take an oath to do what we can to heal and restore the health and well-being of our patients. Of course, the physician needs to be reimbursed for his or her time so that he or she can care for themselves and their families, to maintain and restore their own health and well-being. But this does not make medicine a commodity. When we forget that, we run the risk of discouraging outstanding people from choosing and staying in this truly one-of-a-kind profession. 

Safe

When we think deeply, we all know that safety doesn’t exist. We know that the notion of being safe is a construct of our minds, an illusion. Let’s take a moment and ponder this. We are biological beings. The very act of embryonic development is complex and intricate with millions of cells being born, becoming what they should become in orchestrated perfection. But all it takes is for one incorrect message sent between two cells, a few cells go the wrong way, a failure to divide at just the right time, and that’s it – the end of a potential human. And we haven’t even considered yet the difficulties and dangers of childbirth, childhood illnesses, infections, accidents, poisonings, other people… When you think deeply about the inherent dangers of life, the notion of expecting our culture to keep us safe is laughable.

And yet, we expect this every day. We expect that our police will be superheroes, immune to the same wish for safety as everyone else. We believe that our politicians, no less susceptible to the need for feeling safe, to enact and enforce laws that will protect people they do not know and probably do not care about except possibly as a means to gain their next position of power. Even the act of driving to and from work or school feels competitive – I’m going to get there faster, that spot is mine – than a human endeavor. When we feel separate and “exceptional”, we believe that we are entitled to safety, that it is ours, something that belongs to us. And we believe that our leaders can give us complete safety, that it is their job, and our right.

This is perhaps the ultimate con game that robs us all of the gift of caring for one another, of the responsibility for caring. This pseudo-belief that we can be made safe by someone else instills a narrative of “us” and “them” that makes us feel lonely, paranoid, and afraid. When we respond to the inherent lack of safety of our world by giving up our freedom to leaders who promise the impossible, we give them permission to act in destructive ways on our behalf. We allow our leaders to harm others in the mistaken belief that this will at last provide us freedom. If we just kill all those bad people who threaten us, at last we will be free. But we know this is not so.

Globally and historically, we have seen repeatedly that this response has never worked, and never will. Terrible destruction at Hiroshima and Nagasaki stopped a war, but did not eliminate destructive beliefs and actions that continue to wipe out communities and sow fear. We ended one Holocaust in Europe, only to be replaced by others in Europe and Africa and elsewhere. As long as we create a world built on fear, we will perpetuate violence and murder.

Does this inherent absence of safety in our lives mean that we can and should act recklessly, without consideration for others? Does this freedom also mean that since anything can happen to me at any time, I should do whatever I want? Of course not. If we are to survive and thrive as a community and a species, this freedom must encourage an even greater response to remember our connection to one another. We have the ability to choose. This isn’t a right or something given to us, it is biological, to some degree. Even if we are physically imprisoned, we have the ability to choose how we respond to the actions of others. We can choose fear, paranoia, and suffering, or we can choose understanding, connection, meaning, and service.

For me, knowing that every moment might truly be my last creates a freedom to be a better person. I don’t expect my leaders to make me safe. No one can do this, not even my own behavior, as evidenced by the 14 people who died in San Bernadino last week. All were described as kind, generous, warm, connected – the very people on whom violence and death would not, should not in our Judeo-Christian minds, be perpetrated. They probably all wore their seat belts to work that morning, as they should have. They didn’t choose the timing and events of their deaths, but they chose how to spend every moment before that, with grace, generosity, and kindness. While this had no bearing on their murderers, it touched others around them who had better lives because of those who died. To respond to these terrible deaths with fear and more death makes no sense and does not honor those who died. We are more likely to reduce violence by responding with grace. We will honor their lives by acting with compassion and humanity.

Let’s think about the murderers for a moment. They appeared to be trying to kill as many people as they could. Therefore, we can only surmise that they wanted to inflict violent death on as many people as possible before their own deaths, and that there was something in it for them for doing so, otherwise why would they do it? Let’s consider all of the recent American mass murders. Most of them were perpetrated by Americans, neighbors, family members, co-workers. They acquired the beliefs that murdering people would be helpful from somewhere. Can we somehow protect ourselves from everyone with such beliefs? Think about that for a moment. How do we know who they are? Can we know who they are? What is the best way to battle this kind of warfare?

One argument is that we should make sure everyone is armed so that when gunfire breaks out, we can kill the perpetrator. How many times has this happened, despite how many guns are available to Americans? Even more important, how easy has it become to solve problems by shooting? And how many problems have been solved in this way? Are more guns likely to help?

The absence of guns forces us to deal with conflict differently. Those who are violent will act violently. We likely know who these people are from previous behavior. Having a handy firearm allows them to murder with ease. Without a gun, we may have time to find them and those around them the help that they need.

I am not averse to guns, hunters, or target practice. I have owned guns and target practice and hunting is fun when done responsibly. I owned a gun when I was threatened by a dangerous person in my life. I sold it when the presence of a gun was more likely to cause harm than to protect me. Again, responsibility comes into play, that for myself and those around me. I care for my patients with evidence, I try to live by evidence. And I can find no evidence that having more guns leads to more safety. Any leader who tells you this is self-serving and looking for an expedient way to obtain votes. Any leader who generates fear to make promises of safety that cannot be kept is not a leader, they are power hungry and destructive. They do not care about your well being, they care about using your fear to obtain power.

Fear is a self-perpetuating emotion. It is easy to arouse in us because our nervous systems are designed to look for imminent danger. When danger is nowhere near, we often create dangers in our mind that don’t exist because that is what our minds do. Power-hungry people prey on this very human response. They have to then create actual danger to prove that they were right. Is this the kind of world we want to build for our families and our children?

Make no mistake, fear is necessary for our survival. It can protect us from harm in appropriate situations. We can evolve from a reactive fear-based thinking to recognize fear for what it is, and to live not from fear, but along side it. When we let fear control our lives, we give our personal fereedom to something outside of ourselves, conditions of our lives we cannot control. We can help each other heal from these tragedies and create the kind of world we can realistically create, one with inherent danger but also with connection, compassion, and care. We have safety when we know we are connected and act from a sense of community.

The Jennifer Lawrence Effect

Jennifer Lawrence recently wrote about her experience after learning that her male costars were paid much higher salaries than she was paid in recent films after the Sony hacking episode a while back. She described being angry at herself for feeling it was more important at the time to be likeable than to have equitable, appropriate payment for her incredible work. I know what she means.

As an academician, I have spent my life struggling with this kind of reverse fraud. I call it a reverse fraud because there is active deception, but the deception is not to make people think you are better than you are. The deception is designed to make people think you are less than you are so that they feel more at ease in your presence, less threatened, more likeable. I argue, and really this should be obvious to anyone, but when people are asked to squeeze themselves down into a facade for the personal comfort of others, we all lose terribly as a society. This should be obvious, but perhaps it isn’t.

Training to be a scientist requires that you learn how to critically read scientific literature – the works of those who have gone before you – and formulate your own thoughts about their validity. Then you test the ideas you have generated from studying what has gone before. I have worked with scientists who understand this, and when I share my thoughts about a scientific or medical subject, they enjoy discussing the possibilities, leading to new ideas and discoveries. This is how academia should be.

In my training, mostly male physicians didn’t take well to my expressing my thoughts and opinions. Had I been another male, I am certain I would not have been perceived with any threat. I believe my thoughts and ideas would, at the very least, be entertained, heard. I am not so naive to think that there aren’t men out there threatened by other men, but when you look at academics as a whole, even this is accepted. If men find other scientists’ opinions or thoughts threatening, it generates discussion, sometimes loudly.

An entire book was written about one such encounter among male philosophers, called “Wittgenstein’s Poker”. According to the book, a discussion was taking place between prominent philosophers at the Cambridge University Moral Sciences Club in 1946. Ludwig Wittgenstein, who was chairing the meeting, passionately explained his arguments to the paper that was being presented, highlighting his points using a fireplace poker. Various different viewpoints were taken by those in the room or others who heard the story later, but rather than being silenced and told he cannot accept criticism, the actions of Wittgenstein were ultimately seen as passionate discourse. He wasn’t ignored or silenced because of his passion, even though others may have disagreed with him vehemently.

Men who agree find like minded men who agree with them, or some male scientists are alone in their opinions. Sometimes they are right, sometimes they aren’t. But they can speak their mind without the added fear of being alientated just for having thoughts and opinions.

When I have had the audacity to describe data and explain my interpretation of the facts as presented, I have been told that the results are simply artifact. I have been maligned personally. When I explain that other scientists have seen the same thing, rather than consider that my data is a real effect, or perhaps explaining why they think it is artifact, I have been told that I cannot accept criticism. When I spoke up to defend myself, I was told I was difficult. No one would support me openly, for to do so would have tainted them, as well. I received silent support which helped, but did not heal.

When the statement “she cannot accept criticism” appears on your reviews, how do you think this impacts ones career? Imagine how it would feel to stand up for your ideas based on data that is collected, clear as day, only to be shut down and ignored. One has to make a decision at that point: stand up for what you believe and be seen as ugly and unlikeable, or falsify what you are to make everyone around you happier. I think even the Buddha would have been in a quandry over this. To be myself meant to make those around me suffer.

This is only one of many similar stories in my own life, and I am sure there are many such stories from women across the globe.

Is there a way out of this? Very often the way out of suffering is through it. We have to be who we are. We have opinions, thoughts, feelings – some are likeable and some are not. If we all refused to be less than what we are and support each other through the process, and stand by each other, progress could take form. Perhaps other men who see the threat and fear in their colleagues could speak to the men who feel threatened and show how our opinions could be important. Or, perhaps I was wrong and my data was artifact. It would have been better to redirect me with kindness than to publicly shame me. This would have been a better use of everyone’s resources.

Science is about getting closer to the truth. This process only deepens and improves when the thoughts and opinions of all are considered. History is littered with stories of how both men and women have not been believed. But women are most often not only disbelieved, but often personally maligned, put down by being told they “cannot accept criticism”, or worse. Rather than quiet Wittgenstein, when he wasn’t being heard and threw down the poker he used to emphasize his points, he was heard all the more. If anyone said “he cannot accept criticism”, it was drowned out by those who were drawn to his points by his passion. He clearly didn’t care about being liked.

What you really want is to sit around in your pajamas and read the paper

I am a woman in a male dominated field. Once I started studying the heart, I was hooked. I enjoyed thinking about the heart, reading about it, and learning about it. There were probably other fields of medicine that I could have been happy practicing, but cardiology (for me, at least) was exciting, intriguing, and challenging. Given my background in research (I had been in basic science labs for many years), it seemed like a natural fit for me to spend my life in academic cardiology.

When I felt confident that cardiology would be my life career and I began sharing that with people, I was surprised by the responses I got from others. I had done very well in my training as a medical resident. When I compared my work with those of my colleagues, it seemed to me that I was at the very least comparable; based on comments from others, there was no reason to think I couldn’t or shouldn’t consider cardiology as a career.

So you can see that I was completely unprepared for the skeptical looks I got from people when I started to announce my life interest. While I was on the wards rounding on my patients in preparation for rounds with my attending, one of the cardiologists who practiced at the same hospital sat next to me and told me about how his wife, who was a practicing lawyer, now enjoys staying at home in her pajamas and reading the paper, now that she is married to him. Another suggested that what I really needed was a vacation. I am not sure to this day what he meant by this. Perhaps he thought that I was only imagining I could be a cardiologist, that if I took some time off I would get over the idea. I was told by others that I didn’t “look like” a cardiologist – no, I looked more like a pediatrician or a geriatrician. A male resident asked me what kinds of things I cook for dinner. When I told him my husband does the cooking, he paused and started getting red in the face. The resident, my senior, suggested he talk to my husband and tell him who does the cooking in a family.

All of these comments were made in 1995 – only 20 years ago. There were many, many more at the time and since then. These remarks did what they were intended to do – sow doubt. Despite my accomplishments, I began to think I was making a bad choice. Despite the fact that I was in love with the heart, I doubted my ability to practice cardiology.

Fast forward to 2015. Since that time, I have successfully completed a fellowship in cardiology, successfully performed several research post-doctoral fellowships, and published papers both in basic science and clinical science. I earned the esteem of scientists and clinicians and have been invited to speak internationally and domestically. Am I perfect? Of course not. I don’t see myself as the “triple threat” you hear so much about (academicians who are excellent practitioners, writers, and scientists), but I am certainly able and accomplished.

Would the world look different without my work? I would like to think so, but much more important, the women for whom I am now a mentor and a role model would not have had me to look at and decide, “Yes, I can do that”. And of course they can.

Perhaps the most important point I want to make here, and I will say this many times because it is so critical, is that I never had to take what those people said personally. Of course I did, but all that did was cause me to doubt myself. When I listened to my heart, I knew better. I spent many hours feeling hurt by their unskilled comments, but there was no reason I had to take their comments to heart. To be here now is more than revenge. I did what was inside of me, no more, no less. By taking what they said personally, I wasn’t able to live in the present. I gave precious moments to pain and doubt, when all I had to do was smile politely, and keep on going.

Waking Up

I am an academic physician. Being an academic physician is fairly unusual in itself,  but add to that “woman” and “cardiologist”, and you understand why I’ve felt somewhat alone and separate most of my adult life. I feel this way not only at work where I am one of 16% women cardiologists in the US, but also often in my private life where I have not felt understood by many people, some of whom are related to me.

In the past few years I have embarked on a path of awakening. What does that mean, you may ask? It means taking the time to understand who I really am, and what that means to everyone else. It means learning how to respond and not react in my day to day life. This sounds very easy, but it has been extremely difficult, requires lots of time and honesty, and has involved many tears. But it has lead to real groundedness that feels palpable and solid, and has gotten more powerful as I progress in my awakening. I feel more connected to my own life and those of my patients, family, and friends, and even people I’ve not yet met.

I want to share my experience with you, to perhaps be another voice to strengthen your own waking up process, or inspire you to your own practice. I’d love to hear your stories, and I hope mine help you feel less alone. It is my hope that even if you aren’t a woman academic cardiologist, you will still find support and comfort here. Namaste, and welcome.