The professional status of physicians is at risk

According to Wikipedia, up to the beginning of the 19th century there had been only 3 occupations that were considered to be professions, Divinity, Medicine and Law.

A profession is considered a trade or occupation that transforms itself through “the development of formal qualifications based upon education, apprenticeship, and examinations, the emergence of regulatory bodies with powers to admit, discipline members, and enforce adherence to an ethical code of practice.”

Professionals are autonomous, with the “freedom to exercise their independent, professional judgment,” and have “a high degree of control over their own affairs.”  All professions have power, used to control the conduct of its own members, as well as “exercise a dominating influence over its entire field which means that professions can act monopolist, rebuffing competition from ancillary trades and occupations.” A profession is characterized by the power and high prestige it has in society as a whole. It is the power, prestige and value that society confers upon a profession that more clearly defines it.

Physicians have historically been considered the cornerstone of medicine, one of the original and oldest professions. As a result, physicians have for many years now enjoyed a high social status, regard and esteem conferred upon them by society. This high esteem arose primarily from societies’ view and appreciation of the “higher social function of their work, which is regarded as vital to society as a whole” and thus of being special and holding valuable.

I do not believe that the majority of physicians today find themselves meeting many of Wikipedia’s defining characteristics of a profession. Neither as individual physicians, nor as a profession as a whole, do we find ourselves with any significant degree of autonomy, control or power over our own affairs.

Have we done as much as we could have to enforce our ethical code? Do we find ourselves dominating and truly in a position to protect our area of expertise? Have we done and are we doing all we can to ‘rebuff’ the competition? Over time we have gradually accepted being told more and more what to do and how to do it. I believe that to whatever degree we once may have met the defining characteristics of a profession, it was granted to us based solely upon our having survived the education, examinations and apprenticeship(s) we went through. At some point we probably had power enough to protect our area(s) of expertise, but I’m not sure we ever really made the most of it, or even realized we had it.

Over the last several years I believe that as physicians we have put up relatively little resistance to being told what our professional judgment will be, at least if we want to get paid, now referred to as reimbursed. This would not necessarily be all bad, if not for the fact that so much of what we’re being told is based upon cost to the payor and not true quality for the patient. Our government who started things off with entitlements has and is finding it necessary to weigh in even more heavily in order to keep our economy from taking a double dip, or prolonging its slow recovery.

Some hospital systems have formed foundation models, or other types of legal entities needed in their particular state, in order to buy, control and employ groups of physicians. Insurance companies are also getting into the act by buying both hospitals and physician groups. I wonder whose best interest is being considered here. Other hospitals, which are fortunate enough to monopolize their service area, are charging just about however much they want per overnight stay, and insurers have to pay, leaving that much less for physicians and the rest of the healthcare systems’ participants.

Upon entering the profession, I believe that many physicians did not realize that along with the privileges granted to them came the responsibility to guard and protect those privileges, the most important of which was the responsibility of making sure that things were always done in the best interest of the patient. Changes to the characteristics of our profession simply snuck up on most physicians. There has been a certain amount of conscious neglect on our part, most probably from being progressively overwhelmed by busy work, as well as not really knowing what to do about it. How best to protect our area(s) of expertise and/or rebuff the forces working to take away and assume our control, were not part of our education or training.

There has been a fair amount of talk for a while now about the needs for and benefits gained by all parties involved, (e.g. patients, physicians and hospitals) by joining forces and establishing better overall business models, like ACOs. Whether or not you agree with this concept is not as important as that you realize the following. If we care enough about the privileges we earned and the responsibilities that go along with them, it is well past the time that physicians unite, reach common ground, stand up for all that is needed to maintain our status as a profession, thereby allowing us to fight for and protect all that is in a patient’s best interest.

If we don’t, then we should simply expect our continuing transformation back from a profession to a trade or occupation, under the ever increasing control of others.

Richard A. Foullon is a family physician.

 

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  • doc99

    Rage, Rage Against the Dying of the Light – Dylan Thomas

    We have met the enemy and they is us. – Walt Kelley

  • http://makethislookawesome.blogspot.com Pam Curtis

    I’m a little confused by the wording. In the first paragraph, you talk about ” the emergence of regulatory bodies with powers to admit, discipline members, and enforce adherence to an ethical code of practice” and then you go on to talk about professional being autonomous. The two don’t match to me.

    Lawyers aren’t the top of the food chain. The courts are. Heck the court clerks often have more power than any given lawyer. Every lawyer has to go before a judge. It’s not the lawyer’s final say. Far from it.

    But it is the doctor’s final say when it comes to my health. Doctors seem to have this idea that they *should* be the top of the food chain. But that’s not how it really works for any profession. And if you’re talking about Ministry… well, we can see what happened with the “internal governing bodies” there.

    Who do patients go to if a doctor isn’t listening or is behaving badly? Appeal to the doctor’s peers? That’s a great way to run into a “white wall”, just like the “black wall” of the priesthood. And a patient can only go to a lawyer if there are damages. Same with ministries.I’d say doctors are actually suffering from too much autonomy.

    Oh sure, there are lots of regulations…. but that’s a far cry from an actual system with governance and a way to redress wrongs. And the reason why doctors have regulations and ministers don’t …well, y’all are messing with bodies, not just theologies.

    Autonomy is a myth. And it’s not a wise thing to reach for. Too easily that becomes “the smartest guys in the room.” Sure, those are the smartest guys …. in *that* room. What about outside opinions? Well, then there’s the old joke: “Doc, I want a second opinion.” Doc says, “Okay, you’re ugly too.”

    • Joe

      Do you not see the conflict of interests between the court and the legal profession? Being a judge or a clerk is a fast track to a lucrative legal or consulting practice for the young and a reward for the older lawyers where a judgeship is the entry ticket to establishing a political family legacy organization.

    • ninguem

      “…….But it is the doctor’s final say when it comes to my health……”

      Reminder to self: I should never drink coffee while reading KevinMD comments.

  • Melissa

    As stated by Pam – “But it is the doctor’s final say when it comes to my health.”

    This is the myth that society still believes in – I wish I had half of that level of control in my practice.

    Heck, my day would would be provided much higher levels of autonomy if I still had the ability to focus on what biologically/medically matters when I document in the medical records. This autonomy has been precluded by government bureaucrats deciding what’s significant. ( and threatening me with no reimbursement vs. FRAUD accusations if I do not adhere. ) Has anyone noticed bureaucrats, in general, do not make good medical scientist. As a matter of fact, these misguided bureaucratic documentation requirements have vacuumed in huge chunks of time that used to be allocated to interacting with the patient. I presume few patient’s realize how much time, overhead cost, and mental sanity for that matter, are consumed by JUST appeasing the paperwork police. This does not even begin to address the profit margin graphs corporate administrative types are trying to bully you into bowing to. (I suppose if I truly believed the paperwork facilitated better health care, I would embrace it like dental work or any other thing I know I need to do but do not particularly enjoy. But, unfortunately, it only seems to be used to create “loopholes” so the third party payer can forego claims.)

    My conversations, post on this blog, etc. indicate the public has no idea how the physician’s autonomy is being stripped away. The real power now lays in the hands of bureaucrats, insurance CEOs, malpractice norms, hospital CEO’s etc. AND, the highest agenda is not health, but rather money. Maybe we should be doing a better job at informing the public? In short, I so wish the public had a clearer perspective on the forces slowly gaining control over the physicians and patients ability to have the final say in matters of individual health.

    • Creighton

      Maybe we should be doing a better job at informing the public?

      Yes, please. :) I’m a patient, and I’ve been slowly learning this stuff during the long process to get diagnosis and treatment for my rare disease. I think most people have no idea. I had no idea when this whole mess started. These issues contribute so much to the strained relationships between us and our doctors. There is so little information out there about it for the general public.

    • Matt

      You say physician autonomy is being stripped away, but it appears to me that you’re GIVING it away.

  • DougPete

    Hallelujah! Dr. Foullon, you have expressed yourself so well. Thanks for reminding your colleagues they have an obligation to practice guided by their own high standards instead of those imposed by administrators and/or the government. The relationship between doctor and patient is too important to compromise.

  • DRJEBJ

    When I first heard of graduating classes re-writing thier “oaths” I knew we were leaving an era behind. Poor Hippocrates.

  • http://www.ES4P.com Dr Joyce

    Time for doctors to take control and learn the language of business. It doesn’t take an MBA.

  • http://www.endoflifeblog.com Jim deMaine, MD

    Diagnosis: “MDiety Syndrome”! Why are we here? Who gives us the “power”? It’s the patient of course. We are here to serve them, and most have great respect for their doctors. Yes, we need a balance. Where I worked at Group Health in Seattle, it was (and is) a Co-op owned by the patients. The agreement with the Medical Group was that there would be no interference with the practice of medicine. There was always mostly constructive tension between administrators, the Co-op Board, and the docs. If a balance can be achieved then everyone wins. But if the docs are too demanding and unreasonable (not speaking about you or me of course), we lose a lot of credibility.

  • http://www.myheartsisters.org Carolyn Thomas

    Thanks for this, Dr. F.
    As I read your thoughtful post, I was struck by how your profession appears to consider it somehow apart from other “professions” that also fit the description. For example, “A profession is characterized by the power and high prestige it has in society as a whole.” Well, that may depend on geography. Only in the wealthy Western world do physicians expect the “power and high prestige” that having the letters M.D. behind your name confers. If you were a Russian doctor, for example, that phrase would hardly describe your profession.

    As Anton Chekhov (himself a physician) once wrote: “My medical work is progressing little by little. I go on steadily treating patients. I have a lot of friends, and therefore many patients. Half of them I have to treat for nothing, but the other half pay me 3-5 rubles a visit—I need hardly say I have not made a fortune yet.” And Chekhov did not go into government medical service, so actually had what you would call “a high degree of control over his own affairs.” He started writing only to make a bit of extra money, and practiced medicine throughout his stellar literary career. That was long ago, of course, but even now, according to the business journal RiaNovosti, doctors in Russia – particularly rural docs – remain in the list of top 10 jobs with the lowest salaries, along with nurses, shop assistants, secretaries and street cleaners. Not much “power and prestige” there. . .

    Sounds like, sadly, many of our doctors can relate to Chekhov’s lament.

  • Alan D. Cato MD

    Kudos to Dr. Foullon, he has it right.
    On my worst down days, I sometimes think the younger doctors have the upper hand when it comes to soldiering on in this business driven, paper-chase medical atmosphere of today. They should. After all, the young ones have never known any other medical environment for comparison. I have though, and, if that makes my sorrow at today’s system an additional burden for me that my younger colleagues don’t bear, so be it. Paraphrasing the old love saw, it is better to have experienced a grand profession and lost it, than never to have known the grand profession at all!—excerpted from, The Medical Profession Is Dead and the Doctor Is “Critically ill!”(2010) by Alan D. Cato MD, F.A.A.F.P. (past)
    For the past few years, experiences like these and the daily occurrence of countless other insults to the once noble practice of medicine have convinced me that the medical profession is truly dead. I don’t know its precise time of death, but I must have been at its bedside, since it was nothing like this when I first got on board in 1974. Looking back, though, there were clear signs and symptoms even then that the profession was already sub clinically ill. That’s the purpose of this frustrated doc’s rehash of his career and experiences, for placing some of these early signs and symptoms in print, so that anyone, with an interest in medical history and dissatisfied with today’s medical care, can understand how the medical profession came to die, and, for the young doctors in the medical business today,
    providing them with historical proof that a noble medical profession really did once exist!—excerpted from, The Medical Profession Is Dead and the Doctor Is “Critically ill!”(2010) by Alan D. Cato MD, F.A.A.F.P. (past)
    In those days, the best primary care doctors knew who were the best sub-specialists and vice versa. Each recommended the other when the need arose. Medicine then was still an honorable profession percolating with pride, and to be held in high esteem, by
    colleagues, highly esteemed, was one of the most rewarding aspects of it. To be thought of as one of the best thinkers was a kind of carry over from the competitive one-up-man-ship of the clinical medical school years and, believe it or not, was more important than financial success to most physicians then. In those days medicine was a proud
    profession. —excerpted from, The Medical Profession Is Dead and the Doctor Is “Critically ill!”(2010) by Alan D. Cato MD, F.A.A.F.P. (past)
    Respectfully, Alan D. Cato MD, F.A.A.F.P.(past)

  • http://www.facebook.com/people/Jason-Powers/1415928769 Jason Powers

    I have enjoyed reading many posts.  Ive been in practice for 11 years.  Someone correct me if Im wrong but the managed care reform was intended to curtail a runaway health care system.  An old argument but true,  taking money out of doctors’ hands and into large corporations has not only not curtailed the spending, it has made it worse. When we were truly in charge  we spent more time with patients, they were healthier and we didnt do things only because we could eeke out a reimbursement from a system that does not reward prevention but only rewards hasmat-like clean up.  The current system is bankrupting America and we should strongly consider allowing us to regain autonomy.  Doctors are not as greedy and dumb as some suggest.  The crime is that we are not allowed to unionize because health care is a right.  This anti-unionization was passed when we did have autonomy.  Now that we have been relegated to automotons, we should be allowed to formulate a voice.  And I am not speaking about the AMA.  We need a group that is not politically motivated.  We are not poor and sympathy is not what many of us are after.  The considerable time, expense and sacrifice we invest are worth a lot more than where we are heading in our system.  I am double boarded and spend a lot of time maintaing my knowledge base.  I also consider it a privledge to serve others in the practice of medicine.  But several times a day when I have to speak to someone with significantly less training at a managed care company to get approval for a medically indicated medicine, test, or procedure I realize I am not the one with the real MD.  I have to beg a non MD for the right.  I dont even call my prescription pad that anymore.  Its more like a suggestion pad.  Further, when I do speak to a physician who gets paid to deny care without seeing the patient, I want to retch.  How can we allow doctors to practice medicine without examining or interviewing patients?  MDs that get paid more when the insurance company they work for spends less on care is in violation of fundamental principles.

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