Are physicians really that special?

We physicians like to think that we are really different from other workers.  We physicians, perhaps thinking back to that medical school application essay we all wrote, really believe that we went into this career to simply help others.  We physicians truly believe that we always put our patients first.

Because we sincerely believe all of the above, we are shocked when someone like Uwe Reinhardt points out that collectively we act just like any other worker in the economy.  The classic 1986 letters between the Princeton professor Reinhardt and former New England Journal of Medicine editor Arnold Relman highlight the tension between how we think of ourselves and how we act.

Relman thinks physicians are special and he asks Reinhardt the following question:“Do you really see no difference between physicians and hospitals on the one hand, and ‘purveyors of other goods and services,’ on the other?”

Reinhardt is ready with a long answer that should be read in its entirety.  The short answer is that doctors act like any other human beings.   A portion of his answer includes the following:

Surely you will agree that it has been one of American medicine’s more hallowed tenets that piece-rate compensation is the sine qua non of high quality medical care.  Think about this tenet, We have here a profession that openly professes that its members are unlikely to do their best unless they are rewarded in cold cash for every little ministration rendered their patients.  If an economist made that assertion, one might write it off as one more of that profession’s kooky beliefs.  But physicians are saying it.

I have recently written about the inevitable transition from fee for service payment to global,value-based payment systems, and I was surprised when a primary care physician whom I admire tweeted that he thought the end of fee for service would be the end of primary care.

This tension between the ideal of medicine and the economic reality of how medicine is practiced in the United States is perhaps best summarized by Atul Gawande in his famous New Yorker article about McAllen, Texas:

Here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community has come to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.

Recently, I was reminded of this battle for the soul of American medicine when I read two articles in the New York Times. On the front page an article titled “Quiet Doctor, Lavish Insider:  A Parallel Life” describes how a well-respected neurologist at the University of Michigan capped off his successful academic career by cooperating with federal prosecutors to avoid charges in a Wall Street insider stock trading scandal.

The riddle for Dr. Gilman’s longtime friends and colleagues is why a nationally respected neurologist was pulled into the high-rolling life of a consultant to financiers and how he, by his own admission, crossed the line into criminal behavior.

The other article in the Times published on the same day was the obituary of Dr. William F. Housewho invented the cochlear implant.

Neither the institute nor Dr. House made any money on the implant. He never sought a patent on any of his inventions, he said, because he did not want to restrict other researchers. A nephew, Dr. John House, the current president of the House institute, said his uncle had made the deal to license it to the 3M Company not for profit but simply to get it built by a reputable manufacturer.

Reflecting on his business decisions in his memoir, Dr. House acknowledged, ‘I might be a little richer today.’

A major challenge for 21st century American medicine is to cultivate the culture epitomized by Dr. House and avoid the mistakes of Dr. Gilman.

Kent Bottles provides health care leadership consulting and blogs at Kent Bottles Private Views.

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  • krishna

    Physicians are trained professionals and are no different from an engineer, auditor, lawyer, judge, electrician, plumber, hair dresser, or a cobbler.

    I tell this to every patient who equates me with God ( an unfortunate and common practice in India – until either the patient dies or the bill is presented -when they suddenly metamorphosise into demons!!).

    Physicians are human beings ( and some times less so) and have all the failings of one. Physicians come in different kinds and occasionally all kinds may be built into one at various times!!

    To expect physicians to be be enlightened human beings and noble souls is at best wishful thinking and at worst stupidity on the part of society

    • buzzkillerjsmith

      Cobbler? Isn’t that a dessert?

      • NuMoo

        Dude! Cobblestone

  • Shirie Leng

    Having a piece of paper that says you spent 4 years of your life in medical school doesn’t make you anything but in debt. Having an MD doesn’t qualify you to do anything. It gives you permission to learn a skill just like an apprentice does. The reason it looks different to people is that having that piece of paper gives you access to human beings in a way that most people don’t ever experience.

  • querywoman

    A medical degree is a certificate of completion. It does not earn respect. You are in business, just like Wal-Mart or anyone else.
    My past dealings with doctors have left me little to respect! I do know some whom I respect.
    The current medical system lacks an effective complaint system, unlike any other business. My own minister, of a liberal denomination, recently expressed frustration at not being able to complain about a doctor in a hospital situation.
    American doctors are heavily subsidized by the US government, even if you don’t accept government payments. If you went to school on a government loan, then you paid for an education on a buy now, pay later arrangement.
    Even if you didn’t get a costly loan, and most do, all universities are heavily subsidized by the government, even the private ones, especially in the forms of so many students getting government aid.
    Respect went down when doctors quit billing for services, wanted cash on the table, etc. No more treating patients one day a week for free!
    Doctor lifestyles do not support the complaint that you are not getting paid enough!

  • Steven Reznick

    There is the story told of the royal choking on a piece of food. His aides summon a physician who performs the Heimlich manuever and saves the princes life. ” Thank you ,” say the Prince when he recovers. ” How much do I owe the kind doctor?,” he asks. The reply is ” half of what you would have paid me when you were choking on the food.”
    As human beings physicians are no more special than any other group of people. Most entered the profession to help others. We are special only in that we received an opportunity to be trained in a manner that can help relieve suffering and pain and hopefully prevent illness and disease. Every one of us is human and fallible and has their moments they are proud of , and moments they regret. When physicians are given an opportunity to spend time with patients and address their problems their skills and training make them unique and special. When insurers, hospital systems and government and employers dictate their role and participation in the health care system their unique qualities and skills are diminished and eroded.

  • James

    “I am the doctor, and you are the patient, so do what I say or don’t come to see me.” This is when doctors play god.

    “I am just a human being like the rest of you, I made mistakes just like you people did” This is when doctors play human.

    But you can’t play god and human at the same time. Soon you will have to decide why god can make mistakes without being held accountable.

  • buzzkillerjsmith

    My mom told me I was special, but, sadly, a lot of females my own age did not seem to agree.

    So I went to med school, hoping at least I could decide who lives and who dies. Again, my hopes were dashed.
    Maybe I’m not so special after all.

  • Natasha Deonarain, MD, MBA

    Thank you for posing this question, Kent. We really don’t want to do some navel gazing here, having been born and bred to believe that we eat from silver spoons in medicine. But, this is the crux of our emotional struggle right now, I believe, since we’re failing in the eyes of our patients who are questioning what we have been preaching all along. But I believe it goes deeper than that, when we view the biggest picture of all. What have we been conditioned to believe is true? And what if what we have been taught to believe, isn’t what we should believe in the first place?? Here’s an edgy slide show for you…

    And another…

    It’s difficult to stand against what we have been taught to believe to a profession that has believed in something for so long it’s become written on the walls of caves. But, judging from our commonly accepted view that the Earth is round instead of flat…my hope stays strong!

  • Cheryl Handy

    I disagree with krishna that “Physicians are trained professionals and are no different from an engineer, auditor, lawyer, judge, electrician, plumber, hair dresser, or a cobbler.” That description marginalizes the profession. Sure I have experienced some really bad hair cuts. But if my hair dresser screws up or lies to me or ignores me, I don’t die.

    Like it or not, medicine is as much an art as it is a science. Good doctors listen to the patient, extrapolate facts based on objective symptoms and prescribe a course of treatment based on risks versus benefits.

    When the electrician fixes my home’s wiring, I did not sit fearfully in a paper gown. When the lawyer writes up a contract, I do not wait by the phone to hear blood or biopsy results.

    Like it or not, physicians are not just any profession. Physicians are able to give, save or take life. That is a awe-inspiring fact. And if the fact overwhelms a physician or if the fact creates an uncompromising ego that cannot communicate with other docs or patients . . . the physician should consider research or teaching.

  • ♥_♥

    I fail to understand how the connection is made between being a good human being and at the same time trying to make enough money to pay the bills. Most of us do not go into the medical field to just make money. We go into it because we are dedicated enough to the worthy cause of giving other people a better quality of life if at all possible.
    What everyone fails to remember is that every single resource used in a physicians office or a hospital has a price set by the company it is bought from- the physician pays for that. The nurses need to be paid- the physician pays for that. So many other, behind the scene charges- the physician pays for. Malpractice- through the roof.
    Another thing people forget- doctors need to survive as well. We need homes, need food.
    I cannot understand why it is completely okay for a movie star to make millions, a football player (not even the quarterback) to make hundreds of thousands, but it seems wrong that a physician should mak a decent living?
    News flash- though there is some level of modesty we all have, what physicians do is not all that easy. It is stressful and takes most of our lives- and people complain that they must pay? Thank you for being so grateful, really. It’s great to be constantly treated with doubt, suspicion, mistrust by the very people you spent your whole life trying to help.

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