The divergent languages of business and medicine

My business ethics class recently discussed the case of Cipla Pharmaceuticals, an Indian generic drug manufacturer drawing the ire of big pharma by blithely ignoring international patents or employing workarounds to manufacture low-cost generics in direct violation of the patents. Cipla’s founder, Dr. Yusuf Hamied, stressed that Cipla’s goal wasn’t to steal from the bottom line of the likes of Merck and Eli Lilly, but rather to serve its mission of helping the world’s poor gain access to life-saving medications that they could otherwise not afford.

The class discussion was vigorous. Students hailing from careers in pharma vehemently stated their opposition to Cipla’s cause, invoking the necessity for pharmaceutical companies to amortize their costs through sales. Though the incremental costs per pill of actual manufacturing were negligible, the high initial investments in research trials and production required a modicum of intellectual property protection. By capitalizing on the more liberal Indian patent laws, Cipla was undermining their pricing model and directly stealing customer segments.

Others disagreed. After all, the world’s poorest of the poor represented a market that would have been priced out of its products anyway. The case study offered some numbers on the lowest margin that these companies would be able to offer without selling at a loss. The comparison was, roughly, $12,000 versus Cipla’s $300. For the average consumer in the developing world, the treatment was completely out of reach.

At the midpoint of discussion, a classmate from the Middle East, who had been holding back furious tears through most of the discussion, raised a trembling hand and broke his silence. He told us of how his father, when he contracted diabetes, would not have survived if not for the availability of exactly such generic drugs.

He said, “This entire discussion disgusts me.” The sentiment resonated, and most everyone looked down at his or her desk, suddenly chastened.

As a dual degree student in medicine and business, I’m always fascinated by the differences in vocabulary at the two different schools. Back in medical school, we talk about global health, social justice, structural violence, institutional discrimination — the keywords vary but the takeaway is often just this: Health care is a basic human right, and one doesn’t ever turn away a suffering patient, ever.

In fact, the likes of Paul Farmer and Partners in Health take this a step further and elaborate on a physician’s obligations to extend into examining and advocating for change to the social determinants of health, the conditions in which people are born, grow and age, shaped as they are by the distribution of capital and resources at both the global and local level.

As I sat in my front-row seat, I remembered working late nights in the emergency room, convincing the uninsured to accept treatment without fear of going bankrupt. I remembered slipping a $5 bill to a patient in primary care clinic who was non-compliant with her medication regimen because she could not even afford this, the cost of the generic. I remembered traveling to small village-based clinics in India with medical teams, and holding hands with impoverished farmers, feeling ashamed by the disparities in personal wealth and opportunities between us, and ardently wishing for a better world.

At the business school, we use words like incentives, value proposition and return on equity. The liberals in the room had to couch their arguments in these terms. It would have been indelicate to talk about human rights and moral obligations. Instead, perhaps individual governments could leverage their bargaining power and purchase medications for their citizens in bulk. Perhaps governments could directly subsidize medications for their populace.

One of my friends raised his hand and began his comment with “I really do feel a lot of pity for these folks, but I believe strongly that protecting patents is the only way to incentivize …”

I thought about that for a while. The word pity. Synonyms for pity abounded in the discussion, as everyone strove to couch their comments with such a proviso: understand, regret, sorrow, empathy. What do these mean?

While dying of prostate cancer, the late New York Times book critic Anatole Broyard wrote in his memoir, Intoxicated by My Illness, that he expected his doctor to do more than be a “close reader of illness.”

“I see no reason or need for my doctor to love me — nor would I expect him to suffer with me. […] I just wish he would brood on my situation for perhaps five minutes.”

In her Los Angeles Times review of Leslie Jamison’s The Empathy Exams, columnist Suzanne Koven notes that the word “empathy” itself is new, absent even in the 1971 edition of the Oxford English Dictionary.

This represents a seismic cultural shift. Where previously a physician may have been expected to possess intelligence and integrity in good measure, now the third, empathy, has risen to equal if not greater importance.

Empathy, “to suffer with,” is a tall order. When you put yourself in another person’s shoes and consider the weight of their world, no matter if you are a physician, an insurance agent, a lawyer, a business person, there are no caveats. True empathy doesn’t allow for “I feel sorry but …” When you imagine yourself inhabiting your patient’s life, with the all the daily humiliations of poverty, hunger, sanitation, and unfair infrastructure pressing down on you, it becomes impossible to shake that off, and speak only dispassionately on the subject of life and health.

And yet, all of this comes to nothing if those advocating for patients are unable to frame their arguments within the economic lens. The reality of health care is that it operates in the free market, on limited budgets, and paid for by private agencies.

The language of medicine and the language of business don’t simply diverge on technical points. It’s more than a financier’s inability to interpret lab data, or a physician’s impotence at discounting cash flows. It’s in the very definitions of access and rights and economics and morality.

It’s imperative that participants talk with citizens of both spheres, knowing that the divergence lies even deeper, in fundamental views of the world and in considering how humans ought to care for each other.

Samyukta Mullangi is a medical student who writes at her self-titled site, Samyukta Mullangi.

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  • http://www.davisliumd.blogspot.com Davis Liu, MD

    Excellent piece. Given the complexity of health care, we need to embrace the disciplines of both medicine and business. Yet how many of us, doctors, want to be the leaders and step up? It’s in our medical culture not to step into leadership roles. In the best article I’ve come across, “Challenges for Physicians in Formal Leadership Roles: Silos in the Mind” by Thomas N. Gilmore, he notes:

    Because [doctor] training inculcates values of autonomy, learning
    from experience, and professional distance, physicians see a team
    (managerial) approach as ‘other’ and distance themselves from those
    colleagues who take up formal leadership roles.

    The consequences are ambivalence and splits, both among leaders and
    within individuals who accept such leadership roles. A maladaptive
    strategy is often silos in the mind, in which the different bodies of
    knowledge (clinical and business) are kept too separate, with the latter
    denigrated. Yet, many of the current challenges require closer linking
    of substantive medical knowledge with sophisticated organisational and
    managerial knowledge to invent and implement new systems…

    …No talented surgeon would enter the operating room without
    scrubbing, reviewing all the available diagnostic information, and
    checking the infrastructure and the team’s readiness. Yet, that same
    surgeon, as a chair going into a meeting, will grab a folder from his
    secretary and skim it en route to the conference room three doors down
    from his office and begin a meeting with no acknowledgement of absent
    members, and differentiating between those who, respectful of community
    life, informed the leader and those who simply did not turn up. The
    leadership of the meeting often ignores the interdependency of the
    various items to one another and to the overall well-being of the
    institution.

    What Langer (1989) calls ‘mindfulness’, when brought to the adaptive
    challenge facing academic medicine, will go a long way to bringing the
    inherent intelligence and aggression in physicians core training to the
    leadership task.

    In other words, doctors can be great leaders if they have the mindset that they deserve to be there as leaders. It may be however that culturally doctors will continue to denigrate business thoughts and processes even if these same processes (i.e. LEAN), could make care better for patients and doctors.

    Davis Liu, MD
    The Thrifty Patient – Vital Insider Tips to Staying Healthy and Saving
    Money (2012) & also Stay Healthy, Live Longer, Spend Wisely: Making
    Intelligent Choices in America’s Healthcare System

  • SteveCaley

    When a language is fractured into parts, one set of words being used by one type of people, and another by another type of people, it begins to diverge into a dialect, and eventually two different languages which are mutually unintelligible. Even differences in dialect cause difficulty in conveying subtle intent.
    Ethics and morality are not a specialty language, but are a universal set of rules that should be applicable to human behavior. When dismayed by the shadows of ethical judgment, instead we use jargon to slip past these watchers, so that we can get done what we want to be done.
    I fear that in today’s American society, some of what we have unspokenly decided to do is to set aside ethics as impractical. Dwelling on only the ethical set of opportunities certainly does increase the risk of things being unprofitable; and unprofitability is an absolutely intolerable value statement in the business community.
    I fear we are making great strides in avoiding the hampering grasp of morality, and are racing towards a brave New World of efficiency. Modernizing our language is modernizing our thought; we are doing that every day now.

    • Karen Ronk

      I often wonder if my feeling that things used to be different are just looking back with rose colored glasses or have things really changed that much. I have come to believe that yes, things really have changed. At some point, let us say the 1980s/1990s, we decided that the ends justify the means. We decided that the rules are for other people and ethics were passe. Morality is in the eye of the beholder. And most importantly, if you don’t want to use the right “jargon”, the accepted corporate speak, the language of capitulation, then you – you- are the problem. Maybe we should all get together and form an underground network of resistance – but resistance probably is futile.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Very nice article, but I don’t quite agree with the conclusion. The world doesn’t need more pity, regrets or “empathy”, whatever that is, flowing from the shrinking numbers of privileged to the oppressed masses.The world needs justice, fairness and respect.
    The language of business is now the language of callous exploitation gone global. It was never meant to be used this way by its creators. Adam Smith also wrote about Moral Sentiments, but we forget that.
    The modern language of business should not be accommodated in any way. It must be silenced, because the language of business and its practitioners are the one true weapon of mass destruction.

    • SteveCaley

      I recommend Klemperer’s “Lingua Tertia Imperii.” He was a professor of French Literature in Dresden, who scrutinized the Third Reich from within. He had been “judified” and was a suspicious person, although never sent to the camps. The Reich had Göbbels, a true Hæphestus of the language. He could hammer words into lies, not merely in his own speeches – that is the mark of the amateur. He could CHANGE words to MEAN lies, and have people speak them in the common tongue. Much of American business dialect owes a debt of gratitude to the brilliant Göbbels. He may not have been the Father of Lies; but he was the cherished son.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Thank you. I just ordered it. A while back I bought a domain name – VerbalWizardry.org – and was planning on creating a resource to catalog the linguistic aberrations introduced by health care “thought leaders” which are now mindlessly repeated by anyone trying to claim expertise in the matter. I never got around to it, but I think I will now. There isn’t much I can personally do to change the trajectory of things to come, but I think I may be able to document the descent a little bit.

        • SteveCaley

          Thank you, and I’m sure you will find it a very humanizing read. Dr. Klemperer approaches the topic with brilliance and even a bit of humor, consider his life was hanging by a thread for several years in the Nazi empire. “Orwell” understood that language influences thought; Klemperer opines that toxic language can be created which arrests thought entirely, or molds the thinker to its evil purposes.
          Much of the verbal rubbish in the healthcare machine is generated to assure people that they need not think about the difficult topics ahead. Please do proceed with verbal wizardry – I look forward to it!

  • buzzkillerjsmith

    In med school you talk about global health and social justice and structural violence?

    In med school we talked about tuberculosis, mitral valve stenosis, inflammatory bowel disease, ureterolithiasis, penicillin, Staphylococcus aureus, migraine, colon cancer.

    Just another indication of how far down the toilet this profession really is.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Thank you, Dr. Goodman. I would be very interested in your opinion and, if I may hope, collaboration….

  • buzzkillerjsmith

    “Who knows what practical difference…”

    Nor much difference. But bless your heart anyway for thinking that it might.

    I suspect you are not a doc. If you were, you would realize the med students are some of the most intelligent folks in society and can figure our that ethical and sociopolitical stuff out on their own in their free time–if they choose to do so. Force-feeding this stuff just pisses them off. At least the U of WA med students that I precept seem to roll their eyes.

  • buzzkillerjsmith

    Not only can they process huge volumes of info, they can even find it all by themselves! See my comment to Laszlo.

  • buzzkillerjsmith

    Exactly.

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