The devaluation of physicians

Chip Kelly was a former coach and general manager of my beloved Philadelphia Eagles. He was a firm believer in his “system” and felt that his players were disposable and easily replaced.  Because of that, he proceeded to trade away or release very talented players and replace them with less talented players.  Needless to say that without the talent, the team self-destructed, the fans were angered, and it was only after he was replaced that the Eagles were finally able to win the Super Bowl.

What does this have to do with health care?

We are seeing an analogous systematic destruction of health care based on the similar premise that physicians are disposable and easily replaced.  This has manifested in a concerted effort to devalue what physicians do.  The basic message is that physicians, and by proxy, patients, hold little value.  Furthermore, the lack of trust in physicians is stunning.  Let me cite some specific examples.

The most obvious example is the scope of practice issue.  Those who support unsupervised practice of nurse practitioners are basically stating that physician education is of limited importance and not really necessary.  They believe that those with considerably less training can essentially perform the same functions as physicians with the same degree of expertise. In other words, what physicians have learned in their training and what physicians do are inconsequential.  It is discouraging to think that others view my four years of med school, three years of internal medicine residency, and two years of rheumatology training as superfluous.  Of course, the potential monetary ramifications for those who promote this position should not be ignored.

There are other examples.  Prior authorization requires physicians to get “permission” before a procedure or medication will be covered by an insurance entity.  The message: physicians are not qualified to know whether a procedure or medication is appropriate and therefore require oversight.  Otherwise, physicians will prescribe unnecessary (and more importantly expensive) medical care.   There is a notable lack of trust in the ability of physicians to properly care for patients.   Furthermore, a physician’s orders may be reviewed by someone with much less training. For example, a nurse reviewer, who has never seen the patient, will pass judgment as to whether the care that has been recommended is appropriate.

A third example is MOC.  Maintenance of certification as determined by the American Board of Internal Medicine (ABIM) requires that a physician pass a recertification exam every ten years to repeatedly demonstrate that they are “qualified” to practice.  The message: physicians are not competent to practice unless they prove their worth.   Guilty until proven otherwise.  The problem is that the recertification exam is not a measure of a physician’s capabilities.  It merely measures a physician’s knowledge on one given day. Nonetheless, I have now passed the rheumatology boards on three separate occasions (1990, 2000, and 2010) and have been in practice for 30 years.  Despite this, I am not deemed competent to practice by ABIM (and therefore by hospitals and insurance companies) unless I pass a fourth exam in 2020.   Disdain for physicians from ABIM is further demonstrated by the need for a physician taking the exam to place all of his/her belongings in a locker.  The message: physicians cannot be trusted not to cheat.  It has been proposed by some that accumulating CME credits should serve to demonstrate due diligence. ABIM’s response is the concern that physicians would then game the system.  How do we know that physicians won’t simply sign in at the beginning of a lecture and then leave to do something else?

Physicians are entrusted with the health and welfare of our patients every day, yet the ABIM does not trust us to take an exam honestly, nor do they trust us to maintain lifelong learning on our own.  They are the self-appointed enforcers of the medical profession.  We will ignore the obvious financial motivations for ABIM, but their message is clear: Physicians cannot be trusted.

There are other more subtle examples.  The line for signature on insurance forms that used to say physician, now says provider.   As stated by Dr. Hans Dufevelt, “medical provider” is part of the Newspeak of America’s industrialized medical machine. It implies, as Hartzband and Groopman wrote in The New England Journal of Medicine, that: “… care is fundamentally a prepackaged commodity on a shelf that is ‘provided’ to the ‘consumer,’ rather than something personalized and dynamic, crafted by skilled professionals and tailored to the individual patient.”

The combined messages here are that physicians are not trustworthy, will not maintain their education unless forced to do so, do not practice appropriately unless there is oversight and that others with less training can perform just as well. These messages serve to devalue physicians, which furthers the agenda of those who wish to commoditize health care for their own purposes.

Like Chip Kelly, if one has a vested interest in the system, then the talents of the individual players/physicians do not matter.  The problem is that whatever devalues physicians ultimately devalues patients and detracts from the care they receive.   If we diminish the value or even eliminate the most highly trained professionals due to burnout, the ones who will suffer are the patients. The systematic commoditization of health care destroys the very individuality and humanity that must be at the core of health care.

So the question must be asked. “Don’t we as physicians deserve better than having Chip Kelly-type bureaucrats dictate a commoditized health care system that benefits them at the expense of the very providers of those services?  More importantly, don’t our patients deserve better?

Mark Lopatin is a rheumatologist.

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