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We all remember the financial crisis of a few years ago, brought about by banks who were "too big to fail". Now we have hospital networks that are too big to care. Businesses are accountable to their shareholders first, so they focus on products and services which are the most profitable, not what's best for people's well-being. In fact hospitals have more to gain financially from more complications and worse outcomes for patients. Whom should doctors be accountable to?

The AMA code of ethics states

"Under no circumstances may physicians place their own financial interests above the welfare of their patients. The primary objective of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration. For a physician to unnecessarily hospitalize a patient, prescribe a drug, or conduct diagnostic tests for the physician’s financial benefit is unethical. If a conflict develops between the physician’s financial interest and the physician’s responsibilities to the patient, the conflict must be resolved to the patient’s benefit."
That rings completely hollow in today's profit-driven healthcare system of the US. (Can we even call it a healthcare system, since it's neither about health, nor about caring, but all about profit?) How are physicians supposed to put aside financial interests in favor of patients' benefit, when they have to answer to their boss (hospital admins), and meet production quotas, as if they are just factory workers in an assembly line?

We keep hearing how competition will improve healthcare delivery. Is the delivery of medical care supposed to be about competition? Are doctors supposed to "compete" against each other? Based on what factors? In medical school we are taught evidence-based medicine, the art of history-taking, and physical examination. We are not taught pricing. And for good reason! We're not training to stand by the side of the street and sell peanuts; we are training to care for fellow human beings! When did that distinction become lost in our society?

Medicine is not a commodity to be traded, be competed for, be analyzed by MBAs, or be measured for its efficacy through RVUs. It is a human relationship between patient and doctor. So what is so special about medicine? (pdf)

"Unlike a commodity, the primary meaning and importance of medicine has little to do with its efficacy, and more to do with a relationship between one human being in need and another who cares and is trained to help. Efficacy is sought in medical practice because the healer first cares. Efficacy does not imply a commitment to caring, but caring does imply a commitment to efficacy. Efficacy is the primary language of commodity transactions. Caring is the primary language of medicine."
I'm not training to be a physician so I can make shareholders rich. Let's not sully our noble profession by adopting the language of Wall Street, lest we have a shameful throwback to the 19th Century!

Physicians fight disease, and extend and improve the quality of life for their patients. It is quite fair for them to expect a reasonable financial and spiritual reward for the service that they provide to their communities. They want to be rewarded and appreciated for what they do. At the same time, the healthcare system needs to maintain the health and well being of members of society, while keeping costs within reasonable economic constraints. It is too soon to tell if the recent reforms brought about by the Affordable Care Act will satisfy the physicians' needs and those of the general public, especially the poor, but for sure it leaves a lot to wish for by all sides.

Many doctors have chosen to take an alternative path, and "live off the grid" from the whole insurance system. These doctors view medicine as it should be, "more as a ministry than an industry". By rejecting the obsession with growth and profit, they provide better service to their patients, while maintaining better work-life balance for themselves. They derive more satisfaction from their work, while better serving the health needs of their communities. The healthcare system as a whole benefits from lowered costs, since these physicians reduce the number of expensive tests and procedures that are performed or ordered.

Medicine is not the realm of bean counters. If we let them make the rules, we should be aware of the type of reality they create. If that reality does not bring us happiness, then we need to take back control over our profession. Ultimately we create the reality we live in, and if we are not happy with it, we have only ourselves to blame. The good news is that we already know what works (pdf), so there is no need to reinvent the wheel. We just need to have the will to get there.

10:15 PM PT: Community spotlight! Thanks so much!

Tue Feb 04, 2014 at 7:06 AM PT: Thank you for putting this in the recommended list. I'm thrilled!

Originally posted to liberalMedStudent on Mon Feb 03, 2014 at 05:29 PM PST.

Also republished by Community Spotlight.

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Comment Preferences

  •  I'm With You, Health Care Is Not a Market Activity (17+ / 0-)

    The so-called customer can't know how to comparison shop and often is not free to decline.

    Shopping for different insurance plans is absolutely pure gambling. Only a few of us can know with much accuracy what our coming years of health care needs will be, and none of us can know what accidents we may have.

    The whole scheme is completely unethical, both drugs and all the services and other treatments, if they're done for anyone's profit in any way competitive with other national and global businesses.

    We are called to speak for the weak, for the voiceless, for victims of our nation and for those it calls enemy.... --ML King "Beyond Vietnam"

    by Gooserock on Mon Feb 03, 2014 at 05:40:14 PM PST

  •  I've generally come to the notion that almost all (7+ / 0-)

    'commodities' should not be open to trade by speculators, but only allowed for trade by certified producers and processors/users.  Most commodities are things that are essential to the wellbeing of society. (ie, foods or energy)

  •  It's an excellent thing (15+ / 0-)

    to read this from a medical student. From 1975-95 I worked at a medical school, and in the '80s watched as BigMoney swoop in and take over. Changed "medicine" to "health care" to broaden the market, excusing themselves by saying the word "medicine" had negative connotations. Hospital Administrators became CEOs, and maximizing profit became the rule. M.D.s began earning M.B.A.s to gain stature, and some fine researchers went to work for BigPharma.

    It was a hideous thing to see. Some of our senior professors retired early to get away from it. Our Catholic university president was more M.B.A. than S.J., and he sold our hospital to Tenet. ("Thank God and Greyhound He's Gone" -- finally!) The free clinic disappeared -- but the medical students formed their own and found volunteer faculty supervisors. Thanks to those medical students, the free clinics still exist 20 years later.

    It is quite a relief to hear from a medical student on this subject, so many thanks for the diary. Medicine in its previous form was an honorable profession compared to what I see today.

    All the very best to you. Keep up the good fight!

    "Let each unique song be sung and the spell of differentiation be broken" - Winter Rabbit

    by cotterperson on Mon Feb 03, 2014 at 06:25:09 PM PST

  •  important diary, I hope it gets rescued or repost (7+ / 0-)

    it at a better time.  As a retired nurse I salute you.

  •  You have the heart and soul (7+ / 0-)

    Of a public health physician. As you go through school and explore your options, keep that in mind. Remember, there are tuition reimbursement programs for those who will agree to work in under served rural areas.

    If you think you're too small to be effective, you've never been in the dark with a mosquito.

    by marykk on Tue Feb 04, 2014 at 01:06:41 AM PST

  •  In health care, profit is a perverse incentive n/t (6+ / 0-)
  •  As long as some people have access to health (2+ / 0-)
    Recommended by:
    copymark, JerryNA

    care and some people don't, and the determinant is $$$, then, regrettably,  healthcare delivery will be a commodity.

    Fiat justitia ruat caelum "Let justice be done though the heavens fall."

    by bobdevo on Tue Feb 04, 2014 at 04:41:19 AM PST

  •  ACA has financial incentives to lower rate of (3+ / 0-)
    Recommended by:
    indres, ybruti, JerryNA

    hospital acquired infections and avoidable readmissions. The only thing these corporations understand is money. The fact that these nosocomial infections require weeks extra in the hospital , tens of thousands of needless deaths, and billions in additional money spent won't faze them. Only a significant fine and with holding of payments will make them listen and act to protect the patients. And the end result is less human suffering and an overall lower cost of medical care in the country.

    Life is just a bowl of Cherries, that stain your hands and clothes and have pits that break your teeth.

    by OHdog on Tue Feb 04, 2014 at 04:59:49 AM PST

    •  What my local hospital does (1+ / 0-)
      Recommended by:
      OHdog

      is to test every new Medicare patient.

      They apparently generally find the bacteria were already on the patient when the patient arrives.

      Germs are nearly everywhere.

      •  Interesting they feel that only Medicare patients (2+ / 0-)
        Recommended by:
        slouchsock, JerryNA

        have germs. Most elective procedures done in hospitals impact your immune system. And antibiotic therapy opens you up to other infections. Controling for these like using a disinfetant body wash for new admissions, particularly to Intensive Care units, cuts infection rates. Close attention to catheter and IV lines with immediate response to inflammation also reduces infections. And mandatory hand washing/sanitation to the pont of overkill saves insurance money, saves patients money, prevents disease, and save lives.

        Life is just a bowl of Cherries, that stain your hands and clothes and have pits that break your teeth.

        by OHdog on Tue Feb 04, 2014 at 10:17:07 AM PST

        [ Parent ]

        •  It's not the germs they care about, it is the cost (1+ / 0-)
          Recommended by:
          OHdog

          Medicare will not pay for readmission caused by sloppy hospital practices. This is a lawyer-driven "test" trying to weasel their way out of being responsible for the hospital-caused infection and readmission.

  •  The focus on competition (5+ / 0-)
    Recommended by:
    ybruti, cjtjc, JerryNA, AdamSelene, nextstep

    makes sense, within certain parameters. If one party has an absolute monopoly on something, they can charge what they want and to hell with the buyer.

    Competition is sometimes a good solution to this problem - among steel factories, for example, or grocery stores. Sometimes regulation is a better solution - for example, with public utilities.

    There are a few "goods" that are out of control right now, in economic terms, and medicine is one. But it's not for lack of competition, but for lack of transparency. If all healthcare providers were forced to publish a menu of prices on a common website, I suspect we would see the cost of healthcare - and insurance - drop significantly.

    Early to rise and early to bed Makes a man healthy, wealthy, and dead. --Not Benjamin Franklin

    by Boundegar on Tue Feb 04, 2014 at 05:36:06 AM PST

  •  No, I don't think so (1+ / 0-)
    Recommended by:
    ybruti
    Are doctors supposed to "compete" against each other?
    Not against each other, against machines: Technology will replace 80% of what doctors do

    like the article says, cost savings will be substantial, plus imagine the increase in quality that will come about when the 50% of physicians that are below average are replaced by an infallible computer.  

    •  Very interesting article. (0+ / 0-)

      Thanks for the link.

      The spirit of liberty is the spirit which is not too sure that it is right. -- Judge Learned Hand, May 21, 1944

      by ybruti on Tue Feb 04, 2014 at 07:15:39 AM PST

      [ Parent ]

    •  Japanese patent law (0+ / 0-)
      Medical industries are excluded from “industries”, however, and grants of patents for inventions of acts of medical treatment are not recognized, on the ground that they are not industrially applicable. This exclusion stems from the ethical consideration that diagnoses and treatments available to medical practitioners in their treatment of patients must not be limited in any way by the presence of any kind of patent rights, and it is a legal construction adopted due to the lack of any statutory provision expressly denying the validity of patent rights vis-à-vis acts of medical treatment. However, patent rights can be obtained over aspects of medical treatment including pharmaceuticals and medical devices, and the methods of their manufacture (note that Article 69(3) of the Patent Act however stipulates certain limitations on the effect of patent rights obtained for pharmaceuticals).[5]
      http://en.wikipedia.org/...
  •  The MBA mindset strikes again. (2+ / 0-)
    Recommended by:
    ER Doc, JerryNA

    There is nothing that cannot be made a commodity or consumer choice.  Haven't you noticed well before med school that our humanity has been suborned to the bottom line?

    Perhaps physicians are unused to being a cell on a spreadsheet.  Most of us have been part of that trend for too long.  Welcome to the world of the Harvard MBA and the Chicago School of Economics.

    So, YES, medicine/health care is a commodity.  And as long as boards keep on hiring the myopically trained business school sociopaths to organize healthcare, and physicians acquiesce to the relationship, it will remain so into the future with no prospect of change.

  •  Well worth reading (0+ / 0-)

    ...including the links.

  •  What about the cost of education? (2+ / 0-)
    Recommended by:
    JerryNA, liberalMedStudent

    What I rarely see mentioned is the effect on medical students of the cost of medical education.

    I started medical school in 1979, and with the election of St. Reagan and loss of funding to teaching hospitals my tuition increased 150% from first year to fourth.  

    How can we expect doctors who are carrying educational debt larger than their mortgages to ignore their income?

    How can we mourn the dearth of family doctors, but continue to pay them a pittance compared to the higher-priced specialists?

    (Not to mention how can we expect patients who have to fork over cash for larger and larger co-pays to come to their doctors whenever the need arises?)

    Disclaimer:  I finally emigrated to Canada.
    Single payer.
    Single payer!!
    Single payer, yeah!!!!!

  •  I've been told that the doctors (0+ / 0-)

    in my area of Florida are under corporate management.

  •  Allopathic medicine (0+ / 0-)

    The American Medical Association was founded to prevent the practice of homeopathic medicine.  There are other modalities in medicine used around the world that are shut down by the allopathic medicine in the US.  No one disputes that allopathic medicine does a great job in some ways, but chronic illness and other types of unbalance are well treated in other countries using a combination of systems.  Accupuncture is an example.  The purchase and shut-down of community hospitals was vulture capitalism at work.  "Too big to fail" is the result of vulture capitalism.  It covers most large systems in the US:  finance, health care, military and "defense" including the NSA.  All of them have had negative effects on life in the US.

    •  accupuncture is not same as homeopathic (4+ / 0-)
      Recommended by:
      maracucho, JerryNA, slouchsock, nextstep

      homeopathic practice is voodoo, it is not medicine. they take something and dilute it a zillion times, and pretend it does something.

      using the term homeopathy to stand for alternative medical treatments is bad practice.

      •  Actually, acupuncture has very minimal effect. (3+ / 0-)

        The best that can be said for acupuncture is that it's not as bad as homeopathy. If there are more effective treatments, then use those. If not, then let your patients know they're getting not much more than a placebo.

        As far as the prior comment, anyone using the term "allopathic medicine" is a warning signal they're pushing quackery ("alternative" medicine is not medicine). Homeopathy is useless sugar pills and water with no scientific basis and no evidence. Again, if there are more effective treatments, then use those. If not, then know anything marked "homeopathic" is a very expensive placebo, just sugar pills and water with a huge profit mark-up.

        The worst problem with woo-pushers is that people with treatable conditions delay real treatment and empty their wallets for false hope. They're not "alternatives" to medicine, they're unregulated competitors who don't have to prove what they do works. Their business products do not have to pass clinical trials, unlike real medicine.

        Oh, one more comment, for liberalMedStudent: there are good uses for the "bean-counters", but not as accountants for counting profits. We need more emphasis on evidence-based medicine, which is where statisticians can help, and most effective treatment per unit cost, which is where accountants can help. An MD's education can't stop at med school and residency. You have to keep up with best practices and new advances, and the minimal amount of "continuing education" required by your state may not be enough. Given how many people in the US simply cannot afford medical care (a travesty), cost to benefit analysis has to be considered so we can get more people the best care.

        •  yes I agree about high value care (0+ / 0-)

          http://www.acponline.org/...

          but by "bean counting" I mean only counting for sake of profit. Thanks.

        •  Japan has a pretty good medical system (0+ / 0-)

          Japan and China compete in doing medical research based on traditional ideas. This does very little for the average person in China as most people do not have access to decent health care, but it is great for people in Japan. More sources of ideas leads to more and better research. The fact that we in the US can't get medecines based on Asian research makes our medecine less scientific not more.

          I take this stuff personally because I can't get any of the medecines that I got when I was living overseas. I can't even get the antihistimine that I got from the Western doctor in South Korea.

          I have also never had a doctor in the US tell me about anything science related which happens all the time in other countries, if the patient is interested.

    •  founded to advance scientific medicine (1+ / 0-)
      Recommended by:
      JerryNA

      the AMA were reformers who scorned quack medicine, and I'm glad for it.

    •  insult (1+ / 0-)
      Recommended by:
      JerryNA

      "allopathic" is not a term contemporary physicians use to refer to themselves, and is historically an insult.

    •  Living in the US (0+ / 0-)

      The alternative modalities are how I have survived with a pre-existing condition.  What is cruel is the US medical system whether or not you call it allopathic.  The largest affordable and effective global system is homeopathic.  Accupuncture is at the heart of Asian medicine that far exceeds anything the US has to offer.  Please do not be so limited in your thinking.  You are ignoring the great suffering in the US from this "too big too fail" and "too heartless to care" system.

      •  One example of how alternative meds can be (0+ / 0-)

        Helpful - back in late 1990's, my body quit producing the number of red blood cells it should have been making.

        I became so anemic that a trip from my bed to the hallway was more exhausting than a two hour  trek up a series of hillsides had been a month before. Tests were done, and then more tests done.

        Finally it was decided the cause of my anemia was diverticulitis. But since I was so weak, the surgery that my doctor said was the standard treatment, that surgery  had to be postponed till I was no longer so weak.

        While waiting for my strength to return, my spouse bought me a book. And in that book was a whole chapter on how acidophilous could repair the imbalance in the lining of the stomach and intestines by restoring the "good bacteria." I didn't think I had anything to lose. I had my spouse buy me the bottle of acidophilous, and within three days of taking double the dose, I felt pretty good. Within a week, I was feeling normal. I realized I no longer needed to have any surgery.

        Since then I have come to find out that those who have the surgery, and the diverticuli is scraped out, often the condition returns, and it has to be done all over again. Also one side effect is you can end up needing to have a colostomy bag for the rest of your life - a side effect my doctor never mentioned!

        I have no idea how much this surgery would have cost, but I can say that I stayed on acidophilous for six months, and it cost me around $ 22 a month. Also, my doctor was totally dis-interested in hearing about how my condition  had cleared up. This despite the fact that he had said I had a very serious case of diverticulitis!

  •  Medicine should not be a commodity (3+ / 0-)
    Recommended by:
    liberalMedStudent, JerryNA, ybruti

    Medical ethics and practice and patients suffer when everything is reduced to dollars and cents. Be aware though that there is a significant minority of physicians who truly believe the Ayn Rand philosophy. They are older and many are influential in politics.

    There was a tremendous cohort effect in American medicine after WW II. In the 50s and 60s, the US controlled most of the world economy due to the devastation of World War II. The AMA and most physicians opposed Medicare but it greatly increased average physician incomes. The 50s and 60s saw many great medical steps forward (and a few slips backward, such as shutting down the mental hospitals and assuming that a pill was the only treatment needed for mental illness). In the 1960s most drug companies accepted a responsibility to produce essential drugs that couldn’t be patented and generated little if any profit. Alas, no longer. I graduated from medical school in 1963. I worked one night a week in the blood bank as a technician and my wife worked part time- that was enough to cover our costs even with a child. We didn't have to borrow. That's totally impossible today- many MDs accumulate hundreds of thousands of dollars in debt by the time that they finish all training. Of course that debt has poisonous effects on their behavior and attitudes.

    The older generation of libertarian docs doesn’t realize how artificial the situation was in the 50s and 60s and stubbornly resist any modest decline in income and privilege. I tell young people that doctors will have to accept the relative incomes that we had in the 20s and 30s, not bad, but not stratospheric and that nobody should enter medicine who expects to become really rich. I see Obamacare as a seriously flawed and partially symbolic attempt to relieve average Americans of the crushing problem of medical debt and medical bankruptcies. That’s what happens when you turn over writing social welfare legislation to people like Liz Fowler and Max Baucus. The old libertarian bulls don't face bankruptcy, and they fear change.  

  •  No the prescription industry (big pharma) (1+ / 0-)
    Recommended by:
    JerryNA

    is the commodity market.

    My antibiotic I am currently taking off insurance runs $2000/mo.   Yep a simple antibiotic is being driven by the price of what and the scarcity of the materials to make it.  5 yrs ago it was $10/mo off insurance.  

    Cancer drugs are $10,000/dose in some cases.  

    This has got to stop somewhere folks.

    "Death is the winner in any war." - Nightwish/Imaginareum/Song of myself.

    by doingbusinessas on Tue Feb 04, 2014 at 11:47:07 AM PST

    •  Is that commoditization, though? (1+ / 0-)
      Recommended by:
      doingbusinessas

      Any product that finds itself with too much supply to be profitable will find the supply reduced until it reaches economic equilibrium.

      That has nothing to do with stockpiling, trading, or artificial scarcity.

      •  For many years it could be found in the Vet (0+ / 0-)

        market at $2.00 (two dollars) for a weeks dose.  Then they found it was good to use for long term usage for those who have Lyme (it takes 6 months of 400 mg/2x daily) to take it out (among taking two other antibiotics).  Also those with C-Diff take for the same reasons.  

        Big Pharma quit making it, leaving it for the generics pharma to pick it up.  Now there are only 3 world wide companies that make it, and the suppliers who used to make more $$ off the basic components cannot get them fast enough, so their is a shortage of it.  When they make a batch, they can get $2000/mo supply for it even though it only cost them $5.00 to make.

        "Death is the winner in any war." - Nightwish/Imaginareum/Song of myself.

        by doingbusinessas on Tue Feb 04, 2014 at 02:55:44 PM PST

        [ Parent ]

    •  About a year ago, San Francisco Chronicle had a (0+ / 0-)

      lengthy front page article, describing how many pharmaceutical firms out there don't care to make inexpensive meds if not enough people need them. So people are suffering and even dying, simply on account of the profit factor being the ruling force at Big Pharma.

      There are other drugs out there that are effective, and used by many many people, but not considered to be super profitable, so those are not being made either.

      And since Big Pharma holds the puppet strings to most in Congress and the White House, it is not likely that any sort of legislation will come about to stop them from being such slimeballs!

  •  off the grid or boutique? (1+ / 0-)
    Recommended by:
    ybruti

    I haven't finished reading all your links and think this is a good diary.

    Perhaps in another one you could write about being off-the-grid. It sounds good in concept. But utilizing off-the-grid physicians is a penalty for those who already pay for health care via their employment's insurance benefits. It is only going to only work for primary care--as soon as a patient crosses the threshold into needing specialist care, only the uber-wealthy can afford the risk of serious illness while having no insurance.

  •  The doctors that "live off the grid" (1+ / 0-)
    Recommended by:
    slouchsock

    Are certainly not going to be serving the poor, who have no money to pay for their services. They are only going to be serving the middle class and wealthy.

    Otherwise, if someone has a catastrophic illness, they won't be able to pay for treatment.



    Women create the entire labor force.
    ---------------------------------------------
    Sympathy is the strongest instinct in human nature. - Charles Darwin

    by splashy on Tue Feb 04, 2014 at 12:27:47 PM PST

  •  LiberalMedStudent, what are your plans when you (0+ / 0-)

    are a doctor?

    Private practice or small group?  Work for a government run medical facility?  Work at a low income clinc?  Something else?

    I suspect a good new doctor would have many opportunities to practice medicine as your diary describes.

    The most important way to protect the environment is not to have more than one child.

    by nextstep on Tue Feb 04, 2014 at 05:19:49 PM PST

  •  The Hospital system is set up so that the lowest (0+ / 0-)

    Standard of care is offered to the patients.

    This is especially the case in places where it is possible for large Hospital Franchises like Sutter in California to avoid hiring permanent staff, and also to avoid hiring competent staff.

    My last experience in working for a few days, private hire, at one of the most affluent hospitals in the nation, yet 90% of the nurses I encountered were floating nurses, who didn't know where things were, and didn't know the patients. The rest of the staff was what I consider to be illegal hires, people from foreign countries who insisted on ignoring patients by telling them "I din't speak English." (At around the same time, I had worked for UCSF Hospital in San Francisco, and although that hospital also was into diversity, everyone there who was employed spoke English fluently.)

    Not only that, but the bandages were so old, over six years old, that I had to call a friend and have her bring me bandages as the ones supplied by the hospital could no longer be considered sterile!

    Hospitals inside San Francisco are currently being sued for the Legionnaires Disease present at Children's Hospital and at UCSF, even in the operating suite. So the surgeries performed are a success, but the patient ends up contracting Legionnaires and dying!

  •  Not sure I have an answer (0+ / 0-)

    But I do have a question:

    Do you have any data that shows the historical distribution or access to medical service over the past century or so?

    Because, I wonder, is the problem you describe a lowering of the common denominator of service (less for most but but the privileged) or that the distribution has flattened (making it worse for some but better for others)?

    Reason I ask is that I live in a country (China) where there are not enough doctors and not enough facilities to go around, and so, except for the wealthy with private clinics, what most people get is assembly-line service at best, but it's better than no service.

    And in India, which has an even worse ratio of doctors to patients, they have actually worked on perfecting simplified, assembly line care with the goal to make the process as efficient as possible to treat as many people as possible.

    Obviously people from different countries have different expectations, but when there is a lack of resources a good assembly line might be a good solution.

    Your thoughts?

    No one is coming to save us, the future is in our hands.

    by koNko on Thu Feb 06, 2014 at 10:44:06 AM PST

    •  increasing number of primary care providers (0+ / 0-)

      is a good thing, and it gives access to care to more people. but increasing "throughput" for sake of profit is not the same as increasing access to care for sake of caring for people.

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