Commentary: The Bottom Line

      “Consideration of the forgoing will lead you to realize that the practice of medicine is predominantly a humanistic act. Physicians must care about their patients, and they must constantly improve their scientific knowledge about disease. To care and not know is dangerous. To know and not care is even worse. Caring and knowing must be combined to succeed in doctoring.”J. Willis Hurst, MD
      • Hurst J.W.
      Four Hats; On Teaching Medicine and Other Essays.
      The thin thread that holds our existence in this life is broken every time we become sick. We seek medical care to restore our homeostasis through remedies and drugs provided by medical healers. Nonetheless, there is an untold and intense connection between the patient and the clinician that has been traditionally upheld as the key element of the therapeutic patient–physician relationship. In fact, more than the remedies, as patients, we expect to be listened to and cared for by compassionate and competent physicians. A listening and caring physician may turn out to be a more effective healer than the most scientifically updated physician who has little empathy. However, the major threat to this sacred connection between the provider and the patient is the growing practice of the business of medicine where care is sacrificed to see a greater number of “clients,” and thus increased billing.
      The practice of clinical medicine is rapidly transforming with the current worldwide economic crisis. Although no one denies the importance of running a practice in a fiscally responsible way, the core ideals behind “physicianhood” and its mission also seem to be faltering. The principles of the Hippocratic Oath and the Declaration of Geneva are withering and being replaced by the relentless encroachment of business into the practice of medicine. This Oath, traditionally taken by physicians, upholds the ethical practice of medicine, and although mostly of historical value, it is considered a rite of passage. Although we try to abide by this oath in our efforts to improve the health of our patients, our focus has instead been sidetracked by the pursuit of the dollar and the financial bottom line.
      Indeed, in the current healthcare environment, caring for patients may be compared with the production lines in Detroit. Clinical rooms where we look face to face with our patients have been filled by computers, and our schedules have been shortened to a few minutes per patient to open space for more clinical visits. We are losing a powerful window into our patients, and thus to their diagnoses, when we are able to spend just minimal time listening to their stories, in face-to-face contact with them. Loss of time in physical closeness, time in hands-on care, and loss of a gentle palm touching the shoulder of an ill patient, all in favor of moving quickly to the next room, are results of this new brand of medicine. The moral imperative of providing the best possible care for our patients is evaporating from our hands and our stethoscopes.
      Having the time to listen to our patients is currently undervalued and under siege by all business reimbursement parameters. We are measured by indices that equate the number of patients seen and the number of tests requested as key indicators of the quality of care by business parameters. Medical decisions are not only being dictated by protocols that often do not take into account the individual and his or her particular idiosyncrasies but also by policies of our business managers and chief executive officers, people who are not physicians but who are ultimately our bosses. Evidence-based medicine and the best possible clinical judgment may be considered, but hold less weight than financial issues. Physician meeting time has been hijacked by discussions of budget marks and by overt or subliminal messages regarding the numbers of patients seen and the resulting income. One is made to feel like a dinosaur when complex patients with scores of records take an hour to evaluate, and one feels the hierarchy of the practice awaiting your retirement so that the practice can see more patients and thus bill more dollars. The new efficiency is equated with quality medicine. Moreover, the issues surrounding medical insurance coverage are a quagmire. Many colleagues at academic medical centers are not accepting referrals of ill patients with Medicaid and are unable to see them at all if they are uninsured, despite having a life-threatening disease. Indeed, although much attention has been paid to the ubiquitous violations of human rights in access to healthcare in resource-limited settings, there is a relentless war waged on a daily basis against the most vulnerable populations needing medical care on US soil.
      The bottom line in the current healthcare establishment is that it is a challenge to practice as our Oath dictates. The humanitarian aspect of the medical profession is under threat by the business-oriented model. The only solution to restoring the core values of our profession, and the historical legacy of our predecessors, is to challenge the current order in which medical decisions are motivated by financial interests and dictated by business managers; these actors are a critical part of the system, but their roles should be supported by medically oriented and motivated decisions. We as teachers and medical providers need to return to the philosophy of treating every single patient as if we were caring for our mother, our father, or any member of our families.
      The healthcare reform proposed by the current US administration should take into consideration the critical issue of restoring medical decision making by trained healthcare professionals and not by administrators. Health should be seen as a human right. Medical school training also is a critical component in preserving and shaping this humanitarian framework among health sciences students. Our role as caregivers, founded on the Hippocratic axioms of a comprehensive and humane medical practice, is not negotiable by any business standards.


        • Hurst J.W.
        Four Hats; On Teaching Medicine and Other Essays.
        Year Book Medical Publishers, Chicago1970