Most physicians, by our very nature, are not inclined to make waves, especially when it comes to politics. Those that are interested in getting involved may actually run for office, or, like me, resort to writing a blog in an effort to make their opinions heard. Others get caught up in professional organizations such as state medical societies, specialty associations or other national organizations. For the more ambitious, making periodic trips to Washington, DC, to lobby their representatives gives them a sense of active participation in “the system.” I know, I’ve done all these things myself (except running for office) with little to show for the effort.
The fact is, as individual doctors we have very little power to change anything that happens in the political arena. And, while it is true that as a collective we could have significant influence, it doesn’t appear likely that physicians will ever unite behind any single idea, philosophy or action plan. We are indeed a dysfunctional group of cats, and will not be herded no matter how desperate our circumstances become.
This past weekend I heard Andrew Schlafly, Esq., the General Counsel for the Association of American Physicians and Surgeons give a talk on what he referred to as “A War on Doctors.” He accurately described the coordinated efforts by hospitals, third party payers and the government, all designed to control physicians through employment, intimidation, regulation and economic coercion. None of the strategies or tactics he described came as any new revelation to the audience comprised almost exclusively of doctors, but it did serve to focus the discussions that occurred for the duration of the meeting.
Our current healthcare payment system is at the heart of this war on American Medicine. It is an unchallenged fact that healthcare related costs have escalated to the point where they threaten our national financial security. But if you look at where the money actually goes, it isn’t into the pockets of doctors. Estimates place the percentage of total healthcare spending that goes to pay physicians at between 10% and 12% of the healthcare budget. The bulk of the payments go to hospitals, pharmaceutical and device manufacturers, insurance companies, and a myriad of secondary and tertiary “providers” of various health related goods and services. It would then seem reasonable to ask, why wage war on the docs? Simple, we are the easiest targets.
The general lack of organization among physicians makes it possible to manipulate us using the strategies and tactics mentioned above. Similar efforts don’t work well against massive hospital groups and industrial giants, each of whom maintain multi-million dollar lobbies designed specifically to improve their relative position in the system, or at the very least, maintain their status quo. The arguments are also easily made that physicians are responsible for ordering all those expensive tests… and doctors prescribe all those useless drugs… and they are the ones who perform those unnecessary procedures… and they keep people in hospitals for no apparent reason other than money… So, it only follows that doctors must be brought to heel or appropriately punished. Besides, all doctors are rich, right?
I do not wish to imply that America’s doctors are the victims here. In large part we have unwittingly brought this war upon ourselves. For more than 30 years now, the vast majority of doctors have been systematically lured into participating in what has become a corrupt third party payment system. They have passively, and in a some cases actively, participated in “contract medicine” where the payers have subtly and systematically seized control over medical decision making. Problems arise whenever the absolute loyalty and commitment of physicians to their patients becomes an inconvenient obstacle to either the political or economic gain of the payer. Their answer is to attack the physician’s core principles contained in the Code of Medical Ethics. Their weapons include complex economic incentive programs shrouded in innocent sounding names names like “quality improvement”, “gain sharing”, “pay for performance”, and the latest effort, which is tucked neatly inside Obamacare, “Accountable Care Organizations”. Failure to comply with these efforts results in harsh penalties, including both financial penalties and professional sanctions. The strategy is clear, offer small carrots followed by a very large set of sticks.
By all appearances this war is not likely to end well for the doctors. We have limited ammunition, no coordinated strategy or battle plan, and few if any allies. Many physicians have already given up on the idea of independence. It is for this reason that I, and many like me, have chosen a path less traveled. One that can only be referred to as individual, passive non-participation. For the last 12 years I have not participated in any third party contract-based payment schemes, and as of January 2013, I have opted out of the Medicare program. For me, this was a difficult decision, but it was the only option I could see that would allow me to be a truly independent physician.
Some will undoubtedly criticize my stance as being contrary to their interpretation of the Hippocratic Oath. Others may consider me to be selfish and uncaring. To them I would simply offer my signed “Independent Physician’s Rights and Obligations Pledge” as proof of my intent. I’m not sure if any of my colleagues will assume a similar strategy since, as I said, we are all a bunch of cats, and it is not my intent to suggest this is the only course of action. However, I believe that as an American, I have the inalienable right to life, liberty and the pursuit of happiness, including the joy of practicing my life’s work for the benefit of those who seek my help without pressure or interference from the government or any other controlling entity.
The Independent Physician’s Rights and Obligations Pledge
As an independent practicing physician, I hereby acknowledge my role is central to ensuring quality care for all patients. I further recognize the potentially disruptive nature of outside influences on the patient-physician relationship, including various methods of payment. Through this pledge I hereby reaffirm my unconditional commitment to my patients, my colleagues and my profession, and to maintaining my SPIRIT as a physician.
I pledge, to provide personal healthcare to all those who I am privileged to treat, in accordance with my training and experience with a spirit of personal Service.
I pledge, to uphold, defend and perpetuate the time-honored ethics of the medical Profession.
I pledge, to conduct my practice with openness, honesty, fairness and personal Integrity.
I pledge, to keep the time-honored patient-physician relationship based on mutual trust, mutual respect and mutual Responsibility.
I pledge, to establish just and appropriate fees for the services I provide, treating all patients fairly and with compassion, free from any third party attempts to influence my professional judgment or Independence.
I pledge, to work within the community of physicians to ensure the medical profession remains self-regulating and self-governing with respect to education, training, quality assurance and peer review, according to our time-honored Tradition.
Now, before all who are my witness, I accept and embrace these fundamental rights and obligations freely and without reservation, and declare my willingness to abide by them to the best of my ability.
Robert Sewell, MD
The opinions expressed are my own and do not necessarily reflect those of any organization or group. please feel free to review other posts on www.spiritofhealthcare.com and check out my clinical site at www.robertsewellmd.com