Tag Archives: Hippocratic Oath

Life, Liberty and the Pursuit of Practice Happiness

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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.

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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

The Medical Profession In The Brave New World Of Healthcare

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The difference between a job and a profession is a matter of ownership. Anyone who is applying for employment understands that the job they seek actually belongs to someone else. It is typically offered by an individual or a corporation who defines the job and determines who is qualified to perform it. If the job holder is unable or unwilling to do the work, the owner takes the job back and finds someone else to fill the position.

By contrast, a professional owns their own job, having obtained the requisite knowledge and skills through very specific education, training and subsequent experience. Each professional is also charged with being a steward of the profession they have dedicated their life’s efforts to achieving. This stewardship requires the establishment and maintenance of an accepted set of core principles, and it is those core principles that define the profession to the rest of the world.

As a physician, my profession’s core principles have been in existence for about 2,500 years. They have been modified somewhat over the centuries, but by and large they have remained relatively constant since they were first outlined by Hippocrates. His rules for the profession were relatively simple; first do no harm, always do what is best for the patient, consider the patient before self, create no mischief and keep confidential what you see and hear. There is nothing specific in the Hippocratic Oath about charges or payments for physician’s services, but it concludes with the statement, “if you keep this oath, it will be granted to you to enjoy life and the practice of this art, respected by all men in all times.”

Through the ages patients have relied on the physician’s adherence to this basic Code of Medical Ethics as the fundamental basis for the social contract, commonly referred to as the patient/physician relationship. However, in recent years we have witnessed a steady erosion of that relationship as the practice of medicine has centered more on payments than patients. When America’s physicians allowed the camel’s nose of third party payers under their tent, they invited an assault on their time-honored ethics. For decades the patient/physician relationship has been under siege by a variety of forces associated with our convoluted payment system. Does your doctor do what he or she believes is best for you, or follow some “best practice guidelines” offered by a public or private bureaucrat who is holding the purse strings?

For a century and a half the American Medical Association has been the standard bearer for the Code of Medical Ethics in this country, and at one time nearly every physician was a member of that organization. But, since the mid 1960‘s AMA membership has declined steadily until today more than 80 percent of America’s doctors are not members. The reason for the mass exodus from the AMA is simple. Most physicians believe that it is no longer representative of the core values of their profession. As a delegate to the AMA House of Delegates for the last 4 years, I witnessed for myself how the “Business of the House” focuses far more on the finances, politics and social engineering efforts surrounding healthcare than it does in preserving and improving the art, science and ethics of medicine.

At the Interim Meeting of the AMA HOD I was reminded of just how far our professional leadership has drifted away from its core values. The AMA President, Dr. Jeremy Lazarus, gave a speech during the opening session. He called on America’s physicians, “To move from divisiveness to diplomacy, from conflict to collaboration, from the narrow self interest of personal gain to the national interest of mutual goals.” He went on to say, “We need to have a difficult but necessary conversation with the public and our leaders about the tough choices ahead. In June, the AMA passed ethics policy that calls on physicians to be stewards of the resources society entrusts to us. To follow policies on issues such as: Cost versus Value. End of Life Care. The responsibility of patients to own their own health. The need for more public health investment. The very unsustainability of the system itself – absent fundamental change.”

Dr. Lazarus was presenting the AMA’s new strategic plan that promises to discard those core principles which are centered on the individual patient, and replaces them with a new ethical code that shifts the profession’s priorities to meeting the collective good. In his remarks he accused physicians of being selfish, suggesting that we should “… listen to our heart and be driven by science – and not the latest fad or the biggest pile of cash. Knowing in our heart that a medical school diploma is not a treasure map.” Perhaps the new AMA strategy was best summed up when Dr. Lazarus said, “It seems to me the stars have aligned in such a way that our loftiest aspirations are exactly what’s needed now to transform our health care system. And to embrace a new set of core values – ones better suited to integrated care… It once made sense for physicians to value autonomy, independence, and self-sufficiency. But the game has changed.”

This new AMA plan and strategy are merely a continuation of the organizations trend over the last 50 years, which clearly runs contrary to the traditional Code of Medical Ethics. So, it comes as no surprise that the next step will be to make the needed alterations to that pesky code. The Speaker of the House, Dr. Andrew Gurman, spoke to this issue shortly after Dr. Lazarus. He told the delegates that over the next few sessions there was much work to be done on a number of important issues. At the top of the list was the need to “revise” the AMA’s Code of Medical Ethics to be more relevant given the changing healthcare environment. The objective seems obvious. The ethics of Hippocrates simply won’t allow physicians to participate in such things as Accountable Care Organizations, Pay-for-Performance Initiatives, Gain Sharing, Resource Stewardship, Cost versus Value, End of Life Care and other similar euphemisms, each of which translate into rationed care orchestrated by the physician.

The “Brave New World of Healthcare” has become one in which payers exert more and more pressure on physicians to manage costs, and professional organizations abandon their core principles for political expediency. Not surprisingly, many physicians are overwhelmed by this changing environment and feel compelled to seek the safety of employment by a hospital or large integrated system. But when they do, their commitment to individual patients becomes subordinate to the rules of their employer, and their profession with its defining code of ethics is lost forever in favor of job security.

Robert Sewell, MD, FACS

 

 

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

The Healthcare Bubble

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It appears we live in the age of the “bubble”. The current recession was the result of the collapse of the Housing Market bubble. We know about the Credit bubble in Europe with forecasts of countries defaulting. Then there is the periodic Energy bubble here at home, which surfaces every time there is an increase in Mid-East turmoil. It seems we continually go from one economic bubble to the next, but what about the “Healthcare Bubble”?

Recently my son, who is a college student, sent me an article published in Forbes entitled “The Dumbest Idea In The World: Maximizing Shareholder Value” by Steven Denning. This is an essay on how the American capitalist system is being threatened by the practice of executives manipulating corporate performance expectations on Wall Street, in an effort to maximize the value of their companies’ stock. It is a rather intricate discussion, but the conclusion is that over the last 40 years the focus of CEOs has shifted from their products, customers and employees, to pleasing their shareholders with higher stock prices. This is in large part because top level executive compensation is tied directly to the value of the company’s stock.

As I read through this article I couldn’t help but draw a comparison to what has been going on in the healthcare arena over that same period of time. But, instead of shareholders, the priority parties in healthcare are often referred to as “stakeholders”. They include payers (public and private), hospitals and other facilities, regulatory and certifying entities, pharmaceutical companies, medical device manufacturers, a myriad of management companies and numerous other minor players. Oh wait! I almost forgot, there is another stakeholder group known simply as providers. Each of these entities has contributed in one way or another, and often in combination, to a progressive shift away from what has traditionally been a very personal and individual service, to a “system” where healthcare is now doled out as a commodity, largely to the benefit of the stakeholders.

Jack Welch, the former CEO of General Electric, was once the darling of Wall Street because he was the undisputed king of playing the game of maximizing shareholder value. But after his retirement he apparently saw the light. In a 2009 interview he said, “On the face of it, maximizing shareholder value is the dumbest idea in the world. Shareholder value is a result, not a strategy…” I’d like to paraphrase that statement for healthcare; On the face of it, stakeholders managing individual’s healthcare is the dumbest idea in the world. Stakeholder value is a result, not a strategy.

The movement away from the patient as the center of healthcare has been gradual, but it took a major leap forward with the passage of federal healthcare reform in 2010. The Patient Protection and Affordable Care Act is precisely the opposite of what its name implies. It does little to protect patients, is far from affordable and is more about controlling costs than it is about providing care. The true effect of “Obamacare” is to homogenize the delivery of care, with the various stakeholders lead by thousands of unelected bureaucrats, ultimately determining the who, what, when, where and how healthcare services are provided. Moreover, all this is done under the guise of quality improvement and cost effectiveness. The fact the entire federal government, including Congress, and now countless special interest groups have been exempted from this law should provide ample proof of the undesirable nature of such a system.

While CEOs are, by definition, the ultimate decision makers in America’s corporate world, it is the physician who has traditionally held that role in healthcare, but that is changing rapidly. Over the years America’s physicians, the “Chief Health Officers” for their patients, have allowed themselves to be progressively manipulated by the other stakeholders, who’s strategies and tactics have included various financial incentives, regulatory mandates, credentialing guidelines and the most recent trend, physician employment.

An obvious comparison can be made between the corporate CEO who is compensated based on the value of their company’s stock and a physician whose compensation may be based on the profitability of his or her practices to the hospital or insurance company that employs them. Likewise, if the customer suffers when a company fails to respond to their needs, it is the patient who will suffer when their physician’s incentives are misaligned. To date, the only thing that has stood between the patient and stakeholder mandated rationing of care has been the moral and ethical compass of the physician. Now even that is under constant attack by some stakeholders who view the Hippocratic Oath as an inconvenient or outdated philosophy.

The ultimate impact of shifting incentives and conflicting priorities has been the creation of a practice environment where many established physicians feel trapped. On the one hand they can hold to their traditional values and focus exclusively on their patients’ needs and risk financial ruin, or they can compromise those values and learn to play the stakeholder game. Most are struggling in an attempt to do both, but with little success. Many older physicians are opting out of healthcare altogether, while others are simply focusing their practices on services that are outside mainstream medicine. The supply of young physicians, who are in large measure being trained as “shift-workers”, is insufficient to fill the gap created by early retirements and career changes within the older guard. The result is a growing “Healthcare Bubble” where demand for services will soon outstrip supply.

Not surprisingly, one quick-fix being pushed by various stakeholders is a broad expansion in the scope of practice of various paramedical personnel. There is rarely any mention of the level of competence required to safely remove your appendix or manage your high blood pressure.

Many of my physician colleagues have expressed a defeatist attitude, suggesting that changing the healthcare system is impossible. Again, borrowing from Denning’s article, which quotes Vince Lombardi: “We would accomplish many more things if we did not think of them as impossible.”

Clearly, the first step in getting back to patient centered healthcare is the total repeal of Obamacare. This will only happen if the majority of the population demands it, and that is precisely what the next Presidential election is all about. Should Mr. Obama win another term in the White House, there will be virtually no chance that his version of healthcare reform will ever be repealed. If that happens, the Healthcare Bubble is very likely to burst within just a few years. Healthcare will indeed be “free” to all American’s, but will they be able to find it?

 

 

The opinions expressed herein are my own and do not necessarily reflect or represent the policies or opinions of any medical organization or group.

Check out my web site at www.robertsewellmd.com

The Lost Art of Personal Service

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Do you remember your first paying job? Mine was as a gas station attendant in Kansas City, Missouri. Back in those days they called them “service” stations. Cars would drive in off the street and that familiar “double ding” would announce their arrival. I’d run out to greet the driver and ask the standard questions: “Fill ‘er up sir?” “Regular or Ethyl?” (Ethyl was what we called premium back in the day.) “Can I check under the hood?” “Do you want me to check your tire pressures?” I’d then pump the gas and do whatever else the customer asked, and the job wasn’t complete until all the windows were washed. By the way, gasoline was 19 cents a gallon and motor oil was 50 cents a quart.

In the late ‘60s customer service was not extra, it was expected. At $1.15 an hour it was simply part of the job, even in the rather seedy part of town where I was working. Inside the station we had a couple of vending machines where customers would occasionally come in and buy a candy bar for a nickel or a coke for a dime. But the big sellers were cigarettes because back then it seemed almost everybody smoked.

Today it is pretty hard to find a “service station.” I can’t remember the last time someone actually came out to my car to pump the gas or check the oil. Obviously there’s no money in personal service at the pump. Instead, the gas station has actually become a front for the more lucrative convenience store. I’m sure most storeowners wish they’d never offered the “pay at the pump” option. They’d much rather you would come inside to pay so you’d also buy a lottery ticket and a three-dollar energy drink. Times have certainly changed, but not just in the retail business.

The other day I was reflecting on just how much change there has been in the practice of medicine over the 32 years since I first hung up my shingle. I was talking with one of the emergency physicians at our hospital about the fact that more and more of our colleagues have become shift-workers. This started with the specialty of emergency medicine, but it has grown to encompass nearly all areas of medical practice. Today nearly every hospital employs what are referred to as hospitalists. These docs typically work 12-hour shifts entirely in the hospital, caring for patients with whom they have no prior relationship. Likewise they are not likely to have any further contact with the patient once they leave the hospital.

One of the chief responsibilities of hospitalists is to admit and provide inpatient care for patients who come in through the emergency department. Notice I didn’t say emergency “room.” That area of the hospital has become the major portal of entry and hardly qualifies as a “room” any more. Most hospitals also employ various specialists to provide additional services such as radiology, pathology and anesthesia on a contracted basis. Recently, even surgical specialists have been lured into being employees of hospitals rather than maintaining independent practices. As a surgeon myself I find that pill a little hard to swallow.

The idea of performing major surgery on someone and never seeing them again is completely foreign to me. However, that seems to be a growing trend, as personal service gives way to an ever-increasing “drive through” culture. The unfortunate net effect is the gradual erosion of compassion and care. In fact I think it is safe to say that health “care” has morphed into what can only be referred to as health “acts.” I would say health “services” but that would imply that the patient is actually being treated as a customer. Unfortunately, the one paying the bill, and therefore deserving of the label “customer,” is the third party payer. Insurance companies and the Federal government appear to be detached from the actual delivery of health “acts” but, since they are writing the checks, they make most of the rules. Over the years the impact of third party payer rules on the practice of medicine has been enormous. To the point where many of those who entered the medical profession as a calling have become so frustrated with the over regulated environment they have chosen to pursue alternate careers. Others have decided just to go along to get along and the result is the development of a shift-worker mentality.

The tragedy of these changes is not measured in early physician retirements or even a loss of practice satisfaction. Rather, it is the loss of personal care, the basic hallmark of the healing arts. Care is a verb defined as: to be concerned or interested; to provide needed assistance or watchful supervision. These are not the actions of a corporate or governmental entity. Only individual human beings are capable of truly caring for another human being. This is the essence of the Hippocratic Oath, which is clearly under attack by a variety of faceless entities that endeavor to benefit from health “acts” without regard to the basic welfare of those who are in need of health care. It is that very oath that traditionally separates being a physician from virtually every other occupation. But once that personal pledge is not kept the practice of medicine goes from being an honored profession to just another job where service has become a lost art.

 

Visit my website at www.robertsewellmd.com

What is Healthcare Anyway?

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Amid all the political rancor and media hoopla surrounding the American healthcare system and the clamor for reform from all sides, one question has gone unasked; what exactly is this thing we call healthcare? Is it the local hospital with its giant façade and ambulances coming and going all hours of the day and night? Is it the clinic where you sit and wait to have your blood pressure taken? Is it the pharmacy on the corner where you go to pick up your prescriptions? Is it that radiation treatment center you pass going to and from work everyday? Is it your employee services director at work, asking you to choose your insurance plan for next year? Well, the fact is healthcare is none of these things. Rather, it is a personal service provided by one human being to another, and since ancient times the provider of the service has been called “physician” and the recipient simply “patient.” Their relationship has changed somewhat over the centuries, but it has always been based on trust. Today that relationship is being threatened by a variety of controlling interests.

Recently my friend Dr. Ralph Kristeller, a retired internist and former delegate to the AMA from New Jersey, reminded me of the history behind the development of the modern patient-physician relationship and with his permission and encouragement I’d like to share portions of his medical history lesson. It is critical to understand this evolution and as a wise man once said “the best place to begin is at the beginning.”  The problem is that the beginning of medical care took place in different places in the world at different times.  However, it is reasonable and very important to say that “medicine” began when the science and the healing art were disassociated from magic, superstition, and religion.

In ancient times two separate healthcare systems developed around two different concepts, one legal and the other ethical. The first was created in Babylon and was based on a legal writing called the Code of Hammurabi. He was the ruler and able administrator of that city-state. Some 282 provisions were carved into a Dolite obelisk 3,800 years ago. In Babylon, the medical profession had advanced far enough in the public esteem to be rewarded with adequate fees that were carefully prescribed and regulated by laws, which empowered the patient and the state. For example, if the patient was a “gentleman” 10 shekels in silver was the statutory fee for treating a wound or opening an abscess of the eye with a bronze lancet. If the patient was a poor man or a servant the statutory fee was 5 shekels; for a slave the fee was 2 shekels. In addition, if the patient lost his life, or his eye, the law also regulated penalties for the physician. If the patient was a “gentleman” the physician had his hands cut off, but in the case of a “slave,” the physician only had to pay for the slave.

In ancient Greece another guiding principle led to a different healthcare system whose foundation was the social contract established by the Oath of Hippocrates. This system empowered the physician based on a standard code of ethics. Hippocrates was born 2,500 years ago on the Greek island of Kos into a clan of privileged people, the Asclepiads, descendants of Asclepius (“the Doctor-god”). He is given credit for separating the practice of medicine from Greek theory and philosophy, and he crystallized the loose knowledge of the day into a systematic science.  Hippocrates preached clinical inspection and observation as the basis for medical care and alerted colleagues to be ever on the lookout for sources of error.  In developing the art and science of medicine he employed a logical mind and all his senses together with a transparent honesty. Hippocrates also promoted the dignity of the physician’s calling, along with a seriousness and deep respect for his patients, making him by common consent “the Father of Medicine.”  And, of course, he is given credit as the author of the Hippocratic Oath, which states in essence, do no harm, always do what is best for the patient, consider the patient before self, create no mischief and keep confidential what you see and hear. The oath adds at the end, almost as a foot note, “if you keep this oath, it will be granted to you to enjoy life and the practice of this art, respected by all men in all times.”

With the Oath of Hippocrates, medicine took a giant leap forward from the written legal code, which regulated all practices through authoritative edicts, to one that involves a “social contract” between the patient and physician directly.  Most importantly, this social contract is far more empowering than the law because, with it, society entrusted the independent ethical practitioner to do what was best for each individual patient. But in recent years, our system has been drifting back toward a legalistic system. This move has been driven first by “Managed Care” (more accurately called Managed Resource Care) that empowers neither the patient nor the physician, but instead empowers corporate entities offering insurance as a means of payment. More recently, the system is morphing into one of Managed Government Resources, which takes power away from the patient, the physician, and private companies and places it in the hands of the lawmakers.

The question facing the American healthcare system and all the people who participate in it, both physicians and patients, is whether we choose a system that closely resembles the Code of Hammurabi or one based on the social contract of Hippocrates? It would seem that before we can answer that question we must first address the more fundamental question that is the title of this writing “What is Healthcare Anyway?” If one ascribes to the idea that healthcare is a basic human right, then it only makes sense to have it provided for and regulated by the state. But, if one believes, as I do, that healthcare is the most personal of all human “services” then control must remain solely in the hands of those who are directly involved, patients and physicians. Both parties must remain free to engage in an independent “social contract” to pursue their mutual goals of alleviating suffering and promoting individual well-being without interference from anyone who would inject themselves into this sacred relationship for their own economic or political gain.

 

This post was first published on www.robertsewellmd.com in February 2011.