“But where there is danger, there grows also what saves.” Friedrich Hölderlin Attention is our most limited resource. William James proposed…
Do you trust your doctor? Should you trust your doctor?
A recent op-ed in The New York Times suggests that doctor-patient trust is wavering. Pay for performance metrics put in place by insurers, hospital networks and regulatory groups are being used to reward or punish a doctor’s decisions about patient treatment. Here’s how it works, say Pamela Hartzband and Jerome Groopman, two physicians on the faculty of Harvard Medical School: doctors earn a bonus, for example, when they prescribe certain meds or keep patients’ blood pressure and cholesterol levels below a certain threshold. Alternately, doctors are shamed on insurer websites and financially penalised if the metrics aren’t met. This is problematic: medical opinion on best treatment varies, and the carrot and stick approach is pressuring doctors “to withhold treatment that they feel is required” or “to recommend treatment whose risks may outweigh benefits.”
How did we get here? For hundreds of years, medicine was a profession focused on relieving suffering and healing the sick, with the value of health at its centre. Plato wrote, “The physician, as such, studies only the patient’s interest, not his own…The business of the physician, in the strict sense, is not to make money for himself, but to exercise his power over the patient’s body… All that he says and does will be said and done with a view to what is good and proper for the subject for whom he practices his art.”
While doctors were expected to act in the best interests of their patients, they weren’t always respected for it. In Roman times, physicians were the rabble: slaves, freedmen, or foreigners. Until as late as 1745, surgeons belonged to the same guild as barbers; both worked with their hands. In England, doctors tried to impersonate the upper class because professional success was about having the right aristocratic patrons and displaying the right social graces. In America, doctors launched medical schools and societies to bolster the status of the profession.
During the 1800s, being a doctor was still a hard way to make a living. Medical knowledge was scant, and many families, isolated in rural areas with low incomes, cared for their sick at home. Doctors were saved for emergencies; before the invention of the car, a physician’s travel fee alone could be four to five times the visitation fee. Hospitals, run by religious orders that relied on volunteer doctors, nurses, and nuns, were more about charity than expertise and carried the risk of infection. You went to the hospital to die or when you didn’t have family or friends to care for you.
Then came the Industrial Revolution. Work moved from homes to factories. Cities sprouted, and steamboats and railways helped families spread out. Suddenly it was harder to keep a sick person home: there might not be anyone at home to provide care. And with the advent of the phone and the car, doctors were more accessible and affordable. As care for the sick shifted from families and neighbours to doctors and hospitals, healthcare became something to buy and sell.
But while healthcare has been a commodity for some time now, it’s only recently become a full-on industry. Healthcare was bought and sold, but it wasn’t just another thing for sale, like hammers or apples. Medicine was a profession dominated by an ethics code – in 1934 the US explicitly stated that outside investors profiting from medical work was “beneath the dignity of professional practice, is unfair competition within the profession at large, is harmful alike to the profession of medicine and the welfare of the people, and is against sound public policy.” As a profession, medicine was regulated because people thought it had to be; most of us aren’t able to evaluate the quality of help we get, and poor care could leave us disabled or dead.
Before World War II then, medicine was a cottage industry financed mostly by wealthy patients and philanthropists. Most people were uninsured and paid out-of-pocket or in kind for medical services. The health manufacturing industry didn’t exist because there wasn’t enough medical technology to support one, and the government was uninvolved other than through licensing and tax laws.
Then came the information boom. By the early 1940s, X-rays, ECGs, and the four major blood groups were discovered along with insulin, sulfa, penicillin and anaesthetics. Doctors became a symbol of healing. In her memoir, crime novelist PD James recounted the birth of Britain’s National Health Service (free public healthcare) in the 1940s. She said it removed a weight of anxiety from her shoulders due to her mother’s ill health, but added that people expected the program’s annual cost to drop as the nation became healthier year after year. No one, she said, dreamed that it would ever be possible to transplant kidneys and hearts, to overcome infertility. No one dreamed of managing chronic diseases like AIDS. No one dreamed that so many would live for so long.
In the 1950s and ‘60s, major advances were made in surgery, radiation, chemotherapy, organ transplants, and tranquilisers. The body of medical knowledge was now too large for any one person to grasp, and doctors began to specialise. With the rise of new technology, specialisation, insurance coverage, and unregulated payments for doctors’ fees, medicine started looking attractive to outside investors. By the late 1960s, Wall Street was investing in for-profit healthcare facilities. Private capital became a major player in the system, mostly in insurance companies and healthcare technology manufacturers. Multinational healthcare companies developed and, one could only say, thrived; in US-based Humana, for example, an original $8 share in 1968 was worth $336 by 1980.
And now? Now healthcare is just one more multi-billion dollar industry among many, its nature incontrovertible. Medical schools offer joint MD-MBA degrees. Business school graduates hold top jobs in medical organisations. Healthcare policies are laid out by business school professors and economists. As a business, the healthcare industry develops and promotes ever-changing products, ‘medicalises’ problems by advertising all kinds of conditions, stimulates interest in cures, builds consumer demand (remember when no one other than celebrities thought to whiten their teeth?), and tries to get people out to the doctor more.
But where the profession of healthcare was based on the trust that your doctor was acting in your best interests, the business of healthcare is not. A national survey of physicians published in The New England Journal of Medicine in 2007 found that 94% have “a relationship” with the pharmaceutical industry, medical device industry, or other related industries. Which brings us back to Hartzband and Groopman’s concerns. Now there’s an element of unknowing between you and your doctor: is your physician prescribing you a drug or recommending a cancer treatment or rest home because that’s what you need, or because he or she is trying to meet a monthly target?
The value of health, of mental and physical well-being that was at the centre of medicine for hundreds of years, was that an end unto itself in the profession of medicine? In the business of medicine, that value has become a means to an end: fixing the living to make a killing.