American medicine today: A profession under siege

(Boston) The distinctions of the Massachusetts General Hospital (MGH) are many: Affiliation with Harvard Medical School, 3rd oldest U.S. hospital (1811), 2nd highest ranking in the U.S. News survey, world’s largest hospital based research program ($750 million dollar annual budget), and no less than eleven Nobel Laureates have worked or trained there.

Today it is also the site of a remarkable symposium on “the State of the American Medical Profession”. On stage are senior hospital administrators, selected medical Dept. heads, and two representatives of leading insurance companies. The audience is mostly made up of doctors, and other medical professionals. Not surprisingly in a busy hospital muted pagers are frequently heard and doctors come and go in the course of the 2 1/2 hour program.

The discourse which included questions from the audience was highly civil; opinions expressed were very thoughtful and reflective of the extraordinary range of experience among participants.

Though hardly alarmist there was a clear undercurrent of concern about the future of American Medicine. Though Obamacare was not the focus of the symposium, it was nonetheless a looming presence that was frequently referenced.

A major theme of the afternoon was the generational transformation of American Medicine: ”The Way We Were” versus “What We are Now Becoming”. It is a theme that is resonating widely across the country as the national disputation over Obamacare has brought unprecedented attention to America’s doctors and how they go about their work on behalf of their patients.

Through most of its history American medicine was a largely self-governing entity centered upon the doctor-patient relationship. Beginning in the late nineteenth century and throughout the twentieth the most dramatic advances were made in medical education, research, and patient care. World-wide the reputation of American medicine was unmatched.

Over the last half century however there has been a gradual erosion of the practice of medicine owing to the rise of government intervention, serial lawsuits, bureaucratic inertia, and soaring costs.

Significant landmarks in the genesis of government as a major player in American medicine include Medicare and Medicaid which created entitlements to benefit the elderly and the poor. These programs also represented a powerful political impulse aimed at moving the United States in the direction of fully “socialized medicine” similar to that pioneered by Britain’s National Health Service subsequent to 1945.

The good intentions and positive benefits attending these developments were undeniable, but over time the negative side effects became increasingly onerous. The massive increase in government money and regulation incrementally changed both medical insurance and hospital administration. Heretofore largely focused on doctors and patients, they now also had to recognize government as a powerful and demanding client. Furthermore the ever expanding bureaucratic nature of the “new client” would steadily undermine the efficiency of all concerned.

Compounding these dilemmas has been the exponential growth of malpractice lawsuits which have exploded insurance costs for both doctors and hospitals and given rise to “defensive medicine” which has further distorted medical care and economics.

The net result of all of this is perhaps best seen from the perspective of new graduates of American Medical Schools. Greatly burdened with debt, they are entering a profession where workloads have steadily gone up while incomes have gone down. The first question to patients is not “How do you feel?” but “What Insurance do you have?” Time spent with individual patients goes down while number of patients seen goes up. Paperwork, checklists, and bureaucratically defined “outcomes” become the basis of physician evaluation. Senior colleagues are fleeing the profession in record numbers leaving young doctors with a growing number of patients who want to know why the promise of lower cost and better care has gone unfulfilled or why they can’t come to this clinic anymore because someone is “out of network”.

If there is a silver lining here it is that the very toxicity of healthcare as a national political issue may have aroused the American public to a point where they will successfully demand a more rationally designed system that will revivify the doctor-patient relationship as the heart of good medical practice. Failing that the prospects for the doctors and patients of tomorrow will not be bright and that will be a true American Tragedy.

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William Moloney’s columns have appeared in the Wall St. Journal, USA Today, Washington Post, Washington Times, Philadelphia Inquirer, Baltimore Sun, Denver Post, and Human Events.

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