by Marianne Benkert, M.D.
[Spring/Summer 1998; Vol. 25 No. 1]
Business and medicine are uneasy partners and are intersecting each other in ways that have never before been experienced. In the not too distant past, physicians consumed close to 20 percent of the health care dollar but made decisions that controlled 70 percent of the health care dollar. Now it is the plan that owns the patient and the doctor as well. Eighty-four percent of all managed mental health companies are for profit, and four of them now control 70 percent of all managed mental health care (Dec. 1997 survey published in "Physicians for a National Health Program Newsletter"). Their power is incredible. I believe one of the most disastrous consequences of the current climate and one which attacks physicians at their very essence is the loss of professionalism.
A profession, sociologists have suggested, is an occupation that regulates itself through systematic, required training and collegial discipline; that has a service rather than profit orientation enshrined in its code of ethics. Medicine in this country has been able to achieve a singular degree of economic power and cultural authority as no other profession, but service has always been at its core. At the present time, not only have physicians lost their economic power to the HMO, but their professional authority has also been challenged and undermined. The kind of authority claimed by the profession involves not only skill in performing a service, but also the capacity to judge the experience and needs of patients. A physician is able to take into account the distinct kind of dependency which arises from the special emotional needs of patients. Now the business aspect of patient quotas and financial productivity assume foremost importance.
We acquired our sense of professionalism from our teachers, the physicians who instructed us through our long years of training. Our patients were also our teachers, as we made decisions with their best interests as our goal. The values of our profession and a sense of professionalism were being absorbed as surely as the knowledge we acquired on a day to day basis from our textbooks and the time on the wards. Now, our ability to make professional decisions has been violently attacked, We can all report stories of the difficulties in dealing with those who authorize our work with patients. For the physician who prides himself or herself on conscientiousness and thoroughness, there is a heavy emotional toll to be borne. We all know when our dignity as a physician is violated or impugned. Powerful feelings arise. There is anger, shame, and powerlessness. Demoralization and apathy can be the final result, and many physicians are experiencing just these feelings.
Medicine as a noble profession has been demeaned. Perhaps that is one of the reasons that for the first time in many years, the number of medical school applicants has shown a decline. Young people also wonder if their talents will be needed and appreciated. They perceive the turmoil in the health care field at all levels. Some of the students and young residents, many heavily in debt, wonder what their future holds professionally and economically.
In these changing times there is a constant. Professionalism and medical ethics are rooted in the doctor/patient relationship, in which the physician strives to help the patient and do no harm. Physicians as a group have historically held out against the usual organizational demands for control, and now we are among the most controlled of groups, our work questioned and scrutinized at many different levels. This has happened quickly and brutally, impacting on the physician and the patient.
Now is not the time for compliance. There are some directions we can move in, both individually and collectively. As patients access the health care system, we need to help educate them on their health care needs and what is available to them. Thirty second sound bites on TV are hardly informative enough to make an educated decision about health care. Many physicians have learned to lobby and have been effective educators for our elected representatives. This is certainly a new role for many physicians and a wonderful antidote for apathy. Through all the turmoil and transition, the doctor-patient relationship remains and it is still the foundation for satisfaction that we receive from our profession.
Dr. Benkert, a past president of the Baltimore County Medical Association, is chair of the Ethical and Judicial Affairs Council of the Medical and Chirurgical Faculty of Maryland. She is in the private practice of psychiatry in Timonium.