Wednesday, December 19, 2012

The Battle for the Souls of American Doctors

We physicians like to think that we are really different from other workers.  We physicians, perhaps thinking back to that medical school application essay we all wrote, really believe that we went into this career to simply help others.  We physicians truly believe that we always put our patients first. 

Because we sincerely believe all of the above, we are shocked when someone like Uwe Reinhardt points out that collectively we act just like any other worker in the economy.  The classic 1986 letters between the Princeton professor Reinhardt and former New England Journal of Medicine editor Arnold Relman highlight the tension between how we think of ourselves and how we act.

Relman thinks physicians are special and he asks Reinhardt the following question:

“Do you really see no difference between physicians and hospitals on the one hand, and ‘purveyors of other goods and services,’ on the other?”

Reinhardt is ready with a long answer that should be read in its entirety.  The short answer is that doctors act like any other human beings.   A portion of his answer includes the following:

“Surely you will agree that it has been one of American medicine’s more hallowed tenets that piece-rate compensation is the sine qua non of high quality medical care.  Think about this tenet, We have here a profession that openly professes that its members are unlikely to do their best unless they are rewarded in cold cash for every little ministration rendered their patients.  If an economist made that assertion, one might write it off as one more of that profession’s kooky beliefs.  But physicians are saying it.” (

I have recently written about the inevitable transition from fee for service payment to global, value-based payment systems, and I was surprised when a primary care physician whom I admire tweeted that he thought the end of fee for service would be the end of primary care.  (

This tension between the ideal of medicine and the economic reality of how medicine is practiced in the United States is perhaps best summarized by Atul Gawande in his famous New Yorker article about McAllen, Texas:

“Here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community has come to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers." (

This morning I was reminded of this battle for the soul of American medicine when I read two articles in the New York Times.   On the front page an article titled “Quiet Doctor, Lavish Insider:  A Parallel Life” describes how a well-respected neurologist at the University of Michigan capped off his successful academic career by cooperating with federal prosecutors to avoid charges in a Wall Street insider stock trading scandal. 

“The riddle for Dr. Gilman’s longtime friends and colleagues is why a nationally respected neurologist was pulled into the high-rolling life of a consultant to financiers and how he, by his own admission, crossed the line into criminal behavior.”  (

The other article in the Times published on the same day was the obituary of Dr. William F. House who invented the cochlear implant. 

“Neither the institute nor Dr. House made any money on the implant. He never sought a patent on any of his inventions, he said, because he did not want to restrict other researchers. A nephew, Dr. John House, the current president of the House institute, said his uncle had made the deal to license it to the 3M Company not for profit but simply to get it built by a reputable manufacturer.

Reflecting on his business decisions in his memoir, Dr. House acknowledged, ‘I might be a little richer today.’” (

A major challenge for 21st century American medicine is to cultivate the culture epitomized by Dr. House and avoid the mistakes of Dr. Gilman.


  1. Well said, Dr. Bottles, but I view it - as a non-physician - more as an ethical conflict than a mere challenge. Challenges can be lost without jeopardizing one's survival, whereas this ethical conflict goes to the very soul of medical practice, to use your term.

    Physicians get understandably defensive when non-physicians question their ethics, as did Dr. Relman with Professor Reinhardt. But he was assuming what medicine is supposed to be, not what it's become - and 25 years later, even more so.

    Consider that three of the most mainstream of medical practices - defensive medicine, unnecessary medical interventions (overtreatment) and self-referral - all rely on deceiving patients into accepting interventions they don't truly need, many of them with risk of harm.

    These all violate the AMA Code of Ethics to differing degrees, making them inherently unethical. How is it possible to dodge or otherwise obfuscate - with a straight face - the irrefutable fact that so much of mainstream medical practice in America is unethical?

    It isn't, of course. It's only to defend these practices as necessary in today's world and blame others for that perception. This is not winning the battle for the souls of America's doctors, it's ducking the battle altogether.

    The healthcare reform debate offered an opportunity for America's doctors to assume a leadership role - and that opportunity was largely squandered. It's now left to valiant souls like you to try to stir the conscience of a profession that seems to have largely lost its moral compass.

    I wish you well in that effort, but fear it's a hopeless cause. I can only hope I'm proven wrong.

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