True North, or 'Has Medicine Lost It's Way?'

What is True North for medicine? Is there an enduring core value that serves as a reliable touchstone across the nearly infinite range of medical activities? Given how medicine and society change, can there even be an enduring True North? If we have one, are we pursuing it faithfully?  

 

I have always believed that medicine does have a True North: the best interest of the patient. I increasingly see it being undermined and fear it is in danger of being abandoned.

The central role of patient welfare was clearly recognized as far back as Hippocrates:  ”Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.” It is a core principle in the Declaration of Geneva:  “The health of my patient will be my first consideration,” and the Declaration of Helsinki, and is found in The Archimedean Oath,  the Vaidya’s oath for the Hindu physician, and the Oath of Asaph for Hebrew physicians.  Even the AMA states:

“A physician shall, while caring for a patient, regard responsibility to the patient as paramount.”

Is this value still relevant? Should our patients’ welfare still be our primary and overriding concern? I certainly believe so. The best way to answer this is to ask yourself whether YOU want YOUR clinician to be serving YOU, or should he serve the interests of his employer, a hospital, or an insurance company? 

If we are willing to make patient welfare secondary to our values and interests, or to the financial or administrative needs of our employer, or to those of an insurance company, or a drug company, what is to stop us from betraying our patient because a friend or neighbor offers us money? Nothing.

Drs. McNutt and Hadler said it well: 

“If we are following any mandate from any business, hospital, insurer, electronic health record purveyor, or special interest group that truncates our ability to inform a patient and to offer care “with” them in their splendid variability, we are, in our view, abandoning our oath of practice.”

Unless we preserve the unbreakable primacy of our patients’ welfare as the gold standard, we will become soulless mercenaries, selling our services to the most persuasive bidder.

Sadly, I think this is happening. Medical institutions are increasingly owned and run by people highly trained in business and management but with no formal or informal commitment to our True North. Though well meaning, these people and the system they comprise are designed to serve the institutions, boards, payors, stock holders, and various external agencies. Patients have become a raw material for a very lucrative medical industry, and physicians and other professional clinicians have been enlisted as productivity machines.

More than a decade ago the American Board of Internal Medicine Foundation,  the American College of Physicians Foundation, and the European Federation of Internal Medicine clearly recognized this problem. In 2004 they published a Charter clearly defining the core values of Medical Professionalism. It is worth reading. Two of the three fundamental principles are the primacy of patient welfare  (“Market forces, social pressures, and administrative exigencies must not compromise this principle.”) and the principle of patient autonomy. Among the ten clinician responsibilities were the commitment to honesty with patients, and the commitment to maintaining trust by managing conflicts of interest. 

On a grand scale, we see many egregious and highly publicized examples of fraud and greed. Examples include this and this and this and this and this and this and this. Books have been written by prominent figures including by Brownlee and Brawley and Welch. 

Horrifying? Absolutely. But wait. There’s more! Consider deceptively banal but universal and arguably more damaging things like:

  • A fall prevention program that earns money by screening for fall risk without bothering to address the risk factors in identified high risk patients.
  • Paying clinicians less if they do not convince patients to undergo tests (colonoscopy, mammogram, Pap, cervical culture) or treatments (flu shot, pneumococcal vaccine), as opposed to paying them to help patients make their own independent decisions.
  • Developing quality improvement initiatives based on the existence of third party financial incentives rather than based on actual quality needs.
  • Incentivizing clinicians to refer preferentially within an organization, rather than based on the needs or preferences of the patient.
  • Unwillingness to support common primary care point-of-care testing (audiometry, tympanometry, spirometry) with the result that patients are inconvenienced, pay more, and test results are delayed.
  • An ‘educational’ brochure about low dose CT screening for lung cancer that gives misleading statistics and fails to mention risks.
  • Requiring many hours of training for a new set of billing codes but no training for a new set of clinical templates or EHR forms.
  • A hospital sponsored wellness program that duplicates services, ignores current best evidence and evidence-based standards of care, and shifts costs from the hospital to the most vulnerable, those with poor health.

(Note: these are all things I have seen in the last 3 years.)

I understand why institutions and organizations put their business interests ahead of patient welfare. Like the allegorical scorpion, it is their nature and to be expected.  I also understand why leaders and managers put institutional needs ahead of patient needs: they were neither called to patient care nor trained as patient care professionals. They are being true to the institutions they serve. Sad, but not surprising.

What I do not understand, refuse to accept, and struggle to forgive is the willingness of so many clinicians to accede to this, to regularly allow employers, payors, and administrators to undercut our commitment to our patients’ welfare by imposing other competing interests. Where is the outrage?

The only thing necessary for the triumph of evil is for good men to do nothing.

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