Physicians as Veterinarians and Heroes

But gradually the medical profession has been forced to give up this approach for what I like to call a “veterinary ethic,” one that places the interests of the payer (or owner) ahead of the patient.

Jeffrey A. Singer, MD., “The Coming Medical Ethics Crisis,” Reason Magazine, March 15, 2012. Doctor Singer is a general surgeon in Phoenix, Arizona

Physicians as heroes – a dying breed?

Title of article in Hospital Physician, by S.J. Ray, Hospital Physician, February, 1990

March 17, 2012- When I first read Doctor Singer’s Reason Magazine article, I recoiled in disbelief. As the cliche goes, some of my best friends are veterinarians. Surely it hasn’t come to that – doctors treating patients as animals.

But as I read on, I grasped Dr. Singer's point- that physicians are coming to the point that they must follow the dictates and rules of payers, be they government or health plans, the owners of health care policies, rather than the Hippocratic Oath.

At first, I brushed off the Reason Magazine article. But then I saw it reprinted in the Wall Street Journal’s “Notable and Quotable section as follows.

For centuries, my predecessors and I have been inculcated with what has come to be called the "Hippocratic Ethic." This tradition holds that I am ethically required to use the best of my knowledge to recommend to my patient what I consider to be in my patient's best interests—without regard to the interests of the third-party payer, or the government, or anyone else.

But gradually the medical profession has been forced to give up this approach for what I like to call a "veterinary ethic," one that places the interests of the payer (or owner) ahead of the patient. For example, when a pet owner is told by a veterinarian that the pet has a very serious medical condition requiring extremely costly surgery or other therapy, the veterinarian presents the pet's owner with one or more options—from attempt at cure, to palliation, to euthanasia—with the associated costs, and then follows the wishes of the owner.

Several factors in combination are bringing this ethical approach to my profession.

Since the mid-1980s, Medicare has imposed price controls on health care providers. Over the years, in order to accommodate increasing Medicare utilization, physician payments have steadily dropped.

Meanwhile, the regulatory burden on physicians has increased. In the last few years, CMS required all providers to adopt electronic health records or face economic sanctions from Medicare. It is the ultimate goal that every health care provider, including pharmacies, will have electronic databases that will be accessible to the U.S. Department of Health and Human Services (HHS).

In 2009, as part of the so-called stimulus bill, the Federal Commission for the Coordination of Comparative Effectiveness Research (FCCCER) was created. Its mission is to collect the data culled from all electronic health records and make recommendations regarding the comparative effectiveness of drugs, procedures, and therapies. In rendering advice, the FCCCER will essentially answer the following question: What is the most cost-effective way of allocating a fixed amount of resources among a population of roughly 310 million people?

These protocols govern the therapeutic decisions made by the health care practitioner—right down to the pre-operative antibiotics a surgeon may order. Despite the fact that several recent peer-reviewed studies concluded that the protocols have had no positive effect—in fact, one study showed post-op skin infections increased since the protocols were instituted—CMS imposes financial penalties on hospitals that fail to get protocol compliance from their medical staff.

Medical students and residents are now being trained to follow federally-derived protocols and guidelines as a normal part of medical practice. As a result, this new generation of doctors will be less inclined to challenge the recommendations of federal task forces and agencies. Some academics also worry that "teaching to the protocol" might discourage independent thinking and the use of intuitive knowledge, two traits essential to the practice of good medicine.

Whatever came of those halcyon days when doctors were treated as heroes – those days before “protocol medicine“and all the scrutiny and regulations that goes with it?

Well, today I found the antidote in a full page ad in the March 17 New York Times. Its headline ran: “Castle Connolly Medical Ltd, presents The Seventh Annual Physician of the Year Awards, Monday, March 26, 2012, Dinner at 6:30 p.m. The Pierre Hotel, New York."

• The Lifetime Achievement Honorees include Robert Brent, MD, Professor of Pediatrics and Radiology at Jefferson Medical College and John Carlson, MD, Dean Emeritus and Professor of Ophthalmology, at the University Of Miami School Of Medicine.

• The Clinical Excellence Honorees include: Richard Elson, MD, Professor of Dermatology at Yale, Susan Mackinnon, MD, Professor of Plastic and Reconstructive Surgery, at Washington University School of Medicine in St. Louis, and John Magana Martin, Section Chief, Minimally Invasive Surgery and Doctor of Bariatric Surgery and Surgical Quality, as Stanford University School of Medicine

• National Health Leadership Honoree – Marlo Thomas, National Outreach Director, S.t Jude Children’s Research Hospital

In the interest of Full Disclosure, I am on the Medical Advisory Board of America’s Top Doctors, which is published by Castle Connolly Medical Ltd. In the interest of Fairness, I see no reason why Medicine should not have its own version of the Academy Awards honoring physicians rather than cinema celebrities.

Tweet: To request an invitation to the National Physician of the Year Awards, visit www.castleconnollyawards,com/invite/ or call 212-317-6413.