Medical professionalism vs commercialism

fast-cheap-goodThe history of American medicine is the story of the rise and fall of a professional guild.  In the 19th and early 20th Centuries, physicians distinguished themselves from other healers by banding together to form professional associations dedicated to science-based practice.  Even more important, medical ethics put the patient first, above considerations of personal gain or even collective social goods.  The medical guild may have been insular, self-protectively territorial and paternalistic, but it was also self-sacrificing and altruistic.  Doctors earned the public’s trust one patient, or family, at a time.

The last quarter of the 20th Century saw this guild wither under waves of commercialism and populism.  Third party payers started “managing” care, trumping medical decisions with budgetary ones.  Large medical corporations leveraged economies of scale to provide services at lower cost.  Meanwhile, government oversight gradually replaced the guild’s self-policing.  Since the days of Vietnam and Watergate, no authority in America, even medicine, gets a free pass.  With oversight comes infrastructure, formalized quality control, reporting requirements.  Unfortunately, sensible-sounding social policy may be unworkable on the ground.  Private medical practices are gradually disappearing.

The weakening grip of physicians over the practice of medicine re-opened the door for commercial innovation — or pandering, depending on one’s perspective.  Generations ago, patients were drawn to inexpensive folk remedies, expensive patent medicines, and traveling road shows.  The modern parallels are free information on the internet, ads for expensive prescription drugs on television, and slick smartphone apps.  Patients now see a doctor for a one-time encounter online, at an urgent care clinic, or in a “Minute Clinic” behind a chain drugstore.  Enhanced access and convenience, often at lower cost, is the upside.  The downside is fragmentation of medical care rendering it an impersonal commodity, where doctors are interchangeable and patients are widgets on an assembly line.

The hard lesson of the marketplace is caveat emptor.  Little wonder that patients only reluctantly divulge personal matters to strangers in white coats, and increasingly prefer to do their own online research.  A trusting doctor-patient relationship, once the soul of medicine, begins to sound as quaint and precious as “old world craftsmanship” — nice if you can afford a concierge doctor who still offers it.

A number of battles are being waged in this larger war between professionalism and commercialism.  On one side are physicians rallying under the traditional banner of uncompromising standards, and prizing the individual patient over cost and social considerations.  Detractors, however, paint this stance as paternalistic, and say doctors are clinging to the last scraps of guild status and privilege.  On the other side are entrepreneurs happy to “disrupt” the status quo and give the public what it wants, namely lower cost, faster service, and transparency.  Detractors, however, say these entrepreneurs pander to a fast-food mindset that cuts corners and increases medical risk.

The Texas Medical Board ruled earlier this year that doctors must examine patients in person (or “face to face”) before treating them online, essentially declaring telemedicine an adjunct to in-person care, not a replacement.  Teladoc, the largest U.S. telemedicine provider, filed an antitrust lawsuit in U.S. District Court, which suspended the Board’s ruling.  The court’s decision suggests it is not up to doctors to set a standard of medical care.  It’s a marketplace decision.  If people want to be diagnosed without the benefit of a physical examination, and companies choose to provide that service, that’s their right.  It will be interesting to see whether medical malpractice will be harder to prove once the marketplace lowers the standard of care.

Likewise, doctors favor follow-up visits to discuss certain test results, particularly those with life or death implications.   This is motivated by benign paternalism: putting the results in context, softening the blow of bad news, helping the patient not jump to conclusions, framing the next steps.  Many service professionals, from caterers to auto mechanics, offer at least a little of this contextualization.  But it’s a value-added service that costs real money in medical practice.  Many patients prefer to get their results online or directly from the lab instead: it’s faster, less expensive, and feels more transparent.  Interpreting the results with the help of Dr. Google is a risk that saves time and money.

The tension between traditional medical values and expanding commercialism, amplified in this age of instant online information and services, puts the squeeze on physicians. We need to explain our rationales carefully and stand up for high quality in the face of expediency.  Yet we also need to choose our battles. We may be forced to accept a role for medical fast food as well as fine dining.  And this is not only for the sake of affordability, although that’s one very real consideration.  Americans crave speed and convenience, as distasteful as that may be to old-world craftspeople, Cordon Bleu chefs, and principled physicians.  Speed, cost, quality — pick any two.

2 comments to Medical professionalism vs commercialism

  • I notice that you used the term “quality” twice in the last paragraph.

    It is an old term that physicians have abandoned and it is used only rhetorically today. No physicians seem to use it anymore and that is the key problem. It has been replaced by “cost-effectiveness”, “productivity”, “evidence-based”, and “population-based” as though those words are synonymous. Physicians have basically adopted managed care speak and use their terms.

    As far as I can tell there is no tension between “traditional medical values and expanding commercialism” because there is no group of physicians or professional medical organizations willing to stand up to commercial interests. The physicians would rather “have a seat at the table” – and we have seen over the past three decades how that has worked out. Over that same period of time I have heard the term “pick your battles” many times.

    The problem is that physicians as a group don’t want to battle. I suspect that is the result of many of them being raised as part of the manager class of Americans who are taught to profit by colluding with the status quo. The remainder are socialized into the idea that “professionalism” involves stiff upper lip comportment and that means not mixing it up with anybody.

    At least any time I have suggested it and exposing these business practices for what they are my fellow physicians and psychiatrists avoid me like the plaque.

    Commercialism needs to be beaten back by physicians who know what quality is and who can tell these business managers and politicians to shove off. If that is never done – the history of what happens next has already been written.


  • Urgy Doc

    To the above commenter: the unionized industrial workers who stood up to deindustrialization/outsourcing didn’t manage to stop globalization and neither can we as physicians stop this inevitable advance of capitalism. Throw all the wooden shoes you like, the machine goes on. Why should we be any less dehumanized than any other worker in our society?

    I’ve worked outpatient primary care and now work urgent care for a large chain. I find some oft be criticism leveled at urgent care/fast food medicine is true and some is definitely not. Either way, office docs are better served giving patients some of the things they want that urgent care gives them while maintaining the pieces of primary care the docs consider important. For instance, office docs need to make more same-day appointments available. As far as psychiatry goes, the rigidity of psychiatrists leads so many of their patients to the family doc or urgent care doc’s door.

    I really find so much of the urgent care criticism patriarchal and privileged.

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