A dirge for a good profession

Mine is not a unique experience. When I started medical school in 1988, like many of my classmates, I was so committed to becoming a doctor that I could not conceive of another path. In the classroom I learned the usual subjects – anatomy, physiology, physical diagnosis. The grueling pace of medical school and residency were punctuated by moments of wonder: donning a white coat for the first time, with a stethoscope peeking out of a pocket; sitting down exhausted at 3:00 in the morning to write the history and physical for my 9th admission of the day and sensing the magnetic pull of the answers buried in the thick volumes of the patient's chart, certain that I was doing good for someone in need; feeling like a kid at the grown-ups' table during my second year of residency, imbued with the direct responsibility for decisions and finally feeling like a real doctor.

It was in this second year of my residency that I noticed some odd changes. For the first time a physician-administrator dropped in on our morning rounds to point out that our 72-year-old patient admitted three days prior with a pneumonia had used her allotted days of hospitalization, and swift discharge arrangements were needed to minimize hospital’s loss of revenue. Conspicuously muted in the discourse was concern about the patient’s clinical condition. With arrogance and bravado of youth we indicated that the patient would be discharged when we deemed her ready. But then these administrative drop-ins became more frequent, and I got suspicious.

I had been a rather naïve student and young physician: little did I know that, in response to escalating costs and bad behavior of some of my brethren, this trickle of bureaucratic interruption would shortly turn into a fire hose stream of managed care. By the time I completed my training, hordes of hospital-hired discharge planners would be making rounds, scrutinizing all decisions in the name of the institutional bottom line, and not relenting until discharge. I am not opposed to a prompt discharge – unnecessary prolongation of a hospitalization begets complications – but this was ridiculous.

After my residency, followed by a subspecialty fellowship, I wound my way into private practice. The surprises of training yielded to shock at the real world: poorly informed physicians, barrage of prior authorizations for necessary care, growing armies of billing clerks and escalating office overheads, practices embracing entrepreneurship to buffet their bottom lines, creative ways to avoid low reimbursements. While I still derived some satisfaction from my interactions with my patients and their families, this was not the profession touted by the grey-templed patriarchs of medicine’s past.

Perhaps my interests lay elsewhere, or perhaps I just did not have what it takes. I left clinical medicine and went through my Kübler-Ross stages of grief. I grieved for my own lack of perseverance, for the loss of hands-on contact with patients, for the respectability that comes with being a clinician. And while I have regained my personal joie de vivre, I continue to grieve for the medical profession. The task of clinical practice has gotten more Sisyphean: distrustful public, predatory and fraudulent practices, over-testing and over-charging, all to maintain one’s income and avoid law suits. These have led to further spending, over-medicalization, harm, and a profound demoralization of a good profession. Many of my brightest and most dedicated peers are fleeing the bedside to help find solutions or simply to get away from the untenable.

The current US healthcare system is a bloated dangerous exercise in excess, courtesy of successful marketing and of bureaucratic wars. Only the 21^st century $6-million-man, reborn as a CEO, is happy, enjoying the sizable perks bought by skimming 30% off the $2.5 trillion/year budget. And while this is disheartening, it is also an opportunity. Change is difficult and frightening, and necessary. We need to forgo the traditional hysteria manifest in the reform discussions of the 1950s and 1990s. As a society and as a profession we need to look the future courageously in the eye, grab our inertia-laden Congress by the hand and pull them toward our vision of an equitable and just system that leaves no one behind. We went to medical school to help people, so let’s rise out of our status quo mindset and get busy building a healthy society for the future. Amidst these activities we must stop briefly and play the dirge for our good profession. Then out of its ashes we must deliver the Phoenix of a great healthcare system for all.