Author D Silk, MD, the editor of the Bulletin of the Orange County Medical Society, suggests that we should stop crowing about the evolution of medicine from a cottage industry to big business as if that transition means progress. He says it doesn’t. Like your grandmother’s pies and hand-tailored suits, some services are better done by individuals working in their own microenvironments than in corporate beehives. Turning out sick patients on a production line . . . is a sociologic experiment that [is] unfortunate for our patients and ourselves . . . despite widespread dissatisfaction . . . Even a flawed system may last for two or three decades before its weaknesses become so prominent that it disintegrates. It took Russian Communism 70 years to fall of its own weight. . . Doctors were not perfect before corporate medicine besmirched the horizon. But when medicine was a cottage industry, a single error in technique or judgment resulting in a malpractice suit . . . became a local headline. Now billion dollar frauds by corporate medicine are almost daily headlines. When the service must be personal and individual, private schools, portrait painting, playwriting, tailor-made suits, home cooking, dressmakers, nurses, and doctors are all examples of the superiority of what some may derisively call a cottage industry.

Larry L Coble, MD, President of the Fresno-Madera Medical Society, writes about the “Big Vise…What can we do about it?” The “vise” he refers to is between those who purchase health care and demand lower prices as opposed to those who receive health care and demand more services. Those who provide it, namely us, are caught in the middle. He feels that we can relieve the pressure of this vise with two primary and potent influences that we control: Professionalism and Quality. To enhance Professionalism we must 1) reestablish the primacy of the patient advocacy role; 2) resolutely defend the patient-physician relationship; 3) reaffirm our strict adherence to our code of ethics; and 4) reaffirm the necessity for holding ourselves accountable to a principled code of conduct. To improve Quality, we must 1) assure the application of scientific principles to quality outcome measurement; 2) assure that sound clinical research is used in development of clinical guidelines; and 3) assume a leadership role in the development, implementation and refinement of quality improvement programs in the facilities where we provide care. He states that we can help ourselves and our profession, and, more importantly, our patients and community by redirecting our energies from fighting the vice to turning the crank to release the pressure.

Elliot C Lepler, MD, in his first column as president of the Santa Clara County Medical Association, admits that joining the medical society in 1981 was a business decision. Patients had occasionally asked him about his membership; not being a member seemed to have negative connotations. As president he pledges to speak to the business community and the service clubs of Silicon Valley so that a wider audience will be able to hear the “Voice of Medicine.”

(North Carolina Medical Journal, March/April 1998 [NC Med J 1998;59:96-7])

The Role of the Medical Profession in a Managed Care Environment

Editor’s note: At the annual meeting of the North Carolina Medical Society in Pinehurst in November 1997, the Bioethics Committee introduced a resolution that would require the Society to take a specific position relative to the practice of medicine in the present era of third-party payment for and influence over medical care. This proposal engendered considerable debate and heated argument–both in the Reference Committee and in the House of Delegates. The final decision of the House was to file the motion, effectively removing it from action.

It is the opinion of the Editor that this statement offers much value for doctors to ponder. It is worth more reflection than a motion ‘to file.’ If the unexamined life is not worth living, the unexamined practice is not worth practicing. The resolution put forth by the Bioethics Committee asks us to look at the distortions introduced into the doctor-patient relationship by the ancient principle that he who pays the piper calls the tune. Doctors often [are forced to] turn for guidance in medical decisions to the insurance companies (or health maintenance organizations) who pay for their services. Patients, insulated from the need to pay directly for services, undervalue the advice that doctors have to offer.

In order to foster further discussion, the Journal showed the slightly edited version of the resolution printed below to a number of physicians to comment. Several declined to respond. We printed responses we did receive in the March/April, 1998 issue. We invite readers to offer their comments in writing or via electronic mail (yohnOO01@mc.duke.edu).

Statement of the Bioethics Committee of the North Carolina Medical Society

Resolved, that the North Carolina Medical Society adopt as policy the following statement on the medical profession’s role in a managed care environment:

I. Origin of the problem. We believe that most of the current problems in medical care delivery originate from the introduction of insurance as a method of payment for medical care services. Because everyone welcomed this “innovation” as the solution to payment concerns, all believed that they would benefit from this change. Therefore, all parties – physicians, patients, and payers – are responsible for this ultimately unwelcome state of affairs. Each member of this “triangular relationship” – physician, patient, and payer – has nurtured this original insurance concept for his or her own benefit, and gradually transmogrified it into paying for medical care with “other people’s money” or “getting something for nothing” with disastrous consequences.

II. Current state of the managed care environment. Presently, because of the desire that insurance pay for all medical needs and other distortions in our economic system, each member of the triangular relationship has lost control over many of the benefits and responsibilities of the simpler “one-on-one” system. Patients frequently lose the choice of hospital, physician, or provider, and procedures they believe are needed. Payers lose control of costs. And physicians, caught in a disingenuous and coercive system and manipulated by gag clauses, capitation, withholds, and “risk-sharing agreements,” lose the most precious possession of their once noble profession: the public trust in them as caregivers, confidants, and advocates.

III. Our professional objectives. It is the obligation of the profession of medicine to preserve the integrity of the institution of “physicianhood” and the role of the physician as caregiver, confidant, and advocate for the individual patient. This, above all other responsibilities, must be the foundation upon which medical societies and individual physicians base their recommendations and policies in areas of medical care reform. Whatever damages, or may damage, this sacred function should be opposed and actively resisted at all levels of medical leadership regardless of the potential for conflict.

IV- What we must do. To preserve the profession and its social mission, it is the recommendation of the Bioethics Committee that the North Carolina Medical Society promote a resurgence of patient control over choice in medical care and reaffirm the trust in the physician-patient relationship by promoting and implementing wherever possible a system wherein patients must exchange something of value for the services (except those required by medical catastrophe) they receive in the medical marketplace. In addition, the Bioethics Committee recommends that this Society actively promote catastrophic medical insurance as the most moral and just method of managing infrequent, high-cost medical expenses.

It is the belief of the Bioethics Committee that the field of medical care reform is too expansive to “solve” with a few suggestions. We also believe, however, that the following fundamental principles will mollify much of the social upheaval resulting from current medical reform efforts:

1) The patient must regain control of the cost and quality of medical care. This can be accomplished by the exchange of something of mutually agreed upon value between patient and physician for care received.

2) The cost of medical care may, on occasion, exceed the resources of the individual patient. This circumstance should be addressed by a system, of catastrophic medical insurance.

3) Physicians are obligated to continue their tradition of providing care to those who cannot afford it.

We believe that these fundamental principles will establish a foundation upon which to rebuild a medical care delivery system that is fair, equitable, and just.

Reprints, available from:
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Pamphlet No. 1062, August, I998