When I was a summer extern in a Kansas City hospital some years ago, the hospital employed Danish interns. As an idealistic third year medical student, I was struck by their comparison of American medicine with the practice of medicine in Denmark. American doctors, they said, try too hard to please their patients. In their country physicians work for the government; the patients come to their designated doctor, who works from 8:30 to 5. Physicians make decisions without any deference to patients’ feelings; there is no need to entice the patients to come back since they have no other choice.
This freedom to choose, a hallmark of a free society, has been important in our country. However, it is eroding even among professionals. There is diminishing hope then, for patient freedom of choice, and they will be locked into a regimentation that is normally associated with a totalitarian or socialistic society.
An estimated 2/3 to 3/4 of physicians believes in limited government and personal liberty and that humans behave for the betterment of their status, not because of any innate altruism. This becomes noblest under a system of economic and political freedom where we have to provide a wanted service before we can benefit from our endeavors. Any disruption of this process, e.g., by government intrusion, creates more problems than solutions; this holds true, by extension, to the ills we face in medicine.
Adam Smith in his Inquiry into the Wealth of Nations drew an analogy between London and Paris in the eighteenth century. Was Paris with four volumes of laws safer than London which had only a few pages? Most people believe more laws make us toe the mark. However, Professor Smith pointed out that murders and robberies were committed in Paris daily. Meanwhile, London, a larger city with only a few laws, had only three or four robberies or murders per year. Increased laws only worsened society and increased lawlessness and crime.
In discussions with colleagues over the past decade in the staff rooms of our community’s hospitals, I would guess that a large majority agree with the premise that more laws are not the answers to our problems. Yet, many who agree in private will not admit the same if the staff lounge is filled with physicians. Also, many give examples in which they feel the government is the answer to malpractice, gas price inflation, the cost of health care, HMOs, and other problems.
Andrew I. Cohen of the University of Oklahoma defines a “free society” by three key features: 1) private property (which includes our medical license) is protected as inviolable; 2) the government’s role, at most, is to prevent and punish the violation of individual rights; and 3) all human relationships (such as the doctor–patient relationship) are voluntary. To the extent that a society is free, it will provide the best opportunities to nurture and sustain deep friendships or relationships.
Considering what is necessary for a deep relationship, two persons must share some form of good will. This sincere good nurtures a sense of trust and healthy interdependence. If, however, you find yourself in an institutional environment or an alliance that allows no choice, this involuntary relationship will restrict the development of any healthy relationship, including a healthy doctor-patient relationship. A free society will always try to minimize the extent to which human relationships are involuntary.
The practice of medicine has, in a significant way, become an involuntary relationship. The doctor-patient relationship is frequently forced. For twenty years, patients sought my medical advice or opinion and gladly waited for it. If I gave that medical advice at 6:45 pm when the appointment was at 4:45 pm, they thanked me for staying late to see them and some even asked if they could pay me extra for my working late. Now we have administrators who tell doctors that a 15-30 minute wait for patients is unreasonable. The record of that professional opinion was held inviolable by the doctor in trust for the patient. Seldom was that relationship terminated.
Now patients frequently come because they are directed by their insurance carrier into an involuntary relationship, making the doctor–patient relationship suspect. Patients don’t completely trust what the physician records if they believe what is recorded may prevent the care they want.
Occasionally doctors sell their practices for $25 a chart. An administrator who bought the charts, now his organization’s property, may not readily release a patient’s chart to a new doctor. Thereby, the most confidential of all records has been auctioned off to the highest bidder, who considers a patient who has to wait for 30 minutes for an appointment as merely two or three units of lost revenue.
Patients who leave one hospital HMO because the appointment terminates at exactly 15 minutes sometimes find that the doctor in the next HMO presses a time clock when he walks in and a beep goes off after 9 minutes alerting the doctor that he has 60 seconds to bring the medical evaluation to a close and start his/her next appointment. Doctor, medical group, administration, insurance carrier, and patient are all now adversaries in a forced relationship.
Doctors see no hope in solving this problem voluntarily. The profession that in the past looked to the law and lawyers as the ultimate losing game, now is actually looking to lawyers and laws to solve their problems. If we considered ourselves as the protector of our patient’s health, we would never have sold a chart at any price. If we controlled the patient’s medical file we could never be asked to compromise care or to be held hostage. We would continue to have a trusting, healthy interdependent relationship. And none of this has any relationship to laws or lawyers. It’s us, a profession based on principles, simply being professional.