In Search of Medicine's Moral Compass

Rob Tenery, MD

• Publisher: The Small Press
• Year: 2011
• eBook ISBN: 9781612547862
• Topic: Medicine
• Subtopic: Health Care Delivery

In an age where uncertainty rules the day, Dr. Rob Tenery has given us a book that explains how health care has evolved into a $2.6 trillion enterprise. He does this with carefully researched histories and a series of challenging and thought-provoking commentaries on the most important issues of the day. Dr. Tenery's book focuses on a time when doctors and patients worked together to determine the best course of treatment—solutions now being ceded to large corporations and the federal government. He relates, as only a physician can, the challenges, fulfillment, and ethical dilemmas of caring for patients and making the best decisions for their health and well-being. Whether contemplating what doctors can do when nothing can be done, or thinking about the state of the medical profession, his insights are based on real-life experiences with his patients and colleagues. Dr. Tenery brings a perspective and a set of values gained from his father and grandfather, who, together with the author, represent over a century of caring for patients. This book gives you the opportunity to step into the shoes of a dedicated third-generation physician and to see the changing nature of health and medical care through his eyes. This physician of over thirty-seven years is sharing his collected writing for a better understanding of why medicine is a profession and not just another business.

Chapter 1: Health Care: A Right or a Privilege?

 

Taylor “Rex” Spires sold the restaurant chain he started to a conglomerate out of Chicago for a considerable amount of money just over ten years ago. Since then he had been able to get in eighteen holes with three of his buddies on weekends and every Tuesday morning. That was, until last fall, when the jaundice set in. Although he was eighty-four on his last birthday, until then he had never looked or felt his age. The report from his physician was not good. It seems the two double Dewar’s straight up, every evening starting at six, and the one, sometimes two, bottles of merlot he shared with his wife over dinner had taken their toll. He was in end-stage cirrhosis. No more alcohol, no food supplements, and careful attention to his diet were his only hope of putting off the inevitable. Rex had brought up the possibility of a liver transplant, hoping his donations to the medical school over on Harry Hines Boulevard might give a leg up. A week went by before he was officially informed that his place on the transplant list put him at or near the bottom. Although he had not been officially rejected, Rex knew his odds of a second chance were slim to none.

With the ongoing recession, Laticha Winters had been lucky to get the job with LabCor a little over two months ago. A high school dropout, she still lived with her parents. Her boyfriend had brought up the subject of a future wedding once or twice. After several weeks of increasing malaise, she got the bad news when her lab reports revealed a marked increase in her liver enzymes. She was diagnosed with acute infectious hepatitis, probably contracted though exposure to contaminated material at work. Three months of intensive therapy failed to stem the increasing ravages of her disease and, even though her health insurance was not yet in effect, she was added to the transplant list as her only hope. She would apply for workman’s compensation. Even her doctor did not know if she would be eligible.

Rex Spires died in his sleep last Tuesday, leaving his golfing buddies looking to complete their foursome. The Highland Park Methodist Church was full to overflowing with mourners paying tribute to a life well spent.

Laticha Winters, released from the hospital just three weeks ago following her transplant surgery, announced her engagement to a small group of friends at El Fenix.

Is access to health care a right or a privilege? A right would be a benefit granted to all individuals in a given society, such as protection from bodily harm by an outside source that is beyond one’s control. The responsibility for obtaining and paying for this protection is shouldered by all members of that society. Examples would be the military forces, fireman, and policemen. One could use this argument to support the concept that all individuals are entitled to good health and freedom from disease as a basic right. Unfortunately, the costs and limitations of resources make this concept unachievable.

Health care as a privilege would introduce the concept of option. Just being a member of a particular society would not automatically entitle one to the benefit of health care. The answer falls somewhere in between. The right to relief from pain and suffering seems universally accepted in civilized societies and would be limited only by the availability of resources. Benefits over and above this fall into the category of privileges.

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented (1).

All integrated societies offer some form of care to their participants. This country’s overflowing emergency rooms and subsidized outpatient clinics serve as testament that patients who are sick or injured are deserving of care to relieve their pain and suffering, at the very least. These benefits, along with certain preventative measures such as selective immunizations, can be lumped into a basic benefits package, and by most, considered a right of our citizens. The rest would be considered as benefits to be utilized based on the measurable criteria of funding, availability, need, and likelihood of benefit.

In an attempt to justify the enormous expenditures directed toward the care of patients in this country, the ethical arguments of “fair opportunity” and “collective protection” have been espoused. These principles, however, could just as easily be applied to larger segments of the population in a financially constrained system, thus justifying rationing on a case-by-case basis.

Under “collective protection” patients are entitled to protection from general threats that are beyond their control, which includes a basic level of health care. It is not necessarily for their own protection, but to avoid harm to a larger segment of society whom they might contact. “Fair opportunity” does afford individuals the right to develop their skills and pursue goals without undue interference from others, but only if those rights don’t compromise others. (2)

This dilemma is not new to the American public. The need for prioritization in organ transplantation has existed since the technology was first successfully performed on December 23, 1954 (3). Sometimes the decision is made depending on which patient is in the most critical condition and the availability of the needed organ. Sometimes it is based on age—the younger deriving the greatest benefit over the longest time. In the most critical situations, the patient’s financial status has little to do with the decision. With widespread limited resources, an expanding population (especially in the older sector), and growing funding constraints, the concept of allocation has now spread into most other areas of health care delivery.

Although many are reluctant to discuss the subject, there are two levels of health care. With advances in technology, that dichotomy becomes even more apparent. Even in countries that claim to provide nationalized health care, those in power generally fare better than those they govern. Maybe it’s just more personal attention by the providers of health care services, or maybe it’s purchasing care in the “private sector,” as in England, or packing one’s bags and paying for care in another country, as with the oil-rich nations of the Middle East and Canada, whose citizens migrate to the United States.

Keeping up the facade that all health care should be equal has a negative impact on the system. As long as the recourses are available, is it just to deny patients better care if they are willing and able to afford it? The concept discourages innovation. It also encourages the so-called privileged to seek care elsewhere and shifts funds out of the system. A loftier goal is to ensure that everyone has access to a basic level of affordable health care services. That is where countries that offer universal health care have it up on the United States. The difference is that the level of care offered to the masses in most other parts of the world is either substandard or much harder to access.

There are two basic concepts that must be addressed: funding and allocation. One hundred years ago, all funding for health care services came from the patients themselves or went uncollected. Today the broader concept of Gross Domestic Product (GDP) addresses both issues on a larger scale. The term implies that an increase automatically equates to better health care and criteria such as shorter life expectancy and higher infant mortality can be used to root out inefficiencies in the system. Unfortunately other factors such as population make-up and density come into play. More importantly, the concept of using a percentage of the GDP also assigns a dollar value to a human life and changes the argument from a right or a privilege to one of cost–benefit ratio.

Even in the face of this growing complexity, we are drawn back to the fundamental principle upon which this profession was founded: humaneness—the showing of compassion and consideration for our fellow man. Utopian dreams are what raise societies to a higher level. However, it is the cold, hard face of reality that determines which part of those dreams come to fruition.

References

1. “The Code of Hammurabi,” trans. L. W. King, Wikipedia.

2. R. M. Tenery, “Our New Health Care System May Not Be Fair.” American Medical News, November 4, 1996.

3. Merrill, J. P., J. E. Murray, J. H. Harrison, and W.R. Guild, “Successful homotransplantation of the human kidney between identical twins,” Journal of the American Medical Association 160, no. 4 (1956):277–82.

Chapter 2: The Changing of the Professional

 

The night your mother went into labor, who got out of bed and met her at the hospital to ensure her well-being? Hours later, when you uttered your first cry, who made sure you were safe and warm? Christmas morning three years later, when you fell off your new tricycle and broke your arm, who wiped your tears away, put on your cast, and was the first to sign it?

When you and your sweetheart decided to get married, who talked to you about Planned Parenthood? After several anxious hours in the waiting room, who came out and congratulated you on the birth of your first son? After accompanying your unconscious father in the ambulance to the hospital, who told you he didn’t suffer and shed a tear with you?

When you awoke from your angiogram after suffering chest pains at your son’s high school football game, who told you that with the proper therapy, you could lead a relatively normal life? And the day they carry you to the hospital for the last time, who will be at your side, holding your hand, letting you know that you are not alone?

Your doctor.

—AM NEWS. December 16, 1991

Illness is mankind’s common denominator. The delivery of health care is the practice of the science of medicine with compassion thrown in. Even though patient desire plays a compelling role in the outcome, medicine is still a relatively young and imperfect science that is controlled by the laws of nature. As the knowledge base grows, so does the ability to predict and control outcomes. The practitioners of the medical profession are not selling a product, but are sharing their knowledge and expertise.

The term “calling” is usually reserved for those fields of endeavor where the ultimate goal is to accomplish good for others. There is even the inference of influence by a higher power. To many who deliver health care services, medicine is still their calling. To them, there is an implied dedication of purpose and personal reward that comes through self-fulfillment.

In the past, most doctors held a shared vision of what it meant to be a physician. It was the foundation on which the medical profession was established and evolved, not from one generation, but many. That goal also served as the pillar on which patients built their trust.

As physicians grapple with their increasingly complex roles as scientists, business persons, and ministers to their patients, there is a growing fragmentation of the physician community.

There are physicians who work within managed care entities. There are physicians who strongly cling to what remains of the fee-for-service system. Some physicians advertise. Others don’t. Then there is the so-called specialization in medicine. Even the primary care physicians specialize in “primary care.” As a community, physicians are moving away from the mainstream and forming alliances with others who share their common concerns.

This realignment is diverting physicians away from addressing the core problems that are eroding this profession’s autonomy. The beneficence and compassion of their forefathers is being strangled out by liability concerns and compounding regulations that are being heaped on them—the very qualities they had hoped to emulate when first choosing medicine as their life’s calling.

This is not to imply any less dedication by physicians today. It is a resetting of priorities. Although health care with respect to the science and the outcomes is vastly better, there is a proportionate increase in the depersonalization of the doctor–patient relationship. Often, the examination and history are secondary to the diagnostic studies. Doctors spend more time reviewing the charts, test results, and X-rays than being with their patients. They tend to talk more to consulting doctors, dictating machines, and nurses than to their patients. As the science expands, the personal side of health care delivery diminishes.

There are a growing number in the profession who equate their patients to customers—those who purchase a product or service to fulfill a given need or desire. That line of thinking makes the relationship transactional. Patients are paying for services rendered and not guaranteed results, somewhat akin to firemen and policemen. Rather than a contract, the relationship should continue to be personal and based on commitment with the intent of benefit as opposed to financial reward.

Until recently doctors and their patients have had long-standing relationships. With dictates by managed care coverage, increasing specialization, and expanding technology, this is often not possible. No one physician can keep abreast of all medicine’s advances. Especially with complex problems, there is a “team” approach: multiple physicians, multiple disciplines. All too often, the members of the team don’t communicate—leaving the patient with the often-quoted response, “You’ll have to talk to your doctor about that problem.” What doesn’t change is the need for continuity of care. This means that the continuity of caring must remain constant throughout the illness. And “being there,” not always in body but spirit to help the patient face any unknowns that lie ahead; not always the same doctor, but a doctor that they can communicate with about their illness. Someone who doesn’t think of them as a number or a diagnosis to take it all in, shows a little compassion, and lets them know that they are not in their struggle alone. The names and the faces change but the relationship cannot. Every patient still needs his or her own general practitioner.

While advancing the technical aspects of the medical profession, the physician community has failed to preserve many of the privileges and freedoms that were enjoyed by past generations of doctors and their patients. Some would consider this loss a failure by our current generation. A far greater failure would be if they did not instill in those that follow the desire to continue to work for and restore those losses. As with past generations, physicians serve as role models to those who come after them: first in the way they conduct their practices and care for their patients, and second, in the importance of supporting issues that affect other patients, not just those under their care, and the whole of the profession. Too often today, society has turned inward to individual need, ignoring one’s commitment to the larger picture. It’s about being involved, not just with one’s own needs and desires.

A particular physician’s role will be judged not by how much money he or she earned or the number of procedures performed. Physicians will be judged by the patients under their care and the physicians who take over after they are gone. If medicine is better for what they have done, then the profession is well served. Their success will be theirs to celebrate. Unfortunately since they won’t be around, their failures will be borne by others that follow.

Physicians talk about retiring early, looking for alternatives other than direct patient care. Many encourage their children to take another path.

Maybe it’s having almost every medical decision questioned by some faceless employee at a computer terminal. Maybe, it’s having a medication changed by the third-party payer because it is not on their formulary. Maybe it’s seeing longtime patients transfer to another physician because their employer could get a cheaper rate on health care coverage elsewhere. Maybe it’s large insurance companies and hospital corporations forming giant health care conglomerates, while antitrust regulations impede physicians from coming together as competitive entities in the new marketplace. Maybe it’s because all these changes, which increasingly constrain physicians’ independence and question their judgment, also are taking away their sense of personal fulfillment.

—AM NEWS. August 5, 1996

There are those physicians who complain that medicine isn’t what it used to be. Then again, it never was.

Chapter 3: Is Being a Doctor What It Used to Be?

“It’s unfortunate that the best minds are choosing careers in finance and no longer going into medicine,” said a lady at the table across from me at a recent social get-together.

First-time applications to US medical schools were slightly less than twenty-five thousand in 1982–83. It dropped to around twenty-one thousand in 1988–89, then between 1994–97 rose to over thirty-two thousand. It dipped again in 2002–03 and has been on the rise ever since. In 2009–10, the number had risen to 31,063. Adding in reapplications, which vary from 27 to 47 percent more applicants, the trends are the same.

In the year 1976–77, 15,774 students were accepted to their first year of medical school, with an acceptance ratio of 2:7. By 1987–88, the number of applicants had fallen by 33 percent, but the number of first year positions had grown by almost 8 percent to 17,027, for an acceptance ratio of 1:7. By 2009–10, the number entering medical school had grown to 18,390 students from 42,269 applicants or an acceptance ratio of...

Table of contents

• Cover
• Title Page
• Copyright
• Table of Contents
• Foreword
• Acknowledgments
• Author’s Note
• Prologue
• Introduction
• Chapter 1: Health Care: A Right or a Privilege?
• Chapter 2: The Changing of the Professional
• Chapter 3: Is Being a Doctor What It Used to Be?
• Chapter 4: Marketing by the Profession
• Chapter 5: Malpractice or a Poor Outcome?
• Chapter 6: Third-Party Payers
• Chapter 7: When Managed Care Took Control
• Chapter 8: Speaking Out for Physicians
• Chapter 9: Health Care Reformation
• Chapter 10: The Battered “Constants” of Medicine
• Conclusion
• Appendix I: Selected Speeches by the Author
• Appendix II: Selected Commentaries by the Author
• Appendix III: Selected Blog Posts by the Author
• About the Author