Pay, Pride, and Public Purpose: Why America's Doctors Should Support Universal Healthcare

Laura K. Altom, BS, MSIII; Larry R. Churchill, PhD

Disclosures
In This Article

Professional Pride: Commercialism and the Erosion of Physician Self-Esteem

A second answer to the question of why physicians should support universal coverage is to reduce commercialism in healthcare and the damaging effects of commercial forces on professional self-esteem.

Several years ago, one of us (LRC) was talking to a surgeon who was host for a visiting lecture at his institution. Arriving in the early afternoon for an after-dinner talk, we went to the construction site of his new home and we walked together through the emerging shell of beams and girders. It was to be a grand house, roughly 15,000 square feet, with rooms for every possible activity, multiple garages, and every amenity imaginable for a private residence -- and all for 2 people. Clearly it represented the fulfillment of his and his wife's aspirations. His comment about the opulent new residence, half in apology, was: "It gives me a reason to keep working."

We tell this story not because we begrudge physicians, or anyone for that matter, wealth or fulfillment of their material aspirations. Rather, what was striking was that "conspicuous consumption" had become the rationale for continuing a medical practice beyond the point of engagement for intrinsic rewards.[9] Such values might not be worrisome in a corporate CEO or an NBA star, but they are in a physician. They signal the usurpation of the altruistic rewards of medicine by monetary gain. We are not concerned with whether this physician and his spouse should have settled for less opulence, but with how professionalism could be maintained when the motivation that impels the scalpel is the price of the procedure.

Commercial forces have always been a force in medicine, but it is only recently that they have come to dominate. While physicians have consistently sought to portray themselves as purveyors of a social service, until recently in the United States they have functioned as small-business owners. For the greater part of the 20th century, American medicine was a cottage industry with a professional service ethos, populated by solo or group practices, run on fee-for-service, indemnity insurance or out-of-pocket patient financing, providing adequate to good returns for most generalists and handsome pecuniary rewards for specialists. Those who received care were largely those who could pay, either through insurance or out-of-pocket, while the uninsured were the sporadic recipients of charity. So the conduct of medical practice as a business and the use of market forces as the chief mechanism for the distribution of medical goods and services are nothing new in the United States.

What is new is the pervasive presence of large corporations as owners and providers of health services, and the loss of physician autonomy in decision-making that goes with that change. While there were some healthcare corporations in the past, they were typically businesses owned by medical groups or nonprofit organizations that were governed by boards of local citizens and were community oriented. While not always altruistic in their aims, these organizations were often responsive to local needs. The new healthcare corporation has a Wall Street orientation and is responsive to markets and mergers. The new corporate providers are also far more skilled than the cottage industry entrepreneurs at advertising and selling their services, cutting costs, and shaping the way their customers think not only about the services they offer but also about the economic arrangements that undergird their profitability. The healthcare insurance industry's derailing of the Clinton healthcare reforms in 1994 is vivid testimony to their power.

The muscle of the new corporate health entrepreneurs can be documented by looking at the portion of healthcare services they now control, but our interest here is less in the size of their market share and more in the subtle but pervasive ways we have all been encouraged to talk and think about healthcare as a marketable product. For example, physicians are now "providers," while patients have become "consumers." The logic of these terminology changes is reinforced by the methods managed care organizations (MCOs) use to assure their members that quality is being maintained or enhanced -- through "consumer satisfaction surveys." The idea that consumer satisfaction is a good measure of quality means that patients now have the role of customers who, to be effective in this exchange, must be knowledgeable and shrewd in comparisons of price and quality. Health services are now "commodities," in which the cardinal defect is the absence of choice. The absence of choice prohibits the chief means of consumer assurances of value, viz., comparison shopping. In brief, commercialism means that going to see a doctor is increasingly portrayed as purchasing a product or claiming a service -- largely prepaid if one is insured -- rather than seeking help from a trusted professional.

Within the logic of the market, the goal of commercializing health services is to capture a market niche, to enlarge it, and to maximize profits. This, too, is reflected in changes in the idioms that describe the activity. Services to patients by physicians are registered in accountants' ledgers as "medical losses," precisely because these services reduce the fraction of income that can be counted as profit. Advertising is undertaken to attract and sustain the loyalty of carefully selected, low-risk groups, known as "revenue bodies," to whom the cheaper premiums are offered. Most physicians currently function under a variety of incentive systems designed to reduce utilization -- and thus costs -- in keeping with the aims of corporate profitability. If efficiency targets are not met, whatever portion of physicians' incomes that are "at risk" is lost. Thus, clinical choices about how much time to spend with a patient, or what services to provide or recommend, have substantial implications for physicians' incomes. Just how direct and severe these implications are depends on the model being used, and they range from those that simply produce a prudent cost-consciousness to those that are morally perverse because they create a conflict of interest for the physician.

The impact of corporate commercialization of medicine on physicians would be hard to overestimate. The literature of the past 15 years has been filled with carping, complaints, and other signs of demoralization. And this is entirely understandable. The experience of many practitioners has changed from patient care to patient and revenue management. Time spent in clinical activities is routinely cut short by conversations with benefit managers to gain approval for recommended diagnostic procedures or therapies, and the burdens of documentation are far greater as the consequences of nonconformity to insurance guidelines increase. The application of industrial, assembly-line management techniques to medical care has done perhaps more than anything else to reduce the self-esteem of physicians. Seeing more patients for shorter periods of time to meet a managerial quota has led, predictably, to less satisfying relationships for both physicians and patients.

Although we are painting a sobering picture, it is not a surprising one. It would be very strange if the logic of commercialism so pervasive in the rest of society had not invaded the medical sensibility. Physicians are subject to the same pressures as all Americans, increasingly measuring in dollars how they rank as good professionals, good family providers, and more generally as successful persons. In American society, these indices of merit and honor are all thought to be related, directly or indirectly, to the monetary resources one can muster. The result is that physicians are systematically encouraged to think about their most basic stewardship as one of protecting investor resources -- rather than, or at best in addition to, their stewardship of patients. But beyond patient vulnerability, management's claim to physician loyalty marks a profound shift in the sources of professional pride and self-esteem. In the past, this sense of worth was more firmly anchored in helping people, in developing and sustaining therapeutic relationships, and in a general altruism of purpose. The industrial-managerial model of care makes these sources of reward secondary and less available.

We are painting a portrait here of professionalism under siege, not to decry the evils of money or markets, but to note with some concern the diminishment of the traditional sources of professional self-esteem -- patient devotion and pride in skillful practice. What is so troubling about the waning of professional pride in the face of commercial forces is the way that physicians are cut off from the sustaining motivations that make the hard work of medical care rewarding, and sometimes just bearable. The cruelty in this waning of professionalism lies in the way money overpowers all other values and thereby uproots physicians from the deep rewards of recognizing themselves as part of a healing process. Money (and the considerable list of things it can buy) becomes the chief standard against which doctors are encouraged to judge themselves and to be judged. But for professionals, the only god worthy of solemn devotion is signified in the etymology of 'profession,' viz., an avowal of service beyond self.[10] Without this piety technical proficiency may remain intact, and financial rewards may remain plentiful, but professional identity cannot be sustained. As Arthur Okun has remarked, "everybody (but an economist) knows that that money shouldn't buy some things."[11] Yet to be accurate we need to go beyond the moral realm indicated by "should." One of the things money can't buy is a professional identity; this means that every encroachment of commercialism into medicine makes professionalism more fragile.

Would coverage for all Americans eliminate commercial forces from medical practice? That outcome, however desirable, seems unlikely. But it is reasonable to assume that commercial forces would be substantially reduced. No conceivable system of inclusive care could exist with the pervasive commercialism that now characterizes US healthcare. Commercialism exists at all because there are profits to be made, because there are corporate and individual bottom lines to be protected, because physicians must be financially disciplined against their instincts to provide more patient time and more complete care, and because persons with complex and expensive health problems represent financial liabilities to insurers in a system fragmented by health status and money. Universal care would eliminate most or all of these commercializing forces since it would require a clear and vigorous regulatory framework to be feasible. Commercial insurers in medicine make much of their money by shifting costs to others. In any well-conceived and well-managed universal system, such cost shifting would not be possible. Universal systems do not risk-rate insurance premiums, do not contain preexisting condition clauses, do not permit providers and insurers to enroll only the healthiest and lowest-cost patient groups. And universal systems, eschewing profitability and industrial models of physician work and rewards, together with accountability to the public for quality, lessen the tendency to tie physician compensation to denials of needed care. The availability of medical services in a universal system is a policy issue, not an individual decision made at the bedside by a provider with a conflict of interest.

Whatever else it brings, universal access, even in a system with multiple tiers, is a great equalizing force. Commercialism plays upon, and profits from, disparities in health status and income, and as noted above, makes physicians active players in that collusion against the poor and the sick. It is very likely that any system of universal care, whatever the organization and delivery mechanisms, will promote an environment in which physicians can again take pride in recognizing the skillful execution of their unique abilities in serving, healing, and alleviating suffering. For most doctors, a rise in professional self-esteem will be the result.

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