COMMENTARY

Capitalism Is Choking Professionalism in Medicine

This transcript has been edited for clarity.

Hello and welcome. I'm Dr George Lundberg and this is At Large at Medscape.

Medicine has always been both a business and a profession. Chaucer wrote about it in The Canterbury Tales; so did George Bernard Shaw in Major Barbara.

The problem arises when the pendulum swings too far. Back in the 1990s I labeled that pendulum "Medicine's Rocking Horse."[1] But pendulums, naturally, eventually swing both ways. I recently published a commentary on these pages about the special opportune political moment that we in medicine seem to be entering.

In my view, we would not even be having this conversation had it not been for Bernie Sanders, an elderly, Brooklyn-born, independent, self-labeled Democratic socialist senator from a small state and his astonishing 2016 run to be the Democratic nominee for president of the United States. His message—that our economic system had gone off the rails to favor an ultra-wealthy few at the expense of...well, virtually everyone else—resonated strongly with many, especially young people, who seek the prospect of a better life for themselves, their families, friends, and progeny.

A "better life" may not be possible without decent affordable basic healthcare for all. The nonprofit, nonpartisan Commonwealth Fund has published a report[2] of how eight developed countries handle their universal healthcare systems, with an interactive tool that promotes comparison shopping, by country.

Regular readers may recall that I praised Dr Elizabeth Rosenthal's great book, An American Sickness, in 2017.[3] This book blows the monetary conspiracy of corporate American medicine sky high and instructs American consumers about all of corporate medicine's tricks, and how consumers may defend themselves against the onslaught of money-hunger that assails the American sick.

In 2018, with an entirely different level and focus, New Mexico's Dr Howard Waitzkin and the Working Group on Health Beyond Capitalism published an influential book called Health Care Under the Knife.[4] In it, they exhort all physicians to rebel against the denial of professionalism that has been foisted upon them (us) as the newest "proletariat."

Waitzkin cites a personal example of being denied his professionalism by the new "employee" status in a hierarchy of corporate decision-makers intent on one thing—profit—as a part of the capitalistic takeover of a profession, once known as Medicine, routinizing gross conflicts of interest. These authors give many, many examples, naming names, institutions, and dates. This book contains the best description I have seen of the origin and meaning of the term "medical-industrial complex," coined in 1969 by Health/PAC[5] (Health Policy Advisory Center) as an expression of academic medical center colonialism.

Disagreeing with and expanding upon that concept, in 1980, New England Journal of Medicine editor-in-chief Dr Arnold Relman called it "the new medical-industrial complex."[6] He decried the "large and growing network of private corporations engaged in the business of supplying health services to patients for a profit, services heretofore provided by nonprofit institutions or individual practitioners." (Disclosure: "Bud" Relman and I were competitors at NEJM and JAMA, respectively, and international editorial colleagues for many years.) Bud was so right and he never stopped railing about the travesty of American medicine being turned into a lucrative tool of capitalism.

I am not quite sure whether "sheep" or "lemmings" is the best metaphor for how American physicians have behaved since the corporate takeover took root in the 1980s. Health Care Under the Knife, composed of 13 incisive chapters by 16 distinguished authors, addresses the gross inequities, blaming capitalism-run-amok as the root cause. Although it may be historically impossible, at this late stage, to divorce capitalism from medicine in America, it should be possible, even essential, to stop the pendulum (or rocking horse) at its current extreme and begin the swing back toward a balance.

The United Nations has been ranking "happiness" scores of countries for many years. The report bases its rankings on six key variables: gross domestic product per capita; social support; healthy life expectancy; freedom to make life choices; generosity; and freedom from corruption. The United States has never made it into the top 10. Worse, in recent years our national rank has been dropping; in 2019 it dropped to number 19 of 158.[7] The top 10 are Finland, Denmark, Norway, Iceland, the Netherlands, Switzerland, Canada, New Zealand, Sweden, and Australia. Guess what type of governmental systems they have.

Labels such as Conservative, Liberal, Progressive, Socialist, Republican, Democratic, Independent, Green, Dixiecrat, etc. are short and convenient but, by definition, divide us. I suggest that a better way would be to state desirable national attributes and goals, and work together from and toward those:

  • Healthcare and education as good for all;

  • Safe, drinkable water and safe, breathable air;

  • Government that promotes both robust business and vibrant consumer interests;

  • A tax structure that enables society to achieve these defining elements for all.

Just as medicine has always been both a business and a profession, it is also both an art and a science. Many have lamented the loss of the art, most particularly because of the mandated use of these devilish electronic medical records that compel the doctors' attention to be diverted from the patient in order to click the buttons to capture maximum payment, provide management with controls over physicians, and enforce a limited number of minutes per visit.[8]

In our current version of "Medicine," the art has returned but as an art form of controlling corporations that fleece the patients, payers, and providers, whomsoever they may be, to maximize profits. For more on this topic, read Dr Roy Poses' magnificent continuing blog called Health Care Renewal.[9]

Healthcare doesn't have to be this way. Change is in the air. We can return to professionalism in medicine, but it will require nothing less than personal internal and national political revolution.

That's my opinion. I'm Dr George Lundberg and this is At Large at Medscape.

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