"I'm trying to launch an idea," Eric J. Topol, MD, said about his commentary published in The New Yorker on Monday.
The idea? It's time for doctors to organize themselves to restore the "essence" of medicine, which is the sanctity of the doctor-patient relationship.
Topol, a practicing cardiologist at Scripps in La Jolla, California, and Medscape's editor-in-chief, told Medscape Medical News that he intends for the article to challenge medical societies, which, for all the good they do, can sometimes lose focus on that core relationship in favor of the bottom line.
And it's not just among medical societies; across the medical community, he feels the practice of medicine has withered. Time with patients has declined, while physicians must focus more on electronic health records (EHRs) and other nonclinical work.
"Since 1980, when I graduated, it's just fallen apart. Now we have, on average, less than 10 minutes [with patients]. And it's mainly a keyboard and very little human interaction," he said.
In his commentary, called "Why Doctors Should Organize," Topol proposes a solution: The creation of a "new organization of doctors that has nothing to do with the business of medicine and everything to do with promoting the health of patients."
"Its top priority might be restoring the human factor — the essence of medicine — which has slipped away, taking with it the patient-doctor relationship," he writes.
Topol is calling for more unity among the nation's roughly 900,000 actively practicing physicians. They need to lobby more forcefully on behalf of their patients and for themselves. There's an urgent need for physician activism on a range of issues, including countering misinformation on vaccines and resisting the growing burden of EHRs, he writes in the article.
"Privately, doctors feel despair about their appalling working conditions and the deteriorating doctor-patient relationship," Topol writes. "But there have been no marches on Washington, no picket lines, no social-media campaigns. Why not? Why aren't doctors standing up for themselves and their patients?"
Medicine Is "Balkanized"
Part of the reason may be what has been called a "burnout epidemic." A 2019 Medscape report found 44% of physician respondents reported feeling burnout.
EHRs are often cited as a major contributing factor. First-year residents, or interns, may spend almost five times more hours on indirect patient care than on face-to-face patient care, according to research published in JAMA in April. Most of that time — 10 hours over a 24-hour period — was devoted to EHRs.
In addition to the erosion of the doctor-patient relationship and the issue of burnout, Topol writes that physicians now are "balkanized," with no single organization unifying all of them. And large medical professional groups such as the American Medical Association (AMA) have diminished their power and impact through business deals, he writes, citing a 1990s deal that the AMA considered and then scuppered with the Sunbeam Corporation, a manufacturer of humidifiers and ice packs.
In the article, Topol doesn't lay all the blame at one group's feet. He also criticizes other past deals, like sunscreen manufacturers paying the American Academy of Dermatology (AAD) for their endorsement, or the American Heart Association's (AHA's) decision to "rent out its name."
For instance, Topol explains, qualifying food manufacturers can get a Heart-Check mark logo in exchange for administrative fees.
"The logo adorns thousands of low-fat items, such as Cheerios and various breads, which are not in any meaningful sense heart-healthy," he writes. "For decades, as part of this program, the A.H.A. strongly promoted a low-fat diet, advocating the use of margarine instead of butter, the avoidance of eggs, and the limiting of saturated fats."
Yet this approach to diet "was largely unsupported by data" and "helped fuel the obesity epidemic," Topol said.
He also offers sharp criticism of his own professional group, the American College of Cardiology (ACC), as an example of misplaced priorities. The ACC has done well in terms of preserving the reimbursement rates of cardiologists, while providing educational programs, Topol allows.
"But the A.C.C. does very little to promote the interests of patients, which is why I have recently withheld my dues," Topol writes. "Like many medical societies, it is primarily a trade guild centered on the finances of doctors."
Medical societies contacted by Medscape Medical News stressed that their emphasis was about far more than money, with patients front and center.
In a statement, the AHA called Topol's comments "misinformed," saying that it does not endorse companies, products, or services.
The AHA said its Heart-Check Food Certification Program is intended to help consumers make healthier food choices. Participating food manufacturers pay administrative fees per product to cover program-operating expenses. Approved products display the Heart-Check mark — not the AHA logo, the association points out.
"AHA's dietary guidance is based on a review of peer-reviewed, scientific evidence," the association said.
The AAD also defended its decisions, stating that its "Seal of Recognition" program was created "to help consumers choose sunscreens" and that its criteria for sunscreens were "significantly more stringent than the FDA's."
The group -- which said it ended the program in 2009 "after it became clear that the FDA would be issuing a sunscreen monograph that more closely aligned with the program’s stringent criteria" -- also said its goal is "to support and enhance patient care."
Richard Kovacs, MD, president of the ACC, disagreed with Topol's characterization of his group's work. In a prepared statement, he told Medscape Medical News that the ACC has been an advocate for patients, and cited examples of its work with managing registries and maintaining a dedicated patient education website, CardioSmart.org.
"Everything we advocate for, educate our members on, and develop for clinical practice is to ensure patients are receiving the best possible care," Kovacs said. "Any suggestion to the contrary is false and the opposite of what ACC's over 52,000 members from around the world and dedicated staff are working to accomplish every day."
The AMA declined to comment for this story.
The Good They Do
There's also no doubt that medical societies and organizations do advocate for their doctors' health and the health of patients. Topol mentioned the tragedy of this weekend's mass shootings, and the activism it generated.
The American College of Physicians (ACP) on Monday displayed the kind of leadership that Topol praises.
The ACP called for political action in the wake of the latest mass shootings, which killed at least 31 people in Texas and Ohio. The ACP's senior vice president for government affairs, Bob Doherty, tweeted: "Creating a movement: Use the #DoSomething hash tag to demand that politicians act to stop gun violence."
In his article, Topol highlights the ACP's 2018 Twitter battle with the National Rifle Association, where ACP members were told to "stay in their lane" after the group called for a ban on assault weapons. The ACP (and physicians) responded with the #ThisIsMyLane campaign on Twitter, with its members showing how they have to handle the devastating aftermath of gun violence.
"As a physician, I was thrilled by this display of solidarity and political engagement," Topol writes in his article.
Several physicians interviewed by Medscape Medical News also defended the work done by medical associations, even while agreeing with the broad thesis of Topol's article on other points.
Robert Centor, MD, a past chair of the board of regents of the ACP, agreed with a point Topol raised about the number of administrators in the practice of medicine growing far more than the number of doctors.
"We've ceded responsibility for healthcare too much to the administrators," Centor told Medscape Medical News. "We have done this because the government has gone regulation crazy."
But he argues that many medical associations are working in many ways to combat the stresses on physicians. He cited in particular the work done by Christine Sinsky, MD, who is vice president for professional satisfaction at the AMA, to address the root causes of burnout
Centor suggested that a bureaucratic battleground might be a better place for physicians to fight excess regulation. The Centers for Medicare and Medicaid Services (CMS) can be persuaded, if given enough evidence, to change its policies. This approach may have a more lasting effect than would borrowing union tactics, he said.
"It's one thing to organize against a single hospital. It's another thing to try to organize against all insurance and CMS," he said.
Centor cited a recent CMS proposal as an example of a win for physicians through this approach.
In the draft version of the 2020 Medicare payment rule for physicians released last week, as reported by Medscape Medical News, CMS said it intends to revise the times and medical decision-making process for all of the codes used for evaluation and management visits, requiring performance of history and exam only as medically appropriate.
Many medical groups previously had made the case to CMS about the unnecessary burden imposed by having to repeatedly gather this information, and CMS pointed out its collaboration with the AMA in drafting these new rules.
"We are more likely to have success by doing what we do best, collecting evidence and documenting what the problems are," Centor said.
Rita Redberg, MD, MS, a cardiologist with the University of California, San Francisco, told Medscape Medical News that she agreed with Topol's observation in his article about how many of the new activist-physicians are women. Both Topol and Redberg cited the work of Esther Choo, MD, MPH. Choo helped found the group Time's Up Healthcare, which fights harassment and discrimination, whether due to gender, gender identity, sexual orientation, race, ethnicity, country of origin, disability, or any other factor.
Redberg also questioned how well a bargaining tactic Topol mentioned would work in practice. In his article, Topol recalled witnessing a group of interns and residents striking in 1980 at San Francisco General Hospital, protesting in part over a "disastrous shortage of nurses."
But, physicians are not likely to borrow strikes as a tactic to improve their workplaces, she said.
"Traditionally, strikes are used to address low wages or benefits, and that is not an issue for medicine or most white-collar professions, so it is not surprising that doctors do not generally strike," said Redberg, who is also editor of JAMA Internal Medicine.
Topol told Medscape Medical News that the clock is ticking.
"I don't think anyone can argue with the fact that we're missing an opportunity because we don't have one organization that brings all doctors together," he said.
Medscape Medical News © 2019
Cite this: Doctors Need to Move Beyond Medical Societies, Eric Topol Says - Medscape - Aug 06, 2019.