It’s important for physicians to have strong convictions to guide their practice of medicine. These convictions, however, should be compatible with the code of ethics of the medical profession and informed by the needs that we subserve: the needs of our patients. Though only a first year medical student, I believe that it’s important for me to have guiding principles, state them openly, and be willing to discuss them (and possibly adjust them) when others wish to challenge or encourage them.
1. Everyone should have health care coverage, and physicians should fight for this.
The issue of universal health care coverage is a very controversial issue, partly because so many people believe that a single solution can solve many of health care’s greatest problems everywhere at the same time. Similarly, some people criticize the idea of universal health care coverage because they know, or at least suspect, that current proposals will inevitably fail where they practice (and that this suggests that these proposals will fail everywhere). This probably is not the case: no single solution will bring an answer to health care problems in every country, state, city, and practice setting – at least, not all at once. Some states, like Massachusetts, may benefit dramatically from mandate-based health care policies requiring that each individual purchase a health care insurance plan (and if they can’t afford it, they will receive assistance from the government in purchasing private plans). Some states, like Louisiana, may not be ready for this sort of plan, and may instead benefit from a slower transition from a charity-based safety net system to a system where everyone has their own plan.
Nonetheless, physicians should believe that every patient should have some degree of health care coverage, regardless of the single payer vs. multiple payer debate. It doesn’t matter whether one believes that health care is or isn’t a right. From a practical standpoint alone, it is much better for hospitals to receive reimbursements for care of otherwise uninsured patients, better for the reduction of health care costs overall to make preventive care and primary care more accessible to otherwise uninsured patients, and better for primary care physicians and family practitioners as there would be greater demand for the type of care they provide.
Physicians don’t necessarily have to agree on which health care policy would be best for everyone. However, it is important that physicians care and try to develop or push for plans that will be best for their practice settings (both for themselves and their patients).
2. The worst of enemies may also be your strongest allies.
Physicians tend to villify the forces in health care that make their lives, and the lives of their patients, very difficult: pharmaceutical and biotechnology companies, health insurance providers, and perhaps worst of all, personal liability (aka malpractice) lawyers. While physicians pride themselves on their collective professionalism and integrity (at a much greater efficiency than most other professional groups), there are countless, high-profile examples of the aforementioned entities blatantly lying to the detriment of patients (i.e. pharmaceutical companies hiding adverse results of drug trials, health insurance providers neglecting to pay for care while waiting for their enrollees to die, and malpractice lawyers bending evidence to convince non-medically competent juries of a doctor’s fault).
However, for physicians, a disturbing fact remains that allows these forces to remain in existence, and do so with insufficient regulation from the government: all of these provide valuable resources to health care (although the value of the current delivery of each is highly tenous). Pharmaceutical and biotech companies, though heavily profit-driven, provide health care with valuable new treatments and technology to improve the practice of medicine to some degree (although at the same time raising health care costs). Health insurance providers provide coverage to buffer patients from the increasingly higher costs of health care treatments and technology that might otherwise bankrupt them (aka “catastrophic” health care costs, albeit many insurance companies are failing, sometimes intentionally, to provide adequate coverage). Personal liability lawyers, so-called “ambulance chasers,” are perhaps the least redeemable of these villains, but at the same time, on principle, they attempt to enforce a degree of accountability for the actions of physicians that are inappropriate (although they currently do an extremely bad job of identifying which physicians are trouble makers). All of these entitries are perceived, by physicians and often the general public, as being primarily interested in their own profit. Nonetheless, in name and principle, they provide valuable services.
Furthermore, there are members of these organizations that are not only redeemable, but they are actively seeking to do good and to improve the images of these entities. In order to truly bring about change, physicians could do so much more if they are able to ally with pharmaceutical and biotech companies that are producing affordable and meaningful new treatments and technology (rather than copycat drugs or technologies that don’t actually improvement treatment or diagnosis in a cost-effective manner), insurance companies that are truly trying to limit health care costs while providing adequate coverage for all of their enrollees (including sick, low-income patients), and lawyers who agree to develop physician-lawyer committees that screen malpractice lawsuits for validity before going to trial. They may be hard to find at this point in time, but we will only be shooting ourselves in the foot if we continue to indiscriminately point fingers, thus making these potential allies even harder to find.
3. The patient’s need is the greatest goal.
This should be obvious, but people argue about what constitutes this “need.” Over the past several years, there has been a much greater emphasis in the medical profession on patient autonomy: that is, physicians need to pay more attention to what patients desire. Previously, the doctor’s prerogative carried greater weight. Nonetheless, there are important limitations to patient autonomy: physicians are not required to provide treatments that patients demand. That is, a PCP doesn’t need to write prescriptions for drugs that a patient demands when she feels that he doesn’t need them, and an ER doctor need not deplete his hospital’s or clinic’s blood supply by continuously giving transfusions to a patient whose bleeding cannot be stopped. There have been a select few individual court cases that contradict these general practices, but the just nature of those decisions are questionable.
However, there are two important situations where I believe that the patient’s desire should override the personal convictions of the physician (or pharmacist): the cessation of life support in end-of-life care, and the provision of the morning-after pill. In the former, although an intensivist may wish to convince the patient or his/her family that a disabled life after intensive care can still be very valuable and enjoyable, it is still the patient’s decision (or the decision of his proxy, aka the person with the power of attorney) whether or not to remain on life support. Similarly, as recently ruled in Washington state, pharmacists should fill prescriptions for the morning-after pill, regardless of their personal and/or religious convictions. In both cases, one cannot practice ethically and morally while enforcing one’s personal and/or religious beliefs on another person.
4. Physicians should not be judgmental.
It is absolutely essential for physicians to be critical and skeptical, of their patients as well as their colleagues. However, judging also carries the weight of blame, and we should not be placing blame on anybody as this impairs our ability to care for others (again, patients and fellow colleagues alike).
5. Physicians can make a big difference, and we have the potential to be great leaders.
I believe that there is no excuse for physicians to neglect problems in health care. In other words, apathy is the greatest sin for a physician. While physicians as a professional group may have a significant degree of homogeneity with respect to integrity and professional behavior as compared to other professional groups, there is great variability in the degree to which physicians engage in health care issues outside their own clinical practices (if they practice clinically at all). Physicians in private practice almost invariably have less “spare time” than physicians in academic hospitals due to the high patient volumes set by their clinic or hospital administrations to generate revenue (or set by themselves). Nonetheless, there are so many ways in which all physicians can participate in larger health care reform efforts, particularly with our individual actions, convictions, our voices. Physicians receive considerable respect for being (on average) the smartest, most refined, most worldly, and most well-meaning members of many communities. This respect, however, should not go to waste: we should use the respect given to us in a meaningful way by vocalizing our thoughts on our society’s current problems and our ideas for improvement.
Similarly, although we as physicians (or in my case and those of my colleagues, future physicians) feel entitled to our esteemed positions by the fact that we have to buy our right to practice medicine (i.e. by placing ourself $250,000+ in debt), we are privileged and blessed in the respect that we have been selected to perform a duty to mankind: to care for our fellow man, and attend to the needs of our society. If we see people in need, we should try to help them to the best of our ability. To do nothing is a breach of ethics. Other forces in health care (that might hinder this goal, such as by providing little reimbursement or by threatening litigation) should help facilitate this goal of giving aid to those who need help: it is this desire to help our sick (whether out of humanity or practicality) that made our ancestors the first humans, and that make us human.
On a practical level, helping the sick (even if they are poor investments, noncompliant, and belligerent), is a great service to society: health care disparities are a major factor contributing to financial and social drains on our society (i.e. charity health care costs, crime, unemployment, welfare, etc.) because people cannot be productive members of society if they are sick. On a humanistic level, we are all human beings, and there is perhaps nothing in life that is good and worthwhile (including medicine) that doesn’t reassert this truth.
A quote recently passed along to me by my girlfriend, another future physician:
“I am only one, but still I am one. I cannot do everything, but still I can do something; and because I cannot do everything I will not refuse to do the something I can do.” – Edward Everett Hale