In Search of Medicine's Moral Compass

In Search of Medicine’s Moral Compass

Rob Tenery, MD

© 2011 Rob Tenery, MD

All rights reserved. No part of this book may be used or reproduced in any manner without written permission except in the case of brief quotations embodied in critical articles or reviews.

In Search of Medicine’s Moral Compass

The Small Press

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eISBN 978-1-612547-86-2

For more information, please visit: www.robtenerymd.com

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

The Golden Age of Medicine

What Is Organized Medicine?

Choosing Medicine as a Career

The Doctor and His Black Bag

Should We Keep Fee-For-Service?

The Physicians’ Perspective

Physician Participation and Concern

Medicine—Past, Present, and Future

The Ideal versus Reality

Challenging Our Health Care Delivery System

Christopher Columbus’s Voyage

Health Care Reform

Why Are We Here?

Our Last Hope

Appendix II: Selected Commentaries by the Author

The Patient and His Doctor

Compassion—Who Needs It?

Whatever Happened to Word of Mouth?

Is Medicine a Profession or Business? It Matters.

When Medicine Is a Calling and Not Just a Job

More to Being a Physician than Degree in Medicine

Doctors Are Always There, with Their Patients

Have Physicians Lost Something along the Way?

Did You See the Doctor? A Patient Isn’t Sure

Allied Health: Why Can’t Everyone Practice Medicine?

What Doctors Do When Nothing Can Be Done

Much Is Left to Learn about This Imperfect Science

Which Doctors Shall We Choose for Our Heroes?

Can the New Bad Apples Hurt Our Profession?

For Physicians and Presidents, Is Private Life Public?

Time to Pay the Piper?

Interactions between Physicians and the Health Care Technology Industry

What’s Acceptable and What Has Gone Too Far?

With Medicine There Can Be No Money Back Guarantee

Many Answers to Question: Which Doctor is Best

Home Truths from the US

Organized Medicine Must Return to the Three Rs

Does the AMA Really Want a Federation of Medicine?

How Far Must Medicine Compromise?

Balance Billing Would Work Better for All

Single-Payer System Doesn’t Look So Bad These Days

Are Lawyers’ Clients Different From Our Patients?

Perhaps It’s Time for Physicians to Sue Their Patients?

Do Doctors Really Make Too Much?

Home Remedies: A Young Physician’s Lesson

Can We Afford Our Bad Habits?

Facing Organ Donation in a Meaningful Way

Auxiliaries Make Vital Contributions to Medicine

Media Must Accept Responsibility to Patients

Appendix III: Selected Blog Posts by the Author

The State of the Medical Profession

Birthright Citizenship: The Silent Costs

Individual Mandate: The Deeper Issues

Death Panels: Probably Not—A Trojan Horse: Maybe

Turf Battles, but Whose Turf?

Groundhog Day—Our Boring Problems

Medicine’s Increasingly Empty Tent

Whatever Happened to the Whole Story?

Medicine’s Tipping Point: What’s Next?

About the Author

Foreword

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.

Rob 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. Dr. Tenery 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 Rob, 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.

—Louis J. Goodman, PhD

Executive Vice President/CEO, Texas Medical Association

Acknowledgments

This collection of information is based on the collaborative efforts of all those individuals who have chosen the profession of medicine as their life’s work. Their efforts began at a time long before it was a means of financial support but just an act of beneficence for one’s fellow man. It continues today, not just in doctor’s offices, operating rooms, and hospitals, but in corporate headquarters, court rooms, and the halls of legislative bodies across the country—anywhere the welfare of patients is being debated.

I want to thank my wife, Janet, who supported and advised me in my efforts as I tried to balance my obligations to our family and my practice as I represented and now attempt to understand the evolution of this wonderful profession.

Finally, I want to express my deep appreciation to Louis J. Goodman, PhD, executive vice president/CEO of the Texas Medical Association for being a longtime confidant and editing the major body of this work. He continues to give back to this profession with his knowledge of socioeconomics and passion for an unfettered patient–doctor relationship.

Author’s Note

Why write a book on the delivery side of health care? It may not be as exciting as the latest medical breakthrough, but in many ways it is equally important.

I began my medical career following in my father’s footsteps as he made hospital rounds and house calls in the months before my fifth birthday. It has been forty-three years since I walked across the stage and repeated the Hippocratic Oath before accepting my medical degree. During that span of time, I have had the honor of being witness to it all: the introduction of third-party payers, government intervention into every part of this health care system, how defensive medicine has increased costs and driven a wedge into the patient–doctor relationship, how marketing has changed patient’s expectations, how managed care has eroded the doctor’s decision making, how apathy within the physician community is causing physicians to lose control of their own destiny, and how the latest federal legislation threatens what has been considered the world’s best heath care system.

Until about ten years into my practice, I played the role of casual observer—taking whatever was thrown my way. At the urging of my father, I got involved. First it was with my local county medical society, then my state medical association, and then the American Medical Association. Even then, I was still mostly reactionary, responding to the immediate problems with very little understanding as to why those problems arose. Only when I came to realize that history has a way of repeating itself did I decide to delve into the whys. At first, it was writing commentaries for local periodicals. Then I authored a monthly installment in American Medical News for eight years. Two years ago I published the book Dr. Mayo’s Boy: A Century of American Medicine, a one hundred–year overview of the changes in the way doctors and their patients relate as they face maladies. I continue in my search for understanding through my website, Echoes for the Future, where I often look at the social and political issues of the day and how they impact health care.

Although most of the information for this book was readily available, it was so scattered that it made drawing conclusions to serve as guidelines difficult. I discovered that the very tenants that formed the foundation of this profession were being buried in compounding layers of growing physician frustration, changing patient expectations, and increasing third-party payer and governmental control. My hope is that by compiling this information, along with many of my own thoughts, this book can be used not only as a resource for better understanding where we came from, but can be easily accessed for reference when facing the unknowns of our future.

Finally, I chose the e-book format because of its portability, ready access, and the reader’s ability to go to the original material with just a touch of the finger.

Prologue

Attention to the evolution of health care delivery has been mostly centered on the remarkable advances in its science. Every bit as important are the social and financial changes that have permeated all aspects of our ever-evolving society. Doctors, who in the beginning of the twentieth century were sometimes more akin to the ministry, with an assortment of potions and a comprehensive understanding of the human anatomy, are today scientists more closely aligned with the business community.

None of these changes was unexpected. A growing patient population, advancing technology, and increasing costs of health care delivery were predicable byproducts of this evolution. Not as predictable were the changes in the patient–doctor relationship and how the tenants upon which the medical profession was founded are now being called into question by this threatened union.

Just as the discovery of antibiotics and organ transplantation served as pivotal points in the science of medicine, the introduction of health insurance, managed care, and government intervention are equally as important in the evolution of our current delivery system. To be true to the precepts of the profession of medicine, we must first learn from the defining events that brought our current health care system to where it is today—not just when they happened, but why they occurred and what their eventual consequences were and are. And finally, in attempting to address the weaknesses, we must not destroy the good in what has gone on before.

Introduction

Since their earliest days of practice, physicians have vowed to uphold the basic tenants of the medical profession by taking an oath of conduct. Most credit Hippocrates with formally outlining the first standards of physician behavior with his often-quoted oath around 400 BC. In reality it was much earlier, when Hammurabi, the sixth king of Babylon from 1792 BC to 1750 BC, put down what he deemed to be the laws of conduct for the Babylonian people. Carved on an eight-foot-tall stone tablet, only recently discovered in 1901, is a set of laws called the Hammurabi Code; it is regarded as one of the first written codes of law in recorded history. Although his laws cover many aspects of conduct, it is his laws that pertain to physician behavior and patient well-being that are enumerated below:

Code of Hammurabi

#148: If a man takes a wife, and she be seized by disease, if he then desires to take a second wife, he shall not put away his wife who has been attacked by disease, but he shall help her in the house which he has built and support her so long as she lives.

#206: If during a quarrel one man strikes another and wounds him, then he shall swear, I did not injure him wittingly, and pay the physicians.

#215: If a physician makes a large incision with an operating knife and cures it, or if he opens a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money.

#217: If he be the slave of someone, his owner shall give the physician two shekels.

#218: If a physician makes a large incision with an operating knife and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off.

#219: If a physician makes a large incision in the slave of a freed man, and kill him, he shall replace the slave with another slave.

#220: If he had opened a tumor with an operating knife and puts out his eye, he shall pay half his value.

#221: If a physician heals the broken bone or diseased soft part of a man, the patient shall pay the physician five shekels in money.

#222: If he were a free man he shall pay three shekels.

#223: If he were a slave his owner shall pay the physician two shekels.

#278: If any one buy a male or female slave, and before a month has elapsed the benu-disease has developed, he shall return the slave to the seller, and receive the money which he has paid. (1)

The Greek physician Hippocrates was born on the island of Cos between 470 and 460 BC. His family claimed to a have descended from the mythical son of Apollo and patron of medicine, Aesculapius. It has been reported, but not substantiated, that he used his talents as a physician to check the great plague, which swept Athens at the start of the Peloponnesian War. He died at Larissa between 380 and 360 BC.

The time-honored Oath he is credited with authoring around 400 BC shows that even in his day physicians had already formed into guilds, with regulations and professional ideals for those who took up the discipline of the practice of medicine.

Hippocrates demonstrates his awareness of the importance of the art of medicine in the first of his often-quoted Aphorisms: Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.

Oath of Hippocrates

I swear by Apollo the physician and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment,

I will keep this Oath and this stipulation—to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction,

I will impart a knowledge of the Art to my sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others.

I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.

I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art.

I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freeman and slaves. Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken abroad,

I will not divulge, as reckoning that all such that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot. (2)

Orphaned at age three and raised by his older sister, Thomas Percival attended the Edinburg Medical School. He then completed his MD at Leyden before setting up practice in Manchester, England. Encouraged by an uncle who was a physician and his former grammar school rector, he developed an interest in the ethics that surrounded medicine and became devoted to health reform and charity in Manchester.

In 1789 the Manchester infirmary was overwhelmed by patients with typhus and typhoid fever. In trying to deal with the problems, the infirmary’s board of trustees voted to double the physician staff. The existing staff, feeling this was an insult to their capabilities, resigned as a group, leaving a divided physician community. Known for his interest in ethical causes, Percival was asked by the board of the infirmary to help resolve the dispute by writing a code of conduct. His work, Medical Jurisprudence, was printed in 1794.

After encouragement and consultation with colleagues, in 1803 Percival published Medical Ethics. The American Medical Association (AMA) adopted Percival’s code at their first meeting in 1847.

Although revisions to Percival’s code have been made by the AMA in 1903, 1912, 1947, 1994, and 2001 to adapt to the changing times, the major concepts and similar wording still remain (3).

AMA Principles of Medical Ethics

Preamble—The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility not only to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

I.   A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

II.   A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

III.   A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

IV.   A physician shall respect the rights of patients, of colleagues, and other health professionals and shall safeguard patient confidences and privacy within the constraints of the law.

V.   A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues and the public, obtain consultation, and use the talents of other professionals when indicated.

VI.   A physician shall, in the provision of appropriate care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

VII.   A physician shall recognize a responsibility to participate in the activities contributing to the improvement of the community and the betterment of public health.

VIII.   A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

IX.   A physician shall support access to medical care for all people. (4)

The relationship between the physician and the patient should be one based on a commitment by the physician, not predicated on outcomes but efforts. It should not be contractual, centered on promises, but grounded in faith by the patients, that their doctors will always be there for them and only act in their patients’ best interests.

References

1. The Code of Hamurabi, trans. L. W. King, 1910. Ed. R. Hooker (Mesopotamian Text Archives, 1996).

2. Hippocrates, Harvard Classics, Volume 38 (Boston: P.F. Collier and Son, 1910).

3. Major Figures in the History of Medicine: Percival, Thomas (1740–1804), Reynolds Historical Library, accessed February 20, 2008, http://www.uab.edu/​reynolds/​histfigs/​percival.

4. Principles of Medical Ethics, American Medical Association, last modified June 2001, http://www.ama-​assn.org/​ama/​pub/​physician-​resources/​medical-​ethics/​code-​medical-​ethics/​principles-​medical-​ethics.page

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