EDITORIAL

The Army of Medicine without Any Soldiers

Gerald Dorros, MD, DSc
Gerald Dorros, MD, DSc
The United States is in a recession, and shifting priorities have relegated medicine, health care and health insurance to secondary issues. Thus, the real issue of health care will not come to the forefront and receive significant attention. It is likely that physicians’ concerns and needs will be ignored. I believe that the primary resolution of our health-care crisis will not come from the implementation of universal health insurance, but rather through the existence and quality of physicians practicing the best medicine possible for patients. Without adequate numbers of highly trained physicians, people will not receive timely, appropriate, high-quality care. This medical access shortage is present and readily apparent, as evidenced by health-care delivery maldistribution, the lack of timely availability of services and delays in non-urgent treatment. This is underscored by intensive-care specialists remotely monitoring critical-care units, and radiologists, in other states or countries, teleradiographically interpreting images.1 Japan and the United States have similar medical access problems, with too few doctors for an increasing aging population. In 2006, 21% of Japanese were > 65 years of age, with 263,000 active doctors for 128 million people (a ratio of 1:487), while 12% of Americans were > 65 years of age, with 633,000 practicing doctors for 308 million people (ratio of 1:474). By 2030, 72 million American seniors (20% of a 360 million population) will have fewer trained physicians and an even more disparate ratio. Crane2 noted that “50% of physicians, ages 50–65, are frustrated with their practices and plan to sharply cut back or abandon patient care within the next three years…” [He went on to say that] “Only 10%…said the practice of medicine [was] very satisfying, …44%…would not choose medicine as a career…[Even more troublesome is the fact that] 57% said they would discourage their children or other young people from becoming physicians…[Their current practice activities are changing rapidly, with] about 50% saying they will retire over the next three years, seek non-clinical jobs [or] work part time, close their practices to new patients (18% have already done so), or significantly reduce the number of patients they care for. The Council on Graduate Medical Education…[predicted] a shortage of 96,000 physicians by the year 2020. These older physicians do not have much regard for the work ethic of their younger counterparts…[being] less dedicated and hard-working and…[putting] a higher premium on ‘quality-of-life’ issues [by] preferring and expecting fixed hours, a good call schedule with reliable coverage, and regular vacation time…[More] young physicians…are female, with nearly 50% of medical school graduates being women [who]…work 18% fewer hours per week…For these reasons, more than one younger physician may be required to replace the workload of a more senior doctor.” Our nation’s health-care system cannot adequately address the aging and increasing population, the large number of doctors retiring in the next 15 years, rising health-care costs and the increasing numbers of uninsured Americans by eliminating “unnecessary” services or adopting universal health insurance. The physician shortage and maldistribution of practitioners will only become worse and will likely not be helped by universal health insurance. The outcome will be a further reduction in access to care and the delay of elective care, prevention and non-emergent procedures. This situation will directly and adversely impact the quality of health care. A number of factors are exacerbating this situation: 1. Failure to include practicing physicians in discussing health-care access solutions, which in many cases has been left to legislative assistants, policy makers and non-practicing physicians; 2. Physicians not receiving adequate compensation for their knowledge, cognitive and technical skills and dedication to developing less invasive diagnostic and therapeutic alternatives; 3. Restricting the involvement of physicians in ownership of diagnostic and therapeutic equipment, outpatient facilities and hospitals, acknowledging that this can only be accomplished with appropriate management of conflict-of-interest issues; 4. Failure to reform the malpractice system, which has resulted in exorbitant and unnecessary insurance premiums, inappropriate litigation and uncontrolled settlements; 5. Inadequate efforts to reform primary-care medicine to create an effective triage system employing trained clinical nurse clinicians and physician assistants.3 The tragedy is that government and special interest group control of physician practice and compensation, directly and indirectly, will result in the destruction of medicine if left unabated and unchecked. This point was eloquently detailed by Dr. Hendricks in Ayn Rand’s 1957 novel, Atlas Shrugged.4 Physicians have been slow to realize that payers are having a significant impact not only on their compensation, but also on their ability to continue and even to survive in medical practice. In many cases, this has been the unintended (or intended) consequence of compensatory metrics for the technical and cognitive dimensions of physician performance. This methodology determines not only what and how much is paid, but also may detail physician qualifications and influence whether new, innovative, alternative or different diagnostic techniques, procedures or therapies are reimbursed. However, the cognitive work product of the physician is considered almost “impossible” to accurately define. Therefore, the nuances that exist in differentiating as well as providing metrics for physician intelligence, knowledge, skill, cognitive integration and work that result in patient assessment, diagnosis and treatment have been paid at the lowest common denominator. The physician is virtually powerless to disagree, since many consider the physician’s invaluable skills to be within society’s eminent domain, and that physician questioning of this presumption would be inappropriate. The physician either submits or silently exits medicine, because the consequence of protestation is criticism and chastisement in contradistinction to laudation for opposition to governmental subjugation.5 Today, physicians can ameliorate the ravages of disease, as well as the very process of life and death. Society’s intertwining of historical, ethical and moral perspectives, along with religious precepts have defined the responsibilities, obligations and behavior of the physician. Furthermore, society has acknowledged that the potential for harm exists in every medical procedure and treatment. This alignment of societal needs and physician objectives has allowed the latter to directly confront and become accountable for a myriad of intricate, multifaceted, complex ethical issues (e.g., animal experimentation, abortion, contraception, euthanasia, withholding treatment, heroic measures and discontinuation of life-support systems), hazardous therapy (transplantation, radiation) and human experimentation.6 The consequences of society’s conferral of this special status to physicians and the warrant for their protection included stringent obligations and the surrendering of significant personal freedom on the part of physicians so as to be completely dedicated and attentive to their task. Medicine has evolved into a societal inalienable right, with the evolution of indentured physicians performing these duties. Physicians, after years of study, anticipated entering a welcoming professional environment and receiving commensurate financial rewards, but today they encounter an unfriendly and circumspect public and an intimidatory environment, which, ultimately, coerces them to abrogate their thoughts, feelings, needs and voices to utterances of government officials, lawyers, business people, medical industrialists, hospital administrators and the media. However, their words do not advance the physician’s interests, but rather demonize, manipulate, marginalize and subtly or overtly intimidate physicians, which results in worsened conditions. Almost comedically, the government egregiously regulates the salaries of physicians, while demanding a greater physician work product for less pay. Unfortunately, today, societal mores and attitudes no longer cast physicians as independent, well-reasoned and well-spoken patient advocates. This is, in part, due to the fact that physicians have been dominated, coerced and subjugated to the whims of governmental agencies, uninformed legislators, hospital administrations and health-care systems that often acquire physician practices to control the health-care delivery market. Furthermore, lawyers, prosecutors, insurance carriers and device, pharmaceutical and imaging industries often acquire physicians’ knowledge without adequate compensation and compromise physician integrity through coercive financial inducements. Governmental regulation and special interest groups’ lobbying efforts have shaped the steady decline of physician recompense. Businesspeople, lawyers, legislators or lobbyists would not accept such regulated compensation for their work, but these same groups inflict this travesty upon physicians for the serious work they render, a policy not perpetrated against other professions. Physicians are docile, compliant and obedient targets who continue to care for the sick, despite minimization, discounting or elimination of recompense. Ironically, physician altruism, sense of obligation and refusal to abandon the ill result in the vulnerability that enables this situation to exist. On September 16, 1977, a balloon catheter was used to open a narrowed coronary artery. This novel, less traumatic therapy, called angioplasty, metamorphosized medicine by replacing classic surgical procedures with less invasive ones. Angioplasty transformed the dissemination of technology through live, interactive pedagogy, ultimately flattening the vertically tiered worldwide medical hierarchy which had been dominated by American physicians. Normally in business, innovative, more profitable and less costly product iterations are reasons for financial reward, while in medicine, the reverse has occurred. “Between 1993 and 2005, the number of angioplasties performed nearly doubled, 418,000 to 800,000 procedures, while invasive heart bypass surgeries declined from 344,000 a year to 278,000 over the same span.”7 Such physician-created procedures have minimized procedural trauma, reduced complication rates, improved outcomes and shortened hospital stays, permitting increased patient throughput, more compensation per utilized bed-day, easier amortization of fixed costs and increased hospital profitability. Shorter recuperative periods have allowed earlier return to work, a better lifestyle, improved job performance, minimized worker replacement costs and lowered disability payment expenditures. However, the payers realized that by pronouncing these worthwhile technological advances unproven, not “FDA-approved” (whose actual and technical meaning is different than that conveyed by the phrase), and too expensive — as was the physician’s commensurate fee — they would not be obligated to pay, unless really pressed, and their money could be used elsewhere, rather than for better and more economically rendered services. Furthermore, although, granted, difficult to obtain, rather than quantifying the saving of health-care dollars created by more elegant, less traumatic and ingenious techniques and procedures, devices and medicines, which underscored the brilliance and grace of physician ingenuity, societal leaders simply employed inaccurate statistics to pronounce that doctors were getting too much money. But consider that “operators of asphalt spreaders in New York City are required to be paid hourly rates of $49.52, plus $24.80 in benefits, paid federal holidays … [and] Election Day. In contrast, in Manhattan, a 25-minute check-up will garner a Medicare payment of $66.07 in July [2008].”8 U.S. Labor Department 2007 statistics, employing a 50-hour week, detail that Family and General Practitioners earn $72/hour based on a $150,000 salary; Pediatricians, $66/hour, on a $141,000 salary, and Surgeons, $89/hour, on a $184,000 salary. But, the majority of physicians work every third weekend and every third week on-call, and their hourly workweek often approximates at least 80 hours. As such, their hourly wage plummets to less than $34 for a pediatrician and $45 for a surgeon. Detailing similar incongruent statistics for cardiologists, cardiac surgeons, neurosurgeons, anesthesiologists and orthopedic surgeons is comical. “National health spending is expected to increase from $2.2 trillion in 2007 to $2.4 trillion in 2008. Average annual NHE growth is expected to be 6.2 percent per year for 2008 through 2018…Physician and clinical services spending is expected to grow 6.2 percent in 2008, slower than the 6.5 percent growth experienced in 2007. A deceleration in physician price growth from 3.9 percent in 2007 to 2.7 percent in 2008 is the principle factor behind the anticipated slowdown in spending growth. In 2009, physician and clinical spending is projected to grow at nearly the same rate as 2008 at 6.0 percent…Over the projection period (2008–2018), holding physician payment rates constant has only a minor impact on total health spending growth.” Medicare [serving 44 million seniors], expended in 2007, 96.1 billion for the total aggregate physician and clinical services, and projected, for 2008, $102.2 billion, which will go to 633,000 physicians and 267,000 other health-care professionals; this constitutes only 4.73% of the total health-care expenditures in 2007, and 4.26% in 2008.9 In 2007, Medicare expended $431.5 billion,10 of which $96.1 billion was for physician and clinical services (22.3%). But, consider that physician services approximates 60% of this value, about $58 billion, which is $13.5% of Medicare expenditures. This constitutes a small portion of the health-care budget, remembering that total health-care expenditures also include Medicaid, private insurance, state payments and out-of-pocket expenses. Nevertheless, this is a small amount that goes to physicians. Now consider, as reported by Carl Zulauf,11 the $165 billion 1995–2005 farm subsidy payments, of which 73% went to 10% of the recipients. In 2005, a quarter of the subsidies were provided in the form of “direct payments” to landowners, regardless of what they farmed, how much they farmed or if they farmed at all. In December 2007, the $16.5 billion yearly subsidy was increased to $20 billion,12 which is unconscionable, considering what physicians are paid for actually rendering health care. Federal and state governments and health insurers only pay physicians for rendered services when compelled, and often only after a prolonged time. Since physicians have been a weak lobby, governmental agencies and legislators have been able to pit physicians against one another and limit their compensation. In Medicare’s zero-growth, non-expanding budget, the government has lowered the compensation of some physicians through a relative value system assessment in which the physicians determine which medical items, procedures, operations or patient visits would receive more, less or no payment. The medical profession’s participation is their walk to irrelevance, its “Silent Walk of the Lambs” to slaughter. The physician’s knowledge and skill, while important and critical to society, have been marked as having minimal value compared to other politically “important” issues. The physician’s sacrifice of time, family and energy are immaterial and unimportant. Society has declared that material or pleasurable goods can only be monetarily valued because the consumer’s continued purchase provides validation, and, as such, appropriate creator compensation, but these concepts have not been uniformly applied to the physician. Societal leaders neither comprehend nor perceive the magnitude and consequences of their actions. The best and brightest students will no longer enter medicine in sufficient numbers, and physicians will continue to leave medicine for more financially attractive venues in the pharmaceutical and medical device industries, financial institutions, insurance companies, law firms and venture capital firms. This will result in a worsening physician shortage and reduced access to quality medical care. Inadequate physician compensation has become obvious to the corporate world. “In an ambitious effort to shore up U.S. primary-care medicine, a coalition including General Electric Co., International Business Machines Corp. and Verizon Communications Inc. is launching an initiative [Bridges to Excellence] to pay doctors financial incentives…Last year, the program paid out roughly $10 million in bonuses to doctors…A growing number of health insurers and others, including the Federal Medicare program, employ the approach to improve on certain measures aimed at raising health-care quality and lowering costs…cholesterol screenings, diabetes checkups or pap smears, and by meeting other targets, medical practices can typically receive 2% to 6% of their revenue in bonus payments. The new initiative would reward primary-care physicians significantly…[by physicians adopting]…a more integrated approach to coordinating patients’ care…[including] following up on referrals to other physicians, systematically tracking tests, flagging abnormal results and adhering to widely accepted medical guidelines to monitor and treat diabetes and other chronic conditions…Doctors can receive $125 annual bonuses for each patient covered by a participating employer, up to a maximum $100,000 a year…such improvements in quality [could] save $250 to $300 per patient in the first year.”13 The groups’ comedic, yet profound and insightful, pronouncement is only what physicians want to do. Governmental regulation in medical education has played a significant role in this physician shortage.1 In the 1980s, medical schools entered a period of voluntary population control because too many physicians would be “bad for the economy”.2 In the 1990s, the government dictated that more primary-care physicians were critical to correct an excess imbalance, and that “too many specialists were bad”. Through the Balanced Budget Act of 1997, they froze the number of residency positions. Between 1995 and 2006, primary-care residency numbers increased from 39,000 to 41,000, but U.S. physicians’ participation fell from 62% to 54%, and foreign physicians rose from 34% to 38%.14 However, physicians chose not to enter primary care, despite the government’s intent, for a myriad of reasons including inadequate compensation, and also declined to enter difficult, demanding, time-consuming subspecialties. In 2007, only 63% (85/135) of cardiothoracic surgery residency positions (a 5-year-plus program) were filled with U.S. and foreign physicians. In the future, these complicated procedures, e.g., coronary bypass surgery, valve replacement and pediatric heart surgery will be done only in large hospitals in large cities. They will not be available in small cities, inner cities or rural settings.3 For primary-care disciplines, including family practice, pediatrics and obstetrics and gynecology, access and delivery require reassessment as to who will perform such procedures and under whose aegis. A primary health-care triage system utilizing physician assistants and nurse clinicians must be envisioned as a viable solution.4 Unfortunately, alleviation of this health-care delivery shortage will take time to solve because of the length of education required, even if medicine and the primary-care specialties were an attractive, adequately compensated employment opportunity. Thus, the ramifications of prior governmental policies with unintended consequences are now becoming evident, and this is problematic. Society must ensure that the best and brightest students continue to enter medicine, not only to treat, heal and cure patients, but also to create more accurate diagnostic methods and more effective, less traumatic treatments. Medicine, although competitive and difficult, must remain so, and it must be an attractive profession. The following actions may help accomplish this: 1. Increase medical school positions by 50% to 27,000+; 2. Upon completion of training, physicians would participate in a universal, mandatory 2- to 4-year national service program that would eliminate all educational debt: physicians could practice in rural areas, urban inner cities, the Indian Health Service, the Public Health Service, a Public Disaster Health Service or in Military Service; 3. Reform medical malpractice with the creation of specialized physician-dominated review panels, specialized health courts, limitations on punitive and non-economic damages and loser-pays-all legal costs rules. This would significantly lower malpractice premiums, enabling young physicians to practice in the formerly high-risk litigation specialties, e.g., obstetrics and gynecology and neurosurgery; 4. Introduce a triage system enabling primary-care physician to employ and be compensated for nurse clinicians and/or physician assistants who could treat patients under that physician’s aegis; 5. Provide adequate compensation for physician services, including those in cognitive specialties; 6. Eliminate the zero-growth Medicare compensation policy, as well as the enormous farm subsidies; 7. Make preventive care a priority and adequately compensate physicians who perform cognitive services using diagnostic imaging or sophisticated blood or genetic testing to determine nascent disease, which would enable less invasive and more successful curative therapies to evolve; 8. Allow physician participation in business ventures, with appropriate conflict-of interest safeguards. Our society has proclaimed that ethical values are paramount, medicine is an inalienable right and the doctrine of physician sacrifice is part of the physician’s job description. All of these have helped create this underestimated and ill-perceived crisis. Society demands that physicians surrender themselves, their minds and their lives to a societal hierarchy whose laws and statutes not only require, but demand, physician adherence, while precluding rational thought, which directly imperils physician existence and will lead to physician nonexistence. If physicians fail to speak out now, medicine will delete patient care as its primary priority, a responsibility entrusted by society to physicians, eons ago, and not to politicians. Physician subjugation and submission have caused the physician’s loss of those implicit, extant and required cardinal values: rationality of thought, sovereignty of mind, adherence to the best ethical and moral reasoning and concern, empathy and dedication to the patient. Work is the source of physician happiness, but this contentment already has and will continue to morph into resentment unless just, unregulated and market-driven compensation is instituted. Physicians must coalesce as a group and oppose those who wish to lead us into irrelevance, and, consequentially, medicine into oblivion. Physicians can no longer sacrifice because it is their responsibility alone, foregoing what is appropriate to mercy; self-esteem to self-denial; and happiness to adherence to a proscribed list of societal obligations, which they know not to be true. However, despite all the rhetoric regarding health insurance, drug costs and expensive technologies, the candidates, legislators, pundits and gurus fail to comprehend that the primary health-care issue is physician shortage and maldistribution of primary-care and specialty physicians. The consequence of this unabated course of unearned rewards to others and unrewarded work to physicians will be the destruction of medicine and the physician as healer and patient advocate. As such, medicine without physicians would be analogous to an army without soldiers, and this should concern us all. ____________________________ From the Medical Director, Dorros Feuer Interventional Cardiovascular Disease Foundation, Wilson, Wyoming. The author reports no conflicts of interest regarding the content herein. Manuscript submitted April 15, 2009, provisional acceptance given May 12, 2009, final version accepted May 18, 2009. Address for correspondence: Gerald Dorros, MD, DSc (Yeshiva), DSc (Colby, Knight, Ecumenical Hospitalier Order of St. John-Knights of Malta, FACC, FESC, FSCAI, FSVMB, FAHA (Emeritus), FCCC, FACA, FCCP, P.O. Box 1654, 1120 South Thunder Road, Wilson, WY 83014. E-mail: gdorros@dorrosfoundation.org or gdorros@gmail.com
References
1. Cooper RA. The coming era of too few physicians. Bulletin of the American College of Surgeons March 11–18, 2008.

2. Crane M. Older physicians unhappy and looking to bail out of medicine. MedPage Today October 25, 2007.

3. Third Annual AAMC Physician Workforce Research Conference. Drs. Goodman and Salsberg. Physician workforce panning in a broken health care system. Washington, D.C., May 3–4, 2007.

4. Ayn Rand. Atlas Shrugged. Random House, 1957.

5. Rand A, Peikoff L. The forgotten man of socialized medicine: The doctor. Irvine: The Ayn Rand Bookstore, 1957.

6. Rosner F. Modern Medicine and Jewish Ethics. New York: Yeshiva University Press, 1986.

7. The U.S. Agency for Healthcare Research and Quality, 2007.

8. Furchgott-Roth D. The health care rub. New York Sun January 16, 2008.

9. On-line Senior Journal. November 2, 2007.

9. www.cms.hhs.gov/NationalHealthExpendData/downloads/proj2008.pdf, including Table 7. Physician and clinical services expenditures; Aggregate and per capita amounts, percent distribution and annual percent change by source of funds: Calendar years 2003–2018.

10. www.cms.hhs.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp National health expenditures by type of service and source of funds: Calendar years 1960–2007.

11. Zulauf CR. Farm program spending: A Historical perspective. July 2005, The Ohio State University, Agricultural, Environmental, and Developmental Economics; aede.osu.edu/resources/docs/pdf/67K0WX0QGO70JUMWE981Q8HGSNDT8UC6.pdf; and, Figure 1. Spending on farm payment programs, 5-year Olympic moving average, U.S., fiscal years 1965–2005.

12. Amber waves of green. Federal spending and budget issues. Wall Street Journal March 13, 2008.

13. Fuhrman V. Group offers doctors bonuses for better care. Wall Street Journal January 31, 2008.

14. Goldstein J. Health blog: Primary care: Fewer U.S. MDs, more imported docs. Wall Street Journal February 13, 2008.