Dear Physicians: You Are Far More Wealthy Than You Know.

-By A. Joseph Layon, MD, FACP.

This article was written in response to Doctor Moeller’s Post: An Open Letter to Washington, D.C. From a Physician on the Front Lines

With interest, I read and re-read Matthew Moeller’s Open Letter.  My son, a first year medical student at Drexel University in Philadelphia, commented that this missive was being discussed by his colleagues in a tone of moral righteousness.  Interesting.

I know, I remember, what it was like to realize that the way to live an authentic life was to engage in providing health care for our people.  I remember debt, struggle, and 120 work-weeks. All of this, I remember.

And I remember being a third year medical student at The University of California, Davis – Sacramento Medical Center.  My professors, between patients on rounds, arguing how disastrous the health care system was becoming, how it was better in the “old days”, how they / we were suffering, how no one really understood what we had to go through.  Well, you get the idea.

While I understand, empathize and remember much of what Doctor Moeller says in his piece, and while he is – in my view on the mark in much of what he writes – I think he misses several points that are worth comment:

1. Medical School Debt: As a member of the Faculty Senate at the University of Florida I once got into a running argument related to the lack of breadth our undergraduates exhibited prior to their entry into professional school; lack of knowledge of history, language, and cultures other than their own.  Medical training is expensive.  In the not so distant past, a huge portion of this expense – certainly in the State of California where I was both an undergraduate and graduate student – was funded through tax revenue.  This was done not to be nice to our medical students, but because education was considered a social investment.  Proportionally, the monies in education have decreased (see Christopher Newfield, Unmaking the Public University – The Forty-Year Assault on the Middle Class, 2008, Harvard University Press), resulting in a grand portion of the debt saddling Doctor Moeller.  Nowhere in Doctor Moeller’s missive do I find any comment upon this.  The very policies that many in our profession cling to – physicians being, oddly to my mind given our work, frequently conservative and in the Republican or Libertarian camps – i.e., anti-taxation policies, put our medical students – and undergraduates, and graduates – at risk.  These policies put our future at risk.  Doctor Moeller rightly notes his difficulties; but Matt, what about the broader picture ?  This isn’t just a medical student issue.

2. Making the Big Bucks: Educational debt is at least part of the rationale for Doctor Moeller’s cri de coeur.  I have not and would not argue for forced poverty.  After all, we are physicians, not Nuns and Priests; we undertake the Oath of Hippocrates, not an oath of poverty, chastity and obedience.  But there is something slightly unseemly about this discussion of money.  We are – notwithstanding the reference to Professor Newfield’s book, above – still heavily subsidized by our country.  Even with the difficulties of Medicare and Medicaid funding, significant portions of the health dollars we consume come from the tax-payor.  Let’s let the investment bankers (I have at least one in my family) sell themselves to the highest bidder.  We will be ok; we may not be “rich” in the crazy sense that seems to permeate our culture, but we are rich in other ways.  You will have enough money, Doctor Moeller, to live a good life; you will be privileged to care for our sick fellow humans, to ask questions about their lives that no-one else could ask, to probe where even lovers would not dare to go; you will be at your patient’s side when they die.  And you will – it sounds like you already have this – have a family that loves and respects you for what you are and do, not for your bank account.  Matt, you are already rich.  It will really be ok.

3. Organized Medicine and the voices therein: Doctor Moeller notes that the voices heard from organized medicine are”…the older political voices who were physicians when the times were different, when doctors did get reimbursed fairly for their work, when student loan debt was not this high, and when lawsuits were less prevalent. Many of the loudest voices in the healthcare debate are those of lawyers and lobbyists for special interests. They do not care about the well being of patients; that is what doctors do….”  Times were never different; there has always been struggle in medicine over the direction of our profession.  I refused, for many years, to join the American Medical Association; they were backward thinking, conservative, and seemed to be more interested in lining their own pockets than in caring for our people, or at least that was my analysis.  But things and people change.  The AMA supported health care reform, recognizing that ignoring the 50 million of our people who were uninsured or under-insured could not be sustained.  While President Obama’s Affordable Care Act is not the best we could have done, it is at least a first step; the AMA provided support, and I support them for this act.  I am now a member of that group.

The future direction of American medicine is still being debated; we are expensive, our outcomes are poorer than they should be, and quality – real quality not the declarative kind – is not where it should be.  Doctor Moeller, it is up to us to remake the face of American medicine.  Rather than focusing on the issues of student debt, reimbursement, and work hours – even though these are of significance – we should take particular note of patient-centeredness, quality, and the elimination of unwanted variation.  The central issue in the re–make of medicine in our country is that we focus on the patients for whom we are privileged to care, that is, after all, why we entered this profession.

Dr.  Layon serves as Director of Critical Care Medicine at Geisinger Health System. He blogs at Notes From the Southern Heartland

Dr. Moeller’s update to his original post can be read here.

  • Abraham

    Thank you.

  • John Hunt

    Dr. Layon: It is true that many doctors are libertarian minded, meaning socially progressive, economically conservative, I suppose. Or perhaps better: many doctors are in favor of individual freedom. This ethos is very consistent with the disgust that such doctors have both for the crony-corporatist Obamacare, as well as the only slightly less crony-corporatist system of health care prior to Obamacare. I think the term “fascist” is fairly apropos for Obamacare (somewhat moreso than the previous system), and AMA’s support for it is typical to me of AMA’s generally crony-corporatist tendencies–which are exemplified by their cash-cow CPT codes, which through the satanic deal with CMS, creates the-no-less-than INSANE price controlling manacles for all of us.

    I admittedly struggle to understand the mentality of those who support Obamacare. I suppose the supporters fit into one of several very different mentalities. 1) outright fascists, 2) hopeful socialists thinking that Obamacare is a step in the right direction; 3) people who feel we “have to do something” but don’t care enough to do the something wisely. All three of the groups want to force everyone to abide by their preferences: the first group is sick, the second group is probably caring and concerned but suffer from a failure of humility that allows them to justify use of force against their fellow man, and the third group are I suppose just lazy.

    The notion of “can’t we all just live together in peace” is really nice. I love it. The only way to live together in peace is for people to stop using force (and fraud) against others. Persuasion is a great thing to try. But force is wrong. Fascism and socialism involve force and threats of force, and therefore, regardless of potentially positive outcomes (efficiency in fascism, equality of outcomes in pure socialism), they are unacceptable to me, for the ends never justify immoral means. And no matter how you slice it, fascism (obamacare) and socialism require force to implement, and are therefore immoral and unacceptable.

    There are ways to accomplish good goals without relying on evil means. But they require humility, respect for people, and a letting go of the control mentality. They require respect for freedom, voluntary generosity, and the abundance mentality that can be created when people voluntarily synergize.