-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