The Profession that Was

Once upon a time in a land far away, there existed a profession called “medicine,” a profession governed by internally derived standards and values, a profession that relied on both scientific data and experiential knowledge and judgment, a profession that focused on providing excellence in the care of others…
Last week I received a call from “utilization review” concerning the “hospital status” of a woman on whom I had just performed a vaginal hysterectomy by means of morcellation due to its size. The call challenged my decision to admit her for post-operative recovery.
Over the past 25 years we have gradually reduced the length of stay for our post-surgical (hysterectomy) patients from 5-7 days to 1-2. But the current impetus–mandated by insurance reimbursements and led by the governmental agency of the CMS (Center for Medicare-Medicaid Services)—is to require that hysterectomies be performed as an “outpatient” procedure. This entails discharging the patient hours after removal of an intra-abdominal organ with significant collateral circulation. As a default practice, such a mandate is unreasonable and unacceptable. It fails to consider the many contingencies of the individual patient and procedure for which physician judgment is still required.
At the risk of being too graphic, when a vaginal hysterectomy is performed, a major organ is removed through a relatively small orifice, compromising visualization of the surgical field. Inadequately secured blood vessels can retract into the pelvic sidewalls, out of sight, creating a risk of significant post-operative intra-abdominal hemorrhage. Fortunately, such risks materialize infrequently, but the risk still exists and requires a reasonable period of post-operative monitoring and assessment for the safety of the patient. For such bleeding, if it occurs, is potentially disastrous, even more so if the patient is not in the facility.
Over the past decade these same agencies have also become obsessed with pain control for hospitalized patients, developing and utilizing “visual analogue scales” (smiley faces) in an attempt to quantify the subjective and unquantifiable, and insisting that post-surgical patients be “pain-free,” an unreasonable expectation to begin with. Yet now it is proposed that patients be sent home with anesthesia-induced and pain-induced nausea and vomiting that prohibits them from taking their prescribed oral analgesics which results in more pain, more nausea, and more vomiting—a vicious cycle. Moreover, the increased intra-abdominal pressure that occurs with valsalva increases the risk of post-operative hemorrhage. As concerned as the accrediting bodies have been about pain control for hospitalized patients, there is no concern about the adequacy of pain control for patients who are discharged–it seems that it is then no longer their responsibility. But while it may no longer be the “responsibility” of the regulating agency, the pain and care of these patients is still my responsibility and concern.
Over the past few years this has resulted in “insurance-company-mandated-hospital-anxiety-over-lack-of-payment” induced game-playing over hospital status, games characterized by dishonesty and semantics. But these new rules, regulations, and games place physicians in the untenable situation of being morally and legally responsible for patient care that is legislated by a nebulous outside authority, one that lacks knowledge of the particular patient and/or procedural contingencies. Furthermore, as professionals, our calling is to be advocates for our patients and their care. Yet if we advocate for patients by refusing to abide by unreasonable and unacceptable regulations, especially in rural America, the hospitals in which we provide that care are penalized through the withholding of reimbursement and imposition of fines that threaten them with insolvency. Such a situation violates and undermines the concept of professionalism, which by its very nature is governed by internally derived values and standards, not externally imposed regulations.
Medicine is not a game, especially not a zero-sum game. It is a profession defined by excellence in its practices. Or at least it was. How is it that these “authorities” have assumed the right to dictate patient care without assumption of the correlative responsibility for any adverse consequences? I fear that we, ourselves, by shifting our focus from care to compensation, have let the fox into the henhouse. That fox has destroyed the profession…and I fear it is here to stay.

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Jon HolmlundJoel Goodnough, MD Recent comment authors
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Joel Goodnough, MD
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Joel Goodnough, MD

Very well said! I retired from the “business” of Ob-Gyn at the prime age of 58 because it was no longer the profession that I was called into. Now I dread aging and becoming a patient myself.

Jon Holmlund
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Jon Holmlund

Looks like a good example of a serious generic problem–we are sacrificing clinical judgment to the tyranny of rigid rules. Some musings: 1) I recall hearing a Grand Rounds during my medical residency (mid-’80’s) by Dr. Samuel Thier, then head of the Institute of Medicine. He said that a learned profession has three characteristics that define its members: they are committed to lifelong learning, they police themselves, and they value performance above reward. Does medicine meet those now? I would vote “yes” on the first, be worried (no matter how physicians are organized) about the third, and think that the… Read more »