Having recently given two presentations on the nature of the physician-patient relationship, it seems only natural to follow in the footsteps of Jon Holmlund as he has been posting on the concept of professionalism.
As an instrument-rated pilot, I recently recognized an analogy between a training maneuver called “unusual attitudes” and the state of medicine today. Under normal flying circumstances, a plane is kept in straight and level flight by reference to the horizon. In situations where the horizon is obscured, one must learn to rely on their instrument panel. In this particular training maneuver, the instructor takes over the controls and confounds the middle ear of a “hooded” pilot through a series of steep turns, climbs, and dives. After adequately disorienting the pilot, the instructor puts the plane in a pre-spin or pre-stall attitude and returns the controls to the disoriented pilot with instructions to put the plane in straight and level flight with reference only to the instrument panel, not to the horizon. In today’s medical environment, physicians, too, have become disoriented by the commodification of the patient encounter and the medicalization of life. We have lost our horizon; we have lost sight of the fact that we are first of all healers.
What is meant by commodification? A commodity is an object for sale or valued for its usefulness to a consumer; and that usefulness and desirability are marketable. Furthermore, a commodity transaction is fungible: both the place and agent of transaction are interchangeable without detriment to the transaction, for the transaction entails no personal interest between buyer and seller apart from the product. Financial considerations govern the interaction.
This is part of the storm cloud that has obscured the medical horizon, disoriented the physicians, and put health care in an “unusual attitude.” And most of it can be traced to legal changes in the 1990’s which allowed “direct to ‘consumer’” advertising. When medical knowledge, products, and procedures become commodities, and when health care is viewed as a commodity transaction, physicians are impelled by financial incentives and disincentives to be purveyors of a commodity. They become moneymakers for themselves and money-savers for their employer or system. Suddenly, the patient and the healing relationship so vital to the medical encounter, has been lost from the horizon.
Furthermore, when health care is seen as a commodity, business ethics take precedence; and business ethics are not governed by beneficence, the principle that has historically governed medical ethics, but rather by non-maleficence. Merely avoiding harm creates a distinctly different timbre in the “transaction” than seeking the good of the patient. Moreover, like any business, medicine has become corporate- or investor-oriented, aimed at pleasing those outside the medical encounter, whether insurance companies or the government payors. The result is that the focus is now on outcomes, practicality, and the bottom line, all of which are easily quantifiable and controllable. The particular patient with their unquantifiable “contextualities” or peculiarities is again lost from the horizon.
But medicine is not a commodity; it is a relationship—not a fungible or interchangeable relationship with a provider or actor, but a relationship of trust between one who is vulnerable and ill and one who professes to be able to provide helping, healing, caring, and curing. As the late Dr Pellegrino has stated, medicine exists as medicine in the clinical encounter where medical knowledge is employed for the Good of the patient—to heal, cure, contain, or prevent human illness. This knowledge must be integrated into the life of the patient through the interpersonal relationship with the physician.
Is this concept of medicine as grounded in the personal encounter achievable or sustainable in today’s health care environment? I fear not. We have, indeed, been taken captive by outside interests, agencies, and agendas; we are no longer self-governing, but instead serve consumer demands and payor profits and interests. Young physicians entering practice have no knowledge of the historical horizon of health care founded on the “gift of hospitality” of religious orders, or of the physician-patient relationship of helping the vulnerable (rather than catering to the autonomous self). They have been deprived of their instruments and are oriented solely to forward progress with no inclination to consider the shoulders on which they stand. They have been nurtured on the sour milk of the “medical-industrial complex” and are flying upside down–they are disoriented and don’t even know it. And those older physicians who, despite loss of the horizon, can rely on their instruments to maintain straight and level flight, are landing and walking away from the storm–prudently, some might add.
I do often wonder whether I am clinging erroneously to an idealized version of the past when I should be riding the edge of the coin (as I mentioned in my last post). Is it possible to ride the edge of this coin maintaining a hold on the good of the traditional understanding of medicine while moving forward in a new paradigm? Or have we already advanced too far into the storm cloud, deprived of the necessary instruments, to even catch a glimpse of horizon much less an adequate grasp of it, one that would enable us to right the plane before it is too late? Can we ever again be first of all healers?