Courage — An Epistle to a Colleague

Stephen R. Katz, MD
Article Type: 
A Physician's Reflections
May/June 1998
Volume Number: 
Issue Number: 

Dear Jeremy,

In your recent letter to me, you asked: “What do we do to protect our residents and residency programs, and ourselves as the teachers?” The answers to this problem are complex. But clearly, we must start with some basic physician behavioral modifications, if we are to secure any protection for medical education in this country at all, to say nothing about protection of our patients’ rights!

The first change to be made is the hardest. We must abandon an attitude that is prevalent in some of our medical leadership organizations and in many individual physicians. I refer to the posture that says, “to get along you go along.” Instead of playing along with the “managed care” scheme, we must expose it for what it is — an economic model and not a medical model. It’s an economic model that can be exceedingly harmful in individual circumstances and devastating to individual patients. Each and every teaching institution, hospital, and individual physician must actively and effectively oppose managed care. We have forgotten, or perhaps, we have chosen to ignore the fact that medicine cannot be practiced without doctors. When a managed care organization (MCO) throws a contract at you, your hospital, or your academic institution, don’t just sign on the dotted line while meekly mumbling, “Otherwise I’ll be left out.” Just say NO! Managed care needs doctors and hospitals, but we don’t necessarily need them! This is still true now, but it may no longer be true in a few years if certain institutions continue to cut “sweetheart deals” with MCOs. Most of these deals have plenty to do with money and little or nothing to do with good medical care. For example, last year Oxford Health Plan convinced Columbia P&S in New York City to let “advanced practice nurses” (APRNs) function as primary care providers, replacing physicians in this role. How did they hook a prestigious institution like Columbia into a deal like this? With money, of course, Columbia’s Faculty Practice will be reimbursed for the APRNs services, at least for now, at the same rate Oxford pays Columbia for doctor visits! Of course, the APRNs are paid less than Columbia’s physicians, so Columbia will pocket the difference! This is one example of the “addicting subsidies” I address later in this letter.

When an MCO offers you a contract, ask them what benefit they would bring to your patients, to you, to your institution and its teaching program, if you let them in. Don’t just sign on the dotted line because you are panicked over the possibility of losing a few dollars! If you don’t let them in, they can’t “manage” medicine in your practice, in your institution, or anywhere else! If you don’t want them in, the MCO is out! Out of your practice, your hospital, and your community — out of your economic web! They need you — not the other way around. Make them pay for the privilege, including the costs of residency training. But be sure that your residency program is adding value to the patients’ care. If it isn’t, you really should dismantle the program. Most importantly, don’t discount yourself for them. Learn this, and practice it faithfully!

Did you notice another of our mistakes that I deliberately let slip by before? We have allowed Newspeak to take over! We are doctors, not “providers.” The title doctor connotes a certain level of knowledge, training, and expertise. These qualities are not replaceable with cheaper, quickly trained, and turned out generic substitutes! And those we care for are patients, not “consumers.” We do not get “used up” by our patients. Our language usage determines the boundaries of the debate. Let’s start using plain English again, and let us eschew the interchangeable euphemisms created by policy wonks in order to change the ground rules and compass of the debate!

Next, physicians must relearn the scientific method. Surely, you haven’t forgotten this method!

A hypothesis is created, controls are put in place, the hypothesis is tested according to the established protocol, and the results noted. The results, if they can be independently duplicated and if they are beneficial, are then followed in future patient care. So-called “evidence-based medicine,” “outcomes-based research,” and several other “new paradigms” that have been recently created are not scientific methodology! They are management plans. Costs of care are carefully prefigured into the predetermined “conclusions.” The conclusions are based upon group cost/benefit analysis, not individual patient benefit. And the conclusions are not scientific conclusions at all. They are financial goals that become retrospectively justified by the “research.” This is goal-based, circular reasoning gibberish.

You must tell your institutions, and especially your specialty societies, that “evidence-based medicine” is not scientific. It is economic gobbledygook. It is an insult and anathema to the past five hundred years of scientific progress. And you must let the wanna-be, big shot “professors” who grind out this “research” in return for handsome government payments (called “grants” so they smell better), know what you think of their “research.” After all, the only people they usually hear from are their equally grant-laden “peer-reviewing” professors and establishment-cooperating editors of “prestigious journals” who release their latest journals’ contents to the lay press prior to publication so that their “hot and sexy findings” are published in newspapers and discussed by the talking heads on the TV set before the physician even receives the journal! These folks have learned “if it’s published in the lay press, it must be true.” Who are we, mere doctors, to argue with their “scientific method.” Well, we had better start telling them!

And then there is the hardest job. We must wean our hospitals and academic institutions from their addiction to government funds. When Aneuryn Bevan was asked how he would get the British Medical Association to not speak out against socialized medicine in 1947, he said: “I will fill their mouths with gold.” We in the U.S. have up to now unfortunately followed our U.K. cousins in this regard — and we are rapidly learning that the “gold” is diminishing in amount from that promised; it is fool’s gold and leaves a very bad aftertaste — particularly with regard to the welfare of our patients and the future of graduate medical education in this country.

President Lyndon Johnson followed Bevan’s principle in 1965 when he declared the existence of a “medical care crisis” due to “too few doctors.” He started feeding money to the medical schools. He knew what the free cash inflow would do, and the schools fell for

it — hook, line, and sinker. When I went to medical school, the Department of Biochemistry listed six faculty members: Four could teach, the fifth was there for show (a Nobel Prize winner — brilliant, personable, but completely incapable of teaching), and the sixth person was someone whose function I never could ascertain. The last time I thumbed through the school’s Bulletin of Information, the Biochemistry faculty ran on for 8 pages! I am reasonably certain the medical student population, only 38 percent larger than when I went to the school, is still being taught biochemistry by a handful of dedicated souls. Many of the other faculty members are there mainly because government money pays for it, it looks impressive in the catalog, and perhaps, one of the listed names will turn out to be a “winner” and bring more prestige to the school. The schools could easily do without this charade. And they could install their own air conditioning and other necessary research equipment at the time they build new research buildings. Instead, they install them in each lab at later dates, paying for them with funds from the individual laboratory’s government research grants! In business, this would be recognized for what it is — gross waste and inefficiency. In business, these sorts of activities would not be tolerated. The schools should recognize effective elimination of these and other wasteful practices as constituting effective downsizing.

The 1983 Budget Reconciliation Act created another example of this sort of waste and dependency on excessive government funding. This measure set up the Diagnostic Related Group (DRG) system for paying hospitals by diagnosis rather than by actual cost reimbursement. Time was of the essence when Congress was writing this bill; funds were limited, and teaching hospitals were some 8 percent short on their budgets in the originally proposed bill. In order to save time and “get the bill done,” Congress created the “teaching hospital indirect reimbursement item” which amounted to 8 percent of the bills projected budget. Even worse, they made

this bonanza dependent upon the number of residents a hospital had, paying the hospitals about an additional $170,000 per year per resident. Within a year, hospital administrators were recruiting abroad for residents because each resident hired was a walking $170,000 check for the hospital. It is another example of addiction to excessive cash flow and clearly needs re-evaluation and downsizing. Residency programs should exist only so long as they increase the quality and value of care received by the patients. And, they should exist only where they can expose the residents to true quality learning situations along with dedicated physician-teachers. The true costs of these programs should be paid for, but anything else is subsidized waste.

We can do all of this. But not if we keep worrying that “the guy down the street will sign up for less and I’ll be left out!” That is a defeatist philosophy. The powers-that-be rely on this attitude and successfully squeeze us every way they can. We must not give in to such tactics! Nor can we allow ourselves to be consigned to despair.

We must see to it that the institutions that purport to represent us — be they general or specialty societies — actually represent the interests of our patients, our teaching programs, and us! Look around — you will notice many of the “old-guard” medical organizations, and many of our specialty colleges, are actively cooperating with every two-bit politician who pretends to give them half an ear. These groups are busily scrambling willy-nilly to cut out a piece of the pie for the perpetuation of their own bureaucracies! They stopped representing their memberships long ago! Their goal has become preserving and enlarging the place in the sun that their paid officers and staff now occupy — even if this occurs at the expense of the membership and of quality graduate medical education. Therefore, if you don’t think your organization(s) represent you, tell them, and get out! Without a constituency they will either change to conform to our desires, or wither on the vine.

Consider joining some of the newer, more activist, principled rather than politically expedient, medical organizations such as the Association of American Physicians and Surgeons (AAPS), to which I belong, or other professional organizations, so long as the group truly and fairly represents your views and you can comfortably abide by their ethical pronouncements. Be sure they are willing to speak out forcefully on unpopular issues. Be certain that they will take principled positions on important issues and not involve themselves with politically popular posturing. And you must be willing to speak up too. Be an active member of the group, and always, make sure your group advances your patients’ interests.

In the final analysis, only by protecting your patients’ needs, constantly improving the quality of the residency training in your institution, and keeping your institution on the cutting edge of true medical progress can the future of the profession and your own future be made secure!


Best wishes,

Dr. Katz is an obstetrician-gynecologist in Fairfield, CT who closed his private practice of 25 years in 1994 because of his ethical discomfort with managed care. He is now a health care consultant and has been nominated as president-elect of his state medical society. His address is 4604 Black Rock Turnpike, Fairfield, CT 06430-7815. (203) 259-6792. E-mail at CHUCHIM_1@PRODIGY.COM 

 Originally published in the Medical Sentinel 1998;3(3):104-105,107. Copyright © 1998 Association of American Physicians and Surgeons (AAPS).





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