“Doctors are crooks.”
“They’re getting worse than lawyers.”
“I don’t go anymore. They’re just out for a buck, and they don’t really do anything for you anyway.”
“I stopped getting checkups when my old one retired. He was good, took his time. I haven’t found anyone like him since.”
“They always think they know everything … a bit too much self-importance there, without ever walking in my shoes.”
“They all say the same thing; it’s all ‘canned’ advice, and some of them don’t even realize that.”
“I just pick any name off my insurance company’s website. It really makes no difference.”
“Every time I go to the doctor, I get four or five bills or statements. Some say ‘do not pay’, and some say ‘pay this amount’. I ask my doctor, and he says he doesn’t know anything about that side of it, even though the bills have his name on them. I don’t understand why I can’t just get one bill. Are they purposely trying to confuse me, hoping I pay all of them by mistake?”
I’ve heard all of these comments in the last several months. Some of these statements were uttered bitterly by patients, some were shared in confidence by friends and family, and some came from random, mildly inebriated guests at a cocktail party I recently attended. The emotions, the frustration and misconceptions voiced, are themselves not new. And, honestly, they are occasionally well deserved. But I can’t help but feel the prevalence of these sentiments is increasing.
After one too many drinks at the aforementioned gathering, my head spinning a bit from both the alcohol and the mind-numbing small talk, I came to a conclusion. Physicians, particularly primary care physicians, are now bearing the consequences of so many misguided decisions, so many inane policies, so much discordant marketing and misinformation, that the profession’s image is taking an unprecedented beating. I know what you’re thinking — “So what else is new, Einstein? After all, this isn’t some brand new phenomenon, some new, unexpected development.” I thought the same thing.
But then I looked around the room, well-dressed guests toting drinks to and fro as they passed judgment on the many quacks and charlatans they or their family members had encountered in their lives. And it struck me that this is, in fact, new. There’s something happening to the profession, something insidious, something that’s spreading more quickly than one might assume. Namely, physicians are no longer in a position to control their own image. The way patients, our fellow citizens, feel about the profession is mostly governed by forces beyond your control. And with regard to pervasiveness and extent, it is indeed a new phenomenon.
Consider this. A tiny, almost insignificant portion of your patients’ impression of you, of physicians in general, is based on the few minutes you spend with them in your office or examination room. The rest of their impression, aside from some time in your waiting room or on your website if you have one, is formed by a diverse collection of forces that lies outside your sphere of influence. And, with the combination of more insured patients and decreasing reimbursement exerting its paradoxical influence, the time allowed for direct contact with your “customers” is decreasing rapidly.
They spend ten minutes with you, but they spend hours interacting with all of the other components that collectively comprise the current healthcare behemoth. They spend much more time watching pharmaceutical industry and malpractice attorney television commercials, arguing with their health insurance companies, waiting in line at the pharmacy, surfing medical websites of varying credibility, listening to the advice of celebrity physicians, formulating an opinion on the Affordable Care Act based on the musings of cable television pundits, empathizing with friends and family members wronged by the system. Their friends tell them they also had the flu, but their doctor is amazing, and the antibiotics he gave them patched them right up. And they often hear much worse from sources offering the illusion of legitimacy.
In most industries, a tightly controlled marketing message is critical to an enterprise’s success. The tighter the control over that message, the fewer the parties allowed to disrupt it, the easier it is to create a clear, compelling value proposition in a customer’s mind. But as physicians, particularly in today’s environment, your personality, your training and expertise, represent only a fraction of society’s collective opinion of the profession. Your message is, in fact, primarily controlled by external forces and is increasingly drowned out by industry “noise.” Your image is bad and only getting worse; it is increasingly undifferentiated, bland, and unremarkable. The profession simply does not receive or, in fairness, deserve the respect it once did.
Why? The simple answer it that healthcare is like no other industry. Nowhere else in our economy can one find another example of such great and growing separation between a “business” and its “customers.” In no other industry are there so many parties tangibly disrupting the relationship between a profession and those that seek its guidance. And we simply haven’t done enough to adjust. We haven’t allowed the profession to evolve fast enough to meet the demands of our time. We’ve allowed the government, the insurance and biopharmaceutical industries, contract research organizations, pharmacy benefit managers, hospital and health system administrators, and all of the other players in this industry to fundamentally change the profession’s image.
You provide patients a service, but they aren’t the ones that pay you. You are paid by insurance companies or other payors to whom you don’t provide a direct service, yet they have tremendous influence on what you are allowed to do for patients. Those companies, however, do not have the same fiduciary responsibility to your patients that you do. You are frequently visited by pharmaceutical sales representatives who are eager to sell you things you don’t purchase. (Interestingly, the biopharmaceutical industry does obsessively control both its message to you and the message it presents to the public, and the two are often quite contradictory.)
You increasingly prescribe and treat according to algorithms that, in most cases, you had no part in developing. And, in truth, other than a trusting glance at the “unbiased literature,” you often really can’t be sure one drug or therapeutic approach is better than the next. (Assuming that a brief analysis of a study’s results and known conflicts of interest is sufficient to untangle the intentionally complex and perplexing relationships yielding the vast majority of medical research today is simply intellectually dishonest.)
You frequently order tests, prescribe drugs, and recommend consults, but you have little control over your patients’ experience while procuring those products or services. You enforce policies that aren’t yours and operate within a system you have little say in designing or managing. You, necessarily, offer therapies patients often can’t afford. Your therapeutic decisions, which are increasingly tied to the skillfully packaged information in professional journals and databases providing only the illusion of scientific rigor, are scripted and predetermined. You are increasingly providing a commodified service that lacks a unique signature and which more mid-level practitioners are being allowed to provide. And being paid by third parties has conditioned your true “customers” to believe your services are worth little more than a twenty-dollar copayment.
Moreover, patients regularly receive multiple bills or statements in the mail, most with your name plastered all over them simply because you are the PCP or PMD of record, which reinforce the image of the “greedy, uncaring physician,” even though none of that money ends up in your pocket. “Hey, she ordered this stuff; we didn’t do it, but pay us.” Virtually every player in this crowded field uses our profession to lend credibility to their own endeavors, yet we bear the responsibility solely and silently, often having no real opportunity to dissent.
It is truly a bizarre industry composed of disparate, nonsensical policies and ludicrous interrelationships. When patients are confused or angry or hurt, you’re the scapegoat. And all of the other parties involved in healthcare, while they publicly empathize and call for change, love it. And you can’t blame them; they’re in business to make money, and they know image is crucial. If someone else is willing to take the heat, why not go with the flow?
So why am I so concerned about what patients think? Why should we care about the profession’s image? Am I saying physicians need to emulate celebrities and politicians, scrambling to hire image consultants and public relations specialists to help them develop and protect their brand? Do doctors need to be liked? After all, physicians aren’t in the “image business;” they’re in the “helping patients business.” Why should image be of any concern? Well, the answer is it’s not just about image. The perception problem is just a symptom of the disease, an easily observable one. The declining image may be little more than a metaphor, but it is a powerful one that allows us to recognize and visualize a trend – the medical profession, as we know it, is in decline; its relevance is dwindling rapidly.
The point of all this is that the distance between you and your patients has grown in the last twenty years, it continues to grow, and the rate at which that chasm is widening appears to be increasing. The ability for patients to see real value, truly differentiated, unique value, in your services is quickly diminishing. Your services are now mundane, common. You are not physicians; you are “providers”. You are not providing an invaluable service; you are providing something that others can provide equally well at a lower price. You are selling things that can be found lying around on the web or being sold on street corners.
A patient can get both advice and the flu shot from pharmacists; psychologists can now prescribe drugs in some states and more states are jumping on board. Prescription pads and the ability to legally give medical advice are being handed out at an unprecedented rate. Despite once being the central, indispensable figure in the delivery of healthcare, physician compensation represents significantly less than 10% of all healthcare expenditures in this country. Physician influence on healthcare policy, physician ownership and control of the business of medicine, are likely even more negligible in scope. And this was all made possible by one of the most successful marketing ploys ever attempted in this country — the introduction of the word “provider” by the insurance industry.
“Physician” is a unique term with real meaning; “provider” is a word without meaning, a term without history or consequence. Its introduction sought to change the psychology of healthcare, to reorganize the system, to establish a new, conveniently flatter hierarchy, and it was an astounding success. Similarly, “primary care” is a hollow phrase also imposed on the profession. “Family doctor” was a specific term, a warm one that unambiguously conveyed information about level of training, specific role, and accountability. “Primary care,” when coupled with “provider,” sought to completely eradicate that clarity and replace it with vague insinuation, professional anonymity, and an overwhelming sense of transience, a sense of “anyone can do this.”
The next ploy, the current iteration of this brilliant approach intended to reorganize the system, is to drive a wedge between you and your patients, to reach beyond the psychological and into the practical, using every legal administrative hurdle, internet connection, traditional media outlet, government agency, pharmacy, and supermarket to accomplish the task. Hey, maybe Starbucks is next – one free digital rectal exam from a trained barista with the purchase of your next latte.
Using virtually any other industry as a model, the ideal situation would be one where you see patients, and then those patients reach into their pockets and pay you, acutely aware of the value of the service just delivered. You would control as much of a patient’s experience as possible while under your care. You would have the ability to apply at least a modicum of creativity and independence, breaking free of nonsensical, biased algorithms without the fear of malpractice lawsuits. You would not be required to repeatedly pay organizations to “prove” your knowledge by passing tests with little relevance in the real clinical world. You would not be consistently forced to undergo additional training, while others are given more freedom to operate independently in the same fields with significantly less training and accountability.
No document with your name on it would find its way into a patient’s hands if it did not originate from your office. You would have legal recourse to swiftly claim fees left unpaid for failing to comply with arbitrary administrative exercises that play no role in improving patient outcomes. And you would not be forced to complete tomes of useless administrative paperwork in the first place or would, at least, be compensated for doing so. You’d possibly even have some control over what you and your specialty are called. However, none of this legitimately earned courtesy, none of this professional respect, none of this deference for your expertise currently exists.
Instead of a clear, unified message, misinformation and poor policy continue to flood the system. Patients still believe that most physicians are “rich.” Many see physicians as “greedy,” as profiting from human suffering. Many don’t even know what type of training their “provider” has, often assuming that anyone with a white coat can do the same thing, leading to the belief that there is very little room for physician autonomy in developing a unique, well-differentiated service or novel therapeutic approach.
And perhaps rightly so, since breaking free of the almighty algorithm, actually applying any of the knowledge and training in biochemistry, pharmacology, physiology, anatomy, and many other disciplines that physicians possess, is discouraged by the system in the name of a uniform, “evidence-based” approach, no matter how unscientific and biased. If you read the comments following any online articles about the profession, you will quickly find these assertions about the public’s increasingly negative opinion of physicians are accurate.
But the profession hasn’t done enough to reassert its independence and relevance in the modern marketplace. Reimbursement is declining, but medical school tuition is increasing at an unprecedented pace. Residency training, fellowship training, and board certification are all becoming either more difficult to complete, longer, or more expensive, and medical hyperspecialization is touted as necessary, an inevitable trend given the increasing complexity and pace of scientific discovery. Yet others with significantly less medical training are being allowed to do more to meet the growing demand for healthcare services.
Every new strategy is rife with contradiction; every trend diminishes the profession, limits it, and, frankly, puts patients at risk. Each new policy, whether initiated by the government or private insurance companies, every new pharmaceutical company commercial goading patients to seek the latest, equally ineffective, hot drug from you, every new guideline governing professional development or certification, every duplicitous, ineffective attempt at increasing access, only serves to add more complexity to an already tenuous relationship, to create more distance between a physician and his or her patients. Even social media and other emerging technologies, technologies that should hold great potential for the profession, are being used much more effectively by other players to further their own agendas.
I felt compelled to write this piece simply to point out that the way the system is organized and the direction in which it is headed are increasingly breeding what I refer to as a culture of contempt, contempt for the medical profession. Most of what patients find distasteful and unjust about their healthcare experiences is not your fault, yet patients attribute it to you. You bear the brunt of their frustration, despite being increasingly stripped of the ability to control your own practice, to truly be independent, to even compete in an industry you created. And every attempt at correcting the problem only seems to make it worse. Is it a conspiracy? Is it an attempt to completely eradicate the profession? I don’t think there is some master plan to accomplish that, but competing interests and ill-conceived policies are effectively accomplishing the same unfortunate result.
This culture of contempt is spreading, growing in intensity, and the results will be catastrophic. Our current direction won’t just lead to patients not liking or trusting us; it will lead to patients viewing us as insignificant and irrelevant. More importantly, while greater access to care, public health education, and the dissemination of medical information are necessary and beneficial in the right context, the propagation of the message that sound medical advice is a cheap commodity that may be procured anywhere, from the internet to the local pharmacy to the grocery store on the corner, is dangerous.
I understand these opinions may not be popular or politically correct. But the system, in my opinion, is so broken, so dysfunctional, that nothing short of completely restructuring it will do. And this article is intentionally unfocused, little more than a collection of loosely cohesive observations, to reflect precisely the lack of focus and cohesion present in our approach to medical education, professional regulation, and overall healthcare policy. My next piece in this series, however, will outline five strategies the medical profession mustimplement if it would like to remain relevant in a system that has repeatedly shown contempt for it, if it wants to survive.
For now, though, I hope you understand I am not trying to be overly dramatic or alarmist in my characterizations. And perhaps I only see this trend so clearly because I spent eleven years working in other, more traditionally operating industries before joining the profession. But the truth is that without major change I will be writing an article in a few years entitled, “How Physicians Became Clerks – The Downfall of a Once Great and Noble Profession.” Honestly, I could start writing that article today.
Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.
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