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The medical–business complex
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We cannot mortgage the material assets of our grandchildren without asking the loss also of their political and spiritual heritage. We want democracy to survive for all generations to come, not to become the insolvent phantom of tomorrow.
— Farewell Address, President Dwight D. Eisenhower, Jan. 17, 1961
Lord, I’m so tired of payin’ all of these dues
Tired of the war and those industrial fools
I’ve got to make it better cause I’ve got nothin’ to lose
Won’t somebody help me cause I’ve gotten in my shoes
Those industrial military complex blues
— The Steve Miller Band, Industrial Military Hex (Steve Miller), 1970
I’ve had it with the acronym FTE.
Conceptually, I understand the usefulness of measures. Professionally, I find FTE (full-time employee) disparaging. I didn’t have such strong feelings in the past. I liked the convenience and, perhaps most of all, the respect its use garnered, along with other linguistic constructions generated by the medical–business complex types that intrude into our professional space. I failed to see it for what it truly is — an integral part of a conspiracy to rob us as individual physicians of professional dignity and independence.
I wouldn’t be upset if the use of FTE was only a shortcut, a reflection of a kind and gentle approach to the realities of change as they apply to American medicine. It is not. Its use is a function of our profession’s abdication to a culture model of business efficiency. The intrusion of business vernacular is a function of our acceptance of a medical leadership model that emphasizes, supports and yields control to those who take the medical leadership course work, speak the language and drink the Kool-Aid of the medical–business complex. Eisenhower was prescient. Medicine is the 21st century equivalent of the mid-20th century military–industrial model, and you can substitute medicine for democracy.
William T. Gerson
In your career, you might choose to work three-quarters time, but you remain a full-time physician. You might split your time between lab and clinical duties, and although the percentages of time spent might be used to define a salary structure, you remain one physician. You might spend 2 days seeing infectious disease consults and 3 days seeing general pediatric patients, but you remain one pediatrician.
New environment of medicine
Successful as hospitals and hospital systems along with medical schools expanded and captured more money and power, the medical–business complex has now altered the relationship of the individual physician to the institutional and professional whole. The new environment of medicine influences those physicians in training to the greatest extent, and the resulting fracturing of the medical profession by age and form of employment is a disturbing trend. As a physician, once we are not whole we lose and we place ourselves at the mercy of those in power to manipulate us as pawns (or portions of pawns “POPS”).
Once conceptualized as less than whole, I am not a physician. I might be a provider, or a clinician, or a health care worker — but I am not a physician. And the change is not accidental, but an intentional attempt to restructure health care with a business and not a doctor–patient relationship focus. In the medical–business model, no longer is medical leadership defined as a position once obtained that works to ensure the success of those being led, but solely as a position to ensure the continued success of the leader as an instrument of success of the institution. Practicing physicians are increasingly separated from their leaders.
Change in how we communicate
I see the splitting of the whole most profoundly in the way we communicate among ourselves. What was once caring for a patient has become an encounter, a clinical pathway or an entry point. A consultation is no longer an opportunity to discuss the patient with the consultant and to learn or advocate, but a process that begins and ends in the electronic medical record without any real direct physician to physician contact. In this new world, if by chance a radiologist wishes to speak to the physician ordering the chest radiograph to inquire about the nature of the patient’s illness or to discuss the results, she is likely to reach a covering physician (experts now on “handoffs”). In this new world, if by chance I want to order an EEG, PFTs or a cardiac ultrasound, I can do it without speaking to a specialist (not to mention without any idea of the cost). In a nod to efficiency, we have less opportunity to talk to one another, to learn from one another, or to train others as colleagues.
We need to resist the medical–business complex, despite its many successes. We need to support each other as professionals. And although professionalism may not be sufficient to effect the needed changes to the American health care system, it is necessary for such a success. Professionalism is not just a virtue. Its place as one of our core competencies is heartening. It places professionalism on the same playing field as medical knowledge and with it the expectation that it can be taught and refined over the years of medical practice. But it needs to be nurtured.
In truth, professional behavior is a product of the organizational and environmental context of practice. And it is these same factors that have recently transformed current practice, and in my view, placed both medicine and professionalism at risk. The organizational and environmental context of American medicine needs to support professionalism — not collude to destroy it. We can begin by talking to each other. We still have exceptional leaders. We need to change the debate and decrease the degrees of separation.
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.