Not big on rules

Ex­pe­ri­enced physi­cians turned off by in­tru­sive in­ter­ven­tion

Modern Healthcare - - OPINIONS / EDITORIALS -

One of my wife’s un­cles is a prom­i­nent in­ternist in Chicago. He is get­ting near the end of his ca­reer, but he still plans to work for sev­eral more years. He is, how­ever, scal­ing back his prac­tice and see­ing fewer pa­tients un­der fewer cir­cum­stances, in­clud­ing not ac­cept­ing Medi­care. He and I were talk­ing the other day at a fam­ily event, and while he ex­pressed hav­ing re­ceived tremen­dous sat­is­fac­tion from his work as a physi­cian, he is back­ing off be­cause, he told me bluntly, “Too many peo­ple who aren’t doc­tors are telling me what to do.”

Soon af­ter this con­ver­sa­tion, I re­ceived an e-mail with an at­tach­ment from my fa­ther. The at­tach­ment was a 42-page doc­u­ment ti­tled, “Post Mod­ern Bio­med­i­cal Ethics.” It was an es­say writ­ten by my fa­ther, a re­tir­ing gen­eral sur­geon, and while it was much longer than my wife’s un­cle’s re­marks, the sen­ti­ments were sim­i­lar.

My fa­ther, who had a suc­cess­ful pri­vate prac­tice af­ter serv­ing for years as a sur­geon in the Navy and work­ing as a pro­fes­sor of surgery and bio­med­i­cal ethics, penned the work and is sub­mit­ting it to med­i­cal jour­nals in the hopes that what he has learned over his ca­reer can in­flu­ence those who are wield­ing the real in­flu­ence to­day—the peo­ple set­ting up the rules, reg­u­la­tions and guide­lines fu­ture physi­cians must prac­tice by.

Like many sur­geons, my fa­ther is not big on rules. He sees surgery be­ing as much a dance as a science, and, a lot like my wife’s un­cle, does not ap­pre­ci­ate when non-physi­cian bu­reau­crats weigh in on what he does with­out hav­ing the proper con­text.

In his pa­per, my dad points out an in­ter­est­ing fact about the pub­lic’s view of a phrase that many peo­ple see as cen­tral to the med­i­cal pro­fes­sion—“Pri­mum non no­cere,” or “First, do no harm.” My fa­ther writes that the phrase is “an­other sim­u­lacra of virtue that fits the ‘man­age- ment by ob­jec­tive’ stan­dards of con­tem­po­rary pro­duc­tion. It is eas­ier for bu­reau­cratic ex­perts to cor­rect de­vi­a­tions from stan­dard op­er­at­ing pro­ce­dures than to pro­mote ex­cel­lence, such as the cor­rec­tion and preven­tion of med­i­cal er­rors.

“Pri­mum non no­cere is not in the Hip­po­cratic oath, it’s not even Greek, it’s Latin. The ‘doc­trine of in­formed con­sent’ does not work, and can­not work. I don’t mean that physi­cians should not dis­cuss their ac­tions with their pa­tients, but pa­tients can­not syn­the­size co­gently the facts of the pro­posed pro­ce­dure, pro­duc­ing a true in­formed sta­tus where he can ac­tu­ally de­cide for him­self. …”

Or, in other words, “Too many peo­ple who aren’t doc­tors are telling me what to do.”

There are cer­tainly co­gent, and data-rich, ar­gu­ments that could be used to re­fute what my fa­ther be­lieves about in­formed con­sent. There are also a lot of sur­geons who would strongly back up what he says. That be­ing said, I think his real point is more about the ero­sion of the doc­tor’s abil­ity to de­velop and use his or her own per­sonal wis­dom and ex­pe­ri­ence in the wake of an ever-ex­pand­ing ar­ray of rules, reg­u­la­tions and guide­lines be­ing de­vel­oped to di­rect what doc­tors do. In the end, I think what we are see­ing is a real shift in the kind of peo­ple who will be go­ing into medicine. My dad says that the reg­u­la­tory na­ture of his pro­fes­sion is such that if he were a young per­son to­day, he might choose a dif­fer­ent line of work.

That scares me. I cer­tainly think there is more room for doc­tor­pa­tient col­lab­o­ra­tion and in­tel­li­gent over­sight when it comes to what doc­tors do. But when I con­sis­tently hear from ex­pe­ri­enced physi­cians near­ing the end of their ca­reers that they have had it with in­tru­sive in­ter­ven­tions into how they op­er­ate, that’s a bright red flag.

JOHN D. THOMAS Chief of Edi­to­rial


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