From the President...

Liberty ---The Key To Our Professional Future

James P. Weaver, MD


It began as a simple question from the current surgical resident on my service this rotation, "Do you think I should keep going in this residency?" It was not that he was tired of the work load; residents have always worked long hours and gotten few financial rewards. It was not that he was losing interest in his medical education; if anything, medical education is now more fascinating than it was when I went through it over 20 years ago. What he was concerned about without even knowing it, was the deterioration of the working conditions and the loss of liberty of physicians in this country.

Interestingly enough, one of his fellow residents was talking with me during a surgical case earlier that same week. He had told me of his brother who left a surgical residency in his second year and was now an investment banker in Boston. "He's very happy. He works long hours, but he's happy he made the switch."

I realize times have changed. When I was a resident in the early 1970s, there was no question I was doing the right thing and that my future held great potential. In those days, medicine was a promising field to enter; it was a field with a future. I loved science and wanted to do something for people. It was that simple. Granted, there was little concern about the cost of medical care, but, on the other hand, there was an environment that nurtured the independent professional mind, fostered true caring for the patient, and most of all, engendered hope in the students for their future careers. Today's physicians are not only disillusioned with the present but also rightfully discouraged about what they believe lies ahead.

If there is any real benefit in becoming one of the "older" doctors, it's having the knowledge I don't have much longer to tolerate the changes that have occurred in medicine in the past 15 years: I can retire in a few years. It's the younger doctors, the ones who are beginning to question their nascent "calling" that concerns me. I worry, not only about their future, but about the future of medical care itself.

Today's medical environment has become a "justify everything" practice. This is taking the "art," and with it, the professionalism out of medicine. Nudging a patient through a complicated illness is not something that can always be put into a specific outline, but that is what the current payers demand. I sometimes wonder if they demand it so that they can justify their "cut" of the medical pie. After all, if managing something as complicated as illness --- I had eight years of formal training after my M.D. degree --- is done from a distance, without the laying on of hands, a "cookbook" is necessary.

And then there's malpractice. These younger residents have watched the agony of practicing physicians as they go through a legal process that attempts to disparage and discredit the physician and threaten him with financial ruin, even after years of devoted service to patients. Today's settlements can run far beyond what any malpractice insurance will cover.

And finally there is simply liberty. Liberty is missing for physicians. It has been taken from us by our government. Fear of "antitrust" litigation prohibits us from discussing, among ourselves, a professional strategy for dealing with the common threat of third party payment. In addition, in an effort to fulfill its political promises to the elderly, our government has taken any sense of freedom away from practicing physicians. The "value" of a physician's services is now determined arbitrarily by a formula created by a government that is simply looking for ways to cut expenditures. Their formula --- the resource based relative value scale --- has been unilaterally manipulated while promises have been broken, and payment rates have gradually been reduced, from a surgeon's perspective, to a level that is well below what a market would easily support. This imposed and arbitrary reimbursement system has demoralized physicians. The value of one's services in a market, a fundamental premise of all elements of our "supposed" capitalistic system, has been torn from one of our most precious social institutions: the practice of medicine.

I believe physicians have an obligation to society to care for the poor and to always provide competent care to their patients. I would add, however, that society, likewise, has an obligation to physicians that has been neglected: to create and foster an environment that nurtures professionalism. Physicians deserve the same rights as others in society, and just because they possess skills that society needs, it is unconscionable that physicians should be enslaved, as they surely have been, by Medicare and other third-party payers.

There is a difference between public service and public enslavement. I believe the Medicare system has crossed the line into "enslavement" and physicians and their profession can not thrive in this suppressive environment. Society seems to have forgotten liberty must be present for professionalism to prosper. Have we forgotten "with liberty and justice for all?"

Why have so many physicians left the practice of medicine? And why are residents questioning their future in medicine? Even more important, where will future physicians come from, and what will they be like? If AAPS has any mission, it is to protect and preserve the profession of medicine, not for medicine's sake, but for society's. The work we are about, carrying the torch of "liberty in medicine," must continue with even greater vigor. God bless you all, and let us keep up the struggle.

Dr. Weaver is a thoracic surgeon in Durham, North Carolina, and president of the AAPS. E-mail: jpweaver@acpub.duke.edu.