Commentary

The Prostitution of Medical Care

George E. Shambaugh, Jr., MD

Prostitution, "the oldest profession," is the sale for money of what, between lovers, may be life's most precious experience. As a result, this "oldest profession" is held in the lowest esteem.

The medical profession is perhaps the next oldest profession, one that since antiquity has been linked with religion, because the treating physician, with his special knowledge, often can accomplish a "miracle" for a person close to death from injury or infection. There is a famous painting of a bearded, kindly physician sitting by the bedside of a desperately ill child in the days before antibiotics, when TLC (tender loving care) by the doctor and the family was the most important treatment for scarlet fever, diptheria, typhoid fever, pneumonia, and other potentially fatal infections.

I began the practice of medicine in 1932 before the first antibiotic became available. The family doctor in those days was held in the very highest respect and regard, equal to that of the priest or minister. Young men and women were motivated to enter the medical profession because of the love and admiration accorded to the family doctor who, in his one-horse shay, made house calls in the middle of the night in the stormiest weather. In those days, the doctors were paid directly by the patient or his family, with no insurance company, HMO, or government employee of Medicare or Medicaid making the rules and paying the doctor. In those days, doctors took care of the sick whether rich, ordinary, or poor. It was accepted that doctors charged more for the wealthy than for the average person, and that poor people were given exactly the same quality of care at no charge. The love and regard for the physician and the gratitude of the patient were the greatest rewards to doctors for their long and irregular hours.

The first crack in this high regard for physicians began with the decree by the Federal Trade Commission (FTC) that doctoring is a business and that doctors should advertise like any other business. This had been strictly opposed by the medical profession, which believed that the excellence of a physician's services should, by word of mouth, bring him his patients, rather than commercial advertisements that the least scrupulous or least skillful doctor could use to attract patients. For the most part, physicians have abided by their traditional ethics. Advertising in newspapers, billboards, or on TV is not generally approved by the profession.

However, the break in the dike has occurred, and commercial advertisements by qualified physicians are gradually increasing. With this, the same impulse to become wealthy that governs businessmen has begun to infect young doctors. The financial aspect of medicine, once of secondary interest to doctors, has increased with the enormous increase in the cost of a medical education. The young doctor, after high school and four years of college needs another four years of medical school, and now a minimum of three or four years of post-graduate training, sometimes as many as seven years before he/she is finally Board Certified and ready to begin to pay back the more than $100,000 he had to borrow to cover the cost of his education. The size of a doctor's income has become a greater attraction for some, perhaps many, who now enter a medical career.

The enactment by Congress of the Medicare and Medicaid laws, done with the praiseworthy desire to help poor and nearly-poor people needing medical care, has resulted in a totally unanticipated increase in costs, far greater than the gradual increase in the cost of living. The reason is quite clear: When something is free, there is every incentive to use it excessively. Think what would happen if food were declared a "necessary entitlement," for which the government would pay. After all, everyone must eat. Is it not a necessity? Who then would order hamburger when he could order the most expensive and tender steak? Who would be careful not to waste food when everything is free? One's favorite dog would be fed steak instead of dog food. People would become more careless with ordering more and better food than they needed and would freely purchase the most expensive and imported rare foods, why not?

Now we have so-called managed care. Managed by the CEO at the top of the HMO, who utilizes a gatekeeper, a young family practitioner whose job it is to deny tests, treatment, hospitalization, X-ray, and surgery as often as he can without killing the patient. This gatekeeper is rewarded at the end of each year with a generous bonus, which is in exact proportion to how much he has saved by denial. A gatekeeper who does not deny enough is promptly fired and a new one is employed who is more compliant with the wishes of the CEO. A doctor working for an HMO who complains loses his job.

HMOs do not like their finances to be known any more than other businesses operated for profit. Occasionally, however, an employee of an HMO is able to find out the figures. A recent article on HMOs written by a physician who belonged to one was published in The New England Journal of Medicine. He was promptly fired the very next day. The article showed that only 75 percent paid to the HMO ends in medical care, while 25 percent goes for advertising and profit. Thus, of the saving in cost achieved by rationing medical care, one-fourth of it goes to advertising and profits, not medical care.

Meanwhile the doctor, once the most honored and admired member of the community, is repeatedly frustrated by denials of what he decides is best for his patients, while the patients are frustrated by denials by the gatekeeper, who takes orders from a CEO who has little knowledge about health, and cares less.

Frustration with medical care which is increasingly reduced to a pill for every ill rather than having the physician take the time to find out the cause and correct it, has led more and more people to seek out what are called "alternative" health practitioners. These practitioners usually are not paid by Medicare, Medicaid, insurance companies or HMOs and must be paid directly, just as when I first started in practice. These practitioners include some MDs and DOs who refuse to join physicians, herbalists, and others.

Except for these alternative practitioners who, I believe, are doing quite a good job, the quality of medical care is deteriorating. Innovation, so very necessary for advancing the success of medical treatments, is stifled --- if not completely blocked --- by the businessman whose aim always is profit. And when medical care is governed only by the profit motive, it has become prostituted.

 

Dr. Shambaugh is the former Chief of Otolaryngology at Northwestern University and a former editor of the Archives of Otolaryngology. A version of this commentary was published in the February 1998 issue of ENT Journal.

Originally published in the Medical Sentinel 1999;4(2):62, 64. Copyright©1999 Association of American Physicians and Surgeons (AAPS)