The Politics of Medicine

Part of growing up in the fifties and heading off to college in the middle of the sixties was figuring out what to do with the rest of your life, always a tussle between what you wanted to do – play jazz in a smoky basement club in the Village, or alternatively, head out to LA and be a session player backing up the Beach Boys – and what would make the family proud and make your mother weep tears of joy – become a doctor. Sure there were cool doctors on television – Kildare and Marcus Welby and later Ben Casey and Bill Cosby’s Heathcliff (Cliff) Huxtable – all fine fellows. They were kind and helped people and cured what ailed them – but that wasn’t the point. It was the prestige. Doctors were the most respected people in America. They not only cured the sick, they knew the answer to everything about anything. You could ask them about politics or auto repair or growing orchids or the fifth race at Belmont and they’d know the answer. No one argues with a doctor. Their answer on anything would stop all ongoing conversation – there was nothing more to say. And they were rich. No one ever begrudged them the big bucks. And any mother could stop rivals cold with one simple quiet statement – My son is a doctor, by the way. The other mothers would step back in awe. She may have lost that Bridge hand that day – back then suburban moms with big hair did have Bridge parties – but that was the ultimate trump card.

So of course a lot of us headed off to college and declared our major the day we arrived – Pre Med. One was supposed to become a doctor if one possibly could. But then the sixties happened and most of us got sidetracked by the revolution, such as it was. No one wanted to be what they were supposed to be. We had the counterculture – and the long hair and beads and whatnot. That was our new life and we weren’t going to play by anyone else’s rules any longer. So those of us who still liked the idea of being kind and helping people, and fixing the world, ended up in teaching. That’s doing the same sort of things that doctors do, generally, but with no prestige in the slightest and pay far lower than even the guys who drove the city garbage trucks. And no matter what you said no one ever listened to you – not even your students. That sort of thing also can make a mother cry, but not tears of joy. But it happened a lot, all across America.

Only a few became doctors, and what went along with being a doctor – becoming a rock-ribbed Republican who wants the government out of everything, as they weren’t in the doctoring business for their health, or for yours. They were above all pure capitalists. They were in it for the good money, and for everyone else always being in total awe of them. That’s heady stuff – ask Rush Limbaugh or Roger Ailes or Glenn Beck. In fact, that’s what you hear on the new conservative right all the time – Be in awe of me, as you should be, damn it! If Sarah Palin runs this time that will certainly be her message, or her campaign slogan. And none of these folks even had to go to medical school.

But if you believe the New York Times, it seems times are changing, with an apparent shift in politics among physicians:

Doctors were once overwhelmingly male and usually owned their own practices. They generally favored lower taxes and regularly fought lawyers to restrict patient lawsuits. Ronald Reagan came to national political prominence in part by railing against “socialized medicine” on doctors’ behalf.

But doctors are changing. They are abandoning their own practices and taking salaried jobs in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states.

Alex Pareene comments here:

The entire piece offers a fascinating look at a sea change in medicine, and the implications for the politics of healthcare reform are obvious: briefly put, doctors are now more likely to support reform along the lines of the Affordable Care Act than oppose it.

But he says the deeper story only becomes apparent when you combine that item with the Atul Gawande May 26 commencement address to Harvard’s medical school graduating class, Cowboys and Pit Crews, all about doctors who own their own practices – the “cowboys” who are just no longer effective delivers of state-of-the-art medical care:

We are at a cusp point in medical generations. The doctors of former generations lament what medicine has become. If they could start over, the surveys tell us, they wouldn’t choose the profession today. They recall a simpler past without insurance-company hassles, government regulations, malpractice litigation, not to mention nurses and doctors bearing tattoos and talking of wanting “balance” in their lives. These are not the cause of their unease, however. They are symptoms of a deeper condition – which is the reality that medicine’s complexity has exceeded our individual capabilities as doctors. …

But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine.

That is why there is the staff-model now, and Pareene adds this:

For years, Gawande has been the most articulate and convincing proponent of the argument that one of the most promising avenues for reducing the rise in healthcare costs is through the pursuit of team-based approaches to care. Not only is medicine now too complex for any single doctor to master, but hospitals also end up delivering better results – healthier patients – for less cost when they put into place effective team-based care. We need pit crews working together, says Gawande, instead of cowboys roaming the range on their lonesome.

And it seems that is happening:

The New York Times article closes with a grumpy quote from a conservative doctor: “People who are conservative by nature are not going to go into the profession,” he said, “because medicine is not about running your own shop anymore.”

Viewed purely in terms of politics, you can choose to be elated or dismayed by this shift. But if what you truly prize is fixing healthcare so it works, you should be delighted. “Running your own shop” just isn’t an effective organizational strategy for dealing with the complexity of modern medicine. We need a more collective approach.

Collective – maybe he should not have used that word. But when this site went silent in late April – that week spent in the giant Kaiser hospital down the street at the other end of Hollywood – that team model worked just fine. There was no awesome god-like doctor who swooped in and fixed everything – there was a team all subdivided with specific duties and responsibilities, actually having a good time working together, coordinated in a loose hierarchy under a chief internist who kept deferring to the team, making sure she heard what they thought. It was cool. And it kind of felt like the sixties – it was a cooperative of sorts. And no one seemed to be a Republican, although that could be possible. But as no one was snorting and demanding awe from the others, it wasn’t likely. There are telltale signs, you see.

Yes, it seems that doctors have moved from business owners to shift workers – improving healthcare, doing good, having a good time, and disappointing their mothers, of course. And the politics change when that happens, as Aaron Carroll notes:

When I was a fellow, back at the turn of the century, a colleague and I conducted a national survey of physicians to determine their level of support for national health insurance. At the time, I was sure physicians would oppose it en masse. Surprisingly, they did not – at least not to the levels that I had thought they might. In 2007, we repeated the survey to see whether opinions had changed. I grant you that this is not a pure tracking survey of doctor’s political leanings, but it does provide some insight on how physicians’ leanings on this one issue changed…

Remember this was support for federal legislation to establish National Health Insurance. That’s far more radical than the PPACA. And 59 percent of physicians supported it. That was an increase of 10 percent from what we found five years earlier, and it was statistically significant. More than half the respondents from every medical specialty supported it, with the exception of surgical subspecialties, anesthesiologists and radiologists. That means support included a majority of general surgeons, medical subspecialists and obstetricians/gynecologists.

Most significantly, in pretty much every specialty we measured in both years, support went up from 2002 to 2007.

This is bad news for Republicans, and Carroll notes, a potential problem for the American Medical Association:

An unpublished part of our analysis showed that members of the AMA were significantly less likely to support national health insurance than were non-members. Moreover, AMA members were not like other physicians; they were more likely to be older, male and surgical subspecialists.

There were the pure capitalists, or the dinosaurs:

While still regarded as the “voice of physicians,” less than 30 percent of physicians are actually AMA members. … The AMA has, unfortunately, been slow to react to changes before. For instance, in 1921, Congress sought to provide funding to reduce maternal and infant mortality through The Sheppard-Towner Act. The AMA fiercely opposed this piece of legislation. In defiance to what many saw as an organization that was not promoting the welfare of children, a group of motivated pediatricians separated from the pack and formed a new group, the American Academy of Pediatrics. Today the AMA is, of course, a strong supporter of efforts to reduce maternal and infant mortality. Perhaps if they had adapted faster, pediatricians would still play a larger part in the AMA.

We’ll never know for sure, but I think it’s possible that the about-face that the AMA made in support of the PPACA, after strenuously opposing health-care reform in the past, was due to recognition of the changing positions of physicians. I remember hearing many anecdotes of doctors vigorously opposed to the law, but a large survey conducted in 2009 showed that physicians, as a group, supported progressive elements of health-care reform that were eventually dropped.

Yes, they were fine with single-payer and letting people buy into Medicare at fifty-five, or just getting everyone possible into it now. Who knew? This isn’t like the old days.

And also in the New York Times, Robert Pear reports that hospitals are really, really unhappy over new federal regulations that pay them based on the cost of care they provide to Medicare patients when compared to other hospitals:

For the first time in its history, Medicare will soon track spending on millions of individual beneficiaries, reward hospitals that hold down costs and penalize those whose patients prove most expensive… Hospitals could be held accountable not only for the cost of the care they provide, but also for the cost of services performed by doctors and other health care providers in the 90 days after a Medicare patient leaves the hospital. …

Under the new health law, Medicare will reduce payments to hospitals if too many patients are readmitted after treatment for heart attacks, heart failure or pneumonia. In addition, Medicare will cut payments to hospitals if they do not replace paper files with electronic health records, and it will further reduce payments to hospitals with high rates of preventable errors, injuries and infections.

Ah, as with doctors so with hospitals – no automatic awe. No one argues with a doctor or a hospital? Their answer on anything stops all ongoing conversation – there is nothing more to say? Nope, those days are over.

And Kevin Drum ties both items together:

To a large extent, the interests of hospitals and physicians are not only diverging, but becoming actively opposed. In the past, physicians probably would have been as opposed to these new Medicare regulations as hospital administrators, but I’ll bet that’s largely not the case anymore.

Well, yes – doctors are not business owners any longer, just moderately happy highly-paid shift workers. And Drum explains it this way:

As an analogy, this strikes me as having mirror-image similarities to No Child Left Behind, another piece of legislation designed to force efficiency on a particular sector of the economy. At first, parents were largely in favor of NCLB while teachers and school administrators were largely opposed. But as time has passed and suburban schools have started to suffer from the law (either because they’re given failing grades or because inner city schools start competing effectively for the best teachers), the ground has shifted: parents and teachers now find themselves frequently in agreement that NCLB has gone further than they like. This provides a growing political coalition to change or water down the law.

In healthcare, it’s the same dynamic in the opposite direction: a political coalition is breaking up. Doctors and patients are starting to align one way, while hospitals and insurance companies are aligning in another way.

And actually you might see this as the end of the Marcus Welby fifties – and the end of all that my-son-the-doctor nonsense – mom will just have to be proud of her son, the underpaid but quite effective teacher. And obviously this is bad news for the Republicans. They can no longer count on having the god-like doctors in their corner, sticking up for the insurance companies and the for-profit hospitals. Drat – no one really wants to play god any longer. It’s just not cool, and it is, actually, bad medicine. Oh well.

Drum goes on to argue that the good news here is that this makes it less likely that healthcare reform will be repealed – there “just isn’t a united political coalition in favor of it.”

How did that happen? Well, the fifties had to end sooner or later.

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About Alan

The editor is a former systems manager for a large California-based HMO, and a former senior systems manager for Northrop, Hughes-Raytheon, Computer Sciences Corporation, Perot Systems and other such organizations. One position was managing the financial and payroll systems for a large hospital chain. And somewhere in there was a two-year stint in Canada running the systems shop at a General Motors locomotive factory - in London, Ontario. That explains Canadian matters scattered through these pages. Otherwise, think large-scale HR, payroll, financial and manufacturing systems. A résumé is available if you wish. The editor has a graduate degree in Eighteenth-Century British Literature from Duke University where he was a National Woodrow Wilson Fellow, and taught English and music in upstate New York in the seventies, and then in the early eighties moved to California and left teaching. The editor currently resides in Hollywood California, a block north of the Sunset Strip.
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2 Responses to The Politics of Medicine

  1. Peter Barus says:

    I admire anybody who is about thinking things through. A few years ago I tried to launch a project based on the idea that physicians should fix the healthcare system themselves. It didn’t get farther than the first five or six docs I spoke with. I found that indeed, they were already thinking of themselves as small cogs in a very big wheel – if not actually owning large amounts of stock in said wheel. Also, as a gearhead entrepreneur in the ’90s I’d written extensively on the plight of programmers in what I called “the Attention Age”, when it became impossible for one person to master programming languages fast enough. This kind of change I called “the bleeding edge” and was cited for inventing the term in a doctoral thesis by a man I’ve never heard of. I have not read all your postings by any means, but would be interested in what you think about the acceleration of innovation. I had this surfing analogy – catch the wave, or watch it move on without you – but then I realized that catching the next one is tricky, since it may not even be in water.

  2. JOYCELYN SWANSON says:

    Coincidentally, way – way back, I worked for the Mpls television station that aired Doctor Ben Casey so, of course, it was my favorite program and I tried never to miss it. There’s a lot of information in the missive here. Only thing I wanted to add is, that several years ago I asked my family doctor, who also was the administrative doctor in the University Community Clinic I went to, what she thought about Universal Health Care. (We weren’t talking about single payer then.) She said she agreed with U.H.C., but added, “but it’ll never happen.” She has since taken a job in a pain clinic at the hospital they’re associated with. Interesting.

    The other thing I’d like to say is that many years ago, Doctors may have been in the medical field because of prestige and the money, but in the small town in MN that I grew up in, I always got the impression that they were happy to be able to help people get well, took their roles seriously and most of all, didn’t gouge people, and even volunteered in the schools. My parents had no health insurance available to them in the pre-60′s, and people weren’t required to have every test and procedure for fear they might not be or stay healthy. I had six other siblings my parents raised. Good or bad, there weren’t that many sick people either. I think, because most families (households) had gardens, ate fresh vegetables, and the meat market was all fresh cut meat, not sprayed and sausages weren’t stuffed with a bunch of junk. Cancers and obesity were rare and people walked around, stayed busy, and all students in school were required to take gym class and part of that was pretty good exercising a couple days a week. Grade school kids went outside to play, didn’t play checkers and computer games inside as much as they do now. Course they didn’t have computers in those days, but plenty games. We stayed healthy. Now, the same size town with not too much more population has more clinics, more doctors, and the hospital has been quite enlarged and expanded. That ought to tell us something about our society and our way of life besides Universal, Single Pay, Insurance and outrageous bills when you didn’t have riches.

    /J. Swanson, Mpls. Activist

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