College of American Pathologists
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  President’s Desk Column


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The Panacea for our malaise

June 2002
Paul A. Raslavicus, MD

"Professionalism is the essence of the College" were my concluding words in last month’s column. Today we will explore professionalism in medicine and in our own lives.

It all began with Hippocrates, of course. But even before that honorable physician, there was the Greek god Aesculapius and his two daughters, Hygeia and Panacea. Hygeia took care of the welfare of the populace while her sister Panacea was the healer of the individual, truly the first primary care physician. From these two mythical sisters arose the two branches of health care practice: public health and medicine.

The College recognizes in its mission statement the importance of both branches of medicine. It commits the College to the service of Panacea (patients) and Hygeia (public), through representation and service to the profession of pathology.

Panacea, however, for many eons was not a panacea at all. The lack of a scientific approach to disease, the absence of the microscope and the limited understanding of the causes and effects of disease, and the absence of anesthesia and effective pharmaceuticals resulted in extraordinarily ineffective attempts to cure the individual. With the remarkable advances of the last 100 years, the image of the physician changed dramatically. The physician of the modern era became, next to the priest, mullah, or rabbi, the most respected of individuals. The profession aspired to and was admired for its commitment to altruism and a strong professional ethic of caring first and foremost for the patient.

Public health, on the other hand, throughout most of history had many more victories. Concerning itself with controlling the spread of infectious diseases in populations, the public health branch achieved success by isolating and confining the sick and in effecting sanitation measures. With the rise of the science of bacteriology, the techniques of public health care were applied to individuals through immunizations. In more recent times, public health practice has included greater responsibility for individual care through the establishment of health clinics that cater to the financially disadvantaged. Public health also gradually but inexorably began to serve as the interface between the direct care physician and the patient by taking on the responsibilities of the "modern" public health government agency.

Ironically, these efforts to improve health drove these disciplines into conflict. The increasing ability to cure resulted in a relentless rise in costs, and physicians, with a sense of responsibility to patients, were some of the first to suggest the need for health insurance, especially for vulnerable populations, through the Blue Shield and Blue Cross movement. Inevitably, this provided the impetus for the government to likewise address access to care as a public health issue. Medicare and Medicaid were the eventual results. With the imposition of a third party in the care of individuals and the resultant loss of the ability to self-regulate, medicine was on the way to the deprofessionalization.

Despite all the advantages insurance provides, there is one significant disadvantage—and it’s what the economists call the "moral hazard" of insurance. The availability of money provided by "someone else" inevitably results in further escalation of costs. The sick and the not-so-sick worried well loose their instinct to use resources prudently. Likewise, physicians find that insurance provides them with the opportunity to provide sometimes unlimited, sometimes poorly orchestrated, care, and in the process they find for themselves economic enrichment.

The moral hazard of insurance placed medicine on a slippery slope toward self-aggrandizement, which is the antithesis of professionalism. The government accelerated the process with its ever increasing maze of reporting and billing regulations and has set loose, as the Wall Street Journal calls it, "the Medicare police" to encourage whistle blowers and prosecute alleged fraud.

Our malaise has grown deeper by the perversion of the social scheme of managed competition to a uniquely American business-driven managed-care enterprise. The business of health care replaced the practice of medicine. We know that, in general, managed care has not managed health or health costs well but has manipulated patients and infuriated doctors. Health consultant Leland Kaiser has characterized it as "a neurological disaster." Whatever we call it, the strong hand of the insurance entities and of government has further eroded the professionalism of physicians.

How can we fight back against this litany of woes, this relentless loss of self-pride and self-control? How is it that business tycoons and politicians are now protecting patients? This time of chaos in medicine, Dr. Kaiser says, is the opportune time to reconstruct medicine, through well-channeled energy, in the image of the learned and caring profession we have cherished.

First, we must acknowledge our share of the responsibility for the present reality. Second, we must endorse the quality movements of today. We must focus on the development of valid performance measures as better indicators of quality than process and structure standards. We need to commit ourselves to the characteristics defined by the American Board of Medical Specialties that give new meaning to the term "competent physician." They go beyond the store of medical knowledge and proficiency in caring for patients to a commitment to lifelong learning and improvement, superb communication and interpersonal skills, and the ability to understand the effect of systems on the quality of practice.

These are all important characteristics, but the greatest of the all is the overarching attribute of professionalism. It is defined by the humanistic values that previous generations have passed to us. In its "Project Professionalism," the American Board of Internal Medicine defined the essential requirements for rebirth: altruism, accountability, excellence, duty, honor and integrity, and respect for others. The sum of all these is the paragon we call ethical integrity and trustworthiness.

These values must not be empty slogans, but ideals that are etched firmly in our hearts and minds. They give real meaning to the word “doctor,” which it is your privilege to use. (Never a health care provider.) Use it well.