The Panacea for our malaise
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
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
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.