Sunday, May 3, 2009

Hypocrisy and the Hippocratic Oath

The current health care reform debate prompted me to query the doctors in family about their profession.  The doctors in my family provided refreshingly frank feedback, and  devoid of the facade that they would naturally put up if speaking with less familiar individuals.  

I walked away from the conversations with a new regard for medical doctors.  Namely, whereas I had perceived doctors as selfless individuals who worked endless hours for the benefit of others (and who happened to earn a nice living in the meanwhile), my new perception puts medical doctors in the same class as consultants.

Having been a consultant, I have an understanding for the inherit conflict of interest that consultants must deal with.  On one hand, the consultant has to solve a problem for the client.  On the other, the consultant has the goal to maximize his revenue.  The conflict of interest comes when a problem could be solved in a very efficient way (perhaps due to the absence of an actual problem); under this condition, revenue takes a hit.  Being goaled with maximizing revenues often means that the consultant will take a less efficient path or "discover" new problems in an effort to extend the engagement, and thereby aggrandize the bill.  With that, let's take a look at how incentives are created for medical doctors  and why the Hippocratic oath takes a back seat to the almighty dollar.

First, it is important to understand medical billing practices.  This is not a comprehensive study, rather a sketch based on various data points:
  • Billing rate is associated with the doctor's expertise.  Pediatricians make less and intensive care (IC) doctors.  IC doctors with multiple certifications, such as pulmonary disease, make even more.  A pediatrician makes around $150,000 per year.  A high-end specialist can make into the seven figures.
  • Per-minute billing rates are very high.  The figure that was quoted to me was $35/minute.  This makes the hourly rate $2,100 for the average doctor.  Just for comparison sakes, a named partner in California's largest law firm collects less than half this rate.
  • While billing is quoted at a per-minute basis, there is a minimal period for which the patient (or the patient's insurance company) is billed.  The minimum time blocks is 10 minutes.  However, most doctors visit 2 or three patients during the same 1o minute period, effectively tripling the billing rate.
So far, it should be clear that with these billing practices, patients should expect little love from their doctor.  The doctor will be motivated by visiting as many patients as he can during the shortest period of time.  Hopefully, the diagnosis will be accurate.

Another contorting factor is the division of labor among doctors.  As I mentioned above, an IC doctor collects at a specific rate, but an IC doctor with pulmonary disease certification increases his rate by about $100,000 per year.  The distinction between a regular IC doctor and an IC doctor with pulmonary disease certification is the ability to diagnose and treat lung infections.  

Here is the rub:  It is an accepted fact that any patient that spends any appreciable time inside the IC unit will develop a lung infection.  So, the rational IC doctor will want to get a pulmonary disease certification because, if he does not, he will allow the next person to collect the fees for diagnosis and treatment.  Judging by the extra $100,000 per annum increase to the doctor's take home, one can expect a $400,000 total billing that this doctor generates in totality, which is then split between insurance companies, pharmaceuticals, the medical facility, and other administrative costs.

But, if it is an accepted "fact" that any patient that spends any appreciable time inside the IC unit will develop a lung infection, the question is why isn't the medical community working to prevent these infections in the first place?  The way the game is devised, it is far more lucrative to diagnose (or misdiagnose) and prescribe a (hopefully) cure instead of preventing the disease in the first place.  

Which brings me to the Hippocratic Oath.  According to PBS, the modern version of the Hippocratic Oath (written by Luis Lasagna in 1964), has the following directives:

  • I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over treatment and therapeutic nihilism.
  • I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
  • I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
  • I will prevent disease whenever I can, for prevention is preferable to cure.
Without diving into the details, I believe I have demonstrated how the four directives are easily violated - not because medical doctors are callous  - because the way medical establishment practices its business today.  You may be interested to know that there are eight directives altogether, which makes the final clause of the modern oath laughable:

  • If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

The medical establishment has said that at most 50% compliance with the oath is good enough.  We, the patients, just hope that disease diagnosis and treatment has a far better success rate.  

Cough, cough.


e.s.s. said...

The corruption of medical professionals is a commonly discussed issue, but few have addrssed it so poignantly.
For a better part of my life, I have believed that much of the trouble with our healthcare system could be derived from not regulating pharmaceutical companies closely enough (which largely came about due to frustrating experiences with perscription medication as a child). However, I'm now considering that the way in which practitioners are rewarded for their services should shoulder some of that blame. How were you drawn to this issue? I hope not by illness.

Wishing you health,

Amir said...

I was drawn to the topic because of Obama's interest in reforming health care and a series of off-the-cuff conversations with doctors in my family.

I do not want to create a bias against every medical doctor. For instance, a close family member suggested that I take a high doze of omega 9 fatty acids to cure a condition for which other doctors had said was no cure. The non-medicinal "prescription" worked wonderfully.