True Health-Care Reform Hinges on Doctors' Redefined Role
The controversy over the future of health care in the United States is momentous. But the narrowness of the debate—which swirls around coverage, costs, and who pays—obscures other grave threats to the American health-care system.
Restructuring the present scheme for allocating health care and paying for it is a priority. Something has got to give. The laudable professed ambition of the 2010 Affordable Care Act, the centerpiece of President Obama’s first term, was to expand health-care insurance coverage and lower costs. The massive bill, however, was passed on a strictly party-line vote. It shows.
Nothing we know about the logic of government action or the operation of economic regulation supports the federal government’s attempt to simultaneously legislate increased coverage of people, conditions, ailments, therapies, and drugs; lower prices on coverage; appropriate treatments and physicians’ best practices; and ensure patients’ option to keep their doctors and insurance policies. While the Affordable Care Act has reduced the number of uninsured, it has also impelled many insurance providers to cancel policies and hike premiums and deductibles. Meanwhile, many patients have lost their doctors and had their choices of physicians curtailed. Obamacare, moreover, is on a trajectory that will break the federal budget.
Even if on their second try President Trump and Congress succeed in enacting major reforms that restore patient choice and fiscal solvency to the American health-care system, dire problems would remain. Health care has increasingly become a hostile battlefield pitting doctors, nurses, hospital administrators, government bureaucrats, and insurance executives against one another. Patients grapple with harried and unresponsive health care providers, opaque treatments, and unintelligible bills. And providers and patients alike sense that the practice of medicine has gone astray.
Ronald Dworkin, MD, shares this common anxiety. In “Medical Catastrophe: Confessions of an Anesthesiologist,” he provides an uncommonly perceptive diagnosis and constructive prescription.
According to Dworkin (a friend from college), the practice of medicine in America confronts a crisis, at once moral and political. This crisis, however, is rooted not in what divides left and right but rather in how doctors relate to one another and understand themselves, in their virtues and vices, and in their conception of their professional responsibilities and duties as citizens and human beings. Physicians, Dworkin argues, no longer understand what it means to be a doctor.
The author is unusually well positioned to explore the deficit of self-knowledge that afflicts American physicians. With more than a quarter-century of experience as an anesthesiologist, Dworkin knows medicine from the inside. After launching his medical practice, he obtained a PhD in political science from Johns Hopkins University. Over the course of his medical career he has published provocative books on Saint Augustine and modern individualism, on modern medicine’s insidious efforts to transform sadness into a disease and induce artificial happiness through therapy and drugs, and on how capitalism can exploit Marx’s critique. For several years, he has been teaching political philosophy in the George Washington University Honors Program.
Dworkin’s new book combines a variety of sensibilities: the savvy professional, the humanist conversant with the recurrent types and infinite variations of character, and the hardheaded observer of the everyday operations of complex organizations. It is built around harrowing autobiographical tales—transpiring in operating rooms, cramped and dingy sleeping quarters for on-call residents, hospital corridors, and medical conferences—illustrating the proliferation of impatience, overspecialization, cynicism, and alienation among physicians. It provides historical reflections—informed by the experience of his father and grandfather, both physicians—on the transformation of the medical profession over the last century. And it offers lyrical reflections on the hopes, fears, and wayward passions of doctors struggling to maximize profits and minimize overtime, save lives, avoid malpractice disaster, and comply with the imperatives of political correctness, all while maintaining self-respect in a profession that has undergone seismic changes that have been internalized but not understood.
Most doctors are, Dworkin insists, “hard-working professionals” who “take good care of their patients.” In one sense, medicine has never been more professional: It has taken astonishing strides in recent decades in developing technology and establishing protocols that reduce the space for human error. Yet professionalism is eroding: “A doctor’s judgment is often swayed by other side considerations that have nothing to do with medicine,” writes Dworkin. “Many doctors today fear their colleagues; they fear their employers; they worry about crossing the nurses; they worry about antagonizing their patients; they even fear themselves.”
How did this happen? What can be done?
In the golden age of medicine—the period, Dworkin argues, encompassing his father’s and grandfather’s careers—doctors were often all at once scientists, technicians, benefactors, and gentlemen. They derived special satisfaction from integrating their several roles.
All doctors needed to master the sciences of human anatomy and physiology. Not all doctors became surgeons, but most had to develop technical proficiency in touching, probing, and manipulating patients’ bodies; prescribing and administering drugs; and handling instruments, gauges, and monitors. It was not unusual in the golden era for a doctor to appear as a benefactor by functioning “as a businessman without appearing to be a businessman.” And because of his professional dignity and social status, a doctor was expected to be a gentleman—well-mannered, a pillar of the community, capable of discussing politics and the arts without haughtiness or inordinate enthusiasm.
Hyper-specialization, intrusive government and insurance-company oversight, and increasing competition and growing anxieties about compensation have contributed to the erosion of that golden-age synthesis. Dworkin harbors no illusions about restoring it. The routinization and bureaucratization of the professions are, as many a successful big-city lawyer will ruefully attest, brute facts of life in prosperous liberal democracies. Nevertheless, the first step in restoring a measure of balance and professional pride to physicians’ work, maintains Dworkin, must be taken by the medical profession itself.
In the face of a looming shortage of doctors, particularly in primary care, medical education should focus, Dworkin argues, on producing leaders by shifting more of the technical aspects of medicine—routine procedures and prescription writing—to nurses. Doctors should concentrate on “supervising, governing, and coordinating, whether in the care of a single patient or a large demographic group.” For many doctors, Dworkin thinks, this will produce a more exciting and satisfying professional life.
This raises the question of what reforms medical schools must undertake to mold physicians as leaders. Here Dworkin only hints at what is necessary.
To become a leader of a medical team that provides outstanding care, a doctor must, Dworkin contends, acquire not only scientific knowledge and technological proficiency but also emulate the artist who pours himself into his creation. True to his ancient calling and to contemporary realities, a doctor must learn to look within “to transform his knowledge of people into medical decisions.” Such knowledge derives from experience with men and women of all types, wide reading, and constant conversation, all of which, therefore, form indispensable components of physicians’ continuing education.
In America, in the spring of 2017, health-care insurance reform is the beginning of health-care reform. But that is no excuse for overlooking the art of medicine: caring properly for bodies remains inseparable from, as it always has been, the study and cultivation of character.