Medicine: Private or Social Good?

Editor’s Note: The following is from an essay that Andrew Saal, chief medical officer of North Country HealthCare, presented at a nonpartisan health policy forum. North Country is a community health center serving northern Arizona. Their medical team provides primary care to the people of thirteen communities, from Lake Havasu to Flagstaff to Springerville.

As a family physician, I love to teach. Last fall, I had a young medical student with me for rounds at the local hospital. When we dropped by the venerable doctors’ lounge for a quick lunch, one of the newer physicians greeted us in the bustling room.

“Hey, we’re circulating a petition to get our issue on the ballot. We need your help,” he said. “We want to change the state constitution to prevent anyone from mandating health insurance or limiting someone’s right to choose their doctor.” An infinite millisecond lingered as I waited for the inevitable next question. “So, what do you think about health reform?”

I centered myself and spoke in calm, measured phrases, with a warm smile. “I believe that the status quo is unsustainable. I believe that caring for those unable to pay is a matter of civic duty and professional honor. And while a pinch of free enterprise may keep the system nimble and foster innovation, at the end of the day, medicine is a social commodity similar to police and fire services.”

The faraway sounds of a television filled the great emptiness. At the main table, a few of the doctors looked up from their lunches; some nodded while others rolled their eyes. There goes Andrew again.

The new physician appeared to have had some sort of absence seizure. To bring him out of his fugue state, I continued speaking.

“Look, I’m not fond of Medicare reimbursement either. Two private practices dropped all of their Medicare patients this past year – and you know what, I understand their business logic. And good luck finding a primary care practice that is accepting new Medicaid patients.”

His eyes widened and his lips finally moved. A rasping voice rose from inside his chest. “Did you say that medicine was a social commodity?” And thus we began.

“I slaved away ten years of my life to get where I am. I have earned the right to charge what the market will bear.”

“Oh, I agree that we have all worked hard and should be able to care for our families. But are you sure that your medical knowledge is simply proprietary information that you can manipulate on the open market? I mean, if you had invented the iPad or written a novel, then you should be able to sell your idea for a million dollars. But did you really figure out how to deploy a cardiac stent or remove a brain tumor on your own? Aren’t we all standing on the shoulders of giants?”

He looked at me as if I were a heretic in the inner sanctuary of the Temple of Medicine. “Medical research is underwritten by companies that need to recover their costs.”

“True, but medical research is driven by federal dollars. While many for-profit companies invest heavily in university programs and private ventures, the base drivers are still the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC) and other federal programs. The core of our modern medical knowledge was indirectly built by the American taxpayer.”

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The new physician responded: “Thomas Edison invented the light bulb a hundred years ago. His inventions may have led the way, but we have no obligation to credit him every time we do a damn CAT scan. And if Medicare can’t pay the market rate, then I have no obligation to treat those patients.”

“Point taken on the technology,” I conceded. “But are you so sure about having no obligation to serve the old and the poor? Didn’t you take a low-interest federal loan during your medical school? I know quite a few docs who dislike Medicaid and the Arizona Health Care Cost Containment System (AHCCCS) … but they still take a few patients in their panels: The government helped me through school; I’m just doing my part to pay them back.

“Sure, I took some of those loans. But I’ve already paid them off. Besides, I probably could have financed it myself if I had really wanted to.” I smiled, wondering how a middle-class kid with no collateral could ever float a loan for a quarter million dollars.

“Congratulations on paying off your loans,” I offered. “That should free up some money for the next generation of students. But have you really paid back all of the money that your state and the federal government invested in you?” He seemed puzzled. “Medical education cannot exist without federal support,” I continued. “Our university-based system relies on extraordinary state and federal support. Medicare provides reimbursement to a medical residency for every physician in training. The last time I checked, there was not a single American medical school operating by free market rules.”

“Yeah … whatever,” he said. “But a social commodity? I don’t expect society to cut me any breaks, and I sure as heck don’t owe anything to anybody. I earned my diploma.” The medical student shifted uncomfortably at my side, trying to blend in with the wall.

I asked them both: “Have you ever thought about what society gives us simply because we are physicians? We don’t have to earn people’s respect; they give it to us by default. People grant us authority over them solely because we are healers. They share their innermost secrets and trust us to make life and death decisions. You have responsibility and authority, whether you want it or not.”

“I don’t see your point,” my colleague replied.

“Look, when you meet someone on the street and he says that he’s a personal injury lawyer, you probably have some subconscious opinions about his character. If that same person were to tell you that they’re a banker, you probably have a neutral opinion – unless they work for Goldman Sachs. But for the most part, bankers have a clean slate. Maybe they’ll earn your trust and maybe not. Most people have a favorable opinion of teachers. But when someone identifies himself or herself as a police officer or a firefighter, they invoke some fairly positive responses. On some subconscious level, we all believe that this man or woman would be willing to lay down his or her life to save another person as part of their civic duty. When you say that you are a physician, you are invoking the expectation of the highest ethics and human service. You are held in high esteem, whether you’ve earned it or not. People will freely give you power and authority over them solely because of your occupation.”

“Well, what about the military?” my colleague responded. “Not everyone likes a general, and he still has a lot of authority. And, more importantly, a general has to earn his way to the top.”

“They still serve the community and protect the common good,” I said. “So, if people are going to hand power over to you with no questions asked, doesn’t that imply that you have some obligation above and beyond that of the average worker?”

My colleague was troubled for a moment … but quickly shook off the thought. “Dude, we all worked hard to get where we are. We have to unite and do what’s in our best interest in these troubled times.”

“Yes,” I replied. “Yes, we do.”

Then he carried his petition to another doctor who has just entered the lounge. The medical student looked up at me and shrugged her shoulders.

“Will this be on the test?”