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The rules by which medicine is practiced have changed dramatically during the past two decades and especially in the past few years. These changes have come primarily through the efforts of government and industry to control rising medical costs.

In the 1960s, government and society at large made a pivotal decision—the decision to give unlimited medical care to most of our population. Medicare and Medicaid were introduced and private insurance became widely available. Industry responded freely to demands for more and more medical coverage, preferring fringe benefits to spiraling salaries. The end result was what economist Martin Feldstein called “a permanent excess demand for medical services of all kinds.” The cost to society has exceeded all predictions for several reasons. The tremendous explosion of medical technology and, perhaps, its inappropriate application increased not only costs but also its use.

There was unprecedented inflation, a war, and a nuclear arms race. The national debt rose beyond comprehension. The Medicare deficit and the total cost of Canadian health care to government and industry in a word became intolerable. More info about diseases and hot news – Canadian health&care Mall – www.thecanadianhealthcaremall.com, it is essential that cariovascular system is in much regard. The various diseases damages this system and it is very important to read more about their pecularities. Desperate to control medical costs, government and industry began to change the ground rules for the practice of medicine. Have these changes placed the medical profession at risk?

Professionalism

We understand risk perhaps too well, but the word profession is used so loosely today that we tend to forget what it means.

Classically, there are three learned professions—the clergy, the law, and medicine—each vested by society with its confidence and certain rights. In return, society demands of a profession not only competence but also integrity and responsibility.

Several salient elements characterize a profession. A profession must have the authority to decide who will enter it. Physicians no longer control who will enter medical school. At most medical schools, admission committees are composed of laymen, basic scientists, representatives of various disciplines in the university, and few physicians. Government regulations decide admission committee membership in many institutions.

A professional group has the responsibility and must have the right to set and maintain its own standards. The Federal Trade Commission and other governmental agencies and the courts have eroded much of medicines internal control. This applies to specialty organizations, to qualifications for hospital staff membership, and to the ethics of professional behavior.

A third characteristic of a profession requires that the application of its unique body of knowledge and skills be limited to its members. For example, only a lawyer can practice law. This is no longer true for medicine. Through the courts and through legislation, many disciplines outside the medical profession are entering all spheres of diagnosis and treatment.

Thus, because of legislation, regulation and, to a significant extent, the changing attitudes of society, medicine is losing the three essential attributes of a profession. (1) It can no longer determine who enters the profession; (2) it can no longer set its own standards of behavior; and (3) its activities are gradually being opened up to those outside the profession.

A fourth quality essential to a profession is a sense of duty to society (selflessness) and behavior for the benefit of society (even in the face of conflict of interest, which is inherent in the daily activities of a physician). This sense of responsibility and altruism, which is expected from the medical profession, is unfortunately being eroded. Some of this is imposed from without by changes in the rules by which we practice and by loss of prerogatives essential to a profession. But some of the change comes from within. It may be at times the result of our excessive and inappropriate application of medicines’ great advances and our preoccupation with techniques, procedures, and tests rather than with the patient and his problem.

Changes Within the Profession

Change has occurred so rapidly during the past few years that I m not sure that even we in the profession comprehend the impact. Some of these changes seemed innocent and even necessary in the name of cost containment, but in terms of putting the profession at risk, their cost may be high.

One of the first approaches to cost containment was utilization review. It was innocuous on the surface. It seemed reasonable to review professional performance. Utilization review is always called peer review. In reality, however, it soon degenerates into guidelines used by third parties and reviewing agencies in ways not intended by the peers at all. Often these peer review guidelines give license to third parties to decide which services are valid, which are justified, and for which ones they will pay. Closely related is the widely promulgated idea of a second opinion. A second opinion is fine when the patient wants it as part of his right of free choice and his right to control the medical services he receives. When it is required by an agency paying the bill, it is another matter. It then becomes a not so subtle implication that the physician cannot be trusted. It is difficult for a patient to place his life in the hands of one whose judgment must be corroborated by another opinion. The same insurance company that wants two bids to decide how much it will pay for repairing a car after an accident, now wants two opinions to decide whether it will pay for an operation or a hospitalization. And we are not too far from that third party requiring two bids to determine which physician it will pay and, therefore, to which physician the patient must go.

Medicine has always feared the intrusion of government, but perhaps a far greater risk to the profession is the nonmedical corporation. There is a spectrum of such organizations—some for profit and some not for profit. There are health maintenance organizations (HMOs), free standing clinics and emergency rooms, hospital satellites, and franchised chains—the fast-food chains of medicine. Some HMOs began as independent physician practice groups. Sooner or later, whether for profit or not, all of these units tend to be controlled by administrators and the physician becomes an employee of the organization, conforming to its guidelines and requirements. Gradually, he ceases to be an independent professional serving his patient and acting as his patients’ advocate.

In all of these practice schemes, sooner or later the third part, the manager, the boss, is interposed between the patient and the physician. Under his banner of cost containment and high praise for reduced use, the expendable item is the relationship between the physician and his patient, which is compromised and ultimately destroyed.

The Advent of The Diagnosis-Related Group

And now comes the latest and most devastating instrument in the dehumanizing and depersonalizing of American medicine—the diagnosis-related group (DRG), spawned in the department of management engineering at Yale University, New Haven, Conn. The hospital, the patient, and the physician become merely elements in an industrial-like system. The patient and his treatment are the product. The hospital is the factory. The physician is the workman.

The stated objective of the DRG program is “to measure, monitor and control hospital production costs relative to the patients' treatment process.” Accounting firms develop computerized systems for forecasting and controlling costs. Cost analysis and production controls are similar to those used in factories. Dr. Robert Fetter of Yale University, who was one of the designers of the DRG system, said that the basic unit of the hospital output is the completed course of patient treatment. He described the DRG concept as follows: “The quality of care is presumed stable, the system does not attempt to measure the degree of care accomplished during hospitalization or the state of health of the patient at discharge.”

The idea of considering a sick patient with all the complexity of the disease process and his response to it, with all the psychosocial and other factors, to consider this sick person as a member of a DRG with a defined norm for his treatment and a specified number of days in the hospital is so preposterous, so alien in its philosophy to what medicine is, that a numbed profession has barely made a murmur of protest.

Medicine has always emphasized the uniqueness of the individual patient. Now we are told that pneumonia, congestive heart failure, and even shock must be treated in a prescribed way for a certain number of days in the hospital. Somehow the physician who conforms to this engineering design plan is a superior one. He is measured not by the outcome, not by the astuteness of his diagnosis, or the skill of his surgery, but by the number of tests he has used, the cost of the medicines prescribed, and the number of days of hospitalization. We no longer have a patient but a member of a DRG. A coronary, a gallbladder, a hernia, each patient in the infinite variety of his disease is neatly placed in a DRG.

Hospitals are becoming franchised auto parts repair shops where an anatomic part or an organ can be removed or repaired, where the radiator system or the coronary arteries can be flushed and where the valves can be ground or replaced for a set charge and within a specified time.