Patrick Guinan, MD

Modern medicine is in the midst of a morale crisis. In this brief review I will attempt to 1.) explain why, 2.) note that medicine has abrogated control of its destiny, and 3.) suggest that a return to the Hippocratic doctor-patient relationship can save medicine.

This crisis is manifested, to some extent, by a perception on the part of potential medical school applicants that medicine is not as desirable a career as it used to be. Factors include: 1.) physicians are retiring earlier and in greater numbers, 2.) the litigious attitude of society that targets physicians, 3.) the bureaucratization of medicine, and finally, and perhaps most importantly, 4.) the interference of third parties into the doctor-patient relationship.

Why is this happening? It is because the object of the medical act has shifted from the Hippocratic focus on the sick patient to a more broadly social goal. The American Medical Association in 2004 issued a Declaration of Professional Responsibility1 which shifted the physician’s responsibilities from the patient to social ends such as research, community activism, and public education. Medicine became conflicted and ambivalent between focusing on treating a sick patient versus dealing with community health needs. With this ambivalence came conflict and with conflict came the loss of morale.

It might be noted that this began in the 1960’s when the federal government got massively involved in medicine with Medicare, Medicaid and DRG’s.

Let’s be blunt! Many of us went into medicine because of a desire to help suffering fellow humans. It may sound like a cliché but, discounting those few who were in medicine for money or fame, for most of us the hours and hard work were justified by altruism and a desire to help sick fellow human beings.

Now, most medical reimbursements involve third party intermediaries, insurance companies, gatekeepers, and government regulations. The most important person in a doctor’s office is not the nurse, or the lab tech; it is the business manager, bookkeeper, and lawyer.

Medicine used to be Hippocratic. And unusual as this may sound, the doctor-patient relationship was all but sacred. A suffering person came to the doctor and a healing “covenant”(perhaps an old fashioned word) was established. The doctor diagnosed and treated and usually the patient was returned to health. It was hard work but rewarding. No more. It is now a struggle.

An answer to this dilemma may be a reemphasis of the Hippocratic tradition. The Hippocratic tradition was based on the age old human covenant (bond) between a skilled doctor and a suffering person, otherwise known as a doctor-patient relationship. Leon Kass has given perhaps the definitive exposition of what a physician’s commitments should be.2 He cites the covenantal relationship between a competent physician and a sick patient in an effort to restore health to the suffering human person. Edmund Pellegrino further defines the three elements of the physician-patient relationship:

The first element is the person who is ill and needs and seeks help. The second element is the act of profession, the promise the healer makes when he or she enters into the relationship with the person who is ill. The third is the act of medicine or the act of healing.3

This both explicit and implied contract has served both the doctor and humanity well for the past 2500 years, at least until the gradual intrusion of the government and other third parties following the Second World War.

The medical interaction should emphasize the patient and not a third party. That is what the Hippocratic tradition did, and that is what we should return to.

Most physicians will be skeptical that this can be done. If most physicians place their efforts on their covenanted relationships with their patients, it would have an effect. At the present time most patients, and the public at large, sense that doctors are distracted by third party restraints.

Most importantly, a reemphasis of the Hippocratic tradition will reinvigorate medicine. It may not have a great effect on the third party bureaucracy but it will have some effect, and that is perhaps all we can ask. The Oath, which still means something, is a moral commitment to help sick people. We have taken an oath (all versions share the same message) and the reaffirmation of its imperative will immensely improve physician morale.

Better to be a physician aware of, and conforming to, the Hippocratic tradition than a doctor unaware of it and being increasingly depressed and discouraged. It is better to be a doctor than a technician. Medicine must return to its Hippocratic roots: “primum non nocere” (do no harm).

References

  1. http://www.ama-assn.org/ama/pub/category/7491.html
  2. Kass, Leon. Toward a More Natural Science.
  3. Pellegrino, Edmund. The Caring Ethic: The Relation of Physicians To Patient. In Anne H. Bishop and John R. Sudder, Jr., (eds), Caring, Cursing, Coping: Nurse, Physician, Patient Relationship. U of AL Press, Tuscaloosa, AL 1984, pp 8-30.

 


Patrick Guinan, MD, is Chairman of the Board of the Hektoen Institute of Medicine. He is also an Associate Professor in the Department of Urology, in the College of Medicine of the University of Illinois at Chicago.