Rechecking the details of the Hippocratic oath

I had the radio on in the background while doing some chores this evening, and I caught Fresh Air's interview with Atul Gawande, the New Yorker writer and surgeon whose recent article about the costs of health care in a particular Texas city has garnered a lot of attention, including from the President. (I must confess that I have not yet read the full article, though I intend to do so ASAP.) It was a fascinating interview, and I could relate to a great deal of what was said.

In particular, I understood the pressure providers feel to generate revenue, and the conflicting aspects of medicine as healing profession vs. business. (Before I proceed, I would like to make it absolutely clear that I have never once experienced pressure to do anything unethical from any of my employers.) My salary is pegged to the revenue that I generate, and I sweat when I have slow days, or when I take any time off. I wish it were not so, but that's the way it is. One thing Dr. Gawande mentioned about areas where health care costs are low is that pay is not linked to revenue generated (providers are salaried), and I would love to work in a system like that myself, even if it meant I made less money.

Dr. Gawande also discussed the culture of "defensive medicine," wherein providers order tests for fear of missing something or being perceived as "not doing enough," thereby leaving themselves open to legal liability if something goes wrong. I can certainly understand that pressure, too. I like to believe that, personally, I still adhere to the dicta I received as a student and resident that one should only order tests or interventions if there is a specific answer or outcome being sought, not just for the sake of "doing something" or covering one's backside. The shotgun approach to medicine often uncovers useless information, and drives up costs for no reason.

However, the appalling thing I learned, and which goaded me to post, is that physicians can own a stake in facilities that run tests, perform procedures, etc. In other words, they can refer patients to facilities for medical care in which they (the providers) have a financial interest. I feel unspeakably naive as I type this, but I honestly had no idea that this went on. As the interviewer on NPR pointed out, this is a flagrant conflict of interest, and while there are laws to prevent it, there are (apparently) numerous loopholes and consulting firms that help physicians find them. Needless to say, that is a gross violation of medical ethics, and it shocks and nauseates me. I don't know if the administration is looking into closing those loopholes, but I hope to high heaven that it is.

Medicine is supposed to be about the care of patients. Obviously, there are financial considerations that must be accounted for, and to pretend otherwise is inane. But when the financial incentives become the primary reason for seeing patients, then it's time to find another field.