by
MEDICINE - UP TO THE MINUTE
by
Charles A. Bertrand, M.D., FACP, DIM-CD (Ret.)
Associate Clinical Professor of Medicine at New York Medical College
and at the Medical University of South Carolina

HIPPOCRATES IN THE 20TH CENTURY

Hippocrates was a Greek physician who was born in the fifth century BC. He practiced and taught on the island of Kos and was widely respected as an astute clinician and an outstanding teacher. He is known as the Father of Medicine. Even today, when medical students receive their MD's, they take an oath called the Hippocratic Oath. This refers primarily to the standards of ethics in medicine and one of the first provisions is "Primum non nocere". (First, do no harm.)

There is an interesting "dialog" written by Alec Pruchnicki, MD, in the November 27, 1997 issue of The New England Journal of Medicine. This is a "dialog" between Hippocrates and the personnel director of a newly established health maintenance organization (HMO). Just imagine how Hippocrates would fare in some of our newly established medical systems in the United States.


FIRST, DO NO HARM (PENDING PRIOR APPROVAL)

The scene: The office of the personnel director of a newly established health maintenance organization (HMO), who is interviewing a primary care physician.

HMO:Please come in and have a seat. I've been going over your CV and just have a few questions before I explain what we have to offer you. By the way, is Hippocrates your first name or last?

M.D.: I use only one name.

HMO: Your CV said you started your practice in Greece about 400 B.C. We're normally not overly skeptical, but you really don't look your age.

M.D.: Well, I don't smoke, and I've always followed a strict Mediterranean diet. You know, lots of olive oil, fish, fresh fruits, and vegetables.

HMO: Oh, of course. Well, let's get down to business. Since our parent company, MiracleCo Insurance Underwriters, decided to set up an HMO, we here at Comprehensive Reliable Physician Care have been looking for qualified primary care physicians.

M.D.: Yes, I've heard your slogan: When you're covered by CRP Care, it's really a miracle.

HMO: I see you've completed all your foreign medical school exams, and you've gotten your license. Board certified?

M.D.: I was hoping I could qualify under the grandfather provision.

HMO: Okay, we can work on that. Our Public Relations- uh, I mean our Quality Assurance Department insists that we have all board-certified physicians. We usually don't look for academic types, but I notice that you've had a variety of publications in medicine, surgery, and other areas.

M.D.: I always tried to be well rounded and a generalist in my medical practice.

HMO: A generalist! Excellent, that's just the type we're looking for.

M.D.: I'm usually known for my oath. I thought everyone had at least heard of it during their training, even over here in the New World.

HMO: Well, I'm pretty well trained. I have a bachelor's in business finance and a master's in health care administration. But, it doesn't seem to ring a bell. WHat kind of oath is it?

M.D.: It's an oath of ethical behavior.

HMO: Oh. That explains it.

M.D.: There's a copy at the end of my CV.

HMO: Let's see. "I swear by Apollo the physician...blah, blah;ah, blah... gods and goddesses..." Sounds very classy.

M.D.: I tried my best.

HMO: "...to reckon him who taught me this Art equally dear to me as my parents..."

M.D.: We had a high opinion of our teachers and treated them with respect.

HMO: Well, medical education doesn't fit into our program very well.

M.D.: Who will take care of medical education?

HMO: Who knows? Let's see, "I will impart a knowledge of the Art to my own sons, and those of my teachers... blah, blah... but to none others." Sounds pretty restrictive. Keeping down the supply helps control the marketplace. Are you sure you never took business administration yourself?

M.D.: No, we just learned as we went along.

HMO: We have women doctors now, too.

M.D.: I can live with that.

HMO: "I will give no deadly medicine to anyone if asked, nor suggest any such counsel...." So you had problems with the euthanasia debate back then?

M.D.: Quite a bit, that's why it's in the oath. If we didn't control it, before long people could be using it for convenience or to save money on medical costs for their elderly and frail.

HMO: Uh, yeah, we couldn't have that. Where were wee? "I will not give to a woman a pessary to produce abortion." Well, we have physicians who will provide these services if requested, but I can certainly see why you would want to avoid controversy.

M.D.: I put it in out of conviction, not to avoid contro-

HMO: Whatever. "I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work." So, you don't like surgical procedures. Great! "I... will abstain from every voluntary act of mischief and corruption; and further from the seduction of females or males, of freemen and slaves." I like this part about females and males, very politically correct. But, this part about slaves-

M.D.: It was written a long time ago. We can lose the "slave" part.

HMO: Okay. "Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." Well, no signing a gag clause and not giving out confidential information wouldn't bother you?

M.D.: Of course not. Confidentiality about my patients' medical conditions is essential to my medical ethics.

HMO: Uh, that's not exactly what I had in mind. Your patients' records may be available to us or other insurers, physicians, maybe even employers.

M.D.: That seems pretty unethical to me. So, what do you keep confidential?

HMO: Mostly financial agreements between the physicians, such as you, and the HMO. Also, we prefer that you do not tell the patients about the medical procedures that are not covered by their policies. We believe in that old expression, "First, do no harm." Maybe you've heard of it?

M.D.: Yes, I've heard of it. But it was used to warn against doing medical harm to the patients, not financial harm to the insurance company. How will we be able to counsel many sick and frail patients who come to us?

HMO: Many sick and frail patients? Let me explain how we work here at CRP Care. Most of our patients enroll through their employers, so they are usually fairly healthy. The surest way to make money in this business is to avoid sick people as much as possible and seek out healthy ones.

M.D.: How do I know which procedures are covered?

HMO: You contact us ahead of time for major procedures, tests, consultations, hospitalizations, and such, and we approve or deny payment depending on the criteria we have a set up.

M.D.: That's quite a list of items. Doesn't it bother you to be second-guessing medical decisions?

HMO: Oh, we never second-guess medical decisions. After all, we're an insurance company; we don't practice medicine. We just tell you what we'll pay for. You and the patient can decide on anything you want. I know it's a subtle decision, but it's very important to our control of expenses.

M.D.: While not actually taking blame if anything goes wrong. Very ingenious. Back in Greece we had a group of philosophers called the Sophists. You would like them.

HMO: Well, our legal department is still hiring. Send them around. But we don't expect you to take risks for nothing. We have a wide range of financial bonuses if you come in under budget.

M.D.: And if I'm over budget?

HMO: Well, there are financial penalties if you exceed your budget. But I'm sure a person with your experience will know how to run a practice within guidelines.

M.D.: Maybe experience is the key. This system is new. As time goes on, the physicians and other providers will explain things to the administrators and financial people and set things straight.

HMO: Uh, I've got some more bad news for you, Dr. H. It's the financial and business people who run things around here, not the physicians or anyone else. Don't hold your breath waiting for them to come around asking for advice.

M.D.: So it won't get any better?

HMO: Better! Once all the doctors and patients are signed up who can be signed up, it will probably get a lot worse. Some doctors may even find themselves in an oversupply status.

M.D.: You mean unemployed.

HMO: Yes, unemployed. But remember, since we don't provide for medical education, the supply of physicians will eventually shrink to meet our budgets.

M.D.: Wonderful. So, let me see now. We tend to the healthy and avoid the sick. We are rewarded for providing the least care and penalized for providing the most care. This is in a medical system that has minimal concern for ethics, hides information form the patients, and is run by financial people instead of doctors, nurses, or anyone else who cares for the patients.

HMO: Now you've got it, Dr. H. See how easy it is to understand? And you continue to be an independent contractor, especially in terms of risk, since we -

M.D.: I know, I know, you don't practice medicine. Well, my friends warned me about all this, but I had to hear it myself. I'm sorry, but I don't think I can practice medicine in this system.

HMO: All the other HMOs are about the same. If you don't sign up now, you may be locked out.

M.D.: Maybe I've been in practice long enough. Over the years I've invested in some olive groves back in Greece. I could probably do all right just with them. "Bailing out" is the expression, right?

HMO: I'm afraid so. It's too bad. A person with your experience would be a real asset to CRP Care, in spite of that ethical stuff. Are you sure I can't get you to reconsider?

M.D.: I'm sure. Sorry for wasting your time, but I was hoping there would be some way to do this.

HMO: Well, Dr. H., let me make one suggestion - though I don't know why I'm saying this, since it can't possibly profit CRP Care. Before you go home to Greece, stop off in Canada.

M.D.: Thank you for the advice.

HMO: Well, let me see you to the door, Dr. H. I hope everything works out all right, and don't forget that side trip. Goodbye now. Okay, next applicant. Dr. Maimonides? Please come in.



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