The Care of the Doctor

THE CARE OF THE DOCTOR LEON R. KASS* Life is short, I art is long, I occasionfleeting, I attempt perilous, I judgment difficult.—Hippocrates, Aphorisms Today's the day. At last, after 4 long years. Four long years on top of 4 more years, on top of 12 previous years. After 20 years of schooling, you step forward, one and all, at last doctors of medicine. Hippocrates said it first: "Life is short, the art is long, the occasion fleeting." We seize the occasion: we salute you and welcome your entrance into a noble profession. This occasion makes me nostalgic. Twenty-eight years ago—I believe on this very day in June—I was in your place, a graduate of our school of medicine, then an aspiring neurologist, soon to begin my internship. Though I have since wandered far from the path of medical practice, I have kept a watchful eye on our venerable profession, as it struggles to preserve its dignity in the face of numerous challenges and temptations—economic, legal, moral. It seems to me appropriate, as we celebrate this rite of passage, to reflect together on the state of the art, professionally speaking, as it awaits your participation. At first glance, I regret to say, the news is discouraging—especially if one concentrates on the socioeconomic constraints under which medicine is now being practiced. The bad news reached the front pages of The New York Times earlier this year in a series of articles, "Doctors in Distress," reporting on what the Times called the deep demoralization of the medical profession: Address delivered to the class of 1990, Pritzker School of Medicine, University of Chicago , June 1990. *Committee on Social Thought, University of Chicago, 1116 East 59th Street, Chicago, Illinois 60637.© 1991 by The University of Chicago. AU rights reserved. 0031-5982/91/3404-0731$01.00 Perspectives in Biology and Medicine, 34, 4 ¦ Summer 1991 553 Over the past quarter-century, and especially in the last 10 years, doctors have seen their autonomy eroded, their future earnings potential jeopardized, their prestige reduced and their competence challenged by everyone from oversight boards to hostile, litigious patients. [New York Times, February 18, 1990] The causes of these changes are all too familiar. With expenditures on medical care now approaching 12 percent of the gross national product, governmental and private measures aimed at cost containment involve physicians in massive amounts of complicated paperwork and greatly constrain their professional choices. The Diagnostic Related Groups effectively block the use of certain procedures, and the insurance company 's permission is often required before hospitalization or surgery can be accomplished. In many private prepaid health programs, participating physicians are openly pressured to decrease their use of costly diagnostic procedures and to curtail the time spent with patients, all in the name of maximizing financial yield. The removal of the age-old restriction on physician advertising has spawned aggressive and sometimes unsavory business practices, providing ammunition for those who cynically claim that organized medicine is not an ethical profession but just another greedy interest group, scrambling for a place at the public trough. The malpractice crisis shadows everyday practice, causing many a physician defensively to act in ways not reflecting his best clinicaljudgment . And, quite apart from litigation, the rise of the patients' rights and consumer movements, with heightened patient sophistication and new demands, and the growing impersonality of many medical services, have conspired to erode trust, confidence, and respect. Finally, the profession 's most venerable principle of self-restraint—the taboo against active euthanasia—is now under public attack, helped along by certain renegade physicians who take pride in using the tools of healing to construct machines for suicide. No wonder morale is falling. Of the 1,000 physicians surveyed by Gallup for the American Medical Association , nearly 40 percent said that, given what they now knew about medicine , they would definitely not (14 percent) or probably not (25 percent) enter medical school if they had it to do over. Grim news indeed. Life is short, the art is long, the enterprise perilous—perilous, indeed, not only for the patient but also and increasingly for the physician. The bad news leads directly to my...