Reflections of a Medical Student

REFLECTIONS OF A MEDICAL STUDENT HARRY B. BURKE* On my way home from the 1985 American Medical Student Association convention, I realized that the revolution in the practice of medicine that has been occurring for quite some time has not been understood by most of my fellow students. At the convention we debated nuclear missiles and gay rights [1] when we should have been debating the future of medicine. The students know that there might be a temporary surplus of physicians [2,3], and they know that there might be federal loan cutbacks [4]. But they fully expect the medicine they practice to be very similar to that practiced since World War II. What follows are some of the problems that I expect that the medical students of today will have to face as practicing physicians. Individually none ofthese problems is earthshaking. But taken together they guarantee that the future of medicine will be nothing like its recent past. Medicine is experiencing a crisis in public confidence. Public-opinion polls show a consistent erosion in the public's satisfaction with physicians [5-7]. Malpractice suits and awards are increasing at an alarming rate, with no downturn in sight (in spite of the AMA's recent proposals [8]). This crisis in public confidence has profound implications, not only for public policy but also for physician-patient relationships, and it creates a climate in which it will be difficult for me to practice. Historically, price controls have never worked in America, but price controls are being applied to physicians directly via Medicare and Medicaid reimbursement schedules and indirectly via DRGs. This will certainly limit my potential income. But my expenses will not be limited. The average medical student will repay a debt of more than $100,000 (including interest) [9]. The cost of malpractice insurance is so high (in some cases more than $100,000 [10,11]) that it is hard to see how a young physician will ever again be able to "put out his shingle" without *Second-year medical student, Pritzker School of Medicine, University of Chicago. Address: 6044 South Ingleside, Chicago, Illinois 60637.©1986 by The University of Chicago. AU rights reserved. 003 1-5982/86/2902-0470$01 .00 2 14 I Harry B. Burke ¦ Reflections of a Medical Student some form offinancial aid. Is the dream of starting a practicejust that— a dream? Medicine is being restructured away from fee-for-service by HMOs, PPOs, DRGs, Medicare and Medicaid, etc. [12-14]. This may or may not have an adverse impact on physician income. But it will certainly have a negative impact in other areas of medicine. One of the great virtues of the fee-for-service system is that the physician is directly accountable to the patient; the physician is the patient's advocate because the physician works for the patient. Third-party reimbursement via private insurance has, to some extent, reduced the autonomy of the physician-patient relationship; but it is still clear that the physician is employed by the patient. So long as the physician works for the patient, the physician's first responsibility will always be to the patient. But when the physician works for an HMO or is held accountable to the federal government, it is no longer clear where the physician's primary responsibility lies. When there is a conflict between the needs of the patient and the needs of the organization for which the physician works, can the physician decide in favor of the patient? If the physician cannot, then who will be on the patient's side? What is the role of the physician in such a situation? In this situation is there such a thing as patient confidentiality? I face a world where I may not be able to be on the side of the patient, where my relationship with the patient may be adversarial rather than cooperative. And the best interests of the patient may well be subordinated to the economic and political interests of some organization. In countries where organizations take over medicine—whether the organization is the government, via totally socialized medicine, or quasiprivate organizations, such as HMOs—the physician-patient relationship can suffer. Already...