Change the Message

Strong words, but not spoken in anger. He was discouraged.

My friend described what he took to be an unhealthy focus by organized medicine on economics, to the relative exclusion of ethics, quality, and caring for patients. "Many physicians seem more interested in their authority, bottom line, and preserving the status quo than they do about patients." More strong words.

Such sentiments are not unfamiliar. I have heard them before from physicians both in and out of organized medicine. They contain an element of truth.

Look at the current "Legislative Hot List" of CMA-sponsored and CMA-opposed legislation and you will find fully two-thirds of the highlighted bills relate primarily to money — provider contracts, reimbursement rates, unfair payment patterns, scope of practice. The actions of the 2003 CMA House of Delegates give the same impression.

The bulk of what CMA now spends time and energy on is in fact economic. This is despite a large body of policy on record that has less to do with money than with public health and the mission of the organization. In part, that mission is "...to promote the science and art of medicine, the care and well-being of patients, the protection of the public health, and the betterment of the medical profession..."

Much of the problem, of course, is that with many California physicians fighting for economic survival, CMA must concentrate on what seem to be the most vital issues. Beleaguered physicians tend to be vocal. They answer surveys, create resolutions, and actively encourage their representatives in CMA and the legislature to address their plight. This is as it should be.

But the universe of member physicians is large, and many are relatively insulated from the difficult economics of solo and small group practice. From what I have seen, these physicians are much less likely to stimulate or try to direct the activities of organized medicine. Many do not bother to speak out at all.

The result is a skew in priorities, compared to what might better represent the interests and preferences of the entire membership. Since the universe of all physicians includes non-members, the real skew is undoubtedly even larger.

In the past, CMA was more directly and actively involved in public health efforts. Studies related to specific, local public health issues were underwritten and conducted by CMA. Today, if such efforts are not driven by the county medical societies, they don't happen very often if at all. "Insuring Our Future," a recent study dealing with the thousands of uninsured children in the Sacramento region, is one example of a locally commissioned effort that would previously have been carried out by CMA.

With many county medical societies dysfunctional for one reason or another, the effect of the shift in priorities is predictable. Activities related to "the betterment of the profession" (particularly economic betterment) eclipse those dealing with the other parts of the CMA mission. CMA is so busy with RICO, scope of practice battles, reimbursement issues and the like that there is little time left over.

There is, of course, the idealism and altruism of newly-graduated physicians, one of whom was recently overheard to soundly criticize CMA for its focus on the economic self-interest of physicians. It was noteworthy that this physician's own top priority was student loan forgiveness. The focus on economics is insidious if not pervasive.

There are also, of course, important efforts that do make it through. Examples from the most recent CMA House of Delegates include resolutions on childhood obesity, physical education and nutritional standards in schools, incentives to promote health, epi-pen administration, advance directive documentation, education for end-of-life care, and elimination of racial and ethnic disparities in health care.

Nonetheless, not one of those resolutions was designated as high priority by the House. In fact none of some 15 resolutions from the reference committee on Science and Public Health Issues were designated as high priority. Of the five resolutions that did achieve this designation, all were directly or indirectly financial.

Though not all are willing to admit it, physicians own part of the problem. No one, whether janitor, teacher, nurse or physician, wants to suffer a forced decrement in his or her level of autonomy or compensation.

When the pie shrinks, the result is "numerator politics" in which trade organizations scramble to protect their pieces. There is little regard for a denominator that won't support such a strategy across the board. Each group has one eye on its own navel, while it uses the other one to identify villains.

Recent events in Ventura can be interpreted as an example of such economic self-interest run amok. Financially strapped physicians establish and refer to care centers competing directly with local hospitals. Hospital administrators, charged with protecting different economic interests, over-react with unilateral rule changes undercutting the physicians' ability to practice and organize. A gigantic food fight results, in which opposing parties speak about honor from distant sides of an expansive legal table. Both groups want to stay afloat and to deliver quality medical care, but they are divided and conquered in those efforts as dollars spent to wage their war are siphoned off to the lawyers. How ironic. The fact is that despite the relatively high compensation enjoyed by physicians, the practice of medicine is no more inherently noble than any other profession that cares for people. The value question - "how much am I worth?" - is essentially unanswerable, though often a source of hot debate. "Fair compensation" is as legitimately in the eye of the payor as the payee. Large-scale and somewhat fickle social and societal factors ultimately determine the economic fate of professions. One has only to look to medicine in Britain or Russia to be convinced. Or to salaries in the NBA.

But all of this begs the question. Surveys of CMA members consistently show that those who speak up are interested in economic advocacy, with the legislative, regulatory and legal assistance that supports it. The organization in response dwells on these priorities, thereby sending a message to members, non-members and the public that this is what organized medicine is all about.

That is what discourages my friend. He asks: "How can we build teams of people - physicians and non-physicians - to most effectively care for patients while physicians are so focused on economic self-interest and autonomy?"

He tells me: "With a broader focus, more physicians would join organized medicine, and there would be more money for programs."

Finally, he suggests: "Remember to care for patients, and the money will come."

Those were bold words if nothing more - some would say foolish. But they spoke to me about motivation, perception, expectations, and what is truly of value. If the message at CMA and AMA is all about the financial self-interest of physicians, then maybe we should create a better one.

paul.phinney@kp.org