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TAUREEF MOHAMMED
“MEDICINE should be the stuff of social service, not unbridled entrepreneurship,” said the late Arnold Relman in an interview published in the Journal of the American Medical Association (JAMA) in 1991.
Issuing a warning call to JAMA readers – doctors – he added: “Medical entrepreneurship is destroying the traditions of medicine.”
The title of the article was, “Arnold Relman – the last angry doctor.”
Arnold Relman was Professor Emeritus at Harvard Medical School. He was an internist, and a professor of medicine and social medicine. He was editor of the New England Journal of Medicine, one of the leading medical journals in the world, from 1977 to 1991. He was relentless in his fight against for-profit healthcare in the US – in his 80s, he wrote a book on the issue; he died age 91. Perhaps he died an angry man.
In his writings, he warned about the negative impacts of the “medical-industrial complex,” not only on the public, but also on the profession itself.
In an opinion piece in JAMA, in 1992, he wrote: “If physicians choose to act from self-interest, or even if they merely put themselves in positions that suggest self-interest, they risk damaging their most precious possessions – the trust and respect of their patients and the esteem of the general public.”
But do physicians actually have a choice? And what are those choices? Who determines them? Do physicians, particularly early-career physicians, even have the agency to “put themselves” in any position? What if medicine is – like everything else – just a hustle?
It is certainly a hustle for early-career physicians in TT, general practitioners – a surplus of GPs exists – and new specialists trying to break into well-established – and perhaps well-greased – cliques. It is no different in Canada, where, for example, dialysis units – income generators for nephrologists – operate like cartels. Everybody has their turf – practising medicine is a hustle.
Doctors provide a service, and patients pay them for the service. The independent physician’s practice will always be a hustle, regardless of how big or small the hustle is.
A humorous take on the hustle is found in the first chapter of Dr Vincent Tothill’s book, Trinidad’s Doctor’s Office, set in southern Trinidad in the 1920s.
“Doctor: How do you know you have an abscess on the heart?
“Patient: Oh ho! Well, de next doctor in Mucurapo St, he tell me it have an abscess…
“Doctor: Well, if you are attending another doctor, I’m afraid you must go back to him.
“Patient: Oh ho! But I finish with him two years ago and I want to try you. He charge me fifteen dollars, and I hear you only charge one.”
Every patient would ask Dr Tothill, “Doctor, what is your fare?” and his answer was always the same: “One dollar, please.”
This is the everyday hustle that every doctor engages in, sometimes grappling with one’s self about how much one’s skill is worth, and being satisfied that there is no clear answer – this is not what Dr Relman was sounding an alarm over.
Writing in the 1990s, a time when medicine was advancing at breakneck speeds, Dr Relman was witnessing the profession eroding away. Commercialisation, made easy by advancements in medicine which led to the fragmentation of care – go here for a scan, there for a blood test, then come back here to see another specialist – was infiltrating the profession. Conflicts of interest were everywhere: doctors were investing here, there, and everywhere, and sent patients here, there, and everywhere. A noble profession was turning into an ugly one. And today, it is an ugly one.
I remember as a medical student sitting in a clinic in a public hospital, looking on at a consultant doctor complete his assessment. At the end of the visit, the doctor wrote a referral for the patient to see one of his colleagues, a specialist working at a private hospital which the consultant was affiliated with. The audacity! Easy like that, siphoning a patient to a private hospital in front a group of medical students. Now, that was not a hustle; that was a scheme.
And today, there are too many schemes, obscured and complicated by the piecemeal medicine that we practise. The ugliness surfaces on its own, every now and then. Everybody sees it and knows it. I can list more examples here, but I will leave it to your imagination.
But who is responsible? Doctors? I don’t think so. As one Trinidadian physician told me, doctors are simply a product of society.
Taureef Mohammed is a physician from TT working in Canada
E-mail: taureef_im@hotmail.com
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