Maxima Culpa

Who is to blame?

This is the current situation as I see it: Many doctors are unhappy; many patients are unhappy; many hospitals are failing financially. So, who is to blame?

I’m not a doom and gloom guy. I actually love my job. When I go to the hospital, I truly feel like I do something good for humanity and myself. My job is interesting, challenging and certainly makes a huge impact on people’s lives. That said, if I had stayed in clinical medicine, there is a good chance I would have one of my annoying patients in my basement pit with a squeeze-bottle of Jergen’s lotion and an industrial sewing machine ready to prep my next suit.

So why am I in the minority? And again, who is to blame?

If you read the New York Times without periodically retching, then you probably live on the upper west side of Manhattan, make 1.8 million dollars a year as a hedge fund manager and will vote Obama because of your infinite care for the less-fortunate (read: guilt). Unfortunately, the NYT is of the very few newspapers that is well-written and has generally good reporting. You just have to hold your nose for the political articles and the opinion pages. One exception is David Brooks. Ya gotta love anyone whose favorite target is baby-boomer self-importance and hypocrisy.

Brooks’ latest article addresses blame. Specifically, in the mortgage crisis, is the predatory lender; the irresponsible borrower; or the culture that considers irresponsibility acceptable the villain in this play?

Translating to medicine: who or what is to blame: the government’s and administrators’ ill-conceived policy decisions; the doctors who have rolled over and allowed these policies to infest medicine; the irresponsible and unreasonable patients who demand perfect care for free; or the culture that says irresponsibility and unreasonableness is acceptable?

Everyone is going to have a different opinion on where the blame lies, and, as we are well aware, opinions are like assholes: everyone has one, they stink, and they are prominently featured in my favorite films including: Juranal Park, Little Anal Annie and Anus the Menace. Since there “is no right answer” to my question, I want to address the issue of culture: physician culture and patient culture.

Physician culture has always been about the patient. Our culture has always emphasized care, compassion, selflessness and helping people in need. Of course there are exceptions to the rule: some docs are selfish assholes and could give a toss if you live or die. However, that doesn’t change the general culture. People generally go into medicine because they want to do something good for humanity.

Patient culture, traditionally, was about respect for physicians, some degree of personal responsibility, and a recognition that docs do the best we can but, regardless, sometimes people stay sick and die. Maybe this is a ‘rose colored glasses’ view of a halcyon past. It is certainly not the reality of patient culture today: physicians are regularly disrespected, personal responsibility is a joke and if things don’t go perfectly, a lawsuit is waiting right around the corner (again, there are obviously exceptions, but it is a cultural trend). This cultural shift is made possible due to something that Brooks points out in his op-ed piece. We see the obnoxious, jerkoff patient being treated quickly, without complaint and for free by the providers and this gives other patients the signal that this behavior is somehow OK. The behavior of our neighbors, previously not tolerated, is accepted, and it becomes a cultural norm.

The irony here is that physician culture, through the focus on ‘compassion’, has actually enabled this shift. Patients, administrators and the government have noticed that docs actually will sacrifice the self in order to ‘do the right thing’ for the patient. Human nature being what it is, leads patients and administrators to become more aggressive and unreasonable. They see our compassion as weakness and take advantage. Docs have rolled over and been asked to eat feces. We have opened our mouths and said “ahhh”.

Or maybe I’m just overanalyzing the whole thing. Wha’eva, I do what I want.