Who Speaks for Medicine?

By ABRAHAM VERGHESE, M.D.

At a moment when everyone's joining the debate over health-care reform, who speaks for medicine?

By 'medicine' I mean that ancient art and science with origins before Hippocrates, that discipline that has the patient at its center; I'm talking about the 'medicine' that deans across the country will invoke in a few weeks as they exhort first-year medical students to embrace the ideals and values of the noble profession.

Our esteemed medical societies and academies aren't speaking for medicine; they are lobbyists, defending their financial self-interests, lining up for or against the latest bill being proposed. Our great academic institutions and our esteemed medical schools have historically spoken for the cause of medicine, but these days many medical schools are more like big companies with complex financial interests in large hospitals and clinical practices.  What about the large foundations dedicated to health care, such as the Robert Wood Johnson Foundation or the Kaiser Family Foundation? I think their voices have become more potent as they seem largely free of the kinds of conflicts of interest that bind many of us, but they are not quite the voice of medicine.

Before we are irretrievably sucked into Washington's political maneuvering, we desperately need doctors and nurses to speak for the art of medicine. As William Osler, the father and spokesperson of modern medicine said a century ago:

You are in this profession as a calling, not as a business; as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men. Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed. You must work in the missionary spirit with a breadth of charity that raises you far above the petty jealousies of life. . .

I know of primary-care doctors who give their weekends to clinics for the homeless; I know of specialists who volunteer their services to community nonprofits. At a time when many practitioners turn down Medicare and Medicaid patients because government reimbursements don't even pay for overhead costs, others continue to treat them. Long before concierge medicine made house calls fashionable and lucrative, practitioners I know in Laredo and El Paso made home visits to the housebound, poor and elderly. And then of course there is our new Surgeon General - a dedicated primary care physician, a strong signal from the President about the kind of doctors the nation needs.

Physicians like those should speak up for medicine, and argue in favor of paying doctors to spend time with their patients. They should fight against a payment system that has created perverse incentives that encourage unnecessary treatments. Let's make it as lucrative to talk to the patient as it is to do to the patient.

A physician who gets to know the patient can discuss difficult subjects such as end-of-life care while the patient is still relatively healthy -- often sparing them the pain and huge expense of spending their last days of life in an intensive care unit. Physicians with good relationships with their patients can guide them away from futile therapies whose only proven efficacy is making money for drug companies, hospitals and doctors. How wonderful if all our lobbying societies would agree that our goal should be to fulfill Dr. Peabody's old maxim, and not to simply restate it generation after generation: "The secret of the care of the patient is in caring for the patient."

Abraham Verghese is a practicing internist and a professor of medicine at Stanford. His most recent book is Cutting for Stone.

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It's Not The Immigrants, Mr. President, It's The System Set Up to Distribute Benefits of Lawbreaking

By Arizona Physician, Jane M. Orient, M.D. JAPS, July 6th, 2010

On July 1, Barack Obama spoke of the immigrants who helped build our country - such as my great-grandparents. They passed through public health screening, obeyed the law, worked hard, and never got welfare benefits. They learned the English language and American history. Some even carried the Constitution of their beloved adopted homeland in their pocket throughout their lives. They asked only for the opportunity to contribute.

Should we, as Obama suggested, break down the bureaucratic barriers that hinder such people? Absolutely. That is not what the controversy is about.

The issue is illegal immigration - lawbreaking. Controversy is inflamed by marches of angry people, aggressively waving a foreign flag, insulting Americans in a foreign language, and demanding to "take back" the property and earnings of Americans.

Illegals circumvent public health screening, bringing once banished foreign organisms with them. The most serious one is probably multi-drug resistant tuberculosis, which one can catch on a bus. Head lice are far more common than previously in schools. Dengue has reached the continental U.S. and the parasite that causes Chagas disease now infests more than 40 percent of the kissing bugs found near Tucson, compared with only 4 percent in 1964.

Then there's property and environmental destruction in the Arizona desert. Ranchers' land is trampled, and strewn with tons of garbage and human excrement. 

Worse, there are guns - including military assault rifles. Americans are warned to stay out of the Buenos Aires National Wildlife Refuge because it is occupied by heavily armed invaders, who smuggle drugs and humans.  Phoenix, Arizona, is perhaps the kidnapping capital of the world, with heavily armed contingents invading homes and carrying off people for ransom.

While proclaiming that we are "a nation of laws," Obama didn't mention how the U.S. federal government encourages lawlessness. One way is by forcing the private sector to care for illegals free of charge, through the Emergency Medical Treatment and Active Labor Act (EMTALA). Physicians on a hospital staff are required to serve these patients immediately - even if they have scheduled surgeries or an office full of waiting patients.

When hospitals in Border States complained that this unfunded mandate could cause them to close (as many actually have), the federal government offered some reimbursement for services provided under EMTALA to illegals. Hospitals, however, could not inquire about immigration status - they had to somehow divine it without asking, and file a claim without telling.

Doctors owe a duty of confidentiality to their patients. The Oath of Hippocrates states: "All that may come to my knowledge in the exercise of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and never reveal."

Some things, however, ought to be revealed, and by law physicians must report them. These include certain infectious diseases, gunshot wounds, suspected abuse, and evidence of an impending crime.  While the government demands access to more and more sensitive information about citizens from their health records, including illegal drug use, sexual preference, psychiatric history, and gun ownership, one is not allowed to ask basic questions about immigration status. This is a double standard.

Doctors are not law enforcement agents. Their duty is simply to treat patients - even known enemy combatants or criminals. They may not, however, help people evade the law.

Federal law may actually encourage them to do so. According to anonymous reports, "community health centers," which are generously funded by federal tax dollars, not only provide treatment to illegals but also may help them obtain many other welfare benefits to which they are not entitled. Bending or violating the law might keep enrollments expanding and the federal dollars flowing and the staff paid. Immigration officials look the other way, and anyone who dared to raise questions would likely be branded as a "racist." ("ObamaCare," by the way, will expand the reach of such centers from about 5 percent to 10 percent of the population.)

In contrast to Obama's examples, like Jews fleeing Eastern Europe, this time we're not facing just a migration, but an influx having many hallmarks of a foreign invasion. . .

If the United States cannot or does not enforce its laws, Lady Liberty's lamp will no longer beckon to the people throughout the world who are "yearning to breathe free."

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