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From
Sonoma Medicine, the
Official Journal of the Sonoma County Medical Association, Winter
2010
A
Transatlantic Malaise
by John Toton, MD
Physicians
receive an overwhelming number of medical journals and medical
newspapers on topics of current interest, usually supported by
advertising. We scan and sometimes read this flood of information,
but occasionally an article or reference stands out, and we follow
up on it. Such was the case with an article about Physician
Disempowerment: A Transatlantic Malaise, a
"treatise" on the reality of European medicine from the
physician's perspective.
I
downloaded the treatise from www.cmpi.org,
the website for the Center for Medicine in the Public Interest, an
organization that lobbies for a traditional American approach to
medicine. The treatise consists of the full texts of 12
presentations made at a 2008 conference on physician
disempowerment sponsored by CMPI. Half the presenters were
physicians, PhDs and other experts from the United States, and the
other half were from countries with nationalized health care
systems.
Editor
Mark Crane introduces the presentations by affirming the
"American malaise." According to Crane, the United
States is losing doctors because of excess paperwork, retirement,
and practices that are overextended and overworked. He predicts a
shortage of 35,000 to 40,000 primary care physicians by 2025.
"Person
in the street" interviews conducted by CMPI in New York City
highlight how little the public knows about Canadian and European
systems. When asked whether they would want universal health care,
the answer was invariably yes; but when asked how much extra
income tax they would pay, a typical response was, "No, no,
no. We want it to be free, like in Europe."
The
keynote speaker, Dr. Francois Sarkozy (brother of French President
Nicolas Sarkozy), addresses what kind of care one gets in France
"for free." He describes the flight of French physicians
away from private practice to salaried positions. He finds a
paradox that there are now more physicians per population than
ever before, and that many are seeking "the balanced
life" while practicing only 50% to 75% of the time.
Physicians are unionized, and their medical fees are agreed upon
between the government and the union. Having given up their
independence, says Sarkozy, physicians reluctantly accept the
regimentation and loss of collaboration, along with the loss of
accountability and quality assessment.
Sarkozy
identifies a "physician malaise," arguing that all is
not well. Physicians need to recover their respected status and
recognition in the community; they need to relearn the principles
of independent practice, to delegate, to seek efficiency, to
collaborate—in short, to redevelop what they've given up, what
American medical practice up to now fights to maintain.
Dr.
Tim Evans, from Great Britain, describes waiting lists that have
become "intolerable." The country has a population of 60
million and a health care budget exceeding $175 billion per year,
yet Great Britain at any given time has more than 1 million people
on an active waiting list for care and an additional 200,000
trying to get onto that list. Seven million people also have
private medical insurance, and another six million will pay cash
to get their desired or needed care. This situation, says Evans,
is a far cry from a 1948 government promise that "The
National Health Service will provide you with all medical, dental,
and nursing care. Everyone, rich or poor, will be able to use
it." Physicians in the NHS now tell patients, in effect,
"If this is an NHS dialogue, you can have 10 minutes. If you
want to pay privately, then we might have a slightly longer,
slightly more fruitful conversation."
Evans
claims that most British physicians now realize that there are
only two ways to organize health care. One is on an
entrepreneurial basis, where you serve customers and create value.
The other is to organize care politically and put the politicians
in charge, making physicians "a salaried lackey of the
state."
Jacob
Arfwedson, director of the Paris office of CMPI, describes the
issues in Sweden, a country with a longtime government model of
health care. Sweden recently began offering "choice of
care" options with performance-based pay for medical
physician entrepreneurs. The Karolinska Hospital in Stockholm,
known worldwide as a model of state care, now runs training
sessions in private care. The state is naturally opposed to these
developments, but as market-based care models demonstrate improved
services, they are becoming firmly entrenched, according to
Arfwedson . . .
Other
presenters rehash our American complaints and observe that
American baby boomers want universal care at no cost to
themselves. While American physicians are acutely aware of our own
problems, we are grossly unaware of the European and Canadian
systems. Our fellow physicians in these countries have the
experience to advise us of what is ahead.
The
presenters in Physician Disempowerment speak to a wide
range of government mandated and supervised health care options,
all of which appear to weigh heavily on the backs of physician
providers. Although CMPI is clearly an advocacy organization with
a conservative viewpoint, its treatise does offer an informative
window into an experience we may all be facing in the near future.
Dr.
Toton, a Healdsburg orthopedic surgeon, serves on the SCMA
Editorial Board.
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to Sonoma Medicine Winter 2010 Table of Contents
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