VOCATION LOST?

Health Progress, Mar/Apr 2006 by Coleman, Andrea Y

Hospitals Must Bring Physicians Back into the Mission of Medicine

Are physicians as "present" in today's health care as they were in the past? Hardly. The doctor is not in anymoreat least they're not in hospital corridors making rounds or voluntarily attending meetings to monitor and improve care.

The physicians' parking lot at the average medical center has many empty spaces, even at 7 am, the prime time for physician rounds of hospitalized patients. Now that 80 percent of surgery is done on an outpatient basis, many surgeons base their schedules on attendance at outpatient surgery centers-and reduce the time they formerly spent at hospitals. Hospitalists respond to patient problems that occur on evening and night shifts, further reducing the presence of specialists. Meanwhile, primary care physicians often work entirely out of their offices, referring all hospital admissions to other doctors.

Medical staff meetings reflect these changes. In the past, at least half of the staff would attend such meetings. Nowadays, only a sprinkling of officers, paid medical directors, administrators, and the vice president of medical affairs show up. And they talk mainly to themselves.

The fact is that doctors today are no longer "in" the typical U.S. hospital. And even when they are physically present, they may not be psychologically present to the organization in a meaningful way.

The consequences of this relative absence are enormous. Physicians essentially authored the high quality found in the nation's hospitals, including advances in patient care and medical science. At the heart of the physician's vocation is a dedication to treating humanity's ills with skill and compassion. And this dedication has traditionally been exercised within a medical culture that defined the physician's relationships with patients, colleagues, and community. But, in recent years, this broader culture of medicine has been evaporating. Worse, the centrality of the hospital medical staff-defined by its historic purpose, prestige, and power-has dimmed in the Rice of multiple forces acting on it.

LOST PASSION, PROFESSION, PARTNERSHIP

Many influences have worked to erode the historical solidarity of the local medical community. On the national level, these influences include (among many others) advances in technology, reimbursement incentives and disincentives, and the advances of science that have changed the locus of care from inpatient to outpatient.

The medical community has, moreover, been thrust into greater overt competitiveness, different in character from the more graceful (although energetic) traditional competition for patients that was based on affability, availability, and ability. Physicians today tend to identify themselves as medical specialists or even investors, rather than as members of the greater community of physicians, or a particular medical staff, or the local medical society.

At the local level, efforts by managed care organizations to divide and conquer the medical community-as well as physicians' involvement in business ventures, group mergers, and asset sales-have increasingly focused doctors' attention on economic matters. Such a focus tends to marginalize medicine's societal role-the very role linking doctors to the charitable institutions in their midst.

Less noticeable events separate the practicing physician from his or her hospital or peers. For example, some medical staffs have made staff meetings voluntary rather than mandatory. As a result, an important social milieu has disappeared, a milieu in which the social aspects of the physician's role were reinforced.

Dwindling joy in the practice of medicine is a more insidious force for disengagement. Two decades of complaints about the cost of medicine by those paying the bills have subtly helped to redefine medicine as a business, and an inefficient one at that. Medicine is a business, according to many, characterized by "relative value units," "diagnosis-related groups," and compensation formulas that "incent" proper care. All these terms dehumanize the most profoundly human of professions. The business focus reduces those who practice the profession to "providers" or "contractors," updated terms for tradespeople.

The experience of medicine as a calling atrophies. The vocation of medicine (as distinguished from its practice as pragmatic activity) is integral to doctors' practice. A vocation compels right action, inspires sacrifice, holds a covenant with excellence on behalf of the patient, and provides a deep sense of spiritual and professional satisfaction in a physician's life.

Meanwhile, overburdened hospital executives, who are just as focused on their economic challenges, have quietly drifted from a core professional practice of their own: caring, respectful, and frequent engagement with physicians in the clay-to-clay life of the hospital.

For a variety of reasons, then, this diminished sense of medicine as vocation has reduced doctors' participation in the communal, civic, and societal activities of their profession, one of which is collaboration with the hospital and its mission.