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Doctors and Patients as Commodities - A Labor Day Irony [1]

['This Content Is Not Subject To Review Daily Kos Staff Prior To Publication.']

Date: 2023-09-05

I hope you had an excellent Labor Day! As a doctor I have been unable to exercise that basic right to bargain collectively. There’s an ethical imperative to keep working no matter what on behalf of patients. Going on strike might lead to much harm. But this Labor Day did cause me to reflect on just how much you and I have been commodified.



Billboards

Driving to work through Philadelphia is stressful. There are the usual threats we all face from sociopathic drivers and cavernous potholes that shake our bones. There are billboards advertising medical malpractice law firms, Wawa hoagies, and medical malpractice law firms. But there is a new billboard on my morning commute that went up recently. It proclaims the wonder of family physicians, brimming as we are with “experience, compassion, and advanced training.” It made me smile for a moment, until it made me frown.

Why do physician groups, hospitals, and medical practices advertise themselves?

Physicians were not permitted to advertise until the 1970’s after an FTC ruling opened the flood gates. Prior to that, a codified agreement among physicians not to advertise existed since the first AMA code of ethics published in 1847. As a profession, we tried to rise above the cheap tricks and snake oil salesmen by explicitly giving up the economic engine of manipulative advertising. This enhanced our prestige and built trust.

And we became terrible businesspeople. Our pretensions were ripe for exploitation. Healthcare makes up almost 19% of our 23.2 trillion dollar annual GDP, and so it was only a matter of time before we ended up on billboards, fighting for market share with cheap tricks and snake oil salespeople again.

I looked at the billboard as I waited for the red light to change. Experience (?) The male “doctor” depicted on the billboard looks like a 26 year old graduating medical student to me, and the female “doctor” maybe a year older or younger. Compassion (?) Those smiles are fine for the opening greeting of a visit. But the real substance of a primary care visit is usually mired in chronic diseases, grief, anxiety, and suffering of varying degrees. Hopefully the visit is at least bookended in smiles. Advanced training (?) Maybe. It depends on where the young doctors did their medical school and residency training. I’m sure that’s listed somewhere, right?

I was jarred from my billboard contemplations by a bellowing car horn, and the furious, contorted face of the driver behind me, whom I had just made 1.82 seconds late. It’s hard to keep shaking off the endured hostility of the morning commute, to keep slipping back into that billboard-worthy, smiley, compassionate disposition. But we do our best.

Online reviews

Are you old enough, and of sound memory enough, to recall a world before online reviews? It’s getting difficult for me, too.

If breaking the professional taboo of self-advertising resulted in patients losing trust in doctors, then untethering patients to tee off on doctors with anonymous online reviews eroded doctors’ trust in patients.

It started out as an unscientific, highly biased process. People with bad experiences or impressions were more highly motivated to drop negative doctor reviews. Health systems and physician groups slowly adapted. Now, instead of just finding some random website hosting 8 reviews about a physician who sees thousands of patients in a single year, professional survey companies (engaged internally by healthcare systems) often post 600 reviews and counting. Those companies solicit and collect a broad sample of reviews from confirmed patients after they have been seen by the doctor. It’s a bit more fair, and with a big enough sample size some studies have actually found that reviews and ratings might even correlate with quality.

Have you personally been reviewed? It’s not something any of us professionals signed up for when we sacrificed our twenties incurring debt, and feeling the certainty of missing out socially while we often worked 100 hours per week. Sometimes 120 before they capped it. Objectification and commodification through a five star system in return doesn’t feel right. It feels like one might imagine a burger must feel.

I’ll read through my reviews once or twice a year. I’m glad if they serve a purpose for the public in trying to discern quality. But I don’t want to corrupt my intent as a physician. I don’t want to practice for likes and 5 stars. But I admit I read through my reviews before writing this post, and was humbled and reinvigorated by what I read, so a public thank you to everyone who still considers doctors with some regard and trust. Despite the billboards, and the crushing system that often pits doctors and patients, the little guys, against one another… we are truly in this together, and mutually vulnerable.

Patients, a.k.a. consumers

Here’s a quick fable.

Insurance companies pay too little. Healthcare systems consolidate for bargaining power. Small medical practices join the system or languish, or charge patients thousands of dollars for concierge memberships to remain independent. Administration balloons everywhere, and the business-minded underpinnings of our noble pursuit are laid bare. The term patient morphs into the term consumer.

The first time I sat at a meeting and heard patients being referred to as consumers it honestly appalled me. Of course we all need money, and we work for it. But the language we use while doing it matters.

I will never call a patient a consumer.

[A version of this post was first published on EXAMINED, a substack I write as a family doctor. Like a good union, new subscribers are always welcome ☺️]

Top Doc honors for sale

Suffice it to say that this might be the ultimate breaking of that once codified taboo that physicians should not advertise themselves. Top Doc awards, plaques, and frames on the office wall can be purchased. Advertisements in magazines trumpet Top Doc awards in special advertising sections, and seem to be especially common in plastic surgery meccas like LA and Miami.

Other Top Doc awards cannot be purchased, but are instead granted based on nominations and votes from physician peers. This favors physician leaders, administrators, and those in larger practices and systems. It disadvantages doctors who keep their heads down at patient level, out of the spotlight, and out of the institutional leadership positions.

How do you actually find a top doc, and what should qualify someone to be so named? I don’t have all the answers, but I think some combination of checking where the physician trained, finding the sweet spot between being newly minted and well seasoned, positive word of mouth from other people, fellow physicians’ recommendations, and unfortunately a few actual visits with the doctor might suffice. The real Top Doctor needs a balance of persuasiveness and humility, science and art. They should exude a commitment to lifelong learning, and a passion for teaching in small examining rooms with you.

And said doctor should always be running at least a bit late.

~

How can we resist becoming commodities?

Question the billboards. Read reviews generated from internal, fair, broad sampling techniques that pull in hundreds of actual encounters. Or don’t read reviews. I don’t believe that as patients we are consumers. Maybe we are, but I refuse to give power to a language that leads to our sacred doctor-patient relationship being rebranded as a provider-consumer shell of its former glory. And when you find yourself a top doctor, know that they are imperfect, struggling like you to balance professional and family life, and are simultaneously helped and constrained by the system.

None of us should accept being commodities.

We are more special, alive, and indomitable than that.

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[1] Url: https://www.dailykos.com/stories/2023/9/5/2191578/-Doctors-and-Patients-as-Commodities-A-Labor-Day-Irony

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