I have been in private practice for nearly 17 years. I worked in corporate health care straight out of residency, nearly 25 years ago. It didn’t fare well for me. I struggled inside, conflicted by the dissonance between the true mission of medicine and that of corporate medicine. The corporate mission saw patients as commodities for money and physicians as work horses. The boards of these systems used profit alone as the measure of the physician’s success. I saw my colleagues losing contact with what was real. When the hospital told me I did not admit enough patients to meet their projections, I left corporate medicine and never looked back. My vision of medicine conflicted with theirs.
As a physician in private practice, I need to interface with the corporate system. My medical practice accepts insurance, I am a part of an Independent Physician Network which is affiliated with a local hospital. They base their measure of credibility on what the ABIM (American Board of Internal Medicine) dictates. Their standards have been shown to have little correlation with physician competence and performance. Their requirements of physicians are inhumane. Physicians are weighted down to serve two patriarchs. The corporation that pays their wage and the larger corporation that credentials them. They can’t possibly serve three masters – their vocation and two patriarchs with all their demands.
I write this as a physician who can see through the façade and racket of what corporate medicine has created. This system is like an abusive parent. It is abusive towards physicians who are made vulnerable and dependent. They pay with their cell tissue at the cost of their creative fire. Physicians are hurting. Drug abuse, alcohol and suicide rates among them is at an all-time high. Physician morale is at an all-time low. They are afraid to admit they are hurting. They are forbidden to complain or show vulnerability. What does this say about the health of the healers within the system itself? How do we begin to bring healing to them?
The most recent experience I had with ABIM is when I took the Maintenance of Certification exam. Preparing for this exam entailed studying for nearly 40 hours a week, in addition to my working hours, for months. My brain does not work like a standardized test. When I am with my patients, I utilize both my intuition and medical knowledge to access what I need to construct a differential diagnosis and provide solutions. I cannot function under time pressure like the exam expects. There were many questions that upon further thought I wanted to correct. However, finding them again was impossible in the maze of unnumbered questions. I fail this exam, I will have to start over, preparing again to retake it. This maintenance of certification is tied to my insurance reimbursements.
Does this happen to me in the exam room with my patients? Never.
Can I access the information that I need and synthesize the information to diagnose, treat and heal? Yes.
Does a standardized test measure this? No.
Can a standardized test have so much power over one's life? Passing, failing?
Does failing a test like this negate everything we know in favor of being evaluated by a system that has lost its soul? The board? Who is this board? What gives them the power to do this to physicians who have been in the trenches for decades, helping, healing and loving their patients and their work?
When we entered medical school we placed our spontaneous, creative nature to the side. The critical parent became the voice in the background. It demanded perfection. It still does. Our performance has become the neurosis we perfect for survival. This kind of perfectionism is normalized.
When we complete our training, exhausted and worn, we are vulnerable to the demands of the outer patriarch–corporate medicine. He is satiated by the money we make. If we adapt to his demands, we are rewarded. If we don’t we are abandoned.
My experience of the exam was nothing short of torturous. The Board has become the external critical parent colluding with the critical parent within. He runs roughshod over our sensitivity, creativity, heart and intuition. Without these, our health is at stake. We must reclaim these parts to be whole again.
This is what is upon physicians today. That which makes us human, is not even seen. We are herded together like hostages, serving this angry patriarch. I am questioning what we have created here. What kind of system is this where is no room for process? Fast paced, material centric, product oriented, side stepping the heart - where is it all going? The stress this creates is the highest risk factor for all diseases.
I write about this because I must. I too was a hostage of this system. In some ways I still am. I have not slept well in weeks. Anxiety, worry, fatigue, weariness, nausea....all symptoms triggered by the boards. I have heard and held the pain and anguish of my patients, many whom are physicians. I know this part of the shadow of medicine is real.
We must talk about these issues if we want change.
In the words of Paul Teristein M.D., …”many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice. Perhaps it's time for practicing physicians to take back the leadership of medicine.”
I think it is time we do.
What do you think?