When I first began to discuss this topic with my fellow EP’s and friends I was very surprised at the powerful emotional response it evoked. From my father, a retired orthopedist; “I say you drop it right now! This idea will not put shoes on your children’s feet, or food in their mouths…DROP IT!” From several full
time EP’s; “Sounds good, but don’t mention that I had anything to do with it.” And; “I will be glad to help you but don’t mention me in any way. If you do I will deny any involvement.”
The biggest change in medical practice that has occurred during my 25 years as a physician is the open acceptance of Physician Employment. In 1993 I worked in California, and there were laws preventing the corporate practice of medicine. Even then, however, physicians were actually employed, just not openly. The CEO chose/chooses a group of emergency physicians to staff the hospital’s ED. The terms of the staffing contract are compared to other groups that compete for the contract.
Physician employment was, and is, obviously an intrinsically flawed structure that was considered absolutely unacceptable for obvious reasons for the entire history of medical practice!
When did physician employment start? Well, that is not as clear as the advent of physician employment contracts signed by the CEO. My father, an orthopedist, was on medical staff at 3 local hospitals. When one CEO approached him and demanded that he perform procedures under general anesthetic, rather than by using the regional blocks he preferred (faster, safer, far less expensive for the patient) he was able to say; “That is unacceptable. If you insist, I will perform my procedures at (the other local hospitals).” The CEO rapidly dropped the issue. Were my father employed by a single hospital, with his employment contract signed (or not) annually by the CEO…well you can see the difference!
The CEO wants profit, and the money end of the deal is a great driving force. The CEO decides if He/She will choose a group with an NP/PA model, or a pure physician group, for example. The administration decides if the new EMR will be physician/patient friendly, of if it will squeeze every dollar out of every patient encounter, and keep all of the physicians typing for hours after every shift.
As EP’s we have always been employed. Only in a truly unaffiliated, freestanding ER could we potentially be free of the business dictates of the administration. So…what can we do about it? At this point there is no hope of reversing the trend of physician employment. All we can hope to do is work to ensure that the administration shares our goals and ethos. As physicians we take an oath. The intention of our oath is to ensure that our medical practice retains the goal of serving and helping patients as the overriding force. Profit cannot be the overriding force in medical care. Our oath provides that we should have a comfortable living, and prestige. Certainly, hospital administrators should also receive the fair “fruits of their labors,” but it is arguable that a 49 million dollar annual CEO bonus violates the spirit of medical care. I believe we should extend our line of altruistic thinking, and actions to include the hospital administration.
The Oath that follows is intended as a draft, and not as a final product. I do not claim much originality, and most of the concepts are borrowed from our Hippocratic Oaths, both ancient, and more modern. Collaboration and discussion between physicians and administrators will be needed to arrive at a final document. I believe that many hospital administrators will be proud to agree to, and live by, such an oath.
This is an issue for the “old guard” to address. As a young physician, your job is solely to practice quality medicine, think of your patient’s first, and continue to improve on your capabilities. As a young physician in our current culture you cannot afford to risk appearing critical of current hospital administrative practices.
Medical Administrators Hippocratic Oath
I swear to fulfill, to the best of my ability and judgment, this covenant.
I will realize that as a Medical Administrator I must place people’s welfare ahead of profit and prestige. If I am unable to maintain this prime directive, I will seek employment outside of the medical field.
I will respect the hard-won knowledge and abilities of the physicians and caregivers with whom I work, and which I may employ. I will assist them to provide the best care possible for those that seek our help.
I will gladly share my administrative knowledge and wisdom with those who are to follow. I will share the concepts herein, and counsel my trainees to ensure they find employment that will mirror their ethos. I will assist those not suited to medical administration in their efforts to find a suitable career.
I will work to ensure that resources are available to provide, for the benefit of the sick, all measures that are required.
I will aggressively support and fund the prevention of disease, utilizing those preventative measures that are proven least harmful, and most effective, realizing that prevention is preferable to cure.
I will fund and support equally those effective tests and treatments that are both more, and less profitable.
I will realize that resources are not unlimited, and will strive, with the assistance of my providers, to do the most good, for the most people, with those resources that are available.
I will be very careful with incentives and awards, ensuring that the end result is both safe, and beneficial to the people that entrust me with their health and welfare.
I will value and support both the technical excellence of my colleagues, and their human graces.
I will not reward or praise over treatment or therapeutic nihilism.
I will not be ashamed to not know medicine, as medicine is not my realm of expertise. I will defer decisions regarding treatment and testing to my trusted providers.
I will respect the privacy of my patients, holding myself to the same standards, in that regard, to which I hold my providers.
I will realize that the business decisions that I make have powerful and far reaching effects upon patient care, and will bear this awesome responsibility with great humbleness and awareness of my own frailty. Above all, I must not play at god.
If I do not violate this oath, may I enjoy life and good health, respected while I live, and remembered with affection thereafter.
I would suggest we form a group to discuss and refine the above Oath. A physician group that meets AAEM’s best practice criteria, managed by an administration that agrees to such an oath would indeed be the ideal.
Mark Borden MD, FAAEM