This MPPA Meeting (in its 24th year) was held, Wednesday, October 13, 2021, at 6 PM. Professor Robert G. Kennedy, of St. Thomas Univ, led us in a discussion of Professionalism 101 in Business and Medicine. We met at the Shoreview Community Center in a beautiful room; but with woe—the internet connection was down (possibly due to a local windstorm). That meant that only the 16 in-person folk were in attendance, while the 15 others on Zoom had no way to check in. Despite a digital disaster, we had a great meeting. Read on…
Present were Hannelore Brucker MD, Robert Geist MD, Robert Koshnick MD, Wayne Zuehlke CPA (ret), Marie Casey Olseth MD, Tim Herman (ret), Peter Nelson JD. Dave Feinwachs JD/PhD, Merlin Brown MD, Mike Ainslie MD, Don Gehrig MD, Doug Smith MD, as well as guests Andrea Hillerud MD and husband, Sujit Varna MD, and Prof. Robert Kennedy PhD.
Because I could not record a Zoom meeting, you are left with having to plow through my attempt to capture the meeting’s conversation. If my writing is boring, rest assured that the conversation was thrilling, because of the wit and good humor of our many heavyweight medical system gurus and because of Professor Kennedy’s skillful lead. BTW, we talked about the medical system, not the politicized sophistry of “health care;” the national debate about healthcare is really a debate about Medical care. The “system” politically evolved into powerful crony cartels for alleged “cost control”, patients have become a “population”, a commodity auctioned for servicing.[1],[2]
Last June 9, 2021, we discussed Medical Econ 101—the origin of medical marketplace dystopia of unrelenting cost-price inflation and other distortions, a discussion led by Professors Steve Parente (UMN) and Charles E. Phelps (Rochester Univ. NY). This meeting addressed medicine’s other primordial problem: Professionalism—[its corruption under the guise of “stewardship” is programed “incentives” (aka P4$P, “value pay”, and “bonus opportunities”) for rationing use of MCO corporate and/or CMS money for care.]
Once again please note that my own opinions in these minutes are always enclosed in [brackets—rwg]
Prof. Kennedy noted that Medicine is one of the oldest professions as the medical faculties of medieval universities were large and trained most medical doctors. Standards were set; medical expertise expanded and continued its expansion that led into today’s ability to take care of almost any complex medical affliction. The following paragraphs are Professor Kennedy’s outline; I could not do justice to his many remarks that skillfully filled the outline gaps.
He defined the indispensable characteristic of a professional: the ability to exercise sound and reasonable judgment about important matters in conditions of uncertainty. In order to contribute this judgment, the professional must have autonomy in action. In turn, this autonomy cannot be secured or sustained without trust, which is founded on commitment and specialized knowledge. In other words, knowledge and commitment make possible the exercise of professional judgment in service of individual well-being and the common good.
The Specialized Knowledge of the Professional is an accumulated and ordered knowledge, built up over time by the experience, analysis, and insight of predecessors in the field; a knowledge not only of how things happen but why they happen that way. This is a knowledge of causes, not merely of regularities or techniques. This knowledge is ordinarily acquired in universities and augmented by the experience of the individual professional and of other practitioners. As a result, the professional is the opposite of a self-made person and owes a debt to the predecessors and the communities who made possible the assembly and transmission of this knowledge.
The Commitments of the Professional to be a professional, to “profess,” is to stand for something in a public context, to make a public promise to the community. The first thing that professionals profess is commitment to address problems according to the principles and accepted practices of the discipline. The second thing that professionals profess is to use their special knowledge principally to serve others and not primarily to serve themselves. The Hippocratic Oath is an expression of the commitment to serve and not to harm.
Professionalism means Judgment: professionals make sound judgments in conditions of uncertainty. Autonomy: professionals must be free to make their best judgments in particular circumstances. Commitment: professionals make commitments both to practice according to the standards of their profession and to put the interests of those they serve ahead of their own; Knowledge: professional knowledge is systematic and a knowledge of cause.
Some Observations about the Profession of Medicine: “Healthcare” really means “professional medical services” (physicians, nurses, pharmacists, et al, The “institutionalization” of medical services—Private, not public resources), Unlimited demand vs Finite resources; We have yet to solve the “problem” of affordability-access-quality (What does each of these terms really mean?); [It means the HMO/ACO dilemma: “Cost, Access, Quality—Pick Any Two”; rwg.][3] Medical professionals are victims of their own success (Heightened expectations: the extraordinary as routine, Routine leading to competition.)
Conflicts of Interest and Professional Medicine. Professional performance always entails coping with conflicts of interest. Conflicts in tension with professional standards (Professional standards vs external incentives, Individual rewards/punishments, Institutional pressures, Professional standards vs personal goals); Particular goods vs Common goods (Commitment to individual vs community or Commitment to individual vs organization).
What does professionalism require of you? Balance, Courage, Humility
Open discussion. Our primary care physicians said that their commitment is to their patient not to nebulous “community resources.” “Patients ought to make decisions with their particular resources.” “Population care creates a conflict of interest between 3rd party insurers possessing most of a family medical care budget from premiums profit-driven to restrict care and patients needing more”. A lawyer said the “basic concepts of professionalism overlap with medicine…I also want to deal not with a lesser trained person with a white coat , but with a doc I can trust for expertise and integrity to address my problems.” An accountant looked up his code of ethics and found it 162 pages—Hippocrates, where were you when the CPAs needed a more parsimonious version?
The conflict of interest between UK patients needing dialysis and lack of public NHS resources for it led to a scandalized medical profession that had cooperated with the government assumption that those over age 50 did not need dialysis because they were “too crumbly”—no-treatment meant death; seen by some as “necessary” [a common term in NHS and US “managed care” circles]. Since “Medicare Advantage is an advantage to the insurance corporation I chose Google to find my doc.” Another specialty physician noting the power of such Medicare Advantage crony corporations partnered with government said about America’s families, “give ‘em back their money, and get out of the way…primary docs [on production lines] no longer have time to deal with patients…specialist can afford to sit down for a timely visit.”
The disconnect between care and real prices for care seemed obvious. Another specialist noted that “3rd party system controlling medicine’s dollars interfered with physician autonomy; cash only practice was much more affordable than when finances were controlled by 3rd parties.” Another noted that not only has physician autonomy been lost, but trust in science has been the victim of CDC varying and often contradictory recommendations clothed in “Science.” A rural family physician noted that autonomy was present in the 1960s but lost in the 1970s…subsequent 3rd party control resulted in demand inflation…that was avoidable and can corrected if patients were empowered with their own money for medical care and its insurance.
Professor Kennedy in summary said that he agreed with much, if not all, of what he had heard: there is conflict between professionalism and the current system; the appearance of a price free system would ordinarily never be designed; self-regulation of demand is best; and professionalism is constricted in the current system. We should not forget his admonition: What does professionalism require of you? Balance, Courage, Humility
[RWG comments: After the meeting, Doug Smith, our MPPA President and practicing family doc, wrote me this: “I would be more than happy to discuss the “profession” of medicine with Dr. Kennedy more as there is always this shift to public health/health care when medicine is brought up… the profession of medicine is individual, NOT public health.”
[I wrote Doug and Professor Kennedy that, yes, we ought to continues the discussion together, but I thought more could be said now as well. [For example, Doug expressed the problem that docs’ see today as (government-like) macroeconomic fixed-budgets for a microeconomic medical sector, where millions of transactions take place daily between millions of people. Macroeconomics is where MCO industry/federal/state means of and power to control a fixed budget of an insured population whether in the private or public sector. Clinician choices are a cash only practice, go broke from poor pay MCOs (“our way or the highway” negotiations) and state price fixing, or end up employed by the MCO industry. Typically, a mini-ACO (hospital-medical staff) insurance corporation chain—the way out for many clinicians of which there are few left in private practice. [In an ACO, the insurance risk can in part be transferred to clinicians creating an obvious financial conflict of interest with each patient transferred from corporation to bedside “incented with a bonus opportunity.” The clinicians, as discussed at our meeting, are being replaced with the lesser trained, which function in ‘teams.’ All such “providers” will predictably, at some future time, be financially “accountable” for the corporation’s population care costs. Not all have the history of a MD professional’s >2000-year covenant of exclusive loyalty to the patient. [I wrote Doug that economists, pundits, and politicians tend to think in terms of social engineering (government) fixes for “populations”—his Public Health comment is apropos. They forget that private sector free markets solve cost/price/access/quality problems easily millions of times daily in transactions between millions of people in other microeconomic sectors—these do not suffer un-remedial demand inflation nor do employer’s insure groceries (Why? A discussion for another day, if not obvious.) [The social engineers in DC created demand inflation after 1965 when 85% of the population (employed workers, and the official old, poor, and disabled) suddenly had in-expensive tax-subsidized insurance; care appeared “free” when the boss or government paid for it. Too bad that pundits and politicians always see and can never understand why macroeconomic social engineering for “populations,” a zero-sum fixed-budget game, never works when applied to a microeconomic sector like medicine. To paraphrase the economist John Cassidy: no central authority, however brilliant [or good willed] the managers, can accomplish the functions of freely determined prices for the allocation of labor, capital, and human ingenuity.[4] [The fatal flaw of command-and-control markets, is that real growth results from the flexible non-zero sum private microeconomic sector budgets (of aggregated millions of family budgets) operating in a free market “where millions of transactions….” That’s the economic engine that drives the wealth that leads to ever expanding scientific innovation—the expansion neatly described by Prof. Kennedy. This is an expansion that social engineers see as a problem not as a benefit of a new antibiotic that saves the life of an elderly person with pneumonia and easily keeps them out of the hospital too. [As two nationally renowned economists said at our June 9 meeting, the economic “original sin” of tax subsidies for “Health Care” led to demand inflation; it thus created all “cost control” distortions of the medical sector that followed. To which I have added the distortions of trying fix cost-price demand inflation through franchising fixed-budget corporations profit-driven to ration the “free” care—a nasty and corrupt hidden solution to economic political malpractice that created only the appearance of “free” care. [All this is an accurate description of what happens, when pandering “free” care politicians try to fix the havoc they created with social engineering that takes away the benefits they promised through using profiteering corporations to ration care rather than through admitting their ‘original sin’ of political economic malpractice. Confession would be good, because redemption awaits, if American families become kings in the medical marketplace, as they are now in all other microeconomic sectors. Those sectors work, unlike the medical. There lies political redemption, but it won’t happen until pundits and politicians admit their multiplying errors.[Is there a better way? A better way of financing medical care is possible—it means dethroning the current corporate-state administrative barons, whose real job is rationing “free” care for “cost control”—it’s that simple.
[Needlss to say, care does not appear “free” to people with fixed family budgets. This paradox created by political malpractice is frightful—rwg.]Next meeting: early February 2022
What can we do about the programed destruction of Professionalism; a threat to patients?
That is next in our 101 series of discussions regarding primordial issues in medicine.
In early February 2022 we’ll focus on Politics 101—Pending MN bills and Panaceas. Can we begin to fix medicine one step at a time? Or will one or two panacea books recommending big leaps have solutions to medicine’s cost, access, and quality problems?
Respectfully submitted,
Robert W. Geist MD, MPPA secretary pro tem
651-485-5933
7 Sandpiper Ln
North Oaks, MN 55127
[1]Alok Gupta, Stephen T Parente, Pallab Sanyal. Competitive bidding for health insurance contracts: Lessons from the online HMO auctions. UMN Carlson School MIS Quaterly. Dec 2012. https://experts.umn.edu/en/publications/competitive-bidding-for-health-insurance-contracts-lessons-from-t
[2] Woolhandler S, Himmelstein DU. Annotation: patients on the auction block. Am J Public Health.1996;86:1699-1700.
[3] Bodenheimer T. The Oregon health plan—lessons for the nation. Parts 1 and 2. N Engl J Med. 1997;337:651-655, 720-723.
[4] Cassidy J. The price prophet. The New Yorker. February 7, 2000:44-51
