Professionalism and Medical Social Engagement

Jack Coulehan, Peter C Williams, S. Van McCrary, and Catherine Belling in the Cambridge Quarterly of Healthcare Ethics, 2003 12 21-38,  article, "The Best Lack All Conviction: Biomedical Ethics, Professionalism and Social Responsibility" do a superb job of discussing "Professionalism and Social Engagement".  As a clinician I truly admire the way they summarize the issues clearly.
They begin by asking "Are altruism and social activism appropriate topics for medical education to address/"  While saying we 'admire' doctors who 'work in free clinics' or 'engage in public policy debates" but, "do these activities make them better doctors or simply better people?
I have had to reflect on this alot in my life because it's my personal experience that I have been penalized routinely for putting patients concerns first and "rocking the boat' or 'swimming upstream' against individual and institutional graft and corruption.
I was indeed told that my membership in Physicians for Social Responsibility and my days as a card carrying member of the Canadian Civil Liberties Association was considered a 'fault' in a psychiatrist.  While I was reading Jay Lifton, MD's books, including "Nazi Doctors',  my colleagues who went onto increased power and position were studying "business administration" and reading 'financial columns."
I began a dual speciality in Community Medicine and Psychiatry where at the time the furthest extremes of equation public and private were represented by both faculties. The Community Medicine faculty taught me public health concerns and I even wrote a paper on Psychiatry and Social Responsibility in the 80's in the Canadian journal, seeing it back paged. I wrote responses to medicare decisions in the provincial journals and was actively involved in medicine and politics.
In comparison one colleague saw roughly 50 patients for 30 years having a coffee clutch weekly with these loyal patients.  I saw thousands in comparison and worked on the toughest 'assignments'.  I am usually uttterly exhausted by the end of any clinical day.  I certainly haven't time left over for the constant beaurocratic in fighting and back scratching.
New patients are the greatest risk of complaint.  A 'stable' is never a threat.  My colleague who 'gives patients what they want' has a loyal following. Popularity is their calling.  Rate your doctor has their name as 5 star.  They cherry pick patients and had been seeing their friends only for decades.  They sat on committees and served in the main stream high profile positions.  They had energy for these functions where they ensured that the greatest funding and support went to doctors of like mind.  In the end they had 'position power'.  They never 'rocked the boat' and they never challenged the authorities.
Social responsibility is a precarious position.
I think back to a half dozen complaints I had to the College of Physicians and Surgeons and the most vociferously complaining patients on rate your doctor.  These complaints have been specifically to do with my diagnosis and addressing addictions. While in my psychiatric residency I worked in the Winnipeg Detox.  I fear I was the only psychiatrist who did that, certainly the only one I knew while I was there.  When I came to BC I just naturally continued to diagnose alcoholism and substance dependence according to DSMIV criteria, using AUDIT and CAGE screening tests when available.  Alcoholism and substance abuse disorders were simply rarely diagnosed. The standing joke in the 80's was that you didn't have an alcoholism problem unless you drank more than your doctor.
I have seen patients that other colleagues have 'colluded with' and said they did not have 'alcoholism'.  No clinician would question a list of DUI's and liver disease etc as evidenced based diagnosis but I would invariably be the first to make the "diagnosis" despite dozens of doctors seeing the patients. The patients would be outraged,
The consequences of my doing my 'job' of diagnosing 'alcohol dependence", "cocaine abuse' and other DSMIV Axis I diagnosis has been that my life has been threatened repeatedly, my windows shot out, beer bottles smashed against my windshield, cases of empties thrown at my house, my dog killed.  It would have been professional and socially responsible for my colleagues to have made the correct diagnosis but 'at what cost.'
The consequence of a diagnosis of 'addiction' was that people who were working in safety sensitive areas and were causing accidents in the work place would be 'required' to 'undergo' treatment for the addiction.However if they could get a psychaitrist to say that they were 'depressed' rather than having a 'concurrent diagnosis' they could avoid the  consequence of their actions.  Indeed if they could get a psychaitrist to tell them their mother's lack of breast feeding necessitated their drinking at the age of 50, even better.
The cost of doing the 'right thing' being the 'socially responsible' doctor, is that I have lost at least a quarter million dollars  in real money and time.  I've lost personal time to pursue my own research interests.  Instead of addressing issues of 2012 I'm mired in dealing with what was proven true and beneficial 20 years ago.  Indeed in general psychiatry circles I am surrounded by proponents of 'better living through chemistry' and considered too 'conservative' when it comes to addiction matters.  Social activism is only 'hip' if it's left wing and pro pot smoking.
The politics of medicine favour those who make the most money in the practice of medicine.  Making the most money is based on doing the old technologies and old standards of approach.  The reformer is an enemy of anyone who benefits from the status quo.
All my pro bono work in a variety of areas has in no way benefitted me in the 'hierarchy' of medicine.  Indeed I've heard colleagues contend that if I'm doing these things for free then they are without value.  When doctors have attempted to get paid for all their many hours of 'free' work people collectively become obscenely offended yet would never expect anyone else to work overtime, be on call, or work without pay.  The deeply shameful government year in and year out published the 'gross earnings' of doctors who routinely paid tens of thousands of dollars in training and started earning 10 to 15 years later and died routinely 10 years younger and worked on average 120 hours, the equivalent of 3 government jobs, yet were compensated at a penance of their worth.  When people complain of the 'nationalization' of mines and copywright theft and fixed housing income and interference in private business, I just reflect that I have worked my entire life with a ceiling, and supported government services up the ying yang through taxes and my doing the core clinical work which is what causes the overall health care services to be supported. There is no health care services without doctors but administrators and planners and beaurocrats galore ride on the shirt tails of the work of physicians, work that is commonly donated free. So every time I did 'motivational therapy' regarding quitting smoking going back
Now I'm at the end of my career and if the life expectancy of the doctors I started is anything to speak too, perhaps my life, due to stress and overwork and lack of resources or support.  So many of my colleagues I worked with in early years died in their 60's, and then there were those friends who died young from diseases the caught in their work.  Every doctor I know except some administrative government types and a few for profit only doctors generally does pro bono work.  Even in the 'bad' United States it was standard for doctors to donate their time to the indigent hospitals.  If I were paid in my office today for all the work that I do I'd be a millionaire many times over.  Looking at the fee schedules with a colleague recently we laughed at how the 'bean counters' have set it up so that hospital doctors with accounting departments can ensure that ever cent owed is collected whereas in community medicine and psychiatry bad debt in the name of the game.  I've lost 20$ of my income in uncollected fees in a bad year, 10% in a good year.  When I had a psychopathic staff person steal from me her criminal behaviour was never addressed by police or government.  The doctor is routinely treated as the 'bad' person with all those poor people who are suffering and yet it's so forgotten that doctors are patients too.
I don't get breaks financially.  I don't have people doing things for free for me.  Instead my life has been that people in business learn I'm a doctor and I am double charged even though a doctor saved their baby's life. There's a great lie in business that business people are 'big hearted' . They're not. The rich are rich by not losing money.  Yet we know the standard joke is to invest where doctors are not.  Because doctors collectively are giving it away.
So despite being reasonably re imbursed, not at all in the league of health care administrators when their time off, holidays, lunches, perks, coffees, pensions, plans and everything is truly factored in, we're still working for free alot for the sake of patients. We're covering the indigent. We're all doing our best for children and commonly women and the old.  We're staying late at bed sides and we're really caring.  But when doctors go on salary oddly they work like normal people and the whole system simply cannot afford salaried doctors here.  Salary commonly brings out the 'union' 'work to rule' ideation. Maybe it works elsewhere. Maybe it could work.  The difficulty in the field is that there are those who are communists and those who are capitalists. The socialists sit in between somewhere and mostly we thrive in a mixed economy.  My favourite cosmetic surgeon donated time to the burn clinic. He made his money on nips and tucks and could enjoy restoring children's faces after devastating burns.  The standard medical service payment couldn't pay anything near his fees and any businessman wouldn't work in the low end of the scale with the burn patients. Yet most plastic surgeons I know do just this.  Even the dermatologists, another high paying group who could all be rich overnight if they just stuck to botox instead serve in indigent communities.  It's normal to see this.

So this article definitely wet my whistle.  The AMA recommended 'each physician has an obligation to share in providing care to the indigent".


The authors of this article while raising the question and discussing it conclude
"In summary, it is fair to say that there is a long tradition of social responsibility in the medical profession."

Medical Professionalism Charter 2002

Lancet and the Archives of Internal Medicine in 2002 published the Medical Professionalism Charter 2002 renewing committment to patient care as primary, committment to patient autonomy and a committment to social justice.  Harold Sox, Annals of Internal Medicine, Feb 5, 2002.
I studied community medicine and public health and served in the areas of greatest need. I wrote a paper on Social Responsibility for the Canadian Journal of Psychiatry. I served in the north where doctors simply would not go and in asylums where psychiatrists couldn't be recruited. I worked pro bono for years in many areas and with the dangerously insane and the infected and questionable.  I got on well with doctors who had done missionary service. My colleagues who were most successful and most lauded in awards and promotion were highly particular about concern for the richest of patients.  Indeed, the doctor to the king, has always gone a lot further than the doctor to the poor. I've been an outsider stigmatized with the same stigma that my patients experienced.
Now I see that 'social justice' is part of the 'new world of order' in the 'profession'.  Irks me, considering how much heat I have taken personally for championing lost causes and fighting for the disenfranchised and going where doctors wouldn't go.  I was told by one of the head doctors in the Canadian Medical Protective Association that I was the most persecuted doctor they knew while at the same time I was told by a former head of the Canadian Medical Association that I was possibly the only  psychiatrist with integrity in the province.
I muddle along.  I love medicine and the practice of medicine.  I daily though seem to be fighting government for services for my patients, patients who as ignorantly as I assume those services are available to them as part of the social contract and the taxes we pay.  There have been no elective hospital beds and no nurses and demands for everything political but health care.  I feel like a cop who goes from fighting crime to guarding parking meters.
The charter makes a committment to patients, a committment to honesty with patients, committment to patient confidentiality, committment to appropriate relationships, with patients, committment to improving quality of care, committment to improving access to care, committment to just distribution of finite resources, committment to scientific knowledge, committment to maintaining trust by managing conflict of interest, committment to professional responsibilities.
It has been my experience the authorities pay lip service to the 'committment to honesty with patients."  It's a crock. My own experience and the experiences of my patients testify to the hierarchal dishonesty in the system. Twice I have had doctors lie in their care for me to cover up their errors and save their asses. It's a routine failing in the system.  I have witnessed it routinely.  It's as if there were two ledgers in the health care system, one for the patient to read, and one for the authorities. The same system applies in the baurocracy with secrecy and close doors and clandestine discussions.  Until there is a 'culture of honesty' there will only be the appearances in this regard. The reason I am following the Julian Assange case and Wikileaks is that it speaks to our very own governments real position on honesty to those who are served.  There is too much power in secret societies to expect this to go away with flowery words.
Committment to just distribution of finite resources - I can be committed to anything but in the end the rich and powerful get the kidneys or whatever. No one I know is standing in their way and all of the beaurocratic authorities have been there to assist in this.  Committment to scientific knowledge seems to be mostly whatever scientific knowledge is fashionable.
I am hopeful regarding conflict of interest.  I was forever getting into trouble objecting to the conflicts of interests in patient care. People were doing all manner of dirties locally and I was getting into all manner of trouble bringing it to the attention of the authorities. It was al most like 'no publicity is bad publicity'. Caught red handed the perpetrators of heinous wrongs went right on doing them at increased profit.
Now I don't see this so much.  Partly because I've taken to looking the other way like most of my colleagues always did.  Partly because pharmacists are calling themselves 'professionals' and people are expecting them to act in a less cavalierly tyrranical manner than they have to date so the heats off the doctors and moved to the pharmacists and perhaps others in the system rich on conflict of interest.
Committment to professional responsibilities is a vague thing. The more I 've been committed to my profession the more I've been criticized.  As a specialist and subspecialist I've devoted another 6 or more years of loss of income and study to being trained at best for my patients while my colleagues who didn't do further training remained with position authority and gained more money and power. Today it's common to see the highest ranking professional being ordered about by the lowest common denominator in the health care system. The patient and the doctor are least welcome too often.
I think the charter is a good thing. I wonder about the language. It seems a lot of work and yet it doesn't appear to add much to the code of ethics for physicians . I am not sure I agree with words like 'justice' being used in medicine given such short thrift the word got in legal circles. Blind judges are one thing but blind surgeons are another.
Since 2002 things don't seem to have got much better in the patient care area despite this fine manifesto and I fear mostly there are fewer and fewer hands to do the work while more and more people seem to be getting paid vast sums to talk about the problems of the patients.
That said the charter overall seems fine unless it is used as too many such papers have been used, to beat doctors and deny patients. The devil is in the details.