Medicine cannot be truly humane without care and interpersonal relationships

The rule of economics sickens our healthcare system

by Professor David Holzmann, MD, Zurich

“A last and basic principle, that doctors should be enabled to provide to their patients, is appreciation. A doctor can only find his professional fulfilment if he succeeds in retaining a basic appreciation and offering it to the patient. […] But you cannot prescribe interpersonal relationship and check it in a management system. […] Structures must give space to humanity so that it can flourish. For this purpose there must be a consensus that despite all efficiency dictate as a matter of course money must be invested in good working conditions in healing professions. […] Doctors and nurses must experience appreciation by the system in order to appreciate their patients and engage for them in a human way.”

Giovanni Maio, p. 160f

Still, health is the highest good for human beings. Every physician can experience this as a feedback from the patient, for example in the form of large relief when a medical clarification or a treatment provides a satisfactory result. It is in the great hope of health or of a successful treatment of an illness or an injury, that patients often generously overlook misconduct by doctors or nurses or inconsistencies in administrative processes. Nevertheless, it can be noticed a growing dissatisfaction of the patients. When patients express their complaints in personal feedbacks, letters or letters to the editor in newspapers, there are certain deficiencies mentioned with constant regularity. Doctors and nurses are said to have too little time for the patient, patient partly don’t understand what kind of disease they have and why they need this or that treatment. When corresponding with health insurance companies, hospitals or other treatment institutions a vast number of forms with questions have to be answered and instructions to be read. The complaints of the patients relate to deficiencies in the doctor-patient relationship, which is given less and less attention to or simply is neglected. On the other hand, more and more doctors and care professionals complain that they can spend less and less time for patients because of rigorous activity recording, controlling, reporting and so on devouring more and more time. Where is this time lost for the patient? Why a bureaucracy that is constantly on the increase?

In a well understandable and comprehensible book titled “Geschäftsmodell Gesundheit. Wie der Markt die Heilkunst abschafft” (Business model health care. How market abolishes medicine), Professor Giovanni Maio, specialist for internal medicine and professor for medical ethics, gets to the heart of a current development in our health care system: the health care system is increasingly exposed to the so-called free market; as a consequence administrative and bureaucratic work and especially complying to budget limits is prioritized higher and higher, while the effective care for the patient is increasingly neglected. Doctors as well as nurses and other health professionals are more and more forced to categorize and treat patients according to economic or financial criteria.
Increasingly, medicine is supposed to work by economic or neoliberal principles. This explains why doctors can spend less and less time for the patient. The same is true for other caring professions such as nurses, physiotherapists and so on. Yet, they have chosen their profession to work with patients, but exactly this is what they have to move away from more and more, because the relationship with the patient is no longer at the top of their priority list.
This explains the growing discontent in the medical profession, whose representatives are increasingly relegated to managers and administrators of patient data.

Medicine on the way to DRGs and budgeting

In Germany and in Switzerland a retrospective funding system was in effect up to the early 90s, which means that the patient is supplied first and only after that a hospital determines the actual costs and requests the compensation. After a health care reform – in Switzerland after amending the Health Insurance Act in 1996 – a change occurred in favour of a prospective financing concept. Thus before the patient is treated in a hospital, the latter has to bother with the financing, how it can treat its patients with the resources available. This change enables the hospitals to achieve profits or losses, which is common in commerce, industry and trade. This change in turn affects the mental state of the staff and rubs off on the satisfaction and job security. This is consequently a central idea of Giovanni Maio: The loss of the social, the doctor-patient relationship, as a result of an economic transformation of medicine that targets more and more on performance, financial optimisation and ultimately to generate income. The doctor, however, has a duty of loyalty towards the patient, which he cannot simply give up. A compromise, a balancing of economic benefit and the welfare of the patient can simply not exist because the latter is not negotiable. Certainly it is true that every doctor should give economic thought to medicine. He must have some awareness of costs, but he should not come under pressure and refrain from certain investigations and treatments in order to avoid a deficit of his hospital. Hospital strategies, which are primarily geared towards profit maximising are to be despised.

Practical implications of an economic approach to medicine

Neither politics nor hospital authorities stipulate the doctors openly, that they should treat patients purely according to economic criteria, respectively they do not stipulate the age at which a patient – as in  Great Britain – no longer has a right to a dialysis. “Although the hospital authorities make no clear standards, but through the departmental budgets and the transparency of revenues each department is put subliminally under pressure. They are extorted as it were, but assure that ultimately the doctors should decide for themselves.” (This and the following quotations are taken from the book by Giovanni Maio.) Doctors undergo a structural dictation by depriving them from more and more resources. For example, doctors are more and more burdened with purely bureaucratic tasks such as meticulous activity recording, coding, requests for cost pledge and so on, by which they inevitably have less and less time for the patient.
In addition to the structural also an ideal dictation takes place by which the clinician is prompted subtle, to treat according to economic and not reasonable medical criteria. He is literally forced to categorise patients according to “loss item” or “profit item”, which makes the overdone diagnosis of privately insured patients explainable.
The direct effect of the increasing economisation is the draconian reduction of personnel resp. the personnel costs. Finally now becomes obvious that the dictate of the economy tends to minimise the time of contact with the patient. To reduce this contact time even further, administrative tasks will be given highest priority, “the non-immediate-documenting is sanctioned mercilessly”. Maio sums up consequently: “Within a more economic approach to logic medical treatment is reduced to a technical service to be run as cost effective as possible.” In this concept, however, in which competition and rivalry are top target quantities also unprofitable parts of the enterprise are determined and repelled. A medicine, however, that the patient avoids in this way, no longer deserves to be called medicine.
Conversely, we observe already today in the revenue-oriented patient care profitability criteria that are essentially more central for the decision for a diagnosis and treatment than the patient with his disease himself. Hence blatantly even hospital administrations and health economists talk of customers and no more of patients. Along with this – according to Maio – a deprogramming of the doctors takes place who see themselves forced to more and more act reluctantly according to economic requirements and to have to say goodbye to the compassionate relationship with the patient. Thus, the doctor is in both senses of the loser: He loses the trust of his patients and the meaning of his medical practice.

Theoretical implications of an economised medicine

The role of economy concerning medicine has changed in a way that economy has developed from a servant to the dominator of medicine. The time pressure imposed by bogus arguments rules out tranquil dialogs between physicians and nurses. On the other hand every action is split up in time contingents respectively defined by fixed timeframes.
A central presupposition of economisation is the perception that treatment of sick people has to follow the modus of an algorithm respectively the model of industrial production. But from this moment on the patient is automatically degraded to a mechanism. Accordingly the physicians have to learn to replace personal decisions by rational automatisms whereby the healing professions are deprofessionalised and industrialsed. In this economised system therapy is not adapted to the patient but the patients are adapted to a therapy schedule. Consequently physicians become convertible, because in the clinic it is not about the person of the physician but about the “proces” of treatment. By “managerisation” and “proceduralisation” of therapy in the end an essential part of medicine is rationalised, namely the trustful relationship to the fellow humans. In this economised system there are no more helpers but service providers. The care for the other is substituted by the delivery of ordered and contractually agreed health products. The empathic engagement of the physician is replaced by the obligation to a perfect service. At this point Maio aptly cites Erich Kästner:

“In their hands everything becomes a ware,
In their soul burns electric light,
They measure even the unmeasurable,
There is nothing that cannot be counted.”

Under the dictatorship of this economic reality the physicians and all helpers are forced to set aside integral thinking. The iatric quality is systematically diminished whilst a rampant red tape has broken out. Everything has to be proved, everything  is being controlled, nothing is taken for granted. To the contrary for everything it has to be given account. The physicians find themselves to be under general suspicion. The constant pressure on the physicians does not serve the good of the patients but only the balances. Working in a merely profit-oriented way weakens self-motivation and thus the true strength inherent in this profession, which offers work close to the patient. But especially the dialog between the helpers – physicians or nurses – is not rewarded. On the contrary, expensive technical diagnostics and interventions are much better paid than a thorough and empathic dialog with the patient.
“That this system is functioning like this after all and that the physicians tag along that way is due to the subtle individualisation of a structurally imposed shortage. The shortage of time and resources is determined from above, but the staff of the clinic has to deal with it. They always have to work under growing pressure.” That the healing professions have not enough resisted against this imposed shortage so far, is due to the successful strategy to declare the shortage – which is predetermined from outside – to be an individual problem of the single physician. In such an economic system devotion or service to the community have no place, even are regarded as old-fashioned. According to this way of thinking the relationship to the patient shall no more be a social one but a matter of business.

“Therefore physicians have to formulate much more resolutely, what they actually step up for and for which objectives they are willing to work. The physicians have to find back to a community and communicate even more clearly, that they are unwilling to give up their rationality of care and welfare. They have to advocate actively for a medically logic and disassociate themselves from mere economical evaluation patterns of their work. Since only the patients are the ones who give the doctors their rights to exist.”

Giovanni Maio, p. 153

From patient to customer

In modern medicine – as far as one can speak here of medicine at all – the patient is more rarely seen as troubled fellow human but as consumer of medical services, as responsible customer who has to make a well informed purchase decision. Nevertheless, by his suffering the patient often has no real choice. The economic ambition to induce a customer to buy even in future and possibly constantly from the same vendor cannot really correspond to the aim of a physician. Nevertheless, by the implementation of economic principles our health system is thus far depersonalised, that more and more physicians and hospitals advertise their “offers” in high-gloss brochures, web-sites and so on, whereby they to a lesser extent help and heal but can realise more sales interests.

The problematic area of bonus payments: A reward for the wrong thing

If doctors stand up for the welfare of their patients, this is a genuine social commitment and by this a behaviour different to economic thinking. However, bonus payments are an economic instrument. Many studies show that doctors gain a personal benefit in their profession mainly from their contact with the patient and from the feeling to have helped them. Yet, bonuses lead to a degradation of helping someone and thereby to a threat to this feeling of an inner professional fulfilment. The current economic principles in medicine prefer doctors who see themselves as service providers and primarily, they should not abide by the profession’s own requirements but by the instructions of management. This results in an intended deprofessionalisation. Thus, we experience a devaluation of medical profession, because doctors who rely on their professional status and thereby claim freedom of thought and of treatment, are more difficult to be managed. Nowadays, doctors are performing a balancing act on which they must decide between internal motivation and gratification. They must be aware that financial incentives mean an undermining of the obvious matter of helping.

 

“As long as the physician is called a physician, he pledges himself to provide the common weal. However, that does not mean consequently to refuse help to individual patients in the interest of efficiency and to opt for a prioritisation. Common weal can here only mean that the doctor takes care of the entirety and that he does not waste public funds, even if the individual patient wished that for himself. The obligation towards the common weal, however, means also that the physician must not misuse his stately funded qualification for profit-maximisation, because that would be alienation. That is why doctors have to bring home that as representatives of public interests they would only work in order to fulfil the latest aim of their profession as doctors.”

Giovanni Maio, p. 152

“Is it worth to help?  The wrong way of prioritisation

As a result of the interplay of data orientated modern medicine and calculating economy, currently, everything for what figures can’t be provided is judged as unnecessary. In doing so, diktats of numbers will be established, and these diktats of numbers don’t know qualities, but only quantities. In such a system, the essential need to help the people has no place. A purely economic calculus is limited to charging up the costs against the benefits; the medical approach on the other hand is primarily based on the likelihood of possible medical assistance. This leads to conflicting goals for the doctors. The doctor is primarily an advocate of the patient; he cannot leave his patient to economy, which is just an advocate of good balances. Yet, as long as the doctor calls himself a doctor, he is committed to serving the common good. However, this results neither in refusing aid to certain patients on behalf of efficiency nor in prioritising. Commitment to the common good means that doctors may not abuse their stately financed training and make it serve profit maximisation. This would be a misuse.
  In his book Maio clearly puts the finger on the risk for patients, but also for helping professionals, to become ultimately victims of the increasing economization of medicine. Doctors are expected to learn to think economically; but it is even more important that economists learn to think medically. “Shall medicine serve economy or shall economy serve medicine?” The answer to this initial question is the same for physicians and patients. It is certainly correct if doctors worry about financial and economic issues.

Concluding remarks

For Maio the increasing domination of economy over medicine is a key reason why our health is getting more and more sick and why despite medical advances patients run the risk of being treated worse and worse. Behind this economisation neoliberal agendas of politicians like the former member of cantonal government Buschor (New Public Management) and policy approaches of the Federal council and the parliament must be taken into account. During the past two decades the Federal council was oriented closely towards the requirements of the World Trade Organization (WTO) which imposed on each member country to have fewer financial resources flown into the public services. These WTO requirements together with the neo-liberal economic policies are key reasons why less and less public funds (tax revenues) flow into health care. So whole cantonal hospitals are fully and university hospitals are partially privatized. What sounds liberal on the surface is nothing but the denial of constitutionally granted financial means.    •

Economic pressure on clinics is a danger for physicians and patients

“Hartmannbund” (German association of physicians) feels vindicated by Ethics Council

The “Hartmannbund” feels vindicated, as to their warning against the consequences entailed by economic pressure in German clinics by recent declarations of the German Ethics Council. “Especially the federal states which have reduced their grants for clinics should conceive this result as an alarming reveille”, said the president of Hartmannbund PhD Klaus Reinhardt in Berlin. The advice of the Ethics Council that the patient’s welfare is increasingly failing by the wayside under the prevailing conditions also obliges the clinics to a rethinking. In this context, Hartmannbund explicitly supports the board’s demand that the chief executive should both possess knowledge in special economic competence and medicine and care. Decisions that are predominantly economy oriented would in the length of time unreasonably deteriorate the working situation of doctors and nurses and by that endanger the patients’ welfare. Thus, the by the Ethics Council demanded minimum number of nurses had also to be spilled over to the medical’s staff.
Reinhardt appealed to the Federal Minister of Health, Mr Gröhe, to take the hints of the Ethics Council seriously. A part of this is to ask oneself repeatedly whether the system of per-case flat rates (so-called “Fallpauschalen”, DRG) accompanied by various disincentives could be modified.

Press Release by “Hartmannbund” from 6 April 2016  

(Translation Current Concerns)

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