Add Ethics to the Business of Medicine
What does the modern physician need to get a better handle on? The latest in diagnostic technology and pharmaceutical magic? No. According to a blue ribbon panel that has spent the past 10 months laying the groundwork for sweeping curricular changes at the University of California’s five academic health centers, what the modern physician needs is more business skills and knowledge of economics.
It is too soon to tell how the leaders of the UC medical schools will respond. But given the market-driven changes that are rapidly transforming American health care, the advice is hardly surprising.
Yet as pressing as economic training is at a time when the government, employers and insurance companies are trying to keep health care from growing beyond its current 15% of our gross domestic product, medical students can never be allowed to forget what will be their chief obligation: serving their patients’ interests. While they study the financial implications of being paid on a capitated rather than fee-for-service basis or hone their skills at marketing and pricing their services, future physicians also need to spend time on ethics.
For the past decade, my colleagues and I at the University of Southern California Medical School have been presenting a course that deals directly with many of the concerns raised by the UC panel. Originally a required one-week course for students who were about to graduate, “The Physician in Society” now crams the equivalent of a semester-long course into one month of the medical student’s third year.
When first offered, the course focused on ethical dilemmas. When and how may a physician involve patients in a research study? What should doctors in an intensive care unit do when they have more critically ill patients than beds or when family members fight over withdrawing life-support from a comatose patient?
We still use mock ethics committees and malpractice trials, as well as lectures, readings and discussions, to explore such issues in clinical ethics. But we soon realized that medical school graduates need to know much more about the ways in which health care is organized and financed if they plan to put their biomedical knowledge into practice.
Today’s students recognize that the choices they will make about how and where to practice their profession will be radically different from those faced by the generation that preceded them. They also understand how the current transformation of health care affects their choice of specialty; a clear majority are going into primary care rather than the specialties that used to dominate at a school like USC.
But the students are just beginning to understand how the various systems of health care payment affect the way care is delivered, and they feel anxious about how they will respond to the nearly irresistible economic pressure to adjust to the dictates of managed care companies or the needs of other organizations that increasingly employ physicians who until recently were in private, self-directed practices. To respond to this anxiety, we not only have to familiarize the students with the various ways physicians are paid--and how they sometimes take on financial risks that until recently were the province of insurers; we also have to equip them to evaluate the ethical issues that are posed more acutely by some arrangements than by others. Physicians must know how to distinguish incentives to do less when doing less may actually be better for patients from invitations to compromise on appropriate care primarily to save money for themselves or their employer.
Society will soon realize that the market cannot do a very good job of determining which care of marginal value ought to be provided and which ought to be forgone under what circumstances. The pressures of an aging population and ever-expanding biomedical technology mean that physicians will have to be able to think intelligently about how resources are allocated, not in an ad hoc fashion at the bedside but in a fair, prospective and systematic way.
The curricular additions recommended by the UC panel are thus appropriate, but it is essential to keep an eye on the ethical context. In presenting more about the business side of health care, medical schools must guard against portraying medicine as just another business. The settings in which medicine is practiced are undergoing radical change, but the core ethical values that set medicine apart as a profession are not, and future patients have a right to expect that today’s medical students will learn how to use their ethical compasses to navigate through the stormy new economic waters.
