The Scope of Our Practice
Physicians use statistics, numbers, and controlled research studies to elucidate the origins of disease and find workable therapies and cures. This is the nature of science. The nature of the real world (politics, social evolution, economics) is dictated by other paradigms, other rules. What works in one setting is often unrealistic in the other.
At the dawn of the year 2006, we are witnessing the unfortunate demise of American medicine as we knew it for much of the twentieth century. The culprit: all of us. We have lowered the bar of our expectations, by expanding the scope of practice of non-medical disciplines.
The mechanism of the disease that has stricken American Medicine may be described by some as a simple thing — perhaps we are victims of our own success, our own incredible feats of ingenuity and discovery (new drugs, new therapies and the like). Or perhaps, we are hapless victims of the global economy, the rise of Chinese and Indian capitalism and a stronger European industry, which have all predisposed our great capitalistic machine to an anemia of currency and shrinking resources. Of course, these simplistic analyses fall short because they fail to identify the only way any disease undermines the health of a strong host—namely, inherent vulnerability. The real cause for the decline in stature, respect, revenue, and the ability to attract the ‘best and brightest students’ to pursue a career of medicine in the United States today is a change in the values we Americans hold dear.
At one time, Americans applied a test (a rite of passage, if you will) to those entrusted with the most difficult and sensitive of jobs. This applied to advanced areas of study such as nuclear physics, ‘rocket’ scientists, physicians, and, yes, even lawyers. We held these professions—and others—up on a glorified pedestal not because we were at a loss for heroes (we have always had plenty of statesmen, actors and athletes to romanticize) but because we expected these professionals to elevate the quality and value of life for us.
Some of these professions have stood the test of time; physicians have not fared so well.
Physicians were once the bedrock of the family and the community. You know the old saying, ‘without your health, you have nothing’. God and religion have always been our foundation, but next in line was the town doctor. The mark of a doctor was his degree, a community-accepted standard of accomplishment that was stronger than any brand name commercial product. In business and marketing lingo, the ‘branding’ of a product is the creation of a lasting, positive impression of that entity in the mind of the consumer. At one time, American society branded the M.D. degree as the highest and most revered status of accomplishment in the clinical sciences. ‘We the people’ made this branding stick; we re-enforced it through our values and the way we raised our children.
Today, the rank of medical doctor has fallen in the psyche of the American consumer because healthcare has been reduced to the impersonal status of a commodity. Whereas once the town ‘doc’ was a real person in the real lives of a real community, today he is reduced to the lowest common denominator; today’s doctor is traded on the margins of our corporate mentality. The American physician has been undone by the very numbers and statistics he diligently applied to raise our standard of living and personal health. We should not look elsewhere to place blame for the unconscionable decline of the physician in America, because everyone one of us shares responsibility.
When we disregard the value of an American medical degree by equating a nurse or a technician with a medical doctor, we are undermining the fabric of our healthcare system. When we allow nurse anesthetists or nurse practitioners to operate independently in prescribing medicines and performing procedures previously under the domain of the physician, we are sowing the seeds of destruction for the institution of medicine itself. When we allow a podiatrist to expand his scope of practice to areas previously under the purview of the orthopedic surgeon, we are lessening the value society places in the institution of the American medical school. When we allow a dentist to perform facial cosmetic surgery, we are discounting the training and importance of up to eight years of post-medical school training of the American plastic surgeon.
Society has every right to discount the process of getting mostly ‘A’s in the eight years of high school and college, performing well on the MCAT (medical school admissions test), successfully completing four years of medical school, and passing the national medical school boards; society has every right to minimize the accomplishment of completing a medical internship year followed by anywhere from two to eight years of medical residency; and society has the prerogative to overlook the difficulty of passing the requisite medical subspecialty written and/or oral board exams. Yes, society has the right to declare this process—this training—to be of little value. Society can place lesser degrees (and lesser degrees of training) on parity with medical school and medical residency. But society should know that it does so at its own peril. As the American medical degree falls from grace, so does our national community and collective well-being.