Today is the Jewish New Year, Rosh Hashana. It is a time for renewal, a time for family and, soon, will come a time to atone for one’s sins on Yom Kippur. In order to really ask forgiveness for a sin we must first recognize that we have sinned. Once recognized, moral teaching would hope that we accept self-reproach. Penitence is showing remorse for having done wrong. Only to a penitent man can come redemption, and a man redeemed will experience happiness and joy in work and life much more readily.
“It’s not who we are but what we do that defines us”, so says the superhero in a recent Batman movie. And while not all movies contain such wisdom, on occasion they do. Good men and women, loving to their children and respectful of their parents, can sometimes do bad things. It does not mean they are bad people. For example, a businessman may be a great father and donate time and money to local charities but end up going to jail for embezzlement a la Bernie Madoff. Which leads me to my point; how does a good person become a bad doctor? How has a hospital become more of a danger to birth than a benefit? Specifically, how have the practitioners of medicine evolved from the noble, “first do no harm”, to embrace a culture of expediency, cowardice and fear. And how has the hospital machinery, what is considered the norm today, really performed when it comes to outcomes over the last generation?
If you have followed my writings, talks, blogs and more recently my podcasts you will know the answer to many of these questions. More than 50 years ago the takeover of medicine began by the profiteers who, by definition, looked at the business side of medicine as if it were an automobile factory. How to become more efficient? How to avoid liability? How to control costs? Essentially, how to control everything! But medicine is not automobiles. It’s people, individual people, often with life altering issues that don’t fit the assembly line thinking. It’s messy by the businessman’s standard. But rather than realize that, or maybe even despite realizing it, there was just too much money to be made and power to be had by taking it over. Lost in this was the lonely patient. And soon even the practitioner, the person actually doing the work, was just a cog in the machine. Initially, a very noisy cog but gradually the noisy cogs get “greased” and became what they once detested or they are beaten up and replaced by the system. Doctors either become a “part of the crew, part of the ship” (to ironically quote another Pirate story) or they were tossed overboard, sometimes metaphorically and sometimes literally.
With the seeming inevitability of a government takeover of healthcare and the race to socialized medicine this metamorphosis will be complete. The designed impersonalization of the system frees any one or group of people from responsibility. And once an immense and monolithic entity is freed from any culpability it will always lead to corruption and tyranny. It will be like the current Internal Revenue Service scandal of oppression where no one is responsible and those that should be plead the Fifth Amendment and are never brought to task. However, unlike the IRS, those that seek the takeover of the health care system will sugar coat their motives under the disguise of “safety”. “The welfare of humanity is always the alibi of tyrants” was written by French Philosopher Albert Camus almost 60 years ago. Awareness of this mechanism is of utmost importance for it explains much about the fruit our system is baring.
How is it that good, well-meaning people inside the system have let this happen and may even support it? It is human nature for members to want to be accepted in their group and for many it is their dominating psychological motivation. When the businessmen, lawyers, politicians and administrators who run health care now send out a message of how things are to be done, well, who are the nurses and doctors, dependent on the system for their livelihood, to complain? And so these good people who admittedly love their families and possibly regularly attend their church just easily surrender to EMR and to limited formularies and to restrictive policies like VBAC bans and mandatory lab tests and one size fits all lengthy admission forms and annual board recertification and silly mandatory human resource seminars. Need I go on? Policies and actions that put individual patient’s desire and rights off the radar screen if not dead last. Not only do the caregivers submit but they begin to defend their behavior as “standard of care”! They join committees and participate in this bureaucratic process so as to be accepted and “part of the crew…” Even when they know there are other options and evidence supported choices. I suspect that the administrators and their ilk know this, too. And in order to justify the correctness of their position they ridicule or ignore evidence to the contrary. This is called cognitive dissonance and I have written on this before. (“Safety or Cognitive Dissonance” May 27, 2012 /supportdrfischbein/2012/05/safety-or-cognitive-dissonance.html/supportdrfischbein/2012/05/safety-or-cognitive-dissonance.html )
The failure of good people to stand up on behalf of each individual family they care for may be practical but let’s not call it right. The good people that leave their home each day to drive to work at the local hospital do not say to themselves, “Let’s see what mischief I can cause today for some poor suffering patient” or “Let’s see how impersonal I can make our policy so that I limit the institution’s liability”. But somehow that is what happens each and every day for over 50 years in this profession. In 1970, the cesarean section rate in the United States was < 6%, In 1990 it was 22% and now in 2012 it is 32.8%. There has been little decline in the neonatal death rate between 1970 and 1990 and almost none in the last 23 years. Yet the cesarean section rate has gone up 500% since 1970 and over 50% in the last generation with no measurable benefit. Did something suddenly happen to an American woman’s pelvis in one generation? While some modifications of policies are all too slowly reappearing we still have archaic, often ridiculous policies affecting laboring mothers negatively. Some are restrictive movement, restrictive oral intake, standardized charting requirements leading to interruption of natural labor, 90% epidural rates, mother-baby separation and over testing for questionable indications often resulting from economic gain and fear. This fear comes, not so much in the mother, but emanating from the practitioner who endures the realities of the professional climate rather than speak out. A great proportion of women do not have fond memories of their birth process and many women will suffer lifelong emotional and physical trauma from unnecessary inductions and cesarean sections. Babies, too, do not benefit from what is so often considered standard care. Early induction or surgical birth leads to increase risks of lifelong health issues. Ubiquitous standardized policies of immediate vaccination, eye care in culture negative moms and interruption of bonding are for what benefit again?
Courage is the rarest of good human traits. It is not courageous to stand up in front of a group and say what they want to hear. It is courageous to take a moral stand into the lion’s den. My colleagues are good people but they are not courageous. Those that purport to run healthcare, the businessmen, their lawyers and the politicians are worse because they disguise their motivation in the sheep’s clothing of safety. They have to know these outcomes are not what they should be. They have to know the policies they follow when it comes to birth are often dead wrong. How could a 33% cesarean section rate be acceptable to them. Why do they treat mothers and babies as two separate entities? There is so much reliable data that other options are reasonable. They do not respect the individual or the right of informed consent and refusal. And, quite frankly, in normal healthy mothers their statistics and outcomes are awful. Individuals are often good people. When they join organizations, however, they can become conflicted and end up doing bad things. The outcomes of groupthink are easily corrupted and rarely pure and morally upright. Just look at history. The fruits of the impersonal system of healthcare we call normal are rotting and subjugation to this model has not led us to higher ground. On this we should reflect and repent and the Jewish New Year can be an inspirational time to do so. We can redeem ourselves by doing better on behalf of our patients and our souls. Our acts are what define us. “From its fruit shall the tree be known.” (Matthew 7:16)
Shana Tovah, Dr. Stu