Frequently Asked Questions for Dr. Gray
Common FAQ's
Questions in this FAQ:- Do you worry about bringing physicians into the political debate over healthcare? Won’t the polarization of politics today only divide patients and their physician?
- For all the cost increases, is healthcare any better in the U.S. than it used to be? In what ways yes? In what ways no? How and why?
- How did you come to see medicine in terms of ancient Greek philosophy?
- What do you have against trial attorneys, who often provide the last recourse against negligence and incompetence? Are you just seeking protection for your fellow physicians?
- What is the most important problem in medicine today? From the patient’s standpoint? From the physician’s standpoint? What can be done about it?
- What is your vision of the future of healthcare in America?
- Why does healthcare cost so much and what can we do about it? We the patients? We the physicians? We the taxpayers?
- Why have you started this group and what do you hope to achieve? Frankly, there are many more prominent people in medicine today—why are you doing this and what makes you think you can be successful? How do you define success in this group activity?
- You seem to cast things in black-and-white. Do you see no middle ground, as suggested by your name? If so, what? If not, why not? Is there no practical intermediate solution? Is it all-or-nothing for you?
Historically physicians have remained overwhelmingly apolitical—and for two good reasons.
First, physicians are called to serve patients from every walk of life. Whether rich or poor, black or white, or conservative or liberal, Hippocratic physicians treat each patient according to their need. The mere fact patients are human grants them innate dignity, irrespective of their background or political persuasion.
Second, because of the utter vulnerability people face in moments of need, medicine must never become manipulative. If patients ever feel they will receive care only if they voted a particular way, the art of medicine will have lost its soul. We will have lost the battle before we have even begun.
However, if my reading of history and culture is correct, the 2008 election will forever shape American healthcare. I see forces lining up to swing medicine from the Hippocratic tradition enjoyed for the last two millennia toward a Platonic model that will force physicians to become tools of the State. The only way for Hippocratic medicine to survive is for physicians to stand along side their patients and engage in the political debate with a unified voice.
Could this place the patient/physician relationship at risk? Yes, if the proper precautions are not taken. But if patients and their physicians do not engage in the messy world of politics, the patient/physician relationship will be destroyed.
With the dawn of post-Hippocratic medicine, physicians and their patients now face two choices. They can unite and reclaim the higher calling of Hippocrates. Or they can watch a once noble art be destroyed one piece at a time.
Physicians have not sought this battle; the battle knocks at their door.
The answer to this question depends entirely on which metric you choose to determine what is “better.”
From one perspective the answer is undeniably “Yes.” Over the past century life expectancy in America increased by nearly 30 years.* Between 1960 and 2000 infant mortality declined from 26 to less than 7 per 1,000 births. After an aggressive vaccination program, smallpox was eliminated in 1980.
However, in other ways, the health of Americans appears worse. For example, obesity is rampant. Sixty percent of Americans are overweight. The number of obese adults has doubled in the past 20 years and the number of overweight children has tripled in the past 30 years. Driven by this epidemic, a 60% increase in diabetes has occurred over the past decade. If this trend continues, we will see a drop in life expectancy for the first time in modern history.
The key point is that we can find data to support any position we want. In the next two years the future of American healthcare will be fervently debated. A barrage of statistics will be used to sway public opinion. However, as a physician who spends his life at the patient’s bedside, I warn that much of what will be proposed will be detrimental to patient care. Perspectives that seem good to those in the ivory towers of academics and the halls of Congress do no necessarily work when implemented.
For example, in an effort to protect patient privacy (a noble goal), regulations now prevent physicians from placing the patient’s full name on either their door or their chart. Yet, patients walk down the hall in full view of anyone passing by. This policy accomplishes nothing but to increase the risk for medical errors.
Not long ago I had two M. Wilsons (not the real name) side by side, but could not put their first names on either their door or their chart. For a while we were only allowed to use the patient’s initials, such as M.W. This represents but one of many examples of the insane governmental policies under which physicians practice. No wonder patients feel the healthcare system is broken!
The question to ask in the coming political debate is, “Who will make the complex and nuanced healthcare decisions?” Will it be the patient with his or her Hippocratic physician sitting at the bedside? Or will it be politicians and policy makers with little understanding and knowledge of the complexity of real life medicine?
* During this past century life expectance increased from 51 to 80 for women and from 48 to 75 for men.
* Today more than 27% of adults are obese compared to less than 15% in 1980. In 1970 less than 5% of children were overweight; today than number has grown to more than 15%.
3. How did you come to see medicine in terms of ancient Greek philosophy?
When the Unthinkable becomes Thinkable
Driven by a stale breeze, dust swirled at my feet as Mpho played under the burning, African sun. His shirt hung limp where shoulders never formed. Spotting me, his eager eyes danced with excitement as a mischievous grin swept his face. I smiled. His body squirmed with the unending motion of expectant delight. In my hand rested a set of new prosthetic arms.
What to do with infants born with disabilities such as Mpho’s is now the subject of debate in American medical ethics. As a physician committed to Hippocratic medicine, the prospect of infanticide—the killing of deformed or unwanted infants—is unthinkable. However, the Chair of Bioethics at Princeton University has achieved international acclaim championing this very concept.
How did this happen? What does the future hold for American medicine? Beginning in 1998, I set out to answer these questions.
The Role of the Physician
Princeton’s top bioethicist, Peter Singer, suggested America redefine human life to begin at five weeks of age. By declaring newborn infants are not “fully human” he advocated the acceptance of infanticide, the killing of deformed, handicapped, or otherwise unwanted infants.
Through years of extensive research, I discovered the forces driving Singer’s position woven throughout the history of Western thought. The debate over how physicians care for the weak and infirm reaches back into ancient Greece where the contemporaries, Hippocrates and Plato, held diametrically opposing views.
Under a system that placed the welfare of the “State” over that of the individual, Plato maintained only patients who were of benefit to society should receive healthcare. The weak or infirm were either killed or left to die. In contrast, Hippocrates held human life was special leading to the primacy of the patient/physician relationship.
Plato’s physician was a tool of the State used to regulate healthcare. For Hippocrates, the physician was a patient advocate who held the publics implicit trust.
Will We Follow Hippocrates or Plato?
Politicians will soon present “universal healthcare” as the solution to our present healthcare crisis. This concept will be sold to the public as “providing healthcare for everyone.” However, once Americans are dependent solely upon the government for healthcare, when the government faces budgetary shortfalls cuts in healthcare that are “advantageous to the State” will inevitably follow.
Americans witnessed the extraordinary seizure of power during the summer of 2005 when five Supreme Court Justices ruled in Kelo v. New London that local governments could seize private property if it was in the best interest of “society.” This is socialism pure and simple.
History teaches us there is flow to history. Over time, the unthinkable becomes the thinkable. With more time, the thinkable becomes accepted and a brave new world emerges. If our government can now legally seize our homes under the banner of “public benefit,” there is no reason to expect that it will not limit our access to healthcare for similar reasons.
Because physician reimbursement will depend solely upon compliance with government regulations, physicians will be trapped as a tool of the “State.” They will no longer be the patient advocates. Under socialized medicine they will no longer be Hippocratic physicians.
The reforms that I propose do not obstruct legitimate malpractice suits nor do they protect negligent physicians. In fact the penalty for true incompetence is increased: in every case brought to trial, the physician is at risk of losing his or her medical license. Million dollar suits do not just punish the physician involved. They punish all physicians, and by extension, their patients.
Every physician I know believes patients injured by true negligence should receive appropriate compensation. In fact, under the reforms I have outlined, patients receive a greater percentage of malpractice dollars than they currently do. But when less than 1% of medical malpractice suits are won by jury trial, something is wrong. Balance must be restored.
My primary concern is where the medical/legal system is taking healthcare. Obstetricians may now work one day in three just to pay for malpractice coverage. Some physician cannot afford to leave their practice and move to another state with lower malpractice rates because of what is called a “tail.” A “tail” is an additional malpractice fee that must be paid when a physician leaves a practice to cover possible future suits. For some physicians their “tail” can approach $100,000 simply to leave their practice.
However, even more important than the financial aspects of our failed tort system, the constant threat of litigation strips the physician of the intrinsic reward of practicing medicine. Many physicians are irrevocably changed after a suit, even if they win. Many once altruistic physicians are now closing their doors. Every week physicians choose to stop delivering babies; many hospitals now go without neurosurgical coverage—all because of the litigious practice environment. We must reform America’s medical/legal system to protect the future of medicine and patient care.
If I distill the difficulties facing medicine today down to one fundamental issue, that issue is the failure of the patient/physician relationship. Physicians are now healthcare “providers.” Patients are healthcare “consumers.”
Patients want their doctor to listen with compassion then care for their heartfelt needs. However, patients may wait months to get an appointment with a doctor they hardly know. Then, five minutes later, they often stand holding a prescription, never having expressed their real concern.
On the other hand, physicians want to care for people without the threat of a career-ending lawsuit lurking behind every door. Laboring under a system weighed down by regulations, forms, and litigation, physicians struggle through their day wondering how they can escape from a profession they invested the best years of their lives to enter.
Both parties once viewed each other with implicit trust and goodwill. However, patients now see physicians as distant and preoccupied. Physicians see patients as potential plaintiffs. Sadly, each is wary of the other.
Restoring the patient/physicians relationship is the central issue Physicians for Reform seeks to address. A key step in this process is reforming a broken tort system that pits patient against physician.
6. What is your vision of the future of healthcare in America?
The answer to one question will determine the future of medicine. Is healthcare oriented toward the patient or the State?
The best way to envision the future of medicine is to understand its past. Historically two archetypal philosophies defined the practice of medicine—that of Hippocrates and that of his contemporary, Plato (see Historical Video). At first this sounds esoteric, but this is the single most important concept we must grasp if we are to understand what is about to take place in American healthcare.
Think of a compass, but rather than north and south, the needle points to either an “H” (representing Hippocrates) or a “P” (representing Plato). Over the past 2,500 years the needle has swung back and forth between these two positions. The angst of contemporary medicine is that the needle points half way in between and we do not yet know which way it will swing. Let me explain…
In Plato’s Republic, the welfare of the State was paramount and the welfare of the individual was secondary. With this understanding Plato specifically addressed the role of the physician. Patients that could contribute to society were treated. Patients that required more resources from society than they could repay were either killed or simply left to die. Under this system physicians were the arbiters of life determining who was fit to treat and who was not. Physicians were in fact merely tools of the State.
In contrast, the foundations of Hippocratic thought began with the welfare of the patient. Hippocrates swore to act in his patient’s best interest even when at great cost to himself. The worldviews of these two men were polar opposites.
Many of Plato’s views were representative of ancient Greece, but over the following centuries, the ideals of Hippocratic medicine steadily replaced them. As a result, Hippocratic medicine dominated western culture for some 1,500 to 2,000 years. For this Hippocrates was named “The Father of Medicine” and the Hippocratic Oath served as the foundation of medical ethics.
However, in the late 1800’s, Friedrich Nietzsche resurrected the ghost of Plato. Using nearly identical language, Nietzsche specifically addressed the role of the physician. For Nietzsche, the physician was to show contempt for the “weak and ill-constituted,” and he questioned if indeed the weak even possessed the right to live. As with Plato, Nietzsche’s ideal physician existed to treat only the strong: those who would benefit society. The needle on the medical compass, having pointed toward “H” for nearly two millennia, was suddenly jerked back toward “P.”
In the following decades, physicians acted out Nietzsche’s philosophy under the iron fist of Hitler. Thousands of mentally ill patients were starved to death in order to reduce the cost of feeding and housing them. “Experiments” such as placing men in ice baths then transferring them to vats of boiling oil were done to “determine how best to rewarm pilots shot down over icy waters.”
After WWII, the Geneva Convention firmly and intentionally pointed the needle back toward “H.” The intent was to reinstate Hippocratic medicine to prevent repeated patient abuse. However, the needle of the medical compass is now swinging steadily back towards “P” as the needs of the State once again take priority.
As America’s healthcare system collapses, a surge of voices will call for socialized medicine. While politicians on both sides of the isle want Americans to have access to quality healthcare, few understand the implications of introducing socialized medicine at this point in our nation’s history.
In the decade to come, budgetary shortfalls will become increasingly important as Medicare and Medicaid expenses soar. America also faces declining Social Security revenues as baby-boomers retire and begin to draw pension. Simply adopting socialized healthcare will not make more funds available. As Canada experienced in the 1990’s, patients will face profound limitations on access to care as the government seeks to reduce spending. The physician will once again become a tool of the State, and the Hippocratic tradition will die.
However, is there another way? Physicians for Reform was created to find solutions to this difficult question.
Healthcare costs are clearly out of control. For the business community, the cost of employee health insurance has risen 50% in the past four years.* Because health insurance is a significant part of the employee’s total compensation (in addition to their tax dollars used to provide healthcare for the uninsured), the cost of healthcare affects every working American.
Advanced technologies, new medications, and state of the art healthcare facilities all contribute to the increased cost. Benefiting from this high tech care, Americans with complex diseases live longer. However, the more complicated a patient’s condition, the more healthcare resources are required.
Not only do Americans receive more care, but that care is often more complex than in other countries. For example, America uses the MRI far more than does Canada. In America, MRI is a common radiological test. In Canada, MRI’s are intentionally limited to reduce healthcare costs.
The legal expectation that nothing should ever be missed fuels this runaway train. Patients with low risk symptoms often present to emergency rooms and receive extensive workups rather than watchful waiting, particularly if these patients do not have a primary care physician and are at risk to not follow-up. In these situations emergency room physicians leave no stone unturned to avoid finding themselves in court. Defensive medicine adds between 70 and 120 billion dollars each year to American healthcare. This represents nearly half of the national deficit.
Using a two-fold approach, Physicians for Reform seeks to reverse this trend. Restoring the essence of Hippocratic medicine will let patients and physicians work together to use our nations limited healthcare resources wisely. Reforming our broken tort system will free physicians to care for patients using their best clinical judgment rather than practicing purely defensive medicine. By lowering the cost of medicine, more Americans can afford health insurance and gain access to outpatient care. This further lowers the cost of healthcare.
*Businesses now spend about $8,500 yearly for employee health coverage up from about $5,500 in 2002. In addition, the employee pitches in another $3,000 more plus deductibles and co-pays.
Why did I start this non-profit? Simply because I had to. The more I study the history of medicine and culture, the more concerned I am about the future of medicine and the future of healthcare in America.
Patients are increasingly frustrated and find it nearly impossible to navigate the American healthcare system. Many of my fellow physicians are ready to abandon medicine altogether. A friend of mine has the number of hours until she retires programmed into her cell phone—and she began her countdown with ten years left to work! Each week I find yet another regulation that prevents me from taking care of my patients efficiently. The absurdity of medicine today has reached a point where I simply cannot remain silent.
Why do I think this will work? We sit at a unique moment in history. Multiple forces are converging to open a door of opportunity:
1. The tremendous physician angst, particularly with respect to medical malpractice, has unified doctors in a way previously unseen. When linked to a clear message for
reform, discontent of this magnitude can mobilize one of the most powerful coalitions in our country.
2. Patients are equally frustrated, but underneath their growing skepticism, they still desire the security once found in the patient/physician relationship. When patients understand what is at stake, they will join physicians to preserve Hippocratic medicine.
3. In an age of tightening profit margins, businesses find it increasingly difficult to maintain health insurance for their employees. Businesses also recognize the forces that can secure medical tort reform can also assist in product liability reform.
4. During the 2008 Presidential election healthcare reform may well dominate the domestic debate. If there has ever been an opportunity for physicians to make their message heard, this is it. By speaking with a unified voice, physicians and their patients will shape the coming debate about the future of American healthcare.
Success for Physicians for Reform rises and falls on the response of physicians. If physicians choose to engage in the debate and appeal to their patients for help, effective reform is possible. If physicians let this chance pass them by and focus on their day-to-day life, this opportunity will vanish, likely to never occur again.
As I read through the pages of history, I see the ebb and flow of two fundamentally different ways of looking at the world. We see this in the thinking of Hippocrates and Plato. As a result, any given problem will have radically different solutions. This discussion should be welcomed.
Personally, whether giving presentations or writing books, I often seek feedback from people who see things from an opposing perspective. Though they disagree with me, my intent changing is not to change their mind. I benefit from the discussion because I more fully understand the complexities of the question.
The coming political debate over healthcare reform will be heated, emotional, and difficult to understand. Socialized medicine will be presented in such a way that it will appear to solve America’s healthcare crisis. However, it is essential to understand where this road leads. Helping Americans recognize the philosophies underlying the various positions is one of the primary goals of Physicians for Reform.
In the end “we the people” will decide which path America will take by virtue of who we elect to office. This is both the highest privilege and the greatest responsibility of a constitutional republic. We must choose, and we must choose wisely.
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