Sunday Dialogue: Medicine as a Business

The New York Times, February 10, 2014

Dr. Howard Corwin's letter to the editor of the New York Times on how the drive to increase profits has compromised doctors’ ethics and their treatment of patients prompted several responses. Dr. Corwin's original letter, two of the responses, including one by the former editor of the New England Journal of Medicine, Dr. Arnold Relman, and Dr. Corwin's response are below. The full selection of responses is posted online here.

To the Editor:

Recent accusations against the for-profit hospital chain Health Management Associates (“Hospital Chain Said to Scheme to Inflate Bills,” front page, Jan. 24), including that it put pressure on doctors to admit patients to increase profits, demonstrate the destructive power of the corporatization of medicine on the practice of medicine. The ethical base is lost when businesspeople take over and destroy the traditions of medical practice. Hospital Corporation of America, the nation’s largest for-profit hospital chain, is under investigation for similar practices.

Leaders of corporate America care little about the credo that established medicine as a noble profession, operated not for profitability but for the good of the patients. Sadly, doctors within the corporate system who have opposed fraudulent and illegal practices designed to maximize profitability are punished and terminated. Meanwhile, the white-collar criminal behavior of corporate executives is not adequately punished.

Such practices have a corrosive effect on independent doctors as well. This leads many to game the system and find loopholes to maximize profits. Costs soar. Hospitals and medical schools are often complicit.

Many decent doctors deplore the changes in health care delivery systems that foster such abuses. But I find it hard to be heard when I speak of accountability. I call on our current and next generation of medical school graduates to have the vision and courage to take back the leadership of medicine and restore its right to be considered a noble profession.

Naples, Fla., Feb. 3, 2014
The writer was a clinical professor of psychiatry at Tufts University School of Medicine.

Readers React

As a physician myself, I have often shared Dr. Corwin’s lament. But on further reflection I can no longer blame either the corporations or the profession itself.

First, we as a society have decided that medicine and capitalism are a suitable match. We have done so despite the fact that almost no other developed nation considers this a way to dispense health care. Doctors have been not so subtly influenced to make decisions that do no harm, but also maximize income.

Second, when physicians have banded together to form corporate entities or hospitals, they have eventually found themselves out of their depth. None of us learn anything about managing a business in medical school. Enter the management consultant, accompanied by his band of trusted executives with large salaries and a new vocabulary. They have sometimes provided good advice, but unlike the physicians they put profits first and patients next.

Asking new graduates to take back medicine is not the solution. Instead, we must open up a debate in America about whether we consider health care a basic right rather than a commodity. If so, then we must move toward some sort of universal single-payer system.

If not, we should resign ourselves to further encroachment by the corporations and invite the executives into bedside rounds each morning.

Bronxville, N.Y., Feb. 5, 2014
The writer is a psychiatrist.


What needs to be added to Dr. Corwin’s grim but accurate description of the commercialization of our health system is that physicians have compounded the problem by choosing in large numbers to become employees of hospitals. Hospitals, whether for profit or nonprofit, usually behave like business corporations seeking more income. To this end, they expect help from their physician-employees in referring patients and ordering hospital services.

This corruption of the independent professional practice of medicine could be avoided if physicians chose to join nonprofit doctor-managed groups, and with their patients actively supported the kind of basic reform advocated by Physicians for a National Health Program.

Cambridge, Mass., Feb. 5, 2014
The writer is professor emeritus of medicine at Harvard Medical School and former editor in chief of The New England Journal of Medicine.

The Writer Responds

The heart of the doctor is the soul of medicine. Historically the doctor-patient relationship has earned medicine recognition as a noble profession. Corporatization keeps doctors from practicing that time-honored tradition. It is demoralizing to the profession and unsatisfactory for the patients.

I agree with Dr. Singh that America must decide if health care is a basic right rather than a corporate commodity. Dr. Relman decries commercialization in both for profit and nonprofit settings and advocates for single-payer health insurance.

Most doctors believe that receiving adequate medical care should be a human right. Medicine was not meant to be corporatized on a profit-and-loss balance sheet. Capitalism is right for many fields, but not for medicine.

The next generation of sophisticated and caring doctors will have multidisciplinary skills and perspectives that include training in economics, business, public health and public policy. They can be the engine of change and take back medicine from business domination. Their vision, courage and idealism can lead us to well-managed, government-sponsored, single-payer universal health care. Doctors long to return to a system that understands and values doctors and patients, and a code of ethics that ennobles, not degrades, their calling.

Naples, Fla., Feb. 6, 2014

A version of this letter appears in print on February 9, 2014, on page SR10 of the New York edition with the headline: Medicine as a Business.