Hope for Medicine’s Best


		Richard Gunderman, MD, PhD

Richard Gunderman, MD, PhD
ISMA President
ISMA Wellness Steering Committee Chair

Hope for Medicine’ Best According to Dante’s masterpiece, “The Divine Comedy,” over the gate of hell hangs a sign saying, “Abandon all hope, ye who enter here.” Sometimes physicians and health professionals find ourselves battling a similar sense of hopelessness, arising from such circumstances as rules and regulations that detract from patient care, metrics that do not represent the true quality of our work, and clunky information systems that undermine efficiency.

Health care has become increasingly corporatized, in part because the ratio of physicians who do and do not have an ownership interest in their practice has shifted from 4 to 1 several decades ago to 1 to 4 now. If the primary goal of health care is to reduce costs, boost revenue, and raise operating margins, such a transformation makes good sense, but if caring well for patients is the primary mission, then we are sowing seeds of cognitive dissonance.

Knowing that we are not able to focus on what truly matters most, whether in work or life, creates real hazards and costs. Foremost among these is moral injury. We know we should be dedicating ourselves to one purpose, caring well for patients, but we are required to devote a great deal of time and attention to other priorities that drain us of the energy and inspiration we need to do job one. What gets counted is not what really counts the most.

Consider, for example, the concept of community benefit, perhaps the most important justification many hospitals provide for maintaining their nonprofit tax exemption. Such benefit gets calculated in monetary terms, such as financial assistance, charity care, shortfalls in government subsidies, and moneylosing service lines. But health professionals know that they provide crucial benefits nowhere accounted for in such calculations.

Many can empathize with the author of “The Divine Comedy,” who in the work’s memorable first line states that, “Midway on our life’s journey, I found myself lost in a dark woods, for I had wandered from the true path.” Physicians went to medical school and residency not to collect coding and billing data or comply with policies and regulations, but to care well for the sick and injured. The mismatch foments disorientation and discouragement.

Medicine is simply different from other lines of business. Someone who sells cars, insurance, or investment advice would do well to treat customers fairly. But if they fail to do so, the market will discipline them, perhaps by driving them out of business. In medicine, however, patients cannot operate according to the market’s maxim, Buyer beware. They need to be able to trust that health professionals have their best interests at heart.

To take an extreme case, a person suffering from an acute, life-threatening medical condition or a severe traumatic injury cannot take the time to visit physicians in different emergency departments to determine who would best meet their needs. Such a patient needs to be able to assume that they are viewed first and foremost not as a revenue generation opportunity but a human being in need of care, whose trust must be cherished.

Organizational charts, budgets, job descriptions, strategic plans, policy and procedure manuals, and financial statements cannot provide adequate guidance to a physician, nurse, or other health professional aiming to provide a patient with the same kind of care they hope a colleague would offer to one of their loved ones. The language of business is simply insufficient to meet this challenge.

Health professionals are above all responsible – professionally, ethically, and humanly – not to the denizens of the boardroom, the C-suite, or Wall Street, but to the human beings we meet face to face every day, and it is incumbent upon all physicians not only to do what is right but to speak up for it by functioning as effectively as we can as advocates for what we know medically to be appropriate.

As Dante goes through the inferno and sees what misdirected careers and lives really amount to, his sense of what matters most is gradually clarified, even purified. We need something similar in contemporary healthcare – to realize that wasted time, meaningless busy work, and distractions from our true mission represent not mere nuisances but fundamental betrayals of purpose.

Just as marriage is not primarily about getting the dishes done or the trash taken out, so caring for patients is not primarily about ticking boxes or verifying compliance. At their best, both are about building relationships that sustain and enrich what is best in life, enabling human beings to be there for one another, to stay focused on what really matters, and to give and share the very best of which we are capable.

If health professionals are to find real hope, we need to shift attention away from indicators that do not truly reflect excellence in health care – bed utilization rates, average cost per discharge, and operating margins – and toward the things that matter most, such as developing appropriate goals of care, keeping the interests of patients and families first, and creating cultures dedicated to learning and the promotion of excellence.

Hippocrates is counting on us, and so are Galen, Avicenna, Harvey, Osler, and all the teachers and role models who shaped us as the physicians we are today. So long as we let the lower trump the higher, we remain lost in a kind of dark woods, but as we right the ship and ensure that what matters most stays on top, we play our part in ensuring that medicine offers the kind of care that our patients and communities rightly hope to receive.