The Changing Role of the Physician

Now we have become an advocate for insurance payer contracts and also agents for hospitals and large groups to improve their profiles.

This blog is my first opinion piece. It is triggered by what I see as a depression that has come over many of my colleagues in medicine, a depression that is multi-factorial in origin, ranging from decreased physician autonomy, to the change in the concept of a doctor as being the patient’s advocate to now being a cog in a health care machine focused on “cost effective” care for a population of patients, to the new roles physicians are being forced to assume. This depression can be viewed as a form of “learned helplessness” as doctors see their function change in ways they never envisioned or wanted, but are now powerless to confront. I am now with many in medicine who are hoping for the best, while beginning to plan for the worst as our roles change.

Physician – Pharma Relationship

The first role change I want to discuss is the new role of physician as advocate for contracts between payers and pharma. The discussion of this change begins with alterations in the physician-pharma relationship over the past several years: A great deal of controversy was generated when congress discovered that reps from pharma, when discussing new products with physicians, might leave behind some marketing materials such as a pad or a pen with the new drug’s name. The concept that such trinkets could influence prescribing behavior led to the PhRMA guidelines in 2008 where essentially marketing products were banned, voluntarily, in cooperation with the US government by pharma. 

In office meals were still permitted, however and the rep was still able to buy the doctor a sandwich and discuss the new product with the doctor while he or she takes his/her 10 minute lunch break. That still caused some congressional concern about undue influence, however, so that next, the Sunshine Act was passed (in 2013). With the Sunshine act, all such sandwich purchases are recorded and anyone in the US can see how much money has been spent on sandwiches or other lunch-ables for reps to speak to doctors. 

As a physician, I will admit I gain easy access to new information about new medications in this fashion. Reps are usually well trained and knowledgeable about their products and are also careful to only discuss FDA approved uses. However, recently, pharma added a new element to the conversation. Now reps are counseling doctors as to which drugs are better covered by some insurances. “Hey doc, now my product is tier one for two major payors, so use my drug and not my competitors”. That’s right, knowledge of a drug’s effectiveness and side effects are important for me to know, but apparently I now also need to know which pharmaceutical company made the best deal with which payor; it has become my responsibility to put the patient’s out of pocket burden into my consideration for a medication, purely because of some monetary deal that was made. And as new deals get made, I am expected to change my score card. From a patient’s perspective, maybe this makes some sense; however, this is not the practice of medicine I learned in school.

Physician – Hospital Relationship

The second role change is the doctor becoming an agent for large groups and hospitals to improve their images. Many of us are familiar with surveys like Castle Connelly. In these surveys, hospitals are voted on by physicians with the question, “who would you refer your patients to?” or some related type of question.
At face value, this would seem a very reasonable system, as many physicians likely don’t vote at all, so only those fairly motivated about their choice would vote.

However, now hospitals (and larger physician groups) are applying new methods to motivate physicians to vote for them. Emails and letters are sent. Announcements are made. Some hospitals are sponsoring sessions where a doctor can come in, have a meal and cast their vote. If that physician is employed by that hospital, then there is all the more motivation and reason to cast a vote. So, instead of these polls reflecting only a sincere belief by doctors of which is the best hospital, they are becoming a measure of how effective the hospital or large group is to get out the vote.

Doctor – Patient Relationship

I have to admit, being on staff at three hospitals, each of which I think is excellent in its own way, and knowing the new power of surveys in this age of social media, I can’t really blame the hospitals for using these tactics so that their strengths are revealed. However, if I put myself in the role of the person reading the results of these surveys, well, I think I might want to know if a physician took his time and went out of his way to vote, or if a computer was set up waiting for him to click in the physicians lounge by an enabling administrator or other hospital personnel.

Fundamentally, the core change in physician role is a change away from the doctor being the advocate of the individual patient, and the practice of medicine’s evolution from a career or identity to a job. As the pendulum continues to swing in this direction, the learned helplessness continues. However, as long as the doctor-patient relationship exists, we continue to have hope.

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