The Medical profession has gone through major changes from the days-past to present days. The transition from quackery to science, and from role assuming or inheriting to regulated graduate and postgraduate education.

The changes took place over centuries, but the most notable evolution in medical knowledge and training took place in the last couple of centuries and continues to evolve. Evolves may be used to describe positive as well as negative changes.

On the positive side, one can list some of the far-reaching victories of medicine such as: increasing median life spans, development of vaccines, and reducing death rates of various malignancies, development of antibiotics, organs and body parts transplantation and implantation, and, most recently, the introduction of robotics, and artificial intelligence (AI).

On the negative side, one can characterize some the changes in our noble profession as steps back, or “un-noble". Few of these negative steps in our current evolution can be found in the areas of delivery, quality, and accessibility to quality care, personnel shortages, and biases in research. Most of our colleagues, patients, the media, and other observers label these changes as the commercialization of patients’ care by intruding profiteers and business entrepreneurs into medical care.

The reasons behind some of these negative developments cannot be blamed totally or in part on any individuals or groups. It is up to the reader to quantify the distribution of blame on each of these groups/entities:

Physicians and extenders

Some HMO “providers” did not refer captive patients to specialists, or expensive testing, when needed, to preserve the maximum bonuses from the insurers. Others have advised their bonus depleting patients to switch back to Medicare or PPO plans.

Physician extenders ordered unnecessary tests causing delays in treatment and occasional harm in addition to increased cost.

Hospitals employed "providers", went along with their employer’s unwritten demand to refer their patients, exclusively, within the system.

Others adhered to their shifts’ timing, thus refused to treat patients needing their immediate attention, because their shift was nearing its end.

Yet, other providers have elected to enter the field because of higher earnings potential and chose the highest paying specialties, not because of admiring the services they will provide, nor compassion for patients, and serving their needs, but purely for financial goals.

Insurance companies

Insurance companies raised premiums, restricted coverages, wasted office and hospitals staffs’ time, and frustrated patients through the loops of pre-authorization, denials, delays… They harassed physicians by requesting them to appeal and attend endless hearings to get their prescribed treatment finally approved.

Additionally, they delayed payments, disapproved services provided to their enrollees, even after the services were pre-approved in writing.

Hospitals’ systems consolidations

Hospitals’ multi-levels executives, and managers misled our legislators, and regulators to believe and eventually approve their mergers into large systems for the purpose of reducing costs and improving care. These consolidations, of many hospitals into few systems per region resulted, per many published studies in exactly the reverse: higher cost and worse care. Additionally, as an adverse side effect, it led to the closing of many rural hospitals and vanishing of local care in many underserved and rural areas.

Other hospitals’ related issues

1. Given the vast wealth of hospital systems, their market shares, and regardless of their profit status, became the best, salary-wise, employer of choice.
2. The new docs-on-the-block, who even considered an alternative practice settings, discovered less attractive initial salaries, and higher loan payments in starting a new independent practice. If they even considered joining an established independent practice they rejected the relatively low starting salary.
3. Hospitals’ launched an anti-competitive war on independent physicians on their medical staff. The war was launched on several battlefields depending on specialty, success of independent practice, age of practicing independent physician, and other factors that will be discussed later.
4. Some hospital employed Hospitalists, facing no competition from independent hospitalists, diverted patients of independent physicians to their co-employees.
5. Employed physicians are indirectly instructed to limit their referrals to “providers” within the system. They were also limited, along with their immediate families, from receiving care outside the system unless they purchase a much more expensive health insurance plan.
6. Employed physicians in most of these hospital systems are offered bonuses and incentives for referring their patients for lab and diagnostic tests to keep the various departments within the hospitals busy.
7. Anti-competitiveness, within these corporate giants, is engineered by their profit only incentive to remove independent physicians from their medical staff, when the system acquires another, same specialty, “employed provider”.
8. In practical terms, managers and department heads, in cooperation with others in the system start a “witch hunt” campaign against the designated targets for removal. Their tools consist of writing adverse reports about the physician targeted, whether valid or not, to start harassing the competing targeted independent physician. The written reports are circulated through various medical staff committed, composed of an un-defeatable majority of employed physicians and in some cases, APRNs…. And an administrator streamlines the game plan and assure its success of the hunt. The executives on the various committees of the hospital medical staff, takes charge of gathering enough fabricated or exaggerated tales to harass the independent physician all the way into resigning.  If the independent physician does not resign "peacefully", hen the system’s enforcers will place restrictions on his or her practice. In doing so, they guarantee their employed physician a free ride to meet targeted budget, without any embarrassing competition in a criticism-free surroundings.
9. Hospital systems’ executives will pressure various committees of the medical staff to bend the rules to accommodate their profit-driven plans. An example of this practice was observed recently when a hospital within a system forced the credentials’ committee to grant surgical privileges to a surgeon who left clinical work for over 2 years. The committee, composed of employed and contracted physicians and APRNs, accepted, under presume, to grant the surgical privileges based on the employed surgeon’s residency experience many years ago.
10. Employed physicians within a specialty or location become subordinates of a manager who reports to the hospital executives. The office manager has always the final words.

Corporate medicine has stripped medicine from its humanistic characters by putting profit first instead of compassionate care. Meanwhile, the latter (compassionate care) remained displayed only on the system’s webpages, and in the media, to secure subsidies, grants, and donations from all possible donors. The websites lead visitors to believe that the systems are charitable organizations ran by sisters’ orders or other religious organizations systems. Many of the not-for-profits pose as religious organizations, ignoring to disclose that the founders had left the hospitals many years past. The last report, by the US government, disclosed the estimated taxes that these Hospitals avoided paying, by claiming to be charitable not-for-profit, to be over $37 billion.                                                               

Most recently, private equity companies have started buying lucrative physicians’ practices and transformed the physician into a management supervised “Pac-men” to meet the appetite of the investors.

While these changes are evolving in the US, my aim from this editorial is it raise awareness worldwide to some of these short comings, in hope of alerting the practitioners of this most noble profession to protect its “nobility” from the various intruders driven by greed.

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The author declares there is no conflict of interest.

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