John Livingston

Liberty and The Doctor-Patient Relationship

I spent 16 years practicing medicine and surgery in the United States Navy. Some of the best surgeons and most compassionate physicians I ever met in my 46-year career were in the Navy. Military medicine like the Veterans Administration (VA) system and the Indian Health Service (IHS) is a single payor socialized form of medicine. The doctor-patient relationship suffered in ways that many of us who later went on to practice in the private sector didn’t fully understand until we were years removed from that setting. Those who stayed in the system for their entire careers many times never understood the conflicts and agency issues that were inherent in all the transactions between doctor and patient in the Command-and-Control socialized setting.

There were several instances in my career where the doctor-patient relationship was placed in a secondary position—as a doctor, you worked for the US NAVY and not your patient. Patients went to the health care facility and identified with that facility, not an individual provider. I commented on several instances in earlier articles about this “conflict of interest” and how it created a tension within my own conscience and in two cases adversely effected a clinical outcome. When the policy maker is divorced from the transaction and has no skin in the game, and when such a policy by a bureaucrat working for the Centers for Disease Control (CDC) or the Center for Medicare and Medicaid Services (CMS) incentivizes hospital administrators to insist that the doctor who is attending to a patient follows a specific set of clinical guidelines or reimbursements will be adversely impacted, then patient care always suffers.

The goal of any organization—a business, a hospital, government, or the military, requires a laser focus for the specific mission. It must always be front and center. “Mission creep” is what killed our national Covid response. It started to happen years before the political pandemic when hospitals in the name of vertical integration employed increasing numbers of physicians and focused more on metrics, wellness, and populations than on people and patients—and cut the number of beds available for sick patients by 20% over 15 years.

One doesn’t learn about an individual ant by watching an ant colony. The ant acting individually acts very differently than the ant in the colony. Plato called this the Fallacy of Proportion. Large groups of patients act very differently than individual patients. Bureaucrats using population outcome metrics failed miserably when mitigating individual patient risks and therapies. An 80-year-old man with two comorbidities needed a different kind of care and mitigation than a young healthy patient. If the at risk had been handled one way and the young and healthy another, both groups and especially the individuals within the groups would have done much better. Reverse isolation of the at risk would have limited their exposure to the disease. Letting the disease spread amongst the healthy would have allowed for heard immunity to develop more rapidly.

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So, doctors followed protocols prescribed by bureaucrats with little individual “skin in the game”. They knew if they didn’t the hospital administrators at their institutions—who were not looking at clinical outcomes but revenues from Covid incentives to follow protocols, would place their paychecks—also laced with Covid payment incentives, in jeopardy.

The employee health care provider had only one function: Fulfill the task that his or her supervisor gave them, in the prescribed fashion, and satisfy some gameable metric at the same time, while maximizing revenue streams—another metric followed by bureaucrats all the way from government agencies to administrators that run hospitals and answer to boards—not patients and their families.

What suffered in all this was individual liberty. The liberty of the doctor to choose what was best for his/her patient and the liberty for the patient and their families to decide what course of therapy and what health care provider they preferred. Doctors became “company men” working for “the man” and not their patients. Tradesmen instead of professionals.

So here is a rule of “Bureaucristan” offered Nassim Taleb author of SKIN IN THE GAME:

“Peoples whose job and professional survival depend on qualitative job assessments by someone higher up in the organization, (lacking the very skills that are being evaluated) cannot be trusted to make critical decisions. “

Many health care workers thought that certain courses of action during the pandemic were absurd. They were at variance with their scientific understanding of the pandemic, but most of all with their conscience and the conflict between clinical guidelines and protocols and their own professional codes of ethics. The collective cognitive dissonance sits like a cloud over the medical professions today. Such is the price of being a company person. Agency is a “b—”. Liberty is good for the soul—and for the doctor-patient relationship!

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