Over lunch recently, the touchy subject of ObamaCare was raised by a techie friend of mine. My friend, ever-opinionated about politics, asked what I thought. I expressed my concerns about the gray areas of several aspects of the program, citing poor physician involvement in crafting legislation, poor plan participation, unchecked malpractice and the unfunded liability of Medicaid expansion. My business-minded friend wondered, "Could medicine be administered by cheaper physician substitutes?" In essence he was asking, “Could we do without physicians?”
I cautiously replied, “Sure, that’s possible, but I don't think you'd be happy with the results.” I went on to explain that although non-physician providers carry out many health care services, it is usually physicians who make the tough calls – in those life and death decisions, both at the patient and infrastructure level. The education and experience of a physician is what patients trust.
I felt as though I left my friend with something to think about, but he too left a nagging question in my mind: could medicine do without physicians? Why participate in the CSA or organized medicine? Why do we fight?
I reflected on a perspective that came from experience – that of my Aunt “Lillian.” Prior to attending medical school in the 1980’s, I travelled to Beijing, China – then very openly Communist. Family members insisted that I must meet the highly revered Aunt Lillian. They spoke of my distant Aunt in a hushed but somewhat awed tones. No details were provided other than I shouldn't think of leaving China before seeing my distant Aunt.
And Aunt Lillian did not disappoint – she was as described: poised, highly educated and having a presence that commanded respect. As a former high-ranking government official in the party, she regaled me with her stories of Communist China; stories of a flawed humanity and history, for which she had had a front-row seat.
Her own personal story was one of both triumph and sadness; a cautionary tale of a society gone mad, during China’s Cultural Revolution. Among the best and brightest, she had won admission and a scholarship to an Ivy League school in the 1940s where she graduated in English, a rare feat then for a student from China. At the end of the war with the Communist party sweeping to power, a patriotic Aunt Lillian, now in an English doctorate program, our family’s brightest light, went against the fleeing human tide and returned to China.
One part of her story really piqued my interest, as a medical student-to-be – that of her years of “re-education” on the pig farm.
As the grand experiment of communism in China began to fall apart in the 1960s, the famines, broken utilities and dysfunctional economy were deemed the fault of the elites! Quickly those in the educated class found themselves relegated to menial labor jobs. For Aunt Lillian, that meant being sent to work on a pig farm – basically a concentration camp. Barracked alongside her were those of the educated elite: professors, businessmen, attorneys and many physicians. So what did she think of my plan to go to medical school?
“You know physicians were the first people off of the pig farm,” she said with some reflective gravity in her eyes. Life as it had been previously known in China had come to virtual halt: farms, transportation, utilities, schools and most importantly hospitals had ceased to function. Stories filtered to the pig farm about medical tragedies – the son of an important official had died during an appendectomy, somebody’s mother had died from treatable pneumonia, etc. Removing the most educated order of health care providers and the chaos of results speaks for itself. The physicians exiled to pig farming agonized over the news of suffering patients. They knew medicine, and they knew their replacements.
I remembered that conversation from many years ago as I think of the CSA and how far the practice of anesthesia has come. Our specialty has transformed the hospital and surgery to a relatively safe place – in a way almost no other specialty has – with a relentless emphasis on science, safety processes and clinical introspection.
As we talk about integrated clinical processes (of which I am a champion) using other providers (anesthesiologist assistants, nurse anesthetists, registered nurses, etc.), we cannot forget that we, as anesthesiologists and physicians, will have to not only create but also manage these systems. The modern egalitarian temptation and economic urging will be to let “B students" be “A students,” and “C students” be “B students” and so forth until you have a slippery slope of pig slop medicine where nearly anything goes.
We, the physician-anesthesiologists with the education and experience, will have to lead in order to prevent the history of ignorance from repeating itself. We know what is better, safer care for our patients. We know our replacements. The public trust is with physicians.
That is why we fight.
Those decades ago in China, after many hospital casualties, the physicians were plucked from the pig farm, one-by-one. So followed the engineers, teachers etc., because society needed those educated and experienced professionals, to keep virtually every social, government and community function working. In medicine, as physicians and as anesthesiologists, we should command the decisions surrounding the patient, no matter what. The wisdom of fools, that anybody could do anything, was and still is rejected by even Communist China.
My erudite Aunt Lillian as a pig farmer? Two years removed from the pig farm, she would be on the airport tarmac as part of the party greeting President Nixon walking off the plane in Beijing. However, having developed a new mixture of pig slop during her “re-education” period, her pigs grew bigger and fatter than had ever been seen before. “I could have been the greatest pig farmer in China if I they had kept me on that farm,” she concluded then, with a tired but wise smile.
Dr. Chow is a frequent contributor to CSA Online First. Currently he is in private practice and is the incoming Chair for the Department of Anesthesia at Good Samaritan Hospital, San Jose. He also holds an adjunct community faculty position at Stanford School of Medicine and has a master’s degree in Health Services Research in addition to his medical degree from Stanford.