Volume 61, Number 1 - Winter 2010

 

By John Toton, MD

Physicians receive an overwhelming number of medical journals and medical newspapers on topics of current interest, usually supported by advertising. We scan and sometimes read this flood of information, but occasionally an article or reference stands out, and we follow up on it. Such was the case with an article about Physician Disempowerment: A Transatlantic Malaise, a “treatise” on the reality of European medicine from the physician’s perspective.

I downloaded the treatise from www.cmpi.org, the website for the Center for Medicine in the Public Interest, an organization that lobbies for a traditional American approach to medicine. The treatise consists of the full texts of 12 presentations made at a 2008 conference on physician disempowerment sponsored by CMPI. Half the presenters were physicians, PhDs and other experts from the United States, and the other half were from countries with nationalized health care systems.

Editor Mark Crane introduces the presentations by affirming the “American malaise.” According to Crane, the United States is losing doctors because of excess paperwork, retirement, and practices that are overextended and overworked. He predicts a shortage of 35,000 to 40,000 primary care physicians by 2025.

“Person in the street” interviews conducted by CMPI in New York City highlight how little the public knows about Canadian and European systems. When asked whether they would want universal health care, the answer was invariably yes; but when asked how much extra income tax they would pay, a typical response was, “No, no, no. We want it to be free, like in Europe.” 

The keynote speaker, Dr. Francois Sarkozy (brother of French President Nicolas Sarkozy), addresses what kind of care one gets in France “for free.” He describes the flight of French physicians away from private practice to salaried positions. He finds a paradox that there are now more physicians per population than ever before, and that many are seeking “the balanced life” while practicing only 50% to 75% of the time. Physicians are unionized, and their medical fees are agreed upon between the government and the union. Having given up their independence, says Sarkozy, physicians reluctantly accept the regimentation and loss of collaboration, along with the loss of accountability and quality assessment. 

Sarkozy identifies a “physician malaise,” arguing that all is not well. Physicians need to recover their respected status and recognition in the community; they need to relearn the principles of independent practice, to delegate, to seek efficiency, to collaborate—in short, to redevelop what they’ve given up, what American medical practice up to now fights to maintain.

Dr. Tim Evans, from Great Britain, describes waiting lists that have become “intolerable.” The country has a population of 60 million and a health care budget exceeding $175 billion per year, yet Great Britain at any given time has more than 1 million people on an active waiting list for care and an additional 200,000 trying to get onto that list. Seven million people also have private medical insurance, and another six million will pay cash to get their desired or needed care. This situation, says Evans, is a far cry from a 1948 government promise that “The National Health Service will provide you with all medical, dental, and nursing care. Everyone, rich or poor, will be able to use it.” Physicians in the NHS now tell patients, in effect, “If this is an NHS dialogue, you can have 10 minutes. If you want to pay privately, then we might have a slightly longer, slightly more fruitful conversation.”

Evans claims that most British physicians now realize that there are only two ways to organize health care. One is on an entrepreneurial basis, where you serve customers and create value. The other is to organize care politically and put the politicians in charge, making physicians “a salaried lackey of the state.” 

Jacob Arfwedson, director of the Paris office of CMPI, describes the issues in Sweden, a country with a longtime government model of health care. Sweden recently began offering “choice of care” options with performance-based pay for medical physician entrepreneurs. The Karolinska Hospital in Stockholm, known worldwide as a model of state care, now runs training sessions in private care. The state is naturally opposed to these developments, but as market-based care models demonstrate improved services, they are becoming firmly entrenched, according to Arfwedson.

Dr. Alfonse Crespo, a Swiss orthopedic surgeon, admits that the Swiss system, once “perfect,” is not as good as it was a few years ago. Until 1994, it functioned well as a complex “clockwork” system with a mix of government oversight and decentralized regulation. The system had a private insurance model, with the government stepping in to subsidize those who could not afford coverage. Crespo says the system worked particularly well in the 1950s, when 50% of the population was subsidized. By the 1980s, however, 90% of the people were subsidized. This 90% was unsustainable, so subsidies were severely restricted in 1994. Since then, the focus has been on cost containment and centralized policy making, leading eventually to a “pencil strike” where physicians for a month saw and treated all their patients but refused to do any charting or fill out any forms. 

Other presenters rehash our American complaints and observe that American baby boomers want universal care at no cost to themselves. While American physicians are acutely aware of our own problems, we are grossly unaware of the European and Canadian systems. Our fellow physicians in these countries have the experience to advise us of what is ahead.

The presenters in Physician Disempowerment speak to a wide range of government mandated and supervised health care options, all of which appear to weigh heavily on the backs of physician providers. Although CMPI is clearly an advocacy organization with a conservative viewpoint, its treatise does offer an informative window into an experience we may all be facing in the near future.

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