Thursday, May 26, 2011

Cynicism versus Engagement

“We can destroy ourselves by cynicism and disillusionment, just as effectively as by bombs."

This observation, from the late, great British historian Kenneth Clark, could be a warning sign to the medical profession. Some of the more incendiary commentary in blogs, editorials, and medical publications today display the classic characteristics of cynicism, which is a profound pessimism accompanied by a deep distrust and even the disparagement of the motivations of others. Physician cynics not only direct their anger at the usual suspects – members of Congress, insurance companies, and government “bureaucrats”—but even at their own colleagues, including the leadership of their own professional societies.

Now, to be clear, I am not talking about principled disagreement and debate over the best policies or course of action, which is good and healthy. It is only when such disagreement becomes “personal”—assuming the worst motivations of others, even when you don’t personally know them—that it becomes the type of self-destructive cynicism described by Clark.

Take the cynics’ charge that the leaders of physician professional associations, including ACP, are living in “Ivory Towers” disconnected from the “real world” of practice, and that they “sold out” the rest of the medical profession by their actions. Really? I know many of these leaders, and they are as grounded in the “real world” of practice as anyone, but with one crucial difference: they are taking time out of their busy lives to help make things better for their colleagues and their patients.

On Sunday and Monday of this week, two of ACP’s key policy committees met in Washington, D.C. Want to know who they are and what they do? The Medical Practice and Quality Committee, which recommends ACP policy on payment and delivery system reform, has 13 members, eight of whom are in private practice (two of them in solo practices!), one is a medical student, one is an internal medicine resident, one is a chair of a department of medicine, one is an assistant professor of medicine, and one is a medical director for a large group practice that has its own associated health insurance company. The Health and Public Policy Committee, which recommends ACP polices relating to workforce and health insurance coverage, has 13 members, four of whom are in private practice, one is the CEO of a medical college, three are professors of medicine, one is an assistant dean, one is a chair of a department of medicine, one is a medical student, one is a hospitalist, and one is an internal medicine resident. Also attending the meetings was the chair of the Board of Regents (private practice doctor) and the ACP president (a professor of medicine).

Then there are the almost 400 medical students, IM residents, and physician members from all types of internal medicine practice and parts of the country who took a minimum of two days out of their busy personal and professional lives to participate in ACP Services Leadership Day on Capitol Hill. If cynicism is the poison, then engagement in trying to make things better is the antidote. Unlike the cynics, these physicians have decided to address their shared frustrations with the state of medicine today by learning about the issues, politics, and policies—from administration officials, ACP staff, members of Congress from both political parties, congressional staff from key health committees, and from a well-known cable TV political analyst—and then to walk the halls of Congress to seek support for ACP’s top legislative priorities.

And this is why that I don’t think that Kenneth Clark’s warning predicts the future of the medical profession. Yes, cynics get a lot of attention, but there are many, many more physicians who are grounded in all of the glorious diversity of internal medicine practice today, who understand that the best way to achieve change is not to reflexively dismiss the ideas and the motives of others, but to engage in the political process through their professional associations for the betterment of the profession and the patients they serve.

Today’s question: Do you think Kenneth Clark’s quote predicts the future of the medical profession?


ryanjo said...

I am proud to espouse views which are often cynical of the way that health care reorganization is proceeding, especially the support that ACP has given the present process. There are many comments here that are worthwhile considering if the leadership was not locked into the present course.

But since we are providing quotes, two to consider:

"The people to fear are not those who disagree with you, but those who disagree with you and are too cowardly to let you know." - Napoleon Bonaparte

"However beautiful the strategy, you should occasionally look at the results." - Winston Churchill

Juliet Mavromatis, MD said...

It was my first time attending ACP Leadership Day and I found it to be thrilling. I really enjoyed seeing the political process in action. There is a fine line between cynicism and skepticism. The latter I view as healthy and positive, the former, as gloomy and nihilistic. I found the internist participants of Leadership Day to be open-minded and reflective of differing viewpoints--not dogmatic. I am proud to have ACP represent me.

DrJHO7 said...

When we, as internists, are faced with a patient who has multiple medical problems, medications, symptoms and abnormal test results, we do not take the approach of cynicism and disillusionment to help optimize their care and improve their health and well-being. Indeed, it is the unique ability of an effective physician to wipe the slate clean as he/she enters the exam room or the hospital room, and to focus their concern, knowledge, experience and compassion on the needs of their patient in the effort to help and heal them.

Clearly, our health system is a complicated "patient" with multiple problems that need solutions, and by necessity, physicians need to be engaged in the development of these solutions, just as we would be in the care of our patients. Collectively, there is alot of brain power and positive energy in our profession, and these are the attributes that will make us likely to succeed in effective reforms, not the dark side.

We should not rely on congress to be the principal leader and decision maker on health system and physician payment reform. Physicans and our organizations need to be in the pilot's seat of health system reforms if we expect to achieve anything like desirable outcomes for us and our patients.

The physicians who sit at the tables of ACP's policy committees, and in the offices of their elected representatives on leadership day are a sign that the talents and energies of internists are being focused on solutions that can bring about desired outcomes. Cynicism/disillusionment are paths to apocolypse - something we and our patients don't want.

Arvind said...

I suppose you include me under the "cynic" category, Bob. However, this post just displays how ignorant you can be about understanding those of us that simply disagree with those in the ACP (like yourself) that continue to promote divisive policies with narrow objectives.

You must agree that policy is mostly driven by politics, at least in DC. So motives do play a major role in how policy in enacted. Therefore we cannot ignore peoples' motives when trying to argue against policies that endanger small practices and promote the destruction of the physician-patient relationship.

Unfortunately, your defense of the so-called leaders comes up way short, since we all know how they sold out the working dues-paying members last year.

And just so you know, even though I am s solo practitioner, I have spent my own time visiting members of Congress as part of an organization that represents the interests on my practice and my patients. By joining the ACP in DC I would legitimize its action, with which I disagree almost completely. So just because you did not see me with the ACP group in DC, you cannot conclude that we "cynics" are not contributing to this debate. Its another matter that no one is listening, especially those like the ACP that are supposed to be our voices.

Just as a gentle warning, Bob, you risk loosing more members if you continue to label people as cynics. If you noticed, a vast majority of those that respond to your blog posts belong to that category....

Harrison said...

Cynicism is necessary.
Otherwise we just have cheerleaders, and that has to be balanced.

But public dialogue is bordering on toxic.

A quote from Napoleon is an interesting addition to this discussion.
Napoleon was a dictator. Keeping quiet around him was a survival skill.

We will have problems if our public dialogue is bounded by fears of consequences of voicing opinions.

With that, I think it should be okay to disagree with Paul Ryan's plan for Medicare, but it is not okay to label his plan as 'Medicare killing.'
It is fair to explain how his plan dramatically changes and limits Medicare.
It is fair to point out that it does nothing to curb the inflation in health care, and it does nothing to change incentives.
It is not fair to imply that he is driven by the intention to kill public support for the health care of the elderly.
He is not.
He seeks a simple and unobtrusive way to limit federal spending on health care.

But the Democrats are guilty of doing to the Republicans exactly what the Republicans did to them when the ACA debate was flaring.
It was not fair then
and it is not fair now.


George said...

"It is fair to point out that it does nothing to curb the inflation in health care, and it does nothing to change incentives."

Market economics proves this statement to be false. By allowing the people who receive service to be more responsible for the cost of the service, the beneficiaries will necessarily be more concerned about cost. As such, they will accept treatments only if they see a valuable cost/benefit ratio. This will, over time, reduce costs as patients become savvier shoppers of health care.

Look at health savings accounts; where they have been instituted, health care expenditures have gone down or have been flat, often with icreased patient satisfaction. Why? In general, people care where their own money is going more than they care about the government's or an insurance company's money. Ryan's premium support is not an HSA, but it is an intriguing idea to help control federal medical spending.

This boils down not to a policy debate, but a philosophical one. Do you believe that a top down, centralized, command and control approach to sectors of the economy is better than a decentralized, regulated, but more flexible approach. Aside from the limitation of individual liberty with the former, just look at the three sectors where the federal government is most involved in financing to get the answer: education, health care, housing. All three have had, or are having, crises in cost appreciation out of proportion to (nonexistent, but for fuel) inflation. To me, it's clear cut.Unfortunately, oftentimes politicians use these crises as evidence for further government intrusion which invariably makes the problem worse; which for health care, means an eventual single payer system which will greatly damage health care in America.