Friday, January 6, 2012

Physician strikes can’t be justified to make a political point, ever.

With Congress’ continued failure to enact a solution to the Medicare SGR problem, more and more physicians may decide that it is time organize a strike or boycott to send a message to Congress. Or something akin to a strike, like a single day when doctors collectively close their offices except for emergency care.

Earlier this year, the ACP Internist published a letter from a member who argued exactly that. He wrote that “it is time for the ACP, AMA, AAFP, and other groups to call for and lead a Medicare strike, whereby physicians refuse to see Medicare patients, except for urgent/emergent problems, for a period of, say, three days. By the way, don’t call Grandma by phone and tell her that her appointment is cancelled. Let her struggle across town and up to the office with her walker, then tell her why she won’t be seen that day, then hand her a piece of paper with the office phone numbers of her senators and representative on it. Maybe then we will see real change. If that doesn’t work, strike for a week. Then two weeks. Then a month. It is obvious that only such action will get rid of the SGR.”

There is precedence for a physician strike to put pressure on legislators. In 2003, the New York Times reported that almost all of the 30,000 physicians in New Jersey “canceled routine checkups and rescheduled elective surgery during the week of Feb. 4 in one of the nation's largest walkouts ever by doctors” to protest the state legislature’s unwillingness to curb malpractice premiums.

It is refreshing, then, that the brand new version of ACP’s code of ethics, published in the current issue of the Annals of Internal Medicine, reaffirms the College's position that strikes, boycotts, and other collective actions to deny care to patients or to inconvenience them are flat out unethical:

“Changes in the practice environment sometimes adversely affect the ability of physicians to provide patients with high-quality care and can challenge the physician's autonomy to exercise independent clinical judgment and even the ability to sustain a practice. However, physician efforts to advocate for system change should not include participation in joint actions that adversely affect access to health care or that result in anticompetitive behavior. Physicians should not engage in strikes, work stoppages, slowdowns, boycotts, or other organized actions that are designed, implicitly or explicitly, to limit or deny services to patients that would otherwise be available. In general, physicians should individually and collectively find advocacy alternatives, such as lobbying lawmakers and working to educate the public, patient groups, and policymakers about their concerns. Protests and marches that constitute protected free speech and political activity can be a legitimate means to seek redress, provided that they do not involve joint decisions to engage in actions that may harm patients.”

Yes, it is frustrating that Congress hasn’t ended the endless cycle of scheduled Medicare payment cuts. Physicians have a right to be angry. Traditional lobbying—persuading our democratically elected lawmakers to do the right thing—is a slog, difficult, time-consuming, and doesn’t always deliver the desired results, especially in today’s broken political system. But professionalism says that “the physician's primary commitment must always be to the patient's welfare and best interests.” [ACP Ethics Manual]. Accordingly, Congress’ failure to do its job cannot be an excuse for physicians not to do theirs. Collective actions to deny care to patients, in order to make a political point, can never be justified.

Today’s question: Do you agree with ACP that physician strikes or boycotts can never be ethically justified?


Arvind said...

Bob, how long would you continue to do your "job" if the ACP kept cutting your salary every year and kept you guessing what your next month's paycheck is going to be? If you can give us an honest answer to this question, maybe then we can consider answering your question. And please don't give me your "ethics" answer...we are all tired of that nonsense.

Steve Lucas said...

This is a terrible idea. Doctors are already perceived to be both wealthy and arrogant and the idea of striking for more pay will only cement that in the public’s eye.

Additionally, many in government feel medicine, all the way down to the private practice, is a government function, or should be controlled by a government entity.

Last week I assisted my wife’s aunt in getting her 100 year old uncle to the doctor. The problem is he is not mobile and is inconstant pain due to arthritis in his back. He also has a gall bladder drain.

I am told he needs a PSA test and this cannot wait, never been mentioned as a problem. We arrive at this large multi-doctor practice that is on a large hospital campus. We enter a large well appointed waiting area where a large staff is moving people around with great efficiency.

Helping to get my wife’s uncle into the lab area her 87 year old aunt is accosted by a nurse who argues about the legal name of the uncle and then wants to know why he was not fasting and states “she” may not be able to do a blood draw. Fasting was not part of the doctor’s orders and is not an issue the nurse should comment on.

The aunt and uncle then go on to see the doctor where the uncle’s mobility and difficulty of office visits is discussed. The doctor’s solution is they should find another doctor or service that can better serve their needs. This does not stop the doctor from scheduling a follow on appointment where a fasting blood draw is to be done.

Back to the gall bladder drain, some very creative and inventive doctors have done a remarkable job of keeping my wife’s uncle alive, and at home he has a good quality of life. This drain must be changed every three months at the hospital next door to the doctor’s office.

The CIO of the hospital has moved on to be CEO of a teaching hospital, but they cannot order a blood draw or get the results to a doctor on the same campus at the time of the procedure to change the gall bladder drain.

The reality of this for myself and others facing similar situations is the doctor is only interested in money. The revenue of an office visit, blood draw, and checking the boxes of test, no matter how questionable, outweighs the needs of the patients.

I am also sure the doctors in this practice are looked upon by their peers as successful. Large practice, large staff, and large revenue stream all make them a success.

The guy with the dirty pony tail and large ear piece and boom mic were not impressive, nor was the “find another doctor” since you cannot come in for office visits impressive.

Yep, go on strike. I would be interested in the calls to the state medical board. The legal suits for the accidents coming and going to the doctor’s office. Then of course you would have the calls to elected representatives to enact even more regulations on the practice of medicine.

Steve Lucas

PCP said...

Professional idealism stands no chance against political cynicism and ineptitude.
This is particularly true in an era where unfortunately our professional leadership increasingly imbibed by washington grandiosity has wholeheartedly embraced the notion of a governmental role in everything medical from womb to tomb.
We have collectively been silenced and sidelined, whilst our professional service model built over hundreds of years is quietly being remade to the liking of the emerging political and economic elites. Who is defending the private practice model of medicine?
Our professonal idealism is now finally and unabashedly being used to silence us into submission. What follows is an inevitable decay in morale and with it quality of health care.

Harrison said...

Employed physicians who work for big organizations that have diverse revenue streams have protected incomes. They won't necessarily feel compelled to strike.
Physicians working for themselves as small business owners can't afford to strike to make political statements. They can however make choices to optimize revenue streams, and they do this routinely as a priority over specific patient care needs.

Ethical statements by organized medicine have meaning.
But more practical issues probably carry more weight.
We can't strike because we are leveraged as businesses in the model that exists.
We need for it to work as it is.
Even a 30% cut leaves 70% of our revenue stream intact.
Although this would be devastating, and it would embitter even more physicians against the political system that we are stuck with, it would be preferable to weather that than it would be to strike.
And many physicians have already positioned themselves so as to be hurt less by such Medicare cuts.
More physicians are choosing employed status.
More are relying on services that are cash payment services -- Botox injections or hair removal services,...
More and more are opting for concierge practices.

We haven't exactly been waiting for the political system to be nice to us.


BDoherty said...
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