Loss of the Medical Mezoi and Medical Citizenship

We are living amid a Great Ethical Collapse. Medicine has failed us in the past four years. But that failure has been part of a much broader failure: Science has failed us. Government has failed us. Academia has failed us. Business has failed us. And, yes, even many of our spiritual leaders have failed us. All have abandoned critical thinking and moral responsibility to a degree we have not seen in the past 80 years. All have been “fundamentally transformed” into Postmodern caricatures of their former selves. “Truth” has become a relative term. Everything, it seems, has been reduced to ideology.

How did we get here? There is a controversial and frankly often misunderstood concept in Complexity Theory, Retrospective Coherence. It is often stated to be a misunderstanding of the inevitability of the endpoint of decisions at certain inflection points in a Complex Adaptive System. In mathematical terms, an inflection point is where the graph of a function changes concavity.

In my understanding, there is no doubt that the origin of social change can indeed be traced to actions taken at certain critical points in time. Those critical of Retrospective Coherence paradoxically take the viewpoint that since it may not turn out the same way in the future, we should just disregard that it may very well do so! 

Football coaches know that certain plays work well against certain defensive formations and call the plays accordingly. They may not always be right, but many times they are. They update their decisions based upon changing experience and knowledge of each opposing team. Technical analysis of price action in investment vehicles does the same. They are not always right, but a significant number of times they are as long as the situation is in the Complex Domain where cause and effect are still operative. Once the situation enters the Chaotic Domain where cause and effect are no longer rationally connected, all bets are off. It would be foolish not to consider a similar strategy in social actions.

A complete discussion of all the elements that came together in a Perfect Storm of Postmodernism to create the Great Ethical Collapse is beyond the scope of this essay. Let me just chart some of the inflection points in Medicine and Healthcare to which I was a witness and participant.

In retrospect, these inflection points led to the systematic devaluation of what I will call Medical Citizenship. I chose this term because it mirrors the larger change in citizenship that is described in the penetrating work of Victor Davis Hanson, The Dying Citizen: How Progressive Elites, Tribalism, and Globalization Are Destroying the Idea of America as well as the Hillsdale College online course, American Citizenship and its Decline. 

Once started, the devaluation of citizenship serves as both a cause and effect. It is like a thermonuclear reaction that reaches criticality. It feeds on itself and, barring any modulating intervention, grows in power.

So, what is “Medical Citizenship?” Hanson describes a Citizen as one who is able to determine:

• The laws under which they live
• How those laws are enforced
• The basic economic, social, and political structure of the society

It arose in the Greek city-states that came into existence following the centuries of the First Dark Age that resulted from the implosion of the Mycenaean Bronze Age in 1177 BC. The stability of the city-state, the Polis, was achieved through a radical idea of Citizenship. To be successful it granted to the Citizens:

• Protection of private property

• Reduction in Tribalism
• Equal protection under the law
• Clear borders
• A collection of rights and duties shared equally

The Romans built upon this system by adding several checks and balances to deal with the problems seen in Greece, such as:

• Accumulation of power in too few hands
• The potential tyranny of the majority

They added checks and balances and the concept of citizenship remained stable for centuries under the Republic. Critical was the existence of a strong and vibrant Middle Class: the Mezoi or Middle Ones. The wealthy could become too separated from the concerns of the community and may corrupt the system for their own ends. The poor could become too dependent on the wealthy or the state and lose the incentive to collaborate for the common good.

The system began to unravel in the 5^th century, with the loss of equal protection under the law, the erosion of the middle class, the destruction of effective borders, and the loss of the system of checks and balances under a return to Tribalism.

Hanson makes the point that these are the very things we see in the present day in the United States and have diminished the value of citizenship. We can see this graphically in the complete loss of border security, preference for non-citizens in many economic programs, the economic destruction of the middle class, and the emphasis on “Diversity, Equity, and Inclusion.” The concept of the United States as a “Melting Pot” is considered demeaning. Equality under the law is discrimination. Meritocracy has been replaced with entitlement. All have been associated with a diminished value to citizenship.

In a very real sense, the practice of medicine has traveled a very similar course. When I completed my fellowship training in 1981, with great hope and excitement I began a solo private practice in Oculoplastic & Orbital Surgery in Milwaukee. I was the first Ophthalmic Subspecialist to do so in the area.

In 1981, opening a private practice, or joining a small group practice was the norm. But there were signs on the horizon that things were about to change. John Geyman from the Department of Family Medicine at the University of Washington published his view of the future of medical practice in the United States. He began his article by quoting from a speech, Medical Practice in 1990, given by Oscar Creech, the Dean of the Tulane University Medical School in 1966 at the Owl Club Banquet and available here:

The private practice of medicine will no longer exist as we know it. Physicians will be geographic full-time employees of the medical center complex, within which they will provide total medical care for the residents of the community, preferably on an annual fee basis, but perhaps as salaried employees of the federal government…Medicine will be practiced on an assembly line basis…[Physicians] will no longer concern themselves with the routine practice of medicine, which will be done by others whose training is more vocationally oriented.

Dr. Creech was remarkably prescient…

In his discussion, Dr. Geyman noted that in 1981:

The general posture of organized medicine and medical education is to favor an open system and avoid regulatory controls.

But he, on the other hand, favored regulatory efforts to control the choices of which specialty medical students could pursue. As a Primary Care Physician, he rightly or wrongly felt that medicine needed significant strengthening of the Primary Care workforce. He was opposed, however, to the inroads being made by Nurse Practitioners working without supervision by a Primary Care physician.

Both physicians eerily were able to predict the future, but in 1981 success as a physician was controlled by the 3 A’s: Ability, Availability, and Affability, and I diligently went about building a practice accordingly. I sought out networking opportunities and cultivated relationships. I was able to refer patients to the people who, in my personal estimation, could give them the best care. 

Hospitals competed for physicians, as the physician controlled the patient. We had a Physicians’ Lounge, a Physicians’ Dining Room in the Cafeteria. We had regular monthly department meetings, quarterly staff meetings, and a huge annual meeting. While some may criticize these as “elitist,” the collegiality it fostered and the opportunity for informal networking and “curbside consults” greatly benefitted all, especially the patients.

My commitment to availability and networking was a door into medical politics and organized medicine. I was a member of several medical societies and, when asked to do a job, had a hard time refusing. This led to appointed and elected positions on hospital staffs and in medical organizations. I started going to “meetings” and had an inside view into the workings of the system. The more I saw, the less I liked it.

On the hospital side, there was the corrosive influence of the hospital administration. On the organizational medicine side, there was the seductive influence of power. For years I did not realize it, but on a personal level, I was being pulled, little by little, away from the Medical Mezoi. And on the level of the entire profession, a similar erosion of the Medical Mezoi was taking place.

For several years, however, it was great. I had to “moonlight” in other offices for the first year to make ends meet, but my private practice flourished. I made a comfortable living and could deliver discounted care (sometimes free) to those who needed it. I continued on the voluntary faculty of the University of Wisconsin and subsidized my academic interests out of my practice. I had become the medical equivalent of the Hoplite, the middle-class citizen-soldier of a Greek city-state!

We had, at the hospital, an equivalent of the assembly of the Polis. I operated under the principles of Autonomy, Mastery, and Purpose, described 25 years later by Daniel Pink as the prime motivators of human activity in his masterful book, Drive: The Surprising Truth About What Motivates Us. 

But trouble was on the horizon. In 1981, healthcare expenditure was 9.2% of GDP, up from 8.9% the year before. By 1990, it was 12.1%. The 1980s saw an increase in healthcare costs as well as a decrease in the percentage of people covered by employer-sponsored health insurance. Medicine was changing in response to these changes in the cost of medicine and how it was paid. The first wave of HMOs hit the market and a combination of fear and greed on the part of physicians started to disrupt things. It was clear that the physicians no longer controlled the patient as insurance plans offered pre-paid options to employers, capturing the directions that the patient was forced to follow.

Enterprising hospitals first captured the Primary Care Physicians by offering them incentives such as Hospitalists to care for their in-patients. Through a combination of such growth and consolidation of hospitals into large conglomerates and insurance networks, the physicians were no longer the entry point for the patients. Once the Primary Care Physicians were locked in, the Specialists were pretty much at the mercy of these networks.

The Medical Mezoi evaporated almost overnight. Hospital staff were no longer independent. Medical staff officers became mere figureheads and employed Chief Medical Officers who assumed the real managerial power. The model of the Roman Republic was over. It was now the Roman Empire. There were two classes of physicians: the few members of the elite nobility who were part of the networks and the serfs who did what they were told.

Don’t misunderstand me. The physicians still made a very good living, but, for the most part, the motivators Dan Pink described, Autonomy, Mastery, and Purpose, were systematically stripped from the picture. The only thing left was the financial remuneration, and that was at the mercy of those who employed the physician. Physicians who thought their expertise would insulate them from these changes were in for a shock as they were told by their referring sources that they could no longer utilize their services as they had an employed physician who could “do the same.”

Of course, that was a fallacy. They may indeed have an employed physician who had the same job description, but they may or may not have the same expertise. But that really didn’t matter. One of the consequences of the devaluation of Mastery was the notion that all “providers,” be they nurses, technicians, or physicians, were the same. They were like electricity that the administrator could plug into the wall to obtain. Health Care Professionals suddenly were a liability instead of an asset! I recall the administrator of the Cardiology “line” at a hospital network actually explaining at a conference, “I would have made a profit if it wasn’t for the ####ed physicians!”

Imagine if a similar paradigm would be imposed for lawyers or accountants. Imagine if all restaurants were forced by an overarching “Hospitality Board” to charge the same for a generic “meal” or if all hotel accommodations were reimbursed the same, regardless of the amenities. It would never happen, of course. The consumer would never stand for it. But in health care, it is the rule, in part because of the difficulty in seeing the “product.”

Well, at least we stopped the runaway healthcare costs, right? No! In 2020, the share of GDP spent on health care rose to 19.5%. That was a 56% increase from 1981! Was there a concomitant increase of 56% in patient satisfaction? A 56% increase in satisfaction or a 56% increase in health?

I was not immune to these titanic changes. I found myself working harder for less compensation. Much of my work was with trauma patients who often had no insurance. In the past, when I was compensated well for my elective patients, I could absorb this loss, but now it became almost impossible to continue to do so.

To make matters worse, as most of my colleagues stopped taking emergency calls, these trauma cases all fell to me. I had to cancel elective-paying patients to make room to operate on those with no insurance coverage at all. It became unsustainable, and I accepted a position as Professor of Ophthalmology at a medical school which allowed me to continue active practice until a herniated disc ended my career as a surgeon because of numbness and weakness in my dominant hand. 

There still were pockets of physicians who could control their destiny, but they were forced out of the classic profession of caring for sick patients. Many Medical Specialists started to deliver Concierge Care in which they would give care for a monthly fee. As this was only for office visits, they were not at risk for catastrophic care or surgery in the hospital. In my own field of Oculoplastic & Orbital Surgery, the best and the brightest made a dramatic shift into aesthetics. Cosmetic surgery, fillers, and enhancements all became a more prominent part of their services, especially if they wished to remain free from employment with either a hospital, clinic, or network. 

By 2020, the scene was completely set for the Great Ethical Collapse. Covid, and even more accurately, our response to it, pushed the system over the edge. The majority of physicians who actually cared for sick patients were either directly employed by, or were forced to obey the dictates of, an administrator class. The Medical Mezoi only existed in memory, and many newer physicians had never experienced it at all! The Medical Mezoi, who may have been able in the past to inject rationality into the picture, were facing a unified front of Big Pharma, Big Government, and the long-captured Big Organized Medicine. 

Physicians now obeyed the directives of their Chief Medical Officers or Deans, as their livelihood depended upon it. Cognitive dissonance was a barrier to even considering that the dictates from the government were not based in fact. Those who dissented were crushed in actions reminiscent of, in their professional severity, the Roman response to the Slave Revolt of Spartacus. 

Reversing, or even blunting this will be a monumental task. Just as creating this monstrosity took years and was largely due to governmental imposition of regulation, so will the remedy. Changing one part of this Complex Adaptive System will likely affect others. Unintended consequences may make things worse. It will take the concerted efforts of physicians, nurses, medical and nursing educators, hospital administrators, health policy experts, economists, etc.

ALL will need to understand Complexity and not just approach this as a Complicated problem. They will need to look at the totality of the problem and not just see it from their own narrow perspective. They must understand that asking the right question is just as important as arriving at the right answer. Too often we have acted upon the right answer to the wrong problem and made things worse.

One thing is certain, however: first, the government-sponsored imposition of diversity, equity, and inclusion must be eliminated. As Victor Davis Hanson points out, these are absolute anchors to the functioning of a viable Citizenship (including a Medical Citizenship) and middle class. This will only be done by a political change in this country. It is ironic to contemplate that the most significant advance in Public Health in 2024 may be in the hands not of physicians, scientists, epidemiologists, or Public Health experts, but in the hands of the voters of this country.

By the time you read this, we will know if that is even in the realm of possibility…