Medicine in the Wilderness

I once was proud of my profession. I spent over 40 years as a clinician, educator, and researcher and for most of that time thought I was engaged in a noble calling. But all that has changed in the last 3 years. Medicine is lost in The Wilderness.

There were warning signals, to be sure. For many years I was heavily involved in medical associations on the local, state, and national levels. Gradually I became disillusioned when I saw that many of my colleagues who gravitated to this activity did not share my views. They enjoyed the politics of medicine. In fact, they enjoyed it too much. I lost interest. Perhaps in retrospect that was part of the problem. The policy of medicine gradually became the politics of medicine. And as is often the case, where there is politics there is also corruption. 

Twenty years ago I was appointed as a technical advisor to a panel of the federal government. I was flown to Washington, housed in an upscale hotel and dined on fancy meals. I saw how intoxicating power can be. I began to somehow consider that I was special. The problem was I was expected to use my technical expertise to advise in a certain way. I realized, almost too late, what was going on. But I did realize it and was not reappointed to that position.

Looking back on it, this experience gave me a taste of how the events of the past three years came to be. I saw how money, power and flattery could cause physicians to shade their recommendations. It happened oh so gradually until one day, integrity was completely lost. The tragedy is that many times, those who lost it did not miss it.

I have come to realize that ethics and medicine have parted ways for many physicians, myself included. Things we once took for granted are gone…evaporated. We reached a point where, relating to COVID, attempts to treat disease were not just ignored but penalized. As a surgeon, I had operated under the obligation of giving Informed Consent to all my patients. I was expected to clearly explain the risks, benefits, and alternatives of my proposed course of action and allow the patient to make the decisions regarding their response to those recommendations. I could be sanctioned for failing in this obligation. However, in COVID, Informed Consent was criminalized…but only for that disease. Those who still felt an obligation to their patients were, and continue to be, vilified, slandered, fired from their position, and in some cases, prosecuted.

One would have thought that organized medicine, and academic medicine in particular, would have rallied to their defense, but that was not the case. They were the primary prosecutors. I shake my head when I think back to the days that I taught medical ethics to residents and medical students. One of the case studies involved discussing how accepting a lunch, or even a pen, from a drug company was unethical. Somehow, individuals who made life and death decisions were suspected of being bribed by a pen! And owning stock in a company and prescribing medications manufactured by that company were absolutely forbidden!

Now where are we? A good deal past the use of pens, for sure!

If a physician from even 10 years ago would look at the contents of most of our medical journals today, I am sure he or she would think they were reading fiction. These are the four articles that make up the Viewpoint section of the September 19, 2023 issue of the Journal of the American Medical Association. 

• Affirmative Action Ruled Unconstitutional: Options for Building a Diverse Health Care Workforce
  Eli Y. Adashi, MD, MS; Philip A. Gruppuso, MD; I. Glenn Cohen, JD

• The Supreme Court’s Rulings on Race Neutrality Threaten Progress in Medicine and Health
  Harald Schmidt, PhD; Lawrence O. Gostin, JD; Michelle A. Williams, ScD

• The Supreme Court Decision on Affirmative Action—Fewer Black Physicians and More Health Disparities for Minoritized Groups
  Valerie Montgomery Rice, MD; Martha L. Elks, MD, PhD; Mark Howse, PhD

• Holistic Admissions at UC Davis—Journey Toward Equity
  Mark C. Henderson, MD; Tonya L. Fancher, MD; Susan Murin, MD

In order to truly understand the departure from what was the norm a mere 10 years ago, this is a link to the contents of the Viewpoint section in the September 18, 2013 issue:

• The HIPAA Conundrum in the Era of Mobile Health and Communications
  C. Jason Wang, MD, PhD; Delphine J. Huang, MS

• A Trial-Based Approach to Statin Guidelines
  Paul M Ridker, MD, MPH; Peter W. F. Wilson, MD

• Medicare Payment for Chronic Care Delivered in a Patient-Centered Medical Home
  Andrew B. Bindman, MD; Jonathan D. Blum, MPP; Richard Kronick, PhD

• PEPFAR’s Antiprostitution Pledge Spending Power and Free Speech in Tension
  Lawrence O. Gostin, JD

The difference in the tenor of the articles is striking, at least to me. In the current articles, the author’s primary focus seems to be finding ways to circumvent the rule of law. In 2013, the two articles that deal with a legislative focus explore how to comply with the rule of law. While some may claim that is a distinction without a difference, I would disagree. Something has changed! Change is inevitable, but is it always positive? Looking back on history, many nations have changed in response to internal and external pressure. Unfortunately, the majority of those changes have been negative. 

Back in 2019, before the Great COVID disaster, Baffy and associates warned us of a change that was occurring in medical and scientific publishing. They observed the concentration of medical and scientific publishing in the hands of a few very large corporations which answered to stakeholders with conflicting interests:

Because the use of complex digital tools and rapidly growing electronic databases require advanced computing skills, Internet-based mega-companies such as Google (Mountainview, Calif), Amazon (Seattle, Wash), Facebook (Menlo Park, Calif), and Apple (Cupertino, Calif) may become interested in spearheading further transformation and outcompete current stakeholders in scholarly communication and develop more user-friendly tools. Such developments could potentially lead to a few large entities controlling the gateways to scientific knowledge, a sobering thought…

Scientific publishing has been a highly profitable industry, and there is little doubt that financial interests will continue to drive its transformation. However, the academic community has a fundamental stake in this process and should understand the trajectories of change to protect enduring values, embrace promising developments, and make scholarly communication increasingly inclusive and efficient.

It would seem the authors were amazingly prescient, as their world has come to pass. Medicine seems, at least to me, to have become the Willing Servant of an Unholy Trinity of Big Pharma, Big Tech and Big Politics. Medical publication and medical education have become more interested in ideology and propaganda than healing, more interested in class than the individual. It is the very antithesis of the concepts contained in the Hippocratic Oath. Although the proponents of the transformation may claim it is being done for a “greater good,” that excuse has been used before in medicine of some nations of the last century. When sanity returned, that excuse was repudiated.

Society now finds itself a passenger on a ship which has been taken over by ideologues. The ship is heading for the rocks. Lookouts stationed high above can see the disaster unfolding and urgently inform the captain of the ship. The captain solves the problem by throwing the lookouts overboard.

This is the dystopian world in which we now live.