by Dr. Lesly Kernisant
As a retired physician, I am still amazed at the pace of progress in American medicine since I began my clinical practice four decades ago. In the field of medicine, the U.S. has achieved an impressive array of technological advances that have translated into marked improvement of human life as reflected in longer individual lifespan over the years. Despite the recent pandemics and the massive human loss to world conflicts in the form of wars, criminal enterprises, homicidal and accidental deaths, one can reasonably conclude that the evidence-based approach used in modern clinical medicine has proven to be successful in containing the rate and the lethality of most major illnesses.
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However, it is worth noting that while the U.S. health system, perhaps the most expensive in terms of cost per capita, is also the most unfair system in the industrialized world. Racial and ethnic inequity is a well-known fact, backed by extensive data on health outcomes in blacks when compared to whites. Over the years, the high cost of medical education in America has somehow thwarted the number of black minds from pursuing a healthcare career.
According to the Association of American Medical Colleges, the number of black physicians is reported to be less than 6% as compared to 16% of Black student-athletes population and 19% in the entertainment field. When I graduated from medical school in 1975, I was among a small group of minority physicians who became aware of health disparities in black and brown communities. At the time, this was considered a nonissue topic, a matter of little importance in a world where “black lives” did not really matter. In this immediate post Jim Crow era, the notion of Health is a right for everyone in America was considered a misnomer, for it was always being perceived as a commodity that can be bought and sold to the highest bidder. Wealth provides a protective shield of exclusivity allowing the rich to prevent illness and the poor to get their illness treated. Hence, wealth and poverty are the two polarizing determinants of health. Wealth is the harbinger of good health and poverty fuels the chronic stressors for poor health. Health inequity was well known then and persists to this day.
The biblical proverb “Heal thyself” could be extrapolated to raise the awareness that culturally sensitive care achieves the best result in the delivery of healthcare services. “Blacks treating blacks” can help in addressing the long existing healthcare disparity crisis in black communities. We all now know that “unconscious bias” is a potent poisonous element contributing to the American health disparity syndrome.
As I observe the gradual change in American medical practice, I am profoundly disappointed with the actual shift from science to the present business model in healthcare services that seem to put profits over outcomes. Most new medical graduates accumulate a great deal of tuition debts and are no longer able to afford the prohibitively expensive option of starting an independently owned medical practice. As employees of mostly free-standing health centers, they are now working just like wage-earners with an hourly productivity output like any production worker contributing to the aggregate number of daily patients seen and treated. As a former executive of a major health system in NYC, I am appalled by the current working conditions under which young physicians are forced to operate.
Medical students are taught to follow the Hippocratic dictum, a commitment to “do no harm” to those who trust them blindly. As part of the medical school education, the ethical standards of this pledged covenant are reinforced daily until all young doctors are trained to serve the public using the strict and principled approach of good patient care at the early stage of their professional career. The avoidance of harm and the ultimate patient well-being became the mantra that guides them through the difficult period of “life and death” situation. It is a professional responsibility that requires not only time commitment to assess, but limitless patience to exercise good judgement.
Unfortunately, the era of big business has virtually transformed good outcomes into metrics that prioritize quantity at the expense of quality. Since most independent health centers are now being run by business-minded executives, the productivity assessment of most doctors is linked to the central business goal of making every patient visit a monetized process of billing to the maximum limit of insurance reimbursement. It is now an expectation that most employed physicians see an average of 3-4 patients/hour, leaving them little time to engage in any substantial discussion with the patient about the treatment proposal or other medical concerns. With this new emphasis on the financial health of a medical practice, the economic divide makes health a commodity governed by wealth and affordability, an added stressor for the poor.
Ultimately, it appears that quality will be largely replaced by quantity. The new practice workflow is now redesigned to follow the factory-style productivity model measured in terms of monetary gains, not good outcomes. As an advocate for patient-centric care, I am sorry to say that our patients have been objectified and treated like herds of cattle in a barn. While productivity at all costs is now the only motivator for excellence, I must admit most patients are not happy when their once friendly doctors are now forced to dismiss them, and shift focus on applying appropriate reimbursement codes for the visit. For the most part, these patients need complex physical and emotional support, but are cut short of their long list of concerns and complaints. One can surmise that there is a direct correlation between the state of health of blacks and whites in America. Such shark contrast in racial differences is also true in the international landscapes of Africa, poor and black and Europe, rich and white. The state of health in poor and rich countries attests to the truism that “Wealth begets Health”.
