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Volume 12, Number 2

The Editor's Turn
On the Road of Ashes

Back and forth across a chasm, politicians and physicians are shouting at each other. One of the clearer notes in the politicians' message is this: "Relax. You people have had it good for a long time, and now it is your turn to take your lumps. After all, if you lose 15 to 20% of your net income, you will still be far better off than most other members of our society." Taking the long view, this may be a fair assessment. If the practice of medicine is a vocation of service, if we are meant to share the trials and tribulations of our patients, we should listen when the community says to us: "Descend from your high place and walk beside us through these arid times."

For at least a generation, society has viewed physicians and, by extension, other health-care workers as part of what John Kenneth Galbraith called "the culture of contentment." We are seen as being among those fortunate enough to be able to manage power and politics so as to preserve our own privileges while the rest of society bears the brunt of economic stress. We are seen thus despite the reality of steadily declining medical incomes, declining job security, and clearly manifested political impotence.

Historically, a descent is inevitable. As Graner1 pointed out several years ago in these pages, physicians and medical science were not always in fashion. In the early decades of this century. physicians were admitted into the aristocracy because society, and particularly those in power, associated the physician with the wonders of modern science. Thus, they were willing to accord to the physician a considerable measure of respect and generous compensation to gain access to these wonders. However, that was then and this is now, and it seems that, despite any efforts to reverse the process, modern society's emphasis on science and economic considerations will force the physician into the role of mere purveyor to society of the products of scientific research.

By the term "road of ashes," Robert Bly2 refers to the time in a man's journey, usually after a period of psychological inflation ("flying high"), when he must hibernate for a time and undergo a profound psychic/spiritual "reality check." This time shares many of the characteristics of hibernation: a man in such a period is passive, na´ve, and numb. When it is over, the man awakens, as if from a long sleep, and takes up again the unique task of which he had lost sight during his giddy spiritual flight. (Anyone facing a period of personal or professional reassessment will find much to comfort them in Iron John, a wise and deeply compassionate book.)

Concerning the profession of medicine, what form will our debasement take? We will certainly undergo a reduction in income. We will suffer a decline in social status- Graner says so.1 In the drafting of Omnibus Bill 26, our political masters in Ontario demonstrated that they expected no significant public outcry when, unilaterally, they made profound changes in the professional and social rights of physicians. However, the greatest of any perceived loss (and the one we must fear most) is the loss by the individual physician of the moral strength, will, and energy needed to protect the patient's best interest. Finally, we must be vigilant, because times like these may lure the physician into a conspiracy with government and with commercial powers. "Conspire" means "to combine privily for unlawful purposes, to plot." As one of us has pointed out elsewhere,3 conspiracy has three elements. First, it is an unlawful act performed away from public view ("privily"); second, it involves the complicity of both parties in an act agreed upon. Finally, the process often is so subtle that both parties can avert their gaze and comfort themselves that someone else is responsible.

The danger of conspiracy is given dramatic illustration in the paper "Extreme Risk-The New Corporate Proposition for Physicians," by Steffie Woolhandler and David U. Himmelstein.4 These physicians had contracts with US Health Care, a highly successful health maintenance organization. One secret to this success is a payment formula that binds the primary care physician's interest to the firm. The base capitation payment barely covers office overhead. An internist with 1500 of the plan's patients might take home more than $150,000 from bonuses and incentives, or nearly nothing. Although some of the bonuses and penalties target quality, most reward limiting care and boosting the HMO's image and enrollment. For instance, for each dollar of emergency care, the plan penalizes the doctor up to 50 cents. This paper carried the following addendum: "On December 1, 1995, Dr. Himmelstein received notice from US Health Care of his termination without cause, effective February 26, 1996."

Of the time of plague, which Allan Mermann forecast,5 Wilkes said, .... .when society is besieged by plague, true physicians are called to seek a centre in their own identity and world view and, from such a centre, be available and present unconditionally to those in need. Plague by its very nature tells us that there are no immediate scientific answers and thus calls the physician to look, to stay, and to become engaged, using moral and spiritual resources beyond science."6 As we write, the Canadian Medical Association is preparing for its 8th Annual CMA Leadership Conference, "Regaining the Perspective on Values: Physicians Surviving and Thriving in Times of Change," to be held in Ottawa, March 1-2, 1996.7 The keynote speaker, Dr. Jennifer James, is a cultural anthropologist from Washington D.C. Discussion leaders and "facilitators" include a stress manager, a military man who is expert in downsizing, a Grand Chief of the Assembly of Manitoba Chiefs, a physician who is also a wife and mother, a former mayor of Ottawa, and a former Olympic track coach, who is a "motivational strategist." However, such conferences aside, we continue to pursue the vision upon which this journal was founded: that, as professionals, we can unite with our fellow citizens in defense of health care that is competent, compassionate, and sustainable. Believing that this vision is still our best option, we ask you to consider another question as you wait for the next Editors' Turn. "If we have concluded that, after centuries of interaction in the stark circumstances of human need, physician and patient have not reached an understanding and formed the bond, how then do we proceed?" At this late hour, can we discover a new language and a new way of relating to each other that will call forth a unique union of health-care worker and citizen- a union that will resist arbitrary (that is, morally unlawful) interference with our health care? [essay will conclude in the next issue of HHCI.]



  1. Graner J. The primary care crisis part I: The contribution of Anti-Scientism, Humane Med 1986; 296-99 and Part II: Physician as laborers. Humane Med 1987; 3: 20-25.
  2. B1y R. Iron John. A Book About Men, Vintage Books, Random House, New York 1992, pp. 56-et seq
  3. Oreopoulos DG. Is it appropriate to offer dialysis to octogenarians? A modern conspiracy. Pent Dial Int (in press)
  4. Woolhandler S, Himmerstein DN. Extreme risk: the new corporate proposition for physicians. N Engl J Med 1995; 333(25): 1706-1707
  5. Mermann A. The art of the doctor in the time of plague. Humane Med 1992; 8(1): 17-29
  6. Wilkes JR. The second mile (editorial).Humane Med 1992; 8:16
  7. Rafuse J. Association News. Can Med Assoc J 1996; 154: 245