 

                     Beyond the Market Place

     As I left my office one afternoon not long ago, I was
startled by an enormous billboard with the message:

                     VISIT YOUR DOCTOR TODAY

     Below this unabashed invitation were listed the telephone
numbers and the franchised locations where I might make his
acquaintance.  It dawned on me in the twilight of that evening
how in this commercialized version of medical practice "my
doctor" would be whichever doctor happened to be on duty that
day, probably a young physician who needed to pay off debts
incurred in medical school, a company doctor, whose individuality
was masked and distorted by his employer's demands.  As I stare
at the billboard, the traffic signal on the street corner changes
to green.  Municipal busses careen up the avenue.  Below their
windows, where last week the Commonwealth cajoled its citizens to
gamble away their hard-earned wages, or photographs of Elysian
landscapes seduced the viewer to nicotine addiction, there, on
large placards, the fast-medicine franchisers offer themselves
again.  At home, I find in my mailbox a brochure from a second
similar medical establishment, this one also promising me a
personal care physician, endorsed with testimonials from
satisfied patients.  Twenty-five new offices in convenient
locations are ready to serve me, and at each one my very own
physician is said to be waiting.  A new medical market-place has
opened for business.

     The entrepreneurs and the consumer advocates who invite us
to go doctor-shopping believe that they are breaking new ground,
but this is not entirely the case. Medical advertising has a long
and interesting history. It was so prevalent during the
Renaissance that a special name was coined for physicians who
advertised. They were called "montambanco", a contraction of
"monta in banco", literally "climb on the (speaker's) platform",
an etymology, incidentally, that is relevant to our professional
meetings as well. The anglicized term "mountebank" soon acquired
a pejorative connotation.  Among those who disapproved was Sir
Francis Bacon who lamented that "Men ... will often preferre a
Mountabanke or Witch before a learned Phisitian." (OED)

     As usual, it is not difficult to surmise why the established
profession deprecated those who attempted to insinuate themselves
into its hierarchy.  Aside, however, from the obvious interest in
protecting social and economic privilege, there is an additional,
more cogent reason for the aversion to advertising in medicine.
The reputation of the traditional physician rests upon the
satisfaction of his patients, and his conduct is directly
controlled by the contentment of those whom he presumes to help.
To the extent that any physician advertises, he makes himself
independent of satisfied patients.  Instead he relies on
publicity and promises to persuade patients to entrust themselves
to him.  Given these differing mechanisms of referral, it is
axiomatic that the conventional physician will come away with the
superior reputation, and this would be the case, even if
objectively the advertising physician were more competent.  Nor
is there reason to conclude that the patients of the advertising
physician are dissatisfied.  The essential point is that their
satisfaction, great or small, as the case may be, is of less
importance to the maintenance of his practice than if he
refrained from such self-promotion.  The Oxford English
Dictionary shows us the mountebank on his elevated platform, as
he "appealed to his audience by means of stories, tricks,
juggling, and the like, in which he was often assisted by a
professional clown or fool." (p.1863) If the billboards don't do
the job, we can expect to see the likes on our television screens
before long.

     The notion that the practice of medicine is in very
important respects a commercial enterprise is no secret to
economists and to those more practical souls who size up the
customer's credit-worthiness, a secret that is sometimes revealed
by physicians' actions even when it is denied by their words.
Physicians prefer to think of themselves as heirs of the learned
doctors of medieval universities rather than of the itinerant
showmen of healing, a "learned profession" whose standard of
conduct should be distinguished from that of the marketplace.
For decades it has assured the health of the country and the
economic well-being of its members as well, by creating an
extraordinarily complex and expensive curriculum of medical
education, which, so long as the government did not intervene,
severely limited the number of available physicians.  In such a
seller's market there was no need to advertise, and a rigorous
prohibition of overt commercialism was readily accepted and
enforced.

     Until a few years ago, the courts tended to accept the
profession's view of itself, holding that physicians should be
judged by higher standards of conduct than (other) business men,
and that the proscription of advertising was not an unlawful
restraint of trade. The Hippocratic vow to refrain from teaching
medicine to all but the sons of physicians was translated into a
formal legal sanction against aiding and abetting the unlicensed
practice of medicine.  Efforts of corporations to inject
themselves into the delivery of medical services were rebuffed on
the hypothesis that the practitioner of medicine was required to
have a soul, and whatever qualifications to practice medicine a
corporation might be able to proffer, possession of a soul was
not one of them.  As a result, medical practice remained the
domain of individual practitioners, responsible only to their
patients, to their consciences, and to whatever standards of
professional conduct their peers established among themselves.

     Of late, this system has been crumbling.  The causes of its
decay are so obvious that one wonders how it could have lasted so
long.  With the complexity of medicine came specialization and
subspecialization, until, except for minor matters, no one
physician was competent to care for all the patient's problems.
The profession responded with cooperative endeavors of various
kinds.  The team approach to medicine proved indispensable when
the patient's disease straddled the boundaries of two or more
specialties.  The onus of corporate medicine was avoided by the
fiction that each physician was directly answerable to the
patient and that one of them, the attending physician, was
ultimately responsible for his care.  In this manner the time-
honored patient physician relationship was thought to be
preserved.  Unavoidably, however, physicians working in concert
assume responsibility also to each other and to the group.  This
responsibility to the clinic or the corporation tends to dilute
the responsibility to the patient.  Only a prejudiced observer
would insist that this consequence of cooperative practice was
never in the patient's interest.  But it requires a prejudice in
the opposite direction to overlook how often and how
systematically co-operative practice requires the physician to
conform and to compromise his treatment of the patient to comply
with the requirements of the institution.

     As the physician becomes a player on a professional team, if
not indeed a wage earner on a corporate payroll, the patient
assumes the sophistication of the consumer who understands that
the visit to the doctor is in fact an encounter with a vendor of
medical services. What transpires in the consultation room in the
physician's office or in the operating room at the hospital
turns out to be nothing more than a market transaction.  This
concept shifts the emphasis from the individuals who render and
receive medical services to the socio-economic framework within
which the medical transaction takes place.  The subject of the
transaction is a service, be it a diagnostic opinion, therapeutic
advice, a surgical operation. The vendor, and as appreciative
recipients of uncounted reimbursement checks we have become quite
comfortable in that role, is the physician who sells his services
in the health-care market.  The purchaser is the patient and his
insuror, in many instances, the government.

     The transaction consists in an exchange of goods, entailing
costs and providing benefits to both participants.  Besides
financial remuneration, the physician derives from it clinical or
surgical experience, reputation and prestige, not to speak of the
satisfaction of wielding power and exercising authority.  It is
also possible that now and then a physician will approach his
work with unclear sentiments of philanthropy, wishing to see
himself and to have himself seen as a benefactor of mankind.
That would be yet another reward which the physician derives from
his relationship to the patient, albeit one that is qualitatively
different from money.  These benefits to the physician are offset
by the expenditure of energy and time on the one hand, and by
social and legal risk on the other.

     The benefits which the purchaser receives are if anything
more difficult to quantify, both in general and in the specific
instance.  This is the case not only because the course of the
disease and its response to treatment vary so greatly, but
because the value of much therapy is marginal, and its non-
financial costs may be impossible to assess.  This difficulty,
incidentally, has the broadest of consequences, and appears to
cast an impenetrable shadow over all attempt to quantify the value
of medical services in the context of cost-benefit analyses.  In
some instances the benefit is plain.  If a patient with hand
movement vision in both eyes has his vision restored by cataract
extraction in one eye, the benefit of such an operation requires
no discussion and is disproportionately great compared with its
cost.  The benefit of the same successful cataract extraction
thereafter performed in the fellow eye is, however, reasonably
subject to dispute; for while the first operation makes all the
difference in the patient's ability to function, the second
operation has little functional consequence, but serves largely
to enhance the body image. There are many other surgical procedures,
and I shall forbear to enumerate them here, where the candid
question: "In what way did the operation make the patient better
off?"  is best answered with embarrassed silence.

     A cardinal tenet of the marketplace view of human
interaction is that the price of the product is set by an
agreement between the purchaser and the seller.  But sometimes
price is not at all commensurate with value.  In theory, the
market will take care of that too, for if the value of a product
is disproportionate to its price, the latter will rise or fall to
meet it.  In matters of medicine, however, this reality principle
is often ineffective, because the patient is incapable of
independent judgment of the value of the services he is
receiving.  Newspaper and broadcast journalism assiduously cater
to the public's appetite for novelties and miracles and make a
business of manufacturing the moulds of fantasy in which the most
bizarre of hopes and fears take shape.  In general, the patient's
valuations are unrealistic, he being inclined to place far too
high a value on some and too low a value on other services.
Paradoxically, patients commonly infer value from price, and
there are few who do not believe that the best physician is he
who charges the most, and that inexpensive medical services are
worth what one pays for them.

     Unavoidably, the rationalization of medicine as a
marketplace entails a reinterpretation of the patient-physician
relationship.  Implicit in the marketplace model is the
assumption that each of the parties to the transaction, the
physician on the one hand and the patient on the other,
participates in the transaction to further his own self-interest.
This may be acceptable so far as the patient is concerned. It is
reasonable that he should wish to purchase  as much health as he
can with the funds at his disposal, although it is clear that he
seldom knows how to get the most for his money. But in regard to
the physician, the implications of the marketplace model are
disquieting.  Can we really condone that he should exploit
commercial transactions with his patient for his own benefit?

     Unavoidably also the market relationship entails the
estrangement of the parties to the transaction.  Consider a sale
of tangibles as the simplest of market exchanges.  Here the
attention of the participants is focussed on the object
exchanged, and for each of them the purpose of the exchange is
essentially selfish, his own aggrandizement.  The personality of
the other participant is a means or an obstacle to this end.  The
buyer wants the service or the commodity; the seller cares only
for the proceeds of the sale.  In the market perspective,
physicians and patients both become anonymous and
interchangeable, not less than the purchasers or sellers of
securities on the stock exchange.  The physician is turned into
an approved vendor, strictly comparable to any other physician in
his specialty, and the patient, for his part, become a recipient
of services, a Medicare or Medicaid number, a beneficiary on the
books of the insuror, a cipher, whose personality, if not
anonymous, is nonetheless irrelevant to the transaction in
question.

     While the interpretation of medical practice as a market
transaction confers indisputable benefits on both the patient and
the physician, each of them has reservations and fulfills the
role assigned to him with a measure of ambivalence. The physician
is dogged by the awareness that remuneration is seldom if ever
commensurate with what he does for the patient. He is rewarded
with disproportionately large fees for efforts that are trivial,
irrelevant or even harmful.  For what he knows to be valuable, he
often receives little payment and no recognition. The patient
for his part, inveterately attempts to construct a relationship
of affection and trust and admiration for his physician which
goes far beyond the dispassionate respect that is due the vendor
of medical services.

     This reluctance of both the physician and the patient to
play the roles that the market theorist would assign to each of
them is a reminder that the market theory of medicine is only a
conceptual model, somewhat analogous to the biophysical
hypotheses that have such an important place in our understanding
of disease. Such description is clearly useful for many purposes;
but it cannot replace experience.  At best the model illustrates
important facets of reality.  At worst it confounds and conceals
them.

     Let us, however, accept the model for what it is, and in the
spirit of experiment, observe the effect of one crucial
modification.  The market theory of medicine which we have
described holds that the physician and his patient are primarily
economic adversaries, and that the value of the relationships to
each depends on what he obtains from the other.  Our modification
consists in postulating a relationship whose value to the
participant should be proportionate not to what he receives but
to what he invests.  On first thought, the hypothesis seems
absurd.  The economics student who came up with such a notion
would fail the course, and the economics professor who
countenanced it would be the laughing stock of his profession.

     But we who are not professors are free to explore the
hypothesis further.  The idea that value should be measured by
what one invests rather than by what one receives explains a
wide range of experience.  It explains the satisfaction which the
scientist derives from his research, even when the research is
fruitless.  It explains why artists paint pictures, why poets
write sonnets, why musicians compose symphonies, and why all
these activities are satisfying, even if the painting is never
exhibited, the poem never published, or the musical composition
is never performed.  Not only the behavior of the scientist and
the artist is rationalized, but even more important, the most
diverse relationships among human beings who care about each
other, between children and their parents, between brothers and
sisters, between friends.  The value of all these bonds is
commensurate with what one invests in them, not with what one
receives, and that is a prospect to which the marketplace is
blind.

     Let us designate this aspect of medical practice which the
economists have overlooked as the existential relationship
between the physician and the patient, and let us distinguish
this existential relationship from the market relationship which
it supplements and with which it is sometimes confused.  Then
value for the physician does not consist in what he acquires from
or through the patient, but rather in the investment of
intelligence and skill and affection which he makes.  It is then
beside the point whether or not his effort is acknowledged or
rewarded, except insofar as the acknowledgement would tend to
disturb rather than to confirm the relationship, to the extent
that it might blur or confuse, even in his own mind, the self-
sufficiency of his devotion.  Whether the patient be rich or
poor, whether he be afflicted with a serious disease or only an
imaginary ailment, whether he recovers because or inspite of the
physician's efforts, whether he succumbs because or inspite of
them, makes no difference.  It is the physician's absorption by
his task which rewards him.  Described in this way, the
existential commitment exhibits unanticipated hazards, and we
begin to understand that it requires to be balanced by the sober
rationalizations of the market.

     An existential intention on the part of the physician is a
natural consequence of his humanness. But what about the patient?
Can he possibly derive any satisfaction from his encounter with
the physician other than the maintenance or recovery of his
health?  That his contact with the physician may indeed have an
analogous dimension often becomes apparent in circumstances where
the physician's efforts have proved manifestly ineffective and
the patient is dying.  Paradoxically, it is in this situation,
where he would have every reason to repudiate the relationship
and devote his remaining resources to other ends, that the
patient often clings most fervently to his physician.  At this
juncture the patient values the relationship irrespective of its
benefits.  He has lost the ability to be critical.  The
competence of the physician becomes irrelevant.  The patient now
cherishes his physician not because of the credentials, or
because of the reputation, not because of the physician's
skills, but because this physician is "my doctor."  It is from
this affection for his physician as a trusted friend that, given
the chance, the dying patient will forgive him the presumptuous-
ness of having undertaken to alter the course of life, and it is
this forgiveness, a remuneration safe from the burglar and from
the tax collector, which is the most precious recompense a
physician can receive.  It has no market value.


                      * * * * *
Copyright 2006, Ernst Jochen Meyer
