PracticalDermatology

Today’s sports stories are not dominated by scores, records, or accomplishments. The hot topic is more compelling: using the platform and stage of sports to lodge a protest, to voice discontent, and to make a statement in a forum meant for competition and entertainment. Agree or disagree, there is a message attempting to be sent, wrapped in a distraction that has taken our focus away from what is important.

Take a minute to think about medicine and all of the injustice we would love to protest against: scope of practice, step therapies, and the assault on reimbursements, such as the latest move by Anthem and the Blues against the -25 modifier. All of these are decisions made for us to work against us. Yet the protests we’re involved with are typically from angry patients who don’t see what is going on behind the scenes, who demand copays back if they have to wait more than 10 minutes (even if they then take 30 minutes of our time showing us their internet search results). Many patients expect high levels of customer service even as they call us by our first names and often disrespect the basic tenants of the physician-patient relationship with online reviews, the most toxic form of protest allowed by “freedom of speech.”

Think of how many physicians, with all of the talk about burnout coming to the front burner, are frustrated with all parts of medicine. Many of us no longer feel appreciated and question why we still practice, but we still go to work…consolidation is rampant as practices are sold every day, insurance companies and pharmacies have diplomatic immunity. But there is a belief that there is nothing we can do because in the eyes of the payers, policymakers, and the public “doctors make too much money.” Discontent leads to second guessing of leadership, the formation of walls between colleagues and division from within, making the cycle spin downhill. Just ask any of the RUC team members who have the scars to prove it.

So, when is our moment to “take a knee”? And who do we protest against? Do physicians band together, despite the fears of anti-trust and collusion in the shadows, and collectively drop insurance plans that interfere with our ability to do our jobs? (That idea might sound good, except where will the patients come from and will everyone join the cause?) Boycott pharmacies and chains that are known to turn our prescriptions into suggestions? (But then where would we turn to get patients treatment?) And what about organized medicine, does a decline in membership, apathy toward involvement, or a public rant against leadership represent a protest…or anarchy?

Our problem comes down to two simple components: ethics and options. Physicians don’t have a lot of options for taking a knee—there isn’t an opportunity for us to not show up for practice in protest or to strike, because our drive and ethical obligations make us show up for our patients. We may have our philosophies, our gripes, and our reasons for wanting to protest, but in the end our options and our ethics collide. At a recent meeting there was a great discussion about how decisions are made for us, and Mark Kaufmann, MD suggested that “acting out of the goodness of our hearts” is the reason we are the victims of the whims of payers, pharmacy benefit managers, and regulating bodies that “count on us to do the right thing for patients.” To make matters worse, even those in our own ranks who call out colleagues as biased and conflicted and want to name names have given ammunition to those working against physicians by inserting philosophy into what is considered “ethical” to create policy. Physicians in California and other states have already seen how editorials and articles based on philosophies have inspired legislation.

Sadly, the punchline is that we don’t take a knee, we don’t stay in the locker room, and we don’t wear armbands in protest. Our ethics keep us focused, our drive gets us up for the challenges we face, and our patients need us to do our jobs and do them well. None of us have the right answer, and if we did, we probably wouldn’t all agree on it. Rather than protesting, we have to stand together and keep our game faces on. And we need to make sure that in the search for those answers, we don’t stop questioning how we can do things better.