I love baseball! It’s in my blood, my grandfather having hand turned major league baseball bats at Hillerich & Bradsby for over 50 years. The exploits of his customers with names like Ruth, Cobb, Musial, Gehrig and Mantle were common dinnertime discussion. Even today, my most treasured possessions are letters from Ted Williams to my grandfather thanking him for making the bats he used in “The Season” – Williams moniker for the year he hit .406 for Boston.
The elegant beauty of baseball derives from its infinite variability, paradoxically made possible by its unwavering, primordial, almost Pythagorean, order; 90 feet base-to-base, nine innings to a game, six outs to an inning, 60-feet 6-inches mound to plate, and three strikes and you’re out. By internalizing this inherent structure into our cognitive unconscious, we come to share a common framework in which to view the game, an understanding player and fan alike rely upon, subconsciously trusting those rules and their implications to be resolute. Upon that constitutive skeleton subtle differences are amplified, inconspicuous changes having profound effect on the way the game plays out, the overall implication of each situation clearly perceived by the initiated but lost on those not steeped in the basics.
Medicine, too, has a stable undercarriage composed of those principles, rules and tenets that serve as a platform upon which the infinite variability of clinical practice is grounded. Their existence never questioned, our fidelity to them unwavering, their omnipresence forms an unconscious, unspoken, inviolate bond between patient and provider.
Primum non nocere, the sanctity of life, the ethos to always do what is best for the patient, self-sacrifice for the good of others and the primacy of the doctor-patient relationship come to mind. Certainly technology advances, clearly medical knowledge evolves, without doubt the tools of the trade change over time; but the fundamentals we all trust should not. Unfortunately, I sense that may no longer be true.
The involvement in the business of medicine of tens of thousands who have never cared for a patient, who are not steeped in the rich marinade of our history, who have never internalized the primal rules of our game have rendered it such that those underpinnings, so trusted and reliable, have become shaken, even pushed aside, all in the headlong pursuit of profit.
We now have an enormous array of entities only tangentially associated with medical care delivery whose only goal is to reap financial reward from the system, making their argument simply for a “piece of the pie” and doing so in some cases with absolutely feckless disregard for the underpinnings of the game. In many cases they are to be forgiven, for they are simply responding to what they perceive to be an opportunity while in other cases the water is much more murky.
The recent wholesale cancellation of physician contracts by a major insurer, while without doubt legally crisp and financially sound, will likely leave many of our societies most vulnerable adrift and afraid, confused by the “rule violating” interposition of a third party severing their relationship with their trusted doctor. The expansion, in some areas, to a “STEMI program on every corner” serving as a marketing tool for the hospital system may improve the “bottom line” but will also stretch too thin an already weary provider network, reduce experience and ultimately diminish patient outcomes.
Physicians are also not without guilt. Recent criminal prosecutions for medical fraud in home health services provision and the flagrant, abusive, unnecessary coronary stenting by some in our ranks serve as painful example of such practice.
It is time for physicians to stand up and re-affirm the unwritten, time honored rules of our game, for no one else can do so. We do this not because it is easy, but because it is the right thing to do. Life is precious, death is the enemy, honor and self-sacrifice our code.
There are two outs in the bottom of the ninth. What are we going to do?