By Russ Gonnering at Brownstone dot org.

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Regular readers of Brownstone Journal have been graced with insight provided by many authors of diverse backgrounds and experiences. As a physician, I have found those authored by Dr. Joseph Varon to be exceptionally helpful in their insight into the state of medicine today. In particular, his essay, "When Physicians are Replaced With a Protocol," struck a chord with me.

Perhaps it was my conscience, as I probably bear some responsibility for furthering this viewpoint, at least on a local level. You see, I once was a True Believer. It was plausible. It seemed so believable, so "scientific," so simple. But it was a vicious hoax that, I am ashamed to say, took me in. Let me tell the story:

In the early 1990's, medicine was under siege. The cost was rising at a steep rate, and some people saw an opportunity. Rather than looking at the rapid corporatization of healthcare and the proliferation of administrative costs, it was easy to shift the blame to the "providers. We were no longer "physicians," but providers of a service. In truth, that is what we had become. The Health Equation had been shifted, whether intentionally or by accident. Just a few years before, physicians had directed patients to hospitals. Now, some bright businessperson, probably from The Wharton School or other such academic Ivory Tower, had seen the profit if the hospitals (or other corporate entities like insurance companies or A COMBINATION OF THE TWO) directed the patients to the physicians. It was like some financial martial arts reversal move…A perfect Sumi Gaeshi:

Physicians had spent so much time thinking about their profession that they ignored the broader picture. Their own combination of fear and greed and the lack of critical thinking about the larger arena were fatal, and they and their patients were to pay a dear price.

I remember very plainly a meeting of our "physicians independent practice association (IPA) that was a poor attempt at nascent collective bargaining meeting with the directors of a startup HMO in the area. The leaders were themselves physicians who only a few months before had been our colleagues but were now filling the role of Kapo in the new order of things. They had a financial stake in things, and they knew it. The tagline of their HMO was "No out-of-pocket expenses!" They were the collaborators with the insurance companies and hospital executives. They sold the area employers (at that time health insurance was still a reality) that they could save them money at our expense. Of course, the hospitals were only too glad to take their cut. They told us how things would be from now on: Do as we say or starve.

There was blustering on the part of some of the physicians: We will never sign with you! said the officers of the IPA. As it turned out, they were the first to stampede to sign, hoping to avoid the cutoff and be left in the cold.

What followed was the complete and total gutting of the physician-patient and physician-physician relationship. The marvelous inventions of capitation and gatekeeper were introduced to the equation: The primary care physicians were given a lump sum payment each month for the number of patients who were assigned to them. They were then expected to pay for the care. Any referral to a specialist (such as myself) had to be approved by them and they realized that would cut into their profits as well.

Any semblance of ethical care swiftly went out the window. Basically, only the minimal amount of care was approved, and specialty referrals were sharply curtailed.

I had been given the job of Chief Quality Officer at my main hospital, and a group of us were sent to Intermountain Healthcare in Salt Lake City to a week-long seminar (Advance Training Program in Clinical Quality Improvement) given by Brent James. James is a visionary surgeon who thought that by cutting out the "quality waste" (perhaps 25%) in healthcare by doing "the right thing th...