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Corporate Physicians: Between Medicine and Management.

Conflict in the Corporation

In a $500 billion health care industry advancing at full throttle, conflict has become a part of virtually every practicing physician's life. Hospitals and third-party payers as well as Health Maintenance Organizations (HMOs) have responded to ever-increasing financial pressure to reduce health care expenditures by trying to influence physicians to reduce marginal spending, hoping all the while that quality of care will not be adversely affected. Increasingly, doctors, as employees, contractors or investors, may have financial interests in "joint ventures" or medical care enterprises whose viability is partly determined by clinical recommendations for patients. While the cost to whomever pays for services is a legitimate consideration in the mix of factors that determine the medical care that physicians offer patients, these interests can compete and conflict with physicians' traditional loyalties to patients. Likewise, new relationships between doctors and institutions are inevitable. The issue is how can such conflicts be managed so that none of the parties suffer inordinately.

In Corporate Physicians: Between Medicine and Management, Diana Chapman Walsh informs us that conflict has long been an integral part of the lives of nonpracticing physicians. Based on interviews with corporate medical directors and others involved a occupational medicine, Walsh insightfully portrays theconflicts that doctors employed by corporations encounter in integrating their professional commitment to support the health of workers and their bureaucratic obligation to support the goals and interests of their corporate employers. The central thesis of the book is succinctly articulated by one of the medical directors interviewed:

We in the profession tend to gloss over the conflicts. But they are real. The corporate physician, if he is to be effective, must be able to effect change in job design, environmental engineering and the social arrangements of work. He hasn't got a chance if he's not part of the management structure. He's got to work from within because these changes cost money. But when he's part of management, employees may doubt his objectivity. No matter what anyone tells you that problem is unresolved.

Walsh convincingly shows that corporate doctors experience conflict in the various activities the traditional occupational physicians engage in when employed by corporations. In the area of personal health care, a major conflict arises in determining the correct boundary between medical services, including prevention programs, offered by the company, and services available from the outside practicing medical community. The anguish prompted by this tension is in part related to occupational physicians' recognition of their declining clinical skills and their professional isolation.

Corporate goals of maximizing profits lead directly to conflicts in the realm of environmental health. Walsh identifies the increasing preoccupation with risk-benefit analysis as leading to "an eternal dilemma of tragic choices." Conflict is also integral to the corporate physician as an adjudicator responsible for assessing employee fitness for work in light of concerns about workplace efficiency and company liability. This bureaucratic imperative certainly results in the corporte physician holding a different viewpoint than that of the employee or the employee's personal physician.

To those of us concerned about the relatively new forms of conflicts of interest confronting practicing physicians, it is somewhat reassuring to know that practitioners of occupational medicine have been caught in the middle for decades and somehow have muddled through. Walsh suggests, late in the book, some procedural approaches to accommodate both the reality and the perception of conflict, for example, contracting determinations of fitness for duty to impartial outsiders. Unfortunately, the procedural techniques that might assist doctors and employees are not explored in any depth, certainly not to the extent of extrapolating lessons for similar conflicts developing in personal health care.

A related disappointment is Walsh's claim that corporate physicians have little or nothing to do with the group benefits programs that consume a much larger portion of a company's budget than occupational health. In the last decade, there has been a significant move to self-funding of health benefits, requiring more company-directed policy for administering the medical care that employees receive and increasing business involvement with various types of managed care programs. While many corporate physicians have been deeply involved in these developments, Walsh's interviewees have not. The problem may be that her interviews tool place between 1978 and 1982.

I approached Corporate Physicians hoping to learn how lessons drawn from conflicts of interest in occupational medicine could be applied to the new relationship and constraints found in providing personal medical care. I was disappointed. However, the book offers important information about what physicians who practice occupational medicine actually do and what dilemmas they face.

Robert A. Berenson is a physician in private practice in Washington, DC.
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Author:Berenson, Robert A.
Publication:The Hastings Center Report
Article Type:Bibliography
Date:Aug 1, 1988
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