HIPPOCRATES ON HMOs

The Plague of Athens

By Gerald D. Klee, M.D.

From the Maryland Medical Journal, April 1, 1996

Where was I to find the answers? Should I participate in HMOs or not? Should I allow

someone else to come between me and the patient and tell me how to practice, or

should I refuse to participate and find myself with very few patients left? If I do

not participate' many of my patients will feel abandoned. If I do participate, I run

the risk of abandoning the principles of medical ethics and harming patients. Having

had no luck finding answers elsewhere, one night I wearily sat down at the computer.

Searching the Internet, I got a lot of information, but no answers. In desperation,

I decided to go right to the top to find out what the father of medicine would say. I

keyed an address: <http://www.ancient greece/medicine.hippocrates>

A face took shape on the screen and Hippocrates himself asked, '"What can I do

for you?"

Stammering with surprise and embarrassment I replied, "I'm sorry to have

disturbed your sleep.''

Hippocrates: "It doesn't matter. I can't sleep."

 Me: "Why not?"

Hippocrates: "It's the news about managed care. After 2400 years, the HMOs are back, ruining medical care, and destroying the profession of medicine. Building on the past, your generation has brought medicine to undreamed-of heights. Now, the HMOs are driving medicine over the cliff, just as they did in my time."

Me: '`Excuse me, sir. How do you know about this'? Where are you?"

Hippocrates: "In Hades, of course. But it's not the same as what you call hell. We have all the amenities here, including medical journals, newspapers, cable TV, and PCs. We're on the Internet and the World Wide Web. We have access to all the news media. The only thing that makes it resemble hell is that no one will listen to us."

 Me: "You said you had HMOs in your time?'

Hippocrates: "It was during the period you call the fifth century BC, the Golden Age of Greece. In Athens, it was the Age of Pericles. Philosophy, art, and science flourished throughout the world. Moreover, good health was worshiped and access to medical care was considered a necessity. These were the best of times, but they soon became the worst of times ''

 Me: "How'?"

Hippocrates: "Because the services of physicians were so highly valued, Hellenic Medical Organizations (HMOs) were formed. These were originally designed to provide good quality medical care to everyone at a nominal cost. The HMOs grew slowly at first and worked reasonably well for a few years. Alas, not all Greeks were lovers of truth. There was an influential group of pseudo-philosophers known as sophists who taught that truth and morality are merely matters of personal opinion. As a result, we had some highly sophisticated liars and thieves among us. It wasn't long before those rascals spotted a business opportunity in HMOs. A revolution in health care soon took place."

Me: "Really? What was it like?"

Hippocrates: "It followed a pattern that should be familiar to you. Business managers took over. They cut costs by cutting services and reducing physician fees, and then put most of the savings into their own pockets. They relegated physicians to a subordinate role and told them how to diagnose and treat patients. Physicians were allowed very little time with patients. In undermining the relationship between the patient and the physician, they destroyed the patient's trust in the physician and with it the therapeutic alliance. The quality of care deteriorated, but the managers persuaded the people that they never had it so good. Besides, if something went wrong, they persuaded the people that it was the physician's fault.

 '`Before long, most Greeks belonged to HMOs and, despite reservations, most Physicians chose to participate if they could, in order to continue seeing patients. I refused to participate on ethical grounds. My major objections to HMOs included their interference with patient care as well as the loss of confidentiality between the patient and the physician. Whatever secrets the patient imparted to the physician had to be passed on to the HMO. Soon, this private information was being gossiped about in public."

 Me: '"What happened to your practice”?

Hippocrates: "I lost a great deal of my practice. Although I had serious financial difficulties, I managed to survive on the little island of Cos and to find patients among the very poor and among those who shared my distrust of HMOs. I knew it   was only a matter of time before the fiasco would end. But who could say exactly when or how? Finally, the storm struck. You have heard of the plague of Athens?"

 Me: "Is that the one Thucydides wrote about?"

Hippocrates: "Very good. But Thucydides didn't tell the whole story. It was a terrible

event. People were dying left and right in Athens and chaos reigned. No one knew the

cause or the cure. The HMOs were of no use. The HMO managers took all the money

and fled. Those HMO physicians who had not perished in the plague were driven out by

angry mobs. Their innocence and good intentions were not enough to save them.

Pericles, the aging leader of Athens, sent a message to me at Cos, begging me to come. I

could not refuse.. In a while the plague was over, the dead were buried and a semblance of order was restored."

Me: "How did you accomplish that?"

Hippocrates: "It is said that I drove out the plague by lighting fires in the public

squares. That is not true. The plague was not a single disease as many believe, but a

variety of illnesses that had been silently taking hold of the people during the years

they had submitted to HMOs. One last disease, probably coming in from abroad,

was enough to trigger the final catastrophe. The HMOs were the real plague of Athens.

In classic fashion, after reaching a crisis, the people of Athens cured themselves by

expelling the offending agent---the HMOs."

Me: So you don't take any credit for saving Athens from the plague?"

Hippocrates: "Of course not. I always taught that with the help of the gods, the

patient heals himself. That is what happened in this case. The physician can only promote

the process of healing. I am happy that I had enough wisdom to stay out of HMOs and

avoid aggravating the problem."

Me: "When did you write the Hippocratic Oath?"

Hippocrates: "I did not write it. The Athenian people composed most of it. After

their experience with HMOs and plague they insisted that physicians must put

patients first and give them their very best. Nothing and no one should come between

physicians and their sacred duty to their patients. The oath was published in the

Journal of the Aegean Medical Association (JAMA), of which I was editor. Perhaps

that is how my name was mistakenly attached to it."

Me: ``The oath seems pretty reasonable. Why do you think some people now say it is

outdated and should be discarded?"

Hippocrates: "Some of it is out of date. But you'll have to figure out for yourself why

anyone would not want to put the patient first. The HMOs in Athens didn't put the

patient first and look what happened. When do you think the plague will strike in your

country?"

Me: "Do you really believe that? No, it couldn't happen here!"

Hippocrates: "See I told you no one listens."

Me: "Do you have any advice for me? Should I or should I not participate in HMOs? It's

a tough decision. There is so much at stake."

Hippocrates: `'You haven't been listening to me!"

Me: "Please, tell me what I should do."

Hippocrates: "I would not presume to tell you what to do. Physicians in my time were

faced with the same predicament. When they sought my advice, I responded with an

aphorism that has since become widely quoted. Perhaps you are familiar with it. It

goes like this:  “Life is short; art is long; opportunity fleeting, experience treacherous, judgment difficult. The physician must be ready, not only to do his duty himself; but also to secure the cooperation of the patient, of those who are in attendance, and of the external agents.”

The screen clicked off and I woke with a start.

GERALD D. KLEE, M. D.

Dr. Klee is a retired psychiatrist, and is a Lecturer Emeritus in the Department of Psychiatry at the Johns Hopkins University School of Medicine, Baltimore, MD.

Maryland Medical Journal April 1, 1996

Reprinted with permission.

Maryland Medical Journal is a publication of the Maryland Medical and Chirurgical Faculty (MedChi)