I think I finally understand the Dilbert comic strip. In 1997, upon graduation from residency, I did something totally countercultural. Instead of opening my own practice, or even joining an existing physician-owned medical group, I took a job in a new practice owned by our local hospital, so I could be free of the administrative demands of running a business. Although rare back then, today that is the norm. According to a study by the Physicians Advocacy Institute (PAI), nearly three quarters of U.S. physicians (74 percent) were employed by hospitals, health systems or corporate entities as of January 1, 2022.[1] The numbers are even higher among new graduates. In the last quarter century, we saw the transformation of the healthcare profession into what was termed “the corporatization of healthcare,” as local hospitals are gobbled up by multistate healthcare entities, all jockeying for market domination. Several experts predict this will eventually culminate in the ultimate corporatization of healthcare—socialized healthcare.

At a local level, this pattern played out in my town as our sole hospital became a regional center, then part of a conglomeration of formerly competing hospitals, and now it is fully expected to be integrated into the next larger merger. It certainly seems as if the world of corporate medicine is here to stay, and the day of physician-owned practices is ostensibly over. Even dentists—the one branch of healthcare that somehow dodged the reforms of the last few decades—are now choosing to be employees. Dilbert is now something even healthcare professionals chuckle at because of their familiarity with the inane.

How does this trend impact our profession? For starters, we must remind ourselves of what it means to be a “professional.” Although today the term is (inappropriately) applied to all sorts of trades (i.e. “professional wrestling”), historically there were only three professionals in society: doctors, lawyers and the clergy. The term “professional” began in the first century AD, when the personal physician to the Roman Emperor Claudius (41-54 AD) coined the term “professio,” meaning “commitment with moral obligation.”[2] It meant one had such a high internal moral code that they didn’t need to be regulated by an outside entity. One’s own self-imposed conscientiousness exceeded any external standard of morality that could be imposed upon them. Money brings a risk that can change one’s moral commitment, does it not? So, we must tread lightly into the world of corporatized healthcare, with the moral compass of our professional character as a check-and-balance to the world of profit and loss spreadsheets. Medical doctors need to be the filter through which Master of Business Administration understand the world of patient care, not the other way around.

Is business good for the business of healthcare? The word business comes from the Old English word “bisignis,” literally translated as “anxiety.” The word picture is that of a Scrooge-like character nervously counting his coins, fretting if they are enough. There are two other words whose origins we should be familiar with as well. The word “patient” comes from the Latin “patiens,” meaning “one who bears a suffering.” In contrast, however, “customer” is a word derived from the Latin “custumarius,” meaning “one whom toll is collected from.”[3] So, who are those we serve? Are they to be seen as ones who bear a great suffering we should help relieve, or as someone from whom tolls should be collected? In the first, we give, and in the second, we take. Etymology can be an inconvenient truth. Money might be a necessary evil, but it’s still an evil, nonetheless. So, we have to be careful to make it our servant, and not allow profit motive to be our motive.

Is there a better way of doing business? When it comes to how we do business with people, we need to remember the difference between a covenant and a contract. A covenant is an agreement or commitment made in trust. The parties value each other. Limits of responsibility are liberal or are not necessary to define, because the basis is a presumption that each person will do what is in the other’s best interest. Historically, doctors have always related to our patients in a covenantal way. Today, however, that language has changed, and a contract is an agreement or commitment made out of distrust. The parties are suspicious of each other, and so the limits of responsibility are restrictive and clearly defined. Unfortunately, that is how the healthcare industry does business today—just as in the past two warring factions tried to keep the peace. How do you think patients feel about that? Which do you think they would prefer? Do they want to be a patient who enters into a covenant, or a customer who enters into a contract?

A curious phenomenon is afoot: despite being more successful in fighting disease than ever before, pessimism is also at an all-time high. A hundred years ago, we could do little to help patients. No antibiotics, no MRI scanners, no vaccines and no readily available lab tests meant we offered little hope. The death of a child was expected among a typical family of 12. Yet, patients were universally positive about the healthcare system. Today, in contrast, we are the most successful we have ever been in fighting disease. In my 30-year career, for instance, I have only had one child under my care (in the U.S.) to die, and it was from abuse—not disease. Surprisingly, virtually every major indicator in polls show patients to be universally pessimistic about the healthcare system today. The numbers are no better among healthcare professionals. Why the dissociation? I would suggest it is because we have lost the “care” part of “healthcare.” What did doctors do a hundred years ago when their patient had a disease they couldn’t cure? They held their hand, telling them it would be alright. They cried with them. They prayed with them. In brief, they helped them bear an overwhelming suffering, and they were loved for it. What do we do today? Physicians have been transformed into data entry techs, spending their days clicking little boxes to prove they are providing quality care, rather than actually providing quality care with the patient sitting just beyond the edge of the computer screen, and they are resented for it.

There is a final word origin you should know. The word “doctor” comes from the Latin word “docere” meaning “teach.”[4] It means doctors are not the only ones who have been well taught, but also by the moral virtue of our education we should teach others as well, so they too may enjoy the benefits of such knowledge. Such is my prescription for the world of healthcare that is rapidly changing into a mishmash of corporate entities that use verbiage such as “customer” instead of “patient,” and “provider” instead of “doctor,” without knowing the difference. That is not to say corporate culture can’t help an industry that has been financially malignant for decades. It may be just what the doctor ordered. It’s just that fiscal rectitude is rarely achieved apart from moral responsibility. People are more than the sum of their profit and loss potential. When we lose sight of that, we have lost the heart of healthcare and negated its virtues.

As healthcare professionals, we need to be that moral compass—an advocate for our patients who feel increasingly more alienated from true care. Who will be their ombudsmen in a time when the industry strives to do no more than most efficiently implement bureaucracy? Their physician—the one whose profession of commitment is covenantal and not contractual. Maybe we should keep a dictionary at hand for the wild ride ahead. Maybe Dilbert should have gone to medical school.

About the Author

Grat Corell, MD, FAAFP, is a board-certified Family Physician, a fellow of the American Academy of Family Physicians, and a member of Christian Medical & Dental Associations. He has practiced medicine in Bristol, Tennessee since 1997, and has been awarded “Best Doctor in Bristol” on several occasions. He did his undergraduate work at Furman University, linguistic training at Nebrija University in Madrid, Spain, attended medical school at the University of South Carolina, and completed his internship and residency at East Tennesee State University. Today, in addition to private practice, he also serves as a clinical assistant professor at both the Quillen College of Medicine and Emory & Henry University’s School of Health Sciences. Dr. Correll has a special passion for missions and has been on over two dozen trips throughout Central and South America. He also enjoys public speaking and has lectured from coast to coast in every venue from small churches to national conferences. He is married, has two children and has two Great Danes.

[1] https://www.physiciansadvocacyinstitute.org/PAI-Research/Physician-Employment-Trends-Specialty-Edition-2019-2021

[2] https://www.oed.com/dictionary/professional_adj?tab=factsheet#28087345

[3] https://www.oed.com/

[4] https://www.oed.com/dictionary/doctor_n?tab=factsheet#6348292