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Journal of Business Ethics (2008) 83:127131 DOI 10.

1007/s10551-007-9616-9

Springer 2007

From Hippocrates to HIPPA: The Collapse Samuel Michael Natale of the Assumptive World

ABSTRACT. This paper studies the developments in the ethical concerns for physicians (Business Concerns) and job satisfaction contigent upon changes in Physicians assumptive world. KEY WORDS: Medical ethics, business assumptive values, shifting ethical values concerns,

Consilience, a model articulated by Edward Wilson, argues that all knowledge and understanding is bound together by some as yet unknown common theory. He argues that there is one grand scheme to explain and unite all that we know and can know http://www.cnn.com/books/beginings/9805/ consilience/) (accessed 8/27/07). The whole concept of Consilience is that a decision is powerful and that its overall effect is seldom understood. This overall effect creates meaning for the many affected by a decision. When a large company lays off workers to increase its prots because of stockholder expectations, the effect is directly born by the laid off workers, and, indirectly, by the store owners in which these workers shopped; extend the analogy, if the workers go on some sort of unemployment, it will cause a demand on the treasury; it effects GNP, It effects well being, families, and shopping. It will ripple through an economy and affect an entire supply chain. If all knowledge is connected, so then are the decisions we base the information or knowledge that we have at our disposal. Decision Theory assumes that all decisions are based on one of three sets of conditions: certainty, uncertainty, risk. In the rst case, certainty, an individual knows everything, and therefore the decision would be made easily and correctly. These are the easiest decisions from a consilient perspective. One example of a decision made with certainty would be the effect is constrained, sharpen the pencil or not, walk the dog or

not. Under conditions of uncertainty, a person is unclear about what is known and which results are best. These decisions can be at the Macro Level. An example of this type of decision is whether to raise revenue targets or not, increase taxes or not. In the risk scenario, someone would know a little about the alternatives, the things that he/she cannot handle and control and the effect of the decision. With the risk model, however, there is some sense of proportionate concerns and sense of success rates, etc. I would add a fourth to the traditional three criteria: a decision type, perhaps we can name it reex decision. An example would be one that physicians may often encounter: a decision which brings together in a single moment, the calculus of risk, the full knowledge of ones training and the physicians world view, to make a decision without a clearly dened thinking it through but, the decision is almost universally precise and correct. What I am arguing is that decisionmaking is all of one piece and, further, that decisions actually create meaning. Our decisions tie to our sense of legacy, that is, how we wish to be remembered whether it is Cleopatra, Toni Morrison, Bill Clinton, or George Bush. Each person make decisions based on how they understand the context of the situation and what they project their legacy will be. What a legacy actually is only history will judge, but all people act to create the meaning that they see as succeeding them. Even here the landscape is changing as Ann Nelson comments from her experience in Human Resources:
The newest generation entering the workforceare typically unconcerned with legacy, or more specically they are concerned with family time to the point of rejecting a career that requires dedication/training/ personal sacrices such as medicine. What are the

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Samuel Michael Natale others, life and the world and those that surround beliefs that may or may not include transcendence. These specic beliefs about transcendence are not our concern here though the global assumptions regarding the self and the world remain paramount. (Rando, 1993) Important studies on the personalities of physicians have been replicated many times and emerge with the same result, namely, that social skills and world view are at least as important as knowledge base in predicting success in both medical school and practice. Acad Med. 1993 Aug; 68(8): 6357. Students psychosocial characteristics as predictors of academic performance in medical school. Hojat M, Robeson M, Damjanov I, Veloski JJ, Glaser K, Gonnella JS. Center for Research in Medical Education and Health Care, Jefferson Medical College, Philadelphia, PA 191075083.) http://www.austenriggs.org/uploads/ news/44_le/perspectives_winter%202007%20web. pdf (accessed 9/20/07) What are these psychosocial measures that constitute success and from where do they arise? In fact, they are the composite that forms the physicians personality and, accordingly, the behaviors that arise from the assumptive worldview of that personality. One acts according to what one believes if they are psychologically healthy. The congruence of affect, behavior and cognition produce the character that arises from the personality. All of this, formed variously within different cultures, forms the bedrock of the persons assumptive world with its values, attitudes, needs and expectations. This is nowhere more prevalent than in driven, committed personalities that see themselves as mission and vocation-driven rather than simply working at a given task. Along with this vocational model originating even before Hippocrates and continuing until somewhat recently was status, privilege and an expectation of success, morally, and economically balanced by responsibilities equally signicant and not for the faint of heart. In addition, as it proceeded apace with an almost Elizabethan worldview with everything in its place and a place for everything. Challenges to the assumptive world The two most frequent challenges to the assumptive world have been loss and stress. In our particular

effects of the generational cultural values on their assumptions and decision-making? In the business world, unless they are going to be highly paid or enjoy signicant time off, they are rarely motivated to share great responsibility, stereotypically speaking (A. Nelson, personal correspondence, 9/21/07)

A step backward: the assumptive world I invite you this evening to journey with me a step further back in the decision chain a journey into our consciousness that will reveal the assumptive world that each of us emerges from and lives within. Far from being simply a theory, the assumptive world is the directly linked cause too much of the dissatisfaction in the world today, as well as the negative experiences reported by physicians around the world. The assumptive world has been dened as a strongly held set of assumptions about the world and the self that is condently maintained and used as a means of recognizing, planning and acting Assumptions such as these are learned and conrmed by the experience of many years. Parkes (1975, p. 132). Since there are different levels of and intensities of assumptions, this concept has been further rened by Janoff-Bulman (p. 5) who argues that these assumptions form the center point of our world and our consciousness, so that they are so much a part of us that we do not challenge them. The concept is further expanded by JanoffBulman to suggest that the three most basic assumptions are: the world is benevolent, the world is meaningful, and the self is worthy. (Janoff-Bulman, 1992, p. 6). It is but a simple-step clinically to move to argue that the individual person and the world are in a meaningful and not random relationship, wherein justice, rewards, and punishments occur not randomly but signicantly. Accordingly, one chooses a career with a purpose in mind, that purpose often being viewed as noble, benign, or positive, such as a desire to heal, suffering, and pain. Since these choices impact ones entire life work, they are dominant themes in the search for meaning that characterizes all of us in this 80 year journey, we call life. In addition these choices appear to stem from one of two sources: those that pertain to self,

From Hippocrates to HIPPA case, the loss of status and responsibility has gone hand-in-hand with the paraprofessional system growth which made some of the discerning tasks of the physicians less than unique and, eventually created an assumption that it could be done without training or high-level insight. The reduction was from professional discernment to task management. This is a consilient reection of the mechanical world, that is, governed by computer technology. Of course the changes were incremental and subtle with varying impact depending on the interpreters point of view. The loss was magnied and intensied by a growing alienation from the social system and its relationships as specialization and technology began to impact the practice of physicians decision making. What we are saying here is that everything that are valued holds within it the possibility of ending or loss thereby producing a challenge to the assumptive world. As roles and contact levels changed for the physician, so did the perception of who the physician wasa role? A person? A concept? A task? Other events also impacted the assumptive world of the physician as litigation rose and specialization increased. Ironically, at one medical convention, a group of doctors were complaining that they were limited in what they could or would attend as the language beyond their own area of interest had become increasingly technical and cultic such that general intelligibility was not available to them. Physicians were being distanced from the person they were treating as more specialization forced consultations and technological intervention rather than personal, empathic interaction during the past few decades.
Survey results suggest that levels of professional satisfaction have dwindled substantially in the past few decades. In 1973, less than 15% of several thousand practicing physicians reported any doubt that they had made the correct career choice. In contrast, surveys administered within the past 10 years have shown that 30 to 40% of practicing physicians would not choose to enter the medical profession if they were deciding on a career again, and an even high percentage would not encourage their children to pursue a medical career. In a telephone survey of 2000 physicians tat was conducted in 1995, 40 percent of the doctors said they would not recommend the profession of medicine to a

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qualied college student. (Zuger, 2004, p. 69; Weinstein and Wolfe, 2007, p. 1181)

As a result of many of these simultaneous occurrences, new levels of dissatisfaction in medicine are being reported and continue to grow signicantly. Concomitant movements As these social shifts were occurring to the physicians world, other economic, psychological and moral environments were also changing. Hearkening back to our premise of Consilience, these changes are all subtly interactive and organically related. Perhaps the clearest examples of this are held within the major ethical concerns in medicine in our day. These can be divided equally into: Social and Economic. Within the social frame of analysis, the predominant issue is, perhaps, government supported medical treatment. Should the government and/or to what degree should the government provide access to medical care? What formulas exist that are both just and realistic without incurring massive entitlements. Further, what is the cost of medical treatment as a function of the average salary in the U.S.? What is the appropriate calculus to determine the costs of medical development as well as balancing this calculus against the law of supply and demand? These examples relate more directly to territorial concerns where we can assume a relatively common culture, economic levels, and useful calculus of implementation. Within the extra-territorial format, all bets are off and a new model needs to evolve to accommodate the human need for healing where resources are impoverished and/or virtually absent. Nor can this need be avoided without bankrupting the concept of medical professional and healer. Entrepreneurship is acceptable as long as it does vacate the category of available care. Underscoring all of these emergent questions is the growing (perhaps, inappropriate) demand for unreasonable risk management, which refers, as you know to the infrastructure an organization creates to manage its liabilities. In health care, it would encompass the following (not an exhaustive list):

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Samuel Michael Natale


sured by the modied drain survey by Sheth, Suzette, C. Ph.D., Capella University, 2007, 138 pages.

General liability; Workers compensation; Employee theft; Bonding of nance staff; Medical malpractice; Research malpractice; Directors and ofcers liability; Key employee coverage (in case a major executive becomes incapacitated); Life insurance and pension plans; Intellectual property risk management. Maintaining even a rudimentary conformity to these legal requirements along with HIPPA demands, a virtual empire needs to be created to manage the social and legal demands. This, of course, takes one away from the primary concern of the healing work and requires valuing prot over service often simply to survive. All of these concerns, added to the Medicaid/ Medicare debacle effectively analyzed by Dr. Suzette Sheth, present a daunting and negative picture. Dr Sheth writes:
According to Montgomery The aging baby boomers in the U.S. and current veterans cohorts are continuing to utilize Medicare benets in increasing numbers among all program parts A, B, C, and D. While Medicare Parts C and D were designated to reduce Medicare expenditures and more efciently utilize services, the increasing utilization of Medicare is expected to bankrupt the program on or before 2030 (Feldstein, 2004; Jacobs & Rapoport, 2004). Another critical economic factor to consider with regard to Medicare reimbursement is based on the fact the 60% of hospitals in the U.S. lose money on services provided to Medicare beneciaries (AHA, 2005). As a result these and other factors, containing healthcare costs (particularly Medicare costs) have become a priority among the stakeholders involved (i.e., patients, providers, and the government). However, based on the relationship between costs, quality, and access (Montgomery et al., 2004), et al., (2004), quality, cost, and access to care are all interrelated regarding patient satisfaction. if the focus becomes too disparate on reducing costs, quality and access to care will suffer. Likewise, if quality improvement becomes a disparate emphasis, costs and access to care will rise accordingly. Striking a balance between moderate costs, high quality, and moderate access to services is indeed most challenging. Perceptions of health are quality as mea-

So how can one respond today? Beyond the normal psychological suggestions that tend to address very narrow adaptations, there are certain actions that one can take to address the insults to ones assumptive world. The conclusions are these: All of our actions affect the world and the world affects each of us. If your perceptions are no longer supported by the world, then neither will your actions based on your assumptions be acceptable to the world. Earnest Becker has pointed out one possible response based on our brain capacity, which allows us to thrive and dominate other species. Since we are able to abstract, we are able to separate ourselves from our own consciousness and relate two orthogonal pieces of information and learning together so that we can imagine an event, objectify the self and project the self into the created environment. If we see that the direction we have created in our minds is possible and desirable, then we can begin to create it in the material world. In short, by the use of imagination, we can, slowly and painfully, recreate the assumptive world as one better adapted to the changing social conditions. Gone are the stereotypes of being the Physician/king/powerbroker; gone are the I am the partner of Dr. X what the new roles within a considerably more modest assumptive world will be yet remains to be seen. However, our ability, under guidance, to reconstruct our assumptions may eventually lead to world more responsive to us and we to it. The question a few years ago was asked, in the picture Ale: whats it all about Ale? You have the answer. It is inside of you, it is based on your assumptions of the world, your practice, your medicine, it is based on your knowledge, your spirit, and the realities that you face. It is based on understanding that every decision you make affects someone, if not the patient, his/her family, the society he/she lives in, yes, even the world at large. In some ways you are the modern day Knights; by your actions you help those in difculties. You attempt to create a better world and you do this with

From Hippocrates to HIPPA an expectation of return. The reality is that return is NOT what you may have thought it was, for the world is a different and changing place. So this evening, I ask you to: Focus on Consilience for what you do affects all even if you do not know it. Focus on your assumptions. They may not be working for the world has changed and your assumptions about it have not. Focus on change to allow you to achieve what you are capable of, knowing the difference between national actions and international actions. Focus on social and economic issuescosts and benets, risk and reward. These are not the same as you may have thought they were. Finally, know that you can create (Becker) the world, as it should be if, and only if, we understand the way it is. If I have done anything this evening, I hope I have opened some small understanding in each of us, that we must consider that there is one grand scheme that explains and unites all that we know and can know, and that we must open up our assumptions to understand that scheme which, problematically, seem to be different for each one of us.

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Feldstein, M.: 2004, Rethinking Social Insurance. Retrieved October 10, 2007, from http://www.nber. org/feldstein/aeajan8.pdf. Jacobs, P. and J. Rapport: 2004, The Economics of Health and Medical Care (Aspen Publishers, Gaithersburg, MD). Janoff-Bulman, R.: 1992, Shattered Assumptions: Towards a New Psychology of Trauma (The Free Press, New York). Montgomery, J. E., J. T. Irish, I. B. Wilson, H. Chang, A. C. Li, W. H. Rogers and D. G. Safran: 2004, Journal of General Internal Medicine 19, 1001. Parkes, C. M.: 1975, What Becomes of Redundant World Models? A Contribution to the Study of Adaptation to Change, British Journal of Medical Psychology 48, 131137. Rando, T. A.: 1993, Treated of Complicated Mourning (Research Press, Chanpaign, IL). Weinstein, L. and H. Wolfe (2007). The Downward Spiral of Physician Satisfaction: An attempt to avert a crisis within by Obstet Gynecol. 109, 11811183. Zuger, A. (2004). Dissatisfaction with Medical Practice, The New England Journal of Medicine. Boston, January 1, Vol. 350. Iss. 1.

School of Business, Adelphi University, Garden City, New York 11530, U.S.A. E-mail: sammyMN@aol.com

References
American Heart Association 2005 Guidelines for CPR and ECC: 2005, Retrieved October 10, 2007, from http://www.americanheart.org/presenter.jhtml?identier=3035517.

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