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The Slippery Slope

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Parable: The Slippery Slope
Mauricio Goihman-Yahr
Dermatology Online Journal 19 (3): 17

Professor ( E ) of Dermatology, Vargas School of Medicine, Central University of Venezuela, Caracas, Venezuela


In the life of individuals, institutions, or even societies, there may be decisions taken that lead to a series of events that end in results that are undesirable. These results may be even essentially irreversible and tragic. In some cases, bearable results can be eventually attained. Even so, these are far from being optimal, at least for those that initiate the process.

Steps taken may be halted or retraced at the beginning, but there is a stage (not an easy one to perceive) after which there is no way back.

Situations such as these were masterfully described by Barbara W Tuchman in her book, The March of Folly [1]. Tuchman analyzed events such as the Trojans taking the wooden horse inside their walls. Other examples include the Renaissance Popes’ provocation of the Protestant Secession, the loss of America to the British, and the welcoming of Hernán Cortés by Montezuma. Monteverde must have regretted letting Simón Bolívar go free and what do we now think about Chamberlain’s sacrifice of Czechoslovakia, allegedly for the sake of world peace?

Similarly, I feel that Medicine, and most near to us Dermatology, is sliding down a slippery slope. If this descent is not stopped soon it will lead to remarkable consequences that will forever alter Medicine, and in my opinion, not for the best. These changes did not start in the US, nor are they present only in this country. In addition, some of what has happened was not by itself damaging. Some decisions, analyzed alone, might be considered as wise or necessary. The problem is in the sequence that has occurred and in the lack of appropriate safeguards, that the road became slippery with a markedly downward slope.

What Is Medicine?

Medicine shares characteristics of other professions and of commercial activities but is much more than that. It is an endeavor that searches to cure or allay the ills of mankind and to understand the functioning of life as it applies to the human body and mind. By the skills and knowledge gained thusly, it can restore and preserve health of individuals and thereby of societies.

Medicine may have started with a patient/physician one to one relationship. Yet, neither the acquisition of knowledge nor its application can nowadays be done solely by this duet. The latter, however, must remain as the basis. The medical establishment had to relate and interact with governments. It had to use the resources of the state to gain knowledge and to apply it. It also had to employ the assistance of governments, religions, and law-making to protect the patients and the physicians from decay within and from aggression and impingement without.

Many physicians are needed and most are not saints and do not live alone, but have families and needs. Most patients cannot afford all eventualities and costs that might occur from the diagnostic and therapeutic procedures that they might need. Furthermore, the teaching of Medicine cannot be solely done on a teacher/pupil scheme. Costs of Public Health cannot be covered by charity and volunteer work. Thus, money and its administration are intimately involved with the modern practice of Medicine. The medical establishment and medical practitioners have to take into account the demands, turfs, needs, and skills of lawyers, legislators, and business persons. Public opinion and its management is another key player in the complex interaction that is being quickly outlined. The main problem is that in this complex relationship physicians nowadays react, rather than act. They relate (in the US at least) as isolated individuals, not as part of organized bodies. In other countries, physicians may be organized in groups, but these groups act and have the mentality of unions. They use strikes and carry placards and shout in public places dressed, perhaps, in white coats. Physicians behave not differently than any other striker with their own best interests in mind, and are judged with similar criteria by the public.

Some examples of diverse issues facing us

Let me include some examples gleaned, in part, from a cursory review of publications and the web.

Early in 2012 in its section of “World Report,” The Lancet published an article analyzing the causes of a massive strike of German doctors [2]. The reasons? Poor pay and allegedly, poor working conditions. Municipal hospitals were reportedly at a risk of becoming insolvent.

Physicians in the U.S. now worry about what to put in their e-charts. Electronic data may be opened for inspection. Thus, the physicians or their patients may be vulnerable to legal actions.

The August 2012 issue of Skin and Allergy News has several articles that have to do with what occupies these lines. Joseph S. Eastern [3] analyzed the Impact of the US Supreme Court’s decision concerning the constitutionality of the Affordable Care Act. He stated that whereas some of the law’s provisions did favor physicians in the short term as (among other things) insurers could no longer exclude applicants because of chronic ailments. Bur, it would also favor physician payment reforms and did not address tort reform or revision of Medicare compensation rules. James C. Mitchiner [4] analyzed several reasons why he would favor a single payer model, an improved Medicare for All program. I am not going to state opinions about the specific and interesting points of view of Dr. Mitchiner. I only wish to point out that physicians would obtain their income from the government. They would become, in essence, employees, without enjoying the rewards of stability, career benefits, and retirement that traditional government employees do enjoy.

In another vein and journal, Arulrajah and Vij, stressed the growing importance of social media for dermatologists [5]. Among the points that they emphasized is online reputation management. Dermatologists should maintain, they stressed, a good online reputation. They also rightly noted that third party reviewers on the Internet can make or break a professional’s reputation and there is not much that the professional can do about it. In this fashion (and I say this, not Arulrajah and Vij) a physician has become like a celebrity whose life is open to gossip and has to use advertisement and public opinion management as actors or politicians do.

If we focus on South America, Venezuela has imported caretakers from Cuba to attend people in underprivileged areas of cities and villages. Venezuelan government disregarded previously existing structures. Imported caretakers work without connections with bona fide general or teaching hospitals. Government created ex nihilo new “medical schools.” Their students and teachers do not measure up to former standards. These schools do not have an organized teaching system for basic sciences or clinical subjects and there is not even the semblance of research. Some protests have come from National Academies and prestigious individuals. Yet, the Medical Establishment has found it difficult to react against a government that now created entropy, although it had been a guarantor and regulator of medical orthodoxy for two centuries.

In sum, the current situation, if left to itself, will lead to physicians being simple technicians, carrying out diagnostic and therapeutic maneuvers. They will be ruled by standards that they did not participate in designing. They will aim their energies at avoiding legal persecution, gaining an income, and doing a job. The best minds will avoid medical schools. Only those that can adapt themselves to this kind of life will learn the profession. They will eventually teach what they know and perpetuate these kinds of practitioner that are not physicians but providers; they won’t have patients, but clients.

A Solution

Physicians are individualists that nevertheless should know how to work in teams. Medicine, as a discipline, is more homogenous and more spread world wide than almost any other branch of knowledge. Prestigious medical journals are universally read. Ethics and scientific societies are also extended through the five continents and many physicians know others of diverse countries, languages, and cultures. They can interchange opinions and are able to cooperate despite distances and political and social divergence. As I was able to point out in a recent paper [6], physicians as physicians should act in the usual web of politics, economics, and clashing interests. They should be in that web, but not of it. Local or national organizations and actions are of importance, but what is really needed is a truly functional World Medical Society, Collegium, or Organization. A world-wide institution could take into consideration needs and strengths of diverse countries and speak with a soft voice but carry a big stick. I do not refer to the World Health Organization, which is involved in Public Health Problems and is in many ways dependent on the respective governments. It would rather be an institution somewhat similar to the set up of the Catholic Church. The latter has to do with an universal faith and has extra national presence. It interacts with nations, diverse peoples, and governments. Members are in almost every country, but are not under the thumb of the governments of these countries insofar as their ministry goes. The World Medical Society would shepherd medical practice and knowledge and would defend the mission of physicians. There would be a central governing council and a director. Trappings of sovereignty and rule would of course be absent. The basis of the Society would be rational, not inspirational. It would be scientific and organizational, not theological. The council and director would be elected and act for given periods of time, not for life. This world wide body would bolster the practice of medicine throughout the planet and would maintain the uniqueness and purity of the medical profession. Physicians would serve, as is their task, but Medicine would not be a puppet the strings of which are pulled by organizations or individuals whose interest is not necessarily the welfare of patients.


Current world-wide events in medicine indicate that, despite advances in knowledge and technology, its practice is increasingly being directed by non-physicians. It is in the hands of those that administer funds, be they governments or private organizations. Physicians have acted in a disorganized fashion or have bent their knees so long as income is guaranteed. Persistence of these trends will likely lead to irreversible situations or damage. A new kind of health provider rather than physician (in the true meaning), adapted to these conditions, will probably emerge and train similar individuals. It is a slippery slope.

I propose the creation of a World Medical Institution. It would interact with and cooperate with national society structures, but it would not be a cog in the societal machine. It would follow an independent world-wide organizational pattern. It would interrupt and reverse the downward spiral into a models and behaviors that go against the interests of patients and of doctors.


1. Tuchman, B.W., The March of Folly, From Troy to VietNam. Ballantine Books, Random House Publishing Group, New York USA 1984.

2. Holt, E., Germany's Hospital Doctors Prepare to Strike en Masse. World Report. The Lancet 2012, 379: 206. [PubMed]

3. Eastern, J.S., Managing your Dermatology Practice. Impact of the Supreme Court Decision, Skin & Allergy News. 2012, 43:8:50.

4. Mitchiner, J.C., Commentary. It is Time for Single-Payer. Skin and Allergy News, 2012. 43:15.

5. Arulrajah, N., Vij, V., The Growing Importance of Social Media for Dermatologists. Practical Dermatology, 2012. 9:22-23.

6. Goihman-Yahr, M., In It but not of It...Relationships of Medicine with Government and Politics. Clinics in Dermatology, 2011, 29:704-707

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