Recent Posts by Dr. Mazur

Demystifying OTC Medications for Allergies and Colds

It is cold and allergy season again.  As we cough, sneeze and scratch our way through fall and winter, drug companies predictably will overwhelm us with their pitches to buy their brand of OTC drugs for relief.  Unfortunately, shopping for OTC medications by brand name is unnecessarily expensive and often leads to the consumption of unnecessary and potentially dangerous drugs.  Despite the dizzying array of over the counter (OTC) medications available to treat allergies and the common cold, the educated consumer really needs only to make a few, well informed choices to both effectively treat symptoms and to save money.  Unfortunately, drug manufacturers complicate what should be a relatively simple selection by creating innumerable mixed drug formulations and promoting their products using a complicated and illogical set of brand names.  In order to dissect the OTC market for colds and allergies, one must understand a few basic principles.  Firstly, unlike food supplements (about which I will write in the future), OTC medications are reviewed and approved by the FDA, and are considered generally safe and effective when taken as directed.  All OTC medications have a unique chemical or generic name, a set of FDA approved indications, and an FDA approved OTC dosing.  “Old” OTC medications are generally “off patent” and are available in multiple products, in multiple formulations, and are marketed under a variety of brand names.  More recently approved OTC medications, often converted from prescription to OTC, may still be covered by a patent allowing the parent company to market the drug exclusively (at a much higher price).  Note also that approved OTC drug doses are often half of those approved for “prescription strength” versions of the same medications that one can often achieve “prescription strength” by doubling the approved OTC dose (not recommended except on the advice of your physician).  One also needs to understand that once a given generic medicine is approved for OTC use and is off patent, any drug company may produce and/or incorporate it into its branded (or unbranded) OTC medications.  Appended to this post is a table designed to help demystify the dizzying array of OTC drugs marketed for allergies and colds.  Note that drug company marketing language is often a clue to the classes of medications included in their particular branded formulation:

  • “Runny nose and itching from a cold” -> first generation antihistamine
  • “Non-sedating runny nose and itching from allergies” -> second generation antihistamine
  • “Attacks multiple causes of nasal allergies, not an antihistamine” -> intranasal corticosteroid spray
  • “Nasal stuffiness and congestion” -> sympathomimetics, usually phenylephrine
  • “Fever, aches and pains” -> acetaminophen and/or other non-steroidal anti-inflammatory drugs (NSAIDs)
  • “Cough” -> dextromethorphan and/or guaifenesin

Treating more symptoms is NOT always better than targeted therapy.  Also, targeted therapy is often a lot more inexpensive.  For colds or URIs (upper respiratory infections), an informed consumer should consider purchasing separately 1) a generic version of a 1st generation antihistamine, 2) generic psuedoephedrine, 3) either acetominophen or another OTC NSAID, and (possibly) 4) dextromethorphan +/- guaifenesin.  Then these four medicines can be selected and taken together to treat the exact symptoms that one is experiencing.  Also the 1st generation antihistamine can be combined with acetominophen or any of the other NSAIDs to create a “pm” or “nighttime” version of the pain reliever.  Finally, for non-infectious, allergic symptoms, one can combine a second generation antihistamine with a decongestant to find rapid acting relief.  However, if one can wait for two to three days for maximum effect, or one can anticipate the timing for the exposure to the allergen, nasal corticosteroid sprays are almost always more effective and better tolerated than the oral medications.  For a detailed description of the various OTC medications used to treat allergies and colds, please review the appended table that I have prepared.  Note that despite the marketing claims, not all of the OTC medications are equally effective at treating the symptom that they claim to mitigate.

Table – OTC Medications for Allergies and Colds


Five Basic Tenets for Health Care Reform

By Thursday, July 23, 2015 1 No tags Permalink 0

_MG_6489 (1)

Note:  I first published this op ed for physicians in the Winter 2008-09 as a newsletter column during my term as Connecticut Governor of the American College of Physicians.  I received so much positive feedback that it was republished in minimally revised form by Connecticut Medicine (the peer-reviewed journal of the Connecticut State Medical Society)  in 2009 [Conn Med 73(6):355-358, 2009].  While some of this content is dated in light of Heath Care Reform (Obamacare) and the “meaningful use” IT subsidies contained within the 2008 economic stimulus package, much still remains relevant today.   -EMM


Five Basic Tenets for Health Care Reform

As this is my final column as your Governor, I thought that I would invoke your forbearance and exploit the “bully pulpit” of both my position and this newsletter to present you with my personal thoughts about health care reform. I do not pretend to know how to pragmatically solve the health care crisis nor do I feel that I have discovered a new blueprint for the future. Rather, after many years involved in medical leadership and political advocacy, both at my hospital and through the American College of Physicians, I have developed some ideas, hopefully informed, about the fundamental principles upon which I believe an efficient, high quality and functional health care system should be structured. Unfortunately, I have to concede at the outset that from a political perspective and taken together, these principles are completely impractical. Given the positions of the two major political parties in the United States, I do not see a realistic, politically pragmatic path to reach the goals that I am about to enunciate. Nevertheless, I cannot help but articulate the principles, however politically naive, with the hope that the political landscape will change at some time in the future and that which is politically impossible today becomes feasible in the future.

Firstly, with health care expenditures currently totaling 16% of the United States GDP, I believe that it is safe to assume that there are sufficient dollars currently being devoted to health care in the United States to create and sustain a truly excellent universal health care system. Japan, with the longest average life expectancy in the world (83 years) and the second lowest infant mortality (2.8 per 1,000 live births) spends only 7.9% of its GDP on health care, only half of the U.S. rate. In absolute dollars, Japan’s annual per capita health care spending is only 38% ($2,690) of that in the United States ($7,026). The United States leads the entire world both in the percentage of GDP and the annual per capita dollars spent on health care and yet our overall health outcomes rank in the middle. While it is also true that the United States leads the world in medical research and technology, research costs consume only 2% of the health care dollar. Therefore, I do not think that it is necessary to add more money to the “pot” to achieve a quality, universal system. I would suggest that if we restructure our health care system on the following five pillars, that system would be capable of providing excellent care to all of our citizens and yet still maintain our leadership in research and technology and require no increase in the level of funding. These fundamental principles are:

            Universal Access: We simply must provide (and appropriately fund) universal access to health care for all of our citizens. Since I believe that we have agreed as a society that health care is an inherent right and not a privilege, the principle of universal access is the simplest and most basic. In our current system, all patients ultimately do receive care, but the care that they receive is neither high quality nor timely nor efficient. We have evolved a hodgepodge of disparate mechanisms to provide care for the underserved, mechanisms that actually serve them quite poorly and cost us substantially more than a universal system. Our dysfunctional and piecemeal approach forces us to provide care during the most expensive, acute exacerbations and end stages of disease, disease that often could and should have been managed chronically or even prevented. Also, currently hospitals must charge their commercial payers substantially more than their costs in order to cross subsidize the care of their uninsured and the Medicaid poor (who are not even covered at a break-even point by Medicaid payments). Private physicians eschew Medicaid patients (for which payments also generally do not cover office costs) and reluctantly care for many of them on a pro bono basis in under funded, poorly organized hospital-based clinics. In order to maintain their bottom lines, hospitals are forced to develop and aggressively promote high margin clinical programs and services, chosen primarily on profit potential rather than social good. It should not be the responsibility of hospitals and physicians alone to figure out how to take care of the poor.  The current reality results in parochial, ad hoc, inefficient and incomplete solutions. It is the responsibility of all of us, as a society and as a country, to shoulder this responsibility. This means developing a health insurance system that provides universal access (and adequate funding) for every member of our society. The problem of the uninsured has been “pushed down” onto the health care providers, exploiting our professional ethics and using the tools of unfunded legislative mandates and regulatory requirements. However, access cannot be solved by providers at the front lines; we must address this issue together, as an informed and progressive society, at the highest level of our government.

            Computerized Health Information Integration: This is the “simplest” pillar of health care reform, one on which everyone appears to agree. The potential value of computerized health information integration is obvious to all of us who take care of patients – less duplication of testing, the availability of a complete medical history and accurate medication list across all venues of care, fewer errors, lower costs etc. However, my concern is the means by which the insurance industry and the federal government are attempting to capitalize information technology implementation within the health care system. Like the problems of the uninsured and the underserved, this issue is being “pushed down” directly onto health care providers, expecting us, in this severely resource constrained environment, to fund the creation of a $156 billion technology infrastructure and support annual operating costs of $48 billion (Kaushal et al., Ann Int Med 143: 165-173, 2005) out of the very limited positive margins we are currently achieving. Computerized health information integration will provide a social good that accrues to the entire society. It is therefore also a societal responsibility and society (i.e. government) should fund it. It has been estimated that physicians who install electronic medical records in their offices will reap only 20% of the financial benefits of such a system. However, physicians (and hospitals) are being asked to bear nearly 100% of the costs. This is not fair, it is not right and it is not economically realistic.

            Rational payments to hospitals and physicians: Internists realize, perhaps better than anyone, how irrational and inequitable our current payment system is. An internist consulting on a complex elderly patient with multiple chronic, life threatening diseases will be paid, for an hour’s worth of difficult cognitive work and thoughtful patient/family interaction, only a small fraction (i.e. 10-20%) of what a radiologist or proceduralist will be paid, for the same amount of physician work and time. Hospitals receive from Medicare approximately 30 fold more reimbursement (exclusive of the equipment cost) for the placement of an intra-cardiac defibrillator than for providing a patient with comprehensive diabetes education over 10 one hour sessions with a trained diabetes nurse. It is no wonder that medical students are choosing radiology over general internal medicine for their specialty training and that hospitals are choosing to develop imaging centers, bariatric surgery programs and interventional cardiovascular centers rather than geriatrics and diabetes programs. Indeed, the free market works and we have created a medical marketplace in the United States that rewards procedures and technology while discouraging cognitive services, longitudinal disease management and face-to-face patient contact with physicians. This dysfunctional payment system, as an unintended consequence, undermines the availability of desirable and very necessary clinical services (geriatrics, psychiatry, primary care etc.) as well as threatens the future composition of the physician workforce. We must rationalize payments to hospitals and physicians to create effectively a flat “playing field” in which no one type of program or service or procedure is inherently more profitable than another, and in which an hour of physician’s time reading images or performing procedures is reimbursed at a rate comparable to an hour performing cognitive work and interacting with patients. Were we to do so, I believe that we as a society would purchase more of those elements of health care (i.e. specific services) that are really required to serve the public good (and generate positive health outcomes) and fewer of those that are largely driven by high marginal profits.

           Overhaul/replacement of the medical malpractice system:  I realize that politicians and the public are tired of hearing from “rich doctors” who complain about rising and/or excessive malpractice premiums. Earlier in my career, I too was a bit of a cynic, believing that “defensive medicine” was overstated as a significant driver of unnecessary health care expenditures. However, as I have matured, I have witnessed (and experienced) a fundamental transformation in the perspective through which we as physicians approach the delivery of patient care, a transformation driven by the necessity to mitigate the pervasive risk of medical malpractice. During the past 25 years, there has been an insidious change in clinical practice by physicians who have shifted from doing that which we genuinely feel is best for our patients to frequently basing our clinical decisions (i.e. testing, hospitalization and even therapy) on that which first and foremost reduces medico-legal risk. Despite unambiguous research indicating that malpractice awards are driven largely by poor clinical outcomes rather than by physician negligence, politicians and the public continue to insist that access to essentially unlimited malpractice awards is required to keep us physicians “honest, i.e. to assure physician quality and reduce the risk of medical error. While for many years I had difficulty accepting the “lottery mentality” of the excessive malpractice awards driven largely by the emotions of lay jurors, I have gradually come to accept our implicit societal decision that an adverse medical outcome should be mitigated by some sort of financial remuneration for the unfortunate victim. However, I would propose that such remuneration should be provided through a society-wide, no fault insurance system program (similar to Workmen’s Compensation) rather than a medical negligence / malpractice system that punishes the involved physician. Some would argue that without the opportunity to prove medical negligence, the individual and society lose the opportunity to control the quality of medical practice and to hold physicians accountable for their clinical decisions. I would propose that we separate the administrative system that regulates physician quality and clinical practice, from that which rewards adverse medical outcomes. Regarding the former, I would have no problem supporting a much more rigorous system for medical licensure and licensure renewal; one which requires physician-specific quality reporting and review, recurrent testing and limited licenses (for those who do not maintain the level of quality necessary for independent, full practice). It is difficult to argue that we as physicians should not be completely qualified and competent throughout our careers. However, the medical malpractice system is working neither to assure physician quality nor to reduce medical error. It is only inexorably driving up the total costs of health care to a level that some Stanford economists (Daniel P. Kessler and Mark McClellan MD, 1996) estimate to be 5 to 9% of the entire health care budget. What a waste of money!

            Rational rationing: Finally, we get to the “R” word – rationing. Rationing is the “third rail” of health care reform – no one wants to touch it. Nevertheless, rationing is a necessary and inevitable component of any universal health care system for which there are finite resources available and in which the demand for services is functionally unlimited. For most products and services, rationing is not required because demand is constrained by an individual’s personal capacity to purchase those products and services. However, we as a society have agreed that health care is a “right” and that everyone should have access to all necessary health care services regardless of their personal economic circumstances. In our society, there is effectively no personal economic consequence for choosing to purchase health care services. While a lot of free market economists believe that creating personal accountability for the purchase of health care services will effectively limit the demand for health care, I do not agree. I believe that the “average” individual has neither the knowledge nor the temperament to routinely make the best (and most cost effective) health care decisions on their own behalf. The health care marketplace will never be rational and consumers are not capable of judging either quality or effectiveness. Rather, I believe that we as a society, aided by physicians, health care analysts and politicians, can and must address health care rationing publicly and make overt allocation decisions – prospectively, transparently, scientifically and effectively, on the basis of social “good”. We have to recognize that rationing is already taking place in the United States and among the other developed countries around the world. In the United States we ration passively, invisibly, and irrationally, allowing services to be allocated to our citizens based upon a mishmash of insurance products and an individual’s age, employment and economic situations. In Canada, health care is rationed by limiting access and centrally budgeting health care resources, producing long queues that reduce the utilization of many high demand and expensive services. Neither of these approaches allocates health care services rationally and thus neither serves its public well. Given the vast amount that we are already spending on health care in the United States, I do not believe that the rational rationing of health care will reduce anyone’s access to necessary and effective procedures and services. But, we have to critically evaluate that for which we do and do not provide funding, investing in only those procedures and services that truly improve meaningful health outcomes. We as physicians observe the squandering of health care resources every day – hundreds of thousands of dollars of ICU care for the tenth and terminal pneumonia of an elderly, malnourished COPD patient; demented, wizened patients sustained on dialysis because their families cannot make the decision to let them die; third line complex chemotherapy or extraordinarily expensive biologic therapy for the patient with metastatic cancer of the lung and essentially no prospect for incremental quality survival; complex back and disc surgery for pain that otherwise would have resolved with time and, countless other examples. Our society, focused intensely on the “rights” of the individual, is loath to make decisions that overtly restrict an individual’s right to choose anything on the health care smorgasboard, regardless of how expensive or ineffective. I believe that we cannot allow our cultural orientation towards the “rights” of the individual to undermine our capacity to create an affordable (and equally effective) health care system that serves our entire society. The right to effective health care should not be translated into the right to all possible health care nor the right to cost ineffective and futile health care. The alternatives to rational rationing are our current approach of de facto irrational rationing and/or financial insolvency of the health care system. We must accept that rationing is an inevitable, necessary and inherent part of all universal health care systems. Let’s ration deliberately and overtly, so that the choices we make are active and evidence-based, not passive. Let’s ration rationally, such that the rationing optimally benefits every one of us and results in universal access with quality, meaningful and effective health care for everyone.

So, there you have it – my personal prescription for the principles on which health care reform should be based. Pie in the sky? You “betcha”! Politically impracticable? Absolutely! But, sensible and reasonable? I think so. Creating a universal system of health care at realistically achievable costs that provides quality outcomes for all is definitely within our reach and clearly within our budget. However, it will require major concessions from both sides of the political aisle and a change in how we as individuals view the balance between our personal “rights” and social benefit. We are at the beginning of a new political era – let us hope that our leaders have the courage to think “out of the box” and are willing break new ground in leading the United States to our shared (and elusive) goal of the best health care system in the world.

Some Good Things (…about being a doctor)

By Thursday, July 23, 2015 0 No tags Permalink 0

Note:  I wrote this column for the American College of Physicians in the Summer of 2007 for my fellow internal medicine physicians.  At a time when physician professional satisfaction was (and unfortunately still is) so low, particularly among internists, I wanted to remind my colleagues of the fundamental reasons we all first chose to enter the field of medicine.  For the non-physician reader, I hope you are reassured, at least a bit, that most of us doctors really do have your (i.e. the patients’) interests at heart and that our motivations are what you would want and expect.-EMM

“Some Good Things”

With the summer upon us, the kids out of school and vacation time imminent, now is perhaps a good time to reflect upon some of the positives of our profession. Most of the time, it appears that our lives as physicians, as well as our discussions concerning medical practice, are dominated by the issues of paperwork, insurance hassles, malpractice litigation, unfairness, underpayment, under-appreciation and overwork, all of which characterize the day-to-day life of the internist in the 21st century. Nevertheless and somewhat surprisingly however, internal medicine remains the largest specialty choice in the National Resident Matching Program, applications to medical schools continue to rise (and have risen annually since 2002, reaching 19,815 applicants in 2006) and medical schools remain highly competitive, with less than one of two applicants accepted in 2006 (according to AAMC data). Children of practicing internal medicine physicians continue to unceremoniously follow their mothers’ and fathers’ footsteps into medical school. And, in the quiet and intimacy of honest conversation, a large proportion of internists will admit (almost embarrassingly) that they love being doctors and would choose the profession all over again if the opportunity were presented to them.

How then do we explain this disconnect between the real, pervasive, destructive and bureaucratic forces frustrating the practice of medicine today (and against which we struggle) and both 1) the resilience and loyalty of its current practitioners and 2) medicine’s continued popularity within the rising generation? I believe that the answer lies within the core values of our profession, in the essence of what we do every day. It is indisputable that no matter what occurs in the economic and political environment that surrounds us, the practice of medicine was, is, and will always be a noble profession. No matter that some bureaucrats may try linguistically to reduce physicians to “providers” and our patients to “clients”, we will always be doctors who care for patients, in our own eyes and the eyes of the public we serve. It is no surprise that in this post 9/11 world, a 2006 Harris pole found that doctors ranked only second to firefighters as the most admired profession in America.

A further exploration of the term “profession” may be informative. Professions are strictly defined as learned, self-regulating occupations that require extensive training, mastery of a specialized body of knowledge and skills, incorporate an internally-defined and administered code of ethics (to which members of the profession formally commit themselves via oath) and require regular advocacy for another group of people who themselves, lack the specific knowledge that would be necessary for their own advocacy in that specialty area. Originally, only the ministry, medicine and law were considered professions and although the term has broadened and become more inclusive in recent years, medicine still epitomizes the essence of what it means to be a “professional”. I would posit that it is the core values of professionalism inherent within the practice of medicine that create our unique relationship with our patients (that persists despite the external environment) and are the source of gratification that sustains us today.

At its most superficial level (as I frequently tell medical students and residents), physicians never have to arrive home in the evening, or look back after an entire career, wondering if their time has been well spent and they have accomplished something of value. At its core, medicine is a profession whose entire existence is dedicated to the relief of suffering and improving the life of our fellow woman and man. How can one ever question the value in that? But, our role in our patients’ lives is profoundly more intense and our responsibilities are far more weighty than those required of one human being simply helping another. I would suggest that the professional relationship that exists between an internist (or family physician) and his/her patient is rivaled only by that of a congregant and his/her minister for its intensity and its depth of candor and honesty. When patients seek physicians’ help to prevent and/or treat their illness, they voluntarily open a unique and intensely personal window of communication through which no one but us, as physicians, are permitted to see. They will tell us the most personal and intimate things about themselves; things that have never been articulated before, that are unknown even to parents, and sibs, and spouses. They open this window with the explicit expectation that we will use the information they provide wisely, to help them heal, confident and that we will not otherwise exploit or violate their privacy. What a privilege! And, what a responsibility! Furthermore, in our singular position as physicians, patients grant us unique access to their physical bodies in ways that would be unacceptable, even illegal outside of the doctor-patient relationship. We are allowed to touch and probe in the most intimate places, we are permitted to stick our patients with needles, cut them with knives and administer potentially toxic chemicals to them. Even just our simple words, gestures and attitudes can carry profound weight; providing compassion and hope and solace. We do all this with their (and society’s) confident expectation that we are acting selflessly and in our patients’ best interests. I don’t know how anyone can be anything but humbled by this responsibility! And, I don’t know how this unique relationship with our fellow human beings, this privileged profession which we occupy, can be anything but rewarding and fulfilling.

The unique access provided to us by our patients necessarily carries with it awesome responsibility. I am fond of challenging my residents not just to achieve clinical competency, but to aspire to clinical virtuosity. Do patients, whose intimate stories, emotions and physical bodies are splayed open before us deserve anything less than a virtuoso physician to heal them? In exchange for the level of unprecedented access they grant, is there not an absolute moral requirement that we, as physicians, become the most skillful and knowledgeable that we can possibly be? And, isn’t it this imperative, this challenge and responsibility, this one-to-one personal accountability to another human being, that sits at the core of the profession of medicine and that which both challenges and nourishes us as physicians?

One may be distracted by the dysfunctional regulatory and business environment in which we practice, but the core experience of being a physician can never be diminished. I believe that we as physicians are privileged to know our patients (and thus to experience humanity) from a unique perspective, one to which no other group of people in the entire world has access. We occupy a central and singular role in our patients’ lives, one that only a physician can fill. We prevent their illnesses, heal their sicknesses, share intimate concerns, celebrate victories and comfort their dying. Every day, we participate in and share the most intimate aspects of life with the wonderful diversity of humanity who seeks our help. And it is this extraordinary experience of being a doctor that provides us compensation far beyond dollars; an experience and a profession which enriches and rewards us personally as human beings as no other occupation can. This is the daily experience that we share uniquely as physicians and for which we can all be thankful. So, as the temperatures rise and you have a moment to contemplate your career in internal medicine, don’t forget the “good things”, the things for which you entered medicine in the first place, the things that make your efforts all worthwhile and which are just as real and just as available today as they were when you first decided to become a doctor.

The “Industrialization” of Medicine

By Tuesday, July 14, 2015 0 No tags Permalink 0

_MG_5233 (3)


Note:  I first published this op ed for physicians in the Spring of 2007 as a newsletter column during my term as Connecticut Governor of the American College of Physicians.  It remains completely relevant today as healthcare remains in transition.   -EMM


It is no secret that many physicians are disgruntled and dissatisfied, and that the medical profession perceives itself as under siege. However, most of us as physicians don’t realize that our dissatisfaction does not arise simply from perceived Kafkaesque, malevolent external forces that include managed care, increasing bureaucracy, regulation, and governmental control. I would suggest that what is happening in health care is more fundamental, i.e. that we are in the midst of a seismic cultural transition in the practice of medicine, one that results in a clash between two completely different and separate worldviews, neither one of which is inherently evil or wrong. The problems and conflict derive from the fact that the “values” held by these two worldviews are largely incompatible; in fact, they are almost mutually exclusive.

I was first introduced to this concept when taking a course at the Harvard School of Public Health for physician leaders. Using the traditional business school approach, a real “case” was presented to the class of a modern company that produced small quantities of unique, fine art quality flatware. The employees of the company were indeed artisans, individually designing, producing and signing each piece, and personally controlling the production process for their handiwork from beginning to end. The beauty of the flatware was such that its popularity and demand grew to the point that the company decided to significantly expand production. A new management team was recruited and an “industrial” production model was implemented. In order to maintain quality and brand identity, designs were standardized, production steps were explicitly defined and segregated, individuals were assigned to specific production steps and measurements of consistency and quality were put in place. In other words, the company moved from a production process dependent on the work an elite group of highly skilled individuals to a mass production or assembly line model in which the system, not the individual, was determinant. Notably (and not unexpectedly), the artisan employees who were so responsible for the initial success of the company were extremely unhappy with this new production model. They rebelled and struggled against its implementation. Ultimately, they were unable to adapt to the new work paradigm and they left the organization. All the artisans were replaced by lower skill workers and the reconstituted company was extremely successful (and continues to flourish today).

This real business “case” is not unique but rather exemplifies what happened to countless industries in the early 1900s as the “industrial revolution” took hold. Prior to that time, most products were created by individual, highly skilled workers who controlled the entire production process from beginning to end. Production knowledge and skills were passed down from senior to junior workers via long apprenticeships. Skilled craftsmen belonged to exclusive guilds that were organized around their products and skills. The industrial revolution resulted in a complete paradigm shift in manufacturing during which the work of product production was totally reorganized and the guild system, as well as most of its craftsmen, were eliminated. This change led to an enormous increase in productivity and resulted in the high standard of living that we currently enjoy today.

This reorganization of the work of production had several components. As described by Darius Rastegar1, these included 1) dividing “work” into discrete (and simpler) tasks, 2) the evaluation and standardization of these tasks and 3) the rise of the managerial class to manage and control the production processes. All of these components, while necessary to achieve the overall goals of high productivity and efficiency, had their own negative consequences. Dividing up the production into simpler tasks required a less skilled workforce and, because of its repetitive character, the work itself became less intrinsically satisfying. Standardization and metrics, while assuring uniformity and at least a reproducible minimal level of quality, eliminated worker autonomy and emphasized “efficiency” and throughput over creativity. Finally, the rise of the managerial class further disempowered the workers and valued worker conformity and compliance over individual autonomy and personal excellence.  Nevertheless, it is difficult to argue that the industrial revolution was “bad”, even though it displaced skilled workers and eliminated many high skilled positions. And, it is equally difficult to maintain that there is not still inherent beauty and value in a carefully handcrafted product by a highly skilled artisan; beauty and value that far exceeds that available in mass manufactured products.

Health Care (now often called the health care industry) was almost a century late in coming to the party but is currently in the midst of its own industrial revolution. The medical industrial revolution is driven by many factors including the increasing complexity of medical knowledge, the rise of evidence based medicine, and public demands for greater transparency and quality with fewer medical errors. However, the fundamental force behind this transformation is economic; public demand for the production of health care “widgets” keeps rising (the appetite of the U.S. population for health care appears unlimited) but the cost of such production is effectively capped at the current level (i.e. 15% of the U.S. GDP). Consequently, the societal demand to improve the “efficiency” of producing health care widgets is irresistible. This requirement for substantially increased efficiency has resulted in the application of the industrial model to health care delivery and directly to doctors who were trained in and are disciples of the “old”, professional medical paradigm.

I would suggest that it is the clash of the cultural worldview of the medical profession with that of the purchasers and managers of health care (insurance companies, health administrators and government) that lies at the heart of so many physicians’ job dissatisfaction today. Physicians are the “artisans” who value such things as the doctor-patient relationship, empathy, continuity of care, individualization, personal commitment and accountability, education, professionalism, selflessness, autonomy and volunteerism. The industrial model values conformity, uniformity, efficiency, throughput, selfishness and compliance. (Capitalism is, in fact, built upon the foundation of avarice.) The conflict in which we currently find ourselves as doctors is that between the values of medical professionalism and those of capitalist commercialism.   Dr. Frank Davidoff wrote about this conflict2, framing the worldviews somewhat differently. He described the physician worldview as the “guardian moral syndrome” and the industrial worldview as the “commercial moral syndrome”. Furthermore, he characterized the current health care system and its working relationship of physicians and managed care (with their conflicting worldviews) as a “monstrous hybrid”.

Certainly, Dr. Davidoff is correct in his characterization of the current state of the health care system and I believe we can agree that the existing model of health care can be only transitional. A more stable and satisfying (to patients and doctors alike) paradigm must emerge because health care (and doctoring) will not go away. Unlike the artisans’ culture of the pre-industrial age, the ethos of medicine cannot completely disappear because the “widgets” of health care cannot be completely uncoupled from our and our patients’ humanity. In fact, our patients are caught right in the middle of this cultural conflict, desiring to consume large quantities of “artisan quality” health care but at industrial, mass-produced prices. The ancient healers, the “medicine men” of antiquity understood the power and “value” of the artistic side of medicine. They recognized that the relief of human suffering and even healing could be achieved by the authority of the (time inefficient) doctor-patient relationship. Even today, with all the technological and pharmaceutical advances available to us, our patients still look to us for reassurance, relief of suffering and healing human interaction. There is no time efficient way to mass-produce these widgets of physician-patient healing and they have real value, even in an industrial, commercial context. But, neither can we physicians, in the context of the nearly unlimited demand for our services, continue to struggle against the industrial model and its values of productivity, measurement, transparency and efficiency. Industrial medicine is here to stay and we need to find a path towards harmonious coexistence with it.

While Dr. Davidoff points out how difficult coexistence of these cultures will be, he suggests that our only hope for success is by implementing an approach called “knowledgeable flexibility”. This approach requires that both “sides” recognize and fully accept the cultural precepts and worldview of the other while acknowledging their inherent irreconcilability. “Knowledgeable flexibility” challenges both physicians and bureaucrats/administrators alike to be educated in and appreciate the alternative worldview and to be, themselves, sufficiently flexible to move back and forth between cultural paradigms as necessary. We as medical leaders must recognize that neither culture has exclusivity on that which is “right” for the future of health care and both worldviews contain valid precepts that must be accommodated. This accommodation will require many more physicians to be conversant in industrial and management principles and all physicians to understand and acknowledge the validity and necessary role of the commercial culture in health care delivery. Similarly, health care administrators must embrace the imperative to try to understand (and appreciate) the tenets of the culture of medicine and be willing to work constructively with physicians to incorporate their professional values into the commercial paradigm. Ongoing and intense communication between individuals on both sides will be required and we need to accept the inevitable fact that an uncomfortable tension will always exist. We physicians cannot be like the artisans of the flatware company, refusing to adapt to change and finally disappearing. Neither can we abandon the core values of the professionalsim that have served physicians and their patients so well over the centuries (and continue to have real economic value today). Crafting the future in health care delivery will require a positive, constructive attitude from both physicians and administrators, a lot of hard work, and ongoing frank, open and empathic communication. We physicians must be part of the future and can be, without abandoning the professional values of our past.


1.  Rastegar DA: Health care becomes an industry. Ann Family Med. 2004;2(1):70-82.

2.  Davidoff F: Medicine and commerce 1: Is managed care a “monstrous hybrid”?   Ann Internal Med. 1998;128(6):496-499.

About Dr. Mazur

By Thursday, January 15, 2015 1 No tags Permalink 0


Dr. Eric Mazur is an internist and specialist in hematology/oncology. He retired one year ago from his role as Vice President and Chief Medical Officer of Norwalk Hospital, a position in which he served for 4 years. He currently co-hosts a weekly, health-oriented local cable TV show and works as an independent healthcare consultant.

As Norwalk Hospital’s Chief Medical Officer, Dr. Mazur was responsible for the medical staff and the quality of all medical care delivered at the hospital. Under his leadership, Norwalk Hospital established certified centers of excellence in lung and colon cancer, pelvic health, hyperbaric oxygen therapy, and joint replacement surgery. In 2010, 2011, and 2012, Norwalk Hospital received the Healthgrades® Distinguished Hospital Award for Clinical Excellence™, the only hospital in Fairfield County to achieve this distinction. Dr. Mazur also served as one of six Norwalk Hospital senior executives on the Integration Team planning for and effecting the merger of Norwalk Hospital with the Western Connecticut Health Network in January 2014. Also in 2014, Dr. Mazur received the William J. Tracey Award from Norwalk Hospital for the doctor who best displays leadership, character, involvement in community service and exemplary clinical skill. Other recent achievements include recognition in 2012 as Master, American College of Physicians, one of only ten living internists in the State of Connecticut so honored, and receipt of the William F. Thornton Award for teaching and medical education from the American College of Physicians. In the last several years, Dr. Mazur has been named repeatedly by Castle Connellyâ to “Top Doctors: New York Metro Area” and listed in Best Doctors in Americaâ.

Prior to his role as Chief Medical Officer, Dr. Mazur served for 16 years as Norwalk Hospital’s Chairman of the Department of Medicine. During that time, he focused his leadership efforts on achieving measurable quality in patient care, excellence in resident education, the introduction of computerized medical records, and the development of a novel teaching hospitalist program that received national recognition. Dr. Mazur also participated in the founding of the Norwalk Community Health Center in 1994, serving on its medical staff and on its Board of Directors from its inception until 2005.

From 2005 to 2009, Dr. Mazur served as the elected representative of Connecticut’s internal medicine physician community as Governor of the Connecticut Chapter of the American College of Physicians (ACP). As ACP Governor, Dr. Mazur was very involved in political advocacy, annually visiting Washington, D.C. to lobby on behalf of primary care, internal medicine, and healthcare reform. For these activities, he received the “Top 10 Key Contact Special Recognition Award” from the ACP in 2005.

Since 2002, Dr. Mazur has served as co-host of “Health Talk”, Optimum TV’s nightly “Local Programming” television show that provides health education for much of lower Fairfield County. During the past 15 years, he has hosted over 575 half hour ”Health Talk” episodes, covering subjects from bunions to pet therapy to cancer research. He has also been a frequently requested guest for local television news and health programs and a popular invited speaker for local community organizations.

Born and raised in Fairfield Connecticut, Dr. Eric Mazur was graduated Phi Beta Kappa and summa cum laude from Princeton University in 1971 with a B.S.E. degree in aerospace and mechanical sciences. In 1975, he was graduated Alpha Omega Alpha from the Johns Hopkins University School of Medicine with an M.D. He completed his first two years of internal medicine residency at the Strong Memorial Hospital, University of Rochester and returned to Connecticut in 1977, completing his internal medicine residency and a hematology/oncology fellowship in 1981 at Yale University. Dr. Mazur spent the first part of his career as Chief of Hematology/Oncology at Miriam Hospital and on the full time medical school faculty of Brown University in Providence RI. At Brown and Miriam Hospital, he developed an active clinical and academic hematology/oncology section and also led a scientific research laboratory that created novel test tube models for studying human blood platelet production. Dr. Mazur has published over 45 scientific papers and his research has been presented both nationally and internationally. He moved to Norwalk Hospital in 1995 where he worked in senior leadership for 20 years. He is currently an Associate Professor of Clinical Medicine at the Yale University School of Medicine.

Dr. Mazur lives in Weston, CT with his wife Abby. They have two grown sons, two granddaughters, and twin grandsons.   Dr. Mazur’s first love is his family but he also enjoys reading fiction, snow skiing, hiking, scuba diving, international travel, languages, digital photography and technology.


Recent Comments by Dr. Mazur

    No comments by Dr. Mazur yet.