Today, patient advocacy, as a viable means to improving the welfare of our society, finds itself in a rather precarious state, fought at high pitch in the pain-filled and bloody trenches of the emergency rooms and operating rooms of hospitals all over the country. Physicians' advocacy, meanwhile, can be likened to white-collar warfare-though ironically fought in the pristine halls of justice or the sterile offices of HMOs and insurance companies. Through some perverse twist, as we enter the second millennium, the practice of medicine has been turned on its head.

How can this have occurred? Our century has been witness to the marvelous advance of medical treatment, from Salk's polio vaccine to Bamard's heart transplant. We lifted the curse of tuberculosis and have seen babies come into this world through in-vitro fertilization. Scientists and physicians have worked hand in hand to develop thousands of treatments, surgical techniques, and pharmaceutical therapies to relieve the most intense pain, cure the incurable, and salvage the unsalvageable.

And yet, we witness so many in our society failing through the cracks of a system that allows teenagers to die on the doorsteps of a hospital emergency room due to a hospital's fear of liability and children to be born of a mother virulently addicted to crack.

Physicians, too, fall prey to onerous burdens on their ability to perform professionally. Our hands are often tied by regulatory measures, our practices pulled under by the weight of malpractice premiums and reduced fees.

Patients suffer. Physicians suffer. And the business of medicine rends asunder the precious and intimate relationship between doctor and patient-without which illness cannot be properly understood.

For as long as men and women have lived, the healing arts have been held sacred. Whether one speaks of a medicine man, a shaman or a country doctor, the paradigm of medicine rests on the unique blend of compassion and knowledge.

Consider the dynamic interplay at work and a revealing truth becomes clear. It is not knowledge that heals, for knowledge may be used for positive or negative ends. In the healing arts, the spark that sets knowledge into motion is compassion.

As physicians, we must show compassion even in the best-case scenarios. In the worst case scenario, when all else fails, the only answer is compassion. But the ability to feel empathy, the ability to step into another person's pain, is neither appealing nor easily accomplished. So we are taught to measure out our compassion with a healthy amount of emotional detachment. As physicians, it is thought, we must preserve ourselves first and foremost before we can assist others. But in my 43 years of medical practice I can say, without a flicker of a doubt in my mind, that the level of compassion in medicine has deteriorated to such a point that we now face what can only be called an all-encompassing professional identity crisis.

Let me pause now to consider the cause of the crisis. Technology, with all its refined elegance and advanced precision, allows physicians to diagnose patients so quickly and execute therapy so rapidly that time spent with Mr. John Doe is summarily reduced to time spent with the Bypass in room 1348. There are other barriers to doctor/patient intimacy, such as highly compacted schedules. And one cannot ignore the fact that some physicians simply lack bedside manner. But I believe that to a greater or lesser extent most of us chose medicine over other careers because it offered unrivaled humanitarian rewards.

So why, in the name of Hippocrates, do we not feel the way we used to about medicine? This is not a rhetorical question. It has answers. Hard answers that require hard solutions in today's socioeconomic order.

Doctors have been stripped by the new business of medicine, which claims to be more inclusive, but is not-which claims to save money, but does so by fattening the cow at the expense of the calf. More than ever, medicine is business. We all know it and we know that patient care is suffering as a result. We know that our professionalism is being threatened by the straitjackets insurance companies and HMOs have put us in.

And yet daily we hear of more and more cutbacks in care. If there is such a shortage of resources in this country that insurance companies are dictating reduced patient care policies, where is all the money coming from to finance their skyscrapers in New York or their corporate Lear jets or their massive TV ad campaigns?

Who is paying the price? Doctors and patients. Factor in malpractice and attorney fees and the picture is crystal clear. It's a brave new world and the word compassion no longer exists in the medical lexicon.

And so we must fight. We must unite in defiance against the trend toward the dehumanization of the patient. For in a slow and creeping way, that is what we are edging toward.

The system contradicts everything we've been taught and everything we pledge to commit ourselves to. And the paradox is that we continue to practice at the risk of losing our livelihood, in the midst of reduced earnings and at the risk of being cooped by these malignant forces.

I love the practice of medicine. I love caring for patients. I love the process of taking histories, of looking a patient in the eye and registering an emotionally alive, real life individual. I love listening through a stethoscope. I love surgery. I love healing. And, when I find myself with a patient who cannot heal, I cherish the fact that I can offer that person a caring, supportive, sympathetic and compassionate emotional alliance. It is my duty, but it is also my greatest reward, and I cringe at how my ability and willingness to be the doctor that I can be is being pulled out from under my feet.

I am reminded of the adage "think globally, act locally." For it is through this society of ours that we can put into focus these and other issues facing the art and science of health care.

The state of medicine today is not at risk because of any real dearth of capital or resources. It is at risk because of overzealous and unmitigated capitalistic management strategies. I am not arguing for a welfare state or socialized medicine, rather I am arguing for a state that fares well and medicates in a socially responsible manner.

It is said that you can measure the moral fiber of a society by how they treat their worst criminals. I believe that the same can be said for how a society treats its ill, it's downtrodden its disenfranchised. On that score we can do much better.

So, let us think globally and act locally to make our voices heard. To enable us to serve - to do no harm - and to fight for preserving the dignity of human life.

I am reminded of an old Persian adage, uttered by an elder of the community who, looking back on his life said: "When I was young, the trait that I revered most in a person was cleverness. Now, that I am older and wiser, I find that compassion is what I value most highly."