"Nine out of ten doctors would not recommend anyone go into medicine today," the headline of an online news post read.
An article in Forbes Magazine last month cited the selfless dedication physicians bring to the practice of medicine caring only for the well being of their patients. Both statements are gross exaggerations. While many doctors are unhappy with the changes in medical practice they are not retiring in droves, and while most doctors care a great deal for their patients there are also those who care more about their compensation. Certainly more of the older generation of practitioners, my generation of physicians, have been stunned by the changes that have occurred over the past 25 years in the delivery of health care, but also by the loss of a sense of power doctors once had. The axis of physician, nurse, patient is now a mosaic which includes many other "providers" not anticipated twenty years ago.
One of the first changes was to remove the doctor from his pinnacle by calling him (his/him will stand for both genders in the interest of brevity) a "health care provider." Thus, medical care deliverers became like Dr. Pepper drinkers, "I'm a Pepper, she's a Pepper, wouldn't you like to be a Pepper too?" We groused about it but only a few of us saw the dark clouds on the western horizon, managed care was approaching. Up until that time the community hospital was basically a doctor's club complete with private dining room. As care became more complicated and sophisticated - intensive care units and CAT scans did not exist in the 1960s when I was an intern and resident - the hospital became more of an independent institution that could serve patients with its own staff to service physician referrals.
In time, the hospital and the physicians on staff found themselves
competing with each other, the hospital was no longer a doctor's club.
This, I admit, is a quick summary of a complicated vector of many
forces, economic ones being the greatest driver. And the economics are
not only the cost of medical care from doctor's office to laboratory, to
hospital care to medical equipment and pharmaceuticals, but for the
shareholders of for profit medical systems. Does it make sense that
insurers of managed care (care is spelled C O S T ) pay dividends to
investors while restricting care to subscribers?
The best summary and description of what has happened to the practice
of medicine and the delivery of health care over the past 50 years can
be found in The Pharos, the publication of AOA, the medical honor
society, Winter 2014 issue. J.Joseph Marr M.D. a retired academic
physician who also graduated from medical school 50 years ago next
month, gives a sober and thorough description of the evolution of
medical care in 2014. The amount spent on health care in the U.S.A.
exceeds that of any other country without superior outcomes resulting.
Something has had to change. I believe fee for service medical care is
probably going to be on the way out in the next decade. There will
always be boutique doctors who don't need a hospital for their patients,
cosmetic surgeons who can do office procedures that don't require over
night stays, psychiatrists, physiatrists and radiologists, for example,
but most others will be in a system of some sort that will carry the
overhead expenses, pay the malpractice premiums, hire the nurses and
physician assistants, and pay the doctor a decent salary. The time spent
with patients will be restricted; one colleague is going to leave a
group that bought his practice because a nurse knocks on his door
relentlessly if he spends more than 20 minutes with a patient who does
not have an emergency. When you are admitted to a hospital on an
emergency (non-elective) basis, you will be seen by an emergency
medicine specialist who will perhaps send you to an intensivist
(intensive care specialist) who, after getting your condition stabilized
will pass you on to a hospitalist (someone who works the floors of the
hospital as a hospital employee) and he may go off shift (12 hours/day
3days in a row) and hand you off to another hospitalist, and at some
point you are an electronic record because no one knows who you were or
how you were before entering the hospital.
If you have a primary care physician, he may come to say hello and
even offer recommendations to the hospital docs, but he doesn't have to.
Thus, the touching portraits of the family doctor at the bedside in the
home of a sick patient will be something to be seen at the Norman
Rockwell museum in Stockbridge, Massachusetts and the old model of the
doctor patient relationship may belong in the museum too. Perhaps that
is where we are headed in general. My adult children read the news on
their cell phones, text their friends rather than call them, and are
content with a different quality of doctor patient relationship. They
look to the web as much as to me for information and neither has a
single primary care doc he turns to for advice. With all of that said, I
have always enjoyed being a doctor and if I were just to be starting
out now I would be participating in the system as it has evolved not
lamenting the loss of what was, and humoring the old fogeys who want to
talk about how it was way back when.
