We are a commune of inquiring, skeptical, politically centrist, capitalist, anglophile, traditionalist New England Yankee humans, humanoids, and animals with many interests beyond and above politics. Each of us has had a high-school education (or GED), but all had ADD so didn't pay attention very well, especially the dogs. Each one of us does "try my best to be just like I am," and none of us enjoys working for others, including for Maggie, from whom we receive neither a nickel nor a dime. Freedom from nags, cranks, government, do-gooders, control-freaks and idiots is all that we ask for.
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Wednesday, March 14. 2007
"Providers" or Physicians?
Stumbling and Mumbling takes a look at Dalrymple's piece on The Proletarianization of Doctors.
Indeed, the de-professionalization of physicians is happening all over the US, and not just in countries with socialized medicine. I most recently became disturbed by this when I was told that docs in a certain charity clinic that I am familiar with have been asked to punch time clocks when they come on duty.
Of course, it's all about money and power. When physicians become employees with no independent function as professionals, they can begin to lose their identity as professionals. It already happened to public school teachers when they unionized, but docs, being generally made of sterner stuff, do not fold so easily.
Fact is, this charity clinic I refer to (which has family practice/general practice, OG/GYN, dental, and psychiatric staff) is staffed by docs who want to sacrifice some of their time to the poor, but they have been told that if they all were to quit, they would be replaced overnight with docs from India and Pakistan who would not view the job as charity at all, and who have a different view of medicine that the traditional American view.
Money and power. It all began in the US when hospitals began to be run by managers instead of by doctors, in the 1970s. Hospital boards with an eye on the bottom line wanted compliant employees instead of cranky, demanding, patient-devoted docs running things.
We should have seen it coming when insurance companies replaced the line for "physician" with a line for "provider." Provider? I am no provider. As a psychoanalyst and psychiatrist, I am quite the opposite: I am a demander, if anything. A demanding friend, whose time is worth a lot. Not a caretaker or care-giver, most of the time.
And that is why I am willing to be paid to teach, but am not willing to be paid to work by anyone other than my patients. Medicine is a fraternity/sorority, and a guild, and a priesthood with daunting responsibilities which extend far beyond the technicalities of medicine into the realms of friendship, love, the soul and the spirit. If that doesn't matter to people, they will live to regret it.
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My ob/gyn said very much the same thing way back in those same 70's re HMOs . . . The doc is working not for you but for the organization, and that destroys the relationship.
What are your thoughts on standards of care? Organizations will exist for economic reasons, but patients may benefit (if not in terms of quality, perhaps cost and access) to care that is regulated across an organization. I know one of the opportunities afforded to practices and groups which "go electronic" and embark on computerized order entry and electronic documentation is the ability to track care given, and so better understand how medicine is practiced. In a sense, this also violates the paternal archetype of physicians, but if patients benefit, let alone if there is a market for that type of care, isn't that where things are going?
To have beancounters dictate medicine is a disturbing thought, but I like to think (I'm biased because this is my job) IT properly applied can empower good doctors (and spread their good care) and hedge/protect against the bad. I'm not sure what derisive terms await those who work in healthcare IT, but I can't think of anything worse than beancounters.
The problem is that, apart from the filthy rich, nobody can afford to pay a psychiatrist what they are worth. So insurance companies are going to be involved, whether we like it or not. I take it you would not consider it ethical to only treat the super-rich and those destitute clinic types you treat for free as many hours as you can afford? The middle class need and deserve good shrinks too, and should not have to choose between a child's education and their own life-saving treatment. Or the child's.
Speaking for my own screwed up family, the only ones who have survived the famly insanity still able to love and work are those who have had years of hideously expensive therapy with psychiatrists. Worth every penny. Although I know that there are not enough psychiatrists to do this, and that it is only the fortunate few who can get the best care, it is my experience that splitting off the person who prescribes from the therapist is a big mistake. Also, I have little use for the quickie cognitive behavioral group therapies beloved by insurance companies. Cure a person who has been depressed their whole life with some bullying to abandon negative thinking? I think not...
Still, grownups who are motivated can usually find a good shrink and work a second job to pay to see one, but it is the devil's own torture trying to find a decent child psychiatrist. Or to be able to get the kid to see him or her more than once every three months once one finds one...Too few of them. Just as there are too few child psychiatric beds in hospitals... And as for a therapist who even understands a kid with multiple diagnoses...one ends up settling for someone kind who cares about the child but who is basically clueless about biology and diagnosis.
Take a random Sunday School teacher in my church and I would venture that they understand my sick kid better than his psychologist of many years. Because the former understand his faith...
It all comes down to how much do we think it is worth to redeem an individual life? There are those who would look at my relatives and say we are too expensive a family, not worth it. Then again, read some of the stuff we write when not ill or hear us teaching or public speaking or rounding up investors for a new factory or starting a new business and one might decide that perhaps some of the money may not have been wasted...
Even though anonymous, retriever, the honesty in your writing is humbling and moves my heart.
Yes, Dr and patient is a personal relationship, not a service contract.
I think the role of IT in medicine is overrated. It can be handy, but it is not transforming.
Kids with complex problems: After many years of research and many millions spent, still little understood, with only band-aid fixes. That is not likely to change. We can impact chemistry a bit, but not the hard wiring. I know what it's like, R: best friend's son.
A few weeks ago I took a stab at the subject of American medical care, and the relationship between patient and physician, "Providers or Physicians?"I recently stumbled upon a better piece on the same subject by Dr. Bob in which he explains that
Tracked: Mar 28, 13:27