The following was a talk given to the Lackawanna County (Pennsylvania) Medical Society on the occasion of receipt of the annual President's Recognition Award.
A survey of physician attitudes conducted by the Physician's
Foundation and completed in September,
2012 received over 13,000 responses from practicing physicians and revealed the
following results: Over three quarters of physicians – 77.4 percent – are somewhat
pessimistic or very pessimistic about the future of the medical profession.
Over 84 percent of physicians agree that the medical profession is in decline.
The majority of physicians – 57.9 percent -- would not recommend medicine as a
career to their children or other young people.[1]
When I was a kid in the 40's my mother took me to our family
doctor who had a nice home on Jefferson
Avenue, which is still there, with his office attached and his name hanging on
a sign outside. That was the common arrangement in those days. One thing that would strike the modern
person if he went to one of those doctors is that when you went in the only one
there was the doctor. There was no
receptionist or business office or file
room or ancillary personnel. And definitely no practice manager. You waited your turn in the waiting room till
he called you in. He knew you and your
family pretty well. When you left you
paid the bill and most people could afford it since in those uncomplicated days
overhead expenses were next to
nothing. For those who couldn’t afford
it customarily there was little or no charge. These doctors stood out in the
community and were pretty well respected.
They proudly displayed their profession, customarily attaching a small
metal insignia with a caduceus to their car license plate. There was a large
contingent from my medical school class who were physician's children. This was
sort of my model when I decided in the 50's to get into pre-med.
I did my training in the pre-Medicare days when the
hospitals had a private service and a ward service. Patients who couldn't pay
the private fee were treated in open 30 bed wards by us doctors in training.
There were some good aspects to that system and some bad. But during my
residency Medicare came along and the
ungrateful seniors made their choice. They abandoned us to the private
hospitals and semi-private rooms and experienced doctors leaving us with the
skid row alcoholics and drug addicts.
So flash forward to today.
Medical care in the past involved two parties, patient and doctor. Now
we have a system whose economics are dominated by third parties who are outside
that relationship, and these third parties include government and insurance
companies and large medical organizations which are being progressively
transformed into health care managers and which are increasingly working in
conjunction with each other. Our political leaders weren't happy with the system that existed in my training days but what we've got today
hasn't turned out to be so hot either. People on both sides of the political
spectrum think that our present system
is sick and I heartily agree. There are a tremendous number of symptoms of this
illness but I thought I'd just pick out a couple to mention.
Instead of a simple fee paid at the door we now have an
incredibly detailed, complicated system for calculating how we bill and receive
payment from the third parties. Everything must be documented in detail to
justify the amount of the fee to the third party payer . And document it we do
because in such a system small changes
in what is recorded can make a big difference in the amount of payment. It's becoming increasingly clear that a major
selling point to doctors for electronic medical records is the automation of
documentation for enhancement of level of service.
Here's another one. We all now get 2 or 3 faxes every day
from the patient's insurance company or
drug plan advising us that they've
noticed that our patient has such and such a diagnosis but is not on such and
such a recommended protocol . Of course they're no longer insurance companies,
they're health plans and they're supposed to look at their computers and
oversee what we're doing. I'm beginning
to ask myself why I bother with reading all these journals and going to all
these medical meetings. I just have to
label the patient with a diagnosis and follow the protocol that pops up on the
computer screen. If I don’t do it right the patient's insurance company will
set me straight again.
As much as I dislike these intrusions I'm still doing
medical practice well past ordinary retirement age just like those old time
doctors. Something happened recently that reminded me why. I received my
application from the state for my medical license renewal and there was the usual demographic
section. And I came to a question
something like whether if I could do it over if I would still choose medical
practice and struggle mentally as I might I had to answer yes - which took
me back a bit because there's so much of it that I dislike intensely. Then
followed a multiple choice question listing possible reasons why I might be
satisfied and of course the answer was the relationship with my patients.
I think that, besides
the clergy, medicine is the ultimate personal occupation. People come to us
sick or worried and invest us with a level of confidence that they give to few
others, even their friends and family. To us it's sometimes all in a day's
work, but it shouldn't be. We have the capacity to turn their lives around, to
reassure them when they're worried, to advocate for them, to counsel them in
ways that they will accept from no one else, and at the very least when worst comes to worst
to console them. Some who come to you
don't care for the way you do things and they leave but for the many that
remain, as the years go by a remarkable relationship forms. I learned about
this in a very personal way when I recently underwent heart valve surgery. The
outpouring of concern, well wishes, phone calls, mass cards and gifts from
patients, some of whom had been coming to me for 25 or 30 years, touched me
deeply.
Modern medical practice is increasingly able to prevent,
diagnose and treat illness. But at the same time too much of our activity is
spent attending to the demands of third parties. Medical practice has gotten
too complicated and there is too much unnecessary overhead. Too many computers
and coders and billers and record clerks and documentation and
pre-authorization and primary and secondary coverage and on and on. Medical records are becoming more and more
for the purpose of documentation for third parties and less and less for
communication of information to ourselves and our colleagues and in fact
because of the conflicting purpose, the communication function of medical
records is continuing to deteriorate badly. The real problem about all of this
is not the hassle factor. The deeply troubling thing is that the need to
perform activities required by the third parties and to meet ever-increasing
overhead expenses is cutting into our fundamental purpose, that is to spend
time with our patients. Talk to any
patient. Our taking time with them is what they value most.
More troubling to me than that however are the efforts by
third party regulators and planners to continue to reorganize medical practice.
In other words what has been done already isn't bad enough. In this view we are
part of an overall system, managers of the patient's health, following
protocols and guidelines to assure uniformity and economy, and of course we are to be managed as
well. One begins to get the ominous
feeling that the usually off-base notices from the health care plans might take
a mandatory tone and that our EMR's might start presenting us with treatment
protocols that cannot be declined.
But being part of a system that manages the health of a
group of patients is not the way I view what we do. Medical practice is a
service relationship that starts with an individual with a unique medical
concern. Each one of us has attained a
certain body of knowledge and what we do is to take that knowledge base,
modified by our experience, and we use
the resources available to us and our colleagues in our community and
apply it to the problem of that individual person sitting in front of us who
comes to us seeking help and advice. We're
not there to fix society, or to worry about the financial condition of the
government or anything other than the interests of that person. Unless that is our attitude I believe that
the ethical and moral foundation of our profession will be lost. I don't really
believe that the third parties are ill-intentioned but at the same time their
interests do not always coincide with that fundamental relationship between the patient and the
doctor. And I believe that the primary
role of organized medicine should be to protect that relationship and in doing
so it is protecting the interests of the doctors in the most fundamental way.
The third party bureaucracy and health care planners are
never going to change course of their own volition. If things continue as they
are going the practice of medicine is in for some tough times. Some think the
cure for our sick system is just for the government to take over everything but
to my mind that treatment would amount to sending the patient to the hospice
unit. This approach would leave us in the
hands of the most oppressive third party of all. I believe that the only
real answer to this situation is to do what Timothy Leary used to say back in
the '60's, that is to TURN ON, TUNE IN and DROP OUT. There is a tiny but growing movement of physicians who have
become frustrated with the system and
are doing just that, dropping out from
government plans and insurance, and this has been going on especially in the
large urban and rural areas. That could be the beginning of a movement or just
a flash in the pan. I suspect that it's going to spread because it's pretty
clear that doctors are in for a future of increasing overhead costs, decreasing
reimbursements and increasing outside
interference with medical practice.
The real key is whether
patients will drop out too and I
am encouraged in this regard by the rapid growth in the use of health savings
accounts in the last few years. If more patients begin to have high deductable
insurance and pay ordinary expenses out of pocket, doctors and medical facilities with low
overhead who post their fees and give more personal attention will be
more attractive. I belong to a medical association one of whose activities is
to help physicians to develop successful
practices free of insurance and government and those who do it report
that they are making a respectable living and enjoying practice much more and
that their patients like it more too. If I were 40 or 45 again in the present
practice environment I would be very tempted to try it. Who knows. In due time, I just might.
[1] http://www.physiciansfoundation.org/healthcare-research/a-survey-of-americas-physicians-practice-patterns-and-perspectives
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