By Ronald J. Glasser
Sunday, May 31, 2009
A few decades ago, the biggest problem in medicine was diagnosis. Is that a heart attack or heartburn? The beginnings of dementia or a stroke? Is the tumor benign or malignant? Medical technology has changed all that. The biggest problem in medicine today is not determining what's wrong with you. It's knowing whom to call at 2 a.m. -- other than 911 -- when something happens. And the nasty little secret is not that your doctor is no longer available, but that he or she is no longer in charge.
Of the 15,000 students who will graduate from medical school this year -- and the roughly 8,000 physicians and surgeons who will finish their specialty training -- more than 93 percent will become employees of large clinics, managed-care companies or hospital systems.
These physicians, as I have seen in my own practice in Minneapolis, are no longer patient advocates. In many ways, they've abandoned the patient to the work rules of health plans and the professional demands of managed care. The Hippocratic Oath has been discarded, and the Golden Rule has become: He who has the gold sets the rules.
What this means is that the care you get -- and how long you get it -- is only the care your health plan will reimburse your doctor for. You can see your psychiatrist or psychologist for five visits; you can stay in the hospital for 48 hours following a hip replacement, or three days after a radical prostatectomy. Simple mastectomies go home the same day, and gall-bladder removals as soon as they wake up from the anesthesia. If the drug prescribed is not on your health plan's list, then your doctor will have to prescribe an approved alternative that may not be as effective.
This kind of care is simply unsustainable. It's not just the enormous amount of money we already spend on health care or the fact that 45 million Americans are uninsured. America is also graying -- by 2015 there will be more 80-year-olds than children under 8 -- and the elderly need more -- and more personalized -- care. People respond differently to treatment, and it must be tailored to the individual patient. Our current depersonalized, disease-based system is not only dangerous but also dysfunctional. And any dysfunctional system will eventually fail. It happened to the financial system, and it will happen in medicine.
From the end of World War II until the mid-1980s, the average medical or surgical group in the United States was made up of three to five physicians. They ran their practice as a privately held company, treating patients, sending out the bills, setting fees and organizing night-call and weekend coverage while deciding how much charity care they would also provide.
The focus was on maintaining good relationships with patients. Doctors cultivated a trusted bedside manner to maintain referrals and their colleagues' respect. The physicians in a small practice knew one another's patients. When someone called after hours, the answering physician would be able to respond to any questions and give realistic suggestions.
I care for a number of spina bifida patients along with another physician. These children have complex problems that include a malfunctioning central nervous system, orthopedic problems, difficulty breathing and recurrent bladder infections. If I didn't know these patients, all I could do if they called after hours would be to send them to the nearest emergency room, where they would sit for hours while someone else who didn't know them tried to figure out what was wrong.
But personal knowledge and concern have evaporated in the world of employee-physicians, replaced by cookie-cutter best-practice guidelines and rules on prescribing drugs, acceptable lengths of hospital stays and the number of clinic patients a doctor must see per hour.
And why not? Everyone in medicine knows that these are no longer the physician's patients. They belong to the insurance companies, the health plans, the hospitals. With that understanding comes personal indifference and professional exhaustion. Today, it's the rare physician who gives a patient his or her private office phone number, something that was almost universal when I first went into practice. Nowadays, if you want to talk to your doctor, you go through the office coordinator or the nurse associate.
The new tsunami in employed physicians has also led to something quite new in the medical profession -- the part-time doctor. According to a recent survey of one of Minneapolis's largest medical clinics, more than 50 percent of the doctors in the pediatrics and family practice departments and more than 70 percent in the ob/gyn department were working part time.
This is great for the employer, who doesn't have to provide retirement or health care benefits. But as a medical organization, you do best not to mention your part-timers to the patients. When I talk to one of these physicians, I'm reminded of what a professor of mine at Johns Hopkins medical school in the 1960s said when one student complained about having to be on the wards every other night. The professor offered a quote he told us was from the pianist Arthur Rubinstein: "When I don't practice one day, I can tell the difference. When I don't practice two days, my wife can tell the difference. When I don't practice three days, anyone can tell the difference."
Thank goodness for technology, which has saved both patients and medicine. MRIs, CAT scans, ultrasounds, pulmonary function tests, angiography, PSA testing, mammograms, molecular genetics, needle biopsy specimens -- all these have reduced the chance of error. But they also offer professional cover to physicians who know little about a given patient apart from that person's array of symptoms.
Why have we witnessed a shift from independent medical practitioner to employee? The accepted reason is the steady growth of managed health care since the late 1970s. Thousands of small-group practices, faced with one or two dominant health plans in a city or geographic area, have been forced to merge to cut better deals on reimbursements. But the shift also appears to be generational. Consciously or unconsciously, we have raised a generation that views the medical profession in economic terms, as a career rather than as a calling.
Not long ago, a senior member of one of the Twin Cities' largest gastroenterology groups confided to me that no one in the group over the age of 55 could tolerate being part of the search committee hiring new physicians. "It isn't like it used to be when you and I were looking to be hired a few decades ago," he said. "We were dutiful and respectful and excited to even be offered a job. . . . Now, it's, 'When will I be completely vested in the retirement plan?' 'I can't work a full day on Friday because the kids play football or soccer on Friday night.' 'I don't want to be on call more than twice a month. And if I do work here, I would like a signing bonus to cover the expenses to move here and the time it would take me to get up to speed.' "
Similarly, Claus Pierach, a professor of medicine who serves on the admissions committee at the University of Minnesota Medical School recently told me that the committee had begun to notice something new a few years ago. When asked "Why do you want to be a doctor?", most applicants still answered as expected: "Because I want to help people." But every so often, a candidate would reply that the reason was "job security."
At first, the committee bristled at this answer. But now members have grown used to hearing it. It is a frequent and unembarrassed response, usually accompanied by the stated desire to go into one of the more lucrative procedure- or diagnostic-based areas of medicine: radiology, dermatology, orthopedics or cardiology. A good income and more desirable lifestyle matter more than the type of patient the doctor might see. Taking care of the needy is no longer on anyone's radar screen. When the administration of a large Minneapolis medical clinic surveyed its 600 doctors this year about whether they'd be willing to work more hours, most said no. When asked whether they would work more hours for more pay, they still said no.
One result of this new attitude is that fellowship slots in the country's leading geriatric training programs are increasingly going unfilled, and some of these programs are closing. U.S. medical school deans admit that students no longer plan to go into such primary-care specialties as pediatrics or family practice and are not interested in caring for the elderly, because the major insurers won't pay for the personal involvement and time that primary-care specialties demand.
Troublingly, medical school professors have helped push the shift to physicians as employees. They've dismissed the concept of a small group practice as unworkable. On the wards and in the clinics, they emphasize the "team player." Medical schools now have mandatory courses on getting along in large group practices. Individual or small practices are dismissed as too complicated and too expensive to run. Large-group-, clinic- or hospital-based employment is presented as the only realistic post-graduate option.
Perhaps we can't go back to the two- or four-physician group practice. But medical school faculties can quit carrying the water for the managed-care companies and the large hospital systems. Our current medical system is out of whack. And those of us who see the edge of the cliff approaching should begin to warn publicly that medicine cannot survive if its real value -- its capacity both to comfort and to heal -- is replaced only by the superficial value of price.
Ronald J. Glasser practices nephrology and is writing a book on medicine and the baby boom generation.