Our doctors are changing.
Most of them have become warier and more competitive. They are under many new pressures, and they are often frustrated and angry.
Until about the 1960s, says Dr. Richard Rada, president of the Academy of Psychosomatic Medicine, doctors basked in a "golden age" when fee-for-service medicine reigned, their advice was rarely questioned and they had "an almost priestly function." "We were lords of all we surveyed," another doctor has said.
No more. Doctors have been propelled by economic juggernauts beyond their control from the virtually unfettered individual decision-making they once enjoyed into new corporate and organizational realms where others control them.
This is just one of many important changes in the way doctors practice medicine in America. Other forces also are moving medicine, some of them in opposing directions.
Doctors have new tools -- CAT scans, body probes, new operations, clever drugs -- that make them better healers. They are becoming divided into more and more super-specialties to handle these tools. At the same time, many are becoming more aware of the need to meld technology and humanity, to treat the whole person, not just a back or belly, and to teach wellness as well as treat sickness.
After years in which the fee-paying government and generous health insurors have rewarded many doctors munificently, at least some doctors -- often younger ones and women -- are turning their backs on working 80-hour weeks and piling up cash. Searching for a balance between career and family, they are willing to work for a health plan that pays them for a shorter work week, and promises a decent pension.
Still, the new health plans and cost controls -- the consequences of a generation of escalating health costs -- are proliferating. They are influencing the best intentioned doctors.
Why should patients care? The danger, say many concerned observers, is that despite many individuals' valiant efforts, medicine is increasingly changing from a caring to a business-minded enterprise.
The business ethic has of course always coexisted and clashed with the medical ethic, but a new struggle for economic survival may decide the battle in favor of business. "In 1985 the practice of medicine became a race, one fraught with growing competition and filled with expanding obstacles," the American Medical Association's American Medical News said this January.
Doctors are increasingly joining HMOs, health maintenance organizations, where patients get all their care, or IPAs, independent practice associations, where the doctors see the plan's patients in their own offices but the plan sets their pay, or a host of related plans.
These plans must operate frugally to compete, and government and health insurors also must control costs. So doctors are pressured to get patients out of the hospital fast, and to use hospitals sparingly. Insurors and health plans increasingly require "preadmission certification" -- meaning approval -- in all but emergencies. Health plans use their primary care doctors as "gatekeepers," meaning the plan will not pay for specialist care unless the gatekeeper approves.
More plans are being sponsored or bought by for-profit corporations. To compete, nonprofit plans act more and more like the for-profits, holding down costs and spurring their doctors' "productivity," often by financial incentives or penalties to "encourage" their seeing more patients per day.
"Productivity" was the issue in last month's 25-day doctor strike against Washington's Group Health Association. Some doctors, like GHA's, have formed unions. The number could grow. One labor negotiator warns doctors that unless they organize to deal with hospitals and health "wholesalers" -- expanding national corporations -- they will be treated as "tradesmen."
Doctors still in private practice are "marketing." Some advertise, some hire publicity agents to spread their names. Many more are sending patients newsletters; moving offices and expanding hours for patients' convenience; reconsidering their prices; thinking generally about how to please patients.
This "new medical marketplace," a phrase often heard, may be good for patients in many ways. Doctors who want to attract patients may listen to them more closely than doctors who already have so many that they dart from one to the other, cutting off questions by their curt demeanor. Patients may also welcome controls on doctors' fees.
True, doctors still average (by 1984 figures) a $108,000 net income. But will doctors whose fees are cut try to see more patients than ever?
The competition may be intensified by a growing number of doctors. Unless there is expansion in the way we use doctors -- perhaps by employing these fresh MDs to give the poor and uninsured better care -- the new numbers may only mean future care by lower-paid clock-watchers at super-efficient health plans, able to hire all the MDs they please.
Being a doctor has never been easy. Despite medicine's advances, doctors still have to guess much of the time, and are often helpless in the face of disease and death. None of us likes to face death. Doctors face it constantly and often see in it their own failure.
Some cope by becoming calloused and cold or, almost worse, developing a hearty false bravado and heavy humor. Some take their patients' tragedies so seriously that they have little hope left to offer their patients who need hope. Some drink or sneak pills.
The best achieve a kind of balance, warm enough to care, detached enough to think.
Will the doctor at his or her best, the patient's protector, remain the same under the pressures of new rules, curbs and restraints, multiplying technologies and the unnerving threat of malpractice suits?
Dr. James Todd, AMA senior deputy executive vice president, has suggested a prescription for these problems -- and a forecast. He believes doctors will stubbornly resist pressures preventing them from giving their patients competent and compassionate care with open communication, and that they will make "selfless patient advocacy" their unceasing job.
May the prescription take.