When Donald Mitchell's grandfather and great-grandfather practiced medicine, they did it in the time-honored wayof American pysician. They worked by themselves, for themselves, answering to no man or woman other than their patients.
Mitchell followed in their footsteps, becoming a dermatologist. But there are significant difference in the way he practices. Donald Mitchell is an employe, working for a prepaid group practice. He is also a memeber of a labor union. He has a long way from the solo, self-employed practice of his forebears.
A generation ago, Mitchell would have been a medical oddity - a lonely exception to the venerated tradition of the American physician as small-time - and occasionally big-time - entrepreneur. Self-employment - the ability to be your own boss - was one of the main attractions of medicine in those days. Medicine was a refuge from the depersonalizing anonymity of corporations and other institutions.
But the practice of medicine, like everything else, is changing rapidly. No one can say how many doctors now work as employes, but a number of authorities - including the American Medical Association - say numbers and percentages are growing.
Shifting from self-employment to employed status solves some pressing problems. But as Mitchell and others make clear, the employed physician has difficulties that the doctor who is his (or her) own boss does not.
The evidence is a long way from certain on whether doctors are better off working as employes, but Mitchell, at least, thinks he sees the future. "I think group practice is the coming thing," Mitchell said. "Group practice is just the way medicine is going to go."
About 60 per cent of physician fees now are paid by some form of health insurance. Insurance means paperwork, and that means someone has to fill out forms. "Doctors in private practice are being deluged with paperwork," Mitchell said.But he is not. Mitchell works for the Group Health Association, one of three prepaid group health plans in the Washington area.
"I don't have to worry about whether a patient can afford to see me or not," Mitchell said. "Money never crosses my mind." He has no forms to fill out, no bills collect, no personnel problems to worry about.
"It's a very pleasant way to practice medicine. I don't have the headaches of having to employ the staff. I get to see whether the nurse doesn't show up, I just call and they send another one."
In contrast, Mitchell said, commercial insurance plans have defined average amounts of billing that a patient will generate for a physician. "If you exceed that," he said, "they come out and look at your books and give you warnings. They tell you they're going to out you off and all that sort of stuff. This is driving physicians in private mractice up the wall. It's going to be morse."
practing in a group has drawbacks. Doctors working as employes find they have all the problems of employes, plus they may find employers asking them to perform in a way that conflicts with their professional judgement.
In January, after making other unsuccessful attempts to develop a comfortable relationship with GHA, the group's physicians voted to form a labor union, which is now negotiating its first contract with GHA. Mitchell and other members of the Group Health Association Physicians Association, as the union is called, said they are not bothered by the notion of joining a union.
Mitchell said the public has a misconception about physicians. "They have wives and children like everyone else," he said. "They go to the bathroom like everyone else. I don't think they're any more avaricious than anyone else. I don't think they're any better than anyone else."
GHA's physicians formerly had a medical council which was given a budget to hire and pay physicians inside the organization and to contract with physicians outside for certain services. The council had substantial control over working conditions for the physicians at GHA.
Rhe council was disbanded after the National Labor Relations Board informed GHA that it was illegal.
In absence of a medical organization, many decisions that had been made by GHA. Physicians, for example, previously had negotiated salaries with the council - made up of their peers. When the council was disbanded, they negotiated - as individuals - with GHA.
One GHA physician - who asked not to be identified - explained some of the concerns that brought him, with some reluctance, to join the union.
"I was feeling very insecure in negotiating as an individual for my future status," the physician said. "I think that was probably one of the more major reasons (for joining the union.) I would feel more comfortable than with an individual contract.
"As in other occupations, the relative supply of various specialties is cyclical, which means that at times I would have absolutely nothing to worry about because they hire people in my specialty anyway. And at other times, people in my specialty are a dime a dozen."
Beside anxieties about job security, physicians where they serve as employes express concern that management decisions - made without consulting the medical staff or against its wishes - could make it more difficult to practice what they regard as best quality medical care.
GHA, a consumer-run organization whose board of trustees is elected by the membership, was formed during the 1930s when the consumer cooperative movement was in its prime. The board carefully monitors medical care to insure that the members are being servce.
One of the steps to increase convenience to members was moving specialists out of central locations into suburban clinics part of the time. Specialists, however, complain that they do not have adequate equipment in the suburbs so the patients have to come to GHA's main location for treatment - increasing the time expense for both doctor and patient.
The union formed by GHA's doctors is only one alternative. Doctors in the mammoth Kaiser-Permanente Health Plan, which has almost 3 million members in California, Oregon and Washington, do not work for the plan. They are employed by the Permanente Medical Group, a separate organization owned and operated by the physicians.
The medical group contracts with the health plan for services of members, who are paid a salary by the group.
In other instances, physicians are forming professional corporations to save taxes and also to deal with institutions - like hospitals - that want to buy their services.
Whatever the form or organization chosen, it is clear that the trend of physicians practising medicine in groups is growing. The American Medical Association this month began offering a course to physicians on "How to Negotiate."
That the AMA cooperates with employed doctors at all- much less those who belong to a union - is an indication of how far events have progressed. In 1927, the AMA's judicial council filed a report with the government House of Delegates stating that the practice of employing physicians "is entering into so many phases of the practice of medicine as to be a distinct menace to the stability of our organization."
The AMA undertook a variety of steps, including a statement that working for a fee was "unethical" for a physician, to discourage physicians from working for a salary rather than the standard fee-for-service.
Many doctors continue to believe that medicine is practiced best when physicians work for themselves - whether alone or in groups - and that when a physician becomes an employe, something is lost.
"I've come to learn that very few people have their own personal incentive that's not tainted by the dollar," said one physician who worked as an employe and then went into private practice. "It's a sorry thing to say, but it's true."
But the movement toward employment of physicians - with impediments removed by action of the federal government and spurred on by the growth of insurance and regulation of physicians - has been inexorable.The AMA's decision to sponsor a course in negotiating for physicians is a decision to swim with the tide.
The target groups, according to Jerry Cloussen, director of the AMA's department of negotiations, are salaried or employed physicians who work for health mintenance who work for health maintenance organizations (prepaid group health plans), for hospitals and for professional groups.
"There are professional groups because of increasing regulation," Clousen said, "because the individual entrepreneur feels he has to join with other entrepreneurs to handle the administrative work. This is somewhat akin to what happened in the labor movement back in the 1800s."
Although the AMA points out to physicians that unionization is not the only form of organization available, Cloussen said, "If employed phsicians choose a union as a vehicle by which they feel they can best achieve their goals, we'll work with them and assist them - sure."
Cloussen agrees with Mitchell that the number and percentage of physicians who work as empolyes will grow. "Many hospitals want to employ physicians," he said. "HMOs are forming. (The Department of Health, Education and Welfare) is pushing HMOs."
The effect on physicians, he said, is that "more and more of them will come into an employed status."
That doctors are not just like any other employment group becomes clear when the question of leverage in bargaining comes up. Labor unions utimately can withhold their labor - strike - if their demands are not met.
Physicians say a strike would violate their commitment to treat their patients. "We don't consider the strike to be an appropriate vehicle in the health delivery system," Cloussen said.
But if the strike is rejected as a tool, he was asked, what's left? "Not a hell of a lot," he said. "I know physicians are not emotionally and psychologically prepared to withhold services and that puts them in hell of a position when you're talking in this area. Doctors are not going to do that . . . I don't think it would ever hap-
[TEXT OMITTED FROM SOURCE] 'There are professional groups because of increasing regulation . . . somewhat akin to the labor movement in the 1800s.'