The Changing Character of Medicine: Are We Headed in the Right Direction?
Vigorous work and determined dedication are minimum requirements for excellence in medicine. Being the best doctors we can be means working long hours on a daily basis, in addition to covering nights, weekends, and holidays on call. It means constant studying to keep up with the latest scientific advances. On top of that, add the tasks of running our own small business as the majority of physicians have done in the past. The work is demanding, but when we can be our own boss, and know we are providing a valuable, and valued, service, it’s well worth our time and financial risk. The honor of sharing the intimate, intensely human experiences of our patients’ lives is immeasurable.
Now pile on reams of government regulations and paper work which add to overhead costs and subtract from time with patients. Toss in threats of felony charges for billing errors and ever-shifting carrots and sticks to get us to practice the way the politicians think we should practice medicine, instead of the treatment we and our patients determine to be in their best interest. Top it off with the rising risk of litigation and malpractice premiums, and is it any wonder that more and more physicians are choosing the path of employee?
Working as an employee is a reasonable and legitimate option. But when political manipulations of the business of medicine drive this choice, we need to look closely at what is going on. Is it really a move in the right direction to have physicians less independent?
Dr. Donald Berwick, head of the Centers for Medicare and Medicaid Services, definitely thinks so:
The primary function of regulation in healthcare…is to constrain decentralized, individualized decision making….No longer is the physician, paternalistically committed to the patient, the driving force in medical care.
Today, this isolated relationship is no longer tenable or possible….The traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of delivery of healthcare.
A recent article in the New York Times relates how the shift from small business owner to employee affects a physician’s politics. But that is far from the most important change that will occur because of this shift. What we really need to pay attention to is how it will affect the practice of medicine itself.
If Obamacare remains the law of the land (unless it is overturned by the Supreme Court), it will mean the end of medicine as we know it in America. Fewer and fewer highly-skilled doctors will become what amounts to low-paid government employees and all you’ll be left with are mediocre or, worse, unqualified, doctors taking care of an ever-growing (and aging) population. It will probably be worse than what they have in England, because some doctors may simply open private practices where the patients would have to pay on a cash basis. So what Obama would have achieved is an even greater divide between rich and poor, with the rich getting very good care because they can afford it and the middle class and poor only getting horrible government-funded medical care. That is, of course, unless the government FORCES doctors to treat everybody at very low cost, in which case you really won’t have a democracy anymore, let alone any freedom of choice for how the doctor will practice.
ACOs are already dead as CMS pocketed most of the funds that should have been distributed to providers. This model is not going to work.
Electronic Medical Records is being sold as a “quality” addition. There are no data to support that, but they do give government access to your every detail. It will turn out to be the “Global Warming” scam of health care.
The next step will be opting out of all government programs, first by the specialties in short supply such as general surgery and those that are underfunded but captive such as Anesthesia. States may try to force the issue by requiring acceptance of government programs as a condition for licensing, but this will fail.
We will become very European…a system of the top doctors will practice outside of the M&M programs that result. Access will be immediate and quality high. Everyone else will be on a waiting list whining how unfair it is to have a system where those that are actually paying the cost of the government care (those that actually pay taxes) are additionally paying for their own care by quality, skilled providers.
Just like with government schools–only there seems to be more animosity toward a “two tiered” system in medical care. We have greatly failed in the education of our populace on the simple truths of economics and the beneficence of profits and free trade. At least now there seems to be a more active conversation going on in the country. Nothing changes quickly–but the more we talk and present our ideas, the better chance we have of moving in the right direction.
The above comment by “anonymous” is mine. I forgot to type in my info before publishing.
Abolish the FDA and the Medical Practice Acts in each state. Let patients vote with their feet as to whom they will see for medical care, what medicines they will take. This will drop the price of medical care like a rock. Worried about quality? Think the FDA and the states’ boards of med are really protecting you from unsafe/unqualified medical care? Don’t make me laugh. The responsible citizen will still be able to find reasonably safe and effective care. Without the gov’t pretending to regulate medicine, multiple private agencies will spring up, offering review and certification, probably with substantially more stringent standards than the govt’s.
With medical care unregulated and massively cheaper, there will be no way or need to have Medicare/Medicaid/Obamacare. Leaving aside of course the fact that Fed involvement with medical care in any way is grossly unConstitutional.
Yeah, I know, unrealistic. But then again, continuing to do what we’re doing, even if we tinker with Medicare and/or repeal Obamacare, is going to result in an inevitable gross reduction in care delivered, either because the program itself will become means-tested to the point of oblivion because there’s no money to pay for Medicare for everyone, or because the Feds will print enough money to continue to pay for everyone such that the money becomes useless, i.e. massive inflation. Either we turn back to the Constitution, or we hit the wall, folks.
I am a medical educator. This article doesn’t really touch on the real problems we have. The real problems include massive debt (both financial and temporal), a “shift-work” attitude that is replacing our former “this is MY responsibility” attitude, and a detachment from our responsibilities to societal leadership.
The debt and the sense that they will never make enough money to catch up is a tremendous driver of behavior. The financial burden on new medical students squeezes them out of areas that they could be good in and into areas where they think the money is best. This results in stark manpower shortages in areas of medicine that don’t pay well. Don’t believe me, do local phone book search for pediatric endocrinologists, or nephrologists. Look at the data recently published by the American Society of Pediatric Hematology and Oncology that estimated that the lifetime earnings deficit between a pediatric oncologist and what he or she could have earned as a general pediatrician was $600,000 over the course of a normal career.
The temporal debt issue is one that never gets talked about. This is the sense that you are falling behind. Not just financially, but in staying on course. You watch your friends marry, buy homes, start families, while you struggle to find time to date. Eventually a career in medicine is seen as a burden.
Work hour and patient care limitations have made it very near impossible for residents to get that sense of being responsible for a clinical service and doing so independently. When I trained in the mid 80′s, I had to develop independent thinking skills as my faculty would bust my chops for calling without a plan. Now, we end up getting calls directly while our residents sleep.
Thanks for writing your perspective and experience. America needs to hear more from physicians about what is really going on in our daily lives.
I am also a board certified physician and educator in a military residency program. I believe that some of the shift towards socialism in our providers’ thinking stems from the medical school demographics. The Military system cannot even fill its scholarships. The majority of medical students are women and a good majority of those are Asian or second generation children of immigrants. These traditionally do not feel compelled to serve our country and are in it for the money and for bringing more of their families over here.
Call me any names you want. This is the way I see it.
Your scholarship program fails due to poor strategy. You emphasize the very expensive east coast schools and other private medical schools because the cost of tuition factors into the “need” of the prospective students. Send them out to my school, and you would do better.
As with any huge government organization, we are inefficient and short sided on many things. However, we cannot deny that the demographics have shifted.
Dr. Haynes is asking the questions that all Americans should be asking.
The end-result of ObamaCare will be a “not my responsibility” mindset amongst the next generation of doctors. Instead, they’ll be content to follow order from their government paymasters, clock out, and go home.
If you don’t want going to the doctor to be like going to the Department of Motor Vehicles to renew your drivers license, then we need to scrap ObamaCare.
This is another excellent piece by this physician. I am happy to see people trying to educate the public on the nuances of where we are headed, and hopefully how we can turn course.
Dr. Haynes keeps trying to educate the public. Sadly, I fear the wrong people, those without power and influence, are listening; while those who could actually change things, never pay attention. Berwick is an idiot.
Who are the people ultimately in charge? The public. We have the politicians we do because of the culture we live in. I think giving the right ideas and means to defend them is a crucial part of the solution.Keeping The discontent alive and on the front page through movements like the tea party is crucial. the kinds of conversations occurring in Washington are very different than even 3 years ago–due to those who used to consider themselves without power and influence.
That said, through Docs 4 Patient Care and other influential organizations, work is being done to educate legislators and national leaders on these same matters. Many are listening.
And–Berwick is wrong, but he is not idiot. That’s part of what makes him so dangerous.
I dont think there is any stopping the slide towords employment based practice for doctors. The megacorp hospital systems are just too large and powerful to oppose.
This week in our city the megasystem closed down the only hospital and trauma center in the poorest area of town. They are not replacing it and do not offer trauma at their downtown hub. Trauma doesnt pay.
The solution? Ship ‘em to County. The County hospital has the only level 1 trauma center left. They beg for money every year and it is on the other side of town.
The suits who run these “non profits” are more ruthless than Donald Trump. They are not afaraid of Obamacare because they have the government in their back pockets. Doctors have no choice in the matter.
If not enough people speak up and take action, then you are right. That is the direction we are heading. Can we change it? I don’t know, but I refuse to let it happen without fighting back.
Profoundly well said by Dr. Haynes. State-run medicine in any form destroys the doctor’s and patient’s free mind and free choice.
I hesitate to add to the informed comments above. However, I think the basic crisis of confidence throughout the West that is tipping us towards ever deeper government interference in the lives of individuals can be traced a prevailing misconception about human consciousness. The reason that the doctor/patient relationship is mistrusted is the reason that any individual initiative is mistrusted. Thinking is believed to be safer when it is the product of a consensus because language, our tool of thought, is believed to be instinct driven and subject to the emotional impulses of our Pleistocene hunter-gatherer ancestors. The notion that language evolved primarily as a means of communication, like the squeaks and calls of animals or ‘mutual grooming activity’, has supplanted the understanding that language is primarily our means of identifying reality so that we can deal with it. We have Darwin’s evolutionary sociologist followers to thank for this perversion. As volitional creatures, we use language to integrate sense data with its appropriate emotional nuance. It’s how we evaluate. It’s how we remember. It’s how we plan. The evolutionary drive to fixation of this specialisation has a cause. But that’s another another story.
Your time and effort in presenting the issues facing all of us with this outrageous government takeover of the healthcare sector of our economy is greatly appreciated. My husband and I do not want to go to a govt doctor’s office. We want privacy, not long times in waiting rooms or to get an X-ray. We are also at an age when we do NOT want to be told, sorry, you’re too old for that expensive procedure. Please keep up the good work!!
Thank you, Dr. Haynes, for trying to alert the public to the alarming trend in health care. As a surgeon who finished training 30 years ago, I can tell you it’s like watching a slow motion train wreck. People now coming out of the long training pipeline have a completely different attitude toward patients. For better or for worse, new doctors now have a day shift clock puncher’s mentality. Patients will not see the damaging effect this has on the quality and safety of their care, especially those gravely ill patients in the hospital. When your doctor punches out at 5, she takes home with her the intimate details of your care. Her attention now will be focused on her family. Whether that’s a good thing is debatable, but it means that you, the patient, will be passed on to another doctor. Despite all the talk of a “warm handoff,” subtle details of your condition cannot be passed on to another doctor. Inevitably important details will be dropped, mistakes made. This was not always the standard of care, but it will be as the independent and dedicated private doctor is replaced with the government-controlled provider.
“My patient” will become “The healthcare user”, cared for by a computer and flow charts.
Dr Haynes has once again hit the nail on the head. We are headed in the wrong direction when it comes to healthcare and that is because doctors became complacent and gave up keys to the store and every other special interest group has swooped in to fill the vacuum and suck out whatever they could from a segment of the economy that accounts for >$1 Trillion annually.
I pray that it is not too late for doctors to show leadership by joining together to save our profession.
Excellent article. How can a patient trust a doctor when the doctor has other loyalties, and has to play stupid games with the carrots and sticks? Working directly for the patient is by far the best for doctor and patient. Costs would come in line, and there is no conflict of interest.
Agree 100%. The only way medical decisions can be made “for the patient” is when the physician is least constrained by an employing body or a govt protocol. An employed physician works for the Hospital, etc… An Obamacare physician works for the Govt. I know, I know, some will argue that a physician who is the owner of a practice has incentive to make money. Have you ever met a hospital or organization that is out to “not make money?” that’s the farse of Obamacare and the ACO idea. The ACO’s will maneuver physician behavior to maximize their profit.
It is even worse under hospital contract. They typically require the doctor to produce a certain amount by seeing a certain number of patients, procedures, etc. They also give bonuses based on productivity.
So a private practice physician who was fine taking more time with patients and earning a little less now finds that if they dont move quicker or perform more procedures they will be out of a job altogether.
Again, Dr. Haynes breathes reality and life into what truly ought to be a common sense, historically-proven case against nationalized healthcare. I say “ought to be,” because it seems so doggone OBVIOUSLY bad policy—yet here we are. What I can’t understand is how the conversation to go down this path without common sense, Americans-approved policy even gets off the ground. We simply can NOT let this take over our country.
Excellent points, Dr. Haynes.
The trend toward employee status has accelerated, mostly because the regulatory burden makes it much harder for a small, independent medical practice to survive.
The big problem is that we as physicians cannot serve two masters without lying to at least one of them. Our professional duty is to serve the patient. Our employer may have different priorities.
So very well said, Dr. Haynes. Your continued vigilance in exposing the ugly realities of state-controlled medicine and health care is a breath of fresh air, and so very much needed at this time in our country’s history. Like all Statist meddling into a country’s economy and the lives of that country’s citizenry, through government intrusion, it always leads to catastrophe, chaos, and diminished quality and quantity of production, progress, prosperity, and life itself — whether that destruction is in the fields of medicine, agriculture and food production, education, banking, other goods and services, or something as simple as personal entertainment — because Statism to exist at all, by its very fundamental nature, has to “always” spread like a cancer to destroy individual freedom and individual rights, including property rights, for everyone — and that includes destroying the free-market economy based on that freedom, with every benefit that comes with it, medical care included. Thank you again, Dr. Haynes, for your continued hard work!!
Excellent analysis, Dr Haynes. Government run medicine corrupts the doctor-patient relationship.
Although i do not agree with Obamacare,the medical community needs to look at itself.
The government wants to gain control for several reasons.The huge amount of medicaid and medicare fraud,medical equipment fraud and the RX drug abuser pill shops run by doctors.
And you have a portion of doctors who are not wonderful,caring people as displayed in the article.There is a vast amount that have no interest in patients other than to toss them pills after their allotted 10 minute visit and call the next paying customer,like a convenience store check out.
I know,i think i’ve met most of them.I could give you a list of over 50 doctors that not only did not diagnosis a birth defect,some almost killed me with medications.
10 years after i lost the ability to walk a resident asked if he could do a muscle biopsy when treating me for a sinus infection.The result was Congenital Myopathic Muscular Dystrophy.I am happy to have a diagnosis.I sued no Dr.who failed me.I had medical insurance through employers since the age of 16 until i could no longer walk at 32.I passed Dr.exams for work even though i could barely rise from a chair.Was this a backwoods-small town area? St.Louis,MO is known for it’s excellent medical care.Was it physically obvious? By the progression to the inability to walk i held on to walls to keep from falling,at 5’8″ i weighed 97 lbs from muscle loss.
My point? Irresponsible,uninterested physicans get paid whether they perform their jobs or not.They need no unions,they protect each other.They do not police their own failures,report each other for being little more than drug dealers and appeasers.Look at prescription drug abuse.It is out of control.
The goverment is looking for answers to solve these problems.Foolishly they think more big government will control the quality and caring of Dr.’s who are functioning for greed.It will simply force the exceptional physicians into a mainstream river with the negligent, Dr.run convenience store check out lines.
That’ll be $300,here’s your RX for Oxycontin.Next!
The federal government wants to control every physician, not just the relative few who make headlines by defrauding Medicaid and running pill mills. As for policing ourselves, you the people have pretty much outlawed that. We used to have a process called peer review, which allowed doctors to review the care of doctors in their communities and to some degree influence them to change for the better. But statute and case law, again put in place by patients like you, have done away with most of that.
I’m sorry you had a bad experience with some of your doctors, but please don’t generalize to the entire population of doctors. We are pretty much at the mercy of patients, believe it or not.
re: ” Irresponsible,uninterested physicans get paid whether they perform their jobs or not.”
Our current system does not adequately allow/require competition based on quality. the best and the worst physician get paid the same by third-party payers (public and private for an office visit, surgical procedure, etc. The new health care law bolsters this third-party payer system, and increases the the proportion who are dependent on government. More free market in health care is how to change this, not more government.
On the other hand, the government does have a key role when fraud and incompetence which causes harm are involved. Addressing those issues is where government should be putting it’s efforts–not on price-fixing medical care, or implementing regulations which punish competent and independent patients and physicians.
Sorry that you went so many years without a diagnosis. Congenital myopathies are difficult to make. Diagnosis of exclusion which can be made with right combination of physicians working together. The neurologist and pathologist working together with review of clinical history if laid out so the information is in a format accessible in real time when you come for the appointment is key.
This is where we want to be. you saw drs x, y and got labs or radiology maybe path report and showed up to the neurologist who is trying to gather all of this and think about a differential diagnosis before you even walk in the door. That is not possible by just pulling up your history in some database. There are barriers to putting up your medical data and for good reasons. Yet there is cost to that if your MRI was done somewhere else and cannot sit down with the radiologist to review. That doctor gets a few words about the general complaint and tries to give the best report they can but not same as a specific consult from someone who has seen and examined you.
Oy. So communication is key but in our communication age for medicine it is more difficult than ever. We try to keep up with the latest software and all that. None of that is free BTW. Costs money to get all that and people to help get the systems and education. The other 80 percent of the Medicare dollar gets spent on many things including these vital resources.
Not perfect system. In my life time from report from radiologist for your CT scan has gone from 24 plus hours to that many minutes. That is net gain but at some cost.
Dear patient,
I am so sorry for the experience you describe. It can’t possibly be typical. Did you ever see a specialist? Muscular dystrophies are rare so it’s not surprising that primary physicians may have missed it but I cannot fathom that you were not sent to a specialist. Are you on an HMO, medicaid?
Fraud is an issue in healthcare. Yet, much if not most of the substantial fraud is perpetuated by non-physicians who the feds negligently pay millions of dollars per month.
Sadly, physicians get all the blame.
Thank you, Dr Haynes, for keeping your voice and experience in there, along with some of the rest of us.
This situation occurred due to 3rd party payment, principally through Medicare and Medicaid. When those programs came in, non-physicians saw a great way to parasitize physicians, essentially using our medical training for them to make money. Now we have huge managers, turning physicians and patients into their pawns, and turning physicians into their serfs. Besides the big management companies, hospitals, and the Medicare contractors, we also have the flood of patients without significant medical problems, who come in because it is free to them. We also have people who make themselves sick, with booze, cigarettes, violent behavior, dangerous drugs, irresponsible sex – after all, there is always someone else there to pick up the pieces for them. Politicians have little or no knowledge of medicine and medical practice, but they meddle with it. They are like children with explosives.
Medical practice is being destroyed. The comment above by a patient; when physicians are inundated by thousands of people complaining about non-problems, the ones like you, with real problems, are far less likely to be taken seriously. It’s the old “call wolf” tale. If someone cries wolf enough times, when there is no wolf, eventually, the cry of “Wolf” will be ignored, when someone like you, who has a real wolf to cry about, tries to bring attention to it.
For example, it used to be that if someone came to the ER with a headache, I would think of Migraine,meningitis, subarachnoid hemorrhage, stroke, malignant hypertension, temporal arteritis, tumor,carotid dissection,pseudotumor cerebri, cluster headache -…you get the picture. But now, it may be just that someone had a family argument, maybe has a slight tension headache, wants to score points within the family “I had to go to the Emergency Room!” (because of you!) and so they show up and join the ranks of people falsely crying wolf. This has a definite, and harmful effect on the physicians trying to deal with medical problems. I am the only person I have heard remark on this problem specifically, but I am convinced it is there, responsible for some people with real problems being thought to be just one more of the legions of people clogging the ER’s and clinics for no good reason these days.
As a patient, I have a selfish reason for wanting a fee for service, totally unregulated free market in medicine: to get the best minds in the field, and to have medical care be available for every pocket book. It is the only way anyone with a serious illness has a chance to get well.
As it is now, the welfare state medicine we have is repelling the best minds from entering, as Dr. Haynes touches on in her essay. It is up to the doctors mainly to assert their right to practice medicine freely, and to assert that it’s moral for them to be paid a fee for their highly valuable skills and intelligence. Also, to assert no one has the right to a doctor’s services by dint of need, no matter how sick or desrving that person is.
Need is NOT a claim on another’s person’s life or work or abilities or wealth.
Roxanne A.
Federal bureaucrats and Congress who were charged with oversight of Medicare and Medicaid have allowed them to go bankrupt. These same institutions want to take over the health insurance of the rest of the country. ObamaCare is a socialist model (look up comments by MMS Director Dr. Donald Berwick) of healthcare rationing couched in the false promise of universal healthcare. It is in reality the takeover of 1/6th of the private sector economy.
Our national organizations have let the public and physicians down in failing to educate the public as to the destructive effect of ObamaCare. Finally there are organizations that are trying to put physicians in the driver seat in terms of defining the debate, such as Docs4PatientCare. If we can repeal this disaster, we need to have plans to fill in the void. These could be enabled by federal legislation that would free states to model some of the plans. With across state line portability, the true cost lowering innovative doctor/patient centered plans could flourish. For a 12 point template plan visit my informational website (no money pitch) at http://www.usaHealthalert.org.
My final comment regards the promotion of the idea that prosecuting fraud and abuse of physicians is a major factor in saving the Medicare budget. If you were to recover 100% of all Medicare payments to physicians you would have saved 6% of the total Medicare budget. Contrast that to the over 100 different agencies in US Health and Human Services and the 6 pages of ObamaCare that spawned 429 of new Federal regulations and one gets the true picture of waste and abuse.