Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


December 12, 2014: Doctors for Hire

By Rob Tenery, MD on December 12, 2014

When medical care transitions from private to institutional, as in a socialized medicine delivery system, depersonalization occurs when the providers change their priority from the patients under their care to the system that employs them.

The Medical Group Management Association has shown that physician productivity falls, sometimes by more than 25%, in hospital based practices versus their counterparts in the private sector. This lost productivity is a consequence of the more fragmented, less accountable care that results from these arrangements.

Most hospitals measure the productivity of the physician practices they purchase in Relative Value Units (RVUs). They are beholding to the RVU system only because that is how they get paid. This is a formula that Medicare already uses to set doctor-payment rates. RVUs are supposed to measure how much time and physical effort a doctor requires to perform different clinical endeavors.

All of this productivity translates into the loss of what should be a critical factor in the effort to offer more health care while containing costs. Hospitals aren’t buying doctors’ practices because they want to reform the delivery of medical care. They are making these purchases to gain local market share and develop monopolies.1

The Affordable Care Act (ACA) pushes hospital-based practices on the assumption that models that worked well in one community can be made to work everywhere. President Obama has touted “staff models” like the Geisinger Health System in Pennsylvania and the Mayo Clinic in Minnesota that employ doctors and then succeed in reducing costs by closely managing what they do. When integrated delivery networks succeed, they are rarely led by a hospital. The ACA seeks to replicate these institutions nationwide (Exchanges), even though their successes had more to do with the local traditions and superior management.1,2

The movement of physicians into an employee status, under the control of these multidisciplinary health care delivery systems, changes more than just their productivity, it potentially changes their priorities and their attitudes.3

To physicians, patients are people in need--- vulnerable, sick and afraid. To health care delivery systems, these same people are customers--- purchasers of health care services. When the physicians’ roles are subordinated to those that employ them, then their role as their patients’ advocates come in conflict with their goals as physicians.

Institutions measure their success by outcomes and the bottom line--- physicians by the lives they have helped.

In the past, most doctors held a shared vision of what it meant to be a physician. It was the bedrock on which the medical profession was established and evolved. That goal also served as the foundation on which patients built their trust. As physicians grapple with their new roles as employees, they now have to divide their loyalty between their own patients, other patients within the system that must share those same resources and the system itself. For without awareness of these other, potentially conflicting needs, these systems fail.

This realignment is diverting physicians away from addressing the core problems that are eroding this profession’s autonomy. The beneficence and compassion of their forefathers is being strangled out by employer demands and compounding regulations that are being heaped on them--- the very qualities they hoped to emulate when first choosing medicine as their life’s calling.

This is not to imply any less dedication by physicians today. It is a resetting of their priorities. Although health care, with respect to the science and the outcomes, is vastly better, there is a proportionate increase in the depersonalization of the doctor/patient relationship. Often, the physical examination and the history are secondary to the diagnostic studies. Doctors spend more time updating their electronic medical records and reviewing test results than examining their patients. They spend more time imputing into their computers and talking to consultants than to their patients.

When the encounter changes from relational to transactional, the practice of medicine is no longer a profession, but a vocation.

An article by The New York Times (NYT) writer Gardiner Harris, titled More Choose Less Hectic Schedules, highlights the sweeping changes in career choices by the emerging physician population. Telling is a reference to a survey by Merritt Hawkins, a top doctor recruitment firm, that quality of life was more important to new physicians than finances. In growing numbers, they want to work fewer hours or even part time and are willing to take salaried positions to achieve their goals.4

The Merritt Hawkins survey also reported that 51% of the positions the firm filled last year were for hospitals, almost a four-fold increase from eight years ago. Added to that number were private sector positions which included income guarantees by hospitals.3 If an increasing number of entering and practicing physicians are working or receive income from hospitals, what does this trend say about our profession’s battle against the corporate practice of medicine? There seems to be a contradiction when the organizations that represent physicians fight to block the corporate takeover of our profession, while more entering physicians are no longer interested in the ‘private practice’ models of their forefathers.

Even more important, this shift indicates “a sweeping cultural overhaul in medicine’s ethos…from being an individual to a team sport…to the point that many patients now see doctors as interchangeable.”4

The resident physician highlighted in the New York Times article, Dr. Kate Dewar, who has chosen a different career path than her primary care physician father is quoted as equating her father’s practice to the movie Groundhog Day, in which “the same boring problems recur endlessly.” She goes on to state, “I like to fix stuff and then move on.” Where in her comments does she personalize her effort to the patient instead of the malady?

Depersonalization is not just occurring in medicine. Self-serve gas stations , Home Depot, Wall Mart and McDonalds have changed the world. By cutting back on the personal services, these giant corporations create cost savings, some of which is passed on to their customers. The delivery of health care has become ‘big business’ controlled by federal regulations, hospital corporations and insurance conglomerates. As referenced in the NYT’s article, in growing numbers, we, the physicians, are letting it happen because of the “sweeping cultural overhaul in medicine’s ethos.”4

Are employed physicians less dedicated than their counterparts in the private sector? Let’s just say they are less consumed with the practice of medicine. Employed physicians are losing control of their profession by legislative fiat (Obamacare), payer mandates and the very corporations they willingly choose to join.

Dr. Kate Dewar’s response in the NYT’s article represents the thinking of many of today’s emerging physicians--- focusing on the malady and not the person.

Is the growing trend of triaging through physician extenders  (nurse PAs, physician’s assistants, etc.) alarming? At the very least, it is adding to the depersonalization of health care delivery.

A sad commentary on a profession that built its reputation on trust!

The soul of the medical profession lies in the hearts of those who share their knowledge and ply their skills to relieve the pain and suffering of those who are in need. Not because of what they receive for their efforts, but because of the good it accomplishes.

References:


  1. Gottlieb, S., American Enterprise Institute.

  2. Graham, J.R., Free of Obama Care Taxes, the Future of Health is Digital, NCPA posting, October 22, 2014.

  3. Tenery, R.M., Working for the Man, Echos for the Future, November, 2014.

  4. Harris, G. More Doctors Say No to Endless Workdays, the New York Times, April 2, 2011.





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