Thursday, February 17, 2011

Wither, the primary care physician.

The spiraling dynamics of medical care:

Patient care is transforming daily. It no longer is the “physician” who came via horse and buggy to be greeted at the door of an infirmed patient’s home. Things evolved from that to doctor offices, and hospitals. And as surely the process morphs into another, the doctors became employed by the hospitals for services that only the hospitals could provide and the process moved along.

Just when equilibrium had been restored between the providers of health care, the sting of  change was in the air. The knowledge of medicine increased voluminously, to the point that specialties arose and within them subspecialties blossomed. Times had changed again chaos reigned supreme. The Internist and the Family Medicine practitioner once the gatekeeper of the health of the community was n the crosshairs and found it difficult to make ends meet, since the patients who used to go to him/her for blood pressure now preferred Cardiologist or a Nephrologist and the blood sugar monitoring was being handled by the Endocrinologist. The specialists started to provide additional limited care to the patients by practicing a little bit of internal medical care since patients did not desire to frequent many physicians. The conflict soon arose between the “gatekeeper” internist/family medicine physicians and the specialist. Noting this irony the insurance companies hopped in to reap some rewards keeping more of the premiums as year-end profits and encouraged patient care to be meted out at the primary care level with the additive incentive for the physician receiving bundled payments. They deemed that if the transfer to specialty care were required then there would be some severance or partial payment at the end of the fiscal year. Their (Insurers) cost benefit spreadsheets showed that specialty care was more expensive then primary care for a similar patient. The complex formulae employed forced many primary care physicians to limit the referrals outside their practice. Unfortunately that limitation was associated with the legal side weighing in with their cries of inadequate care.

The floodgates of crying foul and dashed interpersonal relationships between physicians became the hallmark of medical society. Trust became an empty shell that echoed only the words that were yelled into it. The trade organizations were busy collecting dues as the society was witnessing a turmoil with far-reaching consequences.

As happens with change many physicians not willing to lose the war decided to throw in the towel and if they were in they’re 50s decided to retire from medicine. Their knowledge and experience lost to the multitudes of would-be patients. Those that were younger joined the forces of hospitalists where they were bereft of the tumult of daily practice and the 9-5 job or its equivalent was all they cared about. Do your job, get the paycheck and call it a day.

What then? Well as all things have unintended consequences so does this theme. The hospitals under the scrutiny of the third party payers when squeezed for money ruled in favor of solvency over the contracted doctor. And as surely as this ink dries there are hospitals reducing salaries of the hospitalists or outright canceling their services just to keep their doors open.

Another consequence of greater import is that the independent thinking by the private practitioner has become relegated to the “guidelines” created by the hospitals to streamline their revenue stream for “cost-effective” medical care. Invoking the scout’s honor the hospitalists are dutifully saluting to the demands in order to keep their jobs. When you take the nobility out, all that remains is business. The check is still in the mail at the end of the day and that is all that matters.

A once noble profession is being thrashed on the brutal rocks of economics. And if this wasn’t enough, the depleting supply of those tried and true stalwarts of medicine, the primary care physicians, is rapidly dwindling due to cuts in their practice from attrition of patients and in their professional fees.

Meanwhile the boys in the ivory tower, now have another brilliant idea: Lets get the nurses to start practicing medicine! Now if that isn’t the most illogical form of thinking, I don’t know what is? Why not let the nurses who wish to practice medicine go to medical school. Why not encourage the needs of medical education to those busy science and art majors. Why not make medicine attractive and noble again. Why not have the old strange attractor called desire due to societal influence imbued with nobility be the flag that makes for new converts. Why not call the doctors, “doctors” instead of “providers.” Why not?  Why not resurface the pothole-riddled roads of understanding with fresh thoughts from the physicians in the trenches rather then those opining from their lofty environs? Why keep slipping on the slippery slope to mediocrity and oblivion? There are too many whys and why-nots.

We have entered the realm of unintended consequences due to a few professorial types that entered the hierarchy of medicine and its governance a while ago and as “ivory tower intelligentsia” is wont to do, they have ceded to the pressures of their egotism by creating verbiage and an environment that has slowly disintegrated the nobility and care in medicine.

To that I say, “Leave medicine to its rightful trustee: the physician!”

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