Wednesday, May 11, 2011
The sad demise of the yeoman doctor
In American History we studied the yeoman farmer as the Jeffersonian ideal. The rugged individualist clearing the land, building his home, and creating fertile growing space in the hinterland to feed his family and eventually, the community.
The yeoman farmer was almost entirely supplanted by agribusiness, as economies of scale were created by the efficiencies of amalgamating resources (land) and using technology to efficiently specialize (mono-crop culture).
(The counterweight to this has been the rise of organic farming, but even in that story there is a familiar pattern of big business leveraging itself in the newer market.)
Also being relegated to mythic status is the yeoman doctor, out there by himself (almost always him), caring for generations of family members in the same location. He would attend to his patients in the office, in the hospital, and after hours.
Now comes a wonderfully reported portrait of the last of this dying breed. The New York Times ran a front-page story about Dr. Ronald Sroka, a family doctor who's now taking care of his third generation of families in Crofton, Maryland.
Dr. Sroka has no partner. He doesn't have an electronic medical record. He eschews unnecessary testing since a) he knows his patients so well and b) he's very skilled at diagnosing things with a history and physical examination.
He owns his practice, in the time-honored tradition of doctors hanging out a shingle and making things work by the sweat of their brow. His wife (of course) helps run the business end of the practice.
Now that Dr. Sroka is nearing retirement age, he can't sell his practice. He can't even give it away.
Younger docs (I am one) don't want to work as hard as Dr. Sroka does. We want doctoring to be part of our lives, not the whole thing.
We trade the risk (and reward) of owning a practice for the security (and loss of freedom) of a salaried job in a larger organization.
The same kinds of issues are in play as with agribusiness: Consolidation brings leverage in negotiating contract prices; working for a large organization means economies of scale. The corporate entity takes care of overhead like malpractice, computer systems, even paying the nurses and medical assistants.
The Health Care Reform legislation (PPACA) passed by Congress in 2010 will only accelerate this process. Organizations that integrate care to provide high quality mean that the little guy will be left out in the cold. The sheer bureaucracy of the new changes (e.g. building "accountable care organizations" and "gainsharing risk") will make it harder and harder for solo practitioners and even small groups to survive on their own.
There will obviously be a few holdouts:
--Psychiatrists in Manhattan.
--Concierge doctors, the model of which I think will lead to the rise of the
--Boutique practice. You want to go where everyone knows your name. Where you're treated like an individual. And you're willing to pay out of pocket for the privilege, avoiding the hassles of insurance altogether.
--"Diet" doctors, purveying their own "special" elixirs and potions.
If health care reform means more accessibility and better quality of care, then the changes will be welcome. Yet there will be major disruptions in our current practices and patterns for some time to come.
This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.
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John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
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