American College of Physicians: Internal Medicine — Doctors for Adults ®

 
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Friday, January 20, 2017

Why pick on those independent hero physicians?

Since finishing my residency several years ago, I've worked in almost every type of hospital up and down the East Coast, ranging from big urban academic medical centers to more rural community outposts. Although I primarily practice hospital medicine, working with both smaller private groups and being a hospital employee, I do empathize a lot with my independent practice colleagues and brethren. I almost certainly would have gone down the route of trying to open up my own practice had the conditions for doing so been more favorable (and had I also been able to better suppress my insatiable desire for travel and moving to different places while I'm still young and single!).

What's happened to so many private practice independent physicians over the last decade has been a great shame, because these doctors have been the traditional backbone of our health care system. They are extremely hard workers and labor tirelessly for their patients, typically in an admirably free-spirited and autonomous fashion. But now, due to a combination of regulations and policy directives—it's almost impossible now for these solo practice and smaller group physicians to exist. Without getting into all of the technical reasons why, it all boils down to changes in reimbursement models and policies that favor doctors working in larger health care corporations over small private practice.

Let's look at the type of doctor who has been affected the most. We'll call him Dr. Johnson. Dr. Johnson finished medical school in the early 1980s. He immediately started his own practice after residency and has been his own boss for the last 30 years. He's very popular in his community and loved by all his patients and their families. He is subspecialty board certified but also practices primary care. He embodies the principles of that good old-school physician (the best doctors around). He is a thoughtful problem-solver and enjoys spending time with his patients. But over the last few years it's got more and more difficult for him to keep his practice open. He's had to fulfil a huge number of “tickbox” criteria just to keep up with reimbursements, installed an expensive slow and clunky electronic medical record in his office (or faced stiff penalties if he didn't do so), and is now on the verge of facing an avalanche of even more central regulations. All these things have taken their toll on Dr. Johnson. He's a fine doctor who used to love spending time with his patients. Now he's forced to spend the majority of his day clicking and typing away in front of a screen. His practice was very successful and has already been eyed by a couple of local health care conglomerates—who want his patients. Dr. Johnson would have been happy to work forever (and his patients certainly wanted him too), but now retirement just seems so much more attractive to him. The employees who worked in his office are concerned, because they know how much their lives would change as controlled employees in just another large corporation, instead of the relaxed and friendly environment they currently work in (they'd probably rather just do something else than face this new reality).

So as Dr. Johnson retires from his illustrious and dedicated career, let's ask ourselves 3 questions:
1. Was Dr. Johnson ever the reason why our health care system had such high costs and suboptimal outcomes, and is there a better way to improve “quality” that engages rather than alienates Dr. Johnson?
2. If our health care system is going to have a “patient-centered” and “bottom up” philosophy, why hasn't anyone asked the patients what they thought of their popular independent physician Dr. Johnson?
3. Are we completely missing the other targets, when there are plenty of additional reasons why health care is so expensive—including big pharma and costly new interventions and treatments—all against a backdrop of an ageing population?

I simply fail to believe that losing physicians like Dr. Johnson and just accepting that as “collateral damage” is acceptable. There would have been far better ways to improve health care and cut costs rather than losing our independent doctors and replacing their practices with large health care organizations that actually have multiple additional layers of bureaucracy and expense.

We're barking up the wrong tree and should stop picking on the Dr. Johnsons of America.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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1 Comments:

Blogger Byravan Viswanathan said...

Love this very truthful article. I am proud to say I belonged to that category of the good hard working solo internist described above. I did that for 25 years of my practice. I am now retired and did so in my 62nd. year even though I could have continued for another 5 years. It was because of the pressure of what I call corporate medicine that took over my town in south central Pennsylvania. I am now looking tirelessly for solo independent practitioners like I was here in my retirement place in California for my own health and I have found none. American medicine is being destroyed and is breathing its last. What a shame.

January 26, 2017 at 10:07 AM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
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.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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