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.