Medicine in America: We are not in Santa Monica Anymore
Today, I found the copy of Gray’s Anatomy given to me by my mother many years ago after I told her that I wanted to be a doctor. It reminded me of how often I’m asked about when I decided to become a doctor. And, for most of my life, when asked that question, I have quipped that I couldn’t think of anything else that I was as capable of doing that was both fun and would pay the bills. In the last several years, however, it has not been as easy for me to snap off that retort. Things have changed in the profession of medicine, and drastically so, in the last several years. The art and science of medicine have now been overwhelmed by the politics and economics of healthcare, and I fear for us all—patients and doctors alike—as the fun, the finances, and the integrity of medicine itself fade away.
The truth is that my decision to become a doctor was influenced early on by Hollywood. As a child, I watched the television series, Marcus Welby, MD. Dr. Welby and his associate, Dr. Kiley, were in private practice in Santa Monica, California, and they modeled for all of us in America the ideal medical practice. They were quite simply America’s doctors. I recall one particular evening at home in Massachusetts, in our tiny living room with my mother and my teenage brother, as we watched Robert Young show us exactly how medicine is supposed to work. It was my first lesson in becoming a skilled and compassionate doctor. Leonard Rosenman’s dramatic music set the mood, and Dr. Welby approached his sick patient, lying helplessly and hopelessly in her own bed at home, placed his black bag on the floor, and held his patient’s hand during the entire scene. I can’t recall what they talked about, or the outcome of his visit. But even to this day, I remember distinctly making a decision at that moment that most children make at some point in their lives—to be a doctor.
I don’t ever remember seeing Dr. Welby open his black bag on the show. He had lots of medical instruments in his office, wore a long white coat, and occasionally used his stethoscope to listen to his patient’s heart and lungs while making pleasant conversation. But the point of the series wasn’t to teach the science of medicine; Hollywood simply wanted to use the dramatic ups and downs, twists and turns—comedy and tragedy—in the doctor-patient relationship to its advantage. It wasn’t until after high school that I learned a good doctor needs to know a lot more than just how to have a compassionate touch and how to give sound advice to solve patients’ medical problems. So even if Dr. Welby didn’t have to open his black bag in Hollywood, I would have to fill my own black bag with lots of tools and instruments (including the tool of medical knowledge) to do the job in the real world of medicine. Still, I had a good feel for the art of medicine at a young age as I tackled the science part in the following years.
After training, I made a rare decision. Unlike most of my peers I decided to open a private medical practice. While many of my colleagues elected to specialize further or to accept a salaried teaching position, it seemed natural for me to start a private practice. I had always envisioned myself in a small office, taking my time with patients, and developing long-lasting, professional relationships with extended families in the community. Most would argue that it is a more challenging path to take. And I suspect that the influence of Dr. Welby had much to do with this decision, although I am reluctant to admit openly that Hollywood had shaped my career at its earliest stage. Nonetheless, I had great fun building a successful community practice over 15 years, and, after the first few years of practice, I was able to pay my bills along the way. Initially, medicine was a comedy.
But medicine was not always fun. At the outset, I did not anticipate the immense pressure associated with negotiating health insurance contracts, maintaining hospital credentials, managing office personnel and marketing my business in private medical practice. I was neither prepared for nor warned about the challenges of these business aspects of medical practice during my training, and, in order to be successful, I had to learn fast while I cared for my patients. Along the way, it seemed that I got better and better at the practice of medicine, but I could never quite master the complexities of the business of medicine. I had to hire and rely on self-proclaimed “experts” to explain to me the need for participation in a “HMO”, or the advantage of signing a contract with a “PPO”, and it took years for me to understand the process of medical billing with ICD-9, E&M, CPT and “Modifier” codes, and the ever-changing restrictions and limitations of benefits given to Medicare patients. With all that I had learned in 8 years of training to be a doctor, it just wasn’t enough to simply take care of my patients in order to have a successful medical practice. I also had to accept the responsibility of participating in an evolving and increasingly complex healthcare system, most of which was outside of my understanding and influence and had nothing to do with the practice of medicine itself. I guess all that extra stuff was handled by Dr. Welby—or by his agent—behind the scenes.
Now, after 15 years of practice in medicine, things have really changed for the worse. In the end, I just could not seem to fix the myriad of problems in the healthcare industry as they affected my small private practice. The federal government has stepped in to create a massive bureaucracy that I call “FedMed”, and the resulting confusion and chaos has simply destroyed my ability to care for my patients. As hard as I tried to make sense of FedMed and to adapt my practice to comply with its requirements, I just could not find a way to do so without compromising the doctor-patient relationship. So, I left the practice I created in search of a better way to deliver healthcare to my patients. In the wake of my departure, it was easy to see that the fun, the finances, and, most alarmingly, the sanctity of the doctor-patient relationship—the basis upon which the entire industry of healthcare rests—is now in jeopardy throughout the healthcare system. FedMed failed us. The changes are happening fast, and it seems to me that we are all to blame.
Through Accountable Care Organizations (ACOs), doctors are now expected to prioritize control of medical costs above the welfare of their patients, or pay a financial penalty if they do otherwise. “Pay-for performance” reimbursement contracts incentivize doctors to accept fewer, healthier, and more treatment-compliant patients into their practice and to reject patients whose poor health and poor compliance with treatment plans will place the doctor at financial risk. With shrinking health insurance reimbursement to doctors and hospitals, limited numbers of contracted physicians and panels of patients, and restricted health insurance benefits for patients, most private practices with a fewer physicians must see up to 40 patients a day to keep their doors open. Now, the doctors accept spending less time with their patients and risk making errors in patient care. And so it is very likely that we will see the emergence of large, multi-specialty medical clinics, with rotating doctors—many of whom speak English as a second language—and limited availability, long wait times in the reception area to see the doctor, even longer wait times just to get the appointment to see the doctor, and less time with the doctor once you get back to the treatment room.
The cost of healthcare is rising, the pace of healthcare is quickening, and the quality of healthcare is diminished. I am convinced that our culture is not prepared for this transition.
Patients, already confused about the difference between health insurance and healthcare and increasingly upset at having to pay higher health insurance premiums for, in many cases, less coverage, now question the value of the relationship with their doctor. Their false assumption that the higher cost of their health insurance should translate into more available and affordable healthcare is shattered when patients realize that they are first responsible to pay enormous deductibles to their doctors, and then have to wait longer times at every turn to receive their healthcare. Patients feel betrayed by the very men and women into whose hands they are expected to place their lives, and they find little reassurance and satisfaction when given a packet of written information about how to make appropriate lifestyle changes at the end of their office visits instead of being given opportunity to discuss their concerns—face-to-face—with their doctor. Most feel that they can get the same information with a simple online search and avoid the hassle of waits, delays, and impersonalized medical care at the clinic. And I don’t blame them. Medicine is transitioning from the personal to the population, from the relationship to the regulation, and from managing the disease to managing the dollar.
Doctors, on the other hand, feel the awkward burden of collecting payment for services before even giving medical care to their patients, or risk receiving no payment at all. And, even worse, doctors are realizing that they have lost control of their industry. For decades we have allowed willingly and with little resistance the health insurance industry to acquire control of the flow of healthcare finances, all for the short-term benefit of receiving a guaranteed, contractual payment for services received on behalf of our patients. The consequence of selling out in this manner is that doctors have placed themselves at the choke-point for payment of services, and we now have grown accustomed to defining our relationship with our patients through the perceived value and strength of the patients’ health insurance companies. Our patients are no longer our “patients”. Rather, they are our “panel” and we are their “primary care physician (PCP)”.
The doctor-patient relationship has degraded from a covenant-based commitment to a contractual agreement. And this is precisely the point at which medicine has become a tragedy.
Once again, we are all at fault. Doctors and patients alike are beginning to realize that the entire system of healthcare has changed in a way that is causing doctors by the tens-of-thousands, crushed by the weight and confusion of FedMed, to leave their profession, and patients by the tens-of-millions to experience true abandonment and victimization. It is no wonder that the doctor-patient relationship, the very foundation of healthcare in America, is broken. The real question now is whether or not we have the will to change course and find a way to restore this trusted and noble relationship, and rebuild healthcare in America from the ground up.
Marcus Welby, MD was on television for 8 seasons. I lasted in a traditional private medical practice for 15 years. I believe that we should start taking back America’s healthcare by watching the series episodes because the message for Hollywood and for each of us is quite clear: “We are not in Santa Monica anymore.”
Michael J Lucherini MD MS
Dr. Lucherini specializes in Internal Medicine and Pediatrics. He practices at Summit Medicine and Pediatrics in Mesa, AZ, and is a Pioneer in Direct Access Medicine. His opinions expressed herein are personal and do not necessarily reflect the opinions of his staff, his patients, or his colleagues.
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