Back to the Future in Medical Care

How the Uninvited Third Party Has Spoiled the Dance

I’ve presently reached age 86. Until nine years ago when my wife and I became snowbirds in Florida I had a long-time internal medicine practice. For the great majority of that time I practiced in the old style, always independent, following my patients in the hospital and nursing home, sharing office space, Sunday and holiday call with 2 other docs and generally managing my time and the way I did things as I saw fit. I still maintain my license and try to keep abreast of my areas of interest. In the community where I now live, I keep a medical support group going and give occasional talks. People call me “Doc”, and I like that.

But modern doctors don’t seem to feel that way. I read on the various medical social networking sites about “burnout” and depression. Surveys show that doctors, especially those like me in primary care, are pessimistic about the future of the profession and even recommend against medicine as a career for their children or other young people. My own former internist, who was a friendly and capable doctor, recently retired in his mid-60’s and kept saying he couldn’t wait. And yet he worked for a large hospital network where he had a good salary, with regular vacations, all ancillary expenses paid, no practice administrative headaches, and an incredibly easy work schedule compared to what I had always maintained. So, what was his problem? I think I know.

When I was a kid in the 40's my mother took me to our family doctor who had a nice home on a quiet street with his office attached and his name hanging on a sign outside. That was the common arrangement in those days. One thing that would strike the modern person if he went to one of those doctors is that, on entering, the only one there was the doctor. There was no receptionist or business office or file room or practice manager. You waited your turn in the waiting room till he called you in. He knew you and your family pretty well. When you left you paid the bill, and most people could pay it since in those uncomplicated days overhead expenses were next to nothing. For those who really couldn’t afford it there was little or no charge. These doctors stood out in the community and were well respected. They proudly displayed their profession, customarily attaching a small metal insignia with a caduceus to their car license plate. Far from being discouraged, their children often followed in their footsteps. This was my model when I decided in the 50's to get into my college pre-med course.

I did my medical training in the pre-Medicare days when the hospitals had a private service and a ward service. Patients who couldn't afford to pay were treated in multi-bed open wards by us doctors in training with supervision by attendings. There were some good aspects to that system and some bad. But during my residency Medicare came along and the ungrateful seniors made their choice, abandoning us for the private hospitals and semi-private rooms and more experienced doctors.

Flash forward to today. Medical care in the past involved two parties, patients and doctors. Now we have a system dominated by third parties who are outside that relationship, and these include government and insurance companies and large medical organizations. Our political leaders weren't happy with the situation that existed in my training days but what we've got today hasn't turned out to be so hot either. People on both sides of the political spectrum think that our present system is sick, and I heartily agree. There are a tremendous number of symptoms of this illness, but I thought I'd pick out just a couple to mention.

Instead of a simple fee paid at the door doctors now have an incredibly detailed, complicated arrangement for calculating how they bill and receive payment from the third parties. Everything must be documented in detail to justify the amount of the fee to the outside payer. And document it they do with vengeance because it’s what really counts for the payers. In such a system little changes in what is recorded can make a big difference in the amount of payment.

Here's another one. The old doctor-patient relationship is on the rocks and one wonders if the marriage will survive. Both relate to a system as much as to each other. For the patient the doctor has become a remote creature, impossible to access directly, surrounded by layers of clerical staff and physician substitutes. Patient problem calls go to a recorded message or portal which, can you believe it, guarantee a response within 72 hours. Actual visits require weeks or months of waiting time. Primary care visits are often pro forma, with limited relationship to other of the patients’ medical events. Surgeons and interventionists do their procedures and all follow-ups are often with ancillary personnel.

It shouldn’t be like this. At least in the past, medical practice had always been the ultimate personal occupation. People often come to doctors sick or worried and invest them with a level of confidence that they gave to few others, even their friends and family. To doctors it's sometimes all in a day's work, but it shouldn't be. They have the capacity to turn patients’ lives around, to reassure them when they're worried, to advocate for them, to counsel them in ways that they will accept from no one else, and at the very least when worst comes to worst to console them. In my practice as the years went by, a remarkable relationship formed. I learned about this in a very personal way when I underwent heart valve surgery a number of years ago. The outpouring of concern, well wishes, phone calls, mass cards and gifts from patients, some of whom had been coming to me for 25 or 30 years, touched me deeply.

Modern medical practice is increasingly able to prevent, diagnose and treat illness. But at the same time too much of the modern physician’s activity is spent attending to the demands of third parties. Medical practice has gotten too complicated and there is too much unnecessary overhead. Too many computers and coders and billers and record clerks and documentation and pre-authorization and primary and secondary coverage and on and on. Medical records are now largely for payment documentation and are filled with unnecessary details and are often egregiously erroneous. It’s all a big hassle but the real problem is that the need to perform activities required by the third parties has forced doctors into the arms of big organizations, and has greatly cut into their fundamental purpose, that is to spend time with and closely attend to their patients. Talk to any patient. This is what they value most.

Nowadays it seems like doctors are more like part of an overall organization, managers of the patient's health, following protocols and guidelines to assure uniformity and economy. But it’s not the way I viewed what I did. I was trained to see medical practice as a personal service relationship that involved me and a unique individual with a medical concern. Doctors have attained a certain body of knowledge. They take that knowledge base, modified by their experience, and then they use the resources available to them and their colleagues in the community and apply them to the problem of that individual person sitting in front of them. All that can be done directly, with just two parties, just like in the old days. It’s not the doctor’s job to fix society, or to worry about the financial condition of the government or the viability of the organization or anything other than the interests of that person. That is the time honored moral and ethical foundation of their profession, but we seem to be losing it. The loss is apparently taking a great toll on doctors and those who have traditionally relied on them.

The third-party bureaucracy and health care planners are never going to change course of their own volition. If things continue as they are going the practice of medicine will continue through some further tough times. Some think the cure for our sick system is just for the government to take over everything but to my mind that treatment would amount to sending the patient to the hospice unit. This approach would leave doctors in the hands of the most oppressive third party of all, one with ultimate power and with many other economic and political concerns against which the traditional medical relationship would hold limited sway. To be sure, others of the planners understand the problems with that approach and are busy devising other types of new arrangements to try to improve things but which nevertheless always seem to leave them in charge.

For doctors, however, I believe that the best answer to this situation is for them to do what Timothy Leary used to say way back in the '60's, that is to TUNE IN, TURN ON and DROP OUT. There is a small but growing movement of physicians who have become frustrated with the system and are doing just that, dropping out from government plans and insurance. These include arrangements like DPC practices and direct pay outpatient surgery centers. Doctors who do this report that they are making a respectable living and have much greater satisfaction with what they do.

It's a tough nut to crack. The general public is by now so adapted to the present complicated system of payment and control that any change is looked on as a detriment and is resisted. For that matter doctors are in much the same situation. Most of them see the status quo as a given and rail against it without understanding the real problem or how to change it. For those who are unhappy and frustrated I believe that ultimately their strategy should not be to fight against the third-party payers but instead to withdraw from them. This takes courage and determination but there are a growing number of existing functioning models to follow. The doctors’ monopoly on knowledge and technical skill give them the power to do it. And for a growing number of patients, doctors and doctor owned medical facilities with low overhead who post their fees and give far more personal attention is attractive.

Medical knowledge and treatment today has made astounding progress from the days when I was young and in my training. How we pay for it and deliver it has changed a lot too, but not for the better. We can’t go back to the past, but there’s a lot we can learn from looking back at the simpler way things used to be and applying those lessons to the present day.