Yesterday, the Wall Street Journal had a special section regarding some of the structural changes that have occurred in the practice of medicine in the United States, and projections for what will come in the future. They talk about the rise in the number of nurse practitioners and physician assistants, of health care teams instead of doctors treating your ailments, of robots and AI computers who may perform operations now done by surgeons, and the rise of medical care in drug stores like Walmart and CVS competing directly with primary care. They mention the use of Big Data in health care decisions, and the rapid erosion of privacy of your personal medical information. They don’t mention anything about the increasing corporate control of medicine, with large insurance companies and hospital systems buying up physician practices, and how this might impact you in the future.
As someone who has been practicing medicine in the private sector for over forty years (both solo and in group practice), teaching house staff and medical students at a major university, and with an MBA background serving on the board of trustees of a three hospital medical system, allow me to share my perspectives on some of these changes and their likely impact on you in the future. There is no questioning that the single most important driver of the changes we are now seeing are economic. The United States has the most expensive health care in the world, and not the best in terms of the over-all population. Medicine has become a highly profitable business for the pharmaceutical industry, the medical equipment manufacturers, the insurance companies, and the makers of information technologies. It has also become a lucrative field for the hospital administrators and consultants, but not necessarily for the hospitals themselves. It has become a business of progressively declining profitability for most physicians, who have to contend with rapid increases in regulation and business complexities (for which none have any training in medical school), increased work load, decreased autonomy, and marked increased in the costs of acquiring and maintaining medical education. Most new graduates now choose an employment model for practice, being unable and untrained to deal with the requirements of running a private practice. These changes are occurring as physicians have not been able to organize to effectively state and defend their roles in medicine. It’s not an accident that we are no longer referred to as doctors or physicians, but rather “health care providers” in public discourse, lumping us together with nurses, physician assistants, nurse practitioners, nutritionists, acupuncturists, optometrists, psychologists and the host of other people whose training is shorter, less rigorous, and without the same degree of oversight given to physicians.
A lot of the difficulty from the patient’s perspective comes from being unable to effectively discern which doctor is likely to provide the best care. Even as a physician, I am faced with a similar problem when I have to recommend a doctor to a friend or relative in a location where I personally do not know the individuals in practice. Board certification is a minimum criterion, but we all know a number of board certified doctors to whom we would not refer our patients. Looking at where the person did their training is partially helpful to someone familiar with the better training programs. Looking at patient ratings on Yelp or similar consumer sites only reflects on the social skills of the doctor and his office, not on the quality of care that is provided. Why is it so difficult to define good quality in medicine? It’s because the formal criterion currently used for defining quality comes from process measurements, rather than outcome measurements. It’s relatively easy to measure process; did diabetics get the appropriate tests to monitor their disease, are patient with heart disease receiving cholesterol lowering medicines? Measuring outcomes is a great more difficult, as current EHRs (electronic health records) do not provide the data. (The disasters which the EHR has and continues to cause in medicine are a topic too large to discuss here.)
Truth is, most patients get better or die, depending on the nature and severity of their illness. It’s only in a relatively small percentage, maybe 10-20%, where physician knowledge and skill truly makes the difference between life and death. Given these numbers, and the inherent variations in the number and severity of sick patients any one doctor sees, accounts for the difficulty in separating the wheat from the chafe. The body has a limited vocabulary in illness presentation. You can have pain, fever, nausea, rash, headache, weight loss, bleeding, shortness of breath, blurring of your vision. Since most people coming to a doctor’s office have fairly straightforward problems that tend be seen again and again, a person with limited training can well diagnose and manage these ilnesses. The problem arises when the presenting symptoms are caused by rarer diseases or more complex problems, such as a cold in the setting of someone who has underlying heart or kidney disease. This is the scenario where all those extra years of training and experience are required. We can only diagnose and the treat the diseases we know. This is why, if you have something that falls out of the usual pattern of knowledge of your non-physician health care provider, your diagnosis will likely be missed, or at least significantly delayed.
From an economic model, which is the one used by insurance companies and the government, using non-physicians to provide health care is unquestionably cheaper. It would also be unquestionably cheaper for airlines to use only computers to fly all their planes, instead of having highly trained human pilots to step in should there be a rare emergency. The question is which kind of plane would you choose to fly if the cost of your ticket could be lowered by 10-20%? As for hospitals and insurance companies controlling physician practice, some types of illness and patient demographic is a lot more lucrative to treat than others. How comfortable are you in ceding the decisions regarding what type of care will be available to you to these entities?
I come from the era when medicine was still considered a profession and a calling, rather than primarily a business enterprise. I was trained to place the needs of my patients before all others. Judging by the number of my colleagues who are still willing to risk their lives caring for those who may bring lethal disease to themselves and their families, we still have many who believe in that creed. Given the increasing corporatization of American medicine, how long will our ideals still be here when you need us?