- Del Meyer, MD - https://delmeyer.net -

Recreating Private Practice

UCDMC – One of America’s Best Hospitals

Congratulations to UCD Medical Center for being recognized in six categories in the US News annual survey of America’s Best Hospitals.

It’s Hard to Break Old Habits

The American Medical Writers Association reports on the problems encountered when attempting to set up scientific communication offices in 12 of the 15 independent states of the former Soviet Union. These offices are to produce accurate and timely health bulletins for public health practitioners, policy-makers, the general public and the mass media, in an effort to improve health status. “The dissemination and effective use of timely and accurate health information is critical to pubic health practice throughout the world. In these New Independent States . . . the style of information sharing and scientific communication continued to reflect the tradition of the Soviet Union, which was characterized by information being protected rather than shared and by a ‘data-sent-upward, orders-sent-downward’ attitude toward communication. Thus, health professionals in the Soviet system were encouraged to gather and hold information rather than to share it with colleagues or clients.”

Recreating Private Practice from the Bottom Up

Robert J Cihak, MD, a syndicated columnist and editorial board member of the Association of American Physicians and Surgeons’ Medical Sentinel, states that Medicare reform, from the top down, has little hope. He sees greater hope of reform from the bottom up. “More and more physicians are seeing through the smoke and mirrors of the current managed care and government systems. Physicians in all parts of the country are firing their managed care plans and managers. Many doctors and patients around the country are re-creating truly private medical practice. By cutting out the insurance company middlemen, doctors and patients are doing an end run around insurance company bureaucracies. The SimpleCare.com nonprofit organization that originated in the Seattle area and many other independent doctor organizations around the country are developing parallel tactics. Doctors and patients deal directly with each other on the basis of trust, instead of each having an army of accountants, analysts, police and regulators looking over their shoulders and casting distrustful glances at the other side.”

Has America Lost Faith in its Physicians?

George H Koenig, MD, a neurosurgeon, asks in the San Mateo County Medical Association Bulletin, “Has America Lost Faith in its Physicians?” He expounds, “In many ways ours is a peculiar, inconsistent society. We vehemently criticize Congress, yet overwhelmingly reelect our representatives. We regard television as utterly inane, but won’t miss our favorite sitcom. We are critical of medical care, but invariably love our physicians . . . we forsake local merchants for Safeway and Home Depots; we replace individually-owned pharmacies with Longs and Walgreens and personal relationships are increasingly sacrificed for cheaper, impersonal, mass-market conveniences, while we complain the loss of customer service. America loves a good deal. When Senator Kennedy proclaimed health care a right, every politician and bureaucrat gleefully agreed with little, if any, real dissent or consultation with the medical community. It is in this context that physicians have struggled. What we provide is truly essential and completely dissimilar from other services, also labeled essential. There is simply no way we can meaningfully withhold what we do. And so when managed care came into being, we not only didn’t revolt, we actually felt obligated to make it work! When Medicare . . . slashed reimbursements, we cooperated without much dissent. . . . When patients demand every bit of the care to which they perceive themselves entitled, we acquiesce. When politicians mandate for more in-patient services than society can afford to provide, we acquiesce. And when managed care challenged our long-standing patient-doctor relationships, we acquiesced again. . . .” Koenig then responds to his own question stating that patients have not lost faith in us. “[But they] are awaiting our answer. Let us not disappoint them.”

First, let us redefine ourselves as physicians and not as providers. We should not allow insurance carriers to blur the distinction between MDs/DOs and lesser providers who have a tenuous relationship with their customers, our patients. Second, patients are our partners and need to understand what interferes with the care we try to give. Then, let us act collectively.

Designer Doctors for All

Philip R Alper, MD, internist in Burlingame, draws from the British Medical Journal to recount the history of Nazi medicine and the character of German doctors during the third Reich. Without this documentation, he would not have believed that physicians could lead all other professional groups in their acceptance of Nazism. He notes, “The reward to German physicians for their loyalty was prompt and concrete: an 11% income increase between 1933 and 1934 during the depths of the depression. . . . Doctors actually vied with one another for places in the Nazi extermination apparatus. Articles in the German medical literature were based on experiments on human beings. And organized medicine cooperated fully with the Nazi government. . . . Hitler had no problem in creating designer doctors to suit his own purposes.”

Alper then argues, “Today, in America, we are in the process of designing new doctors for our own times. Traditional medical values are challenged as inadequate and antiquated. Government, academia, employers, insurers, policy experts and editorialists, and some physicians are all busy redefining the physician’s role. The most basic departure from tradition is an insistence that the needs of groups of patients – called populations – take precedence over the needs of individual patients.”

Alper recounts “Physicians as Double Agents,” (JAMA 9/23/98) which concluded “. . . that managed care is here to stay; and, essentially, let’s get on with the job of designing doctors to fit the new circumstances. . . . This expanded role envisioned for physicians includes not only responsibility for all the populations of patients served by all the managed care entities . . . but also . . . to their health care teams . . . as well as to the plans themselves.” The physician will abandon “credibility and trust largely based on professional mystique and prestige” and substitute “credibility and trust based on data and documented evidence of effective treatment.”

Alper then questions “will American physicians embark on the slippery slope of abandoning total loyalty to each patient for a perceived greater good? . . . Will we eventually find ourselves the instruments of some tyranny?”

He recalls the story of Jules, an engineer in Israel’s high-tech industry, who defined the qualifications for a long list of jobs with conceptual exactitude. There was only one problem: his paragons did not exist in real life. Hiring came to a standstill. Jules was transferred to the library.

He concludes, “By analogy, I think America’s doctors and our patients are safe. The nondoctors and nonpracticing doctors who are furiously telling us what we should believe and how we should work are asking more than is humanly possible. It’s not an edifying thought, but the security of our profession and our patients may lie less in our virtue than in the ineptitude of our managers.”