The Race to the Bottom

February 16, 2012

One of my colleagues is an internist.  He works as a solo doc, the casualty of a group liquidated under economic pressure.  He works like a donkey.  I’ve known him for years, our kids have gone to school together and I’ve watched him change.  He’s overworked, overweight, tired and his hair is falling out.  He never sees his kids.  While too proud to admit it, he’s working harder for less.  In between hurried bites at lunch recently he mumbled his mantra surrounding the changing face of medicine, “I’ve got to be lean and mean.  That’s right, lean and mean.

But where does it stop?  At first it was a matter of maintaining a salary. Now it’s survival compounded by the drive to maintain the ideal of something from another place and time.  More patients faster and faster.  It’s American medicine’s the race to the bottom.  It’s humiliating to watch, really.

Those with quiet contempt for the physician relish the dissolution of what was once a proper profession. But I have to wonder who’s really on the losing end here?


{ 16 comments }

Allison February 16, 2012 at 7:12 pm

Why do you not have an effective lobby? Where are your PACs? I want you as a profession to survive, and thrive, but can’t affect this outcome.

civisisus February 16, 2012 at 7:45 pm

not to discount your colleague’s pain, doc, but as for feeling sorry for yourself and your proper profession – get in line. There are plenty of practitioners of “proper professions” whose proper, middle-class vocations are being gutted by “job creators” wielding spreadsheets, lawyers, and the brain-dead bootlicking of people who insist those lizards are ENTITLED to extort disproportionate resources from everyone else, as if the “laws” of economics were like laws of physics.

So knock off your self-pity, lift your chin up, and join others like you who’ve gotten fed up and are ready to fight back. Healing talents, like lots of other high-intellect talents, have value, and deserve rewards. The ways in which those talents are wielded and rewarded will not “return” to some mythological, Marcus Welbyish golden era – but they needn’t succumb to the likes of Jamie Dimon or John Paulsen either.

DrV February 18, 2012 at 10:32 pm

I like your moxie.

Jennifer Fink February 17, 2012 at 9:06 am

We’re all on the losing end — except the insurance companies.

Steve Levine February 17, 2012 at 11:42 am

Obviously, patients, physicians, and American society on “on the losing end.” It’s not a pretty site.

Wendy Sue Swanson, MD February 17, 2012 at 11:47 am

Chilling post, Bryan. And spot-on.
After a recent announcement by my clinic that we needed to expand hours and see (yet again) more patients in 2012 than we did in 2011 than we did in 2010, etc, I did say, OUT LOUD, that they might possibly drive me out of primary care. I have lots of options for work, but providing a pediatric medical home is my first true love. Sometimes I wonder just how long this romance will survive…

Jason G Newland February 17, 2012 at 12:51 pm

Great post about the current struggles in medicine.

It seems this is happening not only in the ambulatory care settings but also among the care of inpatients. As Dr. Swanson mentions, the clinics are being asked to see more patients and to continue to increase that number each year. Isn’t there a point where you can’t see anymore patients? or Frankly, hope to not see more patients because they are healthier?

Our tertiary care children’s hospital tells us as the shift in medicaid patients increases our bottom line will be impacted and therefore, we need to see more patients with less providers. Furthermore, this has led our hospital to look into more ways to see more patients including telemedicine and outreach clinics. Is this right? Does this lead to better care for children or is it just so we can keep growing in order to make more money? I believe there is a ceiling in healthcare and eventually that will be reached. Are we headed for the same fate the financial industry experienced in 2008?

Raymond Cattaneo, MD February 17, 2012 at 4:27 pm

I do not envy those in 1. adult medicine or 2. those in academic medical centers. I am lucky to work in a private, primary care pediatric office at which I set my own hours. I am happy with the number of patients I see in a day, the time it takes me to respond to emails, the time it takes me to sign paperwork, and in the end, the salary I earn. It allows me to have ample time to pursue outside activities such as my MPH, a free health clinic, social media, and my family. More importantly, my patients are happy with me! And, Dr. Swanson…don’t leave primary care…just find a place where you and your talents are respected!

Dave Chase (@chasedave) February 17, 2012 at 5:41 pm

I agree with Dr. Swanson’s “chilling” comment. The most professionally satisfied MDs I know right now are those in Direct Primary Care models (aka “concierge medicine for the masses”). Two parts Marcus Welby, one part Steve Jobs. They have been willing to go against the grain and are professionally and financially rewarded while serving a mix of patients (typically 1/3 are uninsured while the rest are a mix of medium and upper income). Yes, it can be daunting to make the move but isn’t the description above 10x daunting? It does require questioning status quo and answering a fundamental question — who do you want to answer to? Your patients, an employer or an insurance company. All are valid options with pros & cons.

As the saying goes “The future is already here – it’s just not evenly distributed.” Every week, I hear of more primary care docs busting out and making the move to Direct Primary Care. Some are doing it solo (Dr. Craig Koniver who has even closed his bricks & mortar clinic to have a clinic on wheels) while others have big plans (e.g., MedLion, Qliance, Iora Health, etc.). I’ve written extensively about this game-changing movement — see http://www.delicious.com/chasedave/DPCArticles. Patients absolutely love these models as they hate “drive by” appointments as much as the MDs. Most don’t realize this model is supported in the PPACA and there’s a current bill (HR 3315) with bipartisan support to expand this model. The author (Rep Bill Cassidy, MD, GOP) of it was one of the most vocal opponents of the PPACA so it shows that it’s a universally supported common-sense approach as it already has support from the “D’s”.

As I said in a KevinMD piece, I think this is a time for Renaissance of Primary Care. It may sound counter-intuitive but sometimes when thinks are darkest, that’s when there’s the greatest opportunity.

Greg Matthews February 18, 2012 at 9:43 am

The thing that struck me most about this post was this line:

“Now it’s survival compounded by the drive to maintain the ideal of something from another place and time.”

I think that many docs, particularly those who’ve been in practice for many years, still have that “ideal of something from another place and time.” The questions I’d love to see answered (and, as Mr. Chase indicated, there are some bright spots of innovation here):
What is the NEW ideal that physicians – particularly those in primary care – should be seeking?
And if we can ID what that new ideal looks like, then focus on what’s next:
What are the things docs need to do (believe/know/change) in order to shape and realize that future?
What are the things patients need to do (believe/know/change) to make that ideal a reality?
There are a lot of people and organizations out there now who are trying to answer that question in different ways, but I haven’t see any one compelling answer yet. And maybe there won’t be *one* compelling answer. But I hope we find it before we crush more physicians under the weight of the broken system.

DrV February 18, 2012 at 10:29 pm

A new ideal. Thats a provocative question, Greg, and I’m concerned that doctors have been bystanders in system for so long that they don’t realize that they can play a role in medicine’s future. Part of this is our own doing – few are willing to organize. Another part is the loss of professional independence due to technology, administrative control and the independence of the patient. We’re in the early stages of a radical redefinition of the physician.

I suspect that it’s too chaotic right now to take stock of our ideals.

Greg Matthews February 19, 2012 at 4:02 pm

Well said. It’s one of the reason I’m so encouraged to see the explosion of doctors on the social web … I see it, eventually, as a way to form a shared voice and begin shaping that ideal. It may not be quick, but I believe that the first steps have already been taken – by you and by many of your trailblazing colleagues.

Med_Student February 29, 2012 at 7:22 pm

@ChaseDave, @DrV, or any doctor: what advice would you have for current 4th year med students who will soon be in residency in terms of how to approach all the upcoming changes that are occurring daily and with ObamaCare or any version of reform. Reimbursements are going down, hours are increasing, pay decreases, while student debt increases, etc.

I’m still at the beginning of my MD training and already worried sick of what I got myself into.

I guess I could summarize by asking all the practicing doctors, young and old, if your child came to you and asked if he or she goto medical school, what would you say?

Drmattmurray March 3, 2012 at 10:12 am

@Med_Student I’d tell them that during the sacred moments held between a patient and his doctor all of the outside noise about healthcare becomes just that–petty noise. The rewards of our vocation are immeasurable by the dollar when we treasure those moments do what’s best for the unique person in front of us.

Drmattmurray March 3, 2012 at 4:59 pm

Drmattmurray
(moderation preview) 6 hrs, 44 mins ago
@Med_Student I’d tell them that during the sacred moments held between a patient and his doctor all of the outside noise about healthcare becomes just that–petty noise. The rewards of our vocation are immeasurable by the dollar when we treasure those moments and do what’s best for the unique person in front of us.

drmattmurray March 3, 2012 at 5:01 pm

@Med_Student I’d tell them that during the sacred moments held between a patient and his doctor all of the outside noise about healthcare becomes just that–petty noise. The rewards of our vocation are immeasurable by the dollar when we treasure those moments and do what’s best for the unique person in front of us.

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