Because of the complexity of the subject matter, this column will be broken up and published as a small series, placed in print over a number of sequential editions in The World.
They say, the one thing you can count on in life is change. Often change is for the better, but unfortunately this is not always the case. Over the last few decades many aspects of medicine have changed, a lot. These changes have greatly affected you the patient, your doctors and the other health professionals who are trying their best to provide quality care for you. How do you, as a patient, best navigate this new landscape? The old system was so easy. You’d make an appointment with your doctor, physically visit the office, and talk to him or her in person. There was never a computer screen in the room. Your doctor would actually see you, take the time to listen to you, physically examine you, formulate a diagnosis, tell you what he or she thought was wrong and treat your condition appropriately. At that point you’d pay the doctor a reasonable fee for the services and you were out the door. Interaction over. Probably 95% of all physician encounters could still be managed this simply.
Enter insurance companies, managed care, HMO’s, PPO’s, patient quotas, extensive third-party surveillance of your doctor’s management, the need to preauthorization seemingly everything from x-rays to drugs to surgeries, complex and dysfunctional electronic medical records, HIPAA laws, the threat of medical litigation and of course ever evolving governmental regulation. All of a sudden that ideal “Marcus Welby” interaction our parents were used to becomes a distant dream.
I don’t know how many times I’ve heard the complaint, “I saw my new doctor, but I don’t think they actually saw me and never examined me. Instead they were fixated on a computer screen during my visit”. I personally don’t understand how you can diagnose a patient without an exam. It’s the human connection, both verbal and physical, which allows a physician to formulate a diagnosis. Spend enough time listening and a patient will eventually tell you what’s wrong with them. They will give you their diagnosis. Skip these basic steps and things start getting expensive. In lieu of an exam, time pressured practitioners may instead order a batch of tests from the computer. This is one factor contributing to increasing health care costs. Where the computer detracts from the interview, it enables in the ordering of studies. Additionally, if your doctor is being forced to see 4 patients per hour per his or her contract, it’s goodbye human interaction, hello expensive tests. This is the new reality of medicine, which is being run by big business, not your doctor.
Why are some doctors forced to see 30-40 patient’s in a day. Part of the reason may be the organization he/she is working for. Coming out of residency most new physicians prefer signing a “secure” contract with a larger medical conglomerate. The days of creating new private practitioners are over. New graduates are less inclined to take the risks of starting a practice than their predecessors were. A contract guarantees a starting physician an income and offers employment security, but they will frequently carry production requirements. Businesses need to make a profit and your doctor is just an employee in a medical business. He or she needs to produce or else lose their job. Another reason your physician may seem rushed may be the Medicare patient load in the physician’s practice. Medicare hasn’t exactly been kind to your doctor over the past 30 years. Since 1990 the cost of goods in the U.S. has risen over 227%. Not only has physician Medicare pay not mirrored this increase, but has actually dropped 3% during this same period. In fact, in 2022 where the U.S. saw inflation running at over 8%, it was proposed that Medicare payments be cut by another 5%. Considering the costs of everything your physician needs to maintain a practice, medications, supplies, equipment, staffing and the physical office space, providing care for Medicare patients has become a losing proposition unless done at a very high-volume level. Again, goodbye human interaction.
Here’s another reason your doctor may seem stressed or in a bit of a hurry, shortages. The U.S. News 2023 Best Hospitals edition carried the following headline, “Dr.’s in Short supply”. I don’t think that’s exactly groundbreaking news to anyone who has recently tried to find a doctor. Interestingly though, in this same magazine was the article, “11 Signs You Should Fire Your Doctor”. So, doctors are in short supply, yet you should be looking for a reason to leave the one you may be lucky to have? Leave it to the press to create confusion.
So why are doctors in short supply? There are many reasons. One obviously is that the U.S. population is aging faster than it can be supplied with new doctors from medical schools. This has been the case for quite some time. Another is that there is a relatively high percentage of physicians near retirement age. I think there are very few physicians who do not truly love their work. Most would likely continue to work unless the job became unpalatable. What has made working in medicine less desirable is all the new red tape which accompanies practice (and it’s a very large, thick roll of red duct tape). Issues include not just all of the new pressures listed earlier, but now, and perhaps most importantly, the recent pandemic. All combined and we have physicians jumping ship at historic rates. These extraneous factors are leading to premature burn out. Unfortunately, we are seeing a large swath of highly qualified physicians retiring earlier than they probably wanted to. In fact, since the beginning of the pandemic America has lost over 100,000 qualified physicians due to early retirement. Every time an established physician decides he /she can no longer tolerate practice we lose years of health care experience which will never be recovered, and your care suffers. As for the above-mentioned article which suggests firing your doctor, you’d better be sure you have another one lined up as finding a new one will become more challenging with each passing day.
And doctors aren’t the only ones struggling as of late. Most hospitals are also finding it harder to make ends meet. Here the pandemic hasn’t helped at all, where maintaining adequate staffing has become challenging and expensive. Often the problem here may be much more complex and cannot be blamed simply on the pandemic. Many smaller towns have been served by their community hospitals for years. These have been managed and governed differently than those of large hospital conglomerates, ideally in a way which best served the local community and its employees. Recently it seems all hospitals, even the smaller ones, are being run more like businesses where institutional decisions are made with a different mindset. Typical corporate governance often tends to be less forward thinking, focusing more on immediate issues and short-term solutions. Decisions are made, equipment added, restructurings planned, and staff added or subtracted seemingly without consideration of personal repercussions or future business implications. All that seems to matter is getting their way and the immediate bottom line, somehow tomorrow isn’t on the radar. Short term solutions often come back to bite.
Soon a previously successful hospital is suddenly struggling for revenue. This is when they’ll start hiring outside consultants to fix their business, asking for guidance from a group that knows nothing about the inner workings and uniqueness of their institution. In most cases, the solution was right under their noses and not terribly complicated. Take care of what you have, who you have and be true to who you are. Treat your employees and healthcare professionals well and with respect. Listen to them and be flexible to their needs. They are your lifeblood. The fact that they are there means they are dedicated to your institution and community. If they feel the hospital doesn’t care about them, they will move on leading to lost revenue and service shortages. The job market for healthcare workers is exceptionally strong and finding a new job for an unhappy employee isn’t difficult. Doctors can also find other places to do their work. It’s a classic case of cutting off your nose to spite your face. If your employees and staff are happy, you have a better chance of being successful, it’s often just that simple. Employee morale will always serve the institution far better than a consultant’s opinion, where the expensive advice given is rarely applied anyway. The solution exists within, which is true with most things in life. All that needs to be done is to talk, listen and be flexible. Any businesses can go through tough times, getting past these is much easier with a complete and happy cohesive team.
