Thursday, November 10, 2016

Private Independent Practice; The Way It Was , When Time with Other Physicians and Patients Counted

The November 10 issue of the New England Journal of Medicine has an article :The Meaning and the Nature of Physicians' Work."

It opens with this paragraph:

" Medicine was a fundamental order.   Doctors' lounges were central locations  where community internists, specialists, and surgeons ate together, socialized, and 'curb-' each other for patient consultations.  Charts were dept on paper and were often indescribable."

I expressed this picture in my 1988 book And Who Shall Care for the Sick:  The Corporate Transformation of Medicine in Minnesota."

"Remember the good old days  when your fellow physicians were collegial colleagues; when hospitasl were charitable institutions catering to the sick; when youir success depended on your reputation among  your peers; when you built reputations in a year or two and paid off your banker; when you and your office girl handled all your office affairs; when word of your medical skills spread by word of mouth from one patient to another and from one doctor to another; when you were one of the few specialists around; when marketing was unnecessary because being a doctor with good bedside skills was enough, and when advertising was enoggh.  Those days are over for you and hospitals."

And I might add, the gathering of doctors in hospital staff rooms to compare notes, to make referrals to enjoy doctor-to-doctor camaraderie, to share the jobs of practicing medicine are over over.  Now, as a primary care physician you are forced to stay in your office to make ends meet and to make electronic heath record entries and to make 3ends meet because of Medicare, Medicaid, and Health Exchange cuts.  You now have to hand over your hospitalized patients to hospitalists.

Why is this?  Well. it has to do with the corporate transformation of medicine, and the demands of documentation over the needs of doctoring,  Medicine has become a huge business, comprising nearly 20% of GNP.   And it has to do with the ingress of the Internet and the availability of data to anybody and everybody, including insurers, government officials, and consumers themsleves.  And above all else, it has to do with time - the time formerly  spent face-to-face with colleagues in hospital staff room and time spent with with patients.

As the authors of the New England Journal of Medicine piece comment:

" We believe in the coming years, the U.S. medical community will hve to rethink the human-computer interface  and  merge the real patient with the Ipatient. We hve the opportunity to radically redesigned rmedical record systems; initially created for fee-for-service billing, as our organizations shift towards bundled payments, capitation, and risk sharing.  Perhhaps virtual scribes and artificial intelligence  will eventually  reduced our documentation burden.

And perhaps not.   Perhaps the majority of physicians will switch to direct payment and concierge medicine to escape the time-consuming hassles of electronic health records.  If the Trump election reveals anything, it reveals the unpopularity of EHR data among physicians accounts for much  of physician discontent because it consumes time away from patients.   It reveals data documentation has its limits,  as revealed by the false predictions about the election outcome among across the media, policy makers, pundits, and Silicon Valley aficionados.  Data reliability is limited by human data reliability.   The American middle class and blue color workers between the East and West Coasts in fl-over-land  does not rely on or care bout dta.  They car about their livelihoods, their families,l and their cultural traditikns.

As the New England Journal authors conclude,   Among physicians, "technology cannot restore porfessinal satisfactions.  Our professional will have to rebuild a sense of teamwork, community. and the ties that bind us together as human beings.   We believe that will require spending more time with each other and our patients, restoring  some rituals that are meaningful to both us and the people we care for and eliminating those that are not."

Time spent with one another, in other words, is of the essence, and cannot be replaced with data.

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