There is a book, Are You a Doctor, Doctor?, that I often think about as I care for patients today, especially as its message is becoming increasingly difficult to follow in today’s healthcare system. I read the book decades ago while attending Palmer College of Chiropractic in Davenport, Iowa. It was written by a chiropractor who practiced in Wisconsin. He was a very charismatic individual who would visit the campus of Palmer periodically to give lectures to the students. As Dr. Fred Barge walked through campus with his red beret and his well-groomed goatee, he caught the attention of many of the students. I believe that was his intention.
His philosophy made us realize that we as students needed to change our mindset in order to be able to cross the chasm between being a student and being a doctor. We each needed to take on the analytical thought process and the persona of a doctor. We needed to take on the responsibility of caring for those in need of our service, and we needed to be willing to make necessary sacrifices in order to be able to care for our patients.
When we take a look at what healthcare was like 40 or, better yet, 60 years ago, we see that much has certainly changed.
On one hand, there have been improvements. Medical technology has developed to provide diagnostic access to areas of the body that previously could only be explored surgically. We now have robotic surgical procedures which are far less invasive than the surgical procedures that had been employed decades ago.
On the other, there is much we have lost. Foremost: the concept of the family doctor. It wasn't long ago that, at least from my perspective, a single practitioner would care for us from “cradle to grave.” As an example, the doctor who delivered my brothers and me also sewed us up when we gashed our skin in the multitude of mishaps we had over our juvenile years and beyond. I have heard recollections from many of my patients about similar doctors who cared for them throughout their lives.
Many doctors still exist in the field that have the best of intentions and want to help those in need, but sadly the doctor-patient relationship is constantly being challenged by a disjointed healthcare system. Something started changing many years ago, and these changes continue to blossom. I will attempt to dissect them here (please forgive the medical pun).
Specialization
One of the first changes was something called “specialization.” This meant that your family doctor would no longer deliver your children. That was the job of the obstetrician. He or she would no longer care for your heart condition. That was now the job of the cardiologist. If you had a problem with your stomach or bowel that couldn’t be fixed easily, then you needed to see the gastroenterologist.
Now, this is a good and necessary progression in the chain of care for patients whose conditions need further exploration. However, we need to understand that this progression further separates the patient from the caregiver and further diminishes the impact that the primary caregiver has on the overall healthcare relationship.
Corporatization
Over the years, private practices have been progressively gobbled up by large hospital facilities. The local “doc” that once cared for you throughout your lifetime in his or her own privately owned practice became an employee of the hospital. Visits were likely not in the same free-standing office the next time that you went for a checkup. Now as an employee, he or she would come into the office at a set time and leave at the same time every day, just like anyone else who worked for any other company. This certainly eliminated the late nights in the office caring for little Johnny who was up with the croup.
An employee status also meant that if the good doctor didn’t “produce,” whether because of too much time spent with a patient or because too few procedures were performed, he or she could simply be replaced by another employee doctor.
Insurance Mandates
Enter in the birth of “Insurance Mandated Care.” The inception of insurance coverage for healthcare began to be experimented with as early as the 30s and 40s, came into full fruition in the 1960s, and advanced in the early 70s with the advent of HMOs.
This created a whole new concept for both patients and doctors. By limiting reimbursement, the doctor-patient relationship was further strained. Now the doctor needed to make sure that he or she was doing what was necessary for the patient’s care AND had everything in order to be reimbursed by the “carrier” or insurance company. And too often, one had to “jump through hoops” in order to get paid. This meant that perhaps they would have to document time to receive payment for a procedure, and if they spent more time with the patient, they could receive a higher level of reimbursement (more money).
Also, in order for a patient to have a procedure, the doctor may not be able to just order it without having first tried other forms of treatment. I see this in my practice when I want to run more advanced testing such as an MRI. I may not be able to run an MRI evaluation on a patient if I feel that it is necessary for a patient’s accurate diagnosis and care; I must first attempt six weeks of “conservative care” first.
I once had a patient who had fallen. I wanted to perform an x-ray. I was told that I had to wait six weeks before they would approve the test. I suspected that the patient had a compression fracture in the lumbar spine. I had to get on the phone and literally threaten the adjuster, telling him that I was documenting their refusal to allow the patient to have the test and reimburse for it amidst suspicion of a fracture. The threat of a lawsuit was required for them to approve and pay for a necessary test. In the end, the results of the x-ray did confirm that was a compression fracture in the lumbar spine.
Computerization
The advent of computerized documentation certainly changed things as well. Now, in order for the insurance company to reimburse the good doctor for his or her services, all of the necessary information required by the insurance company must have every “i” dotted and every “t“ crossed. This is why I have patients tell me that when they went for their annual physical, the doctor didn’t even touch them. The doctor simply sat at the computer and entered answers to necessary questions asked.
Litigation
Let’s not forget the litigation effect on healthcare as well. Ambulance chasers (i.e., lawyers who seek out accidents to make sales) can make a lot of money from medical malpractice. Now I have to stop right there and say that medical malpractice litigation has its place. There are things that happen to patients that simply should never happen, and true malpractice should be litigated. Meanwhile, mistakes happen and are part of the risk of any procedure. The unfortunate truth is that many cases of medical litigation occur that are frivolous and should never see the light of a courtroom that move forward.
This situation has caused the advent of medical malpractice insurance, along with “CYA medical procedures.” What I mean by this is testing that is done not because it is necessary but simply to make sure that there will be no potential for litigation. This unfortunate reality causes an increase in medical malpractice premiums for the doctors as well as an increase in medical insurance premiums for patients or the companies for which they work.
This too has changed not only the doctor patient relationship, but also the ability for your doctor to be the doctor.
Retail Stopgaps
Whether it’s the result of added stress, a lack of respect for skills required to provide meaningful care, or a variety of other reasons, we now seem to have a shortage of doctors. Meanwhile, I believe we have also seen an exponential increase in sick patients. I've written extensively about how our lifestyles have negatively impacted the health and wellness of our culture. Regardless, to fill the gap, ancillary personnel now must act in the absence of doctors. Hence the need for what would be called Physician’s Assistants (PAs) and Nurse Practitioners (NPs). These individuals take more advanced training and can care for many of the common ailments that people with show up with at the local “Urgent Care Facility.” This has further wreaked havoc on the “Be the Doctor, Doctor” philosophy.
Now that CVS bought Aetna, I am seeing what I predicted years ago: the proverbial “Doc in a Box.” We are now seeing the creation of one-stop retail healthcare. With the right insurance, if you stop in at our local CVS, you can see a PA or NP who can diagnose your condition. Then you can step over to the counter and get the drugs prescribed. And if you have Aetna’s insurance, you will get a discount on both your drugs and your visit.
Perhaps I am being a little facetious, but my hypothetical visit may not be too far from the truth. I first saw these facilities in the CVS in Florida, and I have now seen them in Pennsylvania. I am sure that Walmart will follow suit as well.
Conclusion
This is the state of affairs today regarding the doctor-patient relationship. It has changed significantly in days since I first read Dr. Barge’s book. Some things, I will agree, are for the better. However some things definitely have been for the worse. There is no doubt that we have some excellent healthcare practitioners that still take the "Be the Doctor" advice to heart. Unfortunately they must practice in a system that prefers “provider employees” instead.
In my next newsletter, I will offer some direction and hope for living a longer healthier life regardless of today's less-than-healthy healthcare system.