Doctors are quietly and incrementally bowing out

We talk of disruptive change in health care as a tectonic cataclysm.  We’re hanging by the moment for that one innovation that will flip flop the practice of medicine and bring better, more efficient care.  But if you ask the poor lowly physician struggling on the front lines, we might tell you something different.  We are suffering through a sustained, insidious, devolution.  I see great change.

Reform takes place in fits and sputters.  Regulations are made and then remade.  The product of the governmental assault on the cost of health care is a series of forms and check marks.  Who better to be responsible for such minutia then the wayward primary care physician.  The same beleaguered professional whose numbers are dwindling in direct relation to their pay and inversely related to their work load.  With the passage of the ACA the paperwork has already increased.  The time spent typing away at a computer is multiplying.  Is care any better?

I see great change.  Physicians are looking for a way out.  They are becoming businessman, social media entrepreneurs and commentators, writers, reformers,  and career coaches.  They are retiring early and cutting their hours.  I spend less time in the clinic than ever before.  Each year I replace some of my office time with non clinical revenue generating activities.  The joy of patient care is being overshadowed by regulation.  We are quietly and incrementally bowing out.

The patient narrative is fracturing.  Primary care physicians are using hospitalists.  Patient centered medical homes and large medical groups are favoring speed of access over continuity of care.  A patient no longer has one physician but a team of doctors working on their behalf.  Unfortunately, as opposed to group think, what usually happens is that each provider knows strikingly little about the patient.  Tests are repeated, stories are retold  and modified, there is no longer a holder of knowledge.  A persons narrative not only heard but experienced over years of joint interactions and communications.  We are losing our connection.  Care is suffering.

In reality, the disruption we are looking for has been occurring in a sustained fashion for years.

Are we ready to deal with the consequences?

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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  • http://www.facebook.com/PMRNC Linda Walker

     I’m confused, is this sarcasm? How is this great change?

    “I see great change.  Physicians are looking for a way out.  They are
    becoming businessman, social media entrepreneurs and commentators,
    writers, reformers,  and career coaches.  They are retiring early and
    cutting their hours.  I spend less time in the clinic than ever before. 
    Each year I replace some of my office time with non clinical revenue
    generating activities.  The joy of patient care is being overshadowed by
    regulation.  We are quietly and incrementally bowing out.”

    And what about what is to blame for this, surely it’s not all put on the impending Affordable Healthcare Act but Obamacare sure has put another nail in the coffin of provider’s even if many don’t know it yet. Who can blame physicians for backing out of govt sponsored plan’s like Medicare or Medicaid? They are being pushed out by rising costs in their practices such as malpractice and the never ending regulations that can cripple the small provider!  Change?? for the better?? I don’t think so.. but a good step to change starts in November when you go to vote!

    • Joseph Nemeth

      Great = Large Amount

  • http://twitter.com/drmintz drmintz

    Excellent post (as always).  This “has been occurring in a sustained fashion for years.” See posts on KevinMD from a year ago http://www.kevinmd.com/blog/2010/11/doctors-quietly-opting-medicine.html and http://www.kevinmd.com/blog/2011/03/primary-care-physicians-rebelling-system.html .

    Supporters of ACO’s and similar models of care continue to stress the importance of primary care, yet nothing is being done now to strengthen the ranks of primary care physicians.  The “perfect storm” will likely occur in a few years when policy dictates that these models serve as the major way health care is delivered, but there are no primary care physicians left around to deliver it.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    “But if you ask the poor lowly physician struggling on the front lines….”

    Problem is that nobody is asking, not the lowly physician and not the lowly patient either. Regulations are being made by those who never been either, and are arrogant enough to contend that they represent both.

    • http://twitter.com/NuriahLaMeiga La Meiga

      This is exactly the root of the matter. For over 20 years, this profession has entrusted politicians and organizations such as the AMA, which represents less than 20% of practicing physicians, to speak rationally on behalf of patients and doctors without our direct involvement. How naive is that? And so they continue to bow out. That’s nothing new. “The species that survives is not the most intelligent or strong but the that most adaptable to change.” – Darwin. Medicine is evolving, and fortunately, newer docs are evolving with it.

      • davemills555

        Hard to abandon old habits when they were traditionally so lucrative, right?

  • http://twitter.com/livewellthy Stewart Segal

    Nice eulogy!  Our profession is being systematically murdered and there appears to be no reprieve. 

  • bearing

    “The patient narrative is fracturing.  Primary care physicians are using hospitalists.  Patient centered medical homes and large medical groups are favoring speed of access over continuity of care.  A patient no longer has one physician but a team of doctors working on their behalf.  Unfortunately, as opposed to group think, what usually happens is that each provider knows strikingly little about the patient.”

    Patients are going to have to take ownership of their own narratives, and make plans for when they lose competence to manage them.  There is an opportunity here for a new type of specialist in the paramedical field.

  • http://www.facebook.com/people/Joel-Selmeier/686242826 Joel Selmeier

    None of the reforms address the problem. We could address the problem without any of these stultifying reforms. But everyone is imagining medicine and caregivers to be something they never have been and never will be. They could make more money and work with more freedom if we were not a nation that believes that the way to fix problems is to pass laws and regulate behavior. There is a solution. But no one is talking about it.

    • sj0

       Have you written a post about the solution no one is talking about?  I would like to read it.

  • Seval Gunes

    I am going for early retirement before the full EMR control and command structure kicks in.
    Everybody knows that EMRs do not decrease medical errors, help provide better care or save money but they are excellent tools for the Government to see exactly what you are doing.
    Just wait for stage 2 or 3. I hope that I will be retired by then. 

    • http://twitter.com/kendig Jordan Kendig

      ” A patient no longer has one physician but a team of doctors working on their behalf. Unfortunately, as opposed to group think, what usually happens is that each provider knows strikingly little about the patient. Tests are repeated, stories are retold and modified, there is no longer a holder of knowledge. A persons narrative not only heard but experienced over years of joint interactions and communications. ”

      Hence the urgency behind EMR’s.

      Reference “Docs who used EHRs showed lower malpractice claims”. http://www.healthcareitnews.com/news/docs-who-used-ehrs-showed-lower-malpractice-claims

      “Risk factors for medical error and resultant malpractice claims, including poor communication between providers, difficulty in accessing patient information in a timely manner, unsafe prescribing practices, and lower adherence to clinical guidelines, may be ameliorable by health information technology,” the report notes. “The high quality and availability of proper documentation in EHRs may increase the likelihood of successful defense against malpractice claims.”

  • http://www.thehappymd.com/ Dike Drummond MD

    Thanks for this post Dr. Grumet — and I will provide a counterpoint. For years now I have heard the common refrain that echos yours … “doctors are leaving medicine in droves … ” and have seen no evidence that this perception is actually true. Physician dissatisfaction as measured by burnout surveys sits at an average of 1 in 3 worldwide regardless of specialty. My perception is that changing practice and political uncertainty are increasing those numbers … BUT I see no evidence docs are leaving medicine. They do seem to be working harder and complaining more – Sermo.com being the most obvious example of a virtual venting forum.

    And I do agree … the primary care doc remains the Rodney Dangerfield of the profession.

    My two cents,

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • davemills555

    Doctors are quietly and incrementally bowing out? Really? In spite of the article, the main reason for this seems to be pretty easy to understand. Doctors are tired of always being demonized for doing what you were trained to do, right? You were trained to “do no harm” and simply help people, right? How interesting! Seems to me, that’s true for teachers, police, firefighters, sanitation workers, parks and recreation workers and many other public servants that do not deserve to be demonized just because they happen to want to simply help people but find themselves in the middle of a huge worldwide recession that was caused mostly by corrupt and unregulated banking practices. It does not feel good to be blamed for things you can’t control, right? Doctors are always blamed for things they can’t control. So are the rest of America’s public servants, right? There’s no better evidence than the class warfare that we are witnessing in Wisconsin. A few wealthy oligarchs decided that since they owned everything else, why not own a entire state. So these few wealthy oligarchs proceeded to conduct a war on middle-class public servants by using a few puppets that they got elected to key positions within state government. They succeeded! These few oligarchs now own Wisconsin! Who knows, maybe these few wealthy oligarchs would like to also purchase America’s health care system. My guess is that they already own most of it. As I see it, it’s only a matter of time until they own doctors too. The really sad part is, doctors don’t have a clue that it’s happening. They are so naive. What doctors don’t seem to realize is that they have much more in common with vocational public servants like nurses, teachers, police and firefighters than they do with the wealthy oligarchs in America. The “glass ceiling” is there and doctors don’t know it. Doctors would do better joining forces with the 99 percent than they would trying to achieve 1 percent status. So naive!

    • EruditeEarlobe

      I am sorry to rebut your statement, but your words sound like a leftist diatribe to my ears. The facts are that healthcare, education, and many other rights will have to be rationed and costs controlled. Monies for these items have become scarce as we as both taxpayers and private citizens have accmulated mountains of debt in an orgy of profligacy. It is time to act as rational adults before we end up like the irrational PIIGS of Europe. The vox populi of Wisconsin have spoken clearly on behalf of rational actors.

      • davemills555

        “The vox populi of Wisconsin have spoken clearly on behalf of rational actors.”

        Huh?

        Fact is, the opinion of the “vox populi” was clearly “purchased” by an 8 to 1 spending ratio on TV attack ads. How can true democracy exist when a few wealthy individuals can own the broadcast airwaves like that? Rational actors? There’s nothing rational when a Supreme Court allows and encourages America’s wealthy few to mold and shape the public opinion by flooding the airwaves with false attack ads. Seems to me, only an exploited 1 percent wannabe could possibly think like that.

        • EruditeEarlobe

          The cost advantage when you factor in all of the outside union help by nine major unions and their paid organizers, teacher “sick-ins,” shenanigans by U of W med school academicians, and the MSM biases, and this was more than an evenly funded match for the left. Again, the vox populi made a choice: this was a landslide! Pragmatism won over profligacy. If you still can’t understand the danger of unfunded liabilities, then may I suggest looking at the PIIGS countries in Europe.
          Sent from my Verizon Wireless 4GLTE smartphone

          —– Reply message —–

      • EmilyAnon

        In south Florida in 2008, criminals accounted for $400 million in fraudulant Medicare bills.  That’s just the thefts that were caught. In one year. In one small part of the country.  Estimated $60 billion lost for that year alone country-wide  . (60 minutes – 10/2009)

        Multiply that year after year after year….  the amount lost to fraud might just trump the waste due to the ‘orgy of profligacy’

         

        • EruditeEarlobe

          “Might trump…” sounds like “hope and change.” You are dealing with the foibles of the human heart where instincts that are less than altruistic reside… Sent from my Verizon Wireless 4GLTE smartphone

          —– Reply message —–

        • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

          Here’s a database you might find interesting:
          http://exclusions.oig.hhs.gov

          Anybody who does business with CMS (Medicare/Medicaid) can be excluded from participation for various misbehaviors. It can be doctors, dentists, nurses, the cabdriver in Manhattan that drives a Medicare patient to the hospital.

          You can search by reason for exclusion  - 
          Default on health education loan or scholarship obligation, program-related conviction, quality of care, fraud, etc.

          Usually the physicians get excluded for the basics. Lost their license, controlled substance convictions, failure to pay student loans, etc. You can’t bill Medicare/Medicaid if you lost your license to practice medicine. The student loan thing is a little unique, in that you’re not excluded for a fixed period of time, or permanently, you get reinstated as soon as you’re up-to-date on your loan payments.

          But for the program-related convictions, fraud, the money kind of violations, it’s not the physicians as much as it’s private entities, DME companies were notorious for fraud, that’s why there’s such a crackdown. A practicing doctor would have to commit fraud “retail”, one patient at a time. To commit fraud “wholesale”, hundreds at a time, you need to be a business entity like a DME vendor or a nursing home, or a clinic owner.

          You can look up by type of violation, type of entity (physician vs. nursing home vs. pharmacy vs. DME vendor), or by location……so you can see the dirt in your own neighborhood.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    Kevin here’s a story you might want to cover, sort of related to this:

    http://abclocal.go.com/wtvd/story?section=news/abc11_investigates&id=8656615

  • kholt16

    My father is an internist and growing up, I always knew that I wanted to enter the medical field. I will be starting my first year in medical school this coming August. My father is very encouraging but I have had people who left the medical field warn me of the difficulties that the profession faces today. This article sums it up nicely http://bit.ly/ISg0dq. To highlight a few points we have a problem with the payment system for doctors – doctors have to fight with insurance companies to get reimbursed and the government is criticized by the field for providing low reimbursement rates on a fee-for-service-basis. Furthermore, malpractice premium prices are going through the roof, especially in states like Nevada. Tort reform is essential to address the ridiculous premiums that physicians face and the fee-for-service payment model needs to be replaced. 

  • http://twitter.com/knitsteel kskilesjewelry.biz

    Are they bowing out because of money or because of ethical concerns? I’m unclear after reading the article.

  • http://alanmbradford.com/ Alan Bradford

    Very intriguing post. This actually brought a smile to my face. I can’t wait to be a primary care physician. I wrote about why if anyone cares to take a gander: http://tmblr.co/Zq6oZwOtuiZD