The relevance of physicians is dwindling rapidly

The relevance of physicians is dwindling rapidly

I spend way too much time worrying about “silly” things, things I have no control over. I know this because my wife frequently catches me in the act and urges me to relax, to focus on what I can change. But despite her best efforts, I recently fell off the wagon again and became obsessed with a simple, seemingly innocuous question: Are physicians still relevant? Admittedly, the question appears somewhat absurd. After all, doctors do still succor the ill, a clearly worthy endeavor. But their relevance in our society is, in fact, dwindling rapidly. Allow me to explain.

At one time, physicians enjoyed a virtual monopoly on medical advice. There was no Internet for patients to turn to, no social media to consult, and there were no direct-to-consumer pharmaceutical advertisements “educating” the public about therapeutic innovations. There were also no supermarket chain store clinics or mid-level providers. In fact, there were no “providers” at all, only doctors. And terms like “wellness,” more marketing concept than physiological state, were unheard of.  So unless you were sick, you really had no reason, or time, to contemplate your health. But if you did fall ill, an independent physician was your only choice.

Back then, physicians also exerted considerable control over their professional lives. There were no third-party payers, no unnecessary layers of administration, and there was little government intervention in medical affairs. No bureaucrat would dare tell physicians how long to spend with their patients, what medications to prescribe, or how much their services were worth. Doctors provided a unique, valuable service, and then their patients simply paid them, confident that, for better or worse, a physician’s advice was always his or her own. Independent physicians ruled; their control over a rudimentary industry was complete.

Fast forward several decades, and it’s a brave new world. Health care is no longer the quaint, intimate village it once was, a place where unrushed, independent physicians served patients with unfettered therapeutic autonomy. Instead, it is now a massive metropolis where “employed” physicians roam the streets aimlessly, impotent drifters struggling to engage nameless patients for more than a few minutes at a time. They wander through once familiar territory, amidst towering glass buildings and blaring neon signs built by the bureaucracies now in charge, waiting for instructions, for permission to practice the very profession they created. Their sincere, objective counsel is no longer audible above the big-city cacophony of technological “progress,” corporate profit motive, and government mandate.

Despite the foul smog of competing interests that permeates this new delivery paradigm, one thing is clear — physicians are no longer calling the shots. And each time a physician is instructed to add medically irrelevant information to a patient’s medical record for billing purposes, each time she must alter a successful therapeutic approach to accommodate a change in insurance company policy, each time administrators force him to discharge a patient prematurely or see more patients in less time, each time any physician relinquishes any professional control whatsoever, the medical profession dies a little; it sacrifices a bit of its collective integrity and ceases to be truly relevant.

This is because relevance requires two critical elements: access and trust. Unfortunately, our system prevents physicians from meaningfully pursuing either of these. For example, we now generally equate “access” with health insurance. And doing so allows some to declare victory each time a new patient registers on Healthcare.gov. But quantifying access requires a broader perspective. Does five minutes with a physician constitute access? Does access require seeing a physician at all, or will a mid-level suffice? True access requires ample time with an independent physician, and our system is increasingly incapable of facilitating that.

And trust, an equally important component of relevance, cannot exist when a physician’s integrity is repeatedly compromised by a system that allows third-party payers, government bureaucrats, and health system administrators to subjugate a physician’s training, independence, and judgment for the sake of profit or political expediency. How can physicians establish trust with patients when their thoughts and actions, their practice models and therapeutic approaches, even the legitimate right to define quality in their profession, are no longer their own? The answer is that they can’t.

The tyrannical politico-corporate complex now firmly in control, the widespread dissemination of medical information facilitated by technological innovation, and the ever increasing reliance on non-physician providers have driven physician relevance to an all-time low. But, short of major legislative reforms unlikely to occur in the near future, here are a few things the profession can do to decelerate its frenzied sprint toward irrelevance.

Medical education must meet the demands of our time

The profession has refused to aggressively restructure, shorten, and improve medical education to meet the needs of today’s primary care patients. And so the market has, in effect, relieved it of that responsibility. Many have cited reduced professional standards and compromised clinician quality, both unfounded assertions, as reasons to not change the process by which physicians are trained. But professional vanity and blind loyalty to tradition, the same egotism that leads some to look down their noses at nurse practitioners, are more likely the culprits. And the profession will pay dearly for its continued hubris.

Diagnosing disease, dispensing medical advice, and prescribing medication, activities once exclusively reserved for physicians, have increasingly become the purview of numerous other “providers.” And a dangerous precedent has therefore been set, one intended to prove that medicine can be practiced without physicians, that pieces of their job description, critical ones, can be easily reassigned to others. Allowing that precedent to take hold will further fragment patient care, ensure decreased autonomy, exert downward pressure on compensation, and promote enough infighting to guarantee that no collective voice opposes corporate or government interests.

We should not only provide a path by which talented nurse practitioners can become full members of our profession but also ensure that a retooled, agile medical education system can produce clinicians like them in the future. There is simply no reason not to do this. A family physician is no less a doctor than a neurosurgeon despite having a vastly different skillset and less years of training. And we implicitly trust them to not cut someone’s brain open, even though, legally, they could. The profession must produce a reinvigorated general-practitioner-type role to deliver a powerful message — that the practice of medicine requires a doctor. Failing to do so will make all physicians less relevant.

All physicians must embrace a “concierge mentality”

Our current health care system has left many patients dissatisfied with both the quality and quantity of care they receive. This has created considerable opportunities for independent physicians to creatively address these gaps in patient care and simultaneously develop additional revenue streams by embracing what I refer to as a “concierge mentality.” This approach involves consistently searching for value-added services that complement a payer-dependent practice and exist wherever physician expertise and professional preferences intersect with insured patients’ unmet, unreimbursed medical needs.

Regardless of specialty, this iterative process helps identify affordable services that provide patients with real value and augment physician career satisfaction. Moreover, proactively engaging in this process will not only financially diversify an existing practice but also facilitate, if necessary, a transition to a direct-pay, concierge, or hybrid model. In the coming years, independent physicians’ relevance, their leverage with payers, their very viability as businesses, will increasingly depend on their ability to secure diverse sources of income and provide truly differentiated services.

Physicians must become effective marketers

Exceedingly short, poorly reimbursed office visits dominated by administrative tasks; weeks, months, or even longer between visits; an ever growing body of easily accessible, consumer-oriented medical information, some good, most bad; entire “health-related” industries competing for patients’ attention; harsh socioeconomic conditions driving poor health behaviors — these are the realities of today’s patient care environment. A huge chasm exists between a physician’s ability to sustain meaningful, ongoing relationships with patients and patients’ need for high-quality, objective, relevant health information.

Physicians must embrace a scientifically robust variation of content marketing to bridge this gap. This doesn’t mean they should slick their hair back, take to the airwaves, and implore patients to “come on down to Crazy Dr. Bob’s Health Shack!” It simply requires a technology strategy that successfully keeps patients engaged between visits through HIPAA-compliant use of the Internet and social media. This not only allows physicians to serve as reliable “digital tour guides” but also allows them to meaningfully influence patient behavior in inexpensive ways that can improve outcomes. Creatively using technology to both develop your professional brand and extend your clinical reach is now more critical than ever.

Payers have a vested interest in ensuring that patients view all doctors as cheap commodities, that your presence on some preferred provider list is the sole factor determining whether individuals become, or remain, your patients. The only way to retain some leverage with payers, or justify the monthly fees of a concierge model, is to maintain a truly engaged patient panel that sees differentiated value in your approach. And ten minutes a month is simply not enough time to accomplish that or remain relevant in patients’ lives, no matter how competent and compassionate the clinician.

What do you think? Are physicians as relevant in our society now as they were decades ago?

Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.

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  • Luis Collar, M.D.

    I think the “dilution” is due to multiple phenomena, but I’m not trying to be alarmist at all. I truly think the medical profession as a whole, not just primary care, is in big trouble. Will the profession be eliminated altogether? No. Will it be anything like it has historically been, or like what most people that went into the profession expected it to be? Absolutely not. A lot of the decline is because of policy / exterior forces. But, sadly, a lot of it is the profession’s own fault.

  • Luis Collar, M.D.

    “…interference from seemingly every other stakeholder…”

    Yup. Truly amazing to me on two fronts. One, that the people driving healthcare policy and governing the profession itself are not physicians.

    And, two, that the profession has not reacted sooner to defend the attacks on the very essence of what it has always meant to be a physician. Beneficence? Justice? Non-maleficence? Autonomy? Is it just me, or do the concepts of third-party payors and corpmed both, in their own way, violate all of these? I don’t think the original idea was to adhere to those central tenets of the profession “as long as someone doesn’t make you stop.” Sad for physicians. Sad for patients. And many aren’t even aware of it.

    • Mike Henderson

      The leadership role abdicated by physicians has been filled by everyone else. Are we guilty of benign neglect secondary to our “hubris?”

      • Luis Collar, M.D.

        I think in some ways, yes. Medicine is unique in that when the profession does not advocate for itself it is also not properly advocating for patients. The two parties are inextricably linked, and their interests are more aligned than most realize. Unfortunately, in addition to the policy / political / corporate forces that have had an impact on the profession, I also think physicians are often stigmatized for advocating for their own interests (e.g. “you make too much money already” etc…) Those sentiments are understandable given what the nation and most average Americans are experiencing, but I think the profession could do a better job of publicly expressing how the policies that adversely affect them also, more importantly, adversely affect patients.

  • J Rizzo

    Dream team: Physicians (MD’s and DO’s) team up with politically savvy nurses unions, representing NP’s- form a massive united lobbying Super Pac called “Insurance companies are killing America” and knock the insurance lobby down on its butt.
    Nothing will change until MD’s and NP’s/RN’s start politically working together to take power back. The AMA seems lost and poorly represents many Physicians opinions/ business interests.

    • Luis Collar, M.D.

      I alluded to the need for “clinician unity” in the piece. Definitely agree with your points. We might really need a “dream team” at this point.

      The situation with the AMA is sad, in my opinion. Why isn’t the organization more democratic in its approach? Why don’t members have a say as to how the organization’s yearly budget is spent? What issues to lobby for / against? What pending legislation to support / oppose? What policies from the insurance industry to take a stand against? How much to give to charity? Seems to me like members should have a say on all these issues instead of just getting letters about the organization’s “position” on some thing. Who decides that “position”?

      • J Rizzo

        The AMA is essentially the sole proprietor of CPT codes. CPT codes only benefit two parties: The AMA and insurance companies. In 2012 the AMA made $219 million, I doubt all of that came from membership dues. Pretty shady, really.

        • Luis Collar, M.D.

          That’s what I was referring to. Seems like members should have more say in how at least a significant portion of that money is spent…Might help align the interests of the “leadership” with those of the “membership.”

        • Deceased MD

          Dumb question. How does one own CPT codes? I find this very strange. They are proud owners of numbers for a disease code? What a valuable business model.

          • Luis Collar, M.D.

            Sort of seems similar to the practice of patenting and profiting from a gene or other DNA sequence. “It was always there, but we ‘invented’ it and now own it.”

          • Deceased MD

            I was thinking the same sort of line of thinking but at least the other perhaps may have scientific value one could argue. In essence the AMA has really turned into an “Administratium” as it were. CPT codes are just administrative gibberish. They do not contribute in any way to medicine other than their pocketbooks. and is this something they can actually be proud of?????? Really all we have is sort of powerful secretarial staff running medicine. They are so very weak. As you say, they have no policies (besides CPT codes) no stand on issues etc. etc.

          • Patient Kit

            Perhaps the AMA is secretly a subsidiary of the creepy Dyad Institute. Sorry, I just started watching season 2 of Orphan Black last night. ;-)

          • Luis Collar, M.D.

            Hi PK… Hope all is well. At the risk of sounding like an out-of-touch nerd, I don’t know what Orphan Black is (lol) so I won’t comment. But at least I did get the Married with Children reference from ninguem’s comment. Although that could just mean I’m getting old, lol.

          • Patient Kit

            Hi Doc. Somehow I seriously doubt you’re an out-of-touch nerd or old. More like a busy doc/writer/person. Orphan Black is a really good Canadian TV series in which the awesome actress, Tatiana Maslany, currently plays five different roles. It’s about cloning and what it means to be human. The Dyad Institute is an evil biomed/biotech entity that has some serious experiments and investments going on. It’s a really good show that airs on BBC America here in the US. The whole first season (10 episodes) is currently available for free On Demand via Time Warner cable (another evil empire) if you’re looking for some good TV.

          • Luis Collar, M.D.

            Okay, got it. Actually sounds interesting. I’ll try to watch it. I can never get enough of the good old “evil empire” programming. lol. Sounds like it might be based on reality? Thanks for the heads up.

          • betsynicoletti

            They develop and own the copyright on CPT codes.

      • Deceased MD

        And they’re killing us. Weekly letters if we need AMA life insurance. Probably do if things keep up.

        • Luis Collar, M.D.

          lol… You get those too, huh? I get those, as well as their car insurance and other “business affiliate” advertisements, sometimes multiple times in the same week.

          • Deceased MD

            Exactly!!!! I find them toxic. It’s actually more like daily into the circular file.

          • Luis Collar, M.D.

            One logical question would be whether or not that marketing / advertising money could be better spent on activities that would better serve the needs of their members. I mean, is the argument really that different than what is often said about the pharmaceutical industry and the dollars they spend on marketing instead of R&D?

          • Deceased MD

            exactly. It seems that advertising is running rampant everywhere adding no value to the world in general. In time, they will be defeating themselves.

      • buzzkillersmith

        Won’t work. See my other comment. You will lose. We will all lose.

    • buzzkillersmith

      Nothing will change even if those things happen. Business interests will win at every turn. They’re better than we are at jockeying for money and power. And they always will be.

      I wonder how hard it is to get an executive MBA?

      • Luis Collar, M.D.

        Agree that it may very well be too little too late. But, even setting aside physicians’ interests for a moment, the implications for patients are huge. Do these trends indicate that our society is okay with concepts like “the end of the medical profession as we know it” or “medical care as a cheap commodity”? A decade from now, will physicians really just be clerks or, at best, members of middle management shuffling papers or, more accurately, digitally monitoring workflows? With practice standardization, knowledge management, technology, decision support, mid-levels, the widespread availability of medical information, etc.,do physicians even need to be involved in most patient care? Is it possible the market is just telling us what is best for society, and it “hurts our feelings” to hear it and see it happening? I don’t think it is, which is why I write in the first place, even if it is futile. But your point is well taken.

        Incidentally, not sure if you were serious about the MBA part of the comment, but a friend of mine is currently enrolled in a part-time MBA program now. I’m sure they vary greatly in difficulty, but his exact words were, “it’s a joke compared to med school.” I think the challenge is mainly scheduling / fitting it in with practice / do you want one in the first place.

        • Deceased MD

          And what are his plans once he gets it?

          • Luis Collar, M.D.

            I’m actually not sure what his specific plans are. I know he’s not happy with clinical practice (for many of the reasons I point out in the piece), and I think he’s looking to work for pharma as a medical director or in some other capacity, though I’m not sure. I’ll ask.

          • buzzkillersmith

            I don’t know about his plans but I plan to find out who you really are and then become your evil boss!

          • Deceased MD

            Buzz, come on over. I’m in the Forest lawn cemetery plot 5, row 6. If you come, please bring flowers.

            We all have an evil boss. Take your pick.

          • buzzkillerjsmith

            Drat.

          • buzzkillerjsmith

            I think the likelihood that you’re actually dead is pretty low.

            And a damn good thing, too. Because I’m afraid of ghosts. There, I said it. Halloween I’m under the covers in the footy PJs. I invite people over to keep the headless horseman at bay but they never come. I think it was Night of the Living Dead that did it.

            Please, in the name of all that is decent and normal, stop freakin’ me out.

          • Deceased MD

            I think this blog is freakin’ everyone out. It is a lot more morbid than my sarcasm, but sorry if I freaked you out.

          • hawkeyemd1

            He should run…run like the wind. LOL

          • Deceased MD

            You’re great hawkeyemd. That is the best plan. LOL.

        • buzzkillersmith

          Just kidding about the MBA. But I can dream.

          I agree that implications for pts are huge, but the implications of the Syrian civil war for women and children and old men are huge as well.

          You know as well as I do that pts don’t much enter into it. They are cotton and we pick the cotton and CorpMed and Pharma and the like are the plantation owners.

          A couple tidbits: The NYT has a story today about the degradation of the American middle class. Perhaps even more interesting, there is a new study out showing that the US is an oligarchy, not a democracy. If you google (google owners are oligarchs too) you’ll find it.

          There is no hope. All is lost. All our posts and comments here will have as much influence as urinating into the wind. But still entertaining.

          • Luis Collar, M.D.

            So the toilet picture is appropriate then? lol… Thanks for contributing, BKS.

          • hawkeyemd1

            Great post, as usual. And love the picture, by the way. Very appropriate, IMO.

          • Luis Collar, M.D.

            Thank you for the kind words. I really appreciate it.

          • Luis Collar, M.D.

            Just read the NYT article, by the way… Interesting piece. My original title for this piece on my blog was “Are physicians still relevant?” Maybe the real question is, “Is the middle class still relevant in our society?” And, despite frequent claims to the contrary, most physicians are solidly in the middle class (that is, if you only use three classifications – poor, middle class, and rich).

          • buzzkillerjsmith

            Agree 100%.

          • Patient Kit

            You’re beginning to win me over to the dark side, Doc Buzz. I have one foot in and may be ready to abandon all hope and embrace hopelessness very soon. :-(

          • buzzkillerjsmith

            I really think being able to see the world clearly is of some usefulness.

            And the dark side isn’t so bad. I don’t mind it.

        • buzzkillersmith

          A few other comments: I think that society doesn’t care hardly at all about our work circumstances. My best guess, which might not be all that good, is that primary care docs, those that are left, will transition from clinicians to middle management to a great extent. Meetings and memos, supervising other clinical staff and so on. I also think that this transition will not be attractive to med students, almost all of whom will do other things. As they should. They’re too smart to get caught up in that kind of foolishness.

          The market is indeed sending us a message, but the market is often wrong, as those who bought Miami condos a decade ago know all too well. I think losing primary care medicine will not be good for pts.

          It is possible that the whole or most of medicine will deteriorate to such an extent that it will no longer be of that much interest to the 5% or so of the population with the energy and the cognitive horsepower to practice medicine. The 5% will land on their feet–maybe running CorpMed.

    • liz1rn1

      I do think nurses and doctors should work together more often on these issues. It doesn’t happen often though.

      • Luis Collar, M.D.

        I agree. It’s unfortunate that it doesn’t happen more often.

      • hawkeyemd1

        Some doctors and nurses have a hard time collaborating and getting along enough to get the right patient the right drug at the right time for a simple pneumonia. It’s a nice thought, but I think it might be a bit unrealistic. But, hey, at least the meetings might be fun.

  • Lorne Richardson

    It seems that other professions are cherry picking what physicians used to do and are leaving the most difficult problems to the MD’s. Every health professional is trying to expand there sphere of influence because they are not being compensated for the fundamental tasks they were trained to do.

    • Luis Collar, M.D.

      Great points.

  • ninguem

    Luis

    If you’re going to be a toilet, be a Ferguson.

    http://www.youtube.com/watch?v=IL2YRDzpTL4

    • Luis Collar, M.D.

      lol… I went with American Standard instead… bawooosh…

      • ninguem

        Now that’s a man’s flush.

        • Luis Collar, M.D.

          lol… Thanks for the blast from the past. Hard to believe that was like twenty years ago…

  • John C. Key MD

    Much of the injury is self-inflicted, and continues even today. One term you hear a lot today in the media and politics is “pushback”–”Joe Politico made a statement an received considerable pushback from his opposition”.

    Among us docs, I don’t hear no pushback! We gripe among ourselves about the AMA.the gumment, and our non-physician masters, but where’s the pushback? We just sign the contracts and return to the galley oars.

    The only primary care physicians worthy of the title today are those who have shucked it all and gone into an independent direct patient care. (Full disclosure: I have not, still working on my manhood.)

    • Luis Collar, M.D.

      Definitely agree that there has been no organized “pushback” to speak of. But, honestly, I don’t know that “pushback” would do much good at this point. I think if any change is to take place, it will be gradual and involve greater and greater numbers of physicians moving to direct-pay / concierge practice models. There are really only two ways to regain any leverage with the powers that be. One option is to unionize (unlikely) and the other is to simply exit the system. If enough physicians went direct-pay / concierge, it might force some change.

      • Deceased MD

        The only problem with that for most is the system is stacked against private MD’s. Hospitals have the monopoly and government is supporting them even though as you well know private is cheaper for HC costs.

        • Luis Collar, M.D.

          Good point. I was just referring to the fact that if enough physicians chose to not participate in the system as it currently exists (by going direct-pay, concierge, retiring), and patient access therefore became even more limited, then the powers that be may face considerable political pressure to change at least some of their ways.

          • Deceased MD

            Oh I would hope so. What is alarming to me is that if you compare 20 years ago to now it is getting worse. And the time allotted for pt care is getting worse as well as other disciplines taking over. I am amazed MD’s have put up with this–as well as pts.

          • Luis Collar, M.D.

            Don’t understand MDs lack of response either. But most patients just want their medical issues addressed, particularly as access becomes more of a problem in our system. Many are just happy to receive care, and they are therefore less prone to worry or think about training, credentials, etc… And if the care they receive from mid-levels is good, which is often the case, they have no incentive to probe further into titles, level of education, etc…

          • Deceased MD

            Somehow Rand Paul got another Board of ophthalmology to deal with the increased regulations of the boards. I guess it folded, but he did it before he went into politics as an MD. Granted his dad no doubt helped. Almost seems like we need to become politicians rather than MBA’s.

          • liz1rn1

            I don’t think other disciplines are so much taking over as stepping in to help. Speaking as a nurse, I think NPs, PAs and others do more to help and lower costs than could be done with just more physicians. I do see why it isn’t a great situation for docs, but I don’t think its a bad thing overall. Just my opinion, but I do agree the system isn’t being good to docs in many other ways.

          • hawkeyemd1

            It really isn’t about costs. If it was, the focus would be on the countless other “waste” in the system. Physician compensation is a tiny piece of the overall health care expenditures in this country. NPs and PAs and others do a great job, but once their numbers get large enough they will be just as much a skapegoat as physicians are. Their pay and working conditions will deteriorate just as quickly. And those in charge will seek the next “solution” to the problem they created.

  • Deceased MD

    Very good article as usual Luis. I don’t think I will ever understood why MD’s did not fight back 20 or so years ago when it started getting ugly. Although the AMA lacks concern about its members as it does not rely on dues, I guess it is a really incompetent organization. But I still am baffled as to how MD’s have not fought back on their own. Perhaps they are just so divided? What are your thoughts?

    • betsynicoletti

      Exactly: I believe that the main source of AMA revenue is from the copyright they own for CPT.

      • Luis Collar, M.D.

        Agreed. But they do also collect dues. Though not a primary source of revenue, ethically they do owe their membership’s views at least some representation. Perhaps they should drop the dues and simply focus on CPT codes / publishing as their sole business model?

        • Deceased MD

          good idea. Also rename themselves as such.

      • Deceased MD

        Great article you wrote BTW. Although the new ICD 10 codes feed the data bases, I assume the AMA profits from the increase in coding? Who exactly are the winners here?

        • betsynicoletti

          Thank you for your kind words. I don’t see how the AMA profits since they own CPT. They object to the implementation of ICD-10. CMS wants ICD-10 for the increased specificity. But, I really believe they’ll end up rolling up the data, because it is mindlessly specific. AHA is a co-creator with the CDC of the Clinical Modification data set we are set to use. I guess the AHA thinks that the greater specificity will help with DRG selection. And, there is a huge industry of consultants who are willing to help you implement ICD-10. I’m part of that group. I just don’t believe that it has added value for physicians, but if we have to do it we will.

          • Deceased MD

            I am trying to figure out who MD’s work for. Data miners or pts. So in essence the winners are the data miners. But like you said it will turn out to be a lot of money spent likely on meaningless data. Someone obviously thinks this data is worth a mint. What a waste of resources for HC.

    • Luis Collar, M.D.

      Probably a combination of reasons: the trend wasn’t clear at first, physicians are busy and tend to focus on the job at hand (e.g. patient care), they are not strictly a homogenous group politically (e.g. they have differing views so not easy to agree on one united way forward), their numbers are relatively small (e.g. compared to, for example, the number of lawyers or other professionals in this country), they are not as highly represented in politics (e.g. compared to lawyers / MBAs), etc… Do you think there is one primary reason why they haven’t “fought back” or is it just the result of a combination of issues? Do you think a physician’s role will even be recognizable in the next ten years? I don’t believe it will be.

      Funny that many had feared physicians would become irrelevant due to technology (robots, for example) but, while that might still happen, their relevance is facing a much more serious / imminent threat from policy forces and various other phenomena.

      • Deceased MD

        Reading your post is like watching a Hitchcock film. It’s horrifying. I did not realize that there were so few MD’s compared to lawyers. All I can say is my eyes were wide open and i could see it happening way back. I did not understand all the political interconnections that I have learned from here. But one watches helplessly like your picture of the toilet. I think your question is very valid. The old question, what do you want to be doing in 5 or 10 years has now been replaced by what will happen to us and our profession in 10 years?

        • Luis Collar, M.D.

          Very true. And it’s nowhere near a conspiracy theory. The trend is there, it’s clear, and it’s accelerating.

          • Deceased MD

            Sadly I was in the ER recently- unfortunately I was not work. It was a horror. But the one “lucid” pt ( I say this tongue in cheek) was a very paranoid guy-who of course really did not belong in this ER. Even my grandmother could have seen he had a mental illness). In any case, his CC was that the medical system was out to kill him and I quote. His rational was off ( air embolus from an injection) never the less he seemed the most sane in the whole system. Not only is the system being killed off, our profession etc. but the HC system if we ever need it ourselves is no longer recognizable.

  • Thomas D Guastavino

    The role of extenders in every field, whether it be legal, dental, physical therapy etc. will continue to grow as the economy becomes more and more restrictive. Medicine is no exception. As physicians, we have four choices.
    1) Form a union to protect our interests. This, of course, requires strong leadership.
    2) For medical, move into a supervisory position, especially in a direct pay practice.
    3) For surgeons, develop unique and not easily replaceable skills. Consider going overseas.
    4) Retire

    • Luis Collar, M.D.

      Agree with the four choices. But I would only point out that, of the other career fields you listed, only medicine seems to be moving from “extender” to “replacer” in response to the economic forces in place. Paralegals, for example, cannot represent clients in court or practice law etc… They are highly skilled, and they assist lawyers in their work, but the are not allowed to practice law.

      • Thomas D Guastavino

        Precisely why we as physicians need to move to those areas where we are irreplacable.

        • Luis Collar, M.D.

          Agreed. One of the challenges, though, is that areas where physicians are “irreplaceable” are becoming increasingly difficult to find. I’ve worked at hospitals where PAs routinely perform more than half of the less complex surgical cases almost independently (e.g. surgeon only in OR with them for about 30% or less of the case). That’s just one example, but many others exist, even in fields where physicians’ skills had been viewed as much more “irreplaceable” than, for example, primary care.

          • Deceased MD

            Can you give an example of PA’s doing surgery independently? what kind of procedure?

          • Luis Collar, M.D.

            I’ve personally been in ORs where cholecystectomies, herniorrhaphies, and appendectomies were performed almost exclusively by PAs (as I said, surgeon there at opening incision and dropped in at several points, but vast majority of procedure is completed by PA). One surgical group at the hospital had PAs performing these routinely with minimal supervision.

            I’m not saying it is an inherently good or bad practice. I’m not a surgeon, so I’m not qualified to make that call. But I was just pointing out that it is no longer a reach to think that some non-physician providers might wish to do those types of procedures independently in the near future because, in some cases, they already are. “Irreplaceable” is becoming less applicable to physicians every day.

          • toolate

            That’s shocking. I did not know that was possible. Is it legal? How can it be?

            I never knew I had to be worried about this. In case I ever need surgery – how do I know which surgeons are doing this?

            WHY are they doing this? Egads, I’m aghast. Thought I’d heard it all.

          • Luis Collar, M.D.

            I don’t know about the legalities of it because I am neither a lawyer nor a surgeon. And I don’t know how prevalent it is, though I would suspect it happens to that degree in only a minority of cases at this point. I was surprised at the few cases I saw with my own eyes, and it is concerning if patients aren’t made aware of this, but I frankly wasn’t shocked. Many surgeons work with the same PAs for years, and they’ve performed procedures hundreds of times together. It’s very similar to senior residents that handle increasingly large parts of surgeries with decreasing attending supervision (at the VA, I once saw a senior surgical resident perform an emergent BKA at night without an attending present at all, though he was notified via telephone). It’s also not unlike the practice of having an anesthesiologist supervising nurse anesthetists from a distance. The legalities / technicalities may be different, but the overall concept / trend is similar.

          • Deceased MD

            And I am sure the hospital is charging the same rates as if it were a surgeon.

          • Lisa

            You’re presuming the surgeon is a hospital employee. My ortho surgeon has PAs assist in surgeries; his fees includes the PA services.

          • Dr. Cap

            Unfortunately (or perhaps fortunately in some places) these decisions are left in the hands of the states. My state passed a law that allows APRNs to practice independently of physicians entirely just last week. (Practicing at the “top of their license,” as it were) And there’s another bill on the floor to allow naturopaths to order tests and perform basic procedures like an MD. My suggestion is to poke around the legislatures website and see what they’re trying to pass under your nose while you’re too busy performing secretarial tasks to notice. Oh yeah, thanks for all that advocating AMA!
            [That post was a joke, right?]

          • Luis Collar, M.D.

            Your suggestion about checking for pending legislation is a good one. And I’m not surprised that APRNs can practice independently in your state as that is not all that uncommon anymore. But I am surprised by the naturopath information you cited. I don’t know of any states that have done that before. Are they going to be allowed to prescribe drugs? Thanks for the information. Incidentally, are psychologists allowed to prescribe medications in your state? That is another trend, but I’m not sure how many states currently allow that.

          • Lisa

            When I had cataract surgery, I asked my sister (an OD) if about what I should look for in a surgeon. Did I need the best or was a good surgeon enough? She said I wanted a surgeon who ran a cataract mill. I found a surgeon who did just that and I was/am happy with the results.

            Quite frankly, if I had to have a simple, routine surgery, I want the person who does it to have a lot of experience with the particular sugery. If that person is a PA, working under a surgeon’s direction, I don’t care. What is important to me is the persons surgical skills.

          • Luis Collar, M.D.

            A very reasonable position… As long as patients are fully informed as to who will actually be performing the procedure and what the level of supervision will be, I don’t see a problem with a patient making that choice. But, for example, how would a patient determine how much experience with a particular procedure is enough? And if experience is what the patient is looking for, why wouldn’t he or she want the surgeon to perform it? What about a surgical resident? I suppose it could happen that a very experienced PA is working with a new surgeon, but that generally hasn’t been my experience.

          • Lisa

            Before I had my first hip replacement, I did some research on procedures. I found out which surgeons in my area used the anterior approach, which I was interested in. When I first met with my orthopedic surgeon, I asked him about how many hip replacements he had done and his complication rates. I also talked to several friends who were physical therapists and got their opinion. I also asked my pcp his opinion of my surgeon. With my cataract surgery, I went through a similar process. The difference is that I asked my sister if she would contact one of her colleagues to ask their opinion of local ophthalmologists.

            By the way, my orthopedic surgeon has a PA who assisted both of my hip replacements. From my point of view, the PA had a major role in the process, as he went through the pre-surgical routines and consent forms with me. He also reinforced my surgeons post surgical instructions. Post surgery, the PA took phone calls and directed non-routine calls to the surgeon. When I developed a minor wound infection (a long story in itself, but traceable to the fact that I am sensitive to surgical tapes) after my first hip replacement, the PA had me see the surgeon immediately. The infection resolved quickly; I attribute part of that to the PAs actions.

            All of the surgeries I have had were not emergency situations so I had time to research surgeons. In an emergency situation, you don’t have that luxury.

          • Luis Collar, M.D.

            Thank you for sharing that. It seems like you did quite a bit of research. Did you also look at any data online (e.g. on hospital or physician complication rates / quality scores, etc.)? That data is limited and not available for every procedure type / situation. But just curious if you looked or even wanted something like that? Or are you more comfortable hearing about complication rates / experience from surgeons themselves, along with recommendations from family / friends?

          • Lisa

            i would have looked at on-line data if it had been available, but it wasn’t. But I wouldn’t rely solely on on-line data, mostly because of difficulty in evaluating it.

          • Luis Collar, M.D.

            Got it. Thank you. And I’m glad to hear everything went well with your surgeries. Hope all is well.

          • Patient Kit

            So….surgeons can talk to patients as if they did the surgery and bill as if they did the surgery but residents and PAs can actually do that surgery — and nobody is under any obligation to inform the patient of this? We all just pretend that the surgeon did the surgery? Concerning is one word for this.

          • Luis Collar, M.D.

            As I said above, I’m not a surgeon, but I have observed a large number of surgeries. In the vast majority of cases, the surgeon is there for the entire procedure and does most of the surgery himself / herself. The exception to the rule (the one I was used to seeing) is when a senior surgical resident (usually a chief resident a year from graduating) handles most of the case on his / her own with the attending supervising. That is a standard part of training to be a surgeon. For those cases, usually the attending surgeon tells the patient he will be there supervising but the resident will be performing much of the surgery. That seems logical since the residents are well prepared and need to work more independently their last year before they head out on their own. Junior residents usually just assist and then do more as their training progresses. And patients are usually also told this at teaching hospitals.

            What I was surprised by at one hospital, was that one particular surgical group would use their PAs (three of them) much more than I’d ever seen before, doing much more than even residents at teaching hospitals. That is, they would let the PAs do most of the procedure and, many times, the surgeons weren’t even in the OR. They’d just pop in and out at a couple of points through the procedure but didn’t even really scrub in. Hadn’t seen that before, and, honestly, haven’t seen it since so I don’t know how common it is. It wasn’t a teaching hospital, so I don’t know to what extent the patients were informed as to who would actually be doing the procedure. I also don’t know if they were told the PA would be “assisting,” when in reality they were doing much more than that. I wasn’t privy to those conversations, so I just don’t know what was said. I don’t know about the billing either, but I would assume they were billed as if the surgeon did them because their names were on the “board” as the attending surgeons for those cases. I’m sure the PAs were competent, but I’d never seen PAs doing entire cases almost on their own before, so I was surprised by the practice.

          • EmilyAnon

            I was told the surgeon has to say he performed the operation in order for insurance to pay. Residents and PA’s are salaried by the hospital and can’t bill. After one of my operations, a medical student proudly told me he did my skin stapling. OK, no problem, but even though there was a column in the operating report to list “others” in the room, it didn’t report him being there. The way the report was dictated, it was as if the surgeon did everything – skin to skin. I doubt the patient will ever get a true history of who did what during their operation. I think it’s a given in a teaching hospital that there will be many anonymous “others” performing part/most/all of the operation.

          • hawkeyemd1

            Most of the same things happen in private hospitals too with other providers that aren’t residents like PA’s. It really isn’t that uncommon.

          • hawkeyemd1

            Truth is, a lot of things go on in the OR that patients don’t know about. Most good, but some bad and unbecoming. As a doctor, I think the profession does a very poor job of informing patients exactly what will take place during surgery, or what actually took place once the surgery is over. Informed consent protocols in most hospitals are just a matter of going through the motions. Sad but true

          • Patient Kit

            No wonder they give us a drug cocktail to knock us out, immobilize us and make us forget anything we might have accidentally heard in the OR.

            I consider myself very lucky to have gone through four surgeries (fractured femur, ruptured Achilles tendon, torn meniscus and ovarian cancer) with absolutely no complications. And yet, what I’m reading here about the lack of transparency about what really goes on in ORs is scaring me. I hope the Universe considers my surgery quota for this lifetime complete so I don’t ever have to go back into an OR. And I love my most recent surgeon (assuming he is, in fact, my surgeon).

            What is the point of seeking out a specific surgeon with a good reputation, if that doc might only be supervising your surgery? Scary stuff. More transparency, please. “You don’t want to know what really goes on in there” are not comforting words.

          • Thomas D Guastavino

            Unfortunately, you are observant and correct. That still leaves us with one of the four choices. Standing around and complaining about it his not an option. If we are to fight we need option one, or at least some cohesion within our ranks. Given the current climate (primary care vs. specialist comes to mind) that is not very likely. By the way, I found it very interesting that your post got the attention of the AMA.

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

          You don’t need to move anywhere. Actually, you need to stop moving, or falling back, and start fighting, with at least some conviction. Paralegals are not arguing cases in court not because they are incapable of doing that, but because the bar association is not allowing it.
          Graveyards are full of irreplaceable people….

          • Mike Henderson

            Exactly. When one gives services away for free, then their worth is nothing. We are losing relevance as we have not negotiated for what we are worth. Passively, we have let our relevance slip away and others have recognized that and filled the void.

          • sp gp

            I agree.

            Many here may think this is extreme and may hold a different view, but I decided a long time ago that I never volunteer, and never work without pay. Never.

          • hawkeyemd1

            And no other profession is really expected to the way this one is.

  • doc99

    From the comments, it appears a post entitled “The relevance of the AMA is dwindling rapidly” would be more appropriate.

    • Luis Collar, M.D.

      Good point. Definitely wasn’t the intent of the piece. And, in fairness, they can’t be blamed for the state of the profession (too many other parties, including physicians themselves, are responsible). But it is interesting that other organizations (like the American Bar Association) seem to take a completely different approach at advocating for their members.

      • Deceased MD

        how does the bar advocate?

        • Luis Collar, M.D.

          It’s not as much about the process as it is about the results. Lawyers’ interests seem to be much better protected in our society than physicians’ interests. Again, the AMA aside, why is it that no one other than a lawyer (or supervised law student) can represent a client in court? Or do any other things that constitute “practicing law”? Is it because they are “irreplaceable” in that process, more irreplaceable than physicians are in healthcare? Or are there other forces working to protect the legal profession from losing its identity, forces not at work in medicine? I really don’t know the answer to that, but it is an interesting question.

  • liz1rn1

    I don’t think they are less relevant to people that are actually sick and need their help. But with so many other providers now and so much medical information out there, they really don’t have as much control anymore. Others have commented that they aren’t irreplaceable and that’s a good way to think about it. I don’t think it’s necessarily bad (except for doctors) though. Many people or healthcare professionals can help others now, and people can help themselves, and that’s a good thing. But I do think, as you point out, that the profession doesn’t do a good job of helping itself or keeping up with the times. Similar situations have affected other jobs and careers as well. They didn’t keep up and were replaced or became obsolete. That could be happening here as well.

    • Luis Collar, M.D.

      Great points. I think in many ways, and for a variety of reasons, it is happening. Thanks for contributing.

    • hawkeyemd1

      The key to all of this is for those in charge to make people believe they are replaceable. Once they do that (and they are well on their way) they can restructure health care any way they want.

  • liz1rn1

    Thank you for referring to NPs and PAs as “valuable clinicians”. As a nurse, I always appreciate it when a doctor gives credit to other providers. It doesn’t happen very often, but as I get ready to pursue becoming an NP it is definitely nice to hear.

  • toolate

    You’ve never advocated for any physician. Are you there when physicians are assaulted by the PTB for doing good for pts? Nope. Are you there when docs are called into the nurse manager and chastised like children, and all the doc can do is bow their head, their hands tied, powerless, and wish they could drop dead from the SHAME of it? Nope.

    Did you do anything to stop the horrendous paperwork monstrosity? The awful EMR? The whole Joint cmsn/QI/whateva nonsense? Nope.

    Have you done anything to fight the degradation of this profession, the loss of autonomy, the daily humiliations foisted upon us to satisfy psychopathic admin and misguided academics and profit making parasites? Nope.

    Have you ever helped physicians who’re in dire financial straits because of the whole system? No, to the contrary, you make money off of us, from your CPT codes.

    You do NOT represent doctors. Remember that OUR side is also the pts side. It’s the medical care of ALL of us we’re talking about. The AMA is part of the problem. Doctors are under assault from all sides, and you are part of the enemy forces.

  • goonerdoc

    This is a troll, right? It’s gotta be a troll. Whoever wrote this CAN’T possibly believe this, right?

  • ninguem

    Hey Kevin, when did you turn this into a comedy site?

  • Deceased MD

    I knew you’d show up with the usual propaganda . But the question is if you were really doing something productive for MD’s, why would you have to pay some clerk to write in every time you get negative PR?

  • Luis Collar, M.D.

    I respectfully disagree with your assertion that “physicians are more relevant than ever.” Physicians and patients should, in fact, enjoy considerable relevance in our society. And it would therefore logically follow that their opinions should carry considerable weight in any health policy discussion. But the simple truth is that many physicians are frustrated, countless patients are struggling, and, in numerous ways, our healthcare system is failing them both.

    In my article, I highlight a few of the ways in which physician relevance is declining, but there are many, many more. And as passionate patient advocates shackled by bureaucratic folly, as highly trained professionals too often forced to perform below their potential, as caring individuals that confront tragic systemic injustices and indescribable human suffering on a daily basis, our physicians’ declining relevance should be quite concerning to most, if not all, Americans.

    I believe everyone–citizens, politicians, entrepreneurs, patients, and physicians alike–each in his or her own way, must individually address the wrongs that permeate our system. Collectively, though, the profession must also do more to improve the delivery of care in this country, to, once again, lead with sound logic and unbiased idealism and help guide policy makers in constructing a more just, administratively streamlined system that actually works. Here are just some of the areas in which I believe the profession should either improve or intensify its efforts:

    1.) public relations – The media is rife with stories that place individual physicians in the untenable position of defending unsubstantiated attacks on the profession’s integrity. While it is true that there are isolated cases of physician wrongdoing (professional negligence or billing fraud, for instance), and while it is necessary to publicly condemn the few engaging in those activities, there also needs to be a singular, loud voice responding to most, if not all, of those stories. No article or television broadcast that gratuitously condemns the profession should go unchallenged, particularly those that use sensationalism simply to increase readership or viewership. The profession needs a more active voice, one that speaks the truth about both its failures and successes, one that educates the general public and consistently brings balance and perspective to what is increasingly a one-sided narrative in the media.

    2.) physician autonomy – It is undeniable that physician autonomy has declined significantly in the last several decades. The profession must vehemently and relentlessly oppose any corporate policy or piece of legislation that, in any way, inhibits physicians from acting solely in their patients’ best interests and strictly in accordance with their professional judgment. As long as physicians disproportionately bear both the ethical responsibility for patient outcomes and the legal burden of malpractice lawsuits, no entity should be allowed to influence what medications physicians prescribe, when they discharge hospitalized patients, how many patients they see in a given day, how they choose to update medical records or complete patient notes, what non-value-added, non-clinical activities they must engage in, or which guidelines or best practices they follow. If any employer or third-party payor, public or private, explicitly violates physician autonomy or otherwise induces physicians to act against their patients’ best interests and, in effect, commit malpractice by enacting policies that encroach on their independence, that should become public information. Not only should that entity’s policies be condemned, but it should also assume full legal responsibility for any malpractice claims arising as a result of those policies.

    3.) medical education – The profession must collectively address several concerning trends in medical education. For example, the ever increasing tuition costs associated with undergraduate medical education, costs that have outpaced inflation to a greater extent than overall healthcare costs have, are simply unacceptable. Moreover, post-graduate training, continuing medical education, professional certification / recertification, and ongoing testing requirements, all costly, time-consuming processes with little evidence to support their value to either physicians or patients as they currently exist, must all also be addressed.

    Physicians and patients are inextricably linked; their interests are aligned. Therefore, any policy that prevents physicians from performing their jobs properly, strips them of their independence, or impedes their ability to derive satisfaction from their professional endeavors also adversely affects patients on countless levels.

    I don’t believe any one person or organization is responsible for all that ails our healthcare system. And I also don’t believe that any one person or organization can unilaterally solve all of our problems. But I do think we can all do better, and every single patient in this country deserves it.

    Thank you for contributing to the discussion.

    • Deceased MD

      Well said Luis. They tend to make these formulaic statements and never write back. I think we should have an interactive blog with key physicians at the AMA on KMD to discuss these very issues. Although honestly doubt it will get us anywhere.
      And congrats on 100 posts! This has touched a nerve in a lot of both MD’s and pts alike.

      • Luis Collar, M.D.

        Thank you, DMD. I like your idea about the interactive blog. Regardless of where it goes, it might be useful to have that open exchange of ideas between the two parties.

        • Deceased MD

          You know I wish. But I don’t think the AMA is going to change even with your level headed way and rational thinking. So far I have seen many of their posts and they were written by a robot that wants to pacify anyone upset with them. I do think that they hold much of the accountability.

          • Luis Collar, M.D.

            Maybe if they had more outreach soliciting physician feedback using social media and actually used that information to build some sort of response to the concerns voiced? They could still develop policy as they currently do, but they could dedicate some percentage of their policy activities / budget to addressing those concerns? Using social media is cheap, and, if they show they are acting on the concerns expressed in a tangible way, it might even help their membership numbers. Just a thought…

          • Deceased MD

            You are so diplomatic. I think that is a very good idea. But I think they have no intentions of doing so.
            The only way there could be an organization to represent MD’s is to create a new one and make the others eventually data warehouses of CPT codes that will eventually hopefully become obsolete. Somehow Rand paul created a separate ophthalmology board out of frustration with the existing one, I wish there was somewhere to start such an organization. Your post although effective at getting the point across as always, this one is so depressing. Like a death.

    • http://www.ama-assn.org/ama American Medical Association

      Thanks Dr. Collar, good perspective – especially your point about enhancing and accelerating medical education. We, too, agree that making changes in medical education is imperative.

      Actually, we are very proud of our recently launched Accelerating Change in Medical Education initiative aimed at bringing changes to medical education, which includes proposals like developing new methods for measuring and assessing key competencies for medical students at all levels. The purpose of this being to create more flexible, individualized learning plans, which could allow them to graduate sooner.

      Ultimately, the goal is to work with medical schools to
      identify and widely disseminate the best models for transformative educational change to ensure that today’s medical students are best prepared for the health care environment of tomorrow.

  • sp gp

    I’m a 33 year old internist. Let me briefly say this.

    First, many of the problems physicians face are broadly shared by the middle class. The reason is clear: labor (even educated labor) has little power anymore. Vast, inconceivable sums of currency are now controlled by the banking and corporate elite, of which physicians are not, and were never, a part of.

    Second, physicians deluded themselves for a long time. We chased after the dream, didn’t we. We were “gods” who were going to cure every disease, keep every patient alive forever ordering every test and doing every procedure under the sun, and become rich doing so.

    And none of that is proving to be the case, so it’s time to whine. Myself, I keep one foot in and one foot. I still practice but I’ve ceased participation in so many other ways.

    Most, not all, physicians are middle class slaves paying down the debt and keeping this bankrupt system going. First, admit who you are. That is the first step to enlightenment.

    • Luis Collar, M.D.

      “Most, not all, physicians are middle class slaves paying down the debt
      and keeping this bankrupt system going. First, admit who you are. That
      is the first step to enlightenment.”

      Very true. All middle class Americans are, in many ways, struggling. And the medical profession, while still enjoying above average compensation, is by no means the financial “promised land” that is Wall Street or corporate CEOdom.

    • hawkeyemd1

      “Most, not all, physicians are middle class slaves paying down the debt and keeping this bankrupt system going. First, admit who you are. That is the first step to enlightenment.”

      Amen. Well saidl.

  • Luis Collar, M.D.

    Good point, GD. So far, has only affected the numbers going into primary care. But I do think in another few years, the total number of college students interested in the profession, including most specialties, will decline. Primary care is first, but I believe most others will follow shortly. Particularly as the economy (hopefully) picks up steam and viable opportunities for bright, hard-working graduates abound. Application numbers are cyclical in medicine and never seem to completely break down, but I think we are in for an unprecedented dip in that cycle in the coming years.

  • Luis Collar, M.D.

    I would not. And I, unfortunately, mean that sincerely. I think my posts, if anything, may reflect that too much. I generally try to be realistic regarding medicine’s shortcomings, and, while not overly optimistic, I do occasionally make suggestions regarding ways to improve healthcare in this country. I obviously don’t have all the answers, and some may not agree with my views, but I try to at least stimulate some discussion and raise awareness of some of the issues that adversely affect both patients and physicians.

  • toolate

    Your post is very depressing. It real makes me think.

    I think that once upon a time – within my own living memory – it did feel good, really good, to serve some higher cause. I remember there being something special and uplifting about being a doctor.

    I think this was true everywhere, not just in the U.S., and it had nothing to do with money.

    Now it’s become miserable, all over the world, though the particular form of misery varies between different countries. It has little to do with money, though that has become the only compensation for the misery.

    It’s the social contract that’s broken, and medicine is but one manifestation of it. Used to be that serving the greater good was an honor – remember WWII, when all those kids ran away to war? Think of Britain in WWII. Now it’s every man to himself.

    I think doctors went into this thinking it still matters, but you’re right, nobody gives a damn any more about anything. There’s nothing holy any more, and I mean that in the secular sense. There’s no point in throwing yourself in front of enemy fire, because no one will give a damn. And we’re all less naive, due to mass communications. We know that the good guys don’t win. We know that the party will go on without us and there’s no point to martyrdom.

    This profession involves giving and giving and giving of yourself. Under more and more stressful circumstances. And for that you get attacked, sometimes by other doctors too, more often by all the rest. The worst part is no one ever says thank you. There is no way I can do this in some detached way. It’s an impossible situation.

  • Luis Collar, M.D.

    A brave new world? It sounds far-fetched to most, but, in many ways, I agree. How long that will take, I’m not sure. It depends primarily on how quickly the technology advances. But as I point out in my piece, the trend is already there for anyone willing to see it. I’d previously thought surgery couldn’t be touched, but that theory broke down when I saw PAs doing smaller surgical cases almost entirely on their own (see above comments). It seems cost control is pushing diagnosis / treatment to other providers, and legislation backs that trend (e.g. allowing other providers – PAs, NPs, now psychologists – to prescribe meds. Another commenter here said Naturopathic Medicine docs will be able to prescribe in his state soon, etc… They all diagnose and treat.) So where will physicians end up? What will their role look like? How many will actually be needed? I don’t know. I’d be interested in your thoughts on how long before all this happens. I honestly don’t think it will take much longer. Maybe another decade?

  • Karen Ronk

    With all the gloom and doom (and humorous digressions into cult television and the undead) on this post, I wanted to highlight your thought about physicians keeping relevant with patients through technology.

    I am lucky enough to have an orthopaedic surgeon who actually communicates with me through email, as does his medical assistant. I actually scheduled one of my surgeries through email communication. It has added a level of comfort to the relationship that I have not had with other physicians.

    As a patient, I greatly appreciate not having to deal with endless phone trees or leaving those messages that never get returned. I think that this type of interaction helps to keep doctors relevant in their patient’s lives and certainly builds a more solid foundation for trust.

    • Luis Collar, M.D.

      Thank you so very much for that comment, KR. A big part of what I do is helping physicians / hospitals communicate in different, more effective ways with their patients. Some people may not want that, and that’s fine and their wishes should be respected. But I think more needs to be done so that the patients that can benefit from it actually have the opportunity to do so. Just curious… Would you be interested in getting general information about diseases / drugs / local drug discount programs, etc… that are relevant to you from your doctor on email or twitter? Meaning, say you wanted to quit smoking, or had hypertension… If you could sign up to receive helpful information from your doctor on a weekly basis on those topics (wouldn’t include any of your personal information / medical history etc…), would you find that useful? Say if you (and non-patients also) could sign up on your docs’ website and select categories of interest? Things like tips or motivational reminders about things like diet for hypertension, or smoking cessation, or what causes a particular illnes? Those are just examples, but could really be any disease / health topic you choose. And the information could be completely original and generated by the doctor (and relevant to his / her specialty), or also information that points you to medically / scientifically accurate information on those topics on the web that the doctor agrees is currently the best available on topic.

      • Karen Ronk

        I would be interested in getting relevant information filtered through the experience of my doctors. There is so much out there and a lot of it is conflicting and confusing. Given that every study or clinical trial will benefit some entity, it is hard to know what to believe. I usually go to the NIH website when I hear or read some new study, but I would definitely like to know what my doctors think is the best available information.

        • Luis Collar, M.D.

          Thanks, KR. I try to ask patients their opinion on this every chance I get. Most of the feedback I’ve received thus far seems to reinforce yours. I think effectively communicating with patients in meaningful ways outside the office is becoming increasingly critical.

  • Luis Collar, M.D.

    Great points. Thanks for contributing. I agree that healthcare should be run by healthcare professionals.

    With regard to “factory models in human-service delivery,” I’ve written about that in the past here: http://www.kevinmd.com/blog/2014/01/learn-child-left-measuring-quality-healthcare.html
    and here: http://sapphireequinox.com/blog/a-new-quality-paradigm-for-healthcare/

  • Luis Collar, M.D.

    Very interesting. As I said above, it seems the trend is to have more healthcare roles gain the ability to diagnose illness and prescribe medications (e.g. PAs, NPs, naturopaths, psychologists, pharmacists, optometrists, other mid-levels, etc…) It will be interesting to see what that means for the profession / patients in the future.

  • Luis Collar, M.D.

    Thank you very much for the kind words. I think your father’s declaration was, in many ways, prescient.

    I believe our goal should be to bring physicians and patients closer together, to empower them in their roles as health advisors and decision-makers, respectively.

    Government regulations or oversight, corporate policies, new technologies and medical innovations, the health insurance industry, the biopharmaceutical industry–these all have a role to play in healthcare. However, each should serve to either assist patients in improving their own health or support physicians in helping them accomplish that goal.

    Any of the aforementioned entities that come between patients and physicians, that disrupt that central relationship or hinder the independence of the parties therein, do so to the detriment of the patient, the profession, and the nation.

  • hawkeyemd1

    “What do you think? Are physicians as relevant in our society now as they were decades ago?”

    One word: no. And it will probably only get worse. It isn’t really a profession anymore. Professionals aren’t told what to do and how to do it. We are. Medicine has become a job like any other, full of menial tasks, incompetent bosses and politically correct buzz words and catchphrases. It is just a job now, and not a very good one.

    • Luis Collar, M.D.

      Unfortunately, I agree that’s precisely where it is headed. Any thoughts on how to change that? Thanks for commenting.

  • hawkeyemd1

    Very good point. Health care run by health care professionals? Imagine that.

  • hawkeyemd1

    We may not be “permanently defeated” but it has gotten so bad that how would we even know which battle to fight first? So many different interests involved in controlling and profiting from our work-I don’t think we would even know where to start. And maybe individual patients are on our side, but overall we don’t enjoy the same positive public opinion we once did for many different reasons. I agree with you, but it would definitely be an uphill battle.

  • hawkeyemd1

    All good points, especially:

    “No other stakeholder, I believe, knows as much as physicians about how to make the system work better.”

    Very true. But you’d think someone in charge would have realized that by now.

  • Luis Collar, M.D.

    Couldn’t agree more… And I’m the first one to admit that patients, all Americans, are having a hard time right now, and, in many ways are becoming increasingly irrelevant with regard to stagnant wages, increasing prices, unemployment, public policy, access to healthcare, etc..,. Any hope that things might change for the average American?

  • Luis Collar, M.D.

    I’m really glad to hear that you are doing better with your PCP now. I think we all make generalizations (and for good reason), but there are still some great things happening despite the system’s limitations. I think people, not policies, will ultimately make things better, or at least keep them tolerable.

  • Rick Prab

    If physicians lost control of their profession they can also gain control. Use systems theory. Healthcare is a dynamic system and any loss of more than 4% from its mean can set in a chain of events that can make the pendulum swing other way. Here is the play book how to start the swing.
    1> If you have richer patients move to concierge model
    2> If you have poorer patients move to direct primary care model
    3> Both 1 and 2 can shrink the insured pool by more than 4% a sweet spot for making system swing
    4> Once swing starts the insurance becomes even more expensive and option 1 and 2 become even more enticing and hence more switching will occur for 1 and 2!
    5> Play insurance game smartly. Understand the power the last mile has! Physicians still have tremendous power of influence use it to the advantage using following
    a> create uncompensated work for insurance – Every prior authorization denial is automatically replied with following template ” Since you have denied a medical decision please let us know the medical license number and professional liability license of the individual who denied prior authorization so that it can be put in patient file to be used in adverse outcome” this is just an example – if you move your process to silicon you can create automatic replies for denials and make life of insurance hell
    b> Ask patient to call her insurance for routine eligibility verification, before the sample is sent to lab, for finding the fax number for referral and so on..Remember every call patient makes to insurance will make direct primary care so much more desirable.
    c> Use law to get paid within 30 days
    6> Stop eligibility verification process. Instead use the hotel model. Keep patient’s credit card on file and bill the visit to the card as soon as insurance adjudicates the claim.
    7> Enjoy your profession. Do not bitch. Be Positive. The optimism just permeates and you will be able to have a better tomorrow. More optimistic you become more disoriented Insurance companies become! First they laughed at you. Now they laugh at you. Then they will disintegrate. Physicians are going to take control again.
    8> Once direct primary care kicks in CPT codes become obsolete and AMA’s revenue will dwindle and that will result in AMA becoming defunct and make sure next organization is democratic!

    • Luis Collar, M.D.

      Interesting approach / thoughts. Thanks for contributing.

  • SteveCaley

    America is trying to “do without doctors,” which is an asinine fantasy. It reminds me of the “five-minutes-hate” in society in 1984. Blame someone.

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