There was a time when doctors were doctors

There was a time when doctors were doctors

There was a time when doctors were doctors. There was a time when young men and women sacrificed the best years of their youth, learning to treat patients and conquer diseases, not to become typists, paper pushers, data-entry clerks, or to have hospitals, insurance companies, and the federal government dictate to us how to practice medicine.

There was a time when doctors were trusted. There was a time when we were not guilty until proven otherwise, as viewed by blood-thirsty bounty hunters like the wild dogs of the recovery audit contractor (RAC) unleashed by our ruthless federal government.

There was a time when doctor’s orders were meant to be orders. There was a time when our orders were not subject to endless scrutiny and nonsensical denials by HMOs, pharmacists, hospital formularies, insurance companies, and the federal government.

There was a time when doctor’s opinions were valued and recommendations were followed. There was a time when we were not routinely challenged by our patients, their families, their neighbors, hospital case managers, hospital administrators, medical officers of HMOs, or some random doctors on the other end of the phone 3,000 miles away.

There was a time when doctor’s progress note held useful information. There was a time when our writing contained constructive and consequential discussions on patient’s medical conditions, not a mere memo to be attached to the chart and artificially beefed up with worthless numbers, reports, graphs, and other meaningless rubbish created in anticipation of Medicare audit.

There was a time when doctor’s consultation note was a work of literary art — succinctly crafted and beautifully articulated to efficiently describe the patients and their diseases, and to effectively convey to the reader the well thought-through recommendations of its author.

There was a time when the reader of a medical chart did not have to scroll through 10 pages of repetitious, auto-filled, and computer-generated garbage mandated by the feds, the hospitals, and Joint Commission (JCAHO), only to get to an anemic, malnourished, and anticlimactic — albeit the most important — final section of “discussion and recommendation.”

There was a time when doctors actually wrote orders. There was a time when we did not have to go through 10 steps and 22 keystrokes on a hospital computer just to place a simple order like NPO, which would have otherwise taken 2 seconds with a pen.

There was a time when doctors actually saw patients. There was a time when we spent more time with our patients than with our computers — more time on listening to them than on training Dragon Dictation, typing notes, keeping up with meaningful use, writing rebuttals to RAC, drafting appeals to PPOs, filling out forms, updating problem lists, and reconciling medications on hospital EHR.

There was a time when doctors were welcomed by the hospitals and the communities they served. There was a time when hospitals assigned more parking spaces to doctors than to their own administrators. There was a time when there were no padlocks on the refrigerator in the doctor’s lounge.

There was a time when doctors actually utilized their brains at work. There was a time when practicing medicine was not just about completing forms, checking boxes, navigating pathways, meeting core measures, and predicting — before patients actually arrive at the hospital — whether they would be inpatient or outpatient according to Medicare rules.

There was a time when doctors spent more time thinking about patient care than pushing papers. There was a time when we did not have to sign more documents for a simple outpatient procedure than what is required on a home mortgage application.

There was a time when HMO was still a three-letter word. There was a time when JCAHO was still a five-letter word. There was a time when Obamacare was not a four-letter word.

There was a time when private health insurance was considered good insurance. There was a time when the acronym PPO was not used for blasphemy.

There was a time when patients actually paid their bills. There was a time when the words co-pay, deductible, and coinsurance meant what they truly meant, not some random numbers subject to inventive negotiation and crafty blackmail tactics by some patients.

There was a time when doctors were judged by their credentials and by their professional peers. There was a time when our medical school diploma meant more than the reviews on certain online social media intended for rating restaurants, plumbers, and prostitutes.

There was a time when young men and women went to medical school because having “M.D.” behind our names was the most honorable and respectable thing to do. There was a time when professional gratification for physicians was not an oxymoron.

There was a time when doctors were doctors, physicians, and surgeons. There was a time when we were not referred to as contractors, providers, or whatever other denigrating and demoralizing monikers insurance and government bodies choose to confer on all of us who have dedicated our lives to this once prestigious and highly respected profession.

There was a time when doctors were real doctors.

James Ong is a cardiologist.

Image credit: Shutterstock.com

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

    There was a time when health care was not bankrupting the country and its people. It was the time when doctors were real doctors.

    • PCPMD

      “Yes, but money…”

      Exactly

    • SteveCaley

      We see the damage in the trauma room; we need to understand how the accident was caused, to prevent it and mitigate damage.

  • Markus

    A friend and I recently talked about medicine in the old days. His father and my father in law were general practitioners in rural communities in the 1930′s. They were on call 24/7. The local hospital did not have a MD staffed ER, and people phoned the house (no answering service) or actually drove up and rand the doorbell for after hours problems. They made housecalls. My father in law famously did a C-section in a farmer’s kitchen when the great snow storm of 1937 locked him and his patient in for three days; mother and child did fine. When you made an appointment, no one asked you for insurance information. In those days, not even owners of farms had insurance; hired hands and old folks had very little cash money and certainly no insurance. People actually paid in produce.
    Father in law took two weeks of vacation a year which was almost always spent on a lake in Minnesota. He went to Florida every two winters and drove there. One trip to Mexico in his life. No fancy vacations. There was church every Sunday and football games at his alma mater on Saturday afternoons. I believe that the Lord award his faith far more than the University.
    He wore a suit, hat, and necktie every day and everywhere. His med school classmates and I called him “Bill” (I was born impertinent), but everybody else called him “Doctor.”
    His chart notes were one sentence, indecipherable scribbles.
    He was fiercely antigovernment and opposed Medicare when that was being debated. He provided a lot of care for free, for example most people at the local nursing home where he rounded once a week never got a bill. People paid some in cash, but he had a lot of debt on his books that never did get paid; half the people in town owed him money when he died.
    It was a different time. Doctors lived a more modest life. They worked hard; I believe they worked harder than modern doctors. They got a lot of respect in their communities, but the respect was not a gift but came from selfsacrifice and achievement.
    Bill, I hope the northern pikes are biting in heaven.

    • Suzi Q 38

      Markus, I liked your story.
      I think that doctors back then were doctors not only because they were interested in medicine, but because they were natural “healers” and wanted to help people.

      Of course the doctors of today were sold the idea that they could help others and get rich at the same time.

      Far from it. The insurance companies are making sure of that.

      In all fairness, the bills can not be paid with a sack of potatoes.
      But history and reality are so full and rich with these poignant stories, of a time when doctors were there for us no matter what.

      Refreshing.

      Unfortunately, I never witnessed the selfless dedication that you describe. Having only lived in rather large cities, our doctors had a different mindset. I understand a little, because offices in the city are expensive.

      • Markus

        Doctors in big cities made housecalls in those days which is the reason that New York issued MD license plates to allow the doctor to park in otherwise illegal spots while making those housecalls.
        There were many charity patients, even charity hospitals. My friend’s father went to Jefferson Medical School and interned at the Philadelphia General Hospital (nickname the pig). This was a municipal charity hospital like many others around the country at that time. Care was provided gratis. The senior staff supervising the interns and residents were volunteers and often the most prestigious doctors in town who did it out of a sense of noblesse oblige. The Pig was closed in 1977…a million gruesome, funny, heart-touching stories.
        It was a different time with many problems that are better now, but there were some good in the past, too.

  • http://frugalnurse.com/ Frugal Nurse

    Thank you for this post, Dr. Ong. I began nursing over 30 years ago and I, too, miss the way it used be. I had great working relationships with the doctors; we were focused on doing what was best for the patient. Now…?

    • Suzi Q 38

      It’s scary.

  • Patient Kit

    It’s always a precarious dance with a double-edged sword to indulge in over-romanticizing the past, regardless of the problems of the present. Whenever I hear laments about loss of control of medical info, I think of Umberto Eco’s novel, The Name of the Rose, set in a monastery in 1327, at a time when the church and the educated few controlled information.

    Knowledge is power. That said, there is a lot of misinformation out there and the average person is not trained to know how to interpret all the info available. That’s why we need our doctors. But, overall, it is definitely better to have a well-informed patient population than one who knows nothing. I can have much more informed conversations with my docs now and ask much more informed questions. And, yes, I can even self-treat minor things just fine.

  • DoubtfulGuest

    I have to agree on this, Frank, although it’s otherwise a nice post. I had to figure out part of my diagnosis myself (mitochondrial disease) by reading medical journals, and then find doctors who agreed it was likely and performed the testing. That said, I think it’s likely that some of my doctors would have reached the same conclusion themselves within months or a couple of years, instead of decades, if they’d had enough time during our visits to talk and think with me. I concur with PK on the information access issue. Your medical library story is pretty disturbing.

    • Suzi Q 38

      I remember going to the medical library at the local hospital and being told that I shouldn’t be in there, LOL.

      • DoubtfulGuest

        The more I think about these examples, the more it bothers me. It reinforces this vague feeling of terror I’ve had for awhile, that doctors are not only deciding who lives and who dies but also choosing who has any worth in society and who doesn’t. That gets into the historical role of physicians having more of a priestly status, I guess? I’ve never received spiritual comfort from a doctor but I have experienced something more like schoolyard bullying. Even though I have doctors now who decided I’m worth helping, I’m still dealing with aftereffects from the ones who determined I’m expendable.

        I’d like to know:

        1) If information literacy is important, why keep anyone out of a library?

        2) If you guys think this stuff is cool, why shouldn’t we?

        3) If you want people to take responsibility for their health, shouldn’t we learn how our bodies work?

        • Suzi Q 38

          Yes, the scenario I mentioned happened in the very early 90′s.
          Now I blatantly go to the nurse’s library and access their computer sites. The hospital pays for certain physician websites that are very helpful.
          My favorite right now is a website called “Up To Date.” There are articles and studies already reviewed by independent physician experts who render an opinion or two.
          No one would tell me that I shouldn’t be there, in 2014. I would look at them and say “Make me.”
          “Go ahead, call security. I pay enough for my medical care at your hospital that you should be glad that I am researching about my own cancer. While you’re at it, call the patient advocate.”

  • Suzi Q 38

    There was a time when the majority of doctors cared more about their patients. Plus they knew and remembered each and every one. In order to do that, they took more time with patients.

    The respect was earned, and it still is.

    • Jack Minas

      Dr Ong an excellent article. I am a 1972 graduate and I was lucky to have worked in the period to which you refer. Seeing what health delivery has become I would not take that entry path now

  • Suzi Q 38

    Dr. Caley:

    “….Should an oncologist wonder openly in front of a patient? How do you handle that?…”

    My gyn/oncologist was wondering, and I found the studies for him, the next time I visited. I was fine with it.

    Obviously, I am more motivated to find a course of direction or let things be and do nothing at all. I still need him to help me make the necessary decisions and tell me why I should consider them.

    “……All my patients get my cell phone number….”

    If this has worked out well for you, I have only praise for you.
    I can assure you, there are not very many physicians today that would do what you do, even if it could save a patient from harm.

    I take that back, there are doctors like Pam Wimble who would. They are few and far between.

    • SteveCaley

      It’s amazing HOW FEW patients called me, how respectful they were, and how little of a hassle it was when they had my phone number. My biggest beef was NOT being called when I should – when Mrs. Z went to the ER about something “without wanting to bother you.” That one phone call could sometimes shave off five hours of hassle and a grand out-of-pocket.
      The decision has been made at the top in American Public Medicine, to jettison humanitarian, individualist medicine, and deciding that industrial, mechanistic medicine can be provided by the “hive mind.” I note that in Star Trek, the Borg’s ultimate goal is “achieving perfection.” the way it’s going, we’ll be lucky with “accidental mediocrity” now and again.
      When there’s nothing else I have left to offer a patient, I’m still another human being in the room. If the patient knows that, it’s safe to wonder about things and discuss them together. It works. It’s a shame that “resistance is futile”.
      Industrial modernism, this dehumanizing approach to the individual, has wound up on the rubbish pile of history before the Berlin Wall fell. Why are we still playing with it?

      • Suzi Q 38

        “……When there’s nothing else I have left to offer a patient, I’m still another human being in the room….”

        Yes, and it appears that you know the importance of your presence with your patient. Not all doctors have this mindset. Maybe it is because the oncologist has had to let go of patients. They die, and this is sad, so they try not to become so invested in the future.

        As time and years evolve, they are desensitized to the
        whole patient process of striving to live in spite of and with cancer that they forget that this may be the first and only time that this particular patient has had it. Patients can be angry and fearful when this news is given to them. They need and and deserve a good, understanding physician.

        The physician has the extraordinary opportunity to assist the patient with their new life or help them to make end of life plans if necessary.

        Good for you.

      • Teresa Brown

        My oncologist has given me her phone number. In three years I think I called her once.

  • Rob Burnside

    One of the best contributions (essay + comments) I’ve read in a year of following Kevin. As much as I treasure some of the past, I’m in a mind frame to realize that we can only go forward, not back. I think most of us know this intuitively, but we are often bowled-over by the pace of change, which seems ever-quickening and contrary to stability of any sort. And we crave the familiar.

  • buzzkillerjsmith

    There is a time when Dr. Ong should consider investing in some lottery tickets.

  • DeceasedMD1

    I hope you keep posting. Doesn’t solve a thing but i think we all relate.

  • DeceasedMD1

    Sounds like the “I have a dream speech” from Martin Luther King 50 years ago. Who would think that 50 years later, Blacks would be free and have the opportunity to become President and doctors would be the new black. (focus of discrimination and disrespect).
    Oh and great article. glad Blacks have been given these opportunities. But who would think 50 years later, doctors wouldn’t be?

    • SteveCaley

      Dr. King said that he was out to save not only the children of slaves, but the children of slaveholders – because injustice to one is no different than injustice to another. Apartheid kept black people from freedom; and white people from freedom, although in a little fancier cage.
      If we do not respect those who care for us, treat us, suffer for us, then we do not respect humanity. Look everywhere.
      Black people mostly suffered the theft of labor; Indians, the theft of land. In all oppression, there is the theft of human dignity. Any of us can be mistreated; any of us can be degraded; we are all only just human. There is no classification of people that can merit the theft of their dignity.
      I am not Jewish, but I smell a whiff of anti-Semitism around the complaints about doctors – the rich foreigners in our midst, stealing our livelihood – that’s Joe Goebbels stuff. Whether it is occult anti-Semitism, or just old fashioned inhumanity, I don’t know.
      Humans ARE, first and foremost – we ARE. We ARE human. The details are of very little relevance, the color of our skin, our gender, our nation. First, we ARE.

      • DeceasedMD1

        Extremely thoughtful answer. Oppression is the perfect word for it and as you say it is throughout history. It is very sad and as far as MD’s, in the end it hurts everyone because it is destroying the foundation of pt care.

  • Karen Ronk

    Is it just medicine though, or society in general? What about those crew members on the South Korean ferry who abandoned ship and left all those young people to die? What about the stories we hear about subway/train engineers crashing because they are texting – again taking innocent life. I have a friend whose fiance is a pilot and she tells me stories about all the overlooked regulated safety checks or procedures that he sees when flying with other pilots.

    Too many people have just lost their ethical and moral compass. Shortcuts are okay. The rules do not apply to me. I am more important than the rest of you. I do not care if my action or lack of action harms someone – nothing is ever my fault. And every day we have to make a conscious effort not to be that person.

    I grew up having a great deal of respect for “professionals” in many occupations. I probably idealized them but even so, I firmly believe that all the posts here related to the “good old days” are true.

    That all changed for me after a routine surgery went bad and the doctor involved refused to help me. This doctor, seeing me in his office setting but not for an appointment, only a few months after the surgery (and while I was still undergoing follow-ups), could not remember “what he did to me”. It was supposed to be a simple procedure but it became a more major procedure and was I assure you, quite memorable.

    As someone who used to work in retail ( and can no longer because of that surgery), I could remember the bedroom set I sold to Mrs. Smith a year ago. This of course was a bad doctor, and I have seen good ones since. However, my view of the profession has been forever changed.

    • querywoman

      There were always be good and bad sorts in any profession.

  • Dave Mittman, PA, DFAAPA

    Wow. Just wow.
    I see no responsibility taken here. None whatsoever.
    This magic time was also the time when everyone went into specialties and the primary care providers started to get fewer and fewer. No one said a word. It was the time when going to medical school meant an automatic door to a high salary and private office. Yes, there was sacrifice, but all who make it in America usually have to sacrifice. Nothing is attained for free.
    I just need to hear a bit of “we screwed it up” also. We had almost total control over OUR system and let the system become one that did not serve the country well. Still does not. So others moved in with false promises and false ways of “fixing” the problem. Now we are seeing the system controlled by many, none knowing how to make it work and all out for their little group.
    We reap what we sow.
    Dave

  • querywoman

    Wow! Was there ever a time when doctors treated patients on symptoms? When every visit didn’t start with the BP cuff and give ‘em a chance to come in and start preaching?
    When illnesses mattered more than this or that preventive screening?
    I never lived in such a time.

  • Judgeforyourself37

    Do not blame the physicians. Why:
    1. The cost of a medical education is obscenely high, and many doctors have many years during which they must try to establish a practice and pay off student loans. Other nations have free or low cost education for doctors and others who will enhance society.
    2. Insurance companies think of themselves a medical practitioners. Doctors and other healthy care personnel, i.e. NPs, and nurse practitioners must fight someone with no medical education for “permission” to treat a sick patient.
    3. Hospitals are purchasing many, formerly, private practices. This is another layer of bureaucracy with which a physician must deal.
    4. Hospitals and the physician practices associated with them are being purchased by large hospital chains. Physicians must see too many patients in a day to “please” the administration of the chain, or if the hospital has not been purchased by a large chain, the hospital administration. These administrators cannot seem to fathom the time that it takes to treat, and educate, the average patient.
    Yes, things were simpler in “the good old days,” but time equals change and the above scenario has not been for the good.
    On the flip side the medical advances in surgery, and treatment of, once untreatable, illnesses has been rapid and for the benefit of all.

    • AverageRandomJoe

      If they are run so terribly, open your own practice. The solutions are
      so obvious, it should be simple. If you have the success you claim is
      available at the price you claim is possible, you will make out very
      handsomely.

  • Teresa Brown

    Boy, you aren’t kidding about nursing. Nurses now are treated more like waitresses and people to be screamed at. So many patients and family members have total disrespect for the very people caring for them/their loved ones. Administration thinks it can save money by short staffing. All of this leads to dissatisfaction and apathy among nursing staff.

    • SteveCaley

      ->I was recently looking at an article in Britain; only 70% of RN’s
      last through their first year of employment placement, by the end of the
      second year, it’s less than 50%.
      ->The people in change have a
      profound ignorance of what nursing is; what they know is from a
      scriptwriter’s desk and projected on a TV show. A few years ago, in my
      organization, I was working on a project to improve “Interdisciplinary
      Human Wellness.” But that’s just what the core of nursing IS, to my
      understanding.
      ->If you draw two overlying curves – the relative
      values of nursing care, and patient satisfaction with healthcare – they
      have been dropping like stones for 30-40 years. No surprise there. You
      beat good nursing out of the establishment and it takes a dive. MD/DO
      Medicine’s only 20 years behind RN nursing.
      ->I was recently asked
      – “How do we improve nursing morale at our facility?” I answered –
      Adjusting only for inflation over 50 years, with no other correction,
      nursing salaries today should be $80K – $110K per year. That will
      improve morale.”

      ->The reply I got, was, “Trying to be serious here. What else.”
      ->I couldn’t think of anything else. Maybe little candy hearts on International Nursing Day, Sunday. That’s Mother’s Day – but they’ll have a shift then, no doubt.

  • Homura

    If they even CAN be glorified medical technicians. Stats show that 40-50% of graduate MDs now can’t even get a residency. I’m one of them. I don’t even know where to start to go from here.

  • AverageRandomJoe

    That was exactly my point. Regulation creates barriers to entry that allow these systems to occur. All for the safety of others but making competitors harder to enter to take advantage of high prices. Take a business strategy class. Early on, they will talk about barriers to entry and the best way to do that is through regulation. Then you can get your guy on the regulator (FED or FCC) or you can hire them with a nice job when the exit as a reward for excusing you for not following the regulation (again FCC). Even if you do have to follow it, you have the huge overhead to maintain that structure and a competitor would have a hard time starting with one. It keeps out disruptive technology in favor of the status quo or sustaining technology. Sustaining is nice but disruptive is a leap forward.

    Also, the problems and solutions are not as straight forward as the OP was claiming. I had a longer piece that addressed each one but it kept getting censored.