In the past, physicians were responsible for both the business and practice of medicine. While administrative personnel played an important and complementary role in practice and hospital management, physicians were the cornerstone. In comparison, today the leadership structure in medicine is now an entirely foreign landscape. Administrators dominate medical practices today and, according to the New York Times, their salaries are responsible for a high percentage of medical costs. While the numbers of physicians that are entering the workforce has trended toward a constant number (with little or no growth), the numbers of administrators has risen nearly 3,000 percent over the last 30 years.
Certainly medicine has evolved into more of a business. Physicians that are well versed in business and understand the role of the physician executive are much more successful. It is clear that there is a role for administrators–they are necessary to coordinate and support the clinical work of physicians and those in the hospital or practice. However, now administrators have evolved into the overlords of medical practice and are now dictating how and when and where physicians and other health care providers work. Most of these administrative overlords have zero relevant clinical knowledge or experience.
The rise of the administrators has further complicated the health care landscape during this period of reform. The ACA has expanded the numbers of insured and has promised to provide affordable, accessible care for all Americans. Unfortunately, declining reimbursement and increasing reams of meaningless paperwork, documentation and “core measures” — all created by administrators or legislators — have resulted in the development of a pending physician shortage crisis in the U.S. today.
Much like the fictional Skynet began to control the world in the Terminator movies thru atomization, administrators have assumed control of medicine and have begun to automize the art of medicine thru protocols and algorithms–all with a complete disregard for real clinical trial proven outcomes data. The numbers of new medical students continues to remain steady — very little growth. Bright young minds are choosing other professions.
So, you may ask, how are we going to provide care to the newly insured?
Administrators will suggest that cheaper and less well-trained alternatives to physicians will be the answer. In Minnesota, for example, nurse practitioners are now allowed to practice independently without any physician oversight or supervision. Minute clinics such as those hosted by CVS and others have spread throughout the nation. These clinics have no physician presence and are expected to make clinical decisions based on protocols and algorithms. Now, physicians appear to be a cog in the wheel and must conform to the dictums of those in power. No longer are physicians autonomous scientific entrepreneurs. Creativity in medicine has become suppressed and frowned upon by those in power. We have become worker bees in the factory of the administrative overlords. The evolution of the administrator driven practice has left me with more questions than answers.
What has happened to the art of medicine? What about clinical intuition? If we are eliminating this component of care completely then why don’t we simply create an army of IBM Watson computers to deliver care at the direction of the administrators?
At this point in my career, I expect the practice environment to become increasingly hostile for doctors. For example, the recent Congress “fix” to the Medicare reimbursement schedule averted yet another 20 percent pay cut for services. This “fix” rolls back the antiquated formula by which doctors are paid, but it further empowers nonclinical administrators (and politicians) to determine exactly how doctors should be reimbursed. While adding payments based on quality (which I think is certainly a great idea), it stops short of defining quality and will ultimately allow CMS and HHS to determine what measures will be applied. I expect that these measures will remain clinically irrelevant and lead in no way to improved outcomes for patients.
Physicians must take a stand. We must advocate for our patients and for our profession. Medicine cannot survive and continue to innovate without committed, caring and compassionate physicians who are allowed to do what they do best: practice medicine. We must retake control of health care and limit the scope of power of hospital and practice administrators.
Or, as Schwarzenegger says, it will be “Hasta la vista, docs.”
Image credit: blastr