When I was growing up in the ‘50s and ‘60s, virtually every primary care doctor (pediatrician, internist, GP-there were no FPs) I knew of had his office (women in practice were rare) located in a wing of his home, with the driveway enlarged to accommodate patients. A new physician in practice would simply hang his name on a shingle in front of the house. These doctors were paid in cash, made house calls, and were not quick to refer to specialists.
Emergency rooms were not usually staffed by physicians, although one would likely be on call for each specialty. If you cut your hand, you went to your doctor’s office for sutures, even if he were an internist (they had all done rotating internships and knew the rudiments of surgery, OB, etc.).
These medical warriors made a decent living, but they worked long hours. Burnout was unheard of. Disability insurance carriers loved to issue policies to physicians, because they almost always worked until they dropped.
As I was applying to medical schools in 1969, I enjoyed watching the new TV show, Marcus Welby, MD, starring Robert Young, who had been the epitome of the patriarchal figure in Father Knows Best ten years earlier. Dr. Welby was the quintessential family doctor and friend. He was always close to his patients, dropping in to see them even when he hadn’t been called. The doctor-patient relationship was a bit over the top for script purposes, but Welby was what everyone wanted in his own doctor, and he was a role model for us fledgling medical students.
Medical school and residency brought some reality into the picture, but Welby-types did exist. Even through the eighties, I knew internists and GPs who still had a home office and knew their patients and patients’ families intimately.
I think the first nail in the coffin of the doctor-patient relationship was in 1984, when Medicare started paying hospitals by diagnosis-related group (DRG). Overnight, the goal of hospitals to run as close to 100 percent bed occupancy as possible was replaced by an emphasis on length of stay. To combat shrinking hospital revenues from Medicare, attempts were made to shift the cost to privately insured patients. That led to the meteoric growth in managed care replacing fee-for-service. This affected not only the hospitals, but for the first time, the practicing physician was targeted.
To make a long story short, physician reimbursement was ratcheted down year after year as managed care contracts paid based on a percentage of Medicare. Physicians began to lose their autonomy, and with that came the seeds of burnout. In the early ‘90s, a recently retired internist, the closest thing I ever met to Marcus Welby, told me that his first twenty years of practice were “an absolute joy,” the next five began to be more tolerable than enjoyable, and the final five years were “totally intolerable.”
It would be the subject of another article to describe my downward spiral as a pulmonologist from loving it for the first seven years to bailing out at the end of 2001 after 22 and a half years in practice. Several full- and part-time non-clinical positions followed (including a four-month stretch working in a bowling alley), capped off by two years of going over to the dark side to be medical director for a managed care company. (If you can’t beat ‘em …)
I have now been fully retired for three-and-a-half years, and I am enjoying life. One of my sons went into medicine, despite warnings from my colleagues, but at least, he had the sense to enter a specialty that has no hospital work and virtually no real call schedule.
I follow medical blogs like KevinMD with interest. Having left clinical work prematurely at age 52, I can’t imagine dealing with what physicians have to cope with on a regular basis. Doctors ran hospitals in my day, now it is the other way around. Electronic records sounded like a good idea back then, but the reality of time-consumption and extensive computerized forms are a nightmare. When I go to a doctor, he doesn’t look at me, because he has his head and hands glued to his computer. Others tell me they have the same experience. One MD told me that he can’t remember the last time he saw a nurse in a patient’s room because of similar computer requirements.
One of the best decisions I ever made was to get out of clinical practice. My stress level dropped overnight and has lessened with each passing year. This required long-range planning, financial and otherwise. It involved a reasonable but not austere lifestyle. Having a trustworthy fee-only financial planner helped.
Some of the younger physicians reading this may think I sound like I practiced when dinosaurs walked the earth, but time goes by quickly. I have learned from my years of chronically ill, dying, and critical care patients that as long as you are healthy, you can enjoy life. If you are not happy with the stress of your present work environment, start planning your exit strategy and how long the process will take.
The Marcus Welby physician model has gone the way of the horse-and-buggy, the corded telephone, and the typewriter. Those of us old enough to remember those wonderful doctors miss them and their dedication. Unfortunately, due to changes in the health care environment from an emphasis on the doctor-patient relationship to a business model, we are not likely to see many of them again.
Eugene Rosenberg is a physician.
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