Perhaps the time has arrived to view the clinical practice of medicine differently. The practitioners are now broadly identified either as primary care providers or specialists. Specialty care is more easily defined, but whether such care is used appropriately is another question.
Primary care now includes pediatrics, internal medicine, and family practice with an increasing number of physician extenders, nurse practitioners, and physician assistants. Primary care has transitioned into something quite different than it has been historically. It presently is unclear what the actual role of the primary care provider is. An employed clinician working for a corporate health care entity with 10 to 15 minute RVU compensated client appointments, using the entity’s ancillaries, completing the necessary EMR document screens to assure billing, refilling prescriptions, and triaging any significant complaints or clinical problems to the system’s specialists is the routine.
Careful attention to the Medicare and insurance company contractual mandates for “preventative care,” acceptable screening tests, and immunization compliance, reviewing the bureaucratically designed forms to assure that the approved questions pertaining to physical and emotional health have been completed while at the same time typing and checking the computer screen-generated boxes consumes more of the visit. Those laboratory tests and screening exams deemed acceptable by Medicare and the insurance company payers may be ordered. Amazingly, this all occurs generally with a fully clothed patient without the slightest suggestion of a traditional physical examination. Then begins the same process with the next “client” and the next and the next.
There is the ever-present advice: “If this is an emergency, call 911 or go to the nearest emergency room.” The client finally transitions to a patient upon admission to the emergency room. Then, if admitted to the hospital, the individual becomes a patient of the hospital’s myriad of specialists. The primary care provider is now completely absent from the process of diagnosis and clinical care. Actual illness and diagnostic challenges other than the trivial are now beyond the scope of the primary care providers.
A new medical specialty to bridge the gap
The following question will be controversial. But is a physician really needed for the mundane routine of what now largely constitutes primary care? It is conceivable that a new specialty might be what is needed to fill the void between the present iteration of primary care and the other specialties.
Beginning with the premise of the physician as an educated, knowledgeable, intelligent individual capable of critical thinking, liberally educated in history, philosophy, the classics, economics, sociology, and capable of the rigors of technology and the sciences seems justified. Such multitalented scholars can redefine medicine back to its traditional identity as both a science and an art. The profession can be comprehensive to include multiple disciplines, a variety of motivations guided by an understanding of human nature, and the historical perspective of why medicine has been the greatest of all professions. Certainly included in medical education should be an understanding of business, principles of health care law, medical economics, and the absolute need for physicians to take leadership as a responsibility in the future evolution of health care and its practice. Teaching that what is referred to as a destructive “toxic empathy,” altruism, and professionalism as demanding only sacrifice to the requests and desires of others must finally be denounced to the immorality implicit in such concepts.
After graduation from medical school, those inclined to the challenge of diagnoses and the care of the sick can begin the process of mastering the knowledge needed to attain competency. A thorough understanding of the principles of internal medicine, requisite time to interact meaningfully with patients and to personally elicit a complete history including chief complaint, present illness, family history, past medical history, personal and social history with a thorough review of systems, and then a comprehensive physical examination should constitute an initial patient encounter. An appropriate differential diagnosis should result and confirmatory testing ordered. With a sound understanding of general internal medicine and the multiple disciplines included, most illnesses can be managed by this physician with only appropriate and necessary referrals made to other medical or surgical specialists.
Caring for hospitalized patients should be included. Those comorbidities needing supervision even for elective procedures, oversight of the specialty team involved in a patient’s care, and managing illness that does not need specialty care such as diabetic ketoacidosis, cellulitis, congestive heart failure, and pneumonia to name a few are inpatient responsibilities. Having this new internist as a constant in the care process to whom the patient’s medical history and idiosyncrasies are known can only improve care and outcomes. Transition back to the outpatient setting will be efficient. Additionally, the professional satisfaction, collegiality, and learning that takes place while interacting with one’s peers can bring meaning and joy back to a profession badly in need of both.
The necessity of free market health care
As the health care system has presently evolved, what I have suggested for a new specialty is not possible. Being employed and answerable to a corporate management bureaucracy is not an option. Neither is it tenable to be an indirect employee of the government’s political dysfunction and its huge administrative bureaucracies with their schemes, rules, mandates, regulations, and absolute power over pricing and compensation that are divorced from market freedom and completely arbitrary. To allow insurance companies to inject their contractual nonsense between patient and doctor is equally absurd.
The physician to patient interaction should be personal. Trust should complement an appreciation by the patient for their physician’s devotion to their care. Of course the physician should acknowledge these with their absolute commitment to the patient. This trust, appreciation, and devotion should be earned. Only in this way can the uniqueness of the physician to patient interaction be valued. It is not a right.
It remains amazing how the wisdom of consumers in a market can sort out excellence and value for the scarcity of all products and services. The result is pricing appropriate to supply and demand. Innovation and differentiated excellence results in cost, quality, and service implicit in value. It is not that difficult to imagine a health care system where the dollars are placed in the hands of consumers eventually including those financing present entitlements (if any remain solvent) such that markets for real insurance and providers can emerge as consumers make personal choices that meet their needs. It is insurance that is being suggested, not the contracted payment models that are now erroneously labeled as health care insurance. It is not fantasy to predict that such a new specialty functioning in a free competitive consumer market driven by value and excellence and including a renewed appreciation of the professional relationship between doctor and patient would be infinitely more efficient and less costly. Not only can such a health care model be created for specialists, but in truth it must.
The present system is unsustainable and cannot continue due to several systemic failures:
- Increasing costs
- Fewer doctors
- Inefficiency, fraud, and abuse
- Lack of innovation
- The progressive erosion of personal satisfaction by the decrease in morale accompanied by burnout in what should be a joyous profession
The certainty of the decay is encompassed in the pending insolvency of the Medicare and Social Security entitlements, the Medicaid welfare program, and the immoral $38 trillion federal debt.
Of course, a compassionate society must and can care for its truly needy at a cost infinitesimal to the ridiculously bloated and expanding current Medicaid tragedy. To close and simply for perspective, an interesting fact in a recent Wall Street Journal article revealed that elite attorneys now bill $4,300 an hour with no complaints from their clients.
Allan Dobzyniak is an internal medicine physician.
