I Hate You, Don't Leave Me

Inside the mind of a borderline.

Who Else Is In The Room With You And Your Doctor

How the demise of private practice will change health care.



     Prepare yourself!  The patient-doctor relationship is changing dramatically.  The independent private practitioner is disappearing.  If you are sick, he is unable to make a house call.  If you are really sick, you will probably be cared for in the hospital by an unfamiliar hospitalist.  Half of all doctors in this country are employed by a larger entity—hospital, community clinic, university, insurance company—and this trend will continue.

     It is inevitable that this evolution is unfolding.  Young doctors emerging from training, saddled with huge debts cannot afford the expenses of an independent office.  A larger institution offers equipment, required computer necessities, office staff, insurance, and other resources to begin a practice.  Impending health care legislation promotes integrated treatment, “Best Practices” guidelines, and coordination of treatment with the hope of lessening costs and inefficiencies.

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     The cohort of physicians now near retirement was educated in a different era from those now emerging.  In decades past, Medicine was considered a kind of priestly calling, in which total dedication was expected and spontaneous or planned activities with friends or family were subordinated to the needs of the patient.  Medical training transpired in a macho, stay-up-all-night routine of continued attending and learning, always striving to do what is best for the patient and to earn recognition from colleagues.  In return for this total commitment, the physician received a level of community respect and the independence to minister to his patient to the best of his ability without constraints.  His uniform was a white coat, and his badge a belted beeper.

     The current generation of doctors has learned that overwork and sleep deprivation do not necessarily insure competence.  Current training mandates limited hours.  The message is that Medicine is not a heavenly ordination, but just a job, from which you can punch out at 5 P.M.  In return, the physician has surrendered her prestige.  No longer a doctor, she is a “provider,” or, in the words of some administrative wonks, an “interchangeable medical unit.”  The white coat disappeared and the beeper was co-opted by plumbers and call-girls.

     What may be lost in this trend is the unique relationship between patient and physician.  A new entity is in the exam room, influencing decisions.  The doctor’s employer must manage costs in order to survive.  To earn his pay, the physician must satisfy cost-effective quotas—number of patients seen, services provided, tests ordered.  Will she order the more expensive drug or extra test if it jeopardizes her bonus and even threatens her continued employment?  A European study of screening for prostate cancer found that to prevent one death from prostate cancer, 1,410 men would need to be screened and 48 extra cases would need to be treated at a cost of hundreds of thousands of dollars.  What is the threshold cost considered to be too much to save one life?  And who will decide when the cost of the test is worthwhile?  “Cost-effective,” “efficient” medical care must mean cheaper treatment.  Who will be that one patient who dies because the algorithm did not justify regular screening?  The decision will be determined by the institution, not your family physician.

     The biggest loss in the demise of the independent, private practitioner is the diminution of the Art of medicine.  No matter how much science is discovered, how many algorithms applied, how many computers consulted, some patients just don’t get better as they are supposed to.  Some treatments that should work, don’t always work.  That is when the doctor, unimpeded by outside constraints, must use his experience, instincts, knowledge of “off-label” alternatives to cure.  Because humans are unique, no treatment will fix everyone.  Peering into the eyes of the patient is more instructive than gazing into the screen of the laptop.

Jerold Kreisman, M.D., is a psychiatrist and best-selling author of numerous books.


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