DOCTORS’ LOUNGE
DOCTORS’ LOUNGE
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Call me an optimist, but I think that many doctors will find the joy in clinical practice, but it will be a different kind of practice than was the predominant mode when Lelan Woodmansee took over GLMS( JCMS) from Harry Lehman. At that time the predominant mode of practice was in solo or small group practice. Autonomy was a key element of medical ethics. The physician could determine the number of patients he or she could see. Hours were long. The focus was on the individual- the doctor-patient relationship. I doubt anyone kept statistics on the uninsured. Those who could not afford medical payments used ERs or bartered for services.( I remember the husband of one of my patients in the 1970s negotiated his wife ' s hospital charges for his janitorial services.)
But these are different times with societal and government values that are different. And I suspect that younger physicians have shifts in professional values. Personal debts from training expenses, the consolidations going on in medicine as in other parts of the economy, and the depersonalization of society, all have played a role. So physicians are much more willing to give up autonomy for lifestyle or for freedom from managing an office practice. Trading humanism for rigor is not a negative tradeoff. I hear doctors of my generation worried that without greater patient contact that younger doctors won’ t have the experience to treat their patients well. Of course the flip side of that concern is that without balance in the physician’ s life, developing empathy and humanism in clinical practice is more difficult. Working 70 hour weeks just makes a physician think that this should be the norm for healthy people.
Over the past decade doctors have found that they are in the first phase of hospitals or other entities acquiring physician practices. To recoup the investment in the practice, the hospitals needed to ensure that the practice becomes a profit center. With a predominant fee-for-service environment, then productivity was the prime factor: it was what the entity employing those physicians was looking for. In talking with my friends who feel disaffected in their new employed status, the concern is largely because of the pressures to produce. In their prior private practices doctors could adopt a pace that they were comfortable with but now the pace of practice has been dictated by the employer. Autonomy in practice management is largely gone; although autonomy in clinical decision making remains with the physician.
The second phase will come, I believe, with the lever of MACRA and other " Alternative Payment Models " that apply the financial risk levers of outcomes controlled by physicians. The upside and the downside risk payments for physician clinical activities come from a balanced scorecard weighing measures of
1.) quality of care,
2.) appropriate use of resources( i. e. cost effective medicine),
3.) patient experience, and
4.) use of digital data recording and patient connectivity.
At a recent national meeting, I heard some health system administrators acknowledging that doctors have to be happy for the patient to have a good experience and for the physician to spend enough time to make better use of resources. The catch-phrase used was the migration from the Triple AIM espoused by Don Berwick to the Quadruple AIM that adds physician satisfaction to the others. Of course physicians will need to be facile with the digital platform of the electronic medical record, the population health analytics, and managing the patient portal. Younger physicians have great comfort with such a digital world. There are expectations that the primary and specialty oriented physicians will continue to make better use of physician extenders so that the physician can manage a smaller panel of patients directly while supervising the midlevels who may see more of the routine patients.
I believe the new financial levers will encourage the migration of the practice environment to a point where doctors can feel part of a team but have the autonomy to manage the responsibility for the clinical care including the outcomes, quality and resource use. That is, I think, when we get to that point, doctors can return to taking great satisfaction, and may have more of a personal life too. That is why I remain optimistic about the practice of medicine.
Tom James, MD, is the chief medical officer at Bluegrass Family Health & Population Health for Baptist Health.
28 LOUISVILLE MEDICINE