Louisville Medicine Volume 64, Issue 2 | Page 30

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 .
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