Somewhere along the way, physicians lost their voice. That may not be completely accurate because in the “good old days” (before I even began practice) things were much simpler and they really didn’t require a “voice.” Reimbursements were good, insurance companies didn’t require the frequent hoop-jumping that is commonplace today, and when the physician said they needed a test or wanted to admit a patient into the hospital, the physician’s word was accepted as gospel. In fact, in what I like to call the “really good old days” (before I was born) it was even better. As a previous practice president responsible for the building/infrastructure of a very old private practice (circa 1940’s) I had the opportunity to be in charge of a very long-overdue medical record purge. I was at first amazed to see the entirety of a patient’s lifetime medical records contained on just a few 5×8 index cards. But even more unbelievable to me was the discovery of office notes that read, “Mrs. Smith presents today noting she has been feeling under the weather. We will arrange admission into the hospital for 1-2 weeks for rest and evaluation.” Contrast that with today’s attempts at outpatient therapy for just about anything and the never-ending struggle to turn a poorly reimbursed hospital observation stay into an admission. When I would look admiringly at the 60-70 year old photos of the founding members of the practice, all dressed in suits and posing sans smile, one hand resting comfortably in the grand leather chair while the other hand cooly holding a cigarette, I would often think I was born in the wrong era.
Then came the big profitable business of the health insurance industry. They realized that the real money in medicine came by insuring large numbers of “members” and attempting to spend less on their healthcare costs than what the individual, employer, state or federal government paid and you had a profit. If you insured enough members, with an adequate mix of young and healthy individuals who rarely needed to see the doctor, profits were impressive. Having just missed the heyday of capitation, I was perplexed by the whole idea of encouraging physicians to develop large panels of patients, often times more than they could reasonably care for, and encourage them to not be seen because you had already been paid the fee for their yearly care. I watched physicians trying to leverage their fee-for-service patient visits with capitation visits. I think the money was good and physicians were just busy trying to do what they were trained to do…care for patients. But throughout all of this, things were changing in healthcare. Technology was leading to healthcare inflation and decisions had to be made to control ever-increasing costs. I don’t think enough of us physicians were at the tables involved in these decisions. I also don’t believe that the national organizations we rely upon to be our voice always bargained in our best interest. Call it politics, call it political correctness, the changes being made would not bode well for future generations of physicians. So began the era of physicians being managed by those outside of medicine with such degrees as MBA, MHA, etc.
Often, you can feel helpless, powerless and out of touch. A typical day may require attempting to get approval for a necessary test, a necessary medication, retroactive approval for a recent hospitalization, all while trying to see more and more patients at a dizzying pace, each armed with their own set of “facts” from such sources as Google, Direct-to-Consumer Advertising, Dr. Oz, and the local newspaper doctor’s column. What kind of a voice should and do we physicians have? Let’s take a look at some of the statistics:
AAMC 2019 Update, The Complexities of Physician Supply and Demand: Projections from 2017 to 2032
# of Actively Licensed Physicians in U.S. (2017) 800,300 [226,000 in Primary Care/574,300 Non-Primary care]
# of Nonactive Physicians in U.S. (2015 estimate) 150,000-210,000
# of 1st year Medical Students in U.S. (2018-2019 21,622 (Allopathic), 8124 (Osteopathic)
# of 1st year Residency Positions in U.S. (2019) 35,185
# of 1st year Fellowship Positions in U.S. (2020) 11,545
Using an extrapolation of these numbers, we would have about 1,250,000 individuals actively practicing, training, or previously practicing that would have an interest in the future of Healthcare. With a population of about 330 million in the United States, that represents about .4% of our population. I guess that would make us a minority in the U.S. and therefore, an under-represented voice. Or would it?
Direct healthcare and related industries including research and development, manufacturing, and insurance services represent a significant proportion of labor in the U.S. Estimates range from 14% or greater. Healthcare job growth has outpaced nearly every other major sector of the economy (2018 figures). Health-sector jobs are credited with helping the U.S. economy recover from the financial crisis of 2007-2008. All of this relies on practicing physicians.
Furthermore, besides the incredible complexity and continually evolving nature of Medicine, one can not simply “learn how it works” and begin practice. Practicing medicine without a license is illegal in all states with both criminal and civil liability as a result. In fact, the 10th Amendment of the US Constitution authorizes the states to establish laws and regulations protecting the health, safety, and general welfare of their citizens. As both a profession and a trade, the practice of medicine requires a dizzying array of federal, state, and local certification/licensing along with ongoing credentialing requirements. I don’t need to remind any practicing physician today of what is involved including required documents, fingerprinting, proof of CME, etc. not to mention the continual addition of whatever your state government deems “necessary” such as recent additions of required hours of CME related to Opioid Abuse, Child Abuse, and Sex Trafficking, to name a few. The process of state medical licensure is so painful that I have chosen to pay to keep my Medical License active in several states in which I will probably never return.
Neither the above example of the economic importance of medicine nor the description of why the practice of medicine is limited to only properly trained and licensed individuals addresses the key importance of physicians. Namely, the value placed on human life, both young and old, and our training to improve the quality and increase the quantity of that life. There are a lot of other important jobs in the world. There are also a lot of high-profile and “sexy” occupations, some of which develop the status of hero-worship such as musicians, celebrities, athletes, and tech gurus. Despite my love of music, movies, sports, and all things tech, I would give any one of them up in an instant to save the life of my child. As an aside, this speaks to so many topics for future posts including physician compensation compared to other professions (ours is largely controlled by what the government deems an appropriate reimbursement rate for a service through Medicare upon which all insurances set rates) and the general public’s sense of “value” of our services. How many of you have listened to a patient complain about the $20 copay for their office visit with you while knowing they would have no problems with paying $50-$100 for a sporting event or concert ticket?
In summary, I have laid out some of the causes for the loss of autonomy in medicine as well as arguments for why our profession is so important, thus necessitating a larger voice in the decisions being made for us, about us, and to us. In future posts, I plan to address some of the possible solutions for this crisis which has led to decreased physician satisfaction and increased burnout (yet another topic for a future post). However, you should know that by virtue of your chosen profession, you are part of a very elite and noble group that has tremendous importance in the world. On most days, you probably don’t get that impression at work, but you are.