In my quest to keep on the pulse of medicine, I am fascinated by all of the changes occuring. One of the changes I have seen during my lifetime as a doctor is the solo practicioner, the doc who started practice and “hung their shingle,” is almost extinct.
I live in Silicon Valley, where it is costly to live and practice. I had thought the lack of solo practicioners was just an issue here in California. For a young doctor to go into private practice in the Bay Area is prohibitive- overhead costs, taxes, the difficulty of finding office space (who can compete with google, facebook, and all the internet start ups?), etc. So new doctors in the Bay Area join a group. Kaiser. Palo Alto Clinic. A large group practice. They don’t hang their shingle.
I have written blogs about this in the past. Even within plastic surgery, which is immune to many of the issues other specialties face, you see doctors being rolled up into “Institutes” and “Clinics.” You don’t go to a certain doctor who knows your details by heart. You are seen by someone within the clinic. It could be a nurse, or another doctor, or your doctor. If something goes wrong, you don’t have the doctor’s direct communication. You are filtered through switchboards, receptionists, nurses, other doctors. You see whoever is available.
I read an article last week which I found interesting. It was an Op Ed by Scott Gottlieb entitled “The Doctor won’t see you now. He’s clocked out.” In the article he discusses how Obamacare favors the large hospital, with doctors as hourly employees who clock in and out. Does this give good medical care? Where is the continuity? Where is the understanding your patient, their family history, and noticing the details?
What is the ideal doctor? For plastic surgery knowing what bothers you (it may not be what others notice on you), what your goal is, and understanding your expectations is critical. But a doctor like me- who has no one sandwiched between me, the doctor, and you, the patient- we are a dying breed. I am directly available to my patients. I like knowing my patients. I am, as Dr. Gottleib states, “a relic.”
“Once they work for hospitals, physicians change their behavior in two principal ways. Often they see fewer patients and perform fewer timely procedures. Continuity of care also declines, since a physician’s responsibilities end when his shift is over. This means reduced incentives for doctors to cover weekend calls, see patients in the ER, squeeze in an office visit, or take phone calls rather than turfing them to nurses. It also means physicians no longer take the time to give detailed sign-offs as they pass care of patients to other doctors who cover for them on nights, weekends and days off.”
Hospitals want to roll up all the private doctors to gain their patients. From Dr. Gottleib’s article and research, larger centers don’t lead to more productivity. They give fewer choices to patients, more red tape, and doctors who are forced to see more and more patients in less and less time. It means if you have a question about your surgery, you talk to the nurse, not your doctor.
“hospitals aren’t buying doctors’ practices because they want to reform the delivery of medical care. They are making these purchases to gain local market share and develop monopolies.”
Sad days ahead for medicine. I am glad I will be able to practice in my solo practice, know my patients, and treat them directly. The generation of doctors behind me will likely not have the option.
It is a great article. To read it in full, please click here.