Are patients and physicians the losers? – GWC Mag

Despite technological and pharmaceutical improvements in the advancement of medicine, many changes that have occurred in the delivery of medicine during my 15 years of private practice in plastic surgery have had detrimental consequences for both patients and physicians. I will briefly review these changes and provide my perspective on the future of medicine in the United States.

The development of electronic health records, with the ability to access, chart, and share patient information easily and efficiently, has been an invaluable asset. While this technology comes with a hefty price tag for practices, it has been overwhelmingly beneficial. In addition, telehealth allows patients to be seen and evaluated by physicians without any burden of travel. In conjunction with the evolution of physician “super-specialists,” patients can now receive high levels of expert care from any institution in the world. Finally, minimally invasive and non-invasive treatments and pharmaceuticals have provided additional options for treatment with benefits such as decreased recovery time and fewer side effects.

The corporatization of medicine, transition of physicians from private practice to employment, and use of nurse practitioners to replace physicians have shifted the focus of medical practice away from the delivery of outstanding patient care to shareholder profit. This has led to physician burnout. Patients are now viewed as “units” with associated metrics, rather than human beings needing compassionate care.

As primary care physicians began transitioning away from seeing their own inpatients and into only outpatient care, the role of the hospitalist expanded. Regardless of the reasons that PCPs stopped seeing their patients in the hospital, the underlying message to patients was: “I am not your doctor and not involved with your care when you are acutely ill.” A similar message is being sent in the outpatient setting when no physician sees or is involved in evaluating and treating the patient. We have consequently taught patients that they no longer need physicians.

The development of the hospitalist physician has created an impersonal and fragmented type of care. This has led to higher rates of ED/inpatient admission, greater use of consultants, and longer hospital stays, with increased costs. The transition of physicians from private practice to employment and the use of nurse practitioners to replace physicians have shifted the focus of medical practice away from the delivery of outstanding patient care to shareholder profit.

The corporatization of medicine has caused health care costs to soar, with questionably improved care. Quality is no longer a concern unless it involves a measurable metric that leads to reimbursement or some other recognition or award, such as a Leapfrog Rating. Hospital administrators dictate patient care to their employed physicians with punitive measures dispensed for insubordination. Mortality and morbidity conferences and medical education meetings have been replaced with conferences involving administrators centered on charting, billing, patient metrics, re-admission, and hospital finances. Local hospitals have recently gone so far as to exclude private physicians from seeing their own inpatients or working independently within their facility.

Important decisions on equipment, medications, and other policies are frequently made without any physician input or against physician opinion. Executive boards have replaced private physicians with hospital-employed physicians who reluctantly comply with administrator requests. Referring patients to physicians outside of the network is impermissible, even when better options may be present. Bylaws have been rewritten by hospital attorneys to intimidate staff physicians, allowing the hospital to recoup legal fees against any physician who pursues legal action. Feeling exasperated and defeated, physician turnover is high, and gaps are being sparingly filled by locum tenens physicians at additional costs.

The role of nurse practitioners has expanded beyond the scope of their education as physician shortages mount. Nurse practitioners now see a significant number of patients without any physician input, in all settings. Since hospitals can bill up to 85 to 90 percent of a physician’s fee with an NP, hospitals will continue to use them to replace physicians and pad their bottom line. Defiant physicians who refuse to work with or train the NPs are disciplined. Hospital lobbyists continue to lobby for independent practice of NPs, against organized medicine. These NPs start with less debt and receive significantly higher compensation than any resident despite much less training. Physicians are being forced to train their replacements.

I foresee a future in medicine where:

• Hospitals will continue to exclude private-practice physicians in favor of employed physicians.
• Physician-led care will no longer be the standard of care.
• Nurse practitioners will deliver the majority of patient care, with minimal to no physician oversight.
• Medical schools will slowly be replaced with nursing schools.
• Lump-sum insurance payments will be the norm.
• Increasing deductibles and co-insurance will be standard.
• As insurance becomes unaffordable, physicians will be portrayed as scapegoats by frustrated patients.
• Hospital systems will enter the commercial insurance market.
• U.S. citizens will demand cost control from the government and request a single payer (Medicare).
• Physicians will organize through unions and strikes. This will reaffirm that NPs are the essential providers of care and that physicians are replaceable.
• Due to declining reimbursement and rising wages, the control of hospitals will be turned over to the government.
• The socialization of medicine will become inevitable.

Since hospitals can bill up to 85 to 90 percent of a physician’s fee with an NP, hospitals will continue to use them to replace physicians and pad their bottom line.

What can be done to prevent this collision course we are on:

• Immediate curriculum changes in medical school are needed to focus on non-clinical aspects of medicine, including insurance, leadership, business, and other political aspects.
• Increase the number of combined six-year college and medical school programs to shorten education and decrease debt. Alternatively, consider shortening medical school to three years.
• Medical schools must collaborate with physicians to ensure that physician-led care is sustained.
• Additional ACGME funding is essential to increase resident positions, and the expansion of the assistant physician program should be promoted as an alternative to unmatched students.
• Resident salaries must increase to align with those of salaried NPs, and teaching hospitals should be allowed to bill for resident services.
• Create shorter, more integrated residency programs for physicians seeking specialization.
• Finally, more money must be spent on lobbying for physician-led care.

Organized medicine remains our final hope of bringing together all physicians.

Samer W. Cabbabe is a plastic surgeon.