A Physician’s Reflection on the Changes in Medicine

Monday, June 3, 2013 // Uncategorized

This is from the section of the Annals of Internal Medicine entitled, “On Being a Physician”.  These are the reflections of a physician on the changes in academic medicine over the years as a result of changes in reimbursement.  He laments the dumbing down of medicine and the lack of emphasis on critical thinking.


On Being a Doctor | 21 May 2013

When We Became Rich

George A. Sarosi, MD

Ann Intern Med. 2013;158(10):774-775. doi:10.7326/0003-4819-158-10-201305210-00014
It was a rather difficult faculty meeting. The entire time was given to the director of the faculty practice plan, who went over our tenuous financial situation, emphasizing that revenues were down and that we were not likely to get a raise or a bonus at the end of the year. In discussing the possible remedies, he suggested that we consider reducing some of the frills that we currently enjoyed, the number of fellows that the department was paying, or the educational allowance provided each faculty member. Finally, he warned us that unless we turned around the downward trend of the department income, we might need to make some cuts in compensation.

I couldn’t help but think back to how all of this “prosperity” started. When I was in medical school during the early 1960s, there was no talk about health care costs, length of stay, or diagnosis-related groups. We lived in blissful ignorance of the entire issue of who was paying for the care of our patients. We were exposed only to the charity patients on the ward service and had next to nothing to do with patients on the private service. In fact, the only thing I knew about the private service was what my advisor told me—do not apply for a private service internship because “the attending will not let you do anything.” With this advice in mind, I started my medical internship in a hospital that had mostly nonprivate patients.

During our orientation, not a single word was devoted to the cost of medical care. In fact, the only time any discussion involved money was when we (the medical interns) discovered that the hospital administration trainees were paid four times as much as we were. We then sent a deputation to meet with the hospital director about this salary discrepancy. The response was that the hospital had to pay the administration trainees more because they were “college graduates.”

All admitted patients were initially seen by a medical student before the housestaff to ensure that the students would develop adequate history-taking skills. Except in life-threatening emergencies, these rules were inviolate. When the chairman himself was admitted for some diagnostic tests, he insisted that the medical student see him first. He then severely berated the student for not performing a rectal examination.

Attending rounds were of variable length and quality. We had several truly great attendings who challenged us every day to think in terms of pathophysiology and spent time with the students, honing their skills in summarizing and presenting their findings. The students were an integral part of rounds and were expected to read about all of the patients and help with the scut work.

In January 1966, everything suddenly changed. We were never warned about the forthcoming upheaval. We had never heard the term “Medicaid.” The only visible change in our daily life was that I suddenly had many more forms to fill out on recently discharged patients.

Sometime during the latter part of February, a check for $1800 made out to me showed up in my mailbox. It obviously was not mine, because my annual stipend was $3150. The check was from an insurance company that was the local carrier for Medicaid. I took the check to the medicine office and gave it to the senior secretary. As soon as she saw its distinctive color, she immediately knew what it was. Her only comment was, “Oh, it’s one of those!” She then opened a drawer and pulled out a large stack of similar checks, held together by a wide rubber band.

Although I received a few more similar checks, I stopped thinking about them because someone in the medicine office clearly was in charge of the monies. This blissful state of ignorance was suddenly brought to a halt several weeks later during our weekly department meeting. The meeting included the housestaff as well as the faculty and dealt with patient care and medical education issues.

Unlike all previous meetings, the chairman immediately departed from the usual agenda. He brought with him the large stack of checks. He put these on the lectern, saying that the current situation was unprecedented. He asked the audience for their advice on how to dispose of the money. He thought that these funds should be distributed to the housestaff because, in fact, they took care of the patients.

As soon as he finished that sentence, pandemonium broke out—multiple faculty members started to speak at once, and we (the housestaff) sat dumbfounded. The meeting rapidly spun out of control and ended with no resolution relating to the distribution of the newly acquired largesse.

The next week, a group of dark-suited men with expensive briefcases showed up to work out the details of the embryonic faculty practice plan. The housestaff were never again invited to attend faculty meetings that were now devoted exclusively to discussions about money. At first, not much changed in the daily routine of the hospital, but soon we noticed that several young physicians came to visit and gave grand rounds.

By the next year, a few of these visitors joined the faculty in the various subspecialties of internal medicine. After my chief residency, I joined the Centers for Disease Control and Prevention and eventually returned to the faculty 2 years later as a newly minted junior faculty member. The most notable change was the presence of many new faculty members in various subspecialties of internal medicine, more than doubling the size of the previously small faculty. This welcome change came about because of the sudden availability of new funds in the practice plan.

In the 45-plus years after my resident days, the financial aspects of the entire health care system continued to evolve and the changes have been profound and lasting. During these years, we have learned to live with diagnosis-related groups, direct and indirect medical education payments to the hospitals by Medicare, extensive and punitive “fraud and abuse” investigations of university medical centers by Medicare, markedly increased demands for documentation, and the addition of compliance officers to the practice plan to avoid being accused of “fraud and abuse” due to “upcoding.”

These changes were followed by the work-hour limitations for house officers and the implementation of the electronic medical record, where a single keystroke can generate an entire page of standardized (and useless) history designed to milk the maximum reimbursement from the “payer sources,” and where “cut and paste” has led to hundreds of pages of identical, extensive, and uninformative notes from every person in contact with the patient. Although the electronic medical record has markedly improved the quality and efficiency of medical care, it is important to remember that the impetus to develop it was primarily to facilitate billing.

Along with all of these changes, caring for the patient remained the one constant. The development of evidence-based medicine rationalized therapeutic decisions. Ready access to electronic references is now at one’s fingertips, allowing all of us to get and use the best and most recent information available. The development of order sets has assured a degree of consistency in the level of care, but at the cost of eliminating the need for reflection and critical thinking by the house officer.

The relentless pressure for reduced length of stay has created an avalanche of paperwork that has to be completed by the house officer, all too frequently during the hours set aside for teaching rounds, limiting time for discussion of potentially important considerations for patient care. Finally, the typing of extensive and redundant daily notes has replaced the narrative text, which was an important stimulus of critical thinking.

During the past 45 years of making attending rounds, I learned all of the new fads, mastered the use of the computer, became familiar with the lingo of modern statistics, and can even define and calculate “prior probability.” It is just not as much fun …


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