Physician Culture - Observations after Three Private Doctor Visits

This week as a patient I visited three doctors – a cardiologist, a dermatologist, and an ophthalmologist. The cardiologist was in a group of eight, the dermatologist in a group of two, and the ophthalmologist practiced solo but was part of an eye surgery center founded by a number of ophthalmologists.

As part of my visit, I carried a copy of my book Obama, Doctors, and Health Reform as a spark for reform discussion. The book led to lively discussions about reform in general and about specific reform recommendations of others. These recommendations included eliminating fee-for-service, decreasing the number of specialists, and use of electronic records to facilitate care, affords diagnostic support, and decrease waste.

Not surprisingly, was their agreement that ending fee-for-service was an impractical fantasy, that mandatory electronic medical records were overkill and would do little to improve care, and that shortage of doctors in their specialties was imminent. None of these specialists had an electronic medical record system. The cardiologist thought such a system was inevitable but greeted the idea with a notable lack of enthusiasm. The dermatologist and ophthalmologist said installing EMRs in their practices made no sense, and added it would be cheaper to take a penalty rather than install a system.

All shared the opinion that a centralized command and control system could not possibly control all the variables, permutations, and combinations of patient-doctor interactions that went into decision making on the part of patients and doctors. Most thought a centralized government-run system would continue to decrease reimbursement and would lead to rationing.

All were fatalistic about decisions made in Washington, and all doubted any federally-directed system would improve care on the ground. Most thought Medicare fee reductions were likely but were arbitrary and capricious and had little relation with their cost of doing business. All, however, said they would continue to see and accept new Medicare patients, even if Medicare reimbursement did not cover their costs.

This is a small, perhaps even a meaningless and certainly not a statistically significant sample, but it is relevant to the current debate. In my option, it reflects a general resistance and skepticism about federal intervention. Among doctors, there are no miracles among friends, and no expectations of silver bullets being fired from Washington. These physicians have a free market mindset - an intricate voluntary system of economic, social, and cultural interaction representing desires and needs of individual patients and doctors.