Saturday, May 4, 2013

Physician Fatigue, Resignation, and Future of Health Care

Those who expect to reap the blessings of freedom must undergo the fatigue of supporting it.

Thomas Paine (1737-1809), The American Crisis (1776)

The mass of men lead lives of quiet desperation.  What is called resignation is confirmed desperation.

Henry David Thoreau (1817-1862). Walden (1854)

I was speaking to a physician who is a part-time partner in a successful specialty surgical center.
 I asked  what he thought about his future.  He replied, “We’re tired of fighting. The odds are stacked against us.    We’re just waiting to be bought out.   We’re resigned to the fact that the future belongs to organizational medicine, not to independent practice.  Once we’ve sold out, my partners and I  plan to retire.”
 His  is a story of physician fatigue, resignation, and even desperation.   It is a  story of a fundamental transition to a new brand of medicine – medicine as practiced within and for organizations.
The physician is saying, “Why fight for physician freedom, when the odds, the money, and the power are against you?   Why struggle for independence when you know the future belongs to organizations with the capital,   marketing talent, and administrative  skills, and other resources  to  deal more effectively and efficiently with n the confines of  a competitive  medical environment ?
It is an instructive story.  It indicates future physicians will need entrepreneurial and management educations to form marketable physician businesses attractive enough to be acquired by larger organizations.  It indicates physician leaders will need business training. It indicates the practice of medicine will become the practice of business.
It indicates the truth of Peter F. Ducker’s world’s nearly 50 years ago in The Age of Discontinuity
“ Every single social task of importance today is entrusted to a large institution organized for perpetuity and run by managers. Where the assumptions that govern what we expect and see are still those of the individualistic society of 18th century liberal theory, the reality that governs our behavior is that of organized, indeed organized, power concentrations.”
There is something inevitable about  this physician’s recognition of what the future holds.  In the modern era,  where  health care consumes 20% of the GDP, it will take an organization to get things done.   The complexity of health care, with its emphasis on technology,  its requirements for data collection and transmissions,  its needs for compliance to government rules and regulations, assures us of this.  So does demands for accountability, and measures of value, quality, and profitability.
Organizations are arguably  more efficient and effective, but it’s a sad story too.  Bigger organizations are not necessarily better.  No longer will individual physicians hold their destiny in their own hands. Success may depend on collective enterprises.  These enterprises may result in a loss of individual confidentially and privacy for patients and for physicians too. They will be the passing of an era.
There will be physician dissidents.   Maybe 10% will go into concierge or cash-only practices, or will enter into practice in urgent care centers or walk-in clinics.
What about other physicians?  What does their future hold?
·         Most, perhaps 75%,  will go to work as hospital employees.  America’s 5000 or so hospitals remain  the go-to  health centers in most communities.

·         Many, 15% or so,  will be employed by large integrated health organizations – such as academic medical centers, and the Kaisers, Mayos, and Cleveland Clinics of the world.

·         Many will be employed by more diffuse organizations, like Geisinger.

·         The others will practice in work-site clinics,  at the corporate headquarters of organizations with 100 or more employees.

·         Some will become business partners with hospitals in ‘Big Boxes” with big parking lots and  big outpatient surgical, diagnostic, pharmaceutical, and rehab facilities.

·         Some will work for business “franchises,” consisting of corporate owned and leased outpatient facilities for diseases like diabetes, back pain, or just plain pain, or  diagnostic laboratories or surgicenters for  procedures like hernia repair, cataracts, cosmetic repair or rejuvenation, or colononscopies.

·         Some will be employed by national wide chains of hospitals, like the current Cancer Centers of America,, or as yet unnamed, Musculoskeletal Centers of America. Brain Centers of America, Orthopedic Centers of America, or Birth Centers of America, or Hospice Centers of America.
To quote Yogi Berra,  “The future ain’t what it used to be.”
Tweet:  American medicine is in a transition from independent practice to organizational practices, often owned and operated by non-physicians.



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