Opinion
A PIECE OF MY MIND Charles G. Kels, JD Office of Health Affairs, Department of Homeland Security, and The Judge Advocate General’s Corps, US Air Force Reserve, Washington, DC.
Corresponding Author: Charles G. Kels, JD (charles.kels @hq.dhs.gov). Section Editor: Roxanne K. Young, Associate Senior Editor.
Matchbox Cars My father belongs to a dying breed. A solo practitioner for nearly 40 years, he is part healer, part entrepreneur, full-time virtuoso. Sporting a Tom Selleck–style mustache and a sarcastic wit, he has peered through his slit lamp at countless eyes and brought increased comfort to the people behind them. The self-employed physician straddles two worlds at once, responsible for tending to patients and keeping the lights on. Owning a practice means running a small business. There is no end to the shift and no hour to clock out. Long the backbone of American medicine, the independent physician has made a living by exploiting the labor force—his or her own two hands. A career in medicine is not an entrée to the ranks of the glitterati, but for generations it has offered the prospect of an honorable profession with a comfortable income. I am the beneficiary of this arrangement. The well-trod pathway between examination rooms in my father’s office afforded me every opportunity that his hardscrabble youth lacked. It also gave me something more valuable—a firsthand view of the meaning of responsibility. Most weekends, my father would receive a call that prompted him to drive to the office and see a patient on short notice. I would tag along, flipping through old Highlights magazines in the waiting room while he did his work in the back. As a reward (contingent upon good behavior), he would take me to the pharmacy on the first floor of his office building and allow me to purchase a Matchbox car. I still remember that carousel of die-cast cars, a source of seemingly endless possibilities that I would spin around and around until picking out the perfect one. Eventually, I must have bought every variety the store carried. The huge bucket of toy cars in my bedroom was a testament to my father’s trips to the office on his “days off.” Newer physicians—my wife included—seem not to covet this life, and it’s hard to blame them. After the long, hard slog of medical education and training, solo and small-group practice offers neither optimal work-life balance nor a guaranteed income level. This is to say nothing of the costs of malpractice insurance, the regulatory and administrative complexities of modern health care delivery, the expense of information technology, and the advent of new care and payment models.1 Young parents and professionals often value flexibility and quality of life over the risks and rewards of entrepreneurship.2 While private practice is, at least for now, still quite prevalent, it is hard not to see that the trend is going in the opposite direction.3,4 A quick Internet search yields a veritable avalanche of breathless studies and issue briefs proclaiming the end of medical practice as we know it. Simply put, physicians entering the workforce
in the foreseeable future will be increasingly likely to do so as employees, particularly of hospitals and health systems.1,2 This does not mean we should pine for Marcus Welby, M.D. of television lore. Dr Welby has been gone for some time. Few small-group practitioners make house calls, and specialization makes it nearly impossible for one physician to appropriately manage a complex patient by himself. In lieu of the paradigmatic black bag, most self-employed physicians must invest in thousands of dollars of off ice equipment— oftentimes literally betting the house on the solvency of their practice. I also understand that it is nigh impossible to build a rational health care delivery system on the backs of independent craftsmen like my father, or for that matter any real system at all. A cottage industry, by definition, confers autonomy on its labor force. This arrangement embraces fragmentation and erects barriers to integration, all of which induce migraines for health policy makers.5 Of course, the vast majority of cottage industries withered under the inexorable rise of factory consolidation. Throughout US history, medicine has been the outlier, preserving considerable free agency under the flag of professional sovereignty. In most industries, the small businessperson is now more legend than reality—many would say it is simply medicine’s time to catch up.6 Yet the emerging model, featuring the physician as a labor unit, challenges the very notion of what it means to be a “good doctor.” In place of ingenuity, availability, and patient advocacy, we are more likely to prize those who play well with others and meet quality improvement metrics.5 Physicians who chafe at authority, pushing against bureaucratic hurdles as the champion of their patients, may find themselves in danger of being deemed relics at best, “disruptive physicians” at worst. We need not sugarcoat the past to appreciate it, nor should nostalgia stand in the way of necessary change. Still, I can’t help but wish that every future physician’s child could see their parent as I did, if only for a few moments—resilient, indispensable, and always there to save the day. Most of all, I wish that everyone could know the untold story of small practices like my father’s, places where each workday is filled with a thousand little kindnesses to those in need, delivered not per a protocol but with an impish wink. These are the offices where every physician learns enough Spanish to get by because there is no hospital interpreter to call. They are the waiting rooms where patients are escorted in not by a receptionist calling out names, but by the physician appearing in the flesh, white coat and all, to shake hands and ask about spouses and
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Opinion A Piece of My Mind
children. They are the cupboards where doctors’ searching fingers know which patients may need a little bit extra to get them to the next pharmacy visit. The men and women who run these small practices are, or at least were, the silent majority of the medical profession. They tend not to be found on the editorial boards of topflight journals, in charge of major professional organizations, or at the helm of blue-ribbon committees. Frankly, they don’t have time. As the practice of medicine shifts to more standardized and integrated environments, the days of the devoted artisan are probConflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported. Disclaimer: The views expressed are those of the author and do not necessarily reflect those of the US Department of Homeland Security, Air Force, or Department of Defense. 1. Gunderman R. Who does your physician work for? The Atlantic. November 22, 2013. http://www.theatlantic.com/health/archive/2013/11
468
ably numbered. I sincerely hope the resulting efficiencies will be as salutary to the nation’s physical and fiscal health as some experts project. But I nonetheless worry that sometimes we don’t appreciate what’s lost until it’s already irretrievably gone. Perhaps an anachronism myself, I still hold a heroic view of the physician as master craftsman and enjoy watching my sons’ eyes grow big when I tell them that mommy saves lives for a living. I’m certainly grateful that my wife won’t have to work as many evenings and weekends as my father did. Sadly, the kids will have to make do with my old Matchbox cars.
/who-does-your-physician-work-for/281724/. Accessed November 25, 2013. 2. Kocher R, Sahni NR. Hospitals’ race to employ physicians—the logic behind a money-losing proposition. N Engl J Med. 2011;364(19):1790-1793. 3. Kane CK, Emmons DW. New data on physician practice arrangements: private practice remains strong despite shifts toward hospital employment. Policy Research Perspectives. September 2013. http://www.ama-assn.org/resources/doc/health -policy/prp-physician-practice-arrangements.pdf. Accessed December 1, 2013.
4. Kletke PR, Emmons DW, Gillis KD. Current trends in physicians’ practice arrangements: from owners to employees. JAMA. 1996;276(7):555-560. 5. Swensen SJ, Meyer GS, Nelson EC, et al. Cottage industry to postindustrial care—the revolution in health care delivery. N Engl J Med. 2010;362(5):e12. 6. Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982.
JAMA February 5, 2014 Volume 311, Number 5
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Eastern Kentucky University User on 05/26/2015
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A PIECE OF MY MIND Charles G. Kels, JD Office of Health Affairs, Department of Homeland Security, and The Judge Advocate General’s Corps, US Air Force Reserve, Washington, DC.
Corresponding Author: Charles G. Kels, JD (charles.kels @hq.dhs.gov). Section Editor: Roxanne K. Young, Associate Senior Editor.
Matchbox Cars My father belongs to a dying breed. A solo practitioner for nearly 40 years, he is part healer, part entrepreneur, full-time virtuoso. Sporting a Tom Selleck–style mustache and a sarcastic wit, he has peered through his slit lamp at countless eyes and brought increased comfort to the people behind them. The self-employed physician straddles two worlds at once, responsible for tending to patients and keeping the lights on. Owning a practice means running a small business. There is no end to the shift and no hour to clock out. Long the backbone of American medicine, the independent physician has made a living by exploiting the labor force—his or her own two hands. A career in medicine is not an entrée to the ranks of the glitterati, but for generations it has offered the prospect of an honorable profession with a comfortable income. I am the beneficiary of this arrangement. The well-trod pathway between examination rooms in my father’s office afforded me every opportunity that his hardscrabble youth lacked. It also gave me something more valuable—a firsthand view of the meaning of responsibility. Most weekends, my father would receive a call that prompted him to drive to the office and see a patient on short notice. I would tag along, flipping through old Highlights magazines in the waiting room while he did his work in the back. As a reward (contingent upon good behavior), he would take me to the pharmacy on the first floor of his office building and allow me to purchase a Matchbox car. I still remember that carousel of die-cast cars, a source of seemingly endless possibilities that I would spin around and around until picking out the perfect one. Eventually, I must have bought every variety the store carried. The huge bucket of toy cars in my bedroom was a testament to my father’s trips to the office on his “days off.” Newer physicians—my wife included—seem not to covet this life, and it’s hard to blame them. After the long, hard slog of medical education and training, solo and small-group practice offers neither optimal work-life balance nor a guaranteed income level. This is to say nothing of the costs of malpractice insurance, the regulatory and administrative complexities of modern health care delivery, the expense of information technology, and the advent of new care and payment models.1 Young parents and professionals often value flexibility and quality of life over the risks and rewards of entrepreneurship.2 While private practice is, at least for now, still quite prevalent, it is hard not to see that the trend is going in the opposite direction.3,4 A quick Internet search yields a veritable avalanche of breathless studies and issue briefs proclaiming the end of medical practice as we know it. Simply put, physicians entering the workforce
in the foreseeable future will be increasingly likely to do so as employees, particularly of hospitals and health systems.1,2 This does not mean we should pine for Marcus Welby, M.D. of television lore. Dr Welby has been gone for some time. Few small-group practitioners make house calls, and specialization makes it nearly impossible for one physician to appropriately manage a complex patient by himself. In lieu of the paradigmatic black bag, most self-employed physicians must invest in thousands of dollars of off ice equipment— oftentimes literally betting the house on the solvency of their practice. I also understand that it is nigh impossible to build a rational health care delivery system on the backs of independent craftsmen like my father, or for that matter any real system at all. A cottage industry, by definition, confers autonomy on its labor force. This arrangement embraces fragmentation and erects barriers to integration, all of which induce migraines for health policy makers.5 Of course, the vast majority of cottage industries withered under the inexorable rise of factory consolidation. Throughout US history, medicine has been the outlier, preserving considerable free agency under the flag of professional sovereignty. In most industries, the small businessperson is now more legend than reality—many would say it is simply medicine’s time to catch up.6 Yet the emerging model, featuring the physician as a labor unit, challenges the very notion of what it means to be a “good doctor.” In place of ingenuity, availability, and patient advocacy, we are more likely to prize those who play well with others and meet quality improvement metrics.5 Physicians who chafe at authority, pushing against bureaucratic hurdles as the champion of their patients, may find themselves in danger of being deemed relics at best, “disruptive physicians” at worst. We need not sugarcoat the past to appreciate it, nor should nostalgia stand in the way of necessary change. Still, I can’t help but wish that every future physician’s child could see their parent as I did, if only for a few moments—resilient, indispensable, and always there to save the day. Most of all, I wish that everyone could know the untold story of small practices like my father’s, places where each workday is filled with a thousand little kindnesses to those in need, delivered not per a protocol but with an impish wink. These are the offices where every physician learns enough Spanish to get by because there is no hospital interpreter to call. They are the waiting rooms where patients are escorted in not by a receptionist calling out names, but by the physician appearing in the flesh, white coat and all, to shake hands and ask about spouses and
jama.com
JAMA February 5, 2014 Volume 311, Number 5
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Eastern Kentucky University User on 05/26/2015
467
Opinion A Piece of My Mind
children. They are the cupboards where doctors’ searching fingers know which patients may need a little bit extra to get them to the next pharmacy visit. The men and women who run these small practices are, or at least were, the silent majority of the medical profession. They tend not to be found on the editorial boards of topflight journals, in charge of major professional organizations, or at the helm of blue-ribbon committees. Frankly, they don’t have time. As the practice of medicine shifts to more standardized and integrated environments, the days of the devoted artisan are probConflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported. Disclaimer: The views expressed are those of the author and do not necessarily reflect those of the US Department of Homeland Security, Air Force, or Department of Defense. 1. Gunderman R. Who does your physician work for? The Atlantic. November 22, 2013. http://www.theatlantic.com/health/archive/2013/11
468
ably numbered. I sincerely hope the resulting efficiencies will be as salutary to the nation’s physical and fiscal health as some experts project. But I nonetheless worry that sometimes we don’t appreciate what’s lost until it’s already irretrievably gone. Perhaps an anachronism myself, I still hold a heroic view of the physician as master craftsman and enjoy watching my sons’ eyes grow big when I tell them that mommy saves lives for a living. I’m certainly grateful that my wife won’t have to work as many evenings and weekends as my father did. Sadly, the kids will have to make do with my old Matchbox cars.
/who-does-your-physician-work-for/281724/. Accessed November 25, 2013. 2. Kocher R, Sahni NR. Hospitals’ race to employ physicians—the logic behind a money-losing proposition. N Engl J Med. 2011;364(19):1790-1793. 3. Kane CK, Emmons DW. New data on physician practice arrangements: private practice remains strong despite shifts toward hospital employment. Policy Research Perspectives. September 2013. http://www.ama-assn.org/resources/doc/health -policy/prp-physician-practice-arrangements.pdf. Accessed December 1, 2013.
4. Kletke PR, Emmons DW, Gillis KD. Current trends in physicians’ practice arrangements: from owners to employees. JAMA. 1996;276(7):555-560. 5. Swensen SJ, Meyer GS, Nelson EC, et al. Cottage industry to postindustrial care—the revolution in health care delivery. N Engl J Med. 2010;362(5):e12. 6. Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982.
JAMA February 5, 2014 Volume 311, Number 5
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Eastern Kentucky University User on 05/26/2015
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