Fall from grace

J. Joseph Marr, MD

The author (AΩA, Johns Hopkins as there a certain time when Whenever it occurred, the transforma- University, 1964) is a retired academic it happened? If so, probably tion of the physician during the sec- physician and business executive. He is the inflection point occurred ond half of the twentieth century from a member of the editorial board of The inW the nineties when business took over shaman to skilled labor was inexorable Pharos. formally. That was a watershed series and, in my opinion, will prove to be of events, surely, but the full process irreversible. Illustrations by Jim M’Guinness. seems to have been more like death from All of us who were active in medicine a thousand cuts, some self-inflicted. and medical science during these years

8 The Pharos/Winter 2014 played a role in its transformation. We Two things happened in 1961, when I their time to patient care and paid little were troubled—and then horrified— was a sophomore in medical school, that attention to the institutions in which observers, yet often more than a little were to some degree prophetic. I recog- the care was delivered unless there were complicit. Hubris had much to do with nized both of them as being significant, obvious issues of neglect or mismanage- it, and all of us were culpable to varying but did not see that they were harbingers ment. They also paid little attention to degrees. Is medicine today better, worse, of the future. An article in the Journal patients themselves beyond the office or just different? Does it matter? Perhaps of the American Medical Association or hospital visits. The problem of health not so much to people born in the late chronicled a study of the interpretation care delivery to the medically indigent twentieth century, but it matters much of chest x-rays read both by radiologists was left to municipal hospitals, chari- to those of us who practiced medicine and by a computer. The two methods table clinics, and the free care provided and loved it during the last half of the were about equally accurate. The con- by many medical practitioners. The fact last century. clusion was that computers were no that these municipal hospitals served To answer this question with any better than radiologists. My conclusion sometimes as superb training facili- hope of perspective, it may be valuable was that the radiologists were doing the ties abetted the situation. Management to consider the issue as having two com- best they could and the computer was and planning of indigent care largely ponents: the evolution of medicine itself learning and would do better as time was left to those who tried to respond and the effects of that evolution on the went on. The other event was a conver- to medical-social issues from a back- physician practitioner. The changes in sation with some physicians about the ground of social work, law, or politics. the institutions through which medicine management of hospitals. I wondered These are general statements—there is practiced, important as they are to if physicians should not be managing were physicians and physician groups our current situation, will be treated hospitals themselves since they knew that recognized the problem of delivery as a concomitant and parallel sideline. more about patient care. The response of care—but the emphasis remained on Permit me to be an observer and guide was that physicians could hire people fee-for-service with some charity care here and use some of my own history to do this; the medical staff actually ran done. to illustrate. I do not think of myself as the hospitals anyway. Yes, I thought, but The “threat” of Medicare and Virgil, but rather as a fellow traveler. The actually we work for the administrative Medicaid in the 1960s caused much of comments and illustrative experiences organization. For years afterwards, phy- organized medicine to react strongly I use are, within broad limits, common sicians who recognized this disconnect against governmental intrusion into to us all. and went into administrative medicine medical practice. In particular, the were considered, quite unfairly, as sim- American Medical Association (pre- A brief case history ply unfit for practice and their real im- sumed to be the spokesperson for phy- Those of us born in the late 1930s or portance not credited. Where did that sicians generally) lobbied against any very early 1940s entered medical school lead? Look around. changes in the fee-for-service practitio- in the later 1950s or early 1960s. It was ner model of medical care. The specter a time that I have heard described as “a Hubris of socialized medicine was raised when- Golden Age of Medicine.” A golden age, There was considerable hubris ever any governmental changes were of course, is relative to the observer. We among physicians in this time. We had proposed, but no alternative solution to were at the top of a revered profession social status, financial rewards, and the the problem of the uninsured and under- dedicated to the care of others and al- gratification of playing an important served was put forward. When Lyndon most solely responsible for the manage- role in our society. Did this play a role Johnson brought Medicare and Medicaid ment and delivery of that care; on the in the changes in medicine? I believe into law in 1965, two things happened other hand, that care was very unevenly so. A “cottage industry,” as medicine of among physicians: first, outrage—there distributed and closely related to abil- the time rightly has been called, had was much talk of “socialized medicine” ity to pay. The physician was priest and no incentive to look at the larger social and the downfall of the private practice seer; his opinions were respected, given picture, nor the mechanism to introduce model. Practice nevertheless went on great credence, and sought in areas out- change had it wished to do so. The revo- as usual, although with the realization side of medicine. He was a scholar in lution of biotechnology and biomedical that a major event had occurred, the the broad, liberal-arts sense of the term. engineering as applied to the physician consequences of which were yet to de- He was the alchemist who understood practitioner could be compared to the velop. Second, the slow realization that science, and he knew the workings of industrial revolution and the cottage in- the medical care physicians had been the human body and psyche as well. He dustries that it eliminated. No one saw it providing gratis now would be reim- was a shaman at the end of the age of coming: a computer reading a chest film bursed by the government. Predictably, shamans. It was like that. caused no alarm. Physicians devoted opposition softened. We gradually came

The Pharos/Winter 2014 9 Fall from grace

to tolerate, and then love, the beast. The in the civilian world (start IV fluid or not. I began my slow, yet steady, appre- words from Alexander Pope’s Essay on blood infusions; some surgery to prevent ciation of changing medical economics Man, intended for other situations, were or mitigate larger surgery later), they and the disparity of medical care in our never truer: also made the decisions to do so. Slowly society. it became clear that nonphysicians who Later, in the early 1980s, I was Chief Vice is a monster of so frightful mien, had some training could make these de- of Medicine at the same metropolitan As, to be hated, needs but to be seen; cisions. This had started with the corps- hospital and needed to conserve the Yet seen too oft, familiar with her face, men in World War II, and expanded time and energies of my medical resi- We first endure, then pity, then rapidly in the Korean War, but it came dents. They could not manage seriously embrace.1 into full flower in Viet Nam. And un- ill inpatients and a large outpatient clinic like the situations after the former wars, population without loss of quality of Expansion of the medical care these people came back home to a social care and exhausting themselves in the system milieu needing ways to lower costs while process. Those of us new to medicine in 1965 providing more care to the underserved The solution was to staff the diabetic paid scant attention to these changes or ignored. They began to fit into medi- and hypertension clinics with nurse in the payment system, as there were cine and alter its practice. The expansion practitioners and a single supervising internships and residencies to deal with. of the medical care delivery system and medical resident. This freed about five The familiar operational chain remained the dilution of the physician’s role had house staff from each clinic to man- solidly in place: physician, nurse, and begun in earnest. A very few years later, age in-patients. The nurse practitioners patient. Physician extenders had yet to the paramedic appeared, as early studies were knowledgeable, anxious to prove make a significant appearance. There of firefighters in several metropolitan themselves, and very popular with the were technical personnel in hospitals areas showed that such a rapid response patients, since they spent more time and clinics to be sure, but they provided system could save lives. The delegation with them than the house staff was able ancillary services in laboratories and of immediate care outside of hospitals to do. It was surprisingly popular for all radiology and not direct patient care. and physicians’ offices had begun. concerned, and bitterly opposed by the Surgical technicians were new, and, by My time in the military gave me a medical staff. and large, registered nurses filled these grudging and then wholehearted ap- There was an additional, time- positions. preciation of the skills and enthusiasm consuming issue: a medical resident was Then there was Viet Nam. For those of corpsmen. Diagnosticians they were expected to read all the EKGs for the of us who became part of the military, a not, but they were doers and rather hospital. This was not a teaching exer- world opened with a life-changing array good at it. This was not new, but it cise, it was a billing exercise for the hos- of new experiences and considerations. was to me and started a line of thought pital. The solution came in the form of a Among these were physician extend- about medical care extension and a re- new EKG machine that read the results ers of many sorts (I use this term a bit examination of my reference frame that itself. It eliminated all normal readings; loosely to make the point of the various would become useful several years later. the abnormal tracings still were avail- forces that would come to bear on the Later, as a medical resident, I wrote a able for teaching purposes. This was the delivery of medical care after that war): prescription for a new antihypertensive information technology equivalent of medical corpsmen who, though nar- medication for a lady in the clinic at a the computer-read chest films of fifteen rowly trained, were many times quite city hospital. Because of military service years earlier. The time saved for the good at what they did and often took and graduate school interludes, it had house staff was considerable. This time, serious risks to do their jobs; techni- been a few years since I had been an in- the obvious was clear to me. cians who performed a variety of tasks tern, and new medications had appeared These small but important changes, that simplified the work of physicians that I wanted to try. She thanked me and instituted to provide good medical care (some of these positions existed in civil- went away. About an hour later, she re- in an overused and understaffed envi- ian medicine, but not to the degree that appeared and dropped the prescription ronment, were harbingers of changes in they were employed in the military); he- on my desk with the comment “I can’t medical care to come. licopter medevac pilots greatly improved afford this.” This, of course, destroyed survival of the wounded and would ap- my plan of treatment and waved a large Changes in diagnostic methods ply their skills to air ambulances back flag in my face. We reworked the plan At about the same time, the auto home. using some older and quite generic med- analyzer appeared in clinical laborato- One thing about these workers was ications that cost very little. I managed ries and began to turn out reports with overlooked: not only did they do proce- her for a long time using those generics; twelve and then twenty-five biochemical dures generally reserved for physicians drugs had changed but physiology had tests on small amounts of blood. It was

10 The Pharos/Winter 2014 a wonderful advance and was the lead- medical diagnosis by making it more in cost, the strength of the physician- ing edge of the entry of technology into accurate and efficient. At the same time, patient relationship, and the effect on medical care. Many advances followed it has raised the cost of care, probably our national economy. The physician’s and were woven into the standard of has decreased clinical acumen, and has arcane diagnostic knowledge gave way to care. The unanticipated concomitant made medical care a bit more like that in technology based on science. We slowly was significant overuse and overreliance Star Trek—impersonal, yet efficient and became recipients of technical informa- on these in lieu of clinical judgment. effective—and less like that provided tion and were on the road to becoming They also were used increasingly as de- by the beloved family doctor. Patients skilled labor. fensive medicine and raised the cost of received more time, sympathy, and care not insignificantly. The device ar- personal care from the latter but who The entry of business into medical mamentarium, now much broader, more would go there again? These improve- practice accurate, and more rapid, has improved ments carried a price and that price was As the cost of care became an

The Pharos/Winter 2014 11 Fall from grace

increasingly visible issue, there was agi- A little more case history are termed good business practices. tation to “do something about it.” The It was 1986 when DRGs appeared at Although a “cottage industry” could not practice model was essentially the same our hospital and the sky began to darken. change the system, a business organi- as it had been for hundreds of years, Raising fees for extra work was no longer zation with its hierarchical structure even though group practices had begun permitted. In response, it was decided certainly could, and did. This led to our to deliver care with more efficiency. that if a patient was in an academic current situation, in which physicians Within medicine, there was unrest be- medical center, then, by definition, he who once tried to remain independent cause the ability to pass a device of some or she had a complex problem and we are rushing into the waiting arms of vari- type into the body garnered significantly were to bill accordingly. Hospital rounds ous health care provider organizations. more income. This led not only to spe- were no longer just about patient care Each stage of the weakening of the cialization but also to increasing num- but also about spending time to be sure physician-patient relationship came bers of physicians migrating to more the chart reflected the weighty thinking about gradually, as physicians were re- lucrative specialties and the proliferation that justified the top level of billing for quired to increase patient visits per unit of sub-specialties. This became a par- the visit. I did this for a while and then time, accept lower reimbursement for ticular issue within academic medicine, realized that the flow of teaching rounds these visits, vie with insurance claims where some divisions tended to operate had been completely subverted by the adjustors for compensation or the right at a loss while others had comfortable documentation process. The chart had to carry out diagnostic testing, immerse profits and often did not care to share been well documented before, but now themselves in relative value arcana to them. The pressures to increase clinical the quantity of words became as im- maximize the earned reimbursement, revenue burgeoned for those specialties portant as their quality. Consequently, and, in general, devote more and more that did not have a financial gimmick I made two sets of rounds. The first time and psychic energy to defending (forgive the word, but is appropriate in was teaching and therapeutic rounds the citadel of traditional medical prac- this context). with students and house officers and tice against an onslaught of accountants, Into this, in the early- to mid-1980s, fellows; then, a second set alone to do middle managers, directors, and execu- came two major events that would the additional notes and form checking tives. Individual practitioners or small change medicine forever: first, payment that justified the billing. This, of course group practices now are less and less according to Diagnostic Related Groups took more time—it probably cost me an able to withstand the pressure to sell (DRGs), the lynchpin of various payment additional hour or more each day when their practices to local or regional health changes to come from both the govern- on service—but it led to better teaching. care for-profit organizations. The entre- ment and the insurance industry. The As a physician in academic medicine, preneur increasingly becomes the em- major tool for the savings that would the pressures of time were not those of ployee. We have come to this: the selling come from this was to be the more ef- physicians in private practice, but they of our patrimony to philistines because ficient management of physicians and still led to longer days and a definite there is no other choice. The world does their methods of practice.2 The second feeling of being disingenuous regard- end with a whimper. change was the business management ing the billing situation. I felt I could people who appeared with the promise not justify billing at the highest level all The remains of the day of instituting efficient “business prac- the time and backed down the charges If one looks at the cost in the United tices” that would lower the cost of care. as patients recovered—I heard about it States to deliver health care relative to The increasingly incestuous relation- more than once from those concerned the rest of the world’s countries, we are ship between the insurance industry with revenue flow. in trouble. We know that. If one com- and business conglomerates that man- There came an afternoon in the clinic pares this cost with life expectancy, the aged ever larger and increasingly vora- when I was talking with an older clini- picture is even worse. We know that as cious “health care delivery” systems was cian. He looked upset and finally looked well. The United States spends about the vehicle that ejected medicine from at me and said: “Dammit, Joe, I am not $4500 per capita for a life expectancy its delusional world where the doctor- a Health Care Provider, I am a Doctor.” of about seventy-seven years; Cuba, to patient relationship still was paramount We talked about that and the directions pick only one of many countries, spends and hurled it into the arena where quar- of things for a while and then we both about eleven percent of that for the same terly earnings increases were the only returned to providing health care. life expectancy.3 Our delivery structure thing that seemed to matter. These al- is inordinately large, cumbersome, laden tered forever the nature of medical care Barbarians at the gates and with a variety of profit centers, and bur- and made it health care delivery. The everywhere else dened with regulations for both provider physician now was definitely a mere It was during the 1990s that medicine and patient alike. employee of a system. fell increasingly under the sway of what The shift, in our lifetimes, from

12 The Pharos/Winter 2014 individual and small group practice to will provide more health care, the care physician is only one of these. The phy- institutional medicine was not necessar- will be more affordable to people indi- sician will become—has become—de- ily bad. There are many instances of im- vidually, there will be more preventive creasingly the guide and guardian of proved efficiency and better patient care. medicine, and, probably more emphasis the system and more of a supervisor Kaiser Permanente, one of many not- on behavioral change to bring about in the mosaic of provision of care. I for-profit health care delivery groups, healthier living. While it will not be the feel that we have lost something very has done well in caring for patients at type of care that many of us recall, ulti- important; physicians younger than I a reasonable cost. Size is not necessar- mately it will be a system that provides are not so sure. Perhaps we are looked ily a negative factor. Coupling medical care to people who now cannot afford it. upon in the same way we looked upon care to the profit motives of health care Spend some time talking with the family doctor of another era. He companies and insurance organizations, younger people who know little or noth- was beloved, honored, respected, and he however, has altered the focus of medi- ing about medicine of thirty or forty gave of his time and energy unsparingly. cal practice from patient care to patient years ago. They are quite willing to ac- But he did not cure as many people as care at the lowest possible cost to the cept governmental intrusion if it allows we did. Those who have come after us caregiver organizations and payers. The them to save for their children’s educa- are just as intelligent and competent but intrusion of these companies into the tion. They understand that visits for care have more knowledge and tools and are practice of medicine to bring costs to an are brief and the physician is harried, but curing more people than we did. Good optimum level certainly is appropriate; it is the system they know. The other medicine persists. It is our model that is demanding some discipline from physi- thing they know is that they can afford gone; another has taken its place. cians to be as efficient as possible and to it. The public is indifferent to how the The physician remains; he or she conserve resources also is a reasonable physician feels; it just wants a system practices differently. We still play an request. Interfering with good medical that provides affordable care. important and essential role but it will care simply to cut costs is not. be increasingly supervisory. Can you I remain convinced that until the Coda imagine a physician supervising a cadre profit motive is purged from medicine— Let us set aside the monster of the of physician assistants or nurse practi- read quarterly earnings increases and delivery and payment systems and look tioners in lieu of individual family physi- insurance profits—all talk and action at the resultant of these fifty years with cians? How about a surgeon managing to improve our health care system will respect to medicine itself and physicians. several operations performed by skilled be of little or no benefit. One need only Having reviewed some specific examples technicians or robots? I can imagine look at health care systems around the expanded into the general, we can see all of these. In our own minds, we have world, each with its own inefficien- the changes that have occurred. The been marginalized; in the minds of pa- cies and abuses, and note that the gen- result is a complex body of knowledge tients, we still are here. We remain very eral opinion of consumers is that their that has given patients access to an ever- much in the game. Our problem is with country’s system is good and benefits better level of scientific medicine: earlier the intangibles; we lost the spotlight. all. All of these health care systems are diagnosis and treatment, fewer and less essentially not-for-profit models oper- invasive procedures, telemedicine, the References ated by governments with physicians as tailoring of therapy to genome structure, 1. Pope A. The Poetical Works of Alex- employees.4 use of genomics to manage probabilities ander Pope. New York: Thomas Y. Crowell; But look at the system from another of diseases, better prenatal diagnosis 1896. perspective. Set aside for the moment and therapy, new applications of ro- 2. Eastaugh SR. Managing risk in a the ineptness of the creation of the botic surgery. Regenerative medicine risky world. J Health Care Finance 1999; Affordable Care Act (ACA), its fault- will provide new tissues and, ultimately, 25: 10–16. ridden introduction, and the new bur- new organs. Medicine is unquestionably 3. University of California, Santa Cruz. den on our economy. These are not far better than when we began. We do Health: Global Inequalities in Health. http:// small issues, but they are temporary and, things now as a matter of course that ucatlas.ucsc.edu/health.php. with some difficulty, will be overcome were undreamed of then. Patients are 4. Reid TR. The Healing of America: in the short term. The Supreme Court much better off now. What else would A Global Quest for Better, Cheaper, and decision to uphold the ACA, the failure one expect after half a century? Fairer Health Care. New York: Penguin of the government shutdown in October On the other hand, the straight line Press; 2010. 2013 to alter or rescind the ACA, and of physician-nurse-patient is gone and the general acceptance of the ACA by will not recur. An increasingly complex The author’s e-mail address is: marrj@ much of the public, all ensure that it is therapeutic system requires an increas- mho.com here to stay in one form or another. It ingly complex variety of providers. The

The Pharos/Winter 2014 13