American Doctors: Here Today; Gone Tomorrow

Norman Rockwell 

One of the great untold stories of American life today is that of the itinerant physician.  For decades, one of the operating values of American medicine has been "continuity of care," which meant that a patient could see a doctor who actually "learned" the patient, got to know the patient, took care of the patient over a prolonged period of time, so the patient did not have to recapitulate his or her own history with every visit to the doctor's office. 

This concept even extended to the hospital, where a patient was "admitted" by an intern and resident who stuck with that patient for his entire stay in the hospital, and in the bad old days, stuck with the patient through the first 24-72 hours, getting the patient through his crisis. 

In the hospital setting, this feature of "continuity" had its disadvantages--to be able to stick with the patient, the intern was frequently exhausted, although rarely incoherent as its detractors charged.  So, with Libby Zion laws, the concept of "handing off" the patient to a "team" of shift workers emerged, with results which proved both  better and worse.

But now, if you are observant, this is happening at the level of office practice. 

Doctors have looked at the prospect of signing an office lease, which often committed them to a $500,000 debt over 5 years, and they looked at malpractice insurance policies which, in the case of an internist, might be $5.000 this year and $20,000 the next, and they looked at the costs of telephone and computer systems, and they saw  the costs of employees and their health and unemployment insurance and they looked at the diminishing reimbursements from insurance companies and they said, "ENOUGH! I'M OUTTA HERE." 

And so now arguably 90% of all primary care physicians and non surgical specialists are no longer in "private practice" but work as employees, either for groups of doctors or for large corporate entities.  

What these doctors find is the first contract they sign is the highest pay level they will ever see. Typically, they get 2 years at a set salary and then they go on commission and their salaries plummet. 

So, what do they do? They quit their jobs and move on to another 2 year gig and they keep doing this. 

This poses problems for their families, because taking a new job often means relocating, but if the physician is a woman, she may be a second income in the house and they may not have to move if she can find another gig in the area, and often she can find at least part time work. If the doctor is the primary bread winner, he or she may opt to stay at the corporation at a lower salary, but often they opt to move.

In a state like New Hampshire, which allows "non compete" clauses in contracts, doctors frequently have to move out of state or at least 20 miles away, so there is a built in uprooting. In Massachusetts, where non compete clauses are illegal, the doctor may move down the road or to a neighboring town and simply commutes longer. But he often winds up abandoning his patients and setting up a new practice.

And where does all this leave the patient?

It means you will not likely have a long term relationship with your doctor. It means you will find a new doctor "relearning" you every couple of years. It means your doctor looks at you as a customer to be served rather than as a patient or a friend and it will depersonalize the relationship.

Not that this is all bad, but it is a change.

But have you read about this sea change in medical care in the New York Times or the Washington Post or heard about it on The News Hour or the Business Report or in the Wall Street Journal?