Ex-Practitioner

Here is a nice piece from the Wall Street Journal.   For those that can’t read the link, here are some highlights:

  • But never have I seen so many good intentions leading irreversibly to hell.
  • A number of lean years passed before I could build a robust practice. Yet the experience was exactly what I—and I think many of my colleagues—sought: a personal, direct and unimpeded relationship between me and those who chose to become my patients
  • But treating patients without insurance meant that I had to give my acute attention to the price of every medical intervention. The costs could have a direct and painful impact on a family’s budget. So I had to know the prices for most of the medications I prescribed and of most of the tests I might order. I learned to play for time by waiting, when it was safe to, before ordering an X-ray or a test—and to substitute less-expensive medications for more costly ones wherever possible.
  • Then, in the mid-1970s, things changed, and we became enlightened. Third parties, typically the insurance companies, were interpolated between the physician and the patient. Some of the consequences were unfortunate.
  • Patients knew that any suggestions I might make would have negligible consequences for their own budgets, so “more” became the expectation. A sense of entitlement developed. Why would the doctor hesitate to do some procedure, or hesitate to request a test? Everything was already paid for.
  • This mistrust heightened—and became rational—when “prepaid” group practices became more prevalent. Physician compensation is tied to “efficiencies,” which means reducing the outlays and costs to the group (translation: skimp where possible) and thus generating for internal distribution a larger share of the prepaid premiums.
  • Second opinions proliferated, upping the costs. Patients could get two opinions for the same price: near zero. I could acquire additional knowledge from the feedback of the consultant and was better positioned should some legal controversy arise. One underexamined aspect of defensive medicine is those excessive referrals to diminish responsibility.
  • “Preventive care” became the touchstone. The concept is obvious, but the evidence for its value, and especially its potential for savings, is rarely conclusive.Insurance relationships drove practice relationships. Patients were more likely to come to me because their insurance told them to, and more likely to leave, despite our congeniality, because their insurance required it. Thus our dealings were less personally rewarding, for my patients and for me.When it became increasingly difficult to work according to my principles, I closed my practice, first joining a “prepaid” group for 15 years, and then leaving patient care altogether.
  • As more physicians leave active practice, it must be appreciated that a focus on the economics of health care is not the only, and perhaps not even the most important, reason for their disillusionment. The glow of the personal relationship one might have with one’s patients is being extinguished.
  • Who is better suited than the patient to assess the value to him of the proposed treatment? Kathleen Sebelius? You gotta be kidding.
  • There is no shortage of evidence. ObamaCare will, deliberately and by design, destroy what—while imperfect—has served very well. We have gotten to this point after years of good intentions making bad problems worse. To double down on the very therapy that has brought the system to its present sorry pass is a toe-ticket to the morgue.
  • Dr. Marsh now raises Christmas trees in Ipswich, Mass.

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