It has been nearly 24 years since I began practicing medicine. Since that time, I have been witness to changes that represent the complete antithesis of what medicine should be. Our society thinks it is progress. I beg to differ.
The desensitization of medicine has been a laborious, insidious, gradual process that was intentional, born from the minds of entrepreneurs who saw the potential profitability of a system in which a need (or demand) was inherent. There will always be sick people. Sick people will always come to hospitals and doctors. Since most sick people have no wish to die, they will seek out help and pay whatever is necessary to remain alive. If not them, then their families. In other words, there will be a more or less reliable influx of money. In that space, if one can harness it, lies the ability to create a profit. That was the genius of the C-suite. They were able to foresee the financial dividends in sickness and death.
What they lacked, besides ethics, was an ability to control the physicians who not only led medicine, but were patient advocates. Physicians tend to be passive creatures until the well-being of their patients is threatened. The business people knew this. They did their homework. They had to find a way to counter this…convince physicians that an idea, which was not in the best interests of their patients, was in the best interests of their patients. Once the doctors were convinced, then they would be less likely to oppose legislation, which would be the next step. Why? Because once legislation is enacted, it almost takes an act of God to de-legislate. Legislators don’t like admitting they got it wrong. And accepted money in the process of getting it wrong. There would be no going back. The business people got it right. Lock the public into a system in which they really have no choice in their care or management, they just think they do.
It began with the health maintenance organizations (HMOs). Pay a reasonable monthly fee, receive services to maintain one’s health. You know, keep us healthy so we live as long as possible. Good idea, on the surface. It worked…we are living longer than ever. This is where the business people got it wrong. They didn’t think they would be paying out more and more as people aged. Private insurance companies didn’t like it either. Sure, we lived longer, but aging was also accompanied by more medical issues. More money began exiting the business. That was not supposed to happen. Remember, hospitals were physician-led. Patients were admitted because it was necessary and remained until they were stable. Good medical management. But it cost. The business people had to put a stop to this. Turnover of patients needed to occur more rapidly for the profit margin to increase. These individuals recognized that they needed to be in a position to call the shots. They found the physicians and nurses who believed in the business model and had relegated their oath to their patients to the backburner. You know, the ones who placed the almighty dollar above the patients. And the corporate bigwigs enlisted their help. The private insurance companies? They arbitrarily raised their premiums, increased co-pays, co-insurance and deductibles while providing less coverage. And remained under the radar.
The transition of leadership occurred slowly, with many of us not even noticing. Until the clipboard cops began showing up requesting we discharge patients who should not be discharged. Or suggesting we admit patients who didn’t need to be admitted because the census was low. So the hospital could make more money. The underlying threat being that we either gave them the answer they wanted, did what they requested or risked termination. Most of us folded. We allowed the patient to become the commodity, against our better judgment. A funny thing happens when a negative behavior is repeated over and over. We become desensitized. We begin to make excuses so the unpalatable becomes palatable. Such as sending home the elderly, weak patient because we could not find a source for the weakness. And we ceased being concerned about that person’s social situation. We stopped advocating. We became part of the problem. And attempted to mask it under evidence-based medicine and current practices. Leadership and governmental agencies began creating and demanding that we follow protocols/guidelines/criteria which, when used appropriately, worked well. But when used to make a round stick fit into a square hole, failed. But we did it anyway, we forced the stick into the square hole because we didn’t want to get fired. And we received bonuses for this unconscionable behavior. And then we went home to our families, attended church (or synagogues or mosques, etc.) and pretended to be people of high integrity. When we weren’t. And our colleagues who saw the writing on the wall, spoke up and out and remained true patient advocates…well, we watched them get terminated, demeaned and labeled as “disruptive” or “difficult to work with”. And we said nothing. We attended medical conferences, social gatherings with colleagues, laughed and joked without considering how the individual, who never forgot his oath, was managing to support his family without a job. We dealt with the guilt by blaming the victim. He must have deserved it. We turned our backs on our colleague and supported the C-suite who didn’t give one damn about us. Because that is who signed our paychecks. We sold out. Fear became our God and the hospital, our church.
But it didn’t stop there. The business people decided that physicians were just too damn expensive. But how does one replace a physician? Convince the public they have a cheaper alternative. However, before one can do that, the public has to be persuaded. They needed a wordsmith. Words are powerful and can influence people. That’s why every leader of every country has a speechwriter. From this mentality the word “provider” was born. Physicians, physician assistants (PAs) and nurse practitioners (NPs) became providers. This was no accident. In the past, “PCP” meant primary care physician. By using “provider”, they didn’t have to change the acronym. The public would associate it to mean the same. Genius. It worked. Then the transition began. Over time, physician hours were decreased. More NPs/PAs, also known as mid-level providers (MLPs) were hired. Physicians, at one time, would be able to see every patient that was seen by the MLP. This was imperative to ensure good care and that nothing was missed. It worked for decades. Now it was impossible. A physician with his/her own load of patients cannot see the patients of 2-3 other MLPs. Corporate entities didn’t care since they didn’t own the liability. They would not indemnify the physician so that he/she would not be culpable. Because these businessmen and women did not want the responsibility either. A paradox, since they hired these individuals. They were attempting to make a profit, not lose it in a lawsuit. Let the onus be on the physician. If the doc refused, he/she would be terminated. So the doc accepted the liability because he believed he had no choice. Many times, patients had no idea they were not seeing a physician. However, if they were astute enough to notice, they requested a physician. And got one. Today, the transition is so complete that even if a patient asks for a physician, they are actively discouraged or become a victim of the “bait and switch”. That is, the patient makes an appointment expecting to see a doctor only to find out upon arrival their appointment is with a MLP. If they insist on seeing a physician, they may be advised to make another appointment which might be months away or told to find another practice. And to add insult to injury, the public is being misled into believing that physicians and MLPs are “basically” the same. This is akin to paralegals and attorneys being “basically” the same.
The desensitization of medicine. Patients have no voice and no choice, unless they have good insurance. Eventually, that will provide no guarantee because the C-suite is in control. Put simply, they do not want to pay for physicians or their expertise. The irony is that not one of these corporate individuals uses MLPs in their care. Nope, they want only the best for them and their families. For you, the public? Not so much.