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Views of a new physician.

Views of a New Physician

Before preparing his presentation to the 1989 National Conference on Health Care Leadership and Management this past May, College faculty member Morgan W. McCall, PhD, enlisted the advice of his young doctor nephew on how best to approach his audience. The following article is the nephew's reply. We publish this account not for its accuracy in describing the medical or medical management profession but as an indication of the view of new physician on the state of the health care system. We also publish the article for the good-humored and entertaining view that it presents of one audience's assessment of physicians in management.

Dear Morgan It was with great sorrow that I read of the plight of our hero and his quest to bring enlightenment to an oft unenlightened group. Alas, the term "physician manager" is the epitome of an oxymoron, for never in the history of language have two words been so utterly opposed. Also, alas, you have chosen as one of your advisors someone who knows nothing about managing and only a modicum of doctoring. In your favor is the fact that you will be releasing your wisdom into a virtual vacuum and will certainly leave your audience with more knowledge about managing than it had in the beginning. Following is the briefest history of medicine and a glimpse at some of the issues that have forced the words physician and manager to be used in the same sentence with no humor intended. In the beginning there was disease (although many Judeo-Christian scholars would argue that in the beginning there was health, until man sinned). There were no doctors, and hence no lawyers, and few lived long enough to die of cancer. However, very early on, the ancestors of the modern neurosurgeon appeared. It would please many people to know that this neanderthalic doctor made cave calls. It would not please them to know that he attempted to cure people by drilling holes in their skulls. Apparently some survived. As with some modern treatments, it is unclear whether the patient was cured of his underlying malady, but it is likely he did not seek further medical treatment. The Incas, Egyptians, and, especially, the Chinese greatly advanced the art of medicine and studied disease in great detail. The ancient Greeks slowly started adding some science to the art. However, the average physician still had an image problem, prompting Hippocrates to say, "He guys. Don't hurt anybody." His image consultant changed this to, "Above all, do no harm," added a few paragraphs, and the rest is medical history. In relatively rapid succession, the human body was dissected and described; organ systems were discovered; urine, blood, bile, and feces were tasted and tested; and, finally, man's greatest enemy, the bacterium, was found. Still, few people lived long enough to die of cancer or, for that matter, heart disease. Therefore, the physician was of little more help than his skull-bashing ancestor. His bedside manner had improved, and likely so had his diagnostic skills, but his ability to intervene was still limited to leeches, hacksaws, pliers, and a few tonics. Not until the advent of antibiotics and anesthesia was medicine to change forever. The doctor was no longer just expected to know something; now he could and should do something. And a darkness feel upon the earth and from the mire emerged the first malpractice lawyer. The 1960s also saw the emergence of the physician millionaire. Probably the single most important factor leading to this was the third-party payer. A majority of large businesses provided better and better health care coverage to their employees; employees began to take advantage of those benefits; and some hospitals could make big bucks. Both good and bad doctors could make money--lots of money--simply by opening offices. The federal and state governments joined forces and started providing health care benefits to the elderly and underprivileged through Medicare/Medicaid. Until recently, Medicare often paid whatever the hospital or physician charged. It should be no surprise that national health care costs rose at a rate greater than inflation and that now only the military can boast a larger percentage of our GNP. Something had to give, and, in the late '70s and early '80s, the golden goose was placed on the endangered species list. Both private industry and the federal government sought ways to limit their health care expenditures. The federal government's approach was diagnosis-related groups. It figured the average cost to care for nearly all known disease processes at designated hospitals throughout the country. It then agreed to a fixed fee to hospitals for a given illness. If the doctor and hospital could treat the patient for less, the hospital pocketed the difference. If it cost the hospital more, the hospital absorbed the cost. Under the DRG system, many felt procedural skills were better compensated than intellectual skills. The government is currently addressing these and many other criticisms. A recent federally funded study at Harvard has suggested that a much larger portion of the federal health care dollar be put into primary care and less emphasis be placed on procedures. Private enterprise--i.e., employers and insurers--have used a different strategy. Although many companies still offer traditional Blue Cross/Blue Shield type insurance (office visits not covered but 80 percent of the hospital bill is covered), most also offer some type of HMO. On paper, the HMO concept looks good to everyone but the primary care physician. A patient can go to his specified doctor anytime (he usually has some choice but is limited to the HMO's list), pay a small fee(usually $2-10), and often receive free or discounted medicines. The idea is that if a patient with a health problem is followed closely, is given his medicines, and is properly informed, he is less likely to need hospitalization and the ensuing hospital bills. To attract patients, HMOs often buy out the practices of the busiest doctors in a given area and then use the old practice name and doctors right out of training at low but guaranteed salaries. To attract these younger doctors, the HMO promises set clinic hours, three to four weekends off a month, and few nights of call. The problem with this system has been one of patient and physician disillusionment. Patients in this country have come to expect the best--if the illness is a headache, the patient wants a neurologist. Subspecialists cost more, and the HMOs strongly discourage subspecialty referral, if medically possible. Second, even if subspecialty referral is obviously warranted, the primary doctor must obtain approval, often from the physician manager. Generally, this is a formality, but physicians do not like being told how to treat their patients by other physicians--especially other physicians who have never seen their patients and may have not seen any patients for some time. This is the health care cauldron in which the physician manager now finds himself bubbling. Before the changes instituted by the federal government and private industry, the major concern was how to spend all the money. Now the job is all but impossible as the physician manager tries to balance dramatically opposed forces. He was trained to care for patients in the best way possible; money was not an issue. Now he is also responsible for the bottom line. Patients want the very best, but the HMO and Uncle Sam don't always want to pay for the best. He realizes that he has woefully little if any practical knowledge of how to run a business from his medical school training. Is it any wonder that the physician manager is not well loved? A few suggestions to physician managers from a humble resident and his colleagues: * Attend Morgan's course and listen to

his words of wisdom, words he has

gathered from great managerial minds. * Keep abreast of changes in medicine--every

week, new treatments for old

diseases are being found. Often they

are both cost-saving and beneficial. * More important than keeping abreast

of the field, since you would probably

not be where you are today if you did

not fervently pursue this knowledge,

make sure physicians, nurses, and other

health care workers keep up with their

fields. Offer informal luncheon

discussions with CME credits. If your

primary care doctor knows about the

latest treatment for migraines, he's

less likely to ask you for approval for a

neurology consult, and that's one less

headache for you. * Hire good nurses and nurse specialists

and compensate them adequately. One

happy nurse could save countless

hospital admissions by reinforcing what

the doctor has told patients about their

diseases. * Be accessible. You want to be the first

to hear about a problem, not the last. * If at all possible, continue practicing

medicine. By seing patients, you will

be better able to relate to the doctors

and staff you employ. * Remember, a good product sells

itself, and your product is patient care. Morgan, I know your seminar will be of great help to those who attend. I hope the above simplistic opinion will be of some value.

Your nephew, Chip

David C. (Chip) Molthrop Jr., MD, will finish his internal medicine residency in July and will then start a hematology/oncology fellowship at the University of Alabama at Birmingham.
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Title Annotation:health care delivery
Author:Molthrop, David C.
Publication:Physician Executive
Date:Jan 1, 1990
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