Win the bat­tle, lose the war?

In­ter­gen­er­a­tional dif­fer­ences among docs may define fu­ture of health­care

Modern Healthcare - - OPINIONS COMMENTARY - Sean K. Mur­phy

If you be­lieve the crit­i­cal bat­tles over im­ple­men­ta­tion of the Pa­tient Pro­tec­tion and Af­ford­able Care Act (aka Oba­macare) are be­ing fought among politi­cians, you’re wrong. The real fight is tak­ing place in doc­tors’ lounges at hos­pi­tals across the coun­try. The out­come will de­ter­mine the fu­ture qual­ity of health­care in the U.S. be­cause it will define for the next gen­er­a­tion the very essence of what it means to be a physi­cian.

That Oba­macare is caus­ing tur­moil among physi­cians is not news. Late last year, it was widely re­ported that doc­tors and hos­pi­tals are at war with one an­other all over the coun­try. The re­form law is chang­ing the eco­nomic model in health­care, and soon the vast ma­jor­ity of doc­tors are ex­pected to be­come hos­pi­tal em­ploy­ees—a seis­mic shift from the long­stand­ing tra­di­tion of doc­tors own­ing or work­ing at in­de­pen­dent prac­tices.

What’s new is that while the out­ward con­flict ap­pears to be be­tween doc­tors and hos­pi­tal ad­min­is­tra­tors, the ac­tual bat­tle is among the physi­cians them­selves. The fight isn’t about sta­tus or money. It’s about pa­tient care and a real threat to the long-held be­lief that medicine isn’t like other busi­nesses be­cause peo­ple’s lives are on the line.

Dur­ing the past year, I was a party to a ma­jor univer­sity aca­demic study of physi­cians in a large metropoli­tan set­ting to de­ter­mine the hu­man im­pact of health­care re­form on their psy­ches. Ac­cord­ing to the study find­ings, doc­tors are be­ing threat­ened at a deep, emo­tional level, and it’s be­gin­ning to af­fect their per­for­mance be­cause they are wor­ried about the fu­ture of pa­tient care.

The physi­cians in the study were openly di­vided into two war­ring fac­tions—in­de­pen­dent and em­ployed doc­tors—and vis­i­bly split along gen­er­a­tional lines. The baby boomer doc­tors are re­belling against the com­ing new or­der. They value the per­sonal re­la­tion­ships they have with their pa­tients and the in­de­pen­dence of their med­i­cal de­ci­sions.

By con­trast, the younger physi­cians like the new par­a­digm of hos­pi­tal em­ploy­ment be­cause it pro­vides a bal­anced life—a pre­dictable work­day sched­ule where the pa­tient sees the next avail­able doc­tor if their reg­u­lar doc­tor isn’t work­ing that day or that shift.

The pre­sump­tion is that the rou­tine trans­fer of pa­tient care from one physi­cian to

To (baby boomer physi­cians), be­ing a doc­tor means a 24/7 com­mit­ment to pa­tients and sus­tain­ing per­sonal re­la­tion­ships.

an­other shouldn’t be a prob­lem be­cause the man­dated elec­tronic med­i­cal-record sys­tem will have the nec­es­sary in­for­ma­tion for any doc­tor to make sound med­i­cal de­ci­sions.

And this is the rub: The baby boomer doc­tors say this isn’t the way medicine should be prac­ticed, and they aren’t go­ing down with­out a fight. To them, be­ing a doc­tor means a 24/7 com­mit­ment to pa­tients and sus­tain­ing per­sonal re­la­tion­ships.

No elec­tronic med­i­cal record could ever con­tain enough nu­ance for a physi­cian to re­ally know their pa­tient. The older doc­tors look to their younger coun­ter­parts with dis­dain be­cause, as em­ployed physi­cians, they are will­ing to ac­cept a hos­pi­tal ad­min­is­tra­tor as their mas­ter in ex­change for a few perks and the lee­way to treat pa­tients as tran­sients.

In the eyes of the baby boomer doc­tors, the younger physi­cians sim­ply aren’t pay­ing their dues, and the new prac­tice of medicine will for­ever change the pro­fes­sion and the na­ture of pa­tient care. They see a day com­ing where doc­tors will sim­ply be­come fun­gi­ble tech­ni­cians—highly ed­u­cated assem­bly-line work­ers who can be eas­ily re­placed by the next tech­ni­cian with sim­i­lar train­ing. And the pa­tients will stand in line to see which­ever doc­tor is avail­able, with the qual­ity of care based on the luck of the draw and the last en­try in their elec­tronic med­i­cal record.

In re­but­tal, younger physi­cians say they are com­mit­ted to their pa­tients, and the hos­pi­tal’s vast re­sources al­low for the best prac­tice of medicine. They also be­lieve a bal­anced life­style makes them more com­plete hu­man be­ings, there­fore bet­ter doc­tors. Yet they also fear the in­flu­ence of hos­pi­tal ad­min­is­tra­tors in med­i­cal de­ci­sions and the loss of mar­ketabil­ity that comes with com­modi­tiz­ing an en­tire pro­fes­sion and hav­ing a hos­pi­tal em­ploy­ment con­tract with a non­com­pete clause.

Al­though di­vided by their re­sponse to Oba­macare, the physi­cians are united in their sense of fear about the fu­ture. Is that how you want your physi­cian to show up for work ev­ery day?

With the in­evitabil­ity of the ACA, the baby boomer doc­tors may be fight­ing a los­ing bat­tle. The re­form law has trans­ferred the bulk of power in health­care to the in­sti­tu­tions.

Hos­pi­tals, in­sur­ers and phar­ma­ceu­ti­cal com­pa­nies are all set to gain from the im­ple­men­ta­tion of our new health­care poli­cies.

The in­sur­ers will have more cus­tomers, the pharma com­pa­nies will be able to sell to a man­age­able num­ber of hos­pi­tals rather than a plethora of in­de­pen­dent physi­cian prac­tices, and the hos­pi­tals will en­trap pa­tients and have con­trol over physi­cian costs. That leaves the doc­tors—ar­guably the most im­por­tant peo­ple in health­care de­liv­ery—as the sacrificial lambs.

In the end, as the ACA is fully im­ple­mented, and de­pend­ing on the out­come of the in­ternecine strug­gle rag­ing among physi­cians, Amer­ica may have won the bat­tle of univer­sal cov­er­age, but lost the war over the qual­ity of the health­care we re­ceive.

Sean K. Mur­phy, an in­de­pen­dent con­sul­tant, has been a strate­gic ad­viser to nu­mer­ous hos­pi­tals and health­care sys­tems across the U.S.

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