How We Got Here

      In 1996, I graduated medical school. That’s it. Four years of mental and physical toil, a high stakes national licensing exam, an oral practical, and a written final, and my school said it’s okay to call myself a doctor. But that’s all I was. I was a doctor, but not quite a physician. Not many states would allow me to practice without a post-graduate training program on my resumé. That’s okay. I had chosen Family Medicine, matched into my first-choice residency in an unopposed Family Medicine residency in rural upstate New York, and moved myself from my stopping station in San Diego (my parents’ home) clear across the country to New York. I loaded up the U-Haul trailer to my third-hand used Jeep Grand Cherokee and made the three-day drive. I quickly found a home to rent next to a sawdust on the floor brew pub (not realizing that when I wanted to sleep at night, I wouldn’t be able to due to parking lot debauchery), and introduced myself to seven other nervous, na?ve, and nascent PGY-1’s. After we slayed the attendings at the annual attending-resident softball game (my friend and I were ringers), we were put to work. My first rotation would be the emergency room--baptism by fire, as it were.

           After three more years of hard-core indentured servitude, and two more high-stakes exams, I had to take one more called the Boards.

           Hundreds of thousands of dollars, countless professors and attendings, and thousands of patients. Almost no sleep. Resident drama. Attending drama. Patient drama. Personal drama.

           Now I was a Family Medicine Physician.

           Twenty years later, I would not trade all of that for anything.

           What I would want to get rid of though could fill volumes. Legal requirements. Government regulations. Payer trickery. Medicare requirements. Deceptive billing. Hospital Usual & Customary fee schedules. Seekers. Hoppers. Litigation attorneys. For profit healthcare payers. Third party administrators. Prior authorizations. Drug patent expiration years. Quality programs. Meaningful Use. Direct-To-Consumer Advertising. Consolidation. Monopolization. Market dominance.

           Try singing that to Billy Joel’s “We Didn’t Start the Fire”. You’ll see what I’m getting at.

           Our patients need us. And for whatever reason, we have allowed an industry focused around payment structure to dominate the conversation. And I’m not silly enough to believe that we could execute modern healthcare without a payment structure. What I’m trying to suggest is that this payment structure is not our future. It cannot be. We can already see it’s dwindling into a maddening maelstrom of “value-based” this and “blended model” that. It boils down to, in reality, a payment industry, which should have been busted up under anti-trust statute, making it near impossible for doctors to remain in private practice. So the delivery system has pivot-shifted into employing, consolidating, acquiring, and then leveraging our services and expertise to reward a procedurally oriented system rather than a cognitive and preventive structure so that healthcare delivery systems can isolate the patient encounter into Global Payment quanta which can then be reported to stockholders who have no focus on patient care, only on equity price gains and quarterly dividend payments.

           I close my eyes sometimes, especially at work, when I’m overwhelmed by the drug reps, the ACO reps, the health plan reps, the PT reps, the home health agency reps, the takebacks, the malpractice premium bills, and all of the noise to return to when I was a resident at 2am receiving a 4 year old with empyema due to varicella pneumonia. I vividly recall doing my best to keep her alive, while the family appropriately fretted about their little girl, and calling for Life Flight to take her to the closest Children’s Hospital, and oxygenating her, and tubing her, and keeping her going, making sure her fluid status was exactly perfect and that her acidosis was managed.

           I didn’t care about anything outside of that encounter. If I was spending too much money, it was to keep her alive. If I was losing all my sleep, it was to keep her alive. If I was doing a pleural tap, then it was to keep her alive.

           That’s medicine. And that is what no payer stockholder will ever understand. Not until they’re patients themselves. Then, perhaps, we can end all of the nonsense. Our value is us. It should be as simple as that. If you don’t find value in that, then get out of the industry. We’ll work something out with our patients directly. In the end, they’re the ones who define value. External constructs do not replace 8 years of higher education, 3 years of post-graduate training, and 20 years of hands-on experience and practice. By paying me the same amount as a fresh graduate, you have devalued me. There is no excuse for that nor is there any forgiveness.

           She lived, by the way. That’s all that mattered.