During the 4 decades of my clinical training and practice of medicine, I always felt a sense of ownership and full responsibility in caring for my patients. What I have noticed over the past decade is a gradual transformation in our health care delivery system and in the attitude of our trainees.
Hospitals are being governed as for-profit corporations, run by administrators and lawyers, rather than by physicians, with the aim of becoming more profitable. The same mentality that runs Wall Street has permeated into our noble health care profession, wherein the physicians delivering health care to the patients are viewed as providers delivering goods to the clients. And, as the practice of medicine has turned into a business-oriented model, administrators and lawyers have gained much influence on doctors’ practice of medicine.
House-staff have adopted bankers’ hours, that is, at 5 or 6 PM their responsibilities end, and they pass their patients on to the night shift. Students and residents are more likely to consult Google than to read medical textbooks or do literature search in order to gain in-depth knowledge of a subject. There is a constant rush to finish rounds and notes and to pass on the responsibility of patient care to the next shift. House-staff spend more time on the electronic health record than visiting and examining patients. Morning rounds consist of reading the night shift notes. Murmurs, crackles, edema, etc. are missed because doctors are too busy at their computers writing billable notes. Patients’ related discussions are more often at computer side than at bedside. Notes in electronic health records have gotten longer while their content has gotten less relevant, though more billable. Attending, fellow, resident, and student notes reiterate the same information, each with 10-15 continuous pages. Our billing is compared with other centers to encourage higher billing levels. Patient satisfaction scores for faculty, which predominately reflect the style of the medical care delivery, rather than its quality, are compared to make the business more attractive to our clients (patients).
In 2002 Professor Richard Cooper et al predicted a future workforce shortage in medicine.1 His efforts resulted in increasing numbers of US medical schools, and thus, less reliance on international medical graduates for residency training. The new US medical graduates, who are an average $200,000 in debt, are, not surprisingly, seeking high-paying jobs as hospitalists, and thus, the subspecialties are seeing fewer applicants. Why would anyone who is already $200,000 in debt spend 2 or 3 additional years in training only to be subsequently hired with an income that is at least $100,000 less than a beginning hospitalist? I anticipate a great shortage in the workforce in many subspecialties in the near future.
Although patients in clinic receive continuity of care, their encounters with their primary care physicians are brief, as he/she spends more time staring at a computer screen typing notes than talking with and examining the patient. Patients admitted to a hospital see a new hospitalist on call every 12 hours, who in turn must consult with many subspecialties in order not to miss a serious issue, as they are unfamiliar with the patient and his/her medical problems. The hospital benefits from the multiple consultations and the patient leaves the hospital with multiple bills.
In summary, I am witnessing the commercialization of the health care system as it focuses on industrial-style efficiency and productivity, and with that, losing its original purpose of one human being giving care and comfort to another. I am witnessing the gradual disappearance of good role models, the giants in pathophysiology who understood best the mechanisms of illnesses, those with extraordinary bedside manners and clinical judgment who cared for the body and soul of the patient in a most compassionate manner.
Although this sounds like an old fashioned and nostalgic dream, I just wanted to get it off my chest and share it with those who may feel the same.
Bahar Basmani MD The Am Jour of Medicine
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