In defense of the private practice of medicine

June 21, 2018

It’s time for physicians to re-read the Hippocratic Oath and Oath of Maimonides to ensure the future of medicine.

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.

As an OB/GYN who has been in private solo practice for over three decades, I was somewhat surprised to read that in the Merritt Hawkins most recent survey of graduating residents, only 1 percent desired to go into solo private practice. Remarkably 41 percent of residents indicated they would prefer to be employed by a hospital than any other practice option.

The report authors conclude that payment reforms and emerging payment models, which are documentation-heavy and data-driven, encourage formation of large, integrated organizations such as ACOs, hospital systems, and major medical group models.

They state: “For these and other reasons, many practicing physicians express concerns about and dissatisfaction with the medical profession… Medical residents train with and are mentored by practicing physicians, and there is no doubt that they are exposed to and absorb some of the doubt and discouragement many practicing physicians feel about the state of the medical profession.”

In 1999, Simon et al studied physician’s perceptions of managed care and found that negative views were widespread among medical students, residents, faculty members, and medical school deans. In September 2014, former Secretary of State and then soon-to-be presidential candidate Hillary Clinton told a packed house of 3,000 cardiologists at the annual Transcatheter Cardiovascular Therapeutics (TCT) meeting in 2014:

"The fee-for-service model, which made a lot of sense for a long time, may not make sense for physicians, for hospitals, or any other providers and may not make sense for patients and other payers."

She added the model didn’t rely enough on evidence-based medicine and implied that it was an idea whose time has passed.

It appears to me that physicians as well as medical school faculties respond to the politics of the day. With Hillarycare resulting in the loss of Democratic majorities in both houses of Congress in the 1994 midterm election and in 1997’s As Good As it Gets, Oscar winner Helen Hunt portrayed a character cussing out HMOs to audience applause nationwide, physicians across the country felt vindicated in their practice of medicine and comfort in their oaths to Hippocrates and Maimonides.

So what has happened in the past 20 years?

Is med school poisoning the well?

In speaking to physicians who recently completed medical school, many were taught that the private practice of medicine is dying a slow death. Could the faculty of our medical schools be indoctrinating our future physicians that they should accept the fact:

• private practice will soon be dead?

• private practice doesn't provide "evidence-based medicine"?

• private practice puts individual patient needs ahead of what is good for society?

• protocol driven, algorithm-based decision making is superior to the individual "art of medicine"?

• salaried positions are better to take and fee-for-service is a corrupted conflict of interest?

• "faculty-based or -affiliated" positions are superior to individual practice?

• "faculty-based or -affiliated" positions have better lifestyles than individual or small group practices?

• shift medicine-hospitalists, laborists, intensivists, etc.-offer a better quality of care?

Perhaps in our collective medical practice depression, we are poisoning the minds of the students and residents that we mentor?

In their 2017 study based on over 17,263 doctors, Merritt Hawkins’ Survey of America’s Physicians: Practice Patterns and Perspectives found that only 17 percent of physicians were still in solo private practice, down from 25 percent in 2012. Conversely, 20 percent were in groups of 101 doctors or more, up from 12 percent in 2012. Physicians were overwhelmingly depressed, wouldn’t want their children or family members enter the field of medicine, and many seeking early retirement or alternative jobs.

Can we blame this on the ARRA (2009), ACA (2010), MACRA (2015), and other poorly conceived federal law and regulations?

In December 2016, many medical schools started using a new textbook, “Health Systems Science,” that the AMA created with member schools in a consortium of schools. The authors advocated the integration of the “third pillar of medical education...with the two existing pillars: basic and clinical sciences,” the AMA said in announcing the new book.

Did we, as a national body, agree with this “third pillar?” The Association of American Medical Colleges too has initiatives pushing value-based educational experience. Where in the Hippocratic Oath or Oath of Maimonides is there a discussion of health systems, population health, or value-based incentives?

In the Oath of Maimonides, we are called upon to vow and say “May the love for my art actuate me at all time; may neither avarice nor miserliness…engage my mind.”

Yet government regulators, insurance companies, as well as The Leapfrog Group, Ezekiel Emanuel, MD, and Covered California Chief Medical Officer Lance Lang, MD-who have all advocated protocol-driven medical practice putting what’s important for society before what’s good for the patient- have lost their memory of this oath.  

In Ancient Greece, Hippocrates said, “Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.”  In 1964, Louis Lasagna, the Academic Dean of the School of Medicine at Tufts University, created the modern version of the Hippocratic Oath that most schools use today. In it, we swear to “apply, for the benefit of the sick, all measures which are required...,” not to the benefit of government, the federal budget, an ACO, or the Covered California ACA Exchange.

Perhaps the AMA no longer represents physicians or the practice of medicine but instead coding systems, ACA, and MACRA?

It is time for the leaders of the House of Medicine as well as the faculty and deans of our colleges of medicine to reread those two Oaths.

The solo private practice of medicine serves the patient that sits before us. It is an art as well as a science. It is a calling that needs to be nurtured and taught. It is imperative that those of us who mentor young physicians as well as those of us that teach in our great colleges of medicine advocate for and defend the private practice of medicine.

Howard Mandel, MD, is an OB/GYN in private practice in Los Angeles, Calif.