Now what? 7 tasks for a new beginning

Cover Story

Now what? 7 tasks for a new beginning

Physicians, having suffered the slings and arrows of outrageousfortune, now must take arms against this sea of troubles. The professionneed not be reinvented, just rediscovered—and a new balance struck betweenforces that only seem to be opposing.

By Jeff Forster, Editor

"Things fall apart, the center cannot hold. Mere anarchy is loosedupon the world. The best lack all conviction, while the worst are full ofpassionate intensity."

—William Butler Yeats, The Second Coming, 1921

"We're lost, but we're making good time."

—Yogi Berra, trying to find Cooperstown, NY, 1972

Okay now, let's all take a deep breath, bid good riddance to the endlessmillennium hype, and figure out what's happening to the practice of medicine—andto you, the physician—at this fresh point in time.

It's ironic: Although we quickly tired of the Y2K spook talk, anotherdoomsday voice was crying out from the medical profession through much ofthe '90s:

Physicians have lost control, respect, autonomy. The doctor-patient relationshipis in shambles; it's lost its intimacy and become a commercial transaction—even,at times, an adversarial encounter. The personal touch is gone; there'sjust not enough time for it. Medicine has become more of a business thana profession, and patients, physicians, and health care itself are merecommodities. It's what an FP in rural Virginia calls "the hog farmapproach" to health care.

The lament hasn't lost much of its keening edge as we turn the cornerinto the 21st century. For some of you, combat fatigue has most assuredlyset in, and you are marking time and trekking on until you can make yourexit.

"The system no longer values what I have to offer," says PaulA. Macri, an FP in South Bend, IN, who recently decided to retire after38 years in practice. "It has made my job too energy- and time-consumingfor the wrong reasons." An FP in North Carolina says, "I'm surprisedby the number of docs I used to refer to who've retired. These aren't theold guys. This is the late 50s and early 60s crowd hanging it up."

But hold on just a minute. Not everyone is in a rush to escape. Afterall, if everyone heads for the turnstiles, who'll be left to take care ofthe patients? We do hear other voices, not worry-free but not angst-riddeneither, voices that have a measure of confidence in the possibility of goodoutcomes for doctors:

"I love being a physician," says James Brown, a gastroenterologistin Wenatchee, WA, who has been in practice for 29 years. "It's a wonderfulopportunity to interact with fellow humans when they are in need and vulnerable."Samuel Brody, an internist and geriatrician in Rego Park, NY, puts it thisway: "I still love the joy of making small differences by caring."

At the beginning of a new year, a new century (enough of the M word!),we offer our view of the forces that are shaping—and reshaping—your professionallife. No crystal-ball gazing here; the stuff we're talking about is happeningnow. Truth is, the most significant seismic shift we feel underfoot is thechange in the way physicians and patients regard themselves and one another,and a change in the way society views the doctor's role. It's truly a momentoustime: The profession is rethinking the very question of what it means tobe a doctor today.

Our take on the situation—listening to your voices—is hopeful, thoughnot without a sober understanding that difficult, even Herculean, laborslie ahead. With apologies to the mythologists and scholars, here are seventasks that physicians will have to accomplish, alone and in concert.

1. Gain control of your own time

Time in medical practice today is out of whack, out of synch. Entirelytoo much of it is spent pushing paper, haggling with insurers and the government,and trying to outguess the bureaucratic second-guessers. As one doctor sighs,"Fighting for every penny of income feels degrading." So beforeyou start worrying about regaining control of the health care system (it'stiring just to think about anything that ambitious), worry first about regainingcontrol of the hours in your workday. It's an attainable goal.

Simply put, doctors need to create time for what doctors do best. Improvingthe quality of the day will help in tackling the next task, which is to. . .

2. Rejuvenate the doctor-patient relationship

"People have not changed, fundamentally," says Patricia Elliott,a GP in Rapidan, VA. "They are still sick, lonely, and hurting. Theystill need the doctor for whom the work is a profession, a calling, a caring."

In his essay for our 75th anniversary issue in 1998, retired internistRichard C. Bates, a longtime Medical Economics contributing editor,said, "Somehow, we must . . . give up our selfish financial power struggles and insist on havingas much time with the patient as we determine the situation requires."Today's jargonists call it "face time"; more traditional thinkerstalk about the "healing balm of presence." In short, it meansshowing up, consistently, and communicating, educating, empathizing. A littleeye contact here, a bit of human touch there.

Maybe the doctor-patient relationship can't be exactly what it used tobe, but it certainly can be better than it is now. Harvard pediatricianDonald M. Berwick, president and CEO of the Institute for Healthcare Improvement,is distressed by the "declining levels of trust in the system"on the part of patients and caregivers alike. "The losses involved—human,financial, and moral—are simply unacceptable."

Rejuvenating the doctor-patient relationship will provide a head starton the next task, to . . .

3. Resuscitate the art of medicine—and learn the business of medicine

Many of you fear the art of medicine is dying. It's not really gone,just misplaced, perhaps buried somewhere in the pile of documentation, butby no means irretrievable. And if there's anything that one generation ofphysicians can pass along to the next, the art of medicine would be it.Listen to internist Lance W. Kirkegaard in Lakewood, WA: "Sometimesas I sit by the bedside of an elderly patient, holding her hand and takinga few extra minutes to humanize the experience for her (and for me), I wonderif I'm being inefficient or anachronistic." Our answer to that questionis an emphatic No.

Kirkegaard continues, philosophically: "I've always felt that theart of medicine requires the physician to address the mind-body-spirit connectionactive in all disease processes. The rewards are profound, benefiting thephysician as well as the patient. It's not always easy to practice thesetenets, but I suspect there are more 'old-fashioned' docs than one mightexpect. It's important that we communicate with each other and act as rolemodels for younger physicians."

Amen. Our feeling is that both old-fashioned and newfangled doctors needto be skilled not only in the art and science but also the business ofmedicine. In fact, the two newest ripples in medical school and residencyare (1) an emphasis on humanism and (2) an effort to incorporate businessprinciples and managed care concepts into the curriculum. Yin 101 and Yang102.

There's nothing inherently distasteful in being business-minded and runningan efficient office; this magazine has been preaching that gospel since1923. At the same time, doctors will need to make a convincing casethat they put patients' best interests first. The financial incentives thathealth plans dangle before you will come under increasing scrutiny, notonly in the hot glare of the media but also in the steamy warmth of thecourtroom. Minimizing care to maximize income will sooner or later be exposedfor exactly what it is.

Learning the business of medicine goes hand in glove with task 4, whichis to . . .

4. Master the domain of information technology

There's no reason why finding your way around a computer should be anyless vital to providing good care than, say, finding your way around thelatest diagnostic technology. The hand that manipulates an endoscope candeftly guide a mouse. Internist Peter Basch in Washington, DC, notes thattwo and a half years after adopting an electronic medical record system,he is seeing 20 percent more patients—and spending more time with themin the exam room.

The information assault will be waged on many fronts—clinical information,business information, consumer health information. The e-transaction israpidly becoming a way of life, for everything from ordering medical suppliesand maintaining patient records to scheduling appointments and "conversing"with patients. Management guru Peter Drucker says e-commerce is as importantto the information revolution as the railroad was to the Industrial Revolution.Be ready for it.

Getting a firmer grip on the management of information should also helpdoctors gain more control over their time, strengthen the doctor-patientrelationship, and help stir a proper mix of the art-science-business ofmedicine. In other words, these tasks are patches of the same fabric, stitchedtogether with the golden thread of good intent. Doctors who can handle therelentless tide of information will also be better equipped to educate theirpatients and themselves.

A greater sense of confidence and competence in what they do best willhelp physicians accomplish the next labor, to . . .

5. Revive the spirit of professionalism and pride in being a physician

No matter how jaded doctors may feel by what's become of "the system,"we sense a strong desire to find a way back to solid footing. A wellspringruns deep in most doctors of any generation: A firm belief in the essentialnobility of the profession, a compelling need to be of service, a passionfor self-improvement, and a willingness to put oneself under the most witheringmicroscope of self-scrutiny. You've thought a lot about what it means tobe a doctor, and perhaps that is why so much of the current landscape looksso troubling. You might not feel as apocalyptic as the poet Yeats, but likeYogi Berra, you may feel you're getting nowhere fast.

Frankly, we don't buy the oft-expressed notion that the next generationof doctors will be 9-to-5ers who can take or leave the "job."If "McDonald's Medicine" is really here to stay, we're all introuble. David Rubin, a gastroenterology fellow in Chicago, says, "It'sonly a strict adherence to professionalism that will see us through thesechallenging times."

Today, 125 of the nation's 145 medical and osteopathic schools startthe year with a ceremony in which incoming students put on a white coatand recite the Hippocratic oath. The idea started back in 1989, but as recentlyas 1995 only 11 schools had adopted it. The white coat ceremony has obviouslycaught on in a big way, and some schools have taken the rite a step further.At Tulane University, the ceremony now includes a covenant that acknowledgesthe commercial pressures on today's doctor and underscores the obligationto put patients first.

Rededication to medicine's old virtues will help sustain you throughwhatever lies ahead, including the need to . . .

6. Adjust to a new set of expectations

A new set of rewards and frustrations will accompany the choice of pursuinga career in medicine. "Physicians will simply have to modify some oftheir goals," says Robert J. Hacker, a neurosurgeon in Eugene, OR."The classic draw of medicine—position, power, and wealth—has erodedin recent years. Realigning your goals is more appropriate than trying toreach outdated goals." Another doctor puts it more bluntly: "Ifan aspiring physician is looking for big money, marry into it."

Right now, the disconnect between what medicine was supposed to be andwhat it has turned out to be is severe for physicians trained a generationor two ago. New crops of doctors won't have that baggage to carry, so theymight not miss what they never had. Much depends not only on what you anticipatebut also on what you learn to live with. Hear the voice of Kristin Elliott,an FP in International Falls, MN, who's been in practice for five years:"Ninety percent of the time I enjoy what I do. Unfortunately, the 10percent really seems to sap my enthusiasm. But I think my enjoyment hasincreased as I've become used to my practice."

Ultimately, beyond the high-minded oaths and the devotion to ideals,there is work to be done, and the profession will have to . . .

7. Get beyond anger

It's time for a show of leadership, the articulation of a vision, anend to the lamentations. "None of us thinks that we should be forcedto yield our decision-making authority to some gum-smacking semiliterateclerk at the insurance office," Tampa pathologist Stephen Brantleyeditorialized recently in the Hillsborough County Medical Association Bulletin."But for heaven's sake, doctors, let's not lose our professional dignityand composure. Whining and sniveling aren't going to help the situation."

It's also time for doctors to make positive changes, to reshape officepractice in the image of what they would like it to be. You'll be hearinga lot about "re-engineering" medical practice, in this and otherprofessional publications. The movement, started by the Institute for HealthcareImprovement, is already busy developing prototypes of offices—from solopractices to mega-groups—that function more smoothly and get more donein less time. Individually, many doctors have taken it upon themselves togive their practice a makeover in a way that allows for healthier patients,happier doctors, and a stronger bottom line.

"Doctors have a real opportunity to take on two new roles,"says David B. Nash, an internist and associate professor at Jefferson MedicalCollege in Philadelphia. "First, they can become master educators oftheir patients. As the Internet radically redefines the doctor-patient relationship,it will be up to doctors to help patients interpret and act on the wealthof information that is suddenly so readily accessible." A second rolefor physicians, as Nash sees it, is to serve as "advocates for theirown accountability. Physicians will actively promote performance measurementin their practices and in doing so will regain some of the autonomy theyhave lost. They'll have opportunities to make practice more efficient—andmore enjoyable."

Neeta Ambe-Crain, a gynecologist in Thousand Oaks, CA, at first foundit "overwhelming and even a bit intimidating to have a patient comein with stacks of papers touting the latest and greatest treatments forevery disease process and questioning my opinions on everything. As I'vematured and developed greater confidence, I think I've improved my methodsof dealing with these patients.

"Instead of being annoyed and on the defensive, I compliment thepatient on her initiative and encourage her interest in her health. I tryto appreciate that these patients are overwhelmed; they have not come tomake my day difficult but to seek guidance. I emphasize that informationmust be used in a way that suits the patient's unique health profile, thatmedicine is not a one-size-fits-all T-shirt!"

The medical career: A moveable feast

Medicine will increasingly be viewed as a multifaceted career in whichseveral job changes can be expected throughout a professional lifetime.Health attorney Jack Horsley observes that, in his community of Mattoon,IL, an orthopedist who practiced for 60 years was as familiar a fixtureas the town square. "Now we have had seven orthopedists in the pastfive years; four have moved and two have been replaced," he observes.

Hang out your shingle? Sure, but be prepared to take it down and moveamong various incarnations. Employer? Employee? Office-based doc? Hospitalist?Solo practice? Big group? MD-MBA? Medical director? Disease management specialist?All of the above?

One who has metamorphosed, in reverse Kafka fashion, is Kenneth S. Wayne,an internist and pulmonologist: "In 1992 my medical practice in southernCalifornia went to ruins, thanks to managed care. Now I'm in practice inrural Iowa, and after this quantum change in my life, medicine is againa rewarding profession."

But the career road points in any number of directions. Haddonfield,NJ, internist Lynn Helmer recently joined a managed care company as a medicaldirector after a dozen years in private practice. "I was told I couldmake a difference for hundreds of thousands of patients, not just my individualpanel," she says. "I'm still trying to decide if this is true,and whether it is as rewarding as the one-on-one I was accustomed to."Or consider Tulsa internist Julia Karlak, who left a big clinic to starther own office. Along the way she earned a master's degree in nutritionand took a course in osteopathic manipulation at Oklahoma State.

Far from being clock-punchers, the doctors of tomorrow may turn out tobe well-rounded Renaissance people, the envy of their forebears. The excitementof scientific discovery will keep many of you committed to medicine despitethe bureaucratic BS. You are hopeful that cures for cancer, diabetes, spinalcord injuries, and other debilitating conditions will be found within yourlifetime. As one physician says, "I'm optimistic about being able tohelp people whom now I can only comfort." Meanwhile, the aging populationwill serve up plenty of challenges, with a host of organic as well as psychiatricproblems to reconnoiter.

You won't have to do all this alone. Be prepared to see nurse practitioners,physician assistants, and other health professionals assume prominent positionsin the trenches, especially in primary care practice. The number of nonphysicianproviders doubled between 1992 and 1997, with a further 20 percent jumpexpected by 2001 and another 20 percent leap by 2005. By that time, therewill be as many nonphysician clinicians as physicians in primary care.

Toward a new equilibrium

Essentially, the task at hand for physicians is to find their properplace—their very own comfort zone—in a world that is bewilderingly unlikethe one they once knew. It means seeking and finding a new balance:

A balance between time spent in one's professional career and one'spersonal life. "In our day it was accepted that you worked allthe hours that were necessary," says John Egerton, a family practitionerin Friendswood, TX. "You were supposed to boast about how many timesyou were up in the night to deal with emergencies. 'Weekends? I'm a doctor.I don't get weekends.' But today's graduate wants regular hours, a callrotation, time off, vacations. The emphasis is on family life and leisuretime, not the absolute dedication to medicine. And I'm all for it."

A balance between conventional and alternative medicine. In 10years we won't call it "alternative medicine" anymore. Physicianswill have taken the wheat and discarded the chaff of this movement. A hospitalin New York City boasts on the radio about the alt-med elements of its cardiaccare program. Meanwhile, my urologist, a man whose temples are as gray asmine, recommends saw palmetto for a healthy prostate. Who knows—maybe aromatherapywill make patients actually feel good about sitting in your waiting room.

A balance between attention to the individual patient and diseasemanagement of patient populations. Development of guidelines—and physicianadherence to them—hold the promise of more effective treatment of asthma,heart failure, diabetes, and other diseases where knowledge is now withinreach but poorly grasped.

A balance between trimming the cost and enhancing the quality of care (a task that awaits our very best Houdinis).

A balance between patient care and customer service. "Servicein medical practice suffers these days," says Robert W. Patterson,an FP in Sanford, NC. "We may blame it on the managed care companiesor patients or whomever, but until physicians take responsibility and changewhat is truly horrible service, medical care will always be scrutinizedby Big Brother."

Patterson notes that several members of his family have had bad experienceswith doctors' offices lately: "Abnormal test results were not reportedto them for months. They had great difficulty scheduling surgeries and recheckvisits, and they were actually insulted by office personnel. It seems likedoctors are so far removed from what is going on in the office that theyjust don't care. And these are small practices where this kind of thingshould not be happening."

It's pretty to think that doctors could apply the principles of efficiencyand customer service without losing the human touch. It's beautiful to knowthat many doctors actually think they can do it.

Finding a comfort zone may mean running a practice that minimizes oreven shuns managed care; maybe Tom Jefferson was right when he warned against"entangling alliances." Others will aggressively seek risk-sharingarrangements and those elusive economies of scale. In some markets, theywon't have much choice about signing up. Most physicians will fall somewherein the middle of the spectrum, reserving the option to say No to bad contractsand anything that smacks of indentured servitude. Just be sure to read thosecontracts carefully before signing them.

So where are we? We're in the middle of a shakedown cruise, a changingof the guard. Those who don't like the shape of things to come will getout soon enough; those who remain in the system must try to transform it.Bob Dylan, bless his 58-year-old soul, said, "The times they are a-changin'."The difference is that those who once sang that song are now on the listeningend.

Trends will come and go. Many of the hospitals that not long ago gobbledup physician practices are now spitting them out, an unseemly reflux thatwe seem to have gotten out of our system. Other fads will cling, barnacle-like,to the ship of health care, and some will be dutifully scraped off. Maybemanaged care itself, at least in its present incarnation, will be one ofthem. Certainly the current turbulence in the HMO industry is bound to leavemore shipwrecked doctors, swimming among the debris in search of terra firma.

What remains will be the doctor and the patient and the problem at hand.The prediction here is that more physicians will choose to live by the creedthan die by the screed. They will find a way to keep the profession honorableand not compromise the ancient principles that lie at the very core of itsbeing. And they will somehow find a way to make each day more economicallyefficient and professionally enjoyable. They will find a way because theymust, because no one who stays in practice really wants to be an automaton,or a cipher, or a grouch. Jerome P. Kassirer, erstwhile editor of TheNew England Journal of Medicine, was right when he said that crankydoctors aren't likely to provide the best care.

Turn cartwheels over the joy of practice? Probably not. The heavy worldof health care is just too much with us. But it is not unreasonable to thinkthat physicians will succeed in the simple task of taking care of patientsand feeling good about it.

Let's hope more of them will feel the way Tulsa internist Julia Karlakfeels about it: "I have so much to give and am honored by what patientsgive me."

If we can achieve that state of grace, nothing else will really matter.

"It's still one patient, one physician, one exam room"

Michael L. Pendleton, an FP in Hood River, OR, is typical of manydoctors, midstream in their careers, who have given a lot of thought towhat comes next:

"At 47, I am high enough of forehead and long enough of tooth toacknowledge that I'll probably want to stay in medicine for the rest ofmy life. But I don't know that I want to continue my present situation (privategroup practice in a rural community) beyond another decade. So I'm beginningto plan some exit strategies. These aren't complicated ideas. Still, itsurprises me that I am contemplating this. Five years ago, it wasn't evenon my radar screen.

"Back then, I spent a lot of time thinking about practice expansion,alliances, and the like. I've since discovered that by practicing capablyand competently, and by being a good business person, I've positioned mypractice well for the next millennium. For the last decade or two, medicinehas looked for economies of scale. This has been frustrating to me, becauseat its fundamental level medicine is still one patient, one physician, oneexam room. Therein lies the beauty of what we get the opportunity to do.Indeed, that's what keeps me in medicine—the stories.

"Medicine is still a very noble profession. We are privileged toshare in the thoughts and frailties of individuals and their support systems.I know I'm the best physician I can be when I have a collaborative, ratherthan authoritative, relationship with my patients. Once the high-pitchedrhetoric about managed care dies down, most people will acknowledge thatphysicians do what they do based on a sense of dedication and professionalsatisfaction, rather than pursuit of financial security.

"I'm not sure what the future holds, but I still think the smallpractices—the two- and three-doctor groups—are an effective way of maximizingefficiency and having a rewarding personal life."

An old oath with a new twist

Around the country, the vast majority of medical and osteopathic schoolsnow start the academic year with a "white coat ceremony." Incomingstudents don a physician's jacket and recite the Hippocratic oath, a kindof signing-in-blood of their commitment to the ideals of the profession.

At Tulane University School of Medicine in New Orleans, they've takenit a step further: Doctors-to-be are introduced to a covenant that takesspecial note of today's economic pressures on physicians while reinforcingthe overriding duty to the patient's well-being.

"I was present when my grandson started medical school at Tulanethis year," says otolaryngologist-allergist Wallace Rubin of Metairie,LA. "I was amazed and pleased to see this statement addressed to theClass of 2003. The statement tells it the way it really ought to be andwhat has changed in the last few years."

Patient-physician covenant

Medicine is, at its center, a moral enterprise grounded in a covenant of trust. This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times.

Today, this covenant of trust is significantly threatened. From within, there is growing legitimization of the physician's materialistic self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations. Such distortions of the physician's responsibility degrade the physician-patient relationship that is the central element and structure of clinical care. To capitulate to these alterations of the trust relationship is to significantly alter the physician's role as healer, carer, helper, and advocate for the sick and for the health of all.

By its traditions and very nature, medicine is a special kind of human activity—one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion, and effacement of excessive self-interest. These traits mark physicians as members of a moral community dedicated to something other than its own self-interest.

Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it. Physicians, as physicians, are not, and must never be, commercial entrepreneurs, gateclosers, or agents of fiscal policy that runs counter to our trust. Any defection from the primacy of the patient's well-being places the patient at risk by treatment that may compromise quality of or access to medical care.

We believe the medical profession must reaffirm the primacy of its obligation to the patient through national, state, and local professional societies; our academic, research, and hospital organizations; and especially through personal behavior. As advocates for the promotion of health and support of the sick, we are called upon to discuss, defend, and promulgate medical care by every ethical means available. Only by caring and advocating for the patient can the integrity of our profession be affirmed. Thus we honor our covenant of trust with patients.

Jeff Forster. Now what? 7 tasks for a new beginning.

Medical Economics

2000;1:30.