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October 2000
Volume 64 |
Number 10
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VENTILATIONS
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| Medicine
- The Next Potemkin Village
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Mark J. Lema, M.D., Ph.D. Editor
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Make no mistake when prioritizing the role
of medical care in society, for it clearly ranks among the top
five issues. It is also important to understand that, in the historical
development of societal structure, medical care of community or
tribe members was established early. If politics is regarded as
humankind's oldest occupation, "medicine men" were soon
to follow. Thus, medicine has largely enjoyed a privileged position
in the 5,500 years of recorded history, until today!
Traditional practice paradigms are changing as the very fiber
of the physician-patient-payer triad unravels. Advances in medical
science are enjoying exponential growth. In the next 10 years,
life expectancy for those born in 2010 will realistically extend
to over 100 years! Americans appear to be healthier, albeit fatter,
and physical well-being is largely taken for granted. In fact,
there appears to be a cockiness pervading Washington and managed
care organization verbiage which implies that physicians are not
quite as valuable as they were in the past. After all, most people
are deluded into thinking that eating well, exercising and using
alternative medicine, herbals and massage therapy will guarantee
a longevity unabated by chronic illness. In other words, Americans
seem to put their health on "auto-pilot" or "the
back burner" so that they can focus on the daily pursuit
of success and happiness. As a result, the prestige and respect
for medical doctors have given way to glimpses of disdain and
mockery by the public. From my perspective, however, Armageddon
in health care is about to occur in the next year, and Americans
do not even see it coming!
A recent series of articles in American Medical News identified
the telltale cracks in medicine's tradition of quality patient
care. A cover story titled "Physicians Enticed Into Early
Retirement" reveals the alarming rate of dissatisfaction
and frustration among established doctors.1 In a telephone survey
of 300 physicians age 50 or older, an amazing 64 percent intend
to either retire (38 percent), reduce workload (16 percent) or
see no patients by changing careers (10 percent) in the next one
to three years. In addition, with the cap on residency positions,
reduced applications to medical school, the rising age of the
U.S. population, greater numbers of female physicians needing
to work fewer hours, a severe limitation as to the number of foreign-trained
physicians being granted permanent resident status, the near-bankrupt
status of American medical schools and centers, a punitive tort
system and America's obsession with health, this phenomenon of
early retirement will have a catastrophic impact on access to
medical care in the United States.
The reasons behind early retirement for these professionals are
simple. They trained at a time when doctors made medical decisions
and acted on them. Now, they are "tired of the hassles, the
decreased reimbursement and the loss of autonomy and prestige."
Since doctors traditionally retire because of disability, age
or career change, this recent exodus is a manifestation of their
contempt for an evolving system dominated by managed care cost
reduction at the expense of quality patient care and the mandate
to practice perfectly with in dequate resources.
Another article titled "Physician Extenders in Greater Demand"
revealed that the roles of physician assistants (PAs) and nurse
practitioners (NPs) are expanding into specialty areas with a
resultant 15-20 percent increase in hiring demand.2 Since Medicare
allows for PAs and NPs to bill at 100 percent of physician rates
if the doctor is in the facility, many groups, specialists and
hospitals are answering the physician shortage with lower-paid
nonphysician extenders. While superficially this solution appears
adequate, significant concerns remain. First, if the majority
of patients are initially and routinely examined by nonphysicians,
who will discover the yet-to-be described syndromes? Is it reasonable
to expect lesser-trained PAs and NPs to go from "bedside
to bench, back to bedside" with clinical observations that
need further study? Are we witnessing an attempt by business and
government to redesign "best medical care" into a more
cost-efficient model, or are they simply managing costs to reduce
medicine to the "best care possible" by encouraging
nonphysician care? There is obviously a big difference.
Moreover, short of an official government policy, the expressed
attitude coming from Washington, D.C., is to ratchet down health
care. First, there is an attempt to limit the numbers of doctors
being trained by reducing government support for medical school
and residency programs. Second, the Veterans' Administration and
the Immigration Service have made it very difficult to retain
J-1 (scholastic) visa physicians as staff physicians, after they
complete residency training in our best programs. Third, the Attorney
General employs 200 upwardly mobile assistant attorneys to seek
out "Medicare fraud" and penalize medical schools, hospitals
and physician groups. Ironically, it is universally known that
virtually every physician is not in compliance because of nebulous
or conflicting regulations established by the Health Care Financing
Administration (HCFA). Fourth, the present presidential administration
has stood by and watched business dismantle and beat up the health
care profession. Moreover, the White House actively tried to regulate
and redefinehealth care in 1993 and 1994 without even enlisting
input from the medical community! Is there perhaps a clandestine
plan by the government to encourage this shortage of physicians
in order to supplant it with lesser-trained nonphysician providers
to cover routine care?
Finally, a short two-part series titled "Malaise Is Spreading
Through American Medicine" and "Patients Also Feeling
Medicine's Malaise" underscores the sentiments of most physicians
and patients.3,4 Doctors feel rage, skepticism, hopelessness and
distrust and are thus embattled and frustrated. Patients are perplexed,
anxious, wanting, angry and demanding. Managed cost has put the
physician in the position of gatekeeper as to how the limited
resources will be used. The articles explain that patients now
represent the frustrations physicians feel regarding this new
system. The next patient could become a lawsuit, expend more than
the allocated contact time or be a financial drain. On the other
hand, society is inundated by the media's reporting of daily medical
breakthroughs and thus expects access to a high quality of medical
care. When suddenly encountering the reality of repeated denials,
restricted prescription plans and little continuity in physician
care, they become disillusioned, confused and combative. If the
number-one business principle for success is customer satisfaction,
health care is steadily moving away from number one.
In the 18th century, Grigori Aleksandrovich Potemkin, a Russian
Army officer, created elaborate fake village facades in the Ukraine
and Crimea for Catherine the Great's tours, giving the illusion
of prosperity. A "Potemkin Village" is now defined as
something that appears elaborate and impressive but in actuality
lacks substance. Today's medical care delivery systems face staffing
shortages in both nursing and physician ranks, produce excessive
medical errors and offer treatments that are often denied, delayed
or diluted. Advertising by health maintenance organizations and
hospitals conversely touts high-quality care, increased choices,
innovative therapies and minimal hassles, all conducted in ultra-modern
facilities. It is hard not to feel that the modern day Potemkin
Villages are rapidly becoming America's hospitals and clinics.
One walks through the front door hoping for a cure, only to find
the other side of an unstaffed building!
– M.J.L.
References:
1. Greene J. Physicians enticed into early retirement. Am
Med News. 2000; 43(27):1-2.
2. Greene J. Physician extenders in greater demand. Am Med
News. 2000; 43(27):11-12.
3. Marcus LJ, Dorn BC. Malaise is spreading through American
Medicine. Am Med News. 2000; 43(27):12-13.
4. Marcus LJ, Dorn BC. Patients are feeling medicine's malaise.
Am Med News. 2000; 43(32):16.
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