It's been some time since I first posted on DK my "Tales of a Family Doctor". I hope this isn't the last time.
There are really two things which leave me thinking of my own death today.
First, and most concretely, I received a series of phone calls from a patient since last week. Starting amiably enough, but oddly coming on my cell phone rather than my office phone, he called me "friend" and seemingly without an agenda asked me to call back. Three days later, I wasn't his friend anymore, but I was still his doctor, though "a schmuck, a dildo". And later that day, after I was unable to reach him, I was told "poppa, fatty, momma, bitch.... kapish Jew.... if you don't call me back that nanosecond it could be life or death for a whole lot of people. You don't understand. So get with the picture brother or your not going to make it."
When I arrived in the office the following morning my staff was in a near panic. He had called the office also, this time getting more specific, "...I'll come there and rip your heart out like an Aztec surgeon."
So I called the police. Actually, I visited the police in the city where I live, who told me to contact the police in the city where my patient lives, who told me to contact the police in the town where I work, who told me they would contact the police in the city where my patient lives and they would do a "welfare check" which I think they have done.... but the officer who finally took my report hasn't called me back.
It's probably just an example of a mentally ill guy making vain threat, but I'm actually a bit worried and a bit mystified by the difficulty of getting police help.
But what I am more afraid of is where medicine is headed and what that means for me and my patients--
You see, I am a family doctor who takes care of his patients (including a large number of medicare and medicaid funded patients) the old fashioned way, one at a time, listening carefully, examining as appropriate, and using tests to help me with diagnosis. I'm the kind of doctor who "they" say are in short supply. I'm the kind of doctor which report after report has argued we need more of if we are going to be able to provide cost-effective medical care to our increasingly under-insured population.
Yet the trend in medical bureaucracy is to move towards huge organizations, multi-specialty groups which are designed to extract money from private insurance carriers and to deliver care in a high tech yet impersonal way. The bureaucracy required to make these organizations work takes small time docs like me and grinds us up as feed for the pot. Rather than being valued as cost-effective providers who ought to be rewarded for our contributions to efficient evidence-based care, we are treated as cogs whose primary purpose is to feed patients into the subspecialty clinics in the big building down the street.
Here is an example of the grind, edited modestly for clarity and privacy, from a letter to my colleagues:
As you may know, I am the owner and senior associate of Family Care Associates, a group of five employed physicians and three nurse practitioners who all work part time and together comprise two and a half full time equivalents. Until February of this year Dr. XXX was my primary associate.
Due to personal family changes she decided last fall (2010) that she would leave the practice and return to her childhood home. I spoke on numerous occasions with leaders in the medical group hierarchy about this coming change and sought their help with a transition. In the end, I received no meaningful help but at great personal cost managed to preserve my practice as a primary care resource in our community by bringing on a new primary care physician and by convincing two of my associates who had previously resisted becoming medical group providers to join the group. As a result, when my associate left in mid February 2011 we were able to keep the large majority of her patients within our practice, saving the medical group the costs of transitions, and providing patients with seamless continuity of care.
You can imagine my surprise, then, when I received a check from the medical group shortly after she left and noted that there was no payment associated with my former associates' patients. After inquiring, I was told that the reason for this was that the 2010 payments were only awarded to providers of record as of March 1, 2011. My colleague's last day of work was Feb 8, 2011. I appealed the decision (twice!) and my appeal was denied, despite the fact that the payment would have come to me, as the owner of the practice whose efforts saved (and added to) an important part of the medical group's primary care network.
The appeal was denied despite the fact that the leaders of the organization knew when my associate would be leaving and failed to inform me of the potential financial cost of her leaving a mere 14 working days before the payment cutoff date. Had the hierarchy wished to support me and my efforts to continue our practice as a primary care resource a way could have been found to bend the rules.
It bodes poorly for the future of primary care in this community if this is the kind of support we receive for our efforts to maintain a primary care infrastructure.
I don't mean to whine. Earning the $3000 - $6000 which I would have gotten had they paid me what they ought to have paid wouldn't have materially altered my life. But the mindset of the evolving medical bureaucracy is frightening. The focus has moved from the big picture (supporting cost-effective primary care is smart.....duh!) to the bureaucratic (our policy is to pay providers of record at the time the payments are made, blah, blah, blah), and from the human to the mechanical.
I may or may not have my heart cut out by an Aztec surgeon, but dealing with the bureaucracy of medicine makes me lose heart about the future of American medicine.