The Golden Age of Medical Practice

July 15, 2011
Jeff Brown, MD

There may be a lot of turmoil in the health care industry right now, but Jeff Brown thinks that the best is yet to come.

Don't get excited, this isn't it. The community respect, the unquestioned, open checkbook with little paperwork and skimpy oversight days are past. Those days started sometime after WWII when most Americans began having health insurance coverage. It lasted roughly until sometime around 1990 when "managed care" came into significant coverage, at least here in California.

Having insurance meant that millions of Americans, previously limited by economics, could now access it. As a result, the health status of the average person rose significantly, which was paralleled by the economic status of the average American doctor. And with assured payment, the freedom of an unfettered fee-for-service environment and an unprecedented explosion of medical knowledge and capability, our last generation of doctors rapidly forged ahead on all fronts.

The first warning shot of the forces leading to managed care was the enactment of Medicare in 1965. It was opposed by the medical establishment for a variety of reasons, some prescient, some goofy, as is the American way. But as soon as it took hold, even those opposed initially came enthusiastically to feed at the trough. And gorge we did. Yes the coverage and health of our seniors drastically improved, as did the medical establishment's bottom line.

But like all bubbles, there comes a day of reckoning when sustainability finally raises its threatening head. You can make the argument that there is no better place for a nation to spend its treasure than the health and welfare of its citizens. Yet even the richest nation in the history of mankind has found a practical limit. The overdue awakening has revealed inefficiency, waste and sheer business foolishness on an epic scale.

So the accelerating pace of review, audits and political wrangling about how to reset our efforts in a smarter way has finally overtaken us. Of where it may lead and when that may happen, more later.

What I earlier referred to as the Golden Age was characterized by several traits that are gone or are on their way out. Economic necessity. politics and plain common sense require fundamental changes from these earlier, unplanned practices.

First among them was the unquestioned prerogative of the physician to determine what was best for the patient. It's an age-old, ethically mandated practice, still in force but increasingly modified by the overwhelming weight of new medical knowledge, too much for any individual to master, radically better communication potential among medical professionals and the resultant need for a connected, team approach.

In conjunction with independence and lack of oversight was the third part of the triumvirate, the fee-for-service system paid directly by the insurance company. The patient was effectively left out of the loop as a check and balance factor by being only peripherally aware of the charges and reimbursements involved in medical activity. It all amounted to a virtual blank check on activity and on income. Therefore it was a Golden Age from a physician’s point of view.

So there wasn't much oversight; just your own conscience and perhaps the casual notice of other doctors from time to time, usually in the hospital setting. This is the one place doctors had occasion to professionally gather away from their relative isolation in their small offices.

But, alas, all good things come to an end — especially if, upon closer scrutiny, the "good thing" perhaps wasn't so good. And although uncontrolled expense is the subject and prime force of our current dilemma and debate, the real object is "quality." I put that in quotes because a consensus still has yet to emerge about exactly what that term means.

Oh, we can agree on some basics of "quality" medicine, such as the avoidance of stupid mistakes (like opening the wrong side of the skull, which I have personally witnessed) and the proven benefits of smoking cessation, weight loss, etc. But even academics respectfully disagree about the best approach to a myriad of symptoms and diagnoses, compounded by the ground shifting under our feet as old scientific assumptions are challenged by new information and technologies.

Sturm und Drang

I know that uncertainty breeds anxiety among new doctors trying to make their way and older doctors wondering if they can effectively hold on. It may be Panglossian, but I honestly think the best is yet to be. The Golden Age of Private Practice could actually be replaced by a Golden Age of Medical Practice.

Looking back I am afraid the so-called Golden Age was largely a mélange of ignorance and unrigorous practice steeped in a nice bath of nostalgia. And yet for all of the surrounding our profession, from science to politics, now is really the best time in the history of medicine. And there are even better promises for the near future scientifically and perhaps organizationally if we as a national entity can just get off the dime.