We messed up!

A quote from 1999. And it is 2008, and it only got worse....

Doctor Discontent N Engl J Med 1999

Almost a decade ago, an article in the NEJM about financial incentives in managed care systems led to an outpouring of emotional responses from physicians (Doctor Discontent N Engl J Med 1999 340: 649-653).

It seems like many physicians had noticed the warning signs and the trends that have brought us to a strained and unsustainable system. Why the physician community did very little to address these critical defects is a testament to the incompetence of our leadership and the need for a new way of thinking.

The following are excerpts from the 1999 NEJM correspondence.

"Many of us feel we were sold a bill of goods. As our friends enjoyed life, we studied our way through college and medical school. Years of long hours, low pay, and tremendous responsibility in internships, residencies, and fellowships were accepted as rites of passage. We were taught that the secret to good medical care was to spend time listening to our patients. Instead, we hear the economic hounds baying at the door of the consultation office, asking us to see more patients in an hour than we know we reasonably can. It is so difficult to repay our loans, support our families, and run our offices in the current environment. The explanation is the bottom line."
"Perhaps the ultimate model needs to be one in which patients share some financial responsibility for their own use of health care services so that they begin to value the concept of cost-effective, appropriate care."

"Even as a diagnostic radiologist, I am not shielded from the control of managed care. Daily we fight little scheduling battles, trying to explain to patients why they can come to us for their chest films but not their computed tomographic scans, or why someone failed to obtain authorization for their magnetic resonance imaging (MRI) studies. "

"I am fed up, and even though I am only 49 years old, I have already cut back to half-time. Within two years I will be fully retired. It is just no fun being a doctor anymore. But what really scares me the most is that as I get older, I will become a more and more frequent consumer of health care services delivered by disgruntled physicians who have incentives to give me less and less care."

"We young physicians are forced to learn "billable diagnoses," formularies for different health plans, key diagnoses for which medication costs will be paid, and insurance codes, in order to know whether we can order laboratory tests or studies, instead of ordering the studies and treatments appropriate to the patient's presentation or the known diagnosis. Notes and charts are increasingly organized to aid utilization review rather than to represent clinically useful medical histories."

" Who would have believed a generation ago that the skills of listening and thinking would no longer be considered essential in dealing with people in pain? Who would have believed that these committed physicians would not be followed by like-minded persons? Who would have believed that my [physicians] judgment, honed after years not just of study but of day-to-day dealings with people and their problems, would be constantly questioned by nameless and faceless corporate minions armed with rule books, or that these same anonymous people would determine what continuing education was or was not appropriate? "

We messed up!
Time to do something!