If there’s something that’s a constant in modern society, it’s the erosion of services in certain industries. We’ve all seen it in the airlines. What used to be included in your fare is now charged à la carte, and yet ticket prices are climbing. In medicine, it’s not that different. If you go to the doctor these days, you’re likely to see a midlevel provider and not the physician, yet your out-of-pocket expenses have exploded. So just like the airlines, what you get for what you pay for is eroding. At the same time, we see midlevels and other providers make aggressive plays for more and more autonomy, often pushing the envelope of their practice acts. Regrettably, I fear, this will only continue the erosion of services that seem to be the norm today.
How Medicine Has Become like the Airlines
If you’re like most people who have been flying for 20 years or more, you’ve seen your airlines experience degrade rapidly. We used to be met by hordes of smiling people happy to make the misery of flying just a little better. Today, you print your ticket, tag your own bag, and get to sit in a seat that’s a bit smaller and more cramped than it was just a decade ago. Do you want a meal? Ha! The recent event with a United passenger was just the zeitgeist we all needed to express our collective dissatisfaction. However, is it really any better in medicine?
Twenty years ago you almost always saw the doctor. We complained if our out-of-pocket expense was $5 or $10. Now, most patients spend more time with the physician assistant or nurse practitioner than they do the physician. Our out-of-pocket expenses have climbed to hundreds to thousands of dollars. Just like the airlines, we’re getting less and paying more.
The Midlevel Conundrum
In medicine, like in accounting and law, there are midlevel providers. For physicians, those are nurse practitioners (NPs) and physician assistants (PAs). Also, alternative-medicine practitioners, like naturopaths, have lobbied state legislatures for basically the same status. The idea behind all of these practitioners was that they were there to help the physician be more efficient or take on some of the roles of doctors in rural settings where there were no doctors. At least that’s how all of these midlevels plead their case for licensure. However, that’s not what’s really happened.
All too often the midlevel is substituted completely and utterly for the physician. The doctor is nowhere to be found. While this works for some patients who have simple issues, and some patients like the added time that some midlevels can provide, let’s face it—medicine at its highest levels takes the years and years of medical training that the doctor has amassed. Nowhere is this truer than in dealing with the highly complex musculoskeletal system of bones, joints, muscles, ligaments, tendons, and nerves.
Axing All of Our Midlevels
A few years back, as a practice, we had to make a tough decision. We wanted to move to a concierge environment, where our goals were to spend much more time with each patient, see far fewer patients, and only have physician-level providers see patients. We wanted all of our patients to have 24-7-365 direct access to the physician via phone and e-mail (i.e., no “call” and no phone-answering service). Why? We wanted a practice where we as physicians could do our best work. To explain what that is, let me first discuss the opposite.
Many years ago, on the recommendation of a colleague, we hired a practice consultant to come in and review everything. She wanted to move our then 20-minute physician follow-ups to 5–10 minutes and have a full-time scribe following each physician. Basically, to turn our little boutique practice into a massive assembly line of efficiency. A bit like this Chipotle commercial:
In fact, most orthopedic and pain practices are like this today. You come in and see the midlevel, maybe the doctor blows in for a few minutes, and then some earth-shattering decision about your medical care is made. If you’re lucky, you can then spend some time with the midlevel and have the ability to ask questions. You can’t ever reach the actual doctor. E-mail your doctor directly or call his or her cell? Impossible.
What’s this like from the doctor’s perspective? It’s a nightmare. Doing your best work isn’t even in the equation. All you can do is tread water and try to stay afloat. If you have a conscience, you know deep down that you’re practicing at some fraction of the level that you should be capable.
So we took the plunge and let go of our midlevels and turned 40-minute new-patient evaluations (which were already generous) into 60 minutes. I moved my already generous 20-minute follow-ups into 30 minutes of face-to-face time with the patient. How did it go? I now get to do my best work every day. I can’t imagine going backward to the assembly-line practice so common today.
As more and more doctors have moved to the factory-assembly-line type of practice, they have begun to accept that midlevels should be granted more autonomy, which means that more patients can be stuffed into a day with less work or effort by the doctor. So what began as the doctor’s helper, turned into the physician replacement, which has now evolved into the de facto physician because the doctor is nowhere to be found. Physicians who have sold their practices to hospitals have made this worse as now there’s a corporate bean counter who can see that the spreadsheets look better and better with more and more midlevels in the equation.
Hence, what midlevels can do has begun to creep closer and closer to a physician. However, the training for midlevels has stayed pretty constant, meaning that it’s some fraction of a physician’s training. So just like in the airlines, what we get as consumers gets diluted.
Like the airlines, medicine is bifurcating into two experiences—economy and first class. While in both industries these two experiences have always been there, the gulf between them is expanding at an alarming rate. Regrettably, as midlevels continue to lobby for more and more autonomy and as physicians who have assembly-line practices continue to support it, the level of service for what you get will continue to implode. This will also continue to increase physician burnout. This is why we see a record number of doctors who have decided to retire early. This is also why we see family doctors flocking to concierge practices. The patients lucky enough to be able to afford these practices are essentially purchasing the first-class seats in the medical airplane.
The upshot? On the one hand, it’s strange to see medicine go the way of the airlines we all love to hate. The recent United incident has provided an outlet for us all to scream about how little we now get for what we pay. The same is happening in medicine, and the pace is accelerating with the expansion of midlevel autonomy. Like the airline trends, there is likely no way to stop this from happening. Having said that, some physicians are saying “enough” and deciding to go the opposite direction with their practices by electing to see fewer patients and avoid midlevels. We did that at the Centeno-Schultz Clinic and have never looked back. It’s a rare privilege in 2017 to have gobs and gobs of time to spend with patients, so I realize just how lucky I am!