The Rise and Fall of Medicine

Mark Borden, MD FAAEM

Centuries ago, doctors had few useful treatments. There were a few things that a doctor could do, but mostly he understood the path of disease, could predict the outcome of a problem, and invoked friendly spirits, creatures such as leaches, and occasionally an herbal remedy to help those that suffered. A doctor could do little, but he could sometimes with accuracy say; “Get your affairs in order; you won’t see the next spring.” As time passed, science began to replace faith in healing. Leaches didn’t cost much, local herbs were available, and healing hands had the time to apply their touch and comfort. Science was a bit more expensive. Medicine, X-ray machines, and hospitals cost money. Fees went from “one chicken,” to a certain amount of money. Drug producing companies went from a covered wagon selling “remedies” to huge commercial enterprises with the most powerful political lobby in the world. As a new system arose, teams began to form. Doctors and their nurses (at first subordinate, then a separate but equal team) formed one team, and in the beginning that team, with its training and knowledge of medicine, duty, and commitment to “the patient first,” and promise to adhere to a higher ethic, was in charge. Lots of time, commitment and intense study is required to thoroughly learn pre-med science, four years of medical school, and learn to apply Internship and residency (3-8 years) the knowledge of medicine. This does not leave much time to master business. Criteria to measure medical qualifications are clear, and used often. Now that lots of money was involved, some businessmen began to “help.” Hospitals that were managed by doctors were at a disadvantage financially, since administration and finance also have a skill set. During this period, doctors and nurses outnumbered administrators, and were considered valuable. It was clear that doctors should be shielded from the financial machine. Doctors should be free to put their patients ahead of financial motivations. Clearly, doctors should not be employed, and good laws were adopted to prevent doctors from being employed by, and therefore subject to, the demands of financially motivated administrators. Every administrator needed a few secretaries, though, and there were new departments that needed to be created. New administrators were needed to manage these new departments. Soon there were more administrators, and other managerial personnel, than doctors and nurses (and other medically trained caregivers). Criteria to measure administrative qualifications are vague and not often used. A previous hospital CEO with whom I worked, for example, had no administrative training, and indeed, no college degree.

“As time passed, science began to replace faith in healing.”

Suddenly, doctors were a “nuisance.” They remembered the old days when they were considered important, and treated with respect, and they acted a little grumpy. Administrators complained that doctors were their “problem,” and stated that if doctors could be employed they would be “better able to control them.” The employment model was debated, and then tried. Sure enough, if a doctor could be terminated simply by not renewing an annual contract, that doctor was more responsive to the demands of an administrator.

Some doctors objected to being told which surgeries they could perform, how many patients they needed to see each hour to “make quota,” and which drugs they could (expensive ones) and could not (less expensive though often more proven ones) prescribe, but some just enjoyed “punching the clock” and getting a paycheck without all of that billing hassle and paperwork. At first employment was unusual, then more and more common until in 2019 more doctors were employed by hospitals than independent for the first time in history. Gone are doctor’s lounges...”Why do those doctors need to lounge anyway?” In actuality, that is where doctors met, talked, collaborated, and coordinated care of their patients, while forming relationships with each other, which led to better patient care. Gone are special parking spots for doctors...”Why do those doctors need to park close anyway?” In actuality, coming in again and again all night (instead of 9:00am-5:00pm) makes having a close spot without a long icy parking lot to traverse in the dark, essential. Gone is the time required to conduct a thorough history and physical exam. “I like the doctors that just order a CT scan ($2,000.00) instead of wasting time on a physical exam ($69.00). Maybe

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“The bottom line is that the quality of medical care is suffering as the big dollar business model grows and continues to feed upon itself.”

“At first employment was unusual, then more and more common until in 2019 more doctors were employed by hospitals than independent for the first time in history.”

the administrator doesn’t know that the CT delivers the equivalent of 500 X-rays worth of radiation, or maybe they just don’t know that X-rays are proven to cause cancer? The bottom line is that the quality of medical care is suffering as the big dollar business model grows and continues to feed upon itself. Will patients notice? No. Will new doctors notice? Maybe. Most doctors these days clock in and clock out without ever seeing a “doctor’s lounge.” Then an administrator had a bright thought. Why bother employing a doctor when I can get a PA or NP for half the price? It doesn’t matter to an administrator that doctors have ten times the education and training, what matters is the price! With the right incentives, a midlevel can see just as many patients per hour. Another bright idea! Why don’t we make our own doctors? That will help cure this “doctor shortage” and we business folk know the “law of supply and demand,” right? What does the future hold? We have lost control of our destiny, and if we do not regain it, our patients will continue to pay a higher and higher price. Employees unionize. A union can bargain for better working conditions. When I was in residency, such a thought was beneath my dignity. Now it may be required. Can we enact laws preventing employment of physicians? Must we wait until the government refuses to pay for a two thousand dollar CT until the two hundred dollar ultrasound is proven to be inadequate? The only reason I can write this is that I am no longer employed by an administrator heavy group. Most of our youthful colleagues dare not speak. The “Old Guard” will need to take the lead in the actions that must follow.

Or, we can just retire...and be treated for our acute MI by a brand new shiny PA., that lives far left on the Dunning Kruger curve (the all-knowing bliss of near complete ignorance)...while the EP and cardiologist cover multiple hospitals from home.

It is time for a NEW ERA in emergency physician group management.

The AAEM Physician Group holds true to the values that have guided AAEM for 30 years: fairness, transparency, and empowering our emergency physicians. Democratic, physician-owned, emergency medicine groups provide the highest level of patient care and have the strongest commitment to their hospitals and local communities. The AAEM Physician Group supports existing democratic emergency physician groups and can assist in the creation of new groups.

The AAEM Physician Group can help you:

• Optimize the management of your emergency physician group • Protect your group from external and internal threats • Recruit the best emergency medicine specialists • Access the expertise of top emergency medicine leaders

Mark Reiter, MD MBA MAAEM FAAEM Chief Executive Officer | ceo@aaempg.com Robert M. McNamara, MD MAAEM FAAEM Chief Medical Officer | cmo@aaempg.com

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