The challenges we face as primary care physicians may not be unique to our generation.
Fam Pract Manag. 2010 Jan-Feb;17(1):8-9.
Non-compliant patients, overregulation, poor reimbursement, medicolegal concerns, endless paperwork. It must be a rare family physician practicing in our modern medical dystopia who has not fantasized about traveling back in time to the Golden Age of medical practice, to a simpler time, to the “good old days.” It is with great regret that I report that any such time-traveling family doc would soon discover that many of the frustrations of medical practice management have a lengthier pedigree than one might suppose. The unconvinced need look no further than the book Dollars to Doctors: Or Diplomacy and Prosperity in Medical Practice.1 Published in 1903 by Dr. Nathan Elliott Wood, this turn-of-the-century treatise on practice management offers a glimpse into a world that, despite the gulf of nearly 11 decades, seems remarkably modern.
For starters, what does Wood have to say about primary care medicine? Surely in this saner age, the family doctor was king of medicine. The author quotes a contemporary, Andrew Sloan Draper, then-president of the University of Illinois, in an address he gave to the graduates of the College of Physicians and Surgeons:
“For one I regret the passing of the family doctor. I regret it not more because of inconvenience to the public than because of the unfortunate influence upon the profession. ... [T]hat system of medical specialization which in reasonable measure is well enough, but which, carried to extremes, rests upon no sufficient formalism, limits the character, growth and professional development of the individual physician, imposes needless inconvenience and cost upon the public without compensatory advantages and works a marked change in the feelings of attachment between family and medical adviser which have been the charm and main regard of a physician's life work.”1
In other words, the imminent extinction of primary care and professional dissatisfaction among family physicians will result in overspecialization, inconvenience to patients and rising health care costs. Sound familiar?
Perhaps, then as now, family medicine faced the same encroachment of specialization, but at least physicians of that era were rewarded with a just compensation for their labor. Or were they?
“[Physicians are] a body of men who find it as necessary to earn money upon which to live as the commonest sewer digger, and that the more money he can earn, the better is his position and ability to practice the humane, philanthropic, and charitable acts he is daily and hourly called upon to perform. It is a crime against justice to reduce him to the income of a pauper and demand of him the magnificent generosity of a millionaire.”1
What about the legal challenges we face today? Many modern-day physicians have been served with a subpoena commanding their presence in a court case involving a child custody battle, disputed will or some such legal entanglement where the mental status of the patient might be at issue. I know from firsthand experience that such orders to testify are often received so close to the trial date that there is often little time to comply, let alone prepare. Moreover, it is invariably the physician (and not the attorney who initiated the summons) who must broach the subject of lost revenue and restitution. According to Woods' book, this “modern” inconvenience was all too familiar to physicians 107 years ago:
“It is often attempted to convert a physician into an expert by a general subpoena, and by this subterfuge, deprive him of his just compensation, but this trick may be obviated by the physician himself, if he declare that he lacks the preparation necessary to make him an expert ... This method will soon cure the little two by four pettifoggers who are skinning their clients of every dollar they have in the world, of the habit of beating a physician out of his legitimate fees on the pretence of humanity, which is rarely an adjunct in a court room.”1
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If the turn of the 20th century can offer our time-hopping physician no escape from the threats of professional oblivion, financial demise or legal intrigue, can he at least be consoled with the promise of public approbation? Certainly in this more genteel era of top hats and ragtime music, the time and person of the physician were better respected than is the case in our beleaguered present.
“As soon as the personality of a physician is identified, it matters little where he is, he is certain to be button-holed by these bargain hunters. At a theater, a reception, a restaurant, ball, party, or wherever a physician's tastes or inclinations lead him, the ubiquitous ‘cheap skate’ after something for nothing, or at reduced prices, corners him. Even upon the street he is not safe.”1
What is the early 21st century family doctor to make of this practice management primer that reads – but for the occasional antiquated turn of phrase – like a modern medical office manual with the chapters on ICD-9 codes, third-party insurance and non-physician practitioners curiously absent? Dollars to Doctors is something of a Rorschach test. To the pessimist, it underscores the long history and thereby the intractability of the problems of medical practice management. But to the more sanguine observer, it provides evidence that many of the difficulties of contemporary primary care are not existential threats to the profession but perennial challenges faced by every generation of family physicians.
1. Wood, NE. Dollars to Doctors: Or Diplomacy and Prosperity in Medical Practice. Chicago: The Lion Publishing Company; 1903. http://books.google.com/books?id=Kq0SAAAAYAAJ. Accessed Dec. 14, 2009.
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