While we didn't exactly plan it that way, the first two articles in this issue almost demand to be read together for the contrasts between them. Each was written by a family physician. In the first, Douglas Iliff, MD, explains why he considers solo practice to be the key to the future of family practice. In the other, Rodger Rothenberger, MD, explains why he considers selling his practice and becoming the employee of a larger system to be the key to his future, at least. The pairing neatly captures the confused state of health care today. In answer to the question, “Which way to the future?” fingers point in all directions, not just these two.
I would suspect that a number of readers believe Dr. Iliff is right, more hope he is right and still more wish he were right. The picture he paints is an attractive updating of a traditional ideal of family practice: the independent-minded family physician in determinedly independent practice — the physician who can make his own decisions and his own hours. And many of Iliff's arguments against larger organizations are likely to hit home with readers who belong to such organizations. How much time do groups waste in endless meetings? How many unproductive members of groups are carried by the more productive? How much unnecessary complexity do groups spawn?
In a sort of mirror image of the response to Dr. Iliff's article, I imagine a number of readers agreeing that Dr. Rothenberger is right, more fearing he is right and still more dismissing him as having sold out. He, too, makes a good argument for the course he's taken. How many independent family physicians are finding it impossible to recruit associates? How many are being pushed around by payers? How many are drowning in overwork? How many face an insecure future?
In part, of course, it's likely that Iliff and Rothenberger have ahold of different parts of the health care elephant. Even geography suggests this, since Iliff practices in Kansas and Rothenberger in Pennsylvania — parts of the managed care landscape with two very different terrains. But the image of the blind men and the elephant is not completely adequate to the situation. The health care “system” is not a single beast that happens to have put a massive foot down in one market while swaying a snaky trunk back and forth through another. It's a whole menagerie. Each physician must learn and adapt to the habits of the animal indigenous to his or her local market while not mistaking that animal for the whole zoo. Marilyn Moon, a health economist quoted in “Monitor” in this issue, catches the essence of the situation: “I don't think anyone knows where we are going. This is a wacky period in health care.”