P.D.Q. Bach put it best: “Loud is good, fast is better, loud and fast is best.” The push for bigger, fancier, higher-tech clinics (or cars or houses or anything else) seems inherent in the human constitution. “Best” and “quality” are rather slippery words that tend to mean whatever the speaker or author wants them to mean.

I would never argue that big clinics cannot be good clinics or even great clinics — only that the economics don't make sense to me, despite all the assertions of gurus and futurists and management types. Big clinics have higher, not lower, overhead than small clinics, and since they are paid by piecework — relative value units — just like the small clinics, there is a limit to how much they can bill. Big clinics require subsidies to run. The subsidy can be from an insurance company or hospital that is “vertically integrated” with the clinic, but those arrangements seem to fall apart over time. The subsidy can be from more-productive to less-productive clinic members, but that inevitably results in endless meetings, acrimony and, frequently, dissolution as the clinic moves beyond its start-up idealism. Therefore, the ballyhooed “inevitability” of larger, more comprehensive medical facilities escapes me — and it is apparently beginning to escape Wall Street as well.

When I started practice in 1975, administrators worked for doctors. In 1999, it appears that doctors work for administrators. This incredible flipflop was foreseen by Paul Starr in 1982.¹ I can't tolerate this state of affairs myself because I didn't grow up that way, and I think ultimately it will not work. Still, it seems to be accepted as the normal and natural way of doing things by this generation of medical students, including my daughter, who has been completely brainwashed by the “teamwork” concept. They don't seem to mind working in an environment that, to me, is completely lacking in accountability, for one thing.

Spending a lot of time with patients is not necessarily the same as practicing good medicine — but the practice of medicine does require at least a passing acquaintance with your patient. If doctors are seeing 50 to 60 patients a day (frankly, I don't believe that; it must be another one of those stories the throwaways start), one has to wonder why the patients are going to the doctor. Obviously some visits can be six minutes long, but where is there a supply of endlessly trivial problems that can be dealt with like that day after day? And what does the doctor feel like after 50 such encounters? One can imagine it under special circumstances. It's like that in the jail where I occasionally work, but not in the usual middle-class practice with neurotic, self-absorbed, entitled yup-pies and needy old folks! And certainly not if you have to deal with a real cancer patient, or congestive heart failure in an elderly diabetic with arthritis and hypertension and borderline dementia who insists on living alone, and the family is going crazy ... you know, family practice!

People will always need doctors. Every known society has produced them to fit its own belief system. They are always set apart from more “normal” members of society, and they always have unique (but rarely political) power. Ultimately, real doctors are artists, not merchandisers, and the corporate attempt to turn us into generic “providers” so that we can produce a revenue stream to satisfy a large organization will fail.

I have no doubt that certain parts of medicine can successfully be dealt with Wal-Mart style — mostly discrete procedures like cataract extraction, coronary bypass, and the like. Possibly some chronic diseases — such as asthma, hypertension and diabetes — can be handled more efficiently through a system than one-on-one. Still, I have never experienced a very successful long-term disease management program. Somehow, the organization always breaks down long before the patient does.

I am quite certain that if we stay the course as a profession, remember who we are serving (the patient, not the corporation) and don't get caught up in revenue schemes and expectations that tie us to the International Monetary Fund, we will prevail. If we don't, we will be replaced.

You know, this has all happened before. Followers of the Hippocratic school had to fight to achieve and retain dominance, and they did it by meeting patients' needs. They were so smart that we quote them 2,500 years later: “Life is short, and art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants and externals cooperate.”

In other words, the dance will fail if the doctor isn't the choreographer.