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:
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?
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:
WHAT DO YOU THINK?
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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.
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.