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On my mind
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What have we gotten ourselves into?
This topic has been fermenting for a little while. Not spurred by health care reform per se, but by the changing environment of practice. Many of the threads have been on practitioners minds, and linking the homogenization to change and carrying it over the continuum of medical school — residency — to practice has been on my mind for a while.
Are we seeing the end of an era of independent pediatricians? By that, I mean independent physicians not only in the sense of self-employed private practitioners, but also more importantly independent in terms of thinking and practice style. The homogenization of medical practice is on my mind, in between visits, in my general pediatric practice.
Change does not come easy to any profession, and I suspect medicine is no different in this regard. However, as physicians, our profession truly differs from others. This is in large part because of the intimate nature of our involvement in the health and well being of our patients, the intensity of our training, and unfortunately, by our vulnerability to the vagaries of “allied” forces, if you will, of our professional and hospital organizations, insurance companies, and of course by the current fervor over health care reform. At a time of rapid change in the practice of medicine, more intense perhaps than any I remember in my career, it is easy to be cynical and criticize the annoying aspects of such change. An example would be the hours of missed sleep that myself and many of my fellow pediatricians have lost over the past several years as the issue of standing orders for healthy newborns has bounced between Centers for Medicare & Medicaid Services, The Joint Commission, and the AAP. It’s possible to lose sight of the more profound, and even ominous, changes in medicine afoot.
In the beginning
When I decided 25 years ago, toward the end of my residency, to go into private practice with a fellow resident, I felt I was prepared to do so. Because I could identify a sick infant, manage the hospital care of routine and complex pediatric problems, and was aware of the hidden morbidity of the social and behavioral aspects of pediatric care, I felt I could learn (with enough help) to be an effective general pediatrician. My training in medical school and in residency had no hour limitations, no prescribed course or rotation schedule after my first 1.5 years of medical school or after my second year in residency. I believe this reinforced for me the notion that anything was possible if I individually was curious enough and wanted to allocate the time and resources to a career goal or style of my choice.
I was welcomed on my very first day of medical school as a colleague into this wonderful profession of medicine, and that feeling has never left me. My fellow resident who I was going to enter into practice with had similar feelings, but after I chose a year as chief resident and he as a clinical fellowship, our well-thought-out plans went different directions. He went on to a career in clinical genetics and is now the director of the National Institute of Child Health and Human Development, and I have happily been in private practice in Vermont. He has less night call, but many more meetings. I would not discount the style in which we are trained from the outcome, nor even in the long run from the type of individuals that enter our profession.
Worrisome direction
Our current paradigm in medical school curricula, residency programs, and now in practice is to have us, the product, look and act the same. Our medical school physician educators, residency program directors, and our hospital credentialing, state licensing and national specialty boards are all, in the name of quality and accountability, homogenizing our profession. I worry that this direction will stifle the creativity of our profession as it also acquiesces to a broader societal devaluation of our professional status. Along with other primary care physicians, pediatricians also have some degree of similar emotions as we compare ourselves within the overall medical community. As a member of the American Board of Pediatrics, I do want to say that while maintenance of certification is often painted in bleak colors; there is recognition, validation and ultimately support by the board for the many individual practices of pediatrics that exist today. The board pursues a difficult balance, both because of and obscured by this commitment.
In our current model we become interchangeable as students, residents and practitioners. Thus, we can be dismissed from clinical duties after 16 hour days as residents, follow clinical guidelines and check lists as practitioners that are likely based on inadequate data, and be treated with equal antipathy by clinical administrators, hospital administrators, and ultimately, by our own colleagues. We grudgingly accept RRCs, OPPEs, MOCs, and insurers denying payment for thoughtful care. We have great challenges ahead in medicine. I would like those of us who love clinical medicine, particularly primary care pediatricians to have more of a voice in the future construct of medical care rather than have outside forces, or even those of our own professional organizations, be the power brokers in determining our future.
Undoubtedly we have made tremendous progress in child health over the last quarter century, and it has been a privilege to be in practice over this time. There are indeed pressing issues of quality and cost that deserve our attention. Our practices have evolved over time as we have adapted to both the reality of the current health care needs of our patients and the often frustrating limitations of the health care systems in which we practice. In my next column, I will explore the future challenges and opportunities in practice.
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board.
Disclosure: Dr. Gerson reports no relevant financial disclosures.