Tremors

I am seeing the world of medicine change before my eyes, and I wonder where we’re going.

Never before has there been more information at our disposal, yet more confusion. Like molecules being heated, the Brownian motion happening in medicine seems completely ineffectual for those of us on the front lines of care, geared more toward expensive facades than substance.

For the most part, doctors keep their heads down. Most of us are busy caring for patients, pushing to get home at least once each week before dinner. Most are humble servants to their patients, working tirelessly for their benefit. Sure, there are a few doctors participating in policy or medical associations, but it's clear to the rank and file that their leadership has already cashed out from patient care and are no longer participants in what medicine has become today. Worse: they’re too few in number and too underfunded and occassionally displayed as hood ornaments to validate a central policy decision.

Then there's call. No one likes call, but it must be covered. Doctors understand that medicine is 24/7/365 affair. But there's more people now, more places, and yes, more call. The burden falls on the doctors, so the tremors resonate louder. No large ones, mind you. But they're happening. Doctors are pleasantly, professionally, reaching critical mass.

I suppose there have always been rumblings in medicine, but somehow, the rumblings seem louder than usual. The promises of more with less is taking it’s toll. There are fewer perks these days for the work and risks involved for doctors. No one seems concerned, really, about liability reform. No one cares about doctor pay, except that it’s too much. Even the physician cheerleaders for the current reform efforts look tired. It’s hard to alter the course of a ship guided by business interests steeped in tradition, I guess.

This week doctors saw residents recalled to fill staffing shortages in a large, new teaching facility across town. Doctors there, it seems, were an afterthought. Residency work-hour restrictions prevent the remaining residents from filling the void left by their colleagues. So the extra workload necessarily falls on those who are ultimately responsible and already at risk for untoward outcomes: the already-busy attending physicians. Residents see it in their exhausted attending's eyes. Nothing is said, but the undercurrent is palpable. You see starry-eyed hospital administrators hell-bent on growth don’t fill those voids, doctors do.

Add to this, doctors read how another insurer has decided to change how they will pay doctors. At least that's how the headline read. But insurers don't pay doctors anymore, they pay their employers. How doctors are paid no longer relies on fee for service - that was gone long ago. But the public is told that the fee-for-service is what is broken. But doctors know what's broken are the incentives to maintain the middlemen that course through every layer of health care delivery that exists today in medicine. And God forbid there be more than a cursory mention of defensive medicine's toll. So the cash cow continues: policy-makers have decided that checking boxes on a computer screen or magically limiting readmissions is how "doctors" are to be paid. As if doctors can look in a crystal ball or should be expected plan for every contingency or every personal decision a patient might make or forget to make. Clearly these policy wonks ever heard of the People of Walmart. You see, for them, it's all about what they perceive is quality, remember, and quality involves a computer these days, not to mention maintaining shareholder value. So while insurers continue to cut payments to doctors and you can't get an appointment, remember: that's "quality" working for you.

Oh, and did I mention there’s a hiring freeze right now?

More tremors.

Can you feel them?

-Wes