Private practitioner: A lost medical trust

The family doctor is romanticized in art and literature. We can see the Norman Rockwell painting now — a kindly, plump old fellow, stethoscope hanging from neck, filling out a prescription while mother and children stand by in trust and admiration.

The problem with romanticized characterizations is that we tend to dismiss them as unrealistic. This one, though, is not. The family doctor, or independent practitioner, is real — a fully functioning element of the best medical system in the world. Moreover, he is an integral one. He makes the system work.

Adam Smith explained why in his “Theory of Moral Sentiments.” Human systems, no matter how much we pride ourselves on their complex design or fiscal controls, are at base interconnected individual relationships exchanging gifts, products, assistance or sympathetic favors. Interfere with the trust holding those relationships together and the system falls apart — or takes an unintended form as exemplified by so many failed experiments in socialism.

In modern economic terms, government intrusion into the health care market is transforming family doctors and specialists not just into salaried employees but into “rent-seekers,” that is, agents of corporations seeking to manipulate regulatory agencies to gain monopolistic advantage.

The reform for all of this is to restore the trust lost in the exchange of medical assistance from physician to patient. Again, more doctors now work for hospitals, not patients.

Dr. Chad Davis, an Indianapolis surgeon, explains in part how that came about: “There may not be anything explicit in ObamaCare that says hospitals should buy physician practices, but because it encourages bundled payments for a patient’s care, which a hospital then distributes to the doctor and others, it encourages hospital ownership of doctors and accelerates that process.”

The Wall Street Journal reports that in 2008, 62 percent of doctors were independent. In 2012, that had decreased to 49 percent, and this year it is down to 35 percent.

All of that understood, health care policy needs to reflect why people become doctors and not mechanics, bankers or janitors. It is not to find sinecure in a sparkling new hospital set in beautiful acreage. Nor is it to please an administrator or to meet the actuarial expectations of an insurance company or a federal agency. It is not even for love of humanity (although this is common in all medical professions). It is to put knowledge and skills to work healing the individual patient in front of him, hour after hour, day after day.

Such a role assumes — requires — a sense of ownership of the process, something that was once built into the operational manuals of the great hospitals, e.g., the Mayo Clinic, the Cleveland Clinic and, locally, the Indiana University Medical Center and Riley Hospital for Children.

The research collected in the current issue of The Indiana Policy Review argues that this ownership is absolute. It is destroyed by even the most measured changes imposed in the command-and-control systems that government has put before us. And all of the warning signs — the shift in physician incentives, the loss of transparency, the inscrutable billing, the impersonal economics applied to even life and death decisions — tell us that there is no substitute.

The grim alternative is outlined in a recent article in the City Journal, “Say goodbye to the Family Doctor”:

“Traditionally, doctors felt duty-bound to act solely for their patients’ welfare. The new breed of physician-employees will split their allegiances between their employers and their patients. The employers’ goals will not always coincide with the patients’ best interests or the physicians’ best medical judgments. At minimum, patients will wonder if their doctors are making decisions out of a genuine concern for their health or just trying to save the boss a buck. Salaried employees and independent professionals behave differently.”

The author suggests that we study the recent scandals involving the Department of Veterans Affairs to understand the difference between an independent doctor or specialist and a salaried employee: “They see fewer patients and perform fewer timely procedures.”

If that is the reality, we prefer the romantic — especially where our health is concerned.