I met a recently retired Massachusetts pediatrician at the eightieth birthday party of an honored physician-writer, colleague, and friend. The pediatrician, also a writer, and I talked for a few minutes about his practice and his retirement. He’d built a great practice, he told me, that did what great pediatrics practices always do – they saw kids when they were sick, did their school physicals, helped parents understand their growth and development, and made sure that a child who is hospitalized is getting the right care and support. This pediatrician’s practice also went above and beyond, and used social workers and psychologists to address the many mental health challenges that kids face today. Sounds like a great practice, I said. It was, he replied, but I was losing my shirt doing it. We started losing $1000 a day, so I had to shut down after twenty- five years of practice, in a Boston suburb, which is worth noting because it is evidence that the many challenges primary care doctors and practices face aren’t restricted to Rhode Island.
We moaned about the state of the world, which had chased him out of practice prematurely. And then we also reflected on one of the things that we both missed most, which was taking care of our own patients in the hospital. Yes indeed, once upon a time, primary care doctors went to the hospital every day to see their hospitalized patients and to direct their care as the “attending physician” of record. You see, once upon a time, not very long ago, if you found yourself in the hospital, your family doctor would come to the hospital every day, check your chart, talk to and examine you, talk to the surgeons and other specialists involved in your care, and make sure everyone understood who you were and what you wanted. We made sure that your voice was heard and respected, as we made sure you got the best care available and nudged the hospital systems to get you cared for expeditiously and well. It wasn’t perfect – because we were there only once a day, we needed help addressing problems that arose when we weren’t there, and there were always challenges communicating with nurses, residents and specialists, because the rest of our day was spent in the office, seeing outpatients, and it was sometimes hard to interrupt those visits. Sometimes we rounded at the hospital at six in the morning. We often went back to the hospital and rounded again at eight or nine at night.
The heartbreak is that all this went away by about 2010. Hospitals pulled the support of primary care doctors and chased us out of the hospital. They replaced us with hospitalists, who took turns being a patient’s doctor. Sometimes they switched every week. Sometimes every two weeks. Sometimes once a month. But sometimes every few days, so if you are in the hospital, the person taking care of you is now someone you’ve never met, and who isn’t likely to know you or your family.
Many primary care doctors were happy to leave the hospital, truth be told, tired out by the increasingly complex demands of outpatient practice and by declining reimbursement, which meant we all lost money by going to the hospital. Insurers, to their great shame, helped push us out by keeping payment for hospital visits low, thinking that they’d save money by industrializing health care, while there was some evidence that showed the opposite is true.
Having your doctor who knew you take care of you in the hospital was one thing American medicine did right. Giving that up wasn’t exactly crazy. But it was a sad and unnecessary compromise which left American healthcare poorer and sicker, because it weakened the relationship between doctor and patient, which should be at the center of everything we do.
Michael Fine, MD, is a writer, community organizer, and family physician. He is the chief health strategist for the City of Central Falls, RI, and a former Director of the Rhode Island Department of Health, 2011–2015. He is currently the Board Vice Chair and Co-Founder of the Scituate Health Alliance, and is the recipient of the Barbara Starfield Award, the John Cunningham Award, and the June Rockwell Levy Public Service Award. He is the author of several books, medical, novels and short stories, including On Medicine and Colonialism, Rhode Island Stories, and The Bull and Other Stories, You can learn more about Michael at www.michaelfinemd.com
Join Dr. Michael Fine at the Newport Public Library on August 13.
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No one from the surgical team sees you after surgery in the hospital before discharge anymore either. TY Dr. Fine for bringing attention to these issues- I look forward to, and appreciate, your articles.
In that case, I don’t need to get myself to Miriam or RI Hospital in order for my primary doc to provide care and oversight?