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An Excerpt from the Introduction:  The Doctor is Out

On June 30, 2007, at the relatively young age of 51, I left the practice of medicine. After nearly a quarter-century spent building and managing a busy, locally well-respected, and successful solo private practice in primary care, I chucked it all and walked away from my professional career. Was I the victim of burnout, a vague but insidious ailment common to busy older physicians, which renders them indifferent and inured to patients’ problems and pains? I don’t think so. Rather, it was a resignation. In chess, after a wearying and protracted battle, there comes a moment, shortly before checkmate, when one opponent realizes that all is lost. Moves and countermoves are exhausted; the contest has played out. The time had come for me to leave primary care, to vote with my feet, and to find personal and professional happiness elsewhere. I chose to resign from the practice of internal medicine, exiting 10 to 15 years prematurely, but still with dignity, as I saw the quality and personal satisfaction of primary care eroding. I had lost the match.

Who was my opponent in this metaphorical lost game of chess? I could trot out the common cast of characters so often cursed and vilified in hospital doctors’ lounges, at medical meetings, or wherever two or more physicians convene: the evil insurance industry, the bean-counting bureaucrats at Medicare and Medicaid, or the malevolent malpractice plaintiffs’ attorneys. Certainly, they all had done their part to erode away the rock-solid footing of my practice. Rather than round up the usual suspects, however, I now reflect that, as a solo practitioner of primary care, I have lived through a slow but tectonic change in US health care delivery, a paradigm shift.

I was a premed student in the ‘70s, a time when an older person still could remember house calls made by his family physician, a pillar of the community, and a Norman Rockwell American icon. For the Boomers, the first generation raised on TV, there was Marcus Welby, the avuncular family doctor, an ever-available friend and personal physician to only one patient per weekly episode, who had not yet gone on to re-run syndication. Times change, however, and so did primary care. By the mid-1980s, when I was done with my residency training and busy building my practice, the government and private insurers had begun a concerted effort to contain the escalating cost of health care by fiat. The kindly family doctor was diminished, downgraded, and de-professionalized to a “provider,” a bland descriptor on a clerk’s requisition form. Even worse, New York State’s Medicaid, insuring the indigent, classified me as a “vendor,” a term which sent me into orbit then, and which today still rankles. Hemmed in by profession-specific price controls, reams of restrictive regulations, heavy-handed threats of federal penalties and expulsion from Medicare participation for suspected infractions, I became disheartened. My patients, however, still held the traditional view of their doctor as a knowledgeable authority figure and a personal source of comfort, advice, and strength. They did not know that the supportive scaffold, their primary care physician’s practice, already had developed dry rot.

The years went by and, disregarding the exaggerated reports of my profession’s demise, I busily continued to see patients and practice medicine as I thought best, with a personal touch, a close connection, and a physician-patient relationship best delivered by a solo practitioner in a small office. In the early 1990s, managed care and HMOs arrived on the scene. As a primary care physician, I was recast as a gatekeeper, the fellow at the turnstile of a veritable health care amusement park where those with a ticket (a valid health insurance card) could spend an afternoon with a specialist, take a ride in the MRI scanner, or visit the X-ray funhouse.

What’s in a name? Whether I was a gatekeeper, a provider, or even a vendor, I was where I wanted to be, still practicing primary care medicine in a very traditional way. I cultivated satisfying relationships with several thousand patients and their families, each unique, and I felt rewarded in providing an essential service for my community. The bureaucracy and banditry of the health insurance industry was a slowly constricting circle that annoyed as it encroached, but in the mid-1990s and even early in the first decade of the 21st century, I still could ply my craft.

Time passed. My patients grew older. They probably thought the same about me, but they had grown much older. Elderly women, beneficiaries of an elongated lifespan, continued to come. Even men in their 90s paid me regular visits. Mirroring a national phenomenon, a trend toward the geriatric, my practice increasingly was composed of the fragile, chronically ill sufferers of multiple degenerative diseases, all laden with the psychosocial complexities of the first superannuated, add-on generation in human history. It seemed they were all there, sitting in my waiting room. Medicare apparatchiks and federal “budgeteers,” the bill payers, probably thought so as well.

Now, in 2011, the dark cloud of Medicare insolvency hangs on the horizon, saturated with the heavy burden of 78-million nearly-geriatric Baby Boomers. My quite traditional, small, solo private practice, so 20th-century in concept is no longer viable in a modern Walmart business environment of “everyday low prices” and paper-thin profit margins. Few primary care physicians today are able to meet the extraordinarily large volume of care demanded by the soon-to-be-senescent Woodstock generation. Something must give.

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