By Alec Pruchnicki, MD
During the 1970s when Marcus Welby, M.D. was on TV, I seldom watched it. But, the image of Welby as the kindly, dedicated family doctor we were all familiar with, was well known. This image persists in our memories whether it’s a retired doctor or doctor’s daughter (see WestView September 2018 articles by Dr. Kohls and Hannah Reimann describing medical practice from years ago). That type of medicine is gradually disappearing, either through retirement of physicians, or buyouts by big medical groups (either corporate or academic/hospital based). Why?
Although I never had my own private practice, I am familiar with many of the strengths of the small primary care doctor’s office from my own experience as a patient and from conversations with my colleagues who still maintain their own practices. Attention by the doctor and staff is much more personal so that when you call they recognize you by name and not just your date of birth. The provider (doctor or nurse) knows your history and can provide personal service that the big groups sometimes can’t.
But, medicine has become more complex and expensive with advanced technology, including costly computerized medical records, multiple insurance companies, and the pressure to see as many patients as possible. Even in a small private practice, there is pressure to have an assembly line efficiency to cover costs and salary. The countless consultants who are around trying to tell us how to be efficient remind us that doctors must be part business people in order to survive. Doctors don’t always like this. If we wanted to be in business we would have gone into business, gotten an MBA and be working on Wall Street.
When my own primary care doctor closed his practice and joined a large academic practice he was overjoyed. All the business aspects of his work disappeared and he could spend all his time doing medicine, not bookkeeping. My own primary care practice in geriatrics is owned by Mt. Sinai Hospital. My income might not be as high as someone in private practice but I have good benefits that I would seldom get in my own office.
The benefits don’t all go to the doctors. There are times, believe it or not, when a large center can provide better services than small practices. When medical groups are well run, patients have the benefit of having most services in one location. Instead of going to one place for one specialist, and another for special tests or imaging, it can be done in one place at one time. If records are well kept, all providers have access to all the information about you and this can make quality medical practices better.
Of course, not all places are well run. Both non-profit and profit-making corporations running practices, nursing homes or hospitals have to keep a close eye on finances, and corporate greed, miscalculation or incompetence can easily destroy any medical service. But, medicine is a three trillion-dollar industry and to think that it can be managed by mom and pop level small practices when the entire rest of the economy is centralizing is unrealistic. As Paul Starr pointed out in The Social Transformation of American Medicine, “in 1982, when the medical establishment prevented rationalization of the industry by government, it made rationalization by the private sector inevitable.”
What is the solution? Medicare for All; and Single Payer advocates, including me, think that such a system would streamline the paperwork, greatly decrease the malignant role of corporate profits in medicine, and give the public the opportunity and freedom to advocate for quality care. Without a radical change like this, there is little chance that the weaknesses of current medical practice will disappear by themselves.
Marcus Welby is Dead
By Alec Pruchnicki, MD