Oh Medicine, My Medicine

By

Leonard Zwelling

(For the late, great Dr. Bruce W. Dixon, a great mentor to hippie interns)

http://www.nytimes.com/2014/11/24/health/private-oncologists-being-forced-out-leaving-patients-to-face-higher-bills.html?module=Search&mabReward=relbias%3As%2C%7B%221%22%3A%22RI%3A9%22%7D&_r=0

         This is one of many articles published of late that addresses
the issue of cancer drug costs and prices or reimbursement rates (There’s a
difference. The cost is what the doc pays, the price is what the insurance
company, Medicare or patient reimburses the doc or hospital.) These costs and prices have
everything to do with whether or not a private oncologist’s practice can be
financially solvent.

Cancer
drug administration used to be the way an oncology practice stayed afloat. No
longer. That is why so many oncology practices are being bought up by hospitals
where the reimbursement for cancer drug administration is far more lucrative
than it is for the private oncologist for reasons having to do with differences
in costs and prices in the office vs. hospital setting. There are even federal
programs that allow the purchase of these drugs at lower cash outlays for some
hospitals but not for the private practices.

         This is just another sign that medicine is changing and
another indication to me of how fortunate I have been to be among the last
physicians to participate in the golden age of American medicine. That golden
age is over.

         What are the characteristics of the former world of medicine
that are gone?

         First, everyone thought the grass was greener in the other
guy’s yard. Academics thought that they could make a ton of money if they just went
into private practice. That’s gone. The private docs thought that the academics
didn’t have to struggle with the immense patient care burden that they were
operating under. That’s gone, too.

         Second, physicians got used to being in control of the worlds
in which they operated. That’s gone. The health care-industrial complex is far
more under the control of the insurance companies, the federal government, big
pharma and administrators of huge hospital networks than it is being guided by
medical professionals. In his wonderful book Catastrophic Care, David Goldhill calls health care the island that lives off the coast of the rest of the American economy. Health care land is run by the Surrogates, Medicare, Medicaid and the private insurers who serve as intermediaries between suppliers (doctors) and demanders (patient).

         Third, docs no longer have a potent voice in medical matters
in the US including on Capitol Hill. The major winners in the post-ACA Era are
the insurers. After all, if you were in a business selling a product that the
government just forced more people buy, you would support that legislation,
right? Surely, a small number of patients and no docs are better off because
both groups, providers and consumers, did a terrible job lobbying Congress when
the bill was being formulated.

         Finally, on the local level, for years, despite all of these escalating cost and price trends dating back 20 years or more, MD Anderson was immune from
the financial ups and downs plaguing other academic centers. It was a true
oasis in the academic medical desert. No longer. Anderson is pretty much like
every place else. Just like every place else, it is more and more staffed by
younger people who are unaware of the golden age of American medicine and
figure the treadmill they have jumped upon is the way it always was. It’s not
true, but how could they know when the faculty members who were the
institutional memory are either walking out the door, retiring or being
escorted to their cars?

         I am eternally grateful that I was able to catch the last
wave of the American medical Endless Summer (look up the movie) for the fall
was precipitous and short and we are in the nuclear winter of clinical care.

         I joke with my family that when my current doctors retire,
most of who are my age, I am just going to die. I will swallow the shiny fluorescent
blue barbiturates on the mantel under the sign saying “when you don’t know what
these are, take them.”

         Every day it seems less and less a joke and more and more a
reality. I am not ready to quit on medicine or myself just yet. Well, at least
not on myself. The people I see in charge of medicine right now should be
ashamed, but they were out-smarted by better-equipped adversaries—the
accountants, lawyers and actuaries. I tried to fend them off by getting an MBA
myself, but I ran out of gas and patience for no matter how many degrees the
non-docs acquired, they were never able to understand what it is like to care
for the ill and thus were never able to build a system to accommodate the needs
of those who do. What’s more, not only didn’t they care, they weren’t being
paid to care.

         It’s really too bad, but it is especially too bad for the
young for they will never know the world that we did. They have their own world
of shift changes at 8-hour intervals, hospitalists for the bed-ridden sick, electronic
medical records, patient volume targets at 15-minute intervals and up-coding
when possible. I don’t know about them, but that’s not why I went to medical
school and it is certainly not why I came to Houston.

         Good luck Medicine. I will see you again in the next life.
When I thumb through the book I just received from Amazon about the past 50
years of Duke Chief Medical Residents, many of whom I knew, I realize I am
looking at history and not a reflection of today.

         I am quite sad, but I remain extremely proud to be part of a tradition that stretches from William Osler to Eugene Stead to James Wyngaarden to Joe Greenfield. I am aware of the many gifts they gave me as well as the ones I got first-hand from my Chief Residents Bruce Dixon, Ed Holmes, Charles Scoggin, Dan Scullin and Mike Knowles. Guys, I did my best to pay it forward. Our time is over. No one cares what the Gram stain shows any more. 

Leonard Zwelling