End Notes
Not Paid to Talk
By Richard A. Miner, M.D.
A physician reflects on how the system has changed doctors since his father’s day.
I am the oldest son of a general practitioner who was in solo practice near Milwaukee, Wisconsin, during the 1950s and ’60s. My father worked long hours, made house calls, and often used our kitchen table to stitch up careless friends or neighbors. He’d sometimes get paid in venison or hooked rugs or be promised “We’ll pay you when we can.”
His way of practicing medicine didn’t seem so wonderful to me when I was young. He was often tired. He’d nod off during family meals, birthday parties, and graduations. One time, the rescue squad came to the house because he’d drifted off during a phone call and the operator noticed heavy breathing on the line. My brothers and sisters and I would joke that he had raised sleeping to an art form. He eventually closed his practice to work as an emergency-room physician mainly because it was a way to control his hours without having to say no to people in need. He referred to working only 40 hours a week as being “semi-retired.”
After watching him for years, one thing was clear to me. It wasn’t the money that drove him, though he did have a wife and six children to support. It was that he just loved helping people and couldn’t pass up any opportunity to do so. Years later, as I embarked on my own practice in child and adolescent psychiatry, a specialty choice he forgave me for, I was surprised to learn from my mother, the more practical parent, that although he worked far fewer hours as an ER doc than he had as a GP, his income substantially exceeded that which he earned during his best years as a solo practitioner. Even so, I knew it was not the added income but the opportunity to serve his long-term patients, many of whom followed him to the ER, that kept him excited about his work.
Today, the way my dad practiced seems not just old-fashioned but ancient, as if he’d been a contemporary of Louis Pasteur and driven a horse and buggy rather than a car. Medicine in the age of salaried physicians and managed care places no value on continuity of relationships or care because it can’t assign a dollar value to those activities. Insurance providers have people changing doctors the way they change their cell-phone service providers. Office visits in which the physician gets to know the patient as a unique individual with a family and a life history have been largely replaced by 15-minute visits in which patients, ideally coached in advance, bring up one problem at a time (and schedule separate visits if they have other concerns).
Not only has the managed care model made it more difficult to maintain strong relationships with patients, it has made developing such relationships seem nearly impossible. Once when I was attempting to get authorization for psychotherapy sessions with a long-term patient, a care manager told me, “You’re a psychiatrist. We don’t pay you to talk to people. We have other people to do that.”
The most painful reminder of the way medicine has changed came last February when my mother, who a few days before had been an alert, active 86-year-old, lay in intensive care with pneumonia as her family gathered around her. She was under the care of an internist and a pulmonary specialist, neither of whom seemed aware of us. We literally had to stage a sit-in at the internist’s office until he had a free moment to speak with us. To meet with the pulmonologist, we went to the hospital at 6 a.m., when he was making rounds. He made a point of saying that he had no real obligation to speak with us at all because he’d talked directly with my mother before she went on the respirator and he’d determined that she had no wish for extreme measures. That her message to us, her adult children, might have been different clearly didn’t carry much weight with him. He had no interest in providing support, comfort, or understanding to us as the life-altering events unfolded before us.
I am not so naive as to believe that doctors of old cared about patients and doctors of today do not. But I do believe that our present health care reimbursement system works against individualized, patient-centered care and for high-tech, specialized procedures. As the care manager said, “We don’t pay you to talk to people.” MM
Richard Miner is a child and adolescent psychiatrist in private practice in Edina.