Forbes Article: Why private practice is dying...

[drusso]

http://www.forbes.com/sites/realspin/2016/09/07/why-private-practice-is-dying/2/#406abb564da2

"One of the greatest benefits of private practice is that doctors and patients have much more freedom in how they interact—the essence of the doctor-patient relationship. It is a deeply-personal environment that depends on conversation and working together. In large practices, these interactions are typically guided by rote formulas and directives devised by administrators. Doctors necessarily lose some ability to tailor treatments and prescriptions to individual patients’ unique needs."

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[willabeast]

i saw a dermatologist once who referred to it as the "dumbing down" of medical care. i always assumed the reasoning behind it was to save money, but now i am not so sure. could it be the ego rush of the administrators delighting in subjugating the underlings in the trenches ? big pharma trying to get a lock on what is prescribed? a general distrust of uncontrolled highly educated people doing their own thing, leading to sometimes big jury awards? the USA is well on it's way to becoming a full blown Nanny State. that is clear. the why's are difficult.

//Nanny state is a term of British origin that conveys a view that a government or its policies are overprotective or interfering unduly with personal choice.[1] The term "nanny state" likens government to the role that a nanny has in child rearing. An early usage of the term comes from Conservative British MP Iain Macleod who referred to "what I like to call the nanny state" in the December 3, 1965 edition of The Spectator.[2]//

https://en.wikipedia.org/wiki/Nanny_state

 

[314117]

No. You were right with the first guess. It's all about money.

 

[oldanddone]

it's about money inasmuch as there are contesting factions wanting power to control/have the money. played in a field where there's discourses that use 'safety', 'efficiency', 'excellence', 'measurement' in ways that obfuscate the power grab. most often it's not about 'safety', 'efficiency', 'excellence', 'measurement', that's just language used to want more 'control'. actually, it's not just money at stake. it's also control over the practice of medicine - who gets to be 'professional', who gets to decide, all becoming more externalized, controlled from outside, what it means to be a profession and a healer in relationship with a patient becomes more about 'employee' and 'consumer'. might as well be the worst run call centre ever. certainly not what 'doctor' used to mean in terms of confidante, supporter, healer.

 

[Ducttape]

no, its about the $$$.

when given the choice of strictly deciding between $$$ or control, the majority of entities in medicine - hospitals, big pharma, admin, doctors, advanced practice organizations - will all go for $$$.

 

[clubdeac]

Interestingly the nicest and biggest offices in our hospital go the nurse administrators.... unbelievable. I'm in a clinic with neurosurgery, ortho, urology and wound care and the biggest and nicest office in the clinic is the corner office with large windows, a big desk and lots of pictures and plants. Guess who gets it....

 

[Vandalia]

There are bigger factors at play, and it is to a large (not total) extent a generational issue that isn't limited to medicine.

My younger colleagues of roughly similar economic status (in medicine and out) have people take care of their yards and landscaping, go out or have someone else prepare virtually every meal, send their laundry out, hire someone to change lightbulbs, a few even hire someone to take care of their children even outside of work hours, etc., etc. This continues a trend that my parents complained about: I did not service my own car (too complicated these days and too much of a hassle to deal with used fluids), my wife (yeah, yeah) did not do her own sewing/alterations/repairs, we had someone come in to help clean when she was pregnant, etc., etc. And their parents complained that they didn't can their own food, make their own preservers, make their own clothes, etc., etc.

If you are willing to pay someone else so as not to be bothered by things like mowing the yard and cooking, is it not logical that "this generation" would rather (to essentially) pay someone to avoid the boring work of running a practice?

EDIT: (This was added after drusso's "like" FWIW.) To make it clear, I am not criticizing my younger colleagues for their choices. As you get older, you realize that what you regret is lost time, not lost money. So having more time (hopefully spent with family or something else meaningful) is probably a more mature choice than that made by us old-timers.

 

[oldanddone]

There are bigger factors at play, and it is to a large (not total) extent a generational issue that isn't limited to medicine.

My younger colleagues of roughly similar economic status (in medicine and out) have people take care of their yards and landscaping, go out or have someone else prepare virtually every meal, send their laundry out, hire someone to change lightbulbs, a few even hire someone to take care of their children even outside of work hours, etc., etc. This continues a trend that my parents complained about: I did not service my own car (too complicated these days and too much of a hassle to deal with used fluids), my wife (yeah, yeah) did not do her own sewing/alterations/repairs, we had someone come in to help clean when she was pregnant, etc., etc. And their parents complained that they didn't can their own food, make their own preservers, make their own clothes, etc., etc.

If you are willing to pay someone else so as not to be bothered by things like mowing the yard and cooking, is it not logical that "this generation" would rather (to essentially) pay someone to avoid the boring work of running a practice?

EDIT: (This was added after drusso's "like" FWIW.) To make it clear, I am not criticizing my younger colleagues for their choices. As you get older, you realize that what you regret is lost time, not lost money. So having more time (hopefully spent with family or something else meaningful) is probably a more mature choice than that made by us old-timers.

Time and money are the carrots and perhaps those using the carrots think they want to save money/have more money yet as the article points out the administration bloat is more costly.

There's another ideological shift over time at play. That is the shift from individual autonomy (professional or simply of the citizen/human being ) to a quest for proscribing and standardizing everything. This too relates to money and power to govern. It has crept into all aspects of life. Often the tools come from the business world of quality assurance/total quality management. The tools are often measurement and carrots and sticks tied to measurement. Like little tailors/surveyors measuring everything including what should not be measured with those tools...professionalism, relationship, etc.

 

[oldanddone]

Also the control of the money is contested terrain for who wants that power....Mds. ..Govt...insurance companies...nurses and other allied health...

Same with definitions for the profession...Govt. ..med businesses like kaiser now running its own med school to produce ideologically groomed docs
...med ed...colleges/boards...third parties..many jumping in to get a bit of the power for shaping what definition of the profession is unto miniscule operationalized aspects. .

 

[314117]

oldanddone-
You are making it more complex than it needs to be. You say its about "control", "power" and money. Guess what- control and power come down to money. It's the only way to control anything.
No one actually cares about "what it means to be a profession and a healer" or any BS like that. It is 100% about money, who gets paid what, who controls the money, just like pretty much everything else in the world is.
And I completely agree with your statement that it is "certainly not what 'doctor' used to mean in terms of confidante, supporter, healer."

 

[oldanddone]

www.ilpc.org.uk/portals/56/ilpc2010-paperupload/ilpc2010paper-10626.doc
"The Machinations of Managerialism: New Public Management and the Diminishing Power of Professionals"


agreed it's about the money. and in the process, we lost our autonomy in some big ideological shifts. i'm really effing chafing about that currently. i speak the softy stuff because predominantly i've focused my practice as an FP doing MD Psychotherapy in Canada (where we are in each jurisdiction just about to get reamed whether american or british style. the reaming has to do with more beaurocracy and oversight from all sides including disgustingly from our own in the associations and colleges that are all uncritically participating in this new managerialism, and so the humanistic aspects of medicine as they are getting weeded out is the part that really effs me over. and leaves me raging with impotence.

edit: apologies for the 'lefty' slant of the article. raises the same alarm around loss of autonomy as the forbes article, though, and in that way 'anarchist lefty' can often become great friends with 'libertarian righty'. some of the things around autonomy can make strong 'partnership'.