Monday, June 25, 2012

Why Solo Docs Should Not Sell Out

     Solo Doctoring is a special calling.  There is a bit of The Loneliness of the Long Distance Runner in it.  Here you are, all by yourself in the foggy morning with the patients, with your staff, in your cluttered little office, with your bag of tricks.  You travel a labyrinthine road with each patient for years and years;  it's toilsome, full of calamity, beset by the perplexities of transference and countertransference, but there is joy amidst the heft and storminess of that hundred and fifty-six miles, the joy of having made something happen.  Your patients need you.   They don't come to see you when Pandora's Box is tightly shut, when they feel terrific, or if they've just won the lottery.  And frankly, they aren't interesting people when all the charms of life have showered down upon them.
     The solo doc gets more of the provocative patients, the ones who suffer but are also agents of change.  This is my prejudice, but I am imagining a patient in deep distress wishing to find a fellow traveler on the backwater road to understanding himself.  Doctors in large corporations are not those lonely souls, at least not on the surface.  They are protected by the group, saved by a bulwark of lawyers and accountants who stand at the helm and vouchsafe their jobs, saved by other doctors who "cover" for them when they go on vacation.  You can no more get "coverage" for your patients when you go away than you can for your marriage.
     Patients are provocative when they have a venue to be so--when there is room to move around and bring out their performances; when there is time for the doctor to imagine who is making the puppets dance, and why; when the doctor finds it all irresistible, joins in the drama, and tenders the magic potion.
       Despite the fakery of HIPAA the patient's darkest woes can't find true sanctuary in a gargantuan corporate office.  Are the secrets recorded in the typewritten note really safe from the curious meandering eyes of the hundreds of clerks who handle the thousands of charts every day?  No clinic, however small, is free of employees but if the few staff members have been there for years and greet you like family it feels secure.  When a patient trusts everyone in the office, when the doors are sealed, when the doctor is another lonely soul trekking his way toward the dark end of life, untold stories surface from the black muck of the past;  in that space there are divulged feelings that many doctors would rather not contain because they take too much time.  But in the environment of the solo doc patients experience catharsis, and restoration of health.
     Of the many doctors I've met among the growing subset who sold their little private offices and moved into conglomerates, none seems truly happy.  They act like amputated versions of their old selves.  They don't have the peculiar mannerisms and quirky ways of expressing themselves that you see in solo docs, especially the old country docs.  There's a defensiveness about them, too, in their saying over and over, "I'm really on my own, it's just that the company does all the paperwork and insurance stuff, and they hire and fire..." and "I have more quality of life."  It's as though they have been so thoroughly hypnotized by the recruitment lullabies that they repeat them as facts.
     "You're not happy!" I want to shout, pointing out to them that they've grown lumpish and wan.  But how should I know?
     I do know that a complacent doctor well-protected by corporate bureaucracy doesn't provide "hooks" for the patient to grab onto, and hooks are what allow for relatedness.  My patients are always asking about my life, or making assumptions about me based on idiosyncrasies in my presentation, the artwork I've chosen for my walls, or the jokes and information sheets I hang on bulletin boards.  While I say very little about myself, over the course of many years patients come to know or deduce things about me that allow them to feel comfortable in my presence, even to consider me a fellow-traveler.  This is conducive to their well-being.  It's true that many corporate-owned practices set up doctors in small private offices that simulate those of solo docs.  But this is a deception--it belies their awareness that solo doctoring is best--why else mimic it?-- and I don't think it fools patients.
     My mother's long-time solo cardiologist sold out to a hospital several years ago.  He's the same doctor on the outside, but she has mentioned to me on numerous occasions that he's really not the same, he seems resigned, he has lost his verve.  And she isn't the same either, when she's with him.  She can't confide in him;  she hides her symptoms;  she doesn't want to waste his time.
     There are subtle problems with the doctor-patient relationship in the corporate "delivery of medical care" (a phrase not invented by a solo doc).  My mother's cardiologist isn't in charge any more;  as a result his patient care has gone gray.  Corporate advocates would laugh and say I'm pointing at a specter in the dark.  There's no difference, they'd insist, hiding in the wings while the doctor does his gentle curing, and grabbing the monthly profits from his pockets like burglars.  There is a difference, and I think it alters the patients' well-being and the doctor's.  It's destroying the last bits of what used to make American medicine great.
     The main reason solo docs should not sell out is because maybe we're  happier in our independent orbits than we've been willing to admit, and once we sell out it's hard to turn back.  Even if insurance companies erect roadblocks and the federal and state governments have turned into tyrannical parents, we solo docs manage to do well.  Imagining that life will be simpler when someone else takes charge is like turning our cars over to chauffeurs or allowing a cook to decide every meal we eat.  Like wild animals whose forested habitats have been devastated we can adapt more readily to change than our soft, salaried counterparts.  There isn't a year in solo practice when I haven't had to shift my strategies, add new skills to my repertoire, memorize new codes, analyze documentation requirements, or drastically amend my relationship to insurance companies.
     There is a heart in solo doctoring, and it shrivels up when we sell out.  Solo docs are completely invested in what they do.  Our personalized decisions have immediate effects on the practice, unlike those in larger groups where pyramidal administrations sink new ideas into procedural quicksand, and change is a last resort.  We lone doctors can remedy problems in a day, or we can keep doing things the old-fashioned way when our broad understanding of patients tells us it's for the best.
     I do not understand the incursion of corporations into private medicine.  It's an insidious takeover, an attack on humanity, a blasphemy--and I'm down here in the trenches waving a red flag and shouting, "Help! Help!  Are there any real doctors left?"

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