A Difficult Time
My Journey in Medicine	by Jerry Sobieraj, MD © 2001
Available at and Published by
Also available at:

Chapter 14: What to do about Medicine?

In this book, I have been very critical of the health care system (HCS). I believe my criticism has been valid. Yet, I also believe that criticism should be followed by constructive recommendations. Toward that end, I would recommend the following changes to our HCS. Some of these would be more easily implemented then others. In fact, some would require a wholesale restructuring of the HCS.

The first change would indeed be fundamental. It would require the HCS to change fundamentally its reinforcement system. As Pavlov showed at the turn of the 20th century, reinforcement patterns are critical when trying to elicit and sustain a specific behavior. I feel it is imperative that the HCS reinforce the importance of doctors talking with their patients. It has often been stated to medical students that the history one obtained from a patient contained 80% of the information needed to make a specific diagnosis (some would have argued more than 80%, but not less). The only way to obtain a patient's medical history still requires talking to people. But, the HCS based reimbursement more on what was done to people, than the discussions doctors had with them.

Thus, a major restructuring to support doctors talking with their patients is needed. The only way to ensure this result would be to de-emphasize the lopsided reimbursement of procedures. This would likely be fought tooth and nail by the powers that be in the HCS, as they have accrued their power by manipulating our current, distorted system. Yet, if the people (the patients) speak loudly, clearly and consistently about having time to talk with their doctors, indeed it could happen.

In addition, this primary interaction, the face to face interaction between the doctor and the patient, would need to be elevated to the apex of our HCS pyramid. It would need to be reinforced financially (likely with a time based reimbursement system), and also widely available. Such a change of focus would make it easier for doctors to open up shop where the patients are, instead of being limited to the increasing confines of the corporate medical elite which benefit from subsidies (i.e. facility fees and indirect cost payments). Since talking to a patient would be considered the primary focus of the HCS in this model, a physician wouldn't feel rushed during a visit with a patient. Spending more time with the current patient would be just as financially advantageous as proceeding to the next one.

Ideally, the HCS would permit a primary care physician to be able to hang out a shingle, talk to patients, and obtain adequate reimbursement. This latter objective would be facilitated by a HCS that ensured low overhead. To lower the overhead of a medical practice, the HCS would need to agree upon a universal set of rules. Yet all rules would be beholden to the primary rule, that the face to face interaction of doctor and patient could not be undermined. Also, the HCS would need to support the efficiency and uniformity of process, to prevent an undue burden on physicians' time spent away from their patients.

Much of what President Clinton tried to do in 1992 would have improved the efficiency of the HCS, from a primary care provider's perspective. It may not have been the best way to do it, but unfortunately, a real discussion of the problems with the HCS never occurred. The health insurance industry feared real competition in the health care market. They had become fat cats in the current HCS, and wanted it to stay that way. They concocted the Harry and Louise ads to bring it home (i.e. defeat the bill in Congress), and that they did. Next to Clinton's impeachment, his failure to get health care reform through Congress at a time when reform was so broadly supported by the electorate, may be considered one of his greatest failings. The insurance buying cooperatives President Clinton wanted established in each state were sorely needed in 1992, and remain important today. They are a tool that would allow customers (patients) vote with their feet, and choose an insurer of their liking, as opposed to being forced to accept the insurer who gives their employer the cheapest policy rate.

In addition to discouraging a procedure first mentality in Medicine, equity in physician reimbursement remains an important issue. The salary disparity between physicians of equal training needs to be resolved. Of course under these revisions, those earning more revenue than at present would be happy and those receiving less would be upset. I believe this potential problem is manageable. As I alluded to earlier, most primary care physicians make adequate livings. What they really need is a restructuring of their work environment. Since this change could lower their productivity (i.e. how many patients they could see in a day), to maintain their salaries, the money would have to come from somewhere else. I would view the primary donors as: radiologists, anesthesiologists, ophthalmologists and possibly pathologists. The doctors in these specialties would be upset, and strongly oppose such a change. Yet, would their opposition be credible? After all, they don't necessarily have more training than a primary care doctor, only different training. Surgeons do require extra training (at least two more years) and should receive additional compensation for it. In addition, in order to ensure adequate numbers of specialists, there needs to be some incentives toward that end. These incentives need not be all financial, but they surely could be. When a specialty was showing signs of a shortage, reimbursement could be enhanced, or programs to pay back student loans for people entering those specialties could be established.

Finally, the HCS needs to recognize experience. Many people wouldn't want a rookie treating them, but our HCS could become the Montreal Expos of health care if we don't do something to show that experience is valued (i.e. the HCS could be fielding what is in effect a minor league team in the major leagues). Reimbursement needs to factor in years of experience, and other special training or skills that enhance the primary interaction of doctor and patient. This may include skills in nutritional or behavioral change counseling. Other procedural skills and training should be supported, but not at the expense of the primary, face to face interaction of doctor and patient.

There are other factors such as the cost of medicines which also should be reformed. After all, we are the only country in the world that doesn't regulate the wholesale costs of medications. These and other structural reforms, will be important, but I wanted to emphasize those which have impacted most upon my journey in Medicine.

Ultimately, meaningful reform will be a tall order for our HCS. Yet, to ignore the realities I have discussed in this book would be to our own detriment. I have not been alone in my departure from Medicine. In fact, most people who read these pages likely will have heard about other doctors leaving Medicine. If we, as a society, don't act to reform the current health care system so that it supports primary care, then we'll be left with this reality: "Medicine's a good 20 year profession".

Table of Contents