A few relatively recent developments around physicians and organized medicine, taken together, provide a fascinating picture of some of the issues facing practicing physicians, as well as organized medicine, right now—and also offer a glimpse into the landscape facing clinical and other informaticist in healthcare.
First, I was fascinated to read an article from MedPage Today entitled “AMA President Sets Problem-Solving Agenda—Young ER doc directs AMA focus to the medicine of the future.” The June 10 article, written by Sarah Wickline Wallan, was written during the American Medical Association’s annual meeting, and noted that, “As the AMA debated the formation of a Super PAC to help put more physicians in position of political power, it’s hard to miss the potential of their new president, who says his three-part agenda will better prepare new physicians, protect the current ranks, and make Americans healthier.”
The article focused on the inauguration of Steven J. Stack, M.D., an emergency medicine physician from Lexington, Kentucky, who is the youngest AMA president in 160 years. Dr. Stack told MedPage Today that “We intend to transform the medical school experience as profoundly as it was done over 100 years ago and create and entirely new model and context. Stack told the publiciton that he wanted to push forward three different initiatives: first, to “transform the edical school experience as profoundly as it was done over 100 years ago and create an entirely new model and content”; second, to have the association focus on the management of diabetes and hypertension in patients; and third, he wants to focus on physician satisfaction. Or, as he put it, “We want to restore the joy of the practice of medicine to the practice of medicine. Right now,” he said, there’s such a burdn ofregulatory webs and knots, it’s really daunting for physicians to find a way to get through their day, let alone run a successful practice. In fact, he took particular aim at electronic health records, which he described as having “incredible promise,” but which have “inserted such incredible frustration into physician lives and diminished their efficiency.”
So—those not familiar with organized medicine—the AMA and the state, county, and local medical societies—will not fully understand how revolutionary Dr. Stack’s words are, at least in their rhetoric. I will note here that my first job in healthcare publishing, 26 years ago, was with a state medical society, and not just any state medical society, but one of the most conservative of state medical societies. The assumption in those days was not only that solo or very-small-group private practice was the ideal model for physician practice; it was assumed by the people I worked for that solo and small-group practice would continue to be the norm for most U.S. physicians for… well, kind of forever, basically. Large-group practice and hospital-organization physician employment were seen as anathema, while managed care was seen as an awful scourge, but one that could be “defeated,” with enough “unity in the house of medicine,” as an oft-repeated phrase would have put it.
Indeed, the senior executives at the state medical society I worked with 26 years ago focused at least 90 percent of their energy on, essentially, preventing the future from happening—at least any future that didn’t involve pure fee-for-service reimbursement to solo and very-small-group physicians in private practice, with as minimal a regulatory framework as possible, and a complete rejection of anything like multidisciplinary team-based care, care management, population health management, evidence-based medicine, and any form of electronic technology, basically. Indeed, clinical pathways were ridiculed publicly as “cookbook medicine,” and statements such as “Managed care will never prevail over the house of medicine,” in various formulations, were commonplace.
Not surprisingly, the world that the executives of that state medical society worked so ferociously to maintain has essentially disappeared since then. Today, the percentage of physicians in solo and small-group private practice is shrinking at such a rapid pace that such practice barely exists anymore in the largest cities except among certain types of specialists; while doctors are flocking to hospitals, large medical groups, and integrated health systems in huge numbers, to enter into straight-salary or salary-plus-incentive arrangements of a variety of types.
For evidence of how rapidly the practice environment is changing, one only has to check into a December poll of medical students conducted by the Watertown, Mass.-based athenahealth. The survey, of more than 1,400 medical students, found that, according to a December 15 press release, “The percentage of medical students who will seek employment with a hospital or large group practice has risen to 73 percent, while the percentage of those who aspire to private practice has dwindled to 10 percent—a 50-percent drop since 2008. Students cite a desire for work-life balance and a work environment free of administrative hassle as factors that drove their feedback,” the press release noted. “Also noted by nearly 60 percent of medical students was a dissatisfaction with the instruction they receive related to pctice management and ownership, as well as a lack of training for billing and coding.”
The press release quoted Arvind Ravinutala, a third-year medical student at the University of Southern Californai School of medicine, who said that the current system provides few incentives to purse private practice. “Training is structured around group and hospital settings, so the average student learns nothing about running a practice,” Ravinutala was quoted as saying. “Plus, hospital employers promise candidates a stress-free environment where they can focus on being a doctor without incurring further debt. For most, the choice is obvious.” Interestingly, most of the medical students surveyed were very aware of the challenges of communication between providers as being the biggest obsctacle to effective care coordination, nd were aware of the value of inteorperability in advancing coordinated care in the next 10 years.
What’s fascinating is to see how the athenahealth survey findings, and Arvind Ravinutala’s statements, dovetail with the statements made by Dr. Stack of the AMA. The reality is that the entire landscape around physician practice is now shifting rapidly away from the old “Marcus Welby” world, and towards the new world of physician employment (or de facto employment), multidisciplinary care teams, coordinated and accountable care, population health management, and value-based delivery and payment. And all those factors are absolutely remaking the landscape in which informaticists, especially clinical informaticists, are going to be working in the coming years.
That’s because practicing physicians, under greater pressure than ever before to streamline their workdays, while complying with population health, accountable care, meaningful use, and Medicare-imposed physician accountability measures, and other value-based requirements, are going to be turning to informaticists and especially informaticists, as never before, to help them with a vast array of supports: clinical decision support, dashboards for care management and benchmarking, other forms of analytics and reports for performance improvement, devices and apps for mobility and workflow optimization, and a wide variety of every other kind of IT support.
Are clinical and other informaticists ready? Because in this new world of truly interconnected (and hopefully interoperable!) healthcare, clinical IT must absolutely be all-pervasive and universally and perpetually available, not to mention high capable of making physician practice optimally efficient, and must be supremely user-friendly. And informaticists and IT leaders will be under pressure as never before to assure physicians of continuous, uninterrupted IT support and service.
Meanwhile, the hallowed halls of “organized medicine,” at least those of the AMA and many state medical societies, at least insofar as they once were all-powerful in the healthcare policy and legislative worlds, are fading quickly in the face of the new healthcare. Twenty years from now, medical students entering their residencies in, say, 2035, will read in books about how once, several decades ago, most U.S. physicians practiced in a largely fee-for-service, unaccountable, largely information technology-free environment—and will wonder how that ever could have been.
