Many things have changed over the thirty years that I have been a medical doctor. One of the most detrimental changes for our profession has been the demise of solo and small group practices. The autonomous private practice of medicine has largely been replaced by a form of feudalism. The physicians are the present day ‘vassals,’ subordinate and dependent upon numerous non-physician ‘overlords,’ to whom we are willing to surrender our control and autonomy. We are willing to surrender our control because even doctors now believe that we can not survive the hazards of practicing in the current healthcare delivery system.
The ability of physicians to practice autonomously is no longer primarily determined by their skill, knowledge and experience. Today, we are being ‘permitted’ to practice our trade but only under feudalistic terms and only by tolerating our protectors’ feigned beneficence. In medical feudalism, physicians are given a ‘plot’ of office space, a few staff, and the latest incarnation of the EHR. We are then expected to ’till the soil of patient care.’ Physicians are told where we will order diagnostic tests and to whom we will refer our patients.The hours we work, where we work, and even how we work is determined by others. We are allowed to keep a small percentage of what we collect, the rest is taken by our ‘protectors’ as the price to practice medicine. However, the price to practice medicine keeps rising as overhead costs continue to soar and as physician wellness and happiness plummet.
Possibly, the most important role of the feudal overlord was that of protection. The vassal would be protected from serious harm by an invading force or some other ominous threat. Today’s physicians are being told, that we will be protected from serious harm to our practices and to our livelihoods if we simply comply. According to those who claim to protect us, physicians can not possibly practice medicine on our own because an autonomous doctor can not survive in today’s complex regulatory morass. The complicated regulatory morass we now face has been put in place and is nurtured by the very forces who claim to protect us from it.
Physicians were once their own protectors, standing for the sanctity of the doctor-patient relationship and in defense of our beloved profession. I am encouraged by the potential resurgence of the autonomous practice of medicine occurring in the direct primary care movement. The physician takes his/her skills directly to the patient. The physician is no longer in need of protection because all of the perverse incentives and tortuous regulations no longer apply.
Many centuries ago, feudalism was proven to be a failed construct for a functional society. I believe we are seeing medical-feudalism beginning to meet a similar fate, being proven to be a failed construct for a functional health care delivery system. We must encourage physicians who are boldly attempting new and innovative ways of taking back control of their practices. Let us make sure that the Escambia County Medical Society recognizes the importance of this growing movement as physicians are becoming the instruments for forming a newer smarter health care delivery system which allows patients to gain access to their doctor at a fair price and in a direct way.
– Ellen McKnight, President