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Physician as Businessman: 19th Century to the 21st Century

By Donald C. Faust, MD

The value of our service as physicians is difficult to quantify. Unlike other businesses, we are under a moral obligation to provide our services. We are expected to be available 24 hours per day and yet provide perfect care. Continuing medical education is a must. The government bodies are mandating more aspects of our education. Employers are concerned about medical care given and our costs. Third party groups (the government, insurance companies and their administrators) restrict use of drugs and procedures to control costs.

Lack of medical care was present in the nineteenth century, since the beginning of the age “of modern medicine.” The dynamics have changed but the effects are no different one hundred years later. So, as our profession is assaulted by the media, the government, and the public, it’s important for us to keep our perspective.

Healthcare reform can take diametrically opposite courses. Media attention constantly directs us to more government intervention and a command-control paradigm. What the government dictates will require recognition; it’s important to distinguish the substance of healthcare and its accidents. Those aspects which have remained true for the last 100 years will probably persist, whereas, the late coming accidental changes will fade or require considerable effort to persist.

The health care delivery of 100 years ago shows amazing similarities in the concerns and difficulties of today. The technology was progressing rapidly, causing physicians to wonder how to stay abreast. The high cost and the questions of reimbursement and certification were also at the forefront of concerns. Books and records are available to allow us to understand the business of medicine then as well as the scientific body of knowledge. Contrary to today, there was a true market-oriented approach. The patient was autonomous; personal decisions affected the outcome; and he was forced to be more responsible. Today, by separating the patient from the cost, health care costs are skyrocketing. Healthcare has come to include baths, bed changing, feeding. activities of living, and transportation — once the privilege of the family. Many “alternative” forms of non-medical treatment are being subsidized in the name of healthcare. Where cost is no object, procedures develop which push the cost benefit ratio near infinity.

Many of these changes are brought on by third party payors, i.e., insurance companies, business, or government. Now these groups, in an effort to reign in costs, shift the risk onto physicians and simultaneously continue to spare the patient and themselves responsibility. The physicians thus become both the provider and the insurer, but without the means or resources to assess risk and properly price it. The subtle guarantees, the supposed rights of the patients and the eleemosynary aspects, put the physician in an untenable position and result in dissatisfaction on part of the patient when the physician is unable to perform. The book Physician as Businessman, written in 1894 by Dr. J.J. Taylor, described these issues we are still trying to solve 100+ years since. The technology certainly has improved but the socio-economic issues are still with us: Medicine is too expensive; only the wealthy can afford it and get better care; and the physician is caught in the middle trying to provide care to everyone. Costs have been amazingly static over this period of time. Medicare, Medicaid, and the Affordable Care Act and all prior reforms that ignore these realities have been found wanting. We need to recognize this and institute changes that are beneficial and not harmful to health care as we have enjoyed these many years.

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