Philosophy of Practice

In the mid 1980s was the period, almost 20 years ago, I was attending medical school. During this time we are asked to buy and read a variety of medical text books. Included in this list of textbooks was, of course, a book on internal medicine. Specifically Cecil's Textbook of Medicine, at that time written in 1982. In this is an introductory article with a title of Medicine As A Very Old Profession written by Lewis Thomas, M.D.

In summarizes in this article, that medicine has been available to patients for thousands of years. During this time period, we now question whether or not the doctor was more of a hindrance to patients healthcare than a benefit. According to one Welsh proverb "If you have a friend who is a physician send him to the house of your enemy."

By the turn of the century American medicine had hit, however, a new high stride. It actually realized that the vast majority of what it was previously doing was not helpful to the patient. Many of the drugs we were using before this time were found not be affective and the majority of surgical treatments were more dangerous than the conditions they cured. During this time period you might wonder why a patient would even hire a physician to come to their bedside or what a physician could honestly do for a patient.

The things physicians did at that time was often to reassure the patient that they didn't have some dreaded illness. That they simply had a case of bronchitis and not tuberculosis or consumption as it was called then. Later on sulfa antibiotics, penicillin and a whole variety of other drug treatments were made available. The difference over the previous medicine of the 19th Century vs the 20th Century was that these newer drugs actually had to prove thru scientific research that they actually worked and did what they claimed to do.

During this time period, medical schools became more regulated and even started requiring that a medical student at least attend medical school for a full four years, that they graduate college prior to studying medicine, and that they should do at least a one-year internship before being licensed in any particular state. Although these standards seem to be ridiculously minimum at this time, during the beginning of the 20th Century this was far from the case. Many medical schools were often less than a 6 month period of study and often didn't require such basic studies as anatomy, biochemistry, microbiology, etc. It is interesting to note at the beginning now of the 21st Century that we have allowed uneducated "physicians" back into the practice of medicine. Now there are various "drugs" available without a prescription, that will claim to cure a variety of things. These are called herbal medicines or supplements. Often times the people "prescribing these medications" have no more official medical training than the average person in our society. However, the medical profession is not without justifiable criticism. At this point we have begun to rely more on the science and less on the art of listening to our patients and the careful science/art of the physical exam. Patient's bodies are poked and prodded in various methods. Often times we forget the most important thing is the actual communication between the patient and the doctor. It has often caused erroneous situations which occasionally creep up into the practice of medicine. The modern physician often times resembles a modern business. He is no longer in solo practice, as I still am, but works for a large corporation. He is more concerned about making sure the money that the corporation takes in is distributed evenly amongst himself and his colleagues and how often he or she is on the call schedule and that this too is evenly divided. Your doctor is not really there, such as the one described in the article by Louis Thomas, M.D. Medicine as Very Old Profession to handle any medical crisis that occurs but is only available a set number of days and after-hour call hours. It has been remarked that even the old time doctor would take time off and vacations. However, he was on duty more times than not and available to his patients much more often than our physicians are today. Thus, the emergency rooms are no longer there for just emergencies such as auto accidents, falls from tall places, or midsternal chest pain that develops in the middle of the night, (all of which are appropriate reasons to go to an emergency room) but the emergency rooms have turned out to now be the after-hour clinic. So "bamboozled" is the modern patient by the modern physician that the entire idea of calling on a Sunday morning or afternoon to provide after hour care seems to be something from a forgotten era, even more forgotten than the beloved house call. Some of our esteemed colleagues in the community have gotten medicine down to a 9 to 5 business. They show up promptly early in the morning, probably earlier than I do, and will stay there promptly until noon, take promptly an hour off for lunch and then leave at 5 o'clock. The answering service does not tell you how to get a hold of the doctor but merely to go into the emergency room after hours or to wait and suffer until the morning when the doctor's office is open. Some doctors have an additional ploy which is also concerning. They will tell you they are on call. When you call you will be directed to an "Ask A Nurse" service hoping that the vast majority of questions can be handled by "Ask A Nurse". The "Ask A Nurse" does not turn around on the more complicated cases and ask your doctor. They have a set computer protocol that tells them to refer you back into the emergency room. In some practices, even when presenting to the emergency room and additional care is required in the hospital, the emergency room physician has a hospitalist take care of you or a variety of specialists, whatever seems more appropriate. In short, the doctor is now allowed to slumber in peace and allowed to have his weekend off. He may still technically be on call but he never really responds to the hospital itself or to his clinic other than the prescribed hours of the 9 to 5 period. Thus he can "honestly" look at the patient and tell them he is on call some of the time (a rotating call schedule) but yet never really coming into the hospital to see a patient. Not to say the majority of modern physicians are doing this, but it is a sizable minority that do so and it's greatly concerning since it is increase in number. It is interesting to note that when I was in medical school and was working with physicians they often explained to me that a contract existed between the patient and the doctor. Once you saw a patient in the office and they agreed to be your patient that you were responsible for providing services 24 hours a day, 7 days a week. These physicians would, of course, take vacations, holidays, and time off but they were on duty for their own patients much more often and were much more available than physicians today. When they were on vacation their patients themselves knew that these doctor's needed their rest and didn't mind seeing someone else. Often times the other physician was extremely dedicated as well and willing to see them after hours. It seems that the modern physician has, in essence, forgotten that he has a contract and responsibility to their patients after hours. Some of this may be that the modern physician still practicing this way feel violated in recent years. He or she is no longer able to charge a little bit extra to provide this additional after hours service. No one really came in at 2:00 a.m. for the fees that were generated at that time. They came in because it was expected of them and they charged a little bit more for the routine office call to provide this additional service. These modern insurance companies have decided that they will decide how much the doctor will be able to charge regardless of additional after hours services available. Physicians have often times noticed their wages to go down or the amount of hours actually in the office increase to maintain the same earning as in the past. They often decided it was just easier to concentrate on the office, not to go into the hospital, and not to see patients after hours since neither of these activities generate significant additional income. In addition, the fact that the modern insurance company now tells the patient which doctor they can see, often times removes the inducement for the doctor to see the patient after hours in the hope of developing a goodwill and a long-standing relationship between them and the patient. Although the modern patient may appreciate his or her doctor being more available, they may very well switch doctors next year because their insurance company insists they do so because their employer has switched insurance companies.

In short, my philosophy could be put as simple as this. I define myself more of an old-fashioned general practice than a modern physician. Although we try to apply the modern technology and have much of it available in our office as well, (if not more than most modern physicians) when we leave at 5:00 our responsibility to you is not finished. It seems that although we have certainly endorsed the modern view of medicine, our philosophy could be simply put as this. Although we basically applaud the modern technologies in medicine, we feel that the modern physician in a group practice has forgotten that there is actually something called a patient/doctor relationship. That there is more responsibility than just providing competent care 9 to 5. That the hardest part of medicine is, believe it or not, not dealing with the insurance companies, practicing medicine during regular business hours, doing surgery, but actually doing the tough job of waking up at 2 o'clock in the morning and providing additional medical care when needed. It is easy to be a doctor 9 to 5, but it's hard to be a doctor the rest of the day and that there is a rewarding feeling in being there for one's patients. To be able to take care of patients completely to know that you provide additional care that would not be commonly done. Unfortunately, often times our modern patients do not realize that I do respond to their medical needs after hours. I would not say it is 100% and I have tried in the past to get various physicians to come in with this attitude, however, finding a physician that will do more than lip service to this philosophy is often difficult. Sometimes I myself find that after being up 2 or 3 times in a row I do need to rest. Thus I sometimes have to be off call to our colleagues. However, I do feel that care can best be presented by one physician responding the vast majority of time to your medical needs. Not necessarily sending you off to a variety of specialists when it is not necessary to do so and that most of the care the patients require can be taken care of in a solo practitioners office without the need of involving a large corporation whose care, inevitably, seems to be compromised by the bottom line. Medicine, in short, is a practice that is best not run solely as a business.

Our goal is to be a long-term health care provider in your community, not a short-term care provider moving on to greener pastures when available. It is also not to have you move on to another doctor just due strictly to the requirements of your insurance company. This is not to say that I succeed all the time at this. I have to practice in a modern era with both its blessings and curses. This practice is an island for patients who want to have a modern physician with modern technology, knowledge, and equipment available but would also still like to have a bit of the old time doctor taking care of them, in them, somebody who is actually concerned about the patient, and works for the patients instead of a corporation.

Sincerely yours,

Brian Van Hoozen, D.O.
 

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