Editorial

The End of the Family Doctor

David A. Lombardo

I am admittedly a bit touchy on the subject of doctors as my father was a physician and surgeon-what people called a general practitioner. Born in Sicily in 1907, he was one of eight children in a poor family. How they migrated to Illinois is a long story, but arrive they did in 1919. Life was tough for Italians in those days; there were signs on apartment buildings and employment offices that said, "No Dagos" and "No Wops." 

 It was also a time when the head of the family made all the decisions, period. The oldest brothers already had trades. My uncle Mike was a shoe maker, and my uncle Joe, a carpenter, but the three youngest brothers did not. So, with the great opportunities afforded by the new country in mind, my grandfather lined up the three youngest boys: Ross, Tony and my father. He then pointed to each in turn and issued an edict: Ross would be a lawyer; Tony, a dentist; and my father, a doctor. At age 12, without a word of English yet learned, my father knew he would be a doctor. Being from a poor family, he had to work his way through the remainder of elementary school, high school, college and Northwestern University Medical School. 

 It was those humble, hard-working roots that forged my father's philosophy of medicine. He became a country doctor living in the big city. His patients were primarily immigrants, from every country imaginable, often speaking no English. After my mother died, shortly before my ninth birthday, I became my father's constant companion when I wasn't in school. He took me to the hospital with him seven days a week; the doctors and nurses all but adopted me. He took me on house calls almost every evening, and I watched him help people who had no money and less English. He didn't care; he tended to their needs regardless. Those who could pay paid; those who couldn't..."They would if they could," he would say. 

 After the Army I went to college, and I found a very similar general practitioner in Champaign who would be my doctor for 10 years. Everywhere I moved after college, I had similar good fortune. Other than the practice of making house calls and hospital rounds seven days a week falling by the wayside, every physician I've had since has been cut from the same bolt of cloth: family physicians in private practice who actually care about their patients. 

Soit was with considerable trepidation that I read a recent Chicago Tribune article written by Dr. Cory Franklin. In it he points out a troubling byproduct of the Affordable Health Care Act: the downfall of the traditional family physician. In his article, "The bond between patient and physician is in jeopardy," Franklin explains why most doctors will end up abandoning their private practices and become employees of hospitals, multi-hospital affiliations or the government. Already only 35 percent of doctors currently describe themselves as independent, compared with 62 percent in 2008, and Franklin predicts that medical students about to start their training will have "virtually no chance of starting their own solo practice." 

According to Franklin, the main culprits are the government and the insurance companies. As a result of the Obamacare payment provisions, the government essentially encourages hospitals to "own" doctors because it will pay more for the exact same medical procedure or doctor's visit if it is done in a hospital clinic rather than in an independent doctor's office. "This is a strong incentive for hospitals to buy physicians and their practices. Doctors may have little alternative but to take salaried hospital positions if their practices disband," Franklin wrote. And then there are the federal regulations about electronic records and medical partnerships making it essentially fiscally impossible to start up a new private medical practice. 

To make matters worse, one way for insurance companies to control premiums is by limiting patients' choices of doctors. So the evolution is for hospitals to buy up medical practices and for insurance companies to limit the number of doctors in a given plan. This controls costs by limiting the number of doctors that can see patients thereby increasing the time required to see a doctor; demand is stretched out, but premiums remain the same. 

From the patient's perspective, a doctor in private practice determines treatment by the patient's best interest. A doctor who works for a corporation is put in the position of dividing their loyalty between the patient and the employer who gives them work-the employer whose profits increase in proportion to the tests and procedures required. To which Franklin asks, "With physicians becoming pawns in a much larger game, who will look out for patients? We may never again be completely sure."