By: Shoshana Rockoff  | 

Bioethics in Practice: The End of an Era

Most children dream of a trip to an amusement park or a visit to the ice cream store, but the most exciting trip for my siblings and me growing up was an adventure to Poppy’s office. Nothing was comparable to sitting in an examining chair twice my size with my feet dangling towards the ground while Poppy performed an eye exam. The waiting room chairs became roller coasters of their own, with every pair of glasses I assumed a new identity and putting quarters in the gumball machine for hours on end was somehow extremely entertaining. 

Poppy has built up his optometry practice over the past fifty years and has developed deep connections with his staff and patients. He usually has a good sense as to what people are going through beyond the scope of their physical health.

Until recently, most patients in the U.S. consulted physicians in private medical practices; with the turn of the century, however, this model is in rapid decline. According to a study conducted by the Medical Group Management Association in 2005, more than two-thirds of medical practices were physician owned. Just three years later that number dropped by 50%. Analysts say that with each passing year the number decreases even more. Why is this happening? What is causing the medical world to change at such a fast rate?

When analyzing these questions it’s important to note that physician-owned practices are a hot commodity on the market. According to FierceHealthcare, hospitals, private equity firms, venture-capital groups and even insurance companies are buying out private practices across the country and turning them into big medical businesses. Many of these buyers are not even from the health care world. Private equity firms in general initially invest in reputable physician-owned practices to build a larger network. From there, they gradually increase their ownership of a practice to 60-80% of ownership, and within three to seven years they sell the practice to invest in another one. 

While many of the staff in offices country-wide may look the same, the impact that these business transactions are having on patients and doctors is happening in a subtler way. According to MarketWatch, patient advocates are worried, and medical professionals are arguing that businessmen should not be dictating how they do their jobs. Marni Jameson Carey, Executive Director of the Association of Independent Doctors, said, “These folks don’t have medical licenses to lose; they didn’t take any Hippocratic oaths … They are in it for the profit. And Americans are going to pay for it, either with their health or their finances or both.”

With all of these large medical businesses taking the stage, it may no longer be feasible for private practices to survive, turning this into a process that feeds on itself. A survey conducted by the Doctor Patient Medical Association found that 95% of physicians see corporate-owned medicine as the future. According to an article in The New York Times, many doctors leave medical school with overwhelming debts and the desire for regular work hours. This makes a job at a larger company more appealing, since it doesn’t require start up funds, like building a private practice does, and there are a lot more staff on board in big companies, enabling doctors to have nine to five jobs. These decisions being made by new doctors directly impact older doctors who fear that they will not be able to recruit new junior partners. They therefore sell their practices to bigger businesses so that they can also get salaried jobs.

While this can be extremely difficult for physicians who own practices, this competition may bring about certain positive changes for patients. With the rise of technology, medical equipment is becoming increasingly more advanced and therefore more expensive. Physicians who own their own practices can no longer afford to compete with large companies who have the funds to constantly update and buy new and improved equipment and more organized, computerized record systems. This enables patients to benefit and be treated with the latest technologies owned by the big business medical practices that can afford them. 

If this is the case, then why, according to a 2014 study conducted by the Commonwealth Fund, do physician-owned practices have “significantly lower” numbers of patients going to the hospital with preventable medical problems than corporate health care systems do? Perhaps the answer lies in the fact that doctors who work in privately-owned practices have more autonomy over their decisions and don’t have to work with huge bureaucracies to take action. An alternative theory is that patients are more compelled to visit their private practice physicians on a regular basis because they provide more personal care.  

There is no doubt, however, that a huge part of the answer lies in the doctor-patient relationship that is cultivated by the private practice system. According to an article in The New York Times, “a patient who chooses a doctor in private practice is more likely to see that same doctor during each office visit than a patient who chooses a doctor employed by a health system.” The relationship with a doctor in a private practice is a real and personal one that can span years and even decades. The patient no longer becomes a name in the technologically advanced computer system or a treatment plan written down in the new efficient record system. The patient is a person who needs medical care, with an emphasis not just on the word “medical” but on the word “care,” too.

A price tag cannot be placed on this relationship. This relationship fulfills an aspect of the job that the best medical technology can’t by providing a personal level of medical care. Being a doctor isn’t merely about knowledge — it’s about emotional intelligence and connection. A study conducted by the American Journal of Public Health shows that a positive physician-patient relationship results in greater overall satisfaction for both the doctor and the patient. This positive relationship is certainly more common among private practices. 

With the rise of business medicine, there are, of course, some groundbreaking benefits for the medical world — change is good and healthy. As a society we certainly don’t want our systems to remain stagnant, stifling growth and development. However, within the changing system, it is our responsibility to maintain our values as a society. For doctors, this means continuing to serve patients through relationships and consistency even within the larger system. Just because the method of overall health care is changing does not mean that the way doctors serve and treat patients needs to change too.

As I’ve gotten older, the examination chair in Poppy’s office has become a little bit smaller and the gumball machine and waiting room chairs slightly less exciting. I’ve learned to view the adventure not just through the lense of fun but also of appreciation. To watch my grandfather work in his private practice, the office where he has devoted his time, energy and life to healing people, leaves me speechless. To see patients in their 50s and 60s come in and give my grandfather a hug before he examines their eyes because they’ve known him for decades is remarkable. As the next generation of physicians gets to work within the new health care system, it is important for physicians to adhere to the legacy of doctor-patient relationships that the previous generation has left for us to follow.

Photo Caption: Beds in a hospital
Photo Credit: Pixabay