Truth be known, I was raised by a psychiatrist.
My father, Leonard Zunin, author of two books, had an illustrious career. Some of my fondest memories of childhood were when I would accompany him on his speaking engagements around the country. He was a pacesetter in his day, and our time together inspired me to follow in his footsteps as a physician.
Today he is near the end of life from advanced Parkinson’s disease, which, as he describes, is just when one part of the nervous system wears out faster than the rest of the body.
On Friday my stepmother and I brought him home from a three-week hospital admission for pneumonia at Kaiser in Vallejo, Calif. Friday night we took a much-needed break from days and nights at Dad’s bedside.
At a sushi bar near their home in Napa, we critiqued the stay at Kaiser. Overall, the quality of care was decent. Dad’s case turned out to be quite complex, and numerous medical specialists were involved. Although his pneumonia improved, a bad case of shingles was misdiagnosed. The physicians, who were for the most part competent and compassionate, are all essentially employees of one of the Kaiser Medical Groups.
How does being an employee of a large organization affect a physician’s practice? On the plus side, rank-and-file providers are free of the administrative and financial rigors of running a medical business. Like front-line employees of any other enterprise, while the doctors are in charge of medical decision-making, they have no direct role in managing revenue and expenses, nor are they particularly concerned with patient enrollment, recruitment of staff or process design. They work, and when they go home somebody covers.
The downside is that they must function within the dictates of a large system and comply with all stated policies and procedures. The majority of Kaiser’s gross revenue is predetermined by the number of enrollees multiplied by the premiums charged. The key variable affecting the margin is how much is spent on medical care. Administrators of Kaiser’s hospitals and health plans watch those costs carefully.
Several times, when our family requested specialty consults, we were told at Kaiser that specialists sometimes review the electronic record and speak by phone with the hospitalist — a physician who treats patients of other physicians — instead of examining the patient at the bedside and sharing their recommendations in person. There is also an issue of continuity. Hospitalists are on for a set shift, and then their cases are turned over to the next physician on duty.
To be sure, Kaiser has made excellent use of electronic records. Its providers are well trained, communicate often and work together as a team. Still, there is no substitute for a face-to-face consultation with a specialist or continuity care with a dedicated internist who visits patients daily from admission to discharge.
Traditionally, Americans have been deeply bonded to their physicians and could rely on them to be singularly dedicated to each patient for the long term. Doctors were an integral part of the social fabric of the community. They were also independent, spirited and free-thinking, not beholden to administrators. They did not punch out at the end of their shift like a factory worker.
The cost pressures and mounting demands of health care reform have more and more Hawaii physicians in private practice desperate for an exit strategy. For many that means either finding a job, leaving the state or both. Today, even among medical students, few are motivated or even believe it is possible to start an independent practice.
Now is a defining moment for what it means to be a physician in modern society. There are still those who believe it does not simply mean a well-paid job with good benefits and a comfortable lifestyle. For some there is a call to arms not of muskets and powder, but of hearts and minds to preserve the independent practice of medicine.
When it comes to medical care, Americans still value their bond with the person they call "my doctor." To remain independent, providers must face unprecedented challenges and cultivate new skills. Today marks the birth of the physician-warrior. There is no middle ground.
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Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
