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The Doctor is Out

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"My father and grandfather were both physicians in rural Wisconsin," he says later. "I went to engineering school a couple years first, but with a background like that, it's hard to avoid medicine. And it's a great line to be in; it's a great business." Yet for his dad and grandfather, it wasn't a business. "I'm sure my grandfather would have disliked managed care," Rathert admits freely. "He was his own person. And my dad practiced until he was 90; he'd see anybody that came in the door. On the other hand, they had (bill) collections of 50-60 percent. The benchmark for a good practice is above 90 percent."

Isn't something being lost in the switch to a punched-clock, cookbook-regulated system? "Medicine's much too complex now to be done that way," replies Rathert. "What is available is astounding, in terms of the ability to prevent, diagnose and treat disease. There is still a lot of caring, but there are also fabulous technologies, and it's necessary to manage all that more tightly. You can't continue losing money in a medical practice -- you don't stay in business."

Younger doctors know that better than their elders, he adds. "I identified myself by my job; I'd say, 'I am a pediatrician.' They are lifestyle-oriented. They want to have regular hours, time off, vacations with their families. My dad was on call 24 hours a day, seven days a week, and the phone would ring all hours of the day and night. That's not what people want."

Unfortunately, it's still what their patients want.

The Call of the Tame
The field of medical executives is rising fast: The American College of Physician Executives now has 13,600 members, more than double the 5,711 they had in 1990. "The group of wannabes is huge," sighs search consultant Lyons. "When health care was in its time of largesse, peaking 7 to 10 years ago, being CEO of a health-care system was like being Ike when he was president: You just had to be smart enough to not do anything stupid. Now, on the health-care-executive side, the adults are being separated from the children as we speak."

The move into management isn't all peaches and perks, though. "You lose collegiality with other physicians," says cardiologist Palank. "They see you as a suit, not a white coat. We have lived medicine all our lives as clinicians. There is an emptiness, a void." There's also a lot of maddeningly protracted committee work. "Seeing patients is terrific," sighs Palank. "Diagnosing and correcting a problem. Projects I'm in now may take a year to complete."

If Palank were suffering with chronic pain or disability, he might not bother adjusting. Now that they're mere mortals, physicians have begun claiming disability so freely their insurers have lost money on the payouts. "Physicians used to be like Marcus Welby, delivering a baby that morning and dying that afternoon and enjoying the profession right up to that minute," remarks James D. Johnson, spokesman for Provident Life and Accident Insurance Co., one of the disability biggies. "But with managed care and large group practices, physicians are feeling and acting much more like employees than professionals. Starting in the '80s, we saw an increase in their disability claims. They went from being the best risk to being average. Plus, they had policies to fall back on that became more windfall than safety net."

What he means, according to disability consultant Arthur L. Fries, is that physicians' policies used to be worded broadly and priced generously. Insurers considered them "prime prospects, because they had big needs, big lifestyles and big earnings, and they had an attitude of, 'You work until you drop.'"

Fries used to sell disability insurance himself; now he consults with physicians across the nation who are trying to go on disability. He cites recurring factors: "Increased paperwork, disrespect, unhappiness and managed care telling them when to go to the bathroom." Not to mention salary reductions that provided "quite an encouragement to lean into a disability claim."

The New Generation
Physicians have long been ill-distributed, clambering over each other in metropolitan areas and leaving tiny towns unserved. Now, rumors are flying that we'll soon have a surplus of physicians. So maybe this slight hemorrhage of practicing physicians is just Darwinian necessity?

Medical-school applications are down nationwide, so markedly that the Association of American Medical Colleges is polling its participants to learn why. Applications to St. Louis University School of Medicine dropped from 7,215 in 1997 to 6,206 in 1998. Applications to Washington University School of Medicine dropped from 5,823 to 5,143, and the dean expects them to decrease again in 1999.

Applicants still wildly outnumber the small pool that's chosen, though, and deans insist that the caliber of those students hasn't dropped. Outsiders wonder whether they know what they're getting into. Med students gain their clinical experience at teaching hospitals that see the most serious and complex cases; in that world, managed care has far less say. As for classroom experience, academic medicine's pretty sheltered. Some faculty members do maintain clinical practices, and do moan about the higher patient loads and paperwork rigamarole of managed care, but their malpractice insurance and salaries are paid by the school and their managed-care contracts are negotiated collectively.

Still, even med students absorb a bit of the real world by osmosis. And they do read. "Physicians Enter the Job Market," a recent article in the Medical Student Journal of the American Medical Association, opens with the warning, "The model of the past, when medicine was a reliable field in which hard work was rewarded by a stable and comfortable lifestyle, no longer holds true."

Asked whether students are prepared for the new paradigm, Dr. Alberto Galofre, associate dean for curriculum at St. Louis University School of Medicine, scrawls three rectangles on a yellow pad. He labels the first "medical school," the next "graduate medical education" (residency) and the third "real life." "I deal with here," he explains, pointing to the first rectangle. "When they graduate med school, they go into hospitals for three more years of education. Then real life. And that is where you have the problems.

"We've had these discussions: How much should we do for real life?" he continues. "They should know what managed care is. But shouldn't we prepare them in such a way that it doesn't matter what system is in place tomorrow?"

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