Health Care/Joan Retsinas

The Vanishing Physician

Dr. Kildare. Marcus Welby, MD. Norman Rockwell’s doctor examining a child in a home-office. All gone. Rest in Peace.

The demise began subtly, with words. We went from “GP” (general practitioner) to “Family Physician” to “Primary Care Physician, (PCP)” to the current “Primary Care Practitioner,” with the same “PCP” initials. That PCP umbrella ushered in assistants: physician assistants (PAs) and Nurse Practitioners (NPs), with assistant-level sub-specialties (Nurse-anesthetists, pediatric nurse practitioners …

Health care maintenance organizations hired assistants as triage: assistants could evaluate patients more efficiently, more cost-effectively. For complicated cases, the assistants would refer patients to a physician.Over time the “assistant” role has grown: they now make limited diagnoses, write prescriptions, refer to specialists. Today, many patients see a PA or a NP regularly. That person orders the tests, contacts the patient, follows up. Most of the time that works fine, at least for patients with no complex diseases. But sometimes it doesn’t, and a patient wants “a doctor,” only to find no physician nearby who accepts new patients. As for saving money, though, if this triage saved their employers money, the enrollees didn’t see lower premiums.

When PCPs segued from self-employed to corporate employees, the power of the physician continued to shrink. The employers (Humana, United, Aetna) dictated practice-guidelines for treatments, for prescriptions, for referrals. Many were based on best-practices — ones that often jibed with profits. Suddenly physician-employees had “gag” rules: could a physician tell a patient about a treatment that the plan would not cover? The employers evaluated physicians by their costly referrals: Too many would skew evaluations. Too few might hurt patients. Ditto for the limited formularies. A physician who judged one drug superior might need to go through bureaucratic hoops to justify the expense.

Recently, with abortion, politicians entered the medical arena. Some state legislators rejected medical wisdom to make abortion difficult, even for women with ectopic pregnancies. Some legislators made it illegal to procure abortion pills. Texas officials distributed a pamphlet warning women that abortion would increase their risk of breast cancer — a myth.

Understandably, today’s patients are skeptical of physicians’ advice. Is the Insurer speaking? Is the state? Can you find what you should know on the web? Patients surf for information — some reliable, some far-fetched. After all, if the megalith employers turned physicians into employees, why not turn patients into consumers who “consume” health? Just as consumers search the web, social media, and any sort of grapevine to buy cars or houses, consumers do the same to understand what ails them, and what they should do.

Big Pharma recognized the benefits of patient-consumers. The companies advertise directly to us. (Long ago they advertised directly to physicians). We see beguiling ads that remonstrate “ask your physician about …” (Including the possible side-effects, sotto voce). Most recently companies, starting with weight-loss drugs, are not just advertising, but prescribing. An ad will route a consumer to a physician-on-staff, who will go through a rudimentary protocol, and approve the request. Some people wait months to see a PCP: the drug companies have bypassed that route. In days you can find the drug at your doorstep. Indeed, analysts predict that consumer-patients will save money.

I have no crystal ball.

In this New World of Trump, the incoming health czar, Robert Kennedy Jr., bolsters patients’ skepticism of modern medicine. Should we eviscerate the FDA? Is Big Pharma making zillions by drugging us? Are vaccines causing autism? We have rules for vaccinations, in schools and workplaces. Maybe we will stop that. (A caution: we have already seen a spike in the incidence of measles.) Maybe we will soon take psychedelics, recommended by Mr. Kennedy, not by most PCPs.

Yet maybe there is hope. Maybe science will prevail. AI, built upon data, has emerged as a diagnostic tool. In time AI might destroy the credibility of legislators and the web. We might look to the computer for diagnosing and treating us. The thought is chilling — but no more chilling than the ascendance of Robert Kennedy, state legislators and the web as ersatz physicians.

Joan Retsinas is a sociologist in Providence, R.I., who writes about health care. Email joan.retsinas@gmail.com.

From The Progressive Populist, December 15, 2024

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