THE BLOG
03/01/2013 11:23 am ET | Updated May 01, 2013

Call Your Doctor... on a Rotary Phone

Remember when "going to my doctor's office" was a familiar phrase?

Have you heard it lately? Not as much, I bet.

Now we have urgent care, the community clinic, and new-and-improved emergency rooms.
The Affordable Care Act talks about supporting the primary care physician -- medicalese for your doctor -- but they are whistling past the graveyard. We'll never turn back the clock on this one, any more than a local hamburger stand is going to open in the age of McDonald's. The doctors in practice will play out their hand, and the generation they still serve will always swear by them, but folks under 40, when you ask them who their doctor is, will give you the name of a physician they have become attached to at the local clinic who is doing his community service to retire school loans and will be moving on next year.

Hospitals are soaking up young doctors for staff jobs. In the trade, these positions are called "hospitalists." The doctors pull 12-hour shifts, just like the nurses, and are on the payroll. Family doctors usually default to their services and often surgeons as well. They are Johnny on the spot to make medication adjustments or quickly move a patient going sour to ICU. In my 17 years on the job, calling a primary physician at home at night for an order, say to get lab work in the morning, has incrementally shifted to calls to the hospitalist at hand, or even a face-to-face chat as they make their rounds. This is a good development for patients because they get full and timely treatment all through the night. It also leads to fewer physicians going into primary care... and fewer services to provide when they do.

Emergency room physicians have also emerged as a new breed, now working full time even in the rural "critical access hospitals," the small community hospitals with a helipad out back. Many of these facilities contract with agencies to staff their ERs round the clock with the professional ER doctor on 24-hour shifts. These ERs have morphed into emergency "departments" offering not just emergency services, but services of a 24/7 clinic. Diagnostic imaging and lab work is extensive. I first noticed this in Yuma, Ariz. the winter of 2006 as a traveling nurse at the local hospital. Many nights I did ER duty in the "line and lab" room where I would take blood samples and then attach a normal saline IV fluid line to patients who hadn't even seen a doctor yet! The average ER bill is now about $1,300.

The primary care physician, on the other hand, tracked your blood pressure, weight, immunizations, cholesterol levels and other routine blood work. This baseline data is a tool in forming a diagnosis and long range plan of care. Not to mention that he witnessed you going through life's developmental stages, knew the drug-addicted and hypochondriacs and who wouldn't come in to the office unless they were on death's door. A visit to the doctor's office added up to quality care at reasonable rates ($95 to $265).

The trend away from primary care physicians has been so abrupt that Beltway theorists cannot be blamed for having missed it. Even in the interval between the debates of 2009 over health care and today, things have moved radically away from the traditional doctor's office and toward the one stop shop of other treatment on demand venues. This explains why the Affordable Care Act (see Title V, Subtitle F, Section 5501) wistfully supposes it can mandate a reversal of momentum back to Marcus Welby, M.D.

Private practices will not disappear, but increasingly they will become a niche to provide good old fashioned service to the generation in the habit of "going to see my doctor," while the more mobile young have already discovered the instant gratification of clinics and particularly the ERs. They have also discovered that a third party payer usually takes care of the bill.

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For more by Tom Deegan, click here.