by Richard A. Swenson, MD
Today's Christian Doctor - Summer 2007

Today's "new normal" is an unglued mindscape for some doctors, an exciting opportunity for others. How Christian doctors relate to limitless change will be governed primarily by the quality of their relationship with the One who never changes and their trust that they really are His work in progress.

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Someone took the lid off the blender of my life," one splayed-out physician told me, "and that stuff on the wall is not a mirage." Couple this with Toffler's "a bomb has gone off in our communal psycho-sphere," and you have the unglued mindscape of today's besieged doctors. The enormous change dynamic of modernity extends into nearly every quadrant of medicine, dentistry, and healthcare, and it shows no sign of abating. What we had is gone; what will be is not yet here. Doctors are reeling, attempting to find their balance in stormy seas. The arrival of our future is long overdue. Meanwhile we wait, and pray, and fret. And we adapt.

In the not-too-distant past, we went through our famously rigorous training and attempted to become a clone. The Great Machine brought forth new doctors each after its kind, and it was good. Students went willingly into the funnel, descending into the vast social Coriolis effect, swirling downward into an ever-narrowing vortex, and in the end all coming out in the same place-yet another good doctor in the long tradition of good doctors, entering an esteemed profession, pouring our lives out on the altar of caring and healing. In turn, we were highly reimbursed in every conceivable way by a grateful populace.

Then came the blender. It had to happen, of course. Any honest examination of the cost curve yielded an early diagnosis of unstable angina for the entire system. As each doctor attempted compensation, the clone approach to practice style quickly dissolved into a wild pluralism. Practices today are not only dissimilar-they don't even seem to belong to the same venerable family tree. Furthermore, stigma to these previously anomalous behaviors is blunting. Individualism and variation are now increasingly accepted as normal reactions to healthcare volatility. It's every man and every woman for himself or herself. The new normal.

What Is, and Was, and Will Be

Let's explore together some specifics of what this looks like, as well as the various shapes it might assume in the future:

Full speed ahead - Many doctors continue to do what they've always done, in much the same way, and report high satisfaction. God bless them, each one. They have the enormous privilege of sustainability with joy. Iowa Congressman Jim Leach asked a small town 74-year-old physician when he was going to retire. "I couldn't possibly retire!" exclaimed the doc, ". . . at least not until my father does."

Early retirement - Others have folded up shop early. At one large medical institution, by survey, 40 percent of the internists have contemplated retiring. After accepting the plaque and gold watch, some are sad-they miss it more than they thought. They keep up their licenses, volunteer in free clinics, and travel to missions work. Others are glad-they wish they'd quit earlier. They love golfing every day, or managing their investments from the beach house, or visiting with grandkids. One 48-year-old physician told me he retired to manage apartment complexes.

Off the grid - Some doctors have dropped off the grid and stopped taking insurance, Medicare, or Medicaid. It's cash only. The cost of care is less, administrative expenses are much lower, billing is minimal. Patients are better educated about their costs of service, and each person is treated the same-no HMO discounts or insurance strong-arming. Some doctors even practice out of their homes, keeping matters as straightforward and elementary as possible. The very bold have "gone bare," forsaking malpractice insurance.

Hospital only - When the muon was first discovered in 1937, Nobel Prize-winning particle physicist Isidor Isaac Rabi greeted its arrival with a surprised, "Who ordered that?" In much the same way, hospital-only practices-hospitalists, intensivists, laborists, ER docs-arrived on the scene almost by immaculate conception. But the timing was right, and they have blossomed and will continue as an important practice option. The development, while perhaps resulting in decreased continuity of care and diminished revenues for nonhospital physicians, has allowed for greater life-balance all around.

Mobility - "Job churn" is seen across our nation as never before-in 2005, 40 percent of Americans changed their employment, fifty-five million in all-and this increasingly includes physicians and dentists. While mobility has been with us for decades, never have we witnessed these dimensions. Uprooting and heading toward greener grass is always a stressor, but one many risk willingly. Mid-career changes don't even register a blip on our Richter scale. Some doctors sign on with the competition across town, or go into hospital administration, or do solely pharmaceutical clinical trials, or practice at on-site workplace clinics (more than 25 percent of the nation's 1,000 largest employers will offer in-house health services by 2008), or join franchised retail clinics in Cub Foods (or Eckerd Drugs, Target, Wal-Mart, SuperValu, Piggly Wiggly, Hy-Vee, ShopRite, Food City, CVS, Osco, Walgreens, or Kroger). Some join a locum tenens organization-one acquaintance recently went to Australia for a year to do locums work. Many Christian doctors have explored the option of missions work for the second half of their careers.

Making ends meet - Moonlighting has a long and proud history among debt-strapped residents-a chance to pick up quick cash while gaining valuable clinical experience. But increasingly, many established doctors are taking on "side businesses" to augment their income. A recent Time article (2-27-07) detailed the specifics: one NY cardiologist who earns more after-hours by removing ladies body-hair with laser; an otherwise brilliant pathologist who sells "magnetized" water and testosterone ointment in antiaging ads; an ob-gyn and three anesthesiologists who became financial analysts.

Specialities - Some things in life are simple, some are complex. In medicine, complexity has won, as evidenced by the AMA's listing of 110 National Medical Specialty Society websites. This trend is called differentiation, and it is a relentless subset of progress, virtually unstoppable. As complexity escalates, so will specialization, subspecialization, and super-subspecialization, offering ever more varied professional opportunities to peel down the onion. Omphalology, here we come.

Variations on a theme - When the chronic intensity of daily practice exceeds the willingness of the practitioner, change happens. Some negotiate part-time practice, or find another doctor to job-share (many husband-wife doctor couples have chosen this option). Concierge medicine (or retainer medicine, boutique medicine, executive health programs, platinum practices) has been controversial though unbowed by condemnation. Flat fee clinics-where, for example, $500 per year buys unlimited outpatient visits-are yet another recent permutation.

Where Will It Lead and How Will It End?

What are we to make of such pluralism? Is it a sign of vigor or of desperation? Are doctors pursuing individualism to find their preferred pace and practice, or are they flailing after an elusive ever-receding answer?

There's little doubt that what we are witnessing is historically unprecedented. No one knows what shape healthcare will find itself in when the mountain quits shaking-only that it will be different. At $2.2 trillion a year (and growing $150 billion annually), our healthcare spending exceeds the national GDP of all but five countries. Few people grasp the scale and complexity confronting us.

The paradigm is changing because it must change-there's no other option. The question is who will win the tug-of-war: single-payer, private-sector, or hybrid/mosaic. The shape of our future depends much on that outcome, and doctors are passionately divided.

In a single payer system-perhaps resembling Kennedy's "Medicare for all"-the government will not own the clinics, hospitals, doctors, and pharmacists, but it will be the payer. Money will come in from both individuals and corporations to be distributed according to formula.

On the positive side, such a system will have simplicity (as opposed to 1,500 payers today), uniform paperwork, and universal coverage. Practitioners will begin to settle into a new equilibrium, even if not their political preference. On the negative side, doctors will dislike the formula (since when did we ever like Medicare's distribution?) and will chafe at the annual adjustments, arbitrary cutoffs, bureaucracy, mandates, disincentives, payment delays, and new forms of taxation.

In a private sector system, a panoply of diverse practice styles will continue and possibly expand. Corporations from GM to 3M will perhaps switch from defined benefit to defined contribution, meaning employees Johnny and Susie will now have the $15,000 in their pocket with first-dollar decision making. This will greatly affect how they spend the dedicated healthcare monies, where they will buy insurance (millions would choose faith-based programs), and which type of practitioners they visit.

On the positive side, we will see responsiveness, cost competition, pricing transparency, individual responsibility, accountability, and autonomy. On the negative side, there will be problems with complexity, too many payers, risk pooling, uneven coverage, high costs for sick and elderly, inequities, and excessive profits.

Only God Knows

To call this existential whiplash would be a diagnostic bulls-eye. It's reassuring to know that God is not confused. He never makes mistakes, never loses battles, and is not taking Prozac.

He would reassure us with advice like this: Do not worry about tomorrow. Don't be afraid. Don't be anxious about anything. Guard your heart against hardness. Give your expectations to Me. Run toward Love, not money. Always walk uprightly before a watching world.

No matter what change the future brings, certain fundamentals remain-doctors will always be needed; always practice a glorious profession; always be highly reimbursed in both finances and prestige; always be given authority and granted a platform from which to influence patients and culture; and, always have abundant opportunity for service.

Perhaps a two-fold summary might look like this:

• Care for each patient as completely and compassionately as Jesus would;
• Let God be God.

We cannot control the future, but we can wrestle our motives in the direction of obedience to Christ. Perhaps, in the end, we'll discover that God's project in all this change was . . . us.