The ethos of medicine is born from rugged individualism. There was a man, his black bag, and his experience pitted against a cornucopia of ills and ailments affecting mankind. Essential to this approach is the perspective of the physician focused on the patient as a whole. As medicine was modernized in the 19th and 20th centuries, the knowledge base exploded. In addition, the physician workforce became more diverse and representative of the population. Thus, one person could no longer be the keeper of all knowledge, perspectives, and skills encompassed within the practice of medicine. Sub-specialists were born. This allowed more in-depth exploration of each facet of taking care of the sick, but an unintended consequence was the parsing or disaggregation of the patient into signs, symptoms, and diagnoses. Over time, the focus for each of the blind wise men feeling on the proverbial elephant degenerated into each describing the situation as a trunk, an ear, a belly or a tail. Thus, the reality that they were all describing the same animal was lost. Similarly, in medicine, as the pendulum swung further toward the extreme of subspecialty run care, the focus on the patient as a whole was sacrificed for an in-depth look solely at the list of things being treated.
The disaggregation of the patient led to some key realities affecting physician training, reimbursement for services rendered and the culture of medicine. In post-graduate medical education, physicians and surgeons no longer focused on common core knowledge. Every specialty focused on the ailments within their wheelhouse. The identity of disease consequences, beyond those strictly related to direct pathophysiology, took a back seat. This led to technical experts that sometimes lacked the compassion and comprehensive reasoning to see the impact of disease beyond the textbook and provide solutions that not only follow the algorithm but also were viable within the life construct of the one being treated. Reimbursement for services also changed. It moved from focusing on time and care to focusing on providing fees for “action” like a procedure or consultative service. Thus, being a generalist no longer garnered the billing and collections like sub-specialists. Narrow expertise was valued by the system in the form of higher rates of reimbursement and by the public in the form of a higher social cache and prestige. Finally, the culture of medicine changed through the disaggregation of the patient by subdividing the House of Medicine. The Orthopedic Surgeons could claim utter and complete ignorance on any matter affecting or concerning a non-musculoskeletal pathology – leaving an abused woman with a broken arm healed but not safe. At the same time, the Internist could move past the depression and social isolation caused by chronic and profound illness – leaving a diabetic patient labeled as non-compliant when they actually were just overwhelmed and sad at the realities of their life. This shift in how patients were seen had real consequences and not all of them positive.
To move the conversation from the esoteric and sentimental to that which is more concrete and practical, one must acknowledge how much this change has increased cost in the system. The increases come in part from an expanded number of providers per patient, a lack of efficiency in the system and competing priorities of the sub-specialists. Historically, a newly diagnosed middle-aged, type 2 diabetic would be treated and seen by the town generalist. That physician would talk about the disease impact, manage the patient response to being diagnosed with a chronic illness, and prescribe medication and dietary interventions to prevent morbidity and mortality. This changed in a subspecialist driven approach. The patient would be parsed and treated by the primary physician for general matters, an endocrinologist for diabetes, a psychiatrist for the adjustment issues related to the diagnosis, and countless clinical specialists to train the patient on dietary changes, medication administration, and compliance. Thus, the professional service charges for care go from an office visit and extended time for counseling by one physician to three sets of physician professional fees, and numerous covered encounters with other clinical professionals. In addition to the absolute cost of having multiple doctors involved, there are indirect costs from decreased efficiency having multiple treating providers. Laboratory work to monitor disease management in a diabetic patient is a common area of service duplication. Labs could be ordered by the primary doctor and repeated by the endocrinologist. And, done a third time if the psychiatrist seeks to start a medication with a metabolic side effect. The system paid for three sets of labs when one would have sufficed. Lastly, there is a cost in one specialist prescribing an intervention that improves the patient from their perspective while destabilizing them from the perspective of another specialist. The endocrinologist is focused on keeping the blood sugar under the best possible control in diabetics. If glipizide is a part of the treatment prescription, it may cause a rash or hives. These skin changes can then cause the patient distress about their appearance. This distress then leads to social isolation and symptoms of depression. Those changes cause the psychiatrist involved to increase interventions and medications. Having multiple unconnected providers can drive costs upward as the action of one provider can cause an increase in services by another. The cost increase affects patients, individual physicians, non-physician health care providers, hospitals, and healthcare systems.
In spite of the tremendous clinical triumphs of the era of modern medicine, there has been a negative effect of patient disaggregation. In turn, some of the earliest and easiest reform efforts have focused on restoring the sanctity of the whole patient unit. In medical education, there has been a return to core competencies required of all medical and surgical specialties in addition to the sub-specialty knowledge and skills required. This helps the former rugged individualists realize their place on the team of providers focused on helping patients live healthy and full lives. Reimbursement now incorporates outcome and quality measures that take into account more than just how complex and procedure-oriented the intervention. Reimbursement is also restoring some parity between rates for generalists and specialists as evidenced by the increase in reimbursement rates for initial and follow up evaluation and elimination of consultation codes. These reimbursement changes can make a difference in how medical students select a career path by allowing generalists and subspecialists to be normalized in revenue generation compared to one another. And, finally, the culture of medicine is returning to a point that prioritizes patient-centered care to the same degree as evidence-based medicine. All realize that humpty dumpty has fallen, or was pushed, from the wall and shattered into pieces. Each specialist was happy to select and care for their piece without care for how those pieces were going to reunite the whole. The next iteration of medicine will combine the advances possible through the successes of modern medicine with the good, old-fashioned efficacy of a complete and comprehensive patient-doctor relationship.