As I age, my wife and I always seem to have some kind of medical appointment somewhere on our calendar. That’s not unusual among peers of similar ages. Primary care offices, specialists, dentists, vision care, therapies – there’s always a looming appointment with a physician, dentist, nurse practitioner, physical therapist, etc. We’re fortunate to live in an era when conditions that were previously debilitating or fatal can be treated. Those improvements meant I already lived longer than most of my predecessors. My wife and I are also lucky to have medical insurance during this time when the society has decided that putting insurance corporations into a position of authority in health care is a good idea – even though the majority of people I talk to who experience it believe that it’s not.
There’s a building at the corner of Minor Ave. and James St. in Seattle. In 1959, a group of physicians affiliated to create the Minor & James medical practice in that building. Over time Minor & James grew into a physician-led, multi-specialty medical practice. Beginning in the late 1990s, I went to that building for specialty treatment. I found that the physicians and staff there took the time to know me. So when my one-person primary care physician’s office closed years ago, looking for a replacement among the Minor and James physicians made sense. There were many primary care physicians there, and the common ethos of caring seemed to match my desire to have a doctor who took time to know me as more than a series of symptoms. I looked through the clinic’s list and found a physician whose experience and background suggested he’d fit my needs.
My hunch proved to be accurate as I got to know him, and he got to know me. I didn’t see him very often; but when I did, he always made me comfortable with his knowledge of my life and history. I know that comes from him taking good notes and referencing those notes before walking into the exam room to see me. But the message he sent was clear: He wanted to meet my needs by paying attention to who I am. During each visit, we got to know each other a little more as he inquired what was new in my life and he would reveal humanizing bits of his own. He listened attentively, and if he wasn’t available, one of the ARNP or RN staff who met with me left the same impression. The “care team” as they referenced themselves, were as personable as they were skilled. While I was more used to (and preferred) a small practice, I realized that the solo practitioner’s office was becoming a relic of the past. The Minor & James group maintained that same feeling for me in a much larger organization that, by 2009, had grown to multiple locations and hundreds of employees.
The year 2009 was, as I later discovered, significant for the Minor & James organization. In 2009, Swedish Medical Center and Minor & James Medical completed a transaction where Swedish made a capital investment in Minor & James and became an equity partner. In the years following, Swedish subsumed the Minor & James practice and has now completely rebranded and taken control of Minor & James. Even the Minor & James building is now named “Swedish First Hill Primary Care.”
Folks who are outside of the Seattle area most likely don’t know what Swedish Hospital and its ancillary services are. Swedish traces its roots back to 1910 when it was founded by a group of Swedish-immigrant community members and a Sweden-born doctor who had emigrated to Seattle. From its modest, 24-bed founding, it grew steadily. In 2012, it affiliated with and became absorbed by Providence Health Services. The joint operation became the largest medical provider in Washington state with thousands of employees in all corners of the state.
I was initially fine with the change at the Minor & James building. It was the same people at the same location. Besides, one reason I had looked at the Minor & James practice to find a physician was the building’s long-standing connection to the Swedish system. The doctors had practicing rights at Swedish Hospital, and they used a charting system that allowed them to collaborate with Swedish. When I had needed emergency helicopter transport to a cardiovascular stent lab, the EMTs recommended Swedish. As a result, I had a cardiologist already in that system. I saw a further connection to the Swedish system as a useful way to have my specialist and primary care physician communicate through a shared system. It all worked pretty well… until it didn’t.
First, my primary physician decided to leave the practice. People leave their jobs. So I scoured the clinic’s online site for a replacement. There weren’t many choices. All the choices seemed to be new hires who’d recently graduated from medical school. So I couldn’t read reviews of them. However, one of the new doctors was attached to my “care team,” and that assured that I’d be seeing familiar faces. So I selected him, made an appointment for an initial visit, and hoped for the best.
For the next couple of years, I saw him once annually for my “wellness exam.” That’s the Medicare-standardized visit that takes the place of an annual exam for those of us over age 65. I’d see the medical assistant who’d take vitals, ask me to remember a few words, and instruct me to draw a clock face showing an analog 11:10 on it – the customary, Medicare cognition tests. Then I’d wait for the physician who’d spent 15 or 20 minutes reviewing my chart and conducting a cursory physical examination while asking me generic questions about my health. At the end, he reviewed what medications needed to be reordered for the year. And that was my connection to him. Whenever I had a medical issue in those two years, I could never get scheduled with him and, instead, would see one of the care team. I preferred them anyway since they were people I’d gotten to know over the years, they were well-trained, and they did more than just go through a prescribed diagnostic checklist. The system was not what I hoped for in working with a physician, but it seemed inevitably adequate.
Then I received a letter from Swedish that notified me that my new physician was leaving. As I’d done previously, I imagined that I could go onto the clinic’s web site and see which doctors were accepting patients. At least, I thought, I could start an arrangement that allowed me to continue with the rest of the care team. I found nothing on the site, so I called the office. I explained my circumstance and asked the scheduler to let me know which doctors were accepting patients. She replied that because they’d had physicians either leave or get reassigned, they were short of physicians. No one in that clinic was accepting new patients. I explained that I wasn’t a new patient. After all, I’d been going to that location for medical services for over 25 years, and my last two primary care physicians for the prior decade worked in that clinic. I was only seeking a new primary care physician because the previous two left. In response she explained that since I wasn’t a patient of any of the existing physicians, I was considered a new patient.
They were evicting me from the practice. However, the scheduler explained that I could look elsewhere in the Swedish system for another physician. I began a new search for yet another new primary care physician, my third in three years. I also looked at other systems outside of Swedish. One wasn’t accepting Medicare, and the other only had openings in clinics that were at some distance. They all seem to have been swallowed in the corporate machine that created the dilemma I faced. As a result, I’ve given up hope of ever finding a primary care physician who’ll be more than a technician who dutifully follows the checklist until it’s time to push me along to clear the exam room for the next patient. I’ve settled for an appointment with another Swedish physician at a clinic that’s farther away than I’ve had to go for care. I’m not optimistic about how this new physician will be able to treat me.
The commodification of health care as an industry brought this. The economics of health care make small practices impossible to maintain. Large systems like Providence/Swedish have adopted industrialized models of efficiency where they use patient ratings systems and efficiency metrics to determine the worth of the people who work for them. Like many large organizations, they’ve fallen prey to the Taylorism that ruled the early 20th Century’s manufacturing. The result is the programmed experience I had for two years with my last primary care physician. The result is also that I can be easily and impersonally removed from a practice. It’s nothing personal, and that’s the problem. This style of medicine isn’t about people. It’s about slotting patients into appointments, reviewing check-list processes, going through the motions that prescribe or refer or recommend. Of course, that’s then finished with a bill to my insurers. It’s a mechanization rather than a relationship.
Has all of medicine become like that? In my experience, there are exceptions. The cardiologist I mentioned above has taken time to know enough about me to help me manage my heart and circulatory needs. A few years back, when I called his office with symptoms, his staff briefed him on what was happening. He had me check into the hospital for an overnight stay and an early morning cardiac exploratory catheterization. When the attendants got me ready for the procedure that next morning, I looked up from the bed to see my cardiologist there. He wasn’t scheduled for procedures that day, and the hospital staff had previously told me to expect one of his colleagues who was on rotation that day. But he rescheduled appointments so that he could do it himself. During the procedure, his team discovered a blockage and inserted a stent that resolved my symptoms and saved me from having a future heart attack.
Could another specialist have done that? Of course. But he’s been monitoring my circulatory system for over a decade. He knows that the problem could’ve been more serious and could’ve led to open heart surgery. He was best suited to look at my past history and make that determination. Having someone who’s intimately familiar with my condition gives me a lot of confidence that I’ll be okay. My cardiologist came into the procedure after having had many discussions with me over the years about the status of my circulatory system, tests he ordered performed, my health, and my lifestyle. It’s the relationship and long-term watching of my health that’s as important as his skills. Interestingly, that cardiologist left the Swedish system a few years before that episode. I’ve followed him to his current practice because I wanted to continue the relationship. However, soon after he moved away from Swedish, the new practice he’d joined was purchased by Optum, itself a subsidiary of United Healthcare. I worry what that will mean for his future ability to offer the kind of personalized care he’s provided in the past.
While that kind of relationship still exists, my experiences in finding and keeping a primary care physician tell me that the pressures are working toward limiting or perhaps even extinguishing doctoring that emphasizes the connections that physicians can have with their patients. And, in my perspective, it’s those relationships between care providers and me that are critical to my well-being. When I’m ill or hurting, I want to see a medical professional who knows me well enough to know what my ailments mean in the totality of my life. That’s not possible if I’m treated by a system that can so impersonally dismiss me from the clinic where I’ve had a connection. I’m now forced to find another practice that will meet my needs at a time when I’m aging and will need more medical care. That clearly makes sense on a spreadsheet, but it makes little sense to me as a patient. I can only imagine how disheartening and demoralizing such processes are to the people who work in those systems as these people become deskilled checklist followers instead of the trained professionals they are. There’s no surprise that we have a serious shortage of medical professionals.
Mine is a problem of privilege. After all, I’m over 65, and that means I have Medicare. Also, my retirement plan provides a supplemental insurance. That makes me extremely privileged. Many folks in the U.S. don’t have access to any medical treatment. The costs and availability of medical care exclude millions, and with changes enacted by recent federal legislation, even more will be excluded. People without the high levels of access that I have will have lower life expectancy and more medical issues. Unfortunately, we’ve evolved an establishment of medical corporations and insurance providers that, as much as I might complain about it, gives me more than many others.
It’s important to note that this process is more connected to corporate balance sheets than to patients’ needs. The result is something that, if we’re honest, doesn’t work well for even people like me who are on the inside of the protective bubble created by having insurance. For millions of others, health care doesn’t exist or it’s provided in expensive emergency-room visits that create long-term financial burdens on the people who have no other choice.
We’ve made this dysfunction normative. People without insurance are used to suffering and only seeing a doctor when their condition becomes dire. Those of us with insurance are shuffled from one impersonal office to another as if we’re parts of a Boeing 737 that are being worked on in different shops. We’ve been sold that this all is an optimal process that works better than any other.
I know that there are developed nations whose health care system works better. Is the answer Medicare for all? Or some kind of nationalized subsidy for that underwrites small practices? Or…? I don’t know. I know that what we now have is broken and doesn’t work for a lot of people. I know that even people with access and resources aren’t served well while a lot of people are excluded or limited. So, especially as we enter election season, I’ll be looking to vote for people at all levels of government who’ll acknowledge the failures of the medical system and create solutions that will move it in new directions. My health and the health of the nation demand that.
