If you recognize Steve Jacob's name, you might be from Dallas.
Mr. Jacob is the founding editor of D Healthcare Daily, a publication covering the business of healthcare in Dallas/Fort Worth. Covering healthcare in Texas, he knows a thing or two about independent physicians. They're a special breed, but they value hard work and incomes that reflect that work.
That's why he was somewhat stunned by the results of a 2012 study by the Physicians Foundation: 57.9 percent of physicians would not recommend medicine as a career to their children or other young people.
Why?
Because practicing medicine is harder, in that there's more regulation, tightening reimbursement and it takes more work to make potentially less pay.
Intrigued as to how physicians ended up this way, at a time when we're anticipating needing more and more of them, he authored a new book,"So Long, Marcus Welby, M.D.: How Today's Health Care is Suffocating Independint Physicians – and How Some Changed to Thrive," which was released earlier this year. 
Becker's Hospital Review sat down with him to discuss the book, the rise of physician dissatisfaction and the movement away from medicine as a small business.
Question: Practicing medicine today is very different from the days of Marcus Welby, MD. In the book you write, "Welby's practice style could not survive in today's medical culture.” Certainly, that seems the case with so few solo practitioners these days. What are some of the contributing factors?
Steve Jacob: One of the reasons I picked Marcus Welby as a focus is because a lot of physicians are baby boomers. One out of every four physicians today is 60 or older. When I interviewed many of them to try to understand the issue of physician dissatisfaction, Marcus Welby would come up. They’d say, 'I can’t run a Marcus Welby shop.’ It’s this idea of being a family physician that spent nearly all time with patients. On that show, there was a nurse/receptionist, and that was it. Medicare and the insurance companies paid pretty much whatever the doctors billed. It harkens back to an earlier time when doctors came out of school, hung out a shingle, and joined the business establishment of whatever community they landed in. But, the expenses continue to go up and the business model of being a solo practitioner is very challenging; almost no one wants to do it.
Q: I can understand the desire for that personal connection with patients. It’s much more difficult today for physicians to form personal relationships with patients; instead, they rush to see many patients a day and keep up with documentation and other regulatory demands. But aren’t there drawbacks of this somewhat antiquated way of practicing medicine? Larger, more “corporate” groups bring economies of scale, evidence-based protocols and team-based care. Marcus Welby didn’t have decision support, for example. Maybe he was just following his gut!
SJ: There are two sides of the coin, that's absolutely true. Marcus Welby did treat patients personally, but there was no patient-centered care or shared decision making. It was directive medicine. Probably the paramount motivator for doctors is their autonomy. They inevitably lose some of that when they become part of a bigger group or health system, but they do like the fact that their back office is taken care of, that their compensation is more stable and that they practice more evidence-based medicine and have more access to benchmarking than they ever had before. Marcus Welby doesn’t know how he’s doing compared to his peers; when you’re part of larger group, or an ACO, you’re compared to others. That’s a different way of practicing medicine.
Q: So we have this situation where the practice of medicine has in some ways become less personal in that we treat patients quickly and rely on protocols, but at the same time we encourage shared decisions. How did that come to be? Did the external environment, say increasing regulation and consumerism, hurt solo practice? Or, was it that the new generation of docs just weren’t interested?
SJ: I think they’re two separate issues, both of which contribute to the decline of solo practice. The culture of medicine has changed significantly, in part because of generational difference, which may or may not have resulted from increasing regulation, lower reimbursement and so on. Younger doctors are more likely to consider medicine a job, and they are not going to devote their entire lives to a profession. That’s not necessarily bad, they just want to have more balanced lives. Marcus Welby-era docs worked 80 hours or more per week; it takes two newer doctors to replace one Welby.
The administrative burden piece is something that has developed over time. It’s interesting: our government has sort have become the villain the insurance companies used to be.
Q: What’s interesting is that even with their more balanced lives and the support big practices or hospital employment provide, most doctors don’t identify as being satisfied. In your book you cite a survey that found 58 percent of physicians wouldn’t recommend their career to young people or their children. How disheartening!
SJ: This dissatisfaction is not new, and it's sort of like a rising tide. I don’t know how we’re going to fix it unless we’re able to come up with models that allow doctors less time not in front of patients, and more time in front of them. There’s a certain lack of empowerment; they’re doing more and making less, and I don’t know any other profession that would accept that. It’s not just one thing, it’s a lot of things; physicians are very put upon by a lot of forces.
Q: Some of the new value-based models, like patient-centered medical homes, are intended to pay physicians for spending more time with patients, and helping them prevent and manage conditions. Do you think this will impact the level of dissatisfaction we see among physicians today?
SJ: I have never seen evidence that creation of a patient-centered medical home increases physician satisfaction. However, there are a couple of qualitative factors that could have an impact, and this is strictly my speculation. First, doctors that form medical homes tend to be more satisfied with medicine and the direction of healthcare generally. They tend to be the ones that have bought into the triple aim and value-based reimbursement. Second, medical homes have the capacity to hand off more routine cases to physician assistants and nurse practitioners, perhaps allowing doctors to spend more time with patients. Bottom line, I don't think medical homes in and of themselves will have a big impact either way on physician satisfaction.
Q: Is that the one takeaway you’d like your readers to have from the book?
SJ: Yes, we've been very accepting of physician dissatisfaction, and I think that's wrong. I think we're driving people out of medicine and keeping others away from medicine. Physicians who are more engaged give better care, flat out. So given that, we shouldn’t just accept that doctors are dissatisfied. I can’t say I know how to solve it; it’s a multifactorial problem, but we must address it.