I magine one morning you're craving something sweet, so you stop by the corner doughnut shop. Turns out the wait is half an hour, the clerk is rude and, when you finally get it, the doughnut is stale. Would you buy doughnuts there again? Of course not.
Yet, every day, millions of Americans put up with just that kind of service in their physicians' offices. And they keep going back.
Anyone who has visited a primary care doctor lately knows the drill: You show up on time, only to wait 45 minutes or even an hour. In the examination room, the physician (who offers no apology) seems distracted, harried and eager to get to the next patient. Then you're referred to a specialist - who doesn't have an opening for a month.
Every politician and his Aunt Martha has a scheme to overhaul American health care. But not one of them will solve this problem: Most doctors are awful at serving their patients. The typical hair salon pays more attention to customer service than the typical doctor.
Why? Even the best medical schools give short shrift to practice management. So a doctor can emerge as a skilled diagnostician without a clue how to run a business that serves consumers. In fact, many physicians find it distasteful to think of medicine as a business at all. They feel that it's their mission to serve as many patients as possible rather than to provide the best care possible. Most significant, today's doctors are preoccupied with the bureaucracy of insurance companies, so much so that they've lost the simple logic of the doughnut shop model.
To be sure, physicians are not entirely to blame. With insurance companies dictating how much doctors can charge for services as diverse as a routine checkup or an appendectomy, a doctor has only one route to more income: increase volume.
I know. When I began my own private practice in internal medicine, my volume grew quickly, and so did my work hours. I didn't complain because I took that as a sign of success. But before long I found myself toiling nights and weekends just to keep up with the volume. First I sacrificed my free time to my practice, then my sleep and finally the quality of my practice itself.
From an economist's point of view, my problem was simple. I was making good doughnuts and selling them below market price. I was earning a good living, but I couldn't sustain that level of production. So I took action. I dropped an insurance plan - the one that gave me the least compensation. Almost immediately, I had fewer patients but more time and energy for those I maintained. When my patient ranks swelled and I got too busy again, I dropped another plan. This continued until I reached the right balance of time and patients.
For more than a year, I haven't received a single dollar from any insurance company. I work for my patients. A few hundred doctors across the country are working the same way, some in blue-collar towns. Routine care should be affordable to the middle class, and as more doctors and more patients form relationships that exclude insurance companies, prices will drop. Insurance doesn't make routine care affordable; it makes it more expensive by adding a middleman. I know that some patients can afford nothing, so two afternoons a month I volunteer at a clinic that cares for indigent patients, which I could not have done with the huge patient volume I was seeing a few years ago.
When doctors break free from the shackles of insurance companies, they can practice medicine the way they always hoped they could. And they can get back to the customer service model in which the paramount incentive is providing the best care. Only then can doctors reclaim the simple dignity of any businessman: These are my doughnuts; only I and my customers can determine their worth. (At the end of each week, I will donate some to the needy, but I will not let a third party set the price.)
And when patients are the customers, doctors will listen when they ask for services not on the insurance company menu. If an urgent need arises after hours, patients want to be able to call their own doctor. Patients want to be able to e-mail their doctor with non-urgent questions and to fax them interesting articles. They want to be educated, not just medicated. They want to know they can get in to see their doctor the same day if needed, and that their doctor will be the one taking care of them if they are hospitalized. If doctors had fewer patients, meeting all of these needs would be easy.
How many customers would have to request rainbow sprinkles before the doughnut shop owner kept them in stock?
Fuchs is an internist in Beverly Hills, Calif.
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