Caring for the Tribe: From Addiction to Zen

What is the path forward when every path leads backwards away from the physician and patient? The progressive proletarianization of physicians continues as predicated thirty years ago[1] when this writer's teaching attendings thought it quaint and absurd. Now, however, physicians who could once claim highest income by working independently now pursue employment for income maximization.[2] Contrary to our discipline's thought leaders, idealist values of compassion, service and sacrifice do not appear to be the central drivers/attractors for the practice decisions of physicians. Independent physician community practice which the Searsport author exemplified - and the ancient origins of family practice originally posited as the future of health and wellness - appear to be a profession disappearing. As Dr. Loxterkamp states, those who do not sell out to corporate (including governmental) practice become extinct.

What has now been tried anew which has not been tried before? This author visited Dr. Loxterkamp years ago on the verge of this experiment in his "new model" of partnering community practice with a Community Health Center bureaucracy. The valid goals were presumably enhanced reimbursement, possibly broader leadership, and hopefully a sustainable future. The trade-offs and prior histories of such experiments were shared and, truthfully, there have been no unanticipated consequences. Dr. Loxterkamp's experience remains the common experience of idealists submitting to work for pragmatists. Surrendering professional autonomy and community health to the whims of misguided governmental commisars who are convinced of their superior knowledge and leverage their economic power leads to very predictable outcomes.[3]

In this present analysis, Dr. Loxterkamp concludes by describing wonderful examples of where physicians still do find joy in healing practice. These practices of joyful medicine continue to occur where the relationship of healer with patient comes first and, by extension, the relationships among health care team members also spring from this healing well. What may be perceived as lacking from our thought leader's opinion piece are the following - 1) the reasons for failure of rural CHC retention are many, common, understandable and predictable [4,5], and the lack of explication or certainty in this regard poses the question of whether our author's present employment limits his ability to openly share his findings in an academic journal. 2) the ability to accomplish these wonderful examples of healers' healing practices demands the power which today's said physicians have already surrendered to the bureacracies whom they now supplicate for the needed changes which run counter to the misguided core drivers/attractors of corporate medicine.

This vision of our leading and committed rural physician in Belfast, Maine appears to call us to an ideal practice of medicine which has only and repeatedly been found in the independent and community-based practice which he has left behind. Those of us who continue in the joy of rural community practice on the fringes of the complex sea of healthcare see our economic niches shrinking by the month and year to the whims of self-interested payors and their over confident regulators. When the authentic practice of our healing tribe returns to our historic roots, will any of us be able to afford the sacrifice? And will any healer be appreciated for the sacrifices we make?

1. McKinlay JB, Arches J. Towards the proletarianization of physicians. International Journal of Health Services: Planning, Administration, Evaluation. 1985;15(2):161-95.
2. Roemer M. Proletarianization of physicians or organization of health services? International Journal of Health Services: Planning, Administration, Evaluation. 1986;16(3):469-71.
3. Singleton T, Miller P. The Physician Employment Trend: What You Need to Know. Family Practice Management. 2015;22(4):11-5.
4. Cutchin MP, Norton JC, Quan MM, Bolt D, Hughes S, Lindeman B. To Stay or Not to Stay: Issues in Rural Primary Care Physician Retention in Eastern Kentucky. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association. 1994;10(4):273-8.
5. Lee DM, Nichols T. Physician Recruitment and Retention in Rural and Underserved Areas. International Journal of Health Care Quality Assurance. 2014;27(7):642-52.

Competing interests: None declared