This is a guest article by Silvio Aladjem MD.

For the last thirty years or so, medicine –medical practice- has fought an uphill battle. It started, with the litigious environment of our society and the hunt for millions of dollars awards, regardless of merits, by lawyers who were not so much interested in improving the practice of medicine, as they were in the pot of gold that it represented. As the awards mounted, the liability insurance cost skyrocketed and an 80 to 100,000 dollars yearly premium, was not unusual in high risk practices like obstetrics, anesthesia and other surgical specialties. Some older physicians, simply stopped practicing and retired. Many became hospital employees, thus liberating themselves of the liability problem since the hospital provided the insurance.

Physicians becoming hospital employees was the dawn of the end of medical practice as it used to be. Patients got used to being taken care by whoever was available or on call, rather than by their physician. Actually “their physician” disappeared. It became collective medicine. If you did not like it, you could go somewhere else, except that somewhere else was not any different.

By becoming employees, however, physicians, all of a sudden, had to report to an administration’s MBA who had no notion of medical practice. Their goal was always the bottom line. The office mill became the new standard practice. The new motto: “a patient every fifteen minutes, and the physician could only address one medical problem per visit”. If you had a headache and a belly ache, you had to choose which problem you wanted the physician to address. Don’t think too long, because 15 minutes go by very fast.

Again, older physicians decided to go into early retirement and brand new young physicians took their places. The new physicians, no matter how good their training, had been brought up into the “physician employee” mentality. The “doctor-patient” relation concept was foreign to the new breed of doctors. They did and do a good job, but don’t ask them to remember Mrs. Smith or Mr. Jones. They wouldn’t know the difference, unless they were given the patient’s chart to review. It’s a strict 9 to 5 mentality.

This transition and transformation took a long time. New systems were now in place and new habits were formed, by both patients and doctors.

But if we thought that big changes had occurred already, there is nothing as to what is going to come from now on. The new boss is in town. It’s not the chief of staff at the hospital, it’s not the chief of your service, it’s not even the MBA in the hospital administration. It’s the real BIG BOSS: Our Federal Government, and the rules and regulations of the Affordable Care Act (ACA), also known as Obama Care.

When the debate of the ACA started, before becoming the law of the land, the optimists were looking at European models –Great Britain, Sweden, France, and others- and were hoping our lawmakers will learn something from other countries’ experiences and mistakes. While everyone talked, no one cared to read what was coming. In fact the Speaker of the House Hon. Nancy Pelosi, literally said that “we have to pass the law so that we learn what’s in it”. Was this a “Saturday Night” comic line? Not hardly. She really meant it. They actually did pass it. The law they passed, the ACA, made its debut with big fanfare. The President signed it into law among festivities which were seen on all the TV stations and reported in the national press.

You know the rest of the story, and I am not going to dwell on it. Now, hospitals are not their own masters any more. They have to comply with the law to stay in business. If you went to a doctor lately, you may remember that you had to sign pages and pages of forms mandate by the Government, before they ask you “why are you here?”. Physicians thought that the 15 minutes visit was a problem, but they never anticipated what the new law will bring. Learning a new vocabulary so that you can understand the jargon, electronic records that are repetitive ad nauseam and instead of facilitating care, the way it is now, it’s a burden. Reimbursements are down and contingent upon following protocols that may not be yours; crowding of operating schedules is inevitable, delays will occur, and above all, patients have to follow the script as to where they are going to be taken care of. You have heard about the recent scandal at the VA. That’s just a taste of “government sponsored” medical care. Furthermore, as you all know by now, “you can keep your doctor and you can keep your insurance” promise did not quite tell us the truth.

Once again, many older physicians are opting for retirement, and the new ones will have to adjust their tune to whatever comes.

“Whatever comes” is the crux of the matter, and I don’t really know what’s really coming. In fact, nobody knows.

What I do know, is that it is not going to be consistent with good medical practice. It is, also, not structured with the patient in mind, and it will not give us better care.

I should have entitled this column “How to destroy the best medical care in the world, without really trying”.


SILVIO ALADJEM MD, an obstetrician/gynecologist and Maternal Fetal Medicine (high risk obstetrics) specialist, is Professor Emeritus in obstetrics and gynecology at Michigan State University, College of Human Medicine, in Lansing, MI. He is the author of “10,000 babies: my life in the delivery room” now available on Amazon, Barnes and Noble and other book stores. Dr. Aladjem published extensively in Scientific Medical Journals and wrote several textbooks in the specialty. He can be reached through his website,

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