Loss of Medical Decision-Making, Continuity of Care, and Doctors in Private Practice
Healthcare for Americans is in disarray. Over the past 30 years, businesses have increasingly dominated the field, relegating doctors to a marginal role. Our ranking in medical care compared to other countries continues to decline. Here is some background contributing to these factors.
When I began my medical career, CT scans and MRIs were nonexistent. Scientific advancements and technology facilitated the development of these and many other diagnostic tools.
These changes have improved medical care, allowing physicians to diagnose and treat patients more effectively. The integration of computers has played a vital role in this progress by ensuring better continuity of care, whether at home or in the hospital, through enhanced communication between doctors and patients.
At the same time, motivated by profit, businesses such as insurance companies and hospitals have removed doctors from much of the medical decision-making process.
I have been in private practice for nearly four decades, which means I am a small business owner with the independence to make decisions.
In the past, private practice doctors cared for patients in their offices and made hospital rounds during non-office hours. This sometimes meant tending to hospitalized patients early in the morning, in the evening, or on weekends, but it was manageable.
I trained as an internist, initially in a hospital and later transitioning to my private practice after residency. Typically, I would see patients first in an office setting, getting to know them and their family members while treating them in a non-emergency situation. When they became ill and required hospitalization, I would act as their admitting doctor, overseeing the management of their care.
During my residency training and experience, I learned when it was safe to discharge patients home. I also recognized the importance of maintaining continuity of care in the transition from hospital to home to prevent re-admission.
Most importantly, I got to know my patients personally by asking about their backgrounds, including where they grew up, family life, education, jobs, children, military service, and concerns. This eventually led to a transition into end-of-life decisions. This is the humanity I brought to practicing medicine.
However, hospitals and insurance companies viewed it as economically inefficient for private practitioners to care for hospitalized patients. Balancing hospitalized and office patients was part of my training, and most internists and family practitioners are adept at it. Despite this, with financial interests backing them, the “hospitalist” was born.
What has been lost is continuity of care. Even with technology, office doctors assessing recently discharged patients have a limited ability to understand the full scope of hospitalization. Most of the time, when asked, patients and family members are unaware of the admitting diagnosis, let alone what care is necessary to prevent readmission.
Hospitalists are capable, board-certified practitioners; however, many are young and lack experience. The most troubling aspect of this situation is that they are employed by the hospital or contracted through affiliated physician groups. This arrangement may lead to economic manipulation of their contracts, affecting medical decision-making. How many hospitalists bear the burden of medical school debt, a mortgage, and a family to support? Can we blame them for hesitating to voice their opinions and risking their contracts?
Data collection is pervasive in society and is utilized to assess efficiency. Many hospitalists encounter statistical constraints when evaluating utilization, which includes patient length of stay, lab tests, radiologic images ordered, and requests for specialty consultations. These factors can incur costs and diminish profits, leading to pressure on contracted doctors who are not in private practice to minimize the care they provide. This, of course, could be at the expense of your health.
Hospitalists often lack familiarity with their patients’ backgrounds, knowing them only superficially. This stems from being taught that such information is “irrelevant” and not essential for medical care, making patients feel like they are on a conveyor belt.
In private practice, hospital administrators cannot dictate my medical decisions. Although it is illegal in California for a hospital to practice medicine, they have circumvented this law by using business tactics of coercion.
Some of my colleagues have accepted their roles, remaining only in their office practice despite their training. In contrast, others in private practice continue to see patients in the hospital and office. Technology has allowed them to care for hospitalized patients through computer contact via hospital portals, providing real-time care. Additionally, communication from hospital nurses enables rapid medical decisions, ensuring quality care.
However, private practice physicians are rapidly being driven out of the hospital environment by administrators skilled at creating contracts that compel doctors to adhere to the bottom line.
Ironically, the data collection now directed at doctors reveals the dire healthcare conditions that Americans endure due to the poor decision-making of hospital administrators.
CT scans, MRIs, and computers have greatly benefited physicians by improving patient care. However, the business takeover of medical decision-making, the loss of continuity of care, and the fewer doctors in private practice with an increasing number of contracted physicians susceptible to coercion harm our nation’s health and well-being.
Addressing these factors could be an initial step toward enhancing healthcare for all Americans.
Gene Dorio, M.D.
Originally published in The Signal, our local newspaper, on March 19, 2025.
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