Some of the answers to these questions can be found in a recently published book by Frederick M. Barken, MD, a highly qualified and dedicated internist who closed his primary care internal medicine practice in upstate New York in 2007 at the age of 51.(1) Barken describes in considerable detail how he built a busy, successful, and patient-centered practice, and how it unraveled during the last 3 decades, culminating in his early retirement. His book is based on his personal experiences as well as a thorough review of current literature in this area. Barken decries the devolution of his practice from a patient-friendly, personal enterprise to one in which the practice of medicine was no longer enjoyable. Among other factors, Barken feels that medical practice in the US has lost its social aspects and become progressively a pure business transaction: “Primary care is collapsing, a victim of economists’ tenets of maximized efficiency, profit, and productivity. There is no heading on an accountant’s financial statement for altruism, empathy, a warm smile, or other random acts of kindness that we all appreciate as patients and as people. Physician frustration, alienation, and chronic suppressed anger at such a market model of medicine have done us all, physicians and patients alike, immeasurable harm.” (1)
This entertaining but disturbing book contains many humorous clinical anecdotes that enliven the more serious report of the slow and inexorable destruction of Barken’s practice. I recognized and sympathized with many of the situations that he describes.(2) Both of us are irritated by fanciful direct-to-consumer pharmaceutical advertising, polypharmacy, and polydoctoring. But these were not the major forces that led to Barken’s early retirement and his concern for the survival of primary care internal medicine in the US. What he describes as the reason for the demise of his practice can be summarized in the phrase “too much hassle and too little reward.” And by reward, I mean more than economic gain. Barken loved his patient-centered practice and felt he benefited every day he was able to practice internal medicine as he had been taught during his residency. Over time, administrative and patient expectations and demands increased to the point where the reward of a day’s work well done had evaporated.
The most interesting comments addressed Barken’s recommendations for improving our health care system and rejuvenating primary care.
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— — Joseph S. Alpert, MD, editor-in-chief, The American Journal of Medicine
This article originally appeared in December 2011 issue of The American Journal of Medicine.
