An Ailing Profession

Anesthesiologist Julius Migliori remembers the 1960s fondly. His patients would enter the hospital as much as three days before surgery for elaborate pre-op work, then stick around afterward for a week or so of recovery. And when it came time to pay his bill, many would simply take out their pens and write checks. Forty years later his sons Michael, Stephen and Mark and daughter-in-law Sidney, doctors all, marvel at the mind-boggling simplicity of the old ways. "Because of all the paperwork and the concern about being audited by the insurance company, it may be two months before I even get a bill out," says Stephen, 39, a university-based general surgeon whose patients show up the morning of their operations.

As the pharmaceutical industry takes center stage in the national debate over exploding health-care costs, doctors and hospitals remain prime targets in the battle to reduce medical spending. While much has been made about the impact of managed care on patients, the impact on physicians has been no less profound. It has fundamentally altered the practice of medicine, interfering with doctors' decision making and drastically reducing their once vaunted earning power. Despite the current focus on powerful meds, for most patients their personal physician remains their most critical link to the health-care system. As a two-generation physician family, the Miglioris provide a unique perspective on the evolution of the practice of medicine in America.

Julius, sturdy and clear-eyed at 72, is warm and open. When his sons said they wanted to be doctors, he insisted that they work awhile as hospital orderlies in their hometown of Cranston, R.I., to see his world from a different perspective. He's proud that they followed his lead. But he has no illusions about how the profession has changed. "There was an aura about it, which is long since gone," he says.

When Michael Migliori, now 43, got his first pair of glasses at the age of 11, he could see the leaves on the trees for the first time in his life. He decided right then to become an ophthalmologist so that he could help other people discover the hidden details of the world around them. By the time Michael finished all his training, he was an ophthalmologist and a plastic surgeon. One of his proudest moments came when he operated with his father for the first time. It was a dream come true for both of them. Michael started a solo practice in 1987 and was soon swamped with work. Unfortunately, too much of it was paperwork. "I was the office manager, I was the business manager and I had one secretary," Michael says. As medicine evolved in the 1990s, the paperwork only became more complicated and time-consuming.

One of the worst things, Michael says, was the way insurance companies insinuated themselves into his dealings with patients. As he was taking histories, doing exams and planning treatments, he also had to think about what kind of insurance the patients carried and what he needed to include in their charts to justify his medical decisions. For modern doctors, this two-track mind has become as necessary as a beeper. After 10 years on his own, Michael became a member of a six-physician group in Providence, R.I., called Ophthalmology Consultants. He now works in a state-of-the-art office complete with foot-operated dictation machines to document all patient visits, and a 19-person support staff (not counting nurses), including a business manager, an office manager, five people to transcribe the dictation and four people to handle the billing. All of that costly overhead enables Michael to concentrate more on his patients; each week he operates 10 to 12 times and sees about 75 people in the office.

It also improves his chances of achieving what has become the holy grail of modern medicine--the clean claim. Asked to explain the term, Michael smiles. "Nobody can define a clean claim," he says. "It's like pornography. I don't know what it is, but I know it when I see it." A clean claim is one that goes through the system without a hitch. The insurance company agrees that the treatment was appropriate and that the paperwork is accurate and complete. It then pays the doctor. Says Michael, "We need to document it so that some stranger with no medical training can come in and look at the chart and come to the same conclusion."