Where Care is Given

The way we deliver medicine changes in strange ways. There are more and more places that deliver care; new hospitals, clinics, ambulatory surgery centers, and procedure centers are being built year after year. We are caring for patients at more diverse and more numerous places than ever before. Several decades ago, the idea of a freestanding outpatient surgery center would have seemed crazy; now, they are a profitable business model. The same thing applies to clinics found in pharmacies, flu shots being given at grocery stores, and independent laboratory and radiology facilities.

At the same time, though, specialized care is being concentrated more and more at certain hospitals. For example, bariatric surgery outcomes are better at places that do a lot of weight-reduction surgeries; as a result, these centers of excellence concentrate all the bariatric surgery volume. Parents may take a child with complex congenital heart disease hundreds of miles to a subspecialist who is an expert in that condition. Some patients fly across the country to see the nation's best rheumatologist, geneticist, or hand surgeon.

To me, this is a weird result of unregulated medical expansion. We want to do the best for our patients, and we want to have a successful business doing so. So all the routine stuff spreads out for patient convenience; why go all the way to an academic medical center for routine prenatal care if the local obstetrician can open a clinic where you are. But all the rare stuff coalesces at discrete centers to ensure that experts remain experts and patients get the best care. With rare diseases, patients are willing to go farther and wait longer to see the best oncologist in the area. 

At a top academic medical center, I really enjoy seeing the high concentration of complex diseases. But as I look at jobs and think of the future, I realize most physicians out there work with run-of-the-mill bread-and-butter most of the time.