William was an old-fashioned GP. In his practice he delivered babies, set broken bones, sutured cuts, and ministered to the dying. He made house calls. His profession was his calling. He was the doctor for his community. His wife handled phone calls, record keeping, and to the extent that it was necessary, billing.

The times, they are a changin'.

Their son Bill became a doctor. Bill wanted to be like his Dad. He started out doing house calls but eventually found that it made more sense to see patients in an office since the practice of medicine was changing. To earn income, Bill had to have an organized system to bill insurance companies, which had become the main way that doctors were paid. Eventually he took on a partner, and moved into an office building.

The practice kept growing, adding more doctors in order to attract more patients. Income grew, but everything about managing such a large practice had a more business-like aspect. There was more red tape. Eventually, Bill’s large practice needed thirty-five people to handle billing, collections, and record-keeping.

Bill’s daughter Kate wanted to be a doctor, too. She loved the intellectual challenge of solving puzzles and the biological knowledge that a medical education would provide her. But she’d seen her father miss too many family meals because he was “on call” when she was growing up. She was determined that she would be a different kind of doctor.

She is.

Kate is part of a generation that views doctoring more as a job and less as a vocation. She’s chosen to go into Emergency Medicine, since it affords her a more manageable lifestyle. Kate, like most ER docs, is a shift-worker. At the end of her shifts, she goes home. She’s never “on call.” When she’s home, she’s home. She may spend time reviewing a case in her mind, but she sheds responsibility for it when she leaves the ER.

Kate is an employee. She makes a good salary, but she doesn’t own her practice, or assume the risks and liabilities of running a business on top of being a doctor. At least for now, she likes it that way.

This story of three generations of the Dewar family from Pennsylvania was featured in the NYTimes.

It generated a lot of comments, both from current doctors who resent the notion that relationships with patients were better in the old days, to older professionals who feel that something essential from medicine has been lost.

My own view is that medicine has matured; it’s gone from being a profession to a major industry, and that has entailed myriad changes in its workforce. The doctor-patient relationship, still the crux of the medical exchange (dare it be called the ‘medical transaction?’), has lost some of its inherent value as it’s become wholly commodified. It’s like a dollar. Still important as a unit of measure and trade, but not as valuable as it once was. The technological and regulatory aspects of medical care have rendered the smaller scale medical practice obsolete.

I value time away from medicine (though this blog does keep me thinking about it even on “off” time). I’m glad that there’s been a new emphasis in the profession on centeredness and family; we doctors should role model healthy, non-workaholic behavior for patients. But I do worry that the new regulations limiting work hours for doctor trainees are altogether changing the mentality of what it means to be a doctor. It’s one thing not to want to work all the time, but it’s another altogether to lose one’s sense of calling and responsibility for a patient’s care.

Though I’m on board with the team approach to medical care, with whom will the buck stop?