Gains and Costs — When Medicine Could Do Almost Anything (Except Listen)
CT scanners, organ transplants, statins, EHRs, prior authorizations, eight-minute visits. The most powerful medicine in human history. So why does it so often feel cold?
On October 1, 1971, in a small hospital in Wimbledon, England, a man named Godfrey Hounsfield and a physician named James Ambrose performed the first clinical CT scan on a human patient. The patient was a woman with a suspected brain tumor. The machine spent about four and a half minutes acquiring the data and over two hours reconstructing the image. The tumor was visible.
It was the first time in human history that anyone had been able to look inside a living skull without cutting it open.
The CT scan changed everything. So did MRI a few years later. So did open-heart surgery, organ transplantation, chemotherapy, dialysis, joint replacement, statins, ACE inhibitors, HIV antiretrovirals. The list from 1970 to 2000 is staggering. A baby born in 1995 could reasonably expect to live a decade longer than a baby born in 1955.
These are real gains. They saved my own family members. They saved many of yours. I do not want to discount them for a single sentence.
But there were costs. And the costs were not, mostly, the kind that show up in a clinical trial. They showed up somewhere else — in the relationship between a doctor and a patient, and in the slow erosion of the conditions that make that relationship possible at all.
The Rise of Managed Care
By the 1970s, American healthcare costs were growing faster than the rest of the economy and showed no sign of slowing. Employers — who were paying for most of it — wanted leverage. The federal government, post-Medicare, was already the largest insurer in the country and had its own cost problem.
The answer, between roughly 1973 and 1995, was managed care. The HMO Act of 1973 incentivized health maintenance organizations. By the 1990s, most Americans with employer insurance were in a managed care plan of some kind.
The logic of managed care was simple. If the insurer pays only when care is rationed, structured, and pre-approved, costs come down. To make that work, insurers needed to do two things they had not previously done: tell physicians what they could and could not prescribe or order, and pay physicians not for what they did but for what they were authorized to do.
This is the origin of prior authorization. It is the origin of the in-network/out-of-network distinction. It is the origin of the formulary. It is also the origin of a relationship between physicians and insurers that is, today, openly adversarial.
The intentions were not malicious. The cost problem was real. But the cost-control machinery was built on top of the doctor-patient encounter, and over thirty years it slowly hollowed that encounter out.
The 15-Minute Visit
In 1975, a typical primary care visit was scheduled for 30 minutes. By 2000, it was 15. Today in most fee-for-service primary care practices, it is closer to 8 to 12 minutes of actual face time, with the rest of the slot eaten by documentation, transitions, and the patient changing into a gown.
Eight to twelve minutes is not enough time. It is not enough time to do a real history. It is not enough time to examine a patient unhurriedly. It is not enough time to listen to a story long enough to know what the actual problem is — which, anyone who has been in medicine for a while will tell you, is usually not the chief complaint that got typed into the schedule.
But fifteen-minute slots are what the math requires when reimbursement per visit has been flat for two decades and overhead has not. Physicians did not choose this. Patients did not choose this. The system optimized for billable encounters, and the encounter shrank to fit the billing code.
The Electronic Health Record
The HITECH Act of 2009 — passed as part of the response to the financial crisis — pushed nearly every American physician into electronic health records within a few years. The promise was real: legible notes, fewer prescription errors, better data, interoperability across systems.
Some of that arrived. Most of it did not.
What did arrive was an enormous documentation burden. The average primary care physician today spends roughly two hours on the EHR for every one hour with a patient. We type during the visit. We type after the visit. We type at home in the evening to finish notes that should have been finished in clinic but weren't, because the patient before you was sicker than scheduled and the patient after you needed an emergency referral.
A 2016 study tracked physicians over a working day. They spent 27% of their time on direct patient care and 49% on documentation and administrative work. That ratio has not improved.
This is one of the largest sources of physician burnout in the United States. It is also one of the largest sources of the feeling, on the patient's side, that your doctor is not really paying attention to you. Because, in a literal sense, they often aren't. They are paying attention to a screen.
What Got Lost
By the year 2000, American medicine had become the most technically capable medical system in human history.
It had also become a system in which:
- The average primary care patient could not get a same-day appointment.
- The average primary care visit was twelve minutes or less.
- The average primary care physician spent twice as much time documenting as treating.
- Most clinical decisions were being shaped, at some level, by what the insurer would or would not authorize.
- The continuity of relationship that Fildes painted in 1891 — one doctor, one family, one lifetime — was statistically rare.
You can build a system like this. We did. But you cannot pretend that the relationship at the center of it is the same one painted on the wall.
The Quiet Exodus
Starting around 2010, something started shifting on the physician side. A small but growing number of doctors began leaving conventional fee-for-service practice and building something else.
Some went concierge. Some went direct primary care. Some went into hospital-only roles. Some left medicine altogether.
The common thread was a sense that the structure of the work had become incompatible with the reason most of us went into it. Not the science — the relationship.
I am one of those physicians. I trained in hospital medicine and was good at it. I am not leaving hospital medicine entirely; I'm building a direct care practice alongside it. But the practice I am building is, in some ways, a deliberate withdrawal from the architecture this post is about. No insurance. No fifteen-minute slots. No EHR that I type into while you talk. A flat monthly fee, my actual phone number, and the time to know you.
That is not innovation. That is recovery.
Next in the Arc
Post 5 — the final post in this series — is about where we go from here. About what direct care actually is, what it isn't, what it can and cannot do. About what it means for a patient, in 2026, to have a doctor whose attention is not split.
If you've been with me from the start: thank you. If you're just arriving — The Doctor (Post 1) is the painting. From Hearth to Hospital (Post 2) is how medicine left the home. The Golden Age (Post 3) is how it became an industry. This post is what that industry cost.
Post 5 is what we do with what's left.
Sources & further reading:
Sinsky C, Colligan L, Li L, et al. "Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties." Annals of Internal Medicine, December 2016;165(11):753–760.
Bates DW, Gawande AA. "Improving safety with information technology." New England Journal of Medicine, June 2003;348(25):2526–34. (Early-era EHR promise paper, useful counterpoint.)
Starr P. The Social Transformation of American Medicine. New York: Basic Books, 1982.
Image credit: Brightspeed CT scanner. Photo by Masengesho Musemakwel Thaddee. CC0 Public Domain. Source: PublicDomainPictures.net.
Brian Bost, MD, MPH, is a Med-Peds physician and Physician-Founder of B2 Health Solutions and its clinical practice, B2 Direct Care — a hospitalist-informed, solo DpC micropractice in Denver, Colorado. This is Post 4 of the How Did We Get Here series.
