The "Marcus Welby" family practitioner, both medically omniscient and a close family friend, is rapidly going extinct.
Medical care for most of us is becoming far less personal, and far more fragmented.
A patient goes to a Dermatologist for his acne, a Endocrinologist for his diabetes, an Orthopedist for his backache and a Allergist for his asthma.
Insurance exigencies require frequent doctor changes and once a patient is admitted to a hospital, they meet a new set of hospital specialists that come and go rapidly.
Berwick's goal of limiting care will be curtailed by this diffusion of responsibility.
Walking through the door for "The Conversation" is one of the hardest things doctors do, especially when the doctors, patients and families are strangers.
Deferring such decisions is the easiest course, and will be the one most taken.
Also, the reality of the end of life situation has changed, the goalposts keep moving.
The fact is, something more can usually be done, especially if you are rich.
Dick Cheney, after two coronary bypasses and a dozen coronary stents, recently had a heart pump assist device placed and probably will get a heart transplant.
Steve Jobs got a new liver with controversial medical indications.
Oncologists can always give a new type of chemotherapy, biological therapy can be tried, another procedure can always be attempted.
For a doctor to say that "nothing more can be done" is getting harder and harder, as it just isn't true.
Additionally, a doctors training, ego and "quality" measurements( another initiative of Obamacare) reward specialists and hospitalists for keeping patients alive.
When doctors are getting paid based on their survival statistics, it will be hard to convince them to let patients go.
Finally, the classic end of life decision relies upon a knowledge gap between the physician and the patient.
Traditionally, the doctor's judgment, based on his secret knowledge, was unquestioned.
This is no longer the case.
The internet, and the democratization of knowledge it has engendered, has empowered patients and families to understand their diseases and therapies at a depth unimaginable a short time ago.
Patients come to doctors with the newest studies and treatment recommendations.
If the latest and greatest therapy is not offered by the doctor, the patient will suggest it, as well as quoting survival statistics.
Nothing is more embarrassing to a physician than having a patient know more about a condition than they do, it is happening more and more.
These developments have made the withdrawal of end of life care more and more difficult based on medical reasons.
Instead we are hearing more of "medicare/your insurance won't pay for that".
This is a much different conversation that erodes the very foundations of democracy and fairness the American dream is built on.
More later.