“Just let us be doctors!” The cry that begins our cover story this month probably calls forth echoes from the minds of many readers. Can anyone “just be a doctor” these days? Apparently not where managed care plays a large role, as the cover story suggests. And certainly not where Medicare is concerned. How about in the supposedly quiet harbor of the physician who has accepted a salaried position to get out of the storm? Can such a physician just be a doctor? Maybe, but before you imagine the employed life to be the simple life, read C. Carolyn Thiedke's “Salaried Physicians: Managers in Disguise.” Any organization large enough to employ physicians is probably large enough to distract them from just being doctors.

For most physicians today, “being a doctor” is a complicated business that demands close attention and careful management on several levels. The core of the matter is still and always will be patient care. Heaven knows that “simple” pursuit offers plenty of challenges, both clinical and interpersonal. This issue's article on patient-centered care highlights one ever-present set of these challenges. But around this core of patient management have grown numerous layers of other kinds of management, all more-or-less essential to practice today: self-management, organizational management of the kind described in Thiedke's article, practice management as exemplified in our cover story, population management and even the kind of enterprise management demanded of any physician involved in setting up a provider sponsored organization (PSO) for Medicare contracting.

If you prefer to be pessimistic about all this, you can view the outer layers of management as concentric layers of obstruction muffling the desire just to be a doctor rather like accretions of mud and rock surrounding a diamond. Since I prefer to save my pessimism for good times, when it seems to go farther, I would choose a more homely analogy: the onion. Think of the onion sets being planted in gardens now, at least across the more temperate parts of the country. The layers of each onion are joined at the root and open at the top; the outer layers aren't obstructions to the inner; rather they feed and protect the central shoot. They all express the same principle, and each layer derives its shape from the one inside it.

If the analogy doesn't persuade you — if you can't see forming a PSO as an expression of the same principle embodied in helping a patient get his blood pressure under control — I won't argue too forcefully. Still, if you regard a PSO as an institutional attempt to keep insurance companies out of the exam room, it embodies the same concern for the patient and the patient-physician relationship as a heart-to-heart conversation with Mr. Jones about his half-hearted attempts at dietary control. And if you reflect that the same negotiating abilities are called upon in dealing with a hospital CEO as with Mr. Jones, you may acknowledge that there's at least something to the analogy.

To be just a doctor may not be possible today. But as long as the principles embodied in your patient care efforts are also expressed in all the outer management layers of your life, you can at least be a doctor through and through.