Are Doctors Sheeple?

Imagine a couple caught up in arguing about who should take out the garbage while there's a fire on the stove. The garbage may be a real source of conflict, but bickering about who's turn it is risks the house being engulfed in flames.

Such it was this past week when Daniel Palestrant, MD, Founder & CEO of the physician online forum Sermo, Inc., took a step in the wrong direction by deciding to stand in opposition (subscription) to the AMA:

As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.

While some of his points might be perfectly valid, we wonder how further division amongst our ranks will affect our ability to lobby effectively for the doctors and patients in the current era of health care reform. Do we have the time for such pissing matches? I understand the inherent opportunity for Dr. Palestrant to mobilize the online physician community, but how do we mobilize the majority of physicians and break out of our specialty silos to develop points of consensus? Needless to say, the other partner, the AMA, was none too pleased and shot back:

The AMA has decided not to continue its business relationship with Sermo.

The AMA is always looking for effective ways to communicate with physicians. After an evaluation of the initial relationship with Sermo, we have decided that the value was not there to justify the investment of AMA members’ dues dollars. We continue to explore ways to communicate more effectively with all physicians.

Meanwhile, the politicians and lawyers smile.

This is not about "he said, she said." While Sermo boasts over 100,000 physician registrants, neither organization can say it represents the majority of doctors. Further, to suggest Sermo is any less conflicted than the AMA when it comes to revenue generation is misinformation. But all doctors are keenly aware of the bureaucracy, the middle men, the excess, cover-your-butt tactics needed to shelter them from litigation, their increasingly demanding work hours, frenetic patient visits and diminishing professional payments despite all of their work.

But now, all the politicos see is this: "Look Joe: Sermo guys ain't talking to the AMA and the AMA ain't talkin' to Sermo! Poor bastards. Guess we don't have to worry about them if they can't even agree with each other."

We are, after all, surrounded by professional organizations that have not permitted themselves to devolve into silos. The American Bar Association. The pharmaceutical lobby. The medical device industries. The American Hospital Association, etc. They have political clout. They have a powerful voice on the Hill. They know how to play the game. They have differences in political bents (trial lawyers typically democratic and corporate lawyers typically republican, for instance), but they know how to minimize their internal differences to maintain political bargaining power.

We, on the other hand, are fiercely independent, entrepreneurial, and schizoid: conveniently parsed into our narcissistic silos of primary care, hospitalists, nocturnists, specialists and subspecialists. Some are hospital-employed and others in private practice, some are academic and others fiercely clinical, some are deeply conservative and others even more liberal.

I have to admit I'm still miffed at the CMS proposal to cut cardiologists' fees and shift funds to primary care. I'm miffed at the AMA, too: where was their condemnation of the proposal?

But is this the big issue? To pretend that the cost of doctors' services are the reason for excessive health care costs is a chimera. Look on your latest hospital bill at the exact line items for a health care charge. Look at the "adjustments." Look at what the doctor ends up clearing for that bill. And that's all they can think of to cut?

Enough said.

On the other hand, as one commenter mentioned at the Happy Hospitalist blog in a post on why doctors' salaries are so high:

Take, for example, the Navy SEALS. As an elite unit, their work demands nothing but the absolute best of the best soldiers. In the midst of a shortage and recruiting crisis, the last thing the Navy should do is lower its standards in BUD/S to get more graduates to fill the demand. Lives are dependent upon the quality of the work that the SEALS do. In order to meet the growing demand for the SEAL ranks, the Navy has gone to ultra-marathons, 24 hour adventure races, and Ironman-type competitions to recruit the kinds of people who can hack it as a SEAL.

Medicine is no different. At a time when there are shortages across the board, why does it seem like the government and the industry have created less and less incentive for the best and the brightest to join our ranks? Arduous paperwork, debt, lawsuits, lack of emotional reward due to minimal patient contact, and the ever increasing leftist drone to decrease our income are some extremely powerful motivators to keep the best of the best looking somewhere else for satisfaction in life.

Getting doctors to argue about which among us should get the fee cuts buys into a myth that doctors' fees are the first and foremost reason health care costs are so high. Have doctors insisted on an intelligent discussion about true health care costs in Washington? Why not? Why are we being such sheep buying into the premise that doctors are the problem? Don't tell me that a doctor's pen is the single most expensive piece of medical equipment. Did my pen charge a patient a ridiculous $179,000 gross charge with a $43,000 "credit" seen on a recent 23-hour admission for a biventricular defibrillator implant?

No way. That's because the doctor's fee wasn't even included in the bill.

And what about the "Just To Be Sure" mentality that pervades medicine today? You know the one: "Mrs. Jones, I know you feel fine, but I think we should order another echo this year just to be sure your aortic insufficiency isn't any worse" or "Mr. Jones, we'd better check those liver function tests just to be sure your statin isn't somehow affecting your liver, even though we checked that test 6 months ago." Does the lack of liability reform and exorbitant malpractice awards force this line of reasoning? Dare we hold the politician's feet to the fire on this issue or do we just let the legal status quo with its ridiculous malpractice premiums continue?

I do not know what critical line was crossed that spurred Dr. Palestrant to sever his relationship with the AMA. Perhaps the damage is done. If so, God help us. But at this exact point in time, perhaps reevaluating and reconsidering the potential for reuniting the power of his forum with the established political standing of the AMA might be in the best interest to our profession, however staid the AMA might seem to him. With vigorous effort and collaboration, doctors might then have the ability to collectively voice their concerns to our political establishment and force policies beneficial to all physicians and their patients, rather than splintering our collective voice into impotent fractals of discontent.

Can physicians move out of their silos and develop consensus points we all agree upon?

The house is burning.

-Wes