Wednesday, November 10, 2010

Schooling Doctors

If you haven't been introduced to 33 Charts, a blog by pediatric gastroenterologist Bryan Vartabedian, MD, ("Dr. V") take a minute to do so. I was struck by his honest post entitled "Is It the End of Private Practice?" in which he laments:
I was driven out of private practice in 2004 by rising malpractice premiums and plummeting reimbursement. In Texas at the time the trial attorneys ran the place and medmal insurance carriers simply couldn’t keep up with the greed.

Medical practices are just too expensive to run and the services that physicians provide are dangerously undervalued. You do the math. Sure it’s a complicated issue. But the end result is institutionally employed doctors with institutional pay and the risk of institutional service.

Of course we need to contain costs. And I know, it’s about the patient and nothing else. And all doctors are filthy rich. Of course they are.

Self-annointed experts blather about doctors, medical economics, and solutions. Government bean counters and consultants think they’ve got it figured out. They have no idea what we do, where we’ve been, or the staggering self-sacrifice necessary to manage a panel of chronically ill patients.

I spent the best years of my life working 15-hour days as a scut monkey training to get where I am. But the next generation will be more judicious. As society sees what doctors do as a commodity, society will see commodity doctors.

The plight of the physician in America is now considered dead last. But don’t cry for me. Cry for your self.
Almost immediately, as if to quell Dr. V's concerns, came this comment:
Hard to challenge your conclusion as well as the likely direction of the key trends. But ‘interesting energy’ Bryan…perhaps a calling to leadership?

There is way too much fatalism, and ‘poor me’ victimization in dis-organized medicine today; which I also sense in your piece.

Where is the ‘what’s my (our) part’ reflection? Where’s the ‘ownership’ of the dysfunction?
Bryan was "schooled."

Please, good doctor, don't mention these things, it is unpleasant. Don't you want to be a leader, good doctor? It's not nice to buck the establishment. You must conform now. Don't you want to achieve a senior leadership position in our organization?

For doctors, the subtle undertones of such a challenge are tough to ignore. We aren't stupid. There is a disproportionate salary reward for doctors who chose the leadership route in large health care organizations. Since doctors are exceedingly gifted at working systems to their personal advantage (can you say "medical school gauntlet?"), and with large corporate structures with large corporate management teams with large corporate human services departments eager to earn their employee-doctors' trust, they need "key opinion leaders" that can influence their younger peers. The temptation to abandon patient care in favor of "leadership" is seductive. Worse, when clinical doctors and administrative doctors butt heads in sticky situations regarding patient care, the trump card for administrators looms large now lest you be labeled a "difficult doctor."

"You must allow the EMR to order tests automatically, doctor, it's in the guidelines."

"But my patient will have to pay for those tests!"

"Dear doctor, you do not understand, this is in the best interest of quality care."

"But my patient can't afford all these tests!"

"But, dear doctor, our hospital report cards will suffer if we don't have these tests documented every six months on their chart and if our report card isn't as good as our competitor's report card, you won't make as much money either."


"Shall we move on?"



Dennis said...

Not too long ago after an ablation my ICD fired 12 times in 15 minutes leaving me thinking I would die. It was a error in judgement as to the setting threshold of 150 by a prior EP that slipped through the crack. After the 3rd shock I call 911 and when they arrived everyone thought it wise to hit the ER. I was given a bolus of Cardizem and my HR began to drop... I was not in A fib. At the ER a Medtronic tech was called and the device interrogated... it was a fast SVT no doubt from the ablation. My new EP was called the the device set at 200/220. The ER did nothing other than draw blood and check my enzymes which were elevated due to the multiple shock trauma. However the ER doc decided I should be admitted to be observed. OK... maybe one night but 2 1/2 days of monitoring? I had even brought my own Tikosyn and Toprol. A few days ago I got a copy of the bill to medicare and tricare. The EMT was $1400, the hospital was $16,000, the local Carido was $4,000. Of course the bills were discounted but the billing speaks for what is happening in medical costs. Without insurance I would be bankrupt and would therefor shortly die. As the girls in Thailand say... "no money, no honey"

DrV said...

So much talk about patient empowerment. Little concern for doctor empowerment. Gregg Masters didn't have bad intentions with his comment, however.

Long before you and I were at the bedside, Wes, the medical community lost its voice. Big discussion but I think that's alot of it.

Thanks for the interesting follow up to my post. And congrats on your Oprah mention. If you make it onto the show I want to see you jump on her sofa like Tom Cruise.

Keith said...

Corporate structure and presumed leadership rule the day. CEO's and medical leaders (I use this term loosely) are the ones collecting most of the loot and physicians have been willing sheep to go to work for these ever enlarging medical organizations. The good aspects are organizations that are poised to coordinate care and work as a team, and that have the capital (built up from the good days of medical reimbursement) to install these expensive EMRs. The bad is a corporate mindset and a focus on th bottom line that have served to make our medical system one of the most expensive in the world. As more physicains become employed, they will be less able to speak out honestly (I bet you have to carefully watch what you write for fear of infuriating your boss)and less able to creatively affect the health care system in a positive manner.

Pyhsician leadership is a myth, at least where you practice Wes. It's more like physician sell out to perform the bidding of hospital administration. In this respect, your writer is correct that the future for physicians is not very pretty.

DrWes said...

Dr V-

re: couch jumping on Oprah-

For you, Bryan, anything...

Unknown said...

When I look at the way physicians have been bought and sold over the last 20 years, I am not at all surprised by the concerns raised in the post.

Physicians killed the insurance 'golden goose' in the 1970s with the greed of a small percentage who realized that insurance was paying what was billed, and billed accordingly.

Physicians killed the HMO efforts in the 1980s when a small percentage realized they could do better financially by not ordering things or treating patients in the capitated system, and treated accordingly.

Physicians have continued to make poor choices throughout the 90's to the present. We have stood against reform that in any way might make us more accountable for the money we spend. That might review our actions against our peers for quality, that might require us to continue to prove that we have kept up with the literature through a maintenance of certification.

We continue to sit down with Pharma, let them wine and dine us, and influence the ways we practice and prescribe. We continue to indulge the Key Opinion Leaders even though they have strong ties that bind and bias with Pharma. We have stood by as the patients have effectively been shielded from the actual cost of 'medicine' so that they have no real comprehension of what insurance costs them, what drugs cost them, or whether or not the tests they feel they need are useful or not.

We have stepped away from actually listening to our patients, and instead spend time interrogating our patients, treating labs, not people. Relying on procedures over history and physical. Slowly severing the connection between the Doctor and the Patient.

In doing all of these things we have couched our language in the form of 'putting patients firs' etc. Our requests are always about the benefit of the patients. However, when you scratch below the surface you find that it really seems to be about remuneration or self-protection.

Working in the system in the United States is difficult. The costs are tremendous. However, if we step back from our fear over losing control, and return to truly caring for the patient, listening to the patient, advocating for the patient, then we may just find a job that is rewarding in ways that money cannot buy.

DrWes said...


However, if we step back from our fear over losing control, and return to truly caring for the patient, listening to the patient, advocating for the patient, then we may just find a job that is rewarding in ways that money cannot buy.

Nicely said. But we cannot just do charity care either. Money at some reasonable level, will be still be needed to reward people's hard work and to attract our newest collegues in the years ahead. My concern is that, thanks to all the business interests between the doctor and patient, that it becomes nearly impossible determine what represents real monetary value for the patient.

Anonymous said...

I've gotten fed up with our local prestigious tertiary medical center affiliated w/ a med school. Even with FFS/PPO insurance, getting care via them makes you a de facto HMO patient due to all the regulatory oversight by the administration. Asked the chief of medicine to recommend an independent internist in private practice since I was tired of the rules and regs as a patient. Getting a mammogram ordered and scheduled was a nightmare.
Just found myself a solo internist practicing old school style. Hope he stays in practice another 10 years.

Gary M. Levin said...

Let us know when you will be on Oprah.