Why Aren't Doctors Asking "Why the Secrecy?"

With the turn of the calendar to the new decade, the reality of health care reform has set in for doctors and patients. Already cuts to physician salaries and patient access to care are becoming starkly apparent to those of us on the front lines of health care.

I wonder why doctors have been so ineffectual relative to the other special interests “at the table,” in the health care debate? One would think that those with the knowledge base and skill to manage their patients would be the ultimate power brokers in the efforts of health care reform. Yet here we are, watching the commoditization of our profession at the hands of lawyers and politicians in Washington, eager to avoid being perceived as the spoiler.

There appears to be a curious dichotomy, neither very effective, in physicians reactions to the current health care reform plan before our legislature.

One is an almost incredulous, trusting, beneficent universe position of denial – if I work hard and try to help people, they won’t hurt me, right? Altruism is denial’s cousin in this sense: we need to help everyone and our very beneficence will protect us from harm. I will not suffer, my patients will not suffer, and my family will not suffer because anyone can see that I ask nothing. Selfless quality doctors by definition have no interest in protection of income, of time, of the profession – just appeasement glorified as humanitarianism.

We see this as our professional membership leaders failed to ask about the details of the health bills before them nor inquired about the potential flaws inherent to comparative effectiveness research promulgated on large, unfiltered populations. Rather, our representatives capitulated and mollified themselves with platitudes: “I’m sure it will all work out, after all, 30 million more people will have insurance.” No thought about the 23 million who still won't receive insurance nor the impact that these policies to save money will have for the majority of patients that currently have coverage.

The very idea that adult professionals are normally called upon to defend and define the boundaries of their profession is an anathema to these purists. We are scientists and technicians and humanitarians after all. And so, we wash our hands of the debate in the public yard. But none of this is in fact true. Underneath is the trusting assumption that if one works hard, if one hurts no one and sacrifices one’ life for the greater good, then the world will protect us. What a lovely simple position to cling to in the remaining months or years before the reform bill is implemented. It’s a stubborn adolescent holding on to a fair universe.

The other popular position appears to be one of extreme passivity and martyrdom. The chief marker of this syndrome appears to be comments about seemingly catastrophic events in a tone of voice normally reserved for the weather. Our pay is set to be cut 21% while 30 million more people will expect to be seen. Pay for performance measures will be the norm, despite no proof of their utility at improving care. Gosh, doctor, it looks you’ll just have to be employees now. Never mind that the majority of doctors serving patients are not employees of large hospital systems. "Yep, we lost the farm in ’23, as your mother got sick and of course they repossessed the truck…”; the resigned laconic language of hard times. “Nothing I can do about it” has become doctors’ new tag line.

Passivity or denial. As if doctors have no power.

Sadly, as a political force perhaps we don’t. Harnessed with guilt about harming our patients if we set any reasonable boundary whatsoever, perhaps we are hogtied. We are the ones with the skills. We are the ones with the lifesaving relationships. And yet, as a profession, we feel powerless in this debate.

It is interesting to wonder about the source of this empowerment paradox.

To reinforce this observation, in the midst of the final negotiations that will affect every American's health care, a lonely voice in the sea of rhetoric came forth to insist on transparency to the negotiations to consolidate the most important piece of legislation that will affect every one of our patients' lives. Sadly, it was not the AMA or a collective of physicians voices like SERMO, but C-SPAN.

If we as professionals have any gonads or interest in what will ultimately affect the health care of every American across our country, then we ALL should join C-SPAN in their insistence that “all important negotiations” affecting the reconciliation of the final health care bill be televised publicly.

Mr. President, are you listening?

-Wes

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

Sermo Questioned

Although others have commented before on Sermo and the AMA, Medgadget and Enoch Choi raise some must-read concerns to the discussion of this online "physicians-only" forum.

Given the push for doctors' life histories to be made available to the public, it seems doctor imposters might also include people from the pharmaeutical and medical device industries.

Yuck.

-Wes

11:35 AM CST - Update (h/t KevinMD): Medgadget's Open Letter to Sermo's CEO.

Sermo and the AMA

Peter Turner over at Opensource.Association has some interesting thoughts on Sermo and its relationships with the American Medical Association.

My point is why does the AMA need them to create an environment where “people come together, have their voices heard, and send messages out?” In fact, advocacy is not the main purpose of Sermo which is to sell aggregated information to institutional clients of Sermo....
Would you trust this model?

Doctors are paid for posting and even given Amazon gift cards to join. One student doctor said he was getting between $40-100 per month as a result of his postings. Clients (those in the lower half of the Sermo business model diagram below) pay a subscription fee and in return can post questions to the Sermo community. If doctors vote on one of these postings, they may be financially rewarded for “your astute observations.”

And I especially like the part that explains that full access to JAMA and the Archives journals are free on Sermo, but AMA members must pay for them.

-Wes