Recently, I’ve been reading less-well known health care blogs—and finding some provocative stories.
Below, Edwin Leap–who is a physician and a blogger–tells a story about trying to find a specialist for a very sick child in the middle of the night.
Let me preface Dr. Leap’s story by explaining that, in the past, specialists who had “privileges” at a hospital (to treat patients there and to use the hospital’s very expensive equipment and operating rooms) were routinely “on call” to treat emergency patients. But these days, more and more entrepreneurial doctors are refusing to fulfill what was once seen as a traditional duty—unless they are paid.
In Money-Driven Medicine, I quote the chief operating officer of a rural community hospital who recalls a conversation with a young doctor who walked into his office and informed him that he would no longer be willing to be on call for the ER. When the doctor had signed on with the hospital, he, like all of the other physicians, had agreed to be available to treat ER patients one week a month. Typically that might mean coming into the ER two or three times during that week. But now, he explained, he wanted to spend more time at home with his children. He was not willing to continue answering the calls unless the hospital would pay him $80,000 a year.
The COO was nonplussed. He knew that an additional $80,000 would work out to $2,200-$3,300 each time the physician came in ( He did not ask how the doctor had calculated that quality time with his children was worth $80,000).
“But we have a contract,” he protested.
The doctor nodded: “Times change,” he said easily.
The COO knew that he had a legal and moral responsibility to cover his ER. He also knew that if he paid
this physician, he would have to pay all of the other physicians.
But he didn’t even try to negotiate. Because he also knew that if he
refused to pay the amount asked, he risked alienating not only this
doctor, but all of the others who practiced at his hospital. In
response, they might well begin referring some of their most profitable
business to a hospital in a city just an hour and a half away. He had
no choice but to agree.
This is not an uncommon situation; covering ERs has become a problem
nationwide. A report by the California Senate Office of Research offers
an example of what can happen, citing the case of a man suffering from
internal bleeding who came into the ER of an unidentified California
hospital. Over the next three hours, six gastrointestinal specialists
refused to come to the hospital to treat the patient. Finally, the
director of the emergency room lured a specialist to the hospital with
the promise of $500 cash. The specialist then performed the needed
procedure, and the bleeding was stopped.
Below, Dr. Leap’s post. I will be very interested in your comments.
You won’t help a critically ill child? Is this how low we’ve fallen?
Dr. Edwin Leap, April 4th, 2008
One of my partners recently took care of a child with a
retro-pharyngeal abscess. For the non-medical, this is a serious
infection behind the throat that can easily result in loss of an
airway. The child, some 20 months of age, was obviously very ill.
We frequently don’t have an Ear Nose and Throat physician on call at
our hospital, and the night that child presented was typical. So, the
only viable option was to transfer the child. However, when my partner
tried to find an ENT surgeon to care for this child in a nearby town,
he was met with this response: ‘I’m not on call for your hospital.’
Now, I understand not wanting to have ridiculous referrals. I
understand not wanting to increase your already busy workload. I
understand that being a surgeon is very time intensive already, so the
doc in question probably didn’t need more work. But the thing is, it
wasn’t a drunk with a broken jaw, an elective tonsillectomy, or even a
fish-bone stuck in the throat. It was a child who might have died.
Well, I guess Hippocrates didn’t cover that scenario. You know, sick child from another town. After hours, and all that.
Is this how far we’ve fallen? See, we don’t have endless options for
transfer. We practice in a semi-rural area. It isn’t Manhattan.
There aren’t surgeons on every corner. Trust me, if we could have
handled it, we would.
Is this what doctors have become? Technicians who feel no sense of
urgency or obligation to the sick, in fact, to the most vulnerable of
the sick? Is this how we want our children, or grandchildren,
treated? Dismissively? With a ‘good luck’ and a hearty pat on the
back? With a ’sorry, but you know how business is these days?’ I hope
to heaven not.
That sort of behavior makes me feel angry, and a little sick. It makes
me see how malpractice litigation could get out of hand, or how
national health care might slip in the back door. If we’re so
unprofessional that we can ignore a critically ill child on a
technicality, then maybe we’ll deserve whatever happens.
Fortunately, the overwhelming majority of docs I know would never
behave that way. Like the intensive care docs who ultimately accepted
the child, they do the right thing at the right time, the way we were
taught.
We need to call this behavior what it is; childish and unprofessional.
And we need to remind ourselves, every day, of why we do our jobs. And
that we have a duty to the sick and injured, convenient or not.
It’s worse than this, but at a more basic level. A few years ago, a co-worker and his family when to a local event at a public park and while there, his young daughter broke her arm. This was on a Saturday of a holiday weekend.
They took her to the ER and proceded to sit there for SIX HOURS while the ER called doctor after doctor, trying to find someone who would come in an set the girl’s arm, as the doctor on staff at the time didn’t feel confident enough with a pediatric case to do it himself.
The pediatric specialist on-call flat out refused to come in. He was at a holiday party. So they had to call people who weren’t on call and finally found someone decent enough to come in on a (by this time) Saturday evening.
We’re not talking about surgery here. Just setting a broken bone. But because it was Saturday, on a holiday weekend, they couldn’t get anyone to help her.
Doctors have fallen from grace, they care not one bit about a patient, but about the amount of money they can obtain from anyone they treat,. The medical profession has become a cash cow and a total disgrace. Yes, I understand they have/had outrageous educational expenses and expect to be duly rewarded for all their years of studying and acquiring their degrees. However, the normal and sick patient should never be the subject of their making money !!! It is a disgrace how astronomical their fees have risen to cover basic costs. An er physician now has the audacity to send bills to an er patient for 6,000.00 because the doctor is an out of network doctor….thats ridiculous.
Doctors are a disgrace, plain and simple—I see one and I see nothing but dollar signs, Physician heal thyself and bill thy self and see how it feels when u receive your outrageous bill….Herbs and potions for me—-medical practicioners u are all devils! That spells EVIL….
Margaret–
I understand why you are so disillusioned about doctors.
But the majority do not set their fees.
Those fees are set by a national committee of specialists.
I often have been critical of how much doctors and hospitals charge us,
but I do think that a great many doctors actually care more about their patients than they care about profits.
(Is this the majority of doctors? think the answer varies greatly both by what specialty they are in and where
they practice. In some parts of this country, health care is more “money-driven” than in others.
I suppose one way to look at this is that it’s just another symptom of how the U.S. citizenry, or at least those in the groups with more sway in our social structures, has become pathologically “Me”-focused, having lost sight of the inherent value (and, I’d argue, a necessity for being a humane society) of being “We”-focused.
In his documentary “Sicko” Michael Moore correctly points out the “Me vs We dynamic as a huge issue that must be addressed and corrected if the U.S. is to ever create a way out of our disgraceful health care system that leaves 47 million totally uninsured while millions more are undersinsured, and most of the rest are anxiously insured (due to rising costs).
It’s way past time that we catch up to every single other modern industrialized country on earth and create a national health insurance program, preferable with cost-effective single payer financing such as improved Medicare-for-all.
Maybe I’m reading it wrong but I find it very disturbing and depressing that the doctor who wrote this important post about the ill child in the middle of the night (I have a 3yo and a 7yo…) slips into his story the last 11 words in this comment:
“That sort of behavior makes me feel angry, and a little sick. It makes me see how malpractice litigation could get out of hand, or how national health care might slip in the back door.
To my thinking (shared by the majority of Americans if the polls are accurate) what this country urgently needs is a national health insurance program! Why would Dr Leap seemingly condemn this as something that “might slip in the back door”?
The concept of social solidarity is at play in this post and I hope we’ll each do our part to take an active role in moving our society toward a more caring and humane “We” as in “We’re all in this together” and have that reflected in our social programs. This notion is discussed in detail in Maggie’s excellent posts on National Health Reform at TPMCafe.
BTW, I’m in Boston and the MA individual mandate insurance law is a far cry from social solidarity. It is bankrupting our state b/c it relies entirely on the private insurance market and contains inadequate subsidies to assist all who need help in affording the high-cost products.
From the official state figures, it’s looking like upwards of 200,000 residents will soon be fined (up to $912.00 a year) simply for not being able to afford to buy a private insurance product and not being eligible for state permission to remain uninsured (called getting a mandate “waiver”).
Don’t take my word for it, read thru various reader comments on these 2 mainstream MA health reform blogs:
http://blog.hcfama.org
and
http://www.wbur.org/weblogs/commonhealth
Yes, this is exactly how far we’ve fallen. Even the most prominent Level 1 trauma centers keep banker’s hours. In our experience they couldn’t get a hold of their surgeon’s/specialists/treating physicians after 5 pm. It goes far beyond staffing an ER. If you ask me, a fishbone in the throat or a drunk with a broken jaw doesn’t deserve to suffer or be neglected any more than the next person, we’re supposed to be a civilized society. Were I that hospital COO I would not have agreed to blackmail or threats or intimidation by a physician. Do you really want that physician treating your patients? Reflects poorly on the entire institution. Were I that hospital COO I would have called my local media and broadcast a story about the doctor who’s blackmailing the entire community. People like that hospital COO are the one’s allowing this to happen, I’m glad Dr. Leap posted this blog, yes this exactly what we’ve become.
Anne, I don’t know how on earth this was allowed to pass. How can our government order us to buy a defective product (health insurance) to pay for a defective service (health care)? Are there any lawyers reading this? This smells like a class action lawsuit. It’s outrageous. I’m all for a single payer system, keep the capitalist system for elective procedures, but we’re not doing ourselves (as a society) any favors by not providing basic and preventative care to our citizens. This is a no-brainer.
Yes, how low have we fallen. This can only happen in a democratic republic if the people let it. This is the same constituency that seems unfased by torture,the loss of habeus corpus, 20,000,000 children without healthcare…
Our doctors and hospitals and insurance companies and pharm, they’ve all failed us.!
WE HAVE MET THE ENEMY, IT IS US
While I am not very familiar with the economics of operating a community hospital in a rural area, I wonder about a couple of things. First, my understanding is that for many hospitals, no matter where they are located ,roughly half of their inpatient admissions come through the ER. While ER’s are often considered money losers, a lot of that has to do with hospital accounting. For example, if an ER patient is sent down the hall for a CAT scan or an MRI, the Radiology Department gets credit for the revenue, not the ER. Moreover, many rural hospitals are the only such facility for many miles around which gives them a lot of negotiating power in dealing with insurers who need a hospital in their network to cover that area. Assuming there is enough patient volume to sustain the occupancy rate at an economic level, I don’t see why doctors cannot be paid on an hourly or shift basis to cover the ER up to some specified number of days per month.
For larger hospitals in more urban areas, it might be helpful if more medical practices were owned by hospitals. Alternatively, if doctors were organized into much larger groups it might be easier to cover evenings and weekends as well as ER duty. I find it strange that in our $2 trillion plus healthcare industry, we have very large companies (as measured by revenue) in the drug, device and insurance industries, but doctors, who are at the core of the system, practice, for the most part, in individual or small groups like a cottage industry operating with a guild mentality. Even the hospital sector has very few companies or non-profit groups with more than a couple of billion dollars in annual revenue as compared to over $48 billion for Pfizer last year and over $70 billion for UnitedHealth Group. While there is not all that much economies of scale to be reaped by hospitals that are part of a large group, there are advantages in such areas as access to capital (helpful in paying for electronic records systems), negotiating with payers, and driving systemic change like figuring out how to reduce infection rates and other preventable errors or moving to bundled pricing for expensive surgeries or developing user friendly price and quality transparency tools for both patients and referring doctors.
Barry, here in my city a small group of physicians finally stopped performing procedures at our local mega-hospital because they could never get the equipment and staff they requested to perform surgery safely. They finally left and started their own surgical practice across the street. Interesting theory but it leads to monopoly and I do not think large hospital systems should monopolize the community, here’s an interesting story about a larger group of physicians who did try to organize to improve care: http://www.click2houston.com/investigates/14859070/detail.html
Things are rarely as simple as they seem. I lost a close friend to an infection caused by a fishbone in the throat. In fairness, he was frightened of doctors, and procrastinated being seen until he decided to go to a Kaiser ER, where they found him to be in septic shock and quickly went into multiple organ failure. I can’t really say the system failed him, although I did read a study recently about making local anesthesia, cooling, etc., the standard of care for pediatric injections — he was terrified of injections, possibly from personal experience, possibly because his father injected insulin.
The broken bone is a different matter. In a disaster situation, a simple fracture gets rather low priority. If there was a question of getting a pediatric orthopedist, the ER physician reasonably would be responsible for adequate pain control, but the reality is that nothing terrible is likely to happen due to a 6 hour delay.
Part of the problem is the increasing breakdown in relationships among patients and physicians. Hospitalists may be a good idea from a utilization standpoint, but handoffs can be bad both from outside physician to hospitalist, and even between hospitalists.
Of course, just when you say it’s one way, it goes the other. I happened to have a very nice conversation with a diabetes case management nurse from my insurer, and we concluded I needed an endocrine consult. Today, I was in that office building for unrelated reasons, and thought I’d make an appointment with the recommended endocrinologist. Even though my insurer doesn’t require gatekeeping, even though I have full records, their office procedure was they wanted a primary physician order faxed to them, they would tell the primary care physician when my appointment would be (i.e., no opportunity for me to mention my scheduling needs), and the primary care staff inherited the job of tracking me down and giving me the appointment.
If it wasn’t that I met the endocrinologist in the hallway, and gotten a good vibe from him, I’d try someone else. The administrators have taken over.
Lisa,
I agree with your monopoly point if only one hospital system controls all of the inpatient beds in a region. That is why there needs to be at least two competitors. In my suburban NJ county of approximately 500,000 people, there are five hospitals. One calls itself a community hospital and the other four are called medical centers. All have between about 250 and 500 beds each. If I were a payer (insurer), I would rather deal with two or three ownership entities instead of five. If there were only two or three owners instead of five, it is also less likely that there would be as much duplication of imaging equipment and other facilities as there are now.
I would also point out that in most categories of retailing, for example, there are two national chains that control most of the market share in a given region. In discount department stores, it’s Wal-Mart and Target with K-Mart a weak 3rd. In drug chains, its Walgreens and CVS with Rite Aid a weak 3rd. In home improvement centers, it’s Home Depot and Lowe’s. In office supply stores, it’s Staples and Office Max or Office Depot. In warehouse clubs, it’s Costco and Sam’s Club (division of Wal-Mart). In every case, there is plenty of competition, and consumers benefit from good prices and plenty of selection. There is no reason why the same could not work in healthcare with adequate cost and quality transparency tools available in a user friendly format for both patients and referring doctors. An objective, unbiased infomediary, akin to Consumer Reports, that could help patients sort through the risks and benefits of various treatment options would also be helpful.
I agree with you, Barry, but I don’t think what I see here is healthy competition, I see corruption and collusion. Maybe we can have healthy competition if there was better governance of the industry.
I agree that it seems there has been a fundamental change in how doctors view their responsibility to patients. However, there are a few points that no one has brought up here:
1) The phrase ‘You get what you pay for’ comes to mind. The comparison to the golden days of yore when men where men and doctors were angels is perhaps a bit unfair. As a young physician myself I can speak only from discussions of the past, but it seems to me that doctors where, at one time, respected members of society. Whether it was the chicken or the egg that brought about the change to our current situation, I really don’t know. What I do know is that I begin my career with the foreknowledge that there is a very good chance I will have to defend myself in court. I also see how much medical school cost me and that my government is continually engaged in the process of squeezing my future payments in a vain attempt to ‘save money’ (or whatever excuse they’re using at the time). Then…I also get to deal with patients who either have managed to use Google and in a single hour believe they have attained more in-depth knowledge than I have in 11-14 years of post-high school education or don’t heed my advice and then come back wondering why they’re not getting better. Yet even after all that, I still know in my heart that I made the right choice. The point is that there just might be at least two sides to the whole ‘doctors are a bunch of money-grubbing ___” story line.
2) The case of random doctors being called because the on-call doctor refuses to come in, aside from being grounds for suing the on-call doc, raises an interesting issue. What is a physician’s responsibility to a ‘random’ person? Yes, the little girl needed her arm set and someone needed to do it…but which individual doc should have done it? What if they called me and I said yes? She gets taken care of…and next time some dirtbag on-call doc doesn’t feel like honoring his contract guess that gets called away from his family picnic? Me. So, the real problem in that case was an individual not honoring his contract and he should have to answer for that. However, the question remains as to whether or not the not-on-call docs had any moral obligation to cover for their dirtbag colleague (they do, in my opinion…but then they should have the right to flog the piece of crap who put them in that position).
Just some random thoughts on the other side of the story.
Who said doctors are a bunch of money grubbing ____
t, Jeff C, Ann Malone R.N., Lisa, Leftbank, Barry, HC Berkowitz–thank you all for your responses.
t’s post covers many of the points you touch on, so
let me begin there.
First, with regard to the central moral question, I agree with t, if a doctor is on call and refuses to come in that doctor is the real villain here. That is simply outrageous.
(And I would add that if there is no one in that specialty on call at a hospital (which often happens) the specialist on call at a nearby hospital has an obligation to the community to come in.
Jeff C– Even in the case you describe “only a broken arm”– I agree wtih you that the pediatric specialist who refused was completely out of line. Who cares if it was a holiday? His peers need to talk to him about his responsibities and professionalism. . .
t — At the next level, when you begin calling around to docs who were not on call, I agree that it is hard to say “which one” has the obligation. If the
patient is suffering from a condition that could get worse, in some sense, they all have an obligation to respond; in some sense, none of them do.
If I were a doctor who received a call, and I had come to the ER when I wasn’t on call in the last few months, I would explain that, ask if they would call someone else (assuming it was not a case where time was of the essence) and if they couldnt’ get anyone, come back to me.
I also agree with Howard that there is a real difference between waiting for a broken arm to be set (assuming the ER doc can keep the child out of pain) and waiting with a fishbone stuck in your throat, or with a very small child who is very ill.
BTW, LISA< in the original post, I was bothered by one thing Dr. Leap said--that he could understand how a doctor might refuse to come in for a drunk with a broken jaw . . . Here, I agree with Lisa--that person deserves care too. The fact is, if not attended to, the broken jaw could set itself in such a way that the person wouldnt' be able to eat properly. The jaw would then have to be re-broken, and re-set. In addition, there is a real possibility that the jaw could become infected and the whole situation could go downhill from there. I really don't think that how we feel about the patient (a darling 20-month-old versus a 60-year-old alcoholic) should determine whether or not they get really necessary care. t, I also agree with you that doctors no longer receive the respect they once did. Whether this is the medical profession's fault or society's fault is hard to say. As you suggest, it's a which came first, the chicken or the egg question. Some doctors have ceased to act like professionals; and many others (insurers, drug-makers and patients) have ceased to treat them as professionals. Meanwhile, the clash between hospitals and doctors is particularly unfortunate. They need to work together. They shouldn't be competing with each other. I think the old system, which asked doctors to be "on call' a few day a month for the ER-- in exchange for being able to use the hospital's costly capital equipment, operating rooms, nursing staff, etc for free-- was fair. And back then, I'm quite sure that doctors themselves thought of it as fair. Medicine used to be about professionalism and a certain amount of voluntaism. Doctors need to feel part of a community of doctors and hospitals serving a community of patients. As Ann puts it, the problem is that we have become a "me" society rather than a "we" society. The good news, I think, is that young people going to medical school these days are like t-- they know the situation is bad in many ways, but they choose medicine anyway. This means that they really want to become doctors--and they realize that medicine is not just a business like any other. It's a profession. You take an oath. People coming out of med school today also are much more likely to want to work as a part of a group, on salary, rather than as lone, solo entrepreneurs. I think this also helps get past the "me" mentality to the "we" mentality. Kaiser comes to mind--Many doctors who work for Kaiser are very proud of the organization, and the generallly good care they give, particularly in Northern California. I know Kaiser is not perfect, but doctor turnover and patient turnover is very low. People stick with Kaiser--which says something. Barry-- No, most hopsitals do not make money on their ERS. Have you ever spent 4 or 5 hours in an ER? If you did, you would notice that most people are poorly dressed. Many are on Medicaid; many are uninsured. These are people who have no doctor to go to when they are sick.. (Most specialists do not take Medicaid patients, and many doctors do not take the uninsured.) So they have to go to the ER for their regular health care, which is why our ERs are so crowded. (Go to an ER in Canada and you'll find just a few people there; in Canada everyone has a doctor.) Finally, the whole idea of paying doctors to be on call undermines the ideals of voluntarism and professionalism I was talking about above.
The COO pays everyone else in the hospital to come in after hours the Xray tech, the nurse on the floor, the OR staff, but the doc who is ultimately taking responsibility is supposed to do it for free. Give me a break from all of the altruistic bullcrap. Nobody is entitled to his knowledge and time for “community service”. He has earned the right to ask for whatever he wants. There wasn’t much community service going on when he was going 250,000 in debt and working 100+hour weeks during residency in an innercity ER. The COO has never had to calculate “quality time” with his family because TPS reports don’t need to be done at 3:00 a.m. or in the middle of one of his children’s baseball game. Medicine has been made into a business, so you take it all with that. Being a physician is a job and a job only, never will it be the Marcus Welby- Kumbaya Community Service Cult that most liberals want it to be.
Jenga–
You wrote: “Medicine has been made into a business, so you take it all with that. Being a physician is a job and a job only.”
I understand what you are saying. And as I have written in earlier posts, I think med students need much more help with loans.
But I never want to be treated by a doctor who sees medicine as “a job and a job only.” And none of the many doctors I know, like, and respect would accept that definition of what they do.
A physician that puts his family above his profession is one that has his priorities straight. Its easy to say what you would do as a physician taking call, but unless you are a physician that is currently taking call somewhere you really have no idea what you would do. Unless the facts of the case are presented which shouldn’t be done in a forum like this or anywhere else for patient confidentiality, no one is in any position to 2nd guess the on-call physician. You always hear one-sided arguments on the Internet and situations that may seem like an emergency to an ER doc may not be to someone with a much more vast amount of training in that particular field. The hippocratic oath mentions nothing of being on call every 3rd night and I’m still waiting for why it is OK for the COO to pay everyone else involed with an emergency case (CT tech, Circulating Nurse, CRNA, Scrub Tech, Recovery Nurse), but not the one that ultimately takes full responsibility.
Jenga wrote: “Being a physician is a job and a job only, never will it be the Marcus Welby- Kumbaya Community Service Cult that most liberals want it to be.”
Sorry — not true for me, my father before me, or my grandfather before him. If it is true for you, then you are missing out on a lot of opportunities.
You can discuss the particulars of the case without violating pt confidentiality. Hospital X Dr Y, etc etc etc. Jenga, I didn’t hear anybody say doctors should work for free, the thread started by discussing a doctor who did not honor his contract and the way he went about it.
Maggie and Howard, thanks for your comments, but I have to say that as a parent, when you have a four year old with a broken arm, six hours is way too long a time to wait for treatment. Maybe her life isn’t in danger, but the idea that you can supplant timely treatment with pain medication is a fine example of what is wrong with our entire health care system – take a pill and wait. You wouldn’t wait six hours to get your tags. If they made you sit six hours for your tags, you’d be demanding somebody get fired.
I don’t know what happened to that doctor. Most likely, nothing at all.
Jenga, lots of people work jobs where they are on-call. Few of them like it. Many of them are salaried and don’t get paid for it. Most of them will get fired if they refuse to come in when they are on-call. If an on-call physician refuses to come in for anything other than an equal or greater emergency, that physician should be fired or banned from the hospital or, at the very least, heavily fined. But that is another problem with our health care system – doctors don’t police each other for fear of being policed.
And T- good for you for accepting this calling to medicine. If you treat it as a calling and a responsibility, rather than a business and a job (like Jenga), you’ll greatly reduce your chances of being sued.
Jenga–
You wrote:
“I’m still waiting for why it is OK for the COO to pay everyone else involved with an emergency case (CT tech, Circulating Nurse, CRNA, Scrub Tech, Recovery Nurse), but not the one that ultimately takes full responsibility”
Jenga– the other people you mention are working for the hospital–they are not generating separate fees for themslves. .
The doctor with provileges is not a hospital employee–and he doesn’t share the fees he makes in private practice (or the fees he makes when he hospitalizes patients) with the hospital.
Nevertheless, the hospital lets him/her use its equipment and its operating room, at no charge.
Understanding the dollar value of that access to the hospital’s capital equipment, doctors fought hard . earlier in the century, to make sure that midwives, chiropractors and osteopaths did not have similar access to the hospital’s facilities.
As Paul Starr explains in his history of American Medicien (The Social Transformation of American Medicine):
“The opening of community hospitals to private practitioners meant they were able to use the capital invested in hospital facilities by the public, at no charge, and without any restriction on their fees. (Doctors originally paid for the use of hospitals by giving free care on the wards.)
Today, many younger doctors take the hospital and its facilities for granted. They feel they have a right to use whatever the hospital has to offer–and feel no need to “pay back” to the hospital or the community.
This is something that Starr (who won a Pulitzer for his book in the early 1980s) could see was beginning to happen as medicine became more and more about money:
“The organizational culture of medicine used to be dominated by the ideals of professionalism and voluntarism, which softened the underlying acquisitive activity. The restraint exercised by those ideas now grows weaker.”
It’s a shame that some doctors no longer recognize that soem degree of “voluntarism” goes hand in hand with professionalism.
It’s nice that you put your family first. What if
everyone did that?
As a professoinal, I have often had to put my family second. I’m about to go home, and a story breaks. The newspaper I work for needs me to report on that story–readers depend on us for information. So I cover it.
I suspect you wouldn’t be too happy if, say, in late November of your child’s first grade, the teacher announced that she was pregnant, feeling a little tired and had decided to take a medical leave–and your child then had a series of subsitute techers until Februrary, when she had planned to come back.
But in February, she decided to “put her family first . .”
How would you feel if 6-year old broke her arm late at night, it needed to be set, you took her to an ER and the orthopod wouldn’t come in . (He’s putting his family first).
“Just give her some painkillers,” he tells the ER, “tell the mother to take her home, and go to a doctor in the morning. What’s she making such a big deal out of it? It’s just a broken arm.”
Frankly, I can’t imagine why someone with your priorities would choose medicine as a career.
How incredibly generous of a hospital to a allow a physician to use their equipment. You leave out a big thing in your rant. The hospitals get paid big time to have their equipment used. They aren’t letting the physician use it for free, THEY GET PAID when the physician uses it. They get zero when he or she does not. So don’t act like it’s a benevolent offer of the hospital to allow physicians to grace their hallways. With no physicians the hospital doesn’t exist. The hospital does not share the fees it makes off of the doctors time and use of the equipment either. They have had the ability to hold back cuts in reibursement other physicians could only dream off and now that the physician begins to use their own leverage they expect things from him or her that they wouldn’t do themselves.
Volunteerism- most of those requirements have already been met by graduates by working for upwards of 5 years in a 100+ hr a week residency for 25,000 a year that and a 250,000 dollar debt. Those two things together and they’ve volunteered themselves into a mighty fine hole.
What’s the acceptable angulation for a forearm fracture in a 6 year old? Painkillers and a splint may be better care, maybe the reduction could be done during the day with sedation provided by an anesthesiologist and the child with an empty stomache, mobile fluoroscopy and a cast tech. It may be BETTER care. It’s easy for those to second guess that know nothing about the field. But that may not be convienent and that’s what is most important. Again if you don’t know the particulars of a case don’t second guess.
Jeff- who are those “people on call”- are they say, your plumber? He will come repair your broken pipe at 3:00 am for free. Give us his phone number I have to have that on my fridge.
As far as banning them, that will do wonders for ER coverage. Ask any ER doc how hard it is now to get specialty coverage? Oh yeah, case in point THE ORIGINAL STORY.
What I understood by Maggie’s points were doctors are not charged by hospitals to use their equipement (I’ve been enlightened, learn something new everyday) and that both the hospital and physician are generating revenue by this arrangement, neither paying the other. In exchange, from what I’m understanding, physicians are expected to cover the ER. Jenga, what is the point of YOUR rant? You want physicians to be paid to cover the ER, and charged for using hospital facilities, equipment and resources? This would escalate physician fees and further increase healthcare costs. Nobody said plumbers work for free. She said there’s plenty of professions who put their family second.
What goes around comes around. Physicians are tired of being expected to work for free, being sued at the drop of a hat. They are people too, they are not martyrs, they have a breaking point. Perhaps we are starting to hit it.
Jeff C–
I basically agree that six hours is a very, very long time to wait with a small child and a broken arm.
I simply meant to contrast that with the cases where the medical problem could get much worse with a 6-hour wait. . .
My point is this. It is a false arguement to say that hospitals are completely altruistic by “letting” physicians use their equipment and because of this physicians should take call and have a sense of community because of it. They charge Medicare and Insurance companies for the use of said equipment and if it was such a big burden on them, they would have no problem with physicians purchasing their own MRIs, PT departments, Labs and Surgery Centers so they didn’t have to burden the hospital, but any hospital COO will have a BIG, BIG problem with that.
Lisa-Are you saying all doctors should put their family second? What kind of moral authority do you have to suggest any sort of thing? Don’t suggest something you wouldn’t have yourself or members of your family do. What are these professions that get up every third night for free? I’m still waiting to hear what they are.
Jenga,
It is clear you’re not bothering to actually read these posts in their entirety before submitting your thoughtful response. If you can’t take the time, then why should I or anybody else? This is now the third time I will point out to you, NOBODY SAID DOCTORS SHOULD WORK FOR FREE and at least the second time I’m pointing out to you that nobody said other industries work every third night for free. Maggie said volunteerism is part of professionalism, which any professional would agree with, in ANY industry. Covering the ER in exchange for use of the hospital facilities and equipment is not working for free, have you ever heard of the word “barter?” Jenga, I think the only thing that will satisfy you is to open your own hospital where you can purchase everything yourself and charge whatever you want for your services, facilities and equipment, pay physicians however you see fit. Go for it.
Jenga,
It is clear you’re not bothering to actually read these posts in their entirety before submitting your thoughtful response. If you can’t take the time, then why should I or anybody else? This is now the third time I will point out to you, NOBODY SAID DOCTORS SHOULD WORK FOR FREE and at least the second time I’m pointing out to you that nobody said other industries work every third night for free. Maggie said volunteerism is part of professionalism, which any professional would agree with, in ANY industry. Covering the ER in exchange for use of the hospital facilities and equipment is not working for free, have you ever heard of the word “barter?” Jenga, I think the only thing that will satisfy you is to open your own hospital where you can purchase everything yourself and charge whatever you want for your services, facilities and equipment, pay physicians however you see fit. Go for it.
“They charge Medicare and Insurance companies for the use of said equipment” are you saying the physicians are performing procedures for free? They’re not generating billable revenue to a third party as well? C’mon.
I never suggested I was a moral authority, but since you’ve decided you know me, now you will hear a rant:
“Don’t suggest something you wouldn’t have yourself or members of your family do.” I’m not. First of all, I didn’t suggest anything, Maggie rightfully pointed out volunteerism is part of professionalism. “Bartering” is not volunteerism. But since you brought it up…I don’t talk any talk, I walk the walk. I have been a patient safety advocate for over five years now. My children have grown up and I missed it. My daughter moved away to live with her dad when she was 13, she’s been gone over a year. It’s like my right arm was cut off, but she doesn’t want me to quit. In October 2006 I calculated just the financial costs my committment has cost my family, it topped $150k and I stopped counting. That’s a lot of damn money for somebody who earns $45k a year. I bankrupted my family long ago. I spend almost every waking moment, and moments I should be sleeping, working on patient safety and healthcare improvements. I left my career (as an accountant) for over a year in an attempt to better balance this crusade with my family. I’ve sold my car, my husband has sold his tools, etc so I can travel across the country attending workshops. I’ve presented at same FOR FREE. I given away hundreds and hundreds of books, total cost to me is at least $25 a book, more if I’m shipping it overseas. Who cares? You think I’m interested in taking $20 bucks off Average Joe? Somebody thinks I’m “mad” at some doctor? Are you kidding me? This is my life, I live eat and breathe patient safety/medical errors, healthcare improvement, whatever you want to call it. On the rare events my husband is able to drag me to some event with the family, it’s all I talk about, toss ideas around with everybody, it’s constant and my entire family has sacrified for this crusade and thank goodness I have a very supportive family. Many do not. I vacillate weekly between quitting and digging my heels in further and it’s people like you, Jenga, who make me wonder why I bother. If you devoted at least 1% of the effort that myself and many others like me have devoted, we might actually make some progress and we can all have a life someday. And it’s a lot easier for somebody like you to improve the system than it is for me, because you’re IN the system. No, I’m not martyring myself…you said don’t suggest anything I wouldn’t do myself and I’m just Throwing a big, fat TOUCHE right in your face…..I didn’t suggest anything, I live it daily,.
Oh yea, I forgot to mention in case I didn’t make the point quite clearly enough. I was burning the candle at both ends for years, I would crawl under my desk at close my eyes in the afternoon from sheer exhaustion, after years of this crusade. One or the other had to go. In an effort to better balance my family with my committment to society, I walked away from my paycheck. I went for over a year with zero income, and worked on nothing but pt safety/medical errors/healthcare improvements…spending more money we don’t have, volunteering ALL my time, selling almost everything we own. The threat of foreclosure forced me back into accounting. No I’m not a saint, I’m not suggesting others live their lives this way and quite frankly, I’m not proud of it, but you asked for it and you can just put that in your fahrfanugen and smoke it, Jenga.
Maggie,
“I think the old system, which asked doctors to be “on call’ a few day a month for the ER– in exchange for being able to use the hospital’s costly capital equipment, operating rooms, nursing staff, etc for free– was fair. And back then, I’m quite sure that doctors themselves thought of it as fair.”
OTOH, they thought of it as fair when they could earn a reasonable income without rushing a maximum number of patients through office visits. They thought of it as fair when they could build time to do hospital call on their hospitalized patients into their schedules.
They thought of it as fair when there wasn’t a payor drive, and economic necessity, to turn care over to hospitalists, making them, I suppose, into “officeists”. Certain specialties, of course, need to be hospital-based; I’d really wonder about a community that had a need for an anatomical pathologist or surgical anesthesiologist in solo practice.
HC you hit the nail on the head. Years ago the ER was seen as a “practice builder”. Obviously a way to get busy and be well compensated for the time with a higher population of insured as well as less of a demand for volume in the office. Now it is known as a “practice destroyer”. What does it cost the physician for one uncompenstated case during the middle of the day that forces him to cancel 30-45 paying patients? Who knows. They are not only working for free they are losing money to take ER call. They don’t have to be hit across the face with that skunk to realize, the hell with it, I ain’t taking call.
Lisa- Good for you, but don’t you dare question my effort I worked 5 years of 100+hour weeks for 25-29,000 a year. I’ve paid my dues and then some. I’ve worked 3 days straight before with no sleep, because imagine that people keep getting hurt. I done though, finished. They only way I walk into that ER now is if its worth my while, and warm fuzzies don’t do it anymore. As far as “bartering” both parties have to bring something to the table to be successful. I can do 95% of my surgeries outpatient as well as 95% of my testing and other treatment, so why exactly do I “need” the hospital. I really don’t. When a relationship is lopsided the other party has to bring something to the table to even things out and that now means compensation physicians for taking call.
Jenga, you’re the one who started the finger pointing and “daring.” If you don’t need hospitals anymore, than don’t use them. I was referring to you and others contributing an “effort” to improving the system for everybody, not just your zeal to be “in it to win it” so you get yours or paying dues. I’d love to hear about your efforts at reforming the healthcare system, I’m working with a research organization who would no doubt like to hear your input and feedback as well.
HC Berkowitz–
The great need for specialists covering the ER is not during the day, when they are in their office seeing patients, but at night, when they are home.
That’s when it’s hard to track down a specialist.
During the day, the patient can be sent to a doctor’s office. For example, a few years ago, my husband cut his finger nearly in two–am ambulance took him to an ER, and then the ER directed him to the office of a hand surgeon a block away where the surgeon put his finger back together in the office. . .
But at 10 p.m. the doctor wouldn’t have been in the office,and that’s when someone needs to take call. Whether the hospital can afford to pay them or not depends on the hospital.
But certainly the $80,000 a year one doctor demanded for coming in for an hour or two twice month (if called)was excessive.
When you become a doctor, you know that sometimes you will have to leave a party, leave dinner, get up in the middle of the night–unless you pick a
specialty like cosmetic dermatology. . .
Maggie:
In the hope that you are still following this thread I have a couple of thoughts. I occasionally drop in to your blog and I have enjoyed your insights.
There has been a paradigm shift in the perception of my profession over the 30 years that I have been a physician. Part of this is due to runaway litigation, the generation of lawsuits in response to an adverse outcome regardless of cause. This has created an atmosphere of distrust on BOTH sides of the physician/patient relationship.
The second shift occurred in response to the Libby Zion case in NYC in the late 80’s, resulting in work-hour restrictions during residencies. The “law of unintended consequences” came into play. Residents once left their training with an ingrained reflex to simply get up and treat each and every patient whenever and wherever they might be. We now churn out wonderfully trained young doctors who are accustomed to regular hours and schedules, trained to pass off responsibility at the end of the shift.
Lastly, the inexorable trends of declining reimbursement for each service and excalating expenses and buraucracy have combined with the above to cheapen, in the minds of many, many physicians, their sense that the sacrifices that a physician may make in their personal life are acknowledged and valued by patients personally and society in general. Leave a family gathering when you are not on call in order to provide complex, high-risk care for little or no re-imbursement, with the attendant increase in liability? Tough call. Put yourself in that position when you are on call when doing so will put additional downward pressure on your income, and do so without compensation? Another tough call.
I am a specialist, one whose services are difficult to obtain by ER’s, and I DO cover our ER’s. But I am sympathetic to the issues brought up by the docs involved, and have little sympathy for those who would simplify these issues in search of sound bites, etc.
My world is hard, Maggie, and not getting any easier. Medicine is what I DO, but being a doctor is only part of who I AM. The dialogue necessary to understand both sides is well nigh impossible on a blog.
bingo–
I think you make an important point when you note that: “In response to the Libby Zion case in NYC in the late 80’s, work-hours for residents were restricted. . The “law of unintended consequences” came into play.
“Residents once left their training with an ingrained reflex to simply get up and treat each and every patient whenever and wherever they might be. We now churn out wonderfully trained young doctors who are accustomed to regular hours and schedules, trained to pass off responsibility at the end of the shift.”
I think this has a lot to do with why many of today’s younger doctors don’t want to be on call in the evening. They are accustomed to more regular hours and feel that when their shift is over, it’s over.
At the same time, I’m not entirely sympathetic to the issue that specialists are reluctant to be on call because they earn so much less than they did.
Some specialits do earn less –and many pimary care docs, pediatricians earn less. But
many specialists have watched their total income rise faster than inflation over the past 10 and 20 years.
In some cases this is because they have increased volume, in other cases they’ve become more entrepreneurial, invested in clinics, diagnostic equipment or become consultants for device-makers.
I wrote a post on doctors’ pay a while ago http://www.healthbeatblog.org/2008/01/health-care-spe.html
and the disparities are so great that it’s impossible to make a generalization about doctors’ income.s
But I would say that if a physician is earning $300,000 or $400,000 a year–or much, much more (after expenses)-and he says that this compensation makes him feel that society just doesn’t value him sufficiently . . . . well,
it’s hard to be sympathetic.
You write: “My world is hard, Maggie, and not getting any easier. ”
In fairness, many people live in a world that is hard–and getting harder. The average workers’ income has declined significantly, after inflation, over the past 20 years. And while the average workers’ job does not require as much skill as yours, many people work just as hard–if you measure the physical effort, emotional and even psychological stress involved .(Especially if they are not working for themselves, but working for a boss who makes life very, very difficult.
Or, imagine being an 8th grade teacher in an inner-city public school. If you don’t think society gives doctors respect . .
So while I’m sympathetic to many doctors, I do think some are sometimes inclined to feel a little too sorry for themselves.
This may be because, in the past, society put doctors on such very high pedestals and they were all but guaranteed that their salaries would just keep on going up year after year.
Understandably, if one becomes used to having a certain place in society–and a certain amount of wealth and then your income ceases to rise at the same rate, that is bound to be disconcerting.
MOre importantly, I do think that the loss of trust between patient and doctor is an enormous loss. Some patients have contributed to it with frivolous and simply greedy lawsuits; some doctors have contributed to it be thinking of themselves as “businessmen”or “etrepreneurs” rather than as professionals who put their patients’ interests first.
Finally, I don’t think that “The dialogue necessary to understand both sides is well nigh impossible on a blog.”
Certainly issues like these cannot be resolved in one exchange between two people, but over the course of this thread, we’ve seen some extreme positions here, as well as very reasonable points made on both sides of the issue (including yours.)
By the way–I think it is good that residents’ shifts are shorter–and suspect that they still may too long (in terms of leading to patient errors– see what we wrote here:
http://www.healthbeatblog.org/2008/03/newsflash-docto.html
And I think that as medical schools teach more courses on the “hand-off” patients can be safe when doctors end their shift on time.
Doctors deserve to have a family life, just like everyone else.
But I also think that, as part of their medical training, residents should be told that sometimes they will be needed in emergencies, and that’s why they need to take their turn, covering an ER at night two or three times a month.
I think some element of voluntarism is part of feeling like a professional. I often work an hour or so past the time I’m supposed to go home in order to finish a post, or respond to readers’ comments on a blog. No one asks me to do it–but I care about the work, and so I do it.
Maggie:
Points well taken, and your most polite tone is much appreciated.
A significant problem is one of perception. One’s personal perception is reality for that individual. In my generation even those of us in relatively benign residencies worked 80 hour weeks and received pay that came out to much less than minimum wage. The unspoken understanding was that we would be compensated downstream both financially and by being held in esteem for our sacrifice as well as our expertise. Many of my classmates in college made enormous amounts of money while I was toiling away at my schooling (at a cost of $50K/yr) and training (for a salary of $30k/yr). The fact that my peak salary was substantial in no way will ever bring me to par with those who are at best my intellectual peers. The perception is that I am undervalued.
ER coverage, and the sacrifice of time, family time, sleep, etc., and the increase in stress and risk was once part of the reason why physicians were held in high esteem. That and the rather common practice at the time of providing services for patients at little or no charge if they needed the care and could not afford it. (While my partners and I still routinely do this we are in the minority, dinosaurs if you will.) The perception is that the sacrifice of the physician covering the ER (uncompensated care, impingement on non-work time, dramatically increased liability risk) is not valued by those we serve, and is certainly under-valued by those who run and own hospitals.
While you have little sympathy for the specialist who is making less, our perception is that we are working harder and making less (it’s also the reality, sadly). Comparing me with a teacher or a plumber is a strawman argument–they are not my peers and it is not a valid comparison. We add different value to society. Making that comparison solidifies my perception that my training, skill, experience, and dedication is undervalued and underappreciated.
You or your other readers may consider this nothing more than whining. Be that as it may. But my hope is that this will shed some light on the psychology behind these occurances, not to justify them. YMMV.
The original posting was about a physician who had a contract with a hospital and didn’t honor it, but instead held the COO hostage.
Physicians may very well have a legitimate beef with covering the ER, but is this really the appropriate method to resolve it? Are physicians supporting reniging on contracts?
I agree with Maggie, we’re ALL working a lot harder for a lot less, and paying a lot more for things like gas and food… and healthcare! How about the service industry workers…Starbucks barista’s, casino dealers, et al that have to share their tips with their managers. That’s no fair, either.
If we can’t have good discussion on the internet, then where?
And finally, again it’s only my own opinion and observances, but I don’t think physicians are less respected or valued by society. Personally I had great reverence and respect for the physicians that treated my husband from the minute I walked in the door. By the time our ordeal was over I had a pretty low and dismissive opinion of one, which was self-inflicted by him, but it contributed to my great disrespect for the entire institution as this is who they hired to treat their patients. To this day I still have great respect and gratitude for his treating physician. As far as a generation of litigious society, this too applies to society beyond just healthcare. I again will refer to Michael Townes Watson’s book ” America’s Tunnel Vision: How Insurance Companies’ Propaganda is Corrupting Medicine & Law.” How many of the physicians reading this blog have actually been sued ? I can tell you we never sued anybody or attempted to sue anybody or threatened to sue anybody involved in my husband’s care. It never crossed my mind…yet we were treated as plaintiffs from day one…The Enemy. And this wasn’t just my “perception” and if you want to debate that it was, I will ask, what did they ever do to try and change my “perception?” Nothing. I will tell you, after my husband was discharged from the hospital the insurance company sued him. This ridiculous and expensive litigation dragged on for years. My former employer was sued on a regular basis, not by customers or individuals, but by corporations…ridiculous and baseless lawsuits. The Great Third Party With Deep Pockets gets tagged every time.
Speaking of litigation, the insurance company lawyers dragged that treating physician into depo after depo after depo, asking the same inane and irrelevant questions, it was humiliating and infuriating. Granted, he was paid for giving depo’s, but that’s not the point. His business is taking care of burn patients (and he’s very good at it). Many a day we desperatly needed him on the burn unit, and now here he was, missing from some other burn patient’s bedside because the insurance company lawyers want to grill him again. Once should have been enough. Even though we had no responsibility for this, I didn’t go to those depo’s because I felt awful that this physician was being taken from his patient’s and it was because of our issues. Issues manufactured by insurance company counsel. Additionally, there was a news story here locally that indicated physicians will no longer treat auto-accident victims. Reason? Somebody comes in with a broken wrist from an auto accident, an army of lawyers aren’t far behind. Insurance company v insurance company. The doctor’s office becomes burdened with depo’s, litigation, document copying, mailing, often in triplicate or quadruplictate, etc etc etc. I wrote to the reporter and supported their decision. I’m getting way off-topic now.
Bingo & Lisa–Thanks for your replies . . .
Bingo–I think you make two important points.
First:
“Many of my classmates in college made enormous amounts of money while I was toiling away at my schooling (at a cost of $50K/yr) and training (for a salary of $30k/yr). The fact that my peak salary was substantial in no way will ever bring me to par with those who are at best my intellectual peers. The perception is that I am undervalued.”
I’m guessing that peers in college who made so much money went into business –probably some became CEOs.
And you’re right, by and large they are not your intellectual peers. While I was at Barron’s I interviewed many CEOs of companies like Disney
It is remarkable how dumb many of the most successful are.
When I began writing about medicine, and interviewing
doctors, the contrast was striking.
But the problem here, I think ,is that CEOs and other executives are way overpaid. This began sometime in the 1980s. Before that CEOs did not make six or seven times what a surgeon makes.
Once CEOs became so grossly overpaid, that threw a lot of things out of kilter in our economy and in our society. And I can understand why it would contribute to a doctor’s perception that he is not valued by society.
Your second point is more troubling. You wrote: “Comparing me with a teacher or a plumber is a strawman argument–they are not my peers and it is not a valid comparison.”
As it happens my daughter is a public school teacher. She spent three years teaching first grade in the South Bronx a few blocks from Yankee Stadium and is now teaching first grade at a middle-class school in Brooklyn. (After a year or two, she plans to go back into the trenches. Teaching middle-class kids just isn’t as challenging. But first, she wants to have a baby. Too many teachers at her school in the Bronx were having miscarriages–terrible environment–mice dying in the walls, some rats, windows that don’t open, and overall terrible air quality up there. )
She’s particulary good at teaching kids with severe emotional problems. Some live in homeless shelters, some are physically abused on a regular basis, some . . . . you name it. Often they are very bright (one reason why they’re so angry, I think) and she’s particulary good at getting through to the boys–kids who other teachers just won’t/can’t handle.
She’s also brilliant at teaching reading. By the end of first grade all but three or four of her 22 kids will be reading at or in some cases well above grade level–including, in one case, two kids from Africa who knew only one word of English at the beginning of the year: “toilet.”
I say all of this, not to brag about my daughter, but to point out that she is your intellectual peer. And she is adding at least as much value to society; she, too, is trying to rescue people.
The reason she chose first grade is beccause it’s one of the most challenging greades(teaching kids to read) and she feels that if they learn to read–and to like reading–they’ve got a much better chance of making it through school and getting out of the neighborhood. She also knows that after about 4th grade, it’s too late,
In fact, some of the them are so damaged when they come to her that she wishes she could teach them when they’re 3 or so.
She went to McGill, a much tougher university than the most prestigious in the U.S. (more requirements, more writing, higher standards) and did extremely well. Had she wanted to, she could have gone to med school–or done anything.
To equate “teachers” with “plumbers” is to point out that teachers–especially public school teachers–are, far and away, the most under-valued professionals in our society.
It is not just that they are not well-paid. They are not respected because Americans place so little value on learning. (By contrast, the parents of her African students have taught their children to have great respect for a teacher.)
Finally, in terms of adding value to a society, see Dr. Steve Schroeder’s excellent editorial in the NEJM
http://content.nejm.org/cgi/content/full/357/12/1221
Schroeder writes: “When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these deaths could be prevented . . .”
Health care is not the key to good health, Scroeder argues:
“More fundamental is the recognition that social policies involving basic aspects of life and well-being (e.g., education, taxation, transportation, and housing) have important consequences . . .
“When public policies widen the gap between rich and poor, they also have a negative effect on population health. One reason the United States does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism. Our willingness to tolerate large gaps in income, total wealth, educational quality, and housing has unintended health consequences.
“Until we are willing to confront this reality, our performance on measures of health will suffer.”
My conclusion: If we addressed poverty, providing education and healthcare to the poor (as you and your partners do) that would do more for the health of the nation than if everyone had insurance. You and Emily are in the same profession. And just as I’m very proud of her, you should be very proud of being a doctor (however some in society may view doctors).
Lisa–It’s true that most doctors are never sued (though this varies widely by speciality.) Here I think Bingo’s emphasis on “perception” is useful.
If they perceive or believe that they are in danger of being sued this does undermine the doctor/patient relationship. And the fact is that there a certain number of people out there who think that, when something goes wrong in medical care, that means they have won the lotto.
Maggie,
I don’t think comparing doctors’ compensation to CEO compensation is especially useful. At any given time, exactly 500 people in the entire country are working as a CEO of a Fortune 500 company. Of the many people who may aspire to be a CEO someday, very few make it.
With respect to CEO pay that started to surge in the early 1980’s, there were two primary reasons for it. First, the stock market took off. As you well know, between 1966 and 1982 the stock market as measured by the Dow Jones Industrial Average made no net progress in nominal dollar terms and lost significant value in purchasing power terms. Second, in the early 1990’s Congress passed a law that limited the corporate tax deductibility of compensation to $1 million per year per individual unless the additional compensation is “performance based.” The law of unintended consequences led corporate boards to increase awards of stock options and restricted stock whereas they probably would have paid higher salaries and much less generous option packages in the absence of that legislation. Besides, even if the top five executives of every one of these companies worked for free, the prices those companies would charge for their products would probably not be reduced by more than a fraction of 1% at most.
That all said, smart people who are primarily interested in making money have many more avenues open to them here than in Europe or Canada. Most of professional Wall Street pays well. There are plenty of mid-level investment bankers, traders, sales people, and analysts who make $1 million per year or more with no stock options in the mix. There are also a lot of highly paid people in corporate law, real estate and the executive level of most large industries. Doctors who decide to go to Wall Street to become drug analysts or to insurers to become a Chief Medical Officer can make a lot more money that they could have practicing medicine.
Within medicine itself, the retail drug chains tell me that they pay about $80K plus benefits for pharmacists and slightly less for nurse practitioners to staff their clinics, and there is a widespread shortage of both. I’m all for paying doctors a good salary as opposed to the current fee for service system, but the salary would have to be high enough to induce bright people to go through the rigors of medical school and residency and to ultimately be able to provide at least an upper middle class lifestyle for themselves and their families. I don’t expect them to ever work for anywhere near the level that European doctors are paid even if they come out of medical school with no debt. There are just too many lucrative opportunities to earn a lot more money in other fields with less education and less effort. We have to be able to compete with that.
Barry–
You write: “I don’t expect them to ever work for anywhere near the level that European doctors are paid even if they come out of medical school with no debt. There are just too many lucrative opportunities to earn a lot more money in other fields with less education and less effort. We have to be able to compete with that.”
Here’s what I think you are missing. Many very bright people would simply find business or finance too boring.
(For many bright people, finance is, of course, fascinating. Think Warren Buffett. But even though I have been offered potentially very lucrative Wall Street jobs, it just isn’t what interests me.
Being a doctor is creative and fulfilling in a way that business just isn’t.
I know entrepreneurs can be “creative”–but they just aren’t dealing with the same mysteries, the same degree of ambiguity, the human body and the human soul.
And we definitely don’t need doctors who don’t see a difference between being a physician and running a hedge fund.
We need doctors who are drawn to medicine by their deep fascination with the science and mystery of the human mind and body, and/or a deep desire to help people who are suffering.
It’s a profession, not a career.
I’m extremely impressed by many of the students going to med school these days. They’re bright enough to easily get an MBA and very likely make more money in another area. They are well aware of all of the problems in our health care system. Still, they choose medicine.
Of course, I think that after all that their education entails, they should wind up earning upper-middle class incomes. But doctors in Europe earn upper-middle-class incomes.
And when I was at the INternal Health Care Conference Europe for 3 days, I didn’t hear a single person talk about doctors pay–not in the all of the speeches and panel discussions.
It just an issue.
Some doctors there are definitely unhappy with the paperwork, some of the
bureaucracy, and things that get in the way of doing the by their patients.
Like us, they are very concerned about chronic disease management, better preventive care, better systems and fewer errors.
But absolutely no one was saying “I have to see too many patients–that’s the only way I can make enough money.”
Bingo–
I should add that I recognize that you were probably a member of a generation of med students caught in a transition that people didn’t see coming when you were in med school.
In other words, I suspect that you are a member of my generation–folks who graduated from college in the mid 1960s to very early 1970s, in large part because you and your partners, do see uninsured patients. That’s part of what people who chose medicine back then assumed was part of the profession.)
Thus, you’ve experienced the worst of both worlds.
When you were a resident, you worked extraordinary hours–no one expected to just go home at the end of a shift.
But it was assumed that when you became a doctor, money would never be a problem.
These days, med students and residents are concerned about “life-style issues”–having a family, spending time with their children, etc. (The number of women in the profession has had an effect here.)
And they are
much more willing to work on salary, at a place like Kaiser, where there will always be a cap on how much they make.
So I definitely understand how physicians of your generation feel that you were blind-sided. But I still think you’re lucky to be a doctor, adn I imagine that, despite the state of healthcare today, you derive real satisfaction from your work. I certainly hope I’m right.
People compare salaries of physicians in Europe and the US, but also compare how hard they work as well. US physicians work alot more hours on average than their EU counterparts.
Maggie,
I hear you on both the “calling” aspect of being a doctor as well as your point about European doctors able to live an upper middle class lifestyle on their income.
I suspect, however, that there may be significant differences between the U.S. and Europe with respect to lifestyle expectations generally, how an upper middle class lifestyle is defined, and what it costs to support. For example, Americans generally live in larger houses than most people in other countries. Americans have to pay more for college educations. Americans also have to save more for their retirement to supplement Social Security. For a doctor who wants a nice house in an upscale suburb with a good school district or an upscale condo in a full service building in a major city like NYC, Boston, SF, LA or Chicago, a couple of better cars, expects to be able to take his or her family on a nice vacation each year, send the kids to camp in the summer, maybe have a modest vacation home near the beach or in the mountains, pay for college at a selective, competitive school (if the kids can get accepted), and save enough for a secure retirement, it will probably take a considerably higher income than European doctors earn and find acceptable.
The good news is that assuming about half of doctors’ gross practice revenues go for expenses for staff, office space, equipment and malpractice insurance, their net income only accounts for about 10%-11% or so of total healthcare spending in the U.S. Our challenge is to drive the wasteful excess utilization out of the system, not to drive doctors’ incomes to European levels.
Maggie:
Thank you again for your thoughtful replies.
Barry Carol accurately points out that it is not the compensation of CEO’s that is the applicable comparison, but the compensation of lower-level executives. While I do, in fact, have several peers who are now running Fortune 500 companies or large investment companies, none of my peers were doing so while I was in medical school or training. However, a significant number of my peers did have 6 and 7 figure incomes in our 20’s and 30’s, a significant head start which no physician can hope to overcome. It is THIS disparity that I reference.
I will continue to posit that teachers are not my peers in the marketplace. May we agree that simply doing so leaves my open to the impression that I am insensitive to the charge that I am insensitive to the challenge of teaching and the lack of value placed on teaching in our society, but that this is not the case? While all of your points regarding your daughter are true I continue to hold that they are not germaine to this discussion. She is not my peer in the marketplace. While she could have chosen, on her merits, to become a physician she did not do so, choosing a career with a significantly lower barrier to entry, with a significantly shorter and less arduous entryway. (Incidently, I attended a highly selective, small liberal arts college with a very rigorous academic program. I am skeptical that McGill is any more selective or rigorous than my alma mater) I continue to contend that comparing teaching and medicine is not a valid comparison given the premise of this thread. I agree that lumping teachers and plumbers on my part is equally invalid.
Your observation about my age is accurate enough, and your observation about the priorities of my younger, more recently trained colleagues is quite accurate. As I mentioned in earlier comments the change in training (shift-based) coupled with a seismic change in the prestige afforded physicians due to their sacrifices both while training and while in practice make the original story quite understandable. Simply saying that it shouldn’t be this way, without offering any other rational objective solutions targeted at the cause of this behavior, seems to me to be taking the easy way out.
And yes, Maggie, I am very, very fortunate to be a physician. As testimony to that, were I to win an enormous lottery I would continue to do just what I am doing today, providing specialty care for my patients. I would just have better retirement planning and liability shielding!
And I would still cover the ER…
Bingo–
I wasn’t saying that a public school teacher is your peer in the marketplace.
(I don’t live in the marketplace. As economist Rashie Fein once put it, “we don’t just live in an economy; we live in a society.”)
I simply was saying that a public school teacher could be your intellectual peer in the world (unlike some of the people who graduated with you from college who you didn’t feel were your intellectual peers.)
I’m glad you like your work so very much–I suspected you did.
Maggie:
Did you read Jeff Goldsmith’s piece on April 14 on the Healthcare Blog? Some well-spoken thoughts on the issue of ER coverage in point #3.