Why do you complain so much about residency and medicine? It’s not as if you, personally, can do anything about it and besides, aren’t you done with call and most of the other less than savory aspects of medical training?
Like I always tell people, this blog is not about validating any particular point of view (except mine, of course). I call them like I see them using the occasional foray into satire to highlight what I regard as some of the problems of medicine and medical training. Do I expect that my blog will have any effect on the great storm about to break on us all? Of course not. I am just one guy with a little blog on a little patch of hard drive somewhere on the internet tundra and my thousand or so visitors per day hardly make a stir in the vast expanse of the medical world. Still, change is coming. You can feel it in the air. The frustration in the medical profession hangs thickly around us and I am not the only physician to sense this.
What are some of the Frustrations?
They are legion and one hardly knows where to begin but malpractice has to be at the top of everyone’s list. Protestations of various oleaginous lawyers and policy experts to the contrary, litigation and more importantly, the threat of litigation has a profound impact on how medicine is practiced in this country and its increasing cost. While the actual cost of payouts in malpractice suits is fairly trivial compared to the huge amount of money changing hands in the medical industry, the behaviors engendered by the threat magnify the cost tremendously. Can I quantify the percentage of care we deliver that is wasted on so-called “defensive medicine” (that is, medical practices designed primarily to protect us from frivolous suits)? Of course not. One man’s defensive medicine is another man’s justifiable dilligence. On the other hand as I have eyes I can see that we spend a great deal of money in the hopeless quest for perfection, perhaps the worst place to spend money as the incremental increase in health this buys us is hardly worth the tremendous cost to achieve it.
The fact that I can’t put an exact dollar figure on purely defensive medicine does not mean that there is no problem. Certainly the impact is greater than the combined cost of malpractice insurance and lawsuits and just as certainy if we killed all the lawyers and allowed common sense to work its way back into health care we would save a lot of money in the long run.
In a perfect world, the public would accept that medical care entails risks and the money we spend protecting them against unlikely consequences would be better spent on medical care that makes a difference. Somebody pays for the drunks that detox in the Emergency Department rather than the police drunk tank, for example. Maybe it’s hard to quantify the cost but protecting these patients from the unlikely risk that they will aspirate vomit takes staff and facilities out of service for other productive medical uses. And the money spent on exclusionary workups which have little to do with the chief complaint has to come from somewhere. Since very few people actually pay for their medical care directly and physicians are under a great deal of pressure to avoid getting sued, there is no organic incentive for anybody to think about cost.
Which leads to another frustration for physicians, namely that while on one hand non-medical adminstrators have increasing influence on how doctors practice, they are not exactly sharing the liability. It is perfectly reasonable, for example, for an administrator to try to curtail the use of expensive studies where they are not indicated. On the other hand the administrator doesn’t provide much cover for the physician who knows perfectly well that he can practice perfect evidence-based medicine and still be dragged through a malpractice trial in which his professional reputation,livelihood, and assets are put in jeopardy.
Yeah, but aren’t doctors just complaining a little too much?
Well, everybody complains about their job. And everybody has to deal with the bean counters. But as the economics of medicine are often at odds with the practice of medicine, there is an adversarial relationship between doctors and the accountants. As I said, controlling costs is perfectly justifiable and in a perfect world we would know with certainty how much to spend on every patient. However, even without the uncertainties of defensive medicine, it is not possible to fit every patient into check boxes and standard forms. Sometimes we have to write outsides the allotted area. That’s sort of the point of having physicians and not self-service computer kiosks where patients enter their symptoms and receive exactly the treatment they need with no wasted effort or money. Now, it may come to that in the future as mid-levels and lower level providors are pushed into the breach to stem the onslaught of the aging baby-boomer hordes, armed as they are with their horrific powers of entitlement and inevitable “free” health care, but the public is going to suffer. Not that most will care or know the difference. They will be getting substandard but free health care. Huzzah!
Besides, physcians with their extensive education and abilities are always a convenient scapegoat for politicians looking to redirect the anger of the mob.
Paranoid, aren’t you?
Not at all. But it is easy for anybody looking to curry favor with the electorate to attack physicians. The public believes that we are all multimillionares without a care in the world and, as a class, too smart for our own good. Disliking someone who is wealthier and smarter than you is a primal urge very common in both the trailer parks and the halls of academia, two disparate places that never-the-less share some of the same provinciality and the overbearing confidence of ignorance.
The fact, for example, that even the lowest paid physician generally has to struggle through at least seven years of exhausting training and that he might just be worth his salary never occurs to either group.
Another thing that should bother everyone in the health care industry is the concept that health care is a right and needs to be provided for free. The insanity of this concept is obvious. Rights do not have to be provided, they exist independently of governments and while they must be occasionally secured by either war or revolution, they are not a commodity to be provided to the public. Nobody’s has to work a twelve hour shift at the Department of Free Speech to keep the dissent flowing.
Medical care, on the other hand, is a service provided by people who expect to get paid. And will get paid except for doctors whose compensation under inevitable government run health care can be legislated as low as the congress thinks it can get away with. What are doctors going to do? Go on strike? Of course not. We’ll just suck it up because our ethos forbids us to harm, even by ommission, any of our patients. Nurses on the other hand wouldn’t put up with an attack on their salary for a minute and as a group, know how indispensible they are and leverage this effectively. And they have pretty good juice with the public. Imagine a suicidal politician proposing that nurses and other hospital workers need to accept less pay for the public good. That man would be tarred, feathered, and run out on a rail.
Money, money, money! Is it that important?
Of course it is. Money drives everything. Even your disdainful college professor preaching the gospel of poverty can only do so because he has waged bureaucratic war for his tenured position, a position which may not pay as well as some other careers but one from which it is almost impossible for him to be dislodged and which provides enough income for him to turn his nose at other people’s money. He’s not working for free and neither does anyone else. This is not a bad thing, either. Societies that try to do away with the individual profit motive are dreary, impoverished places because what works in a small commune or a kibbutz cannot be extrapolated to an entire nation. If there is no benefit to working hard, and no risk in not working, the freeloaders, Alexander Zinovyev’s famous “Homo Sovieticus,” tend to take over.
So the disdain for money is fairly unhealthy even in the medical profession. There has to be an incentive for people to work hard and long. You will always have people willing to be physicians of course, but their enthususiasm for seeng that extra patient or coming in from home to operate on a patient on the weekend will diminsh as the rewards for doing it evaporate. Medicine is a rewarding career independent of money but it ain’t that rewarding. It can be something of a grind as I’m sure many Family Medicine physicians would probably tell you after their thirtieth patient of the day.
Speaking of frustrations, there is probably none bigger than the way physicians are reimbursed. The system is crazy and I have only had a small taste of it. They call medicine a business and patients customers but it’s a strange business with the oddest customers and that’s no lie. (Is medical care a right or a customer-driven business?) First of all, many of our customers not only don’t pay a dime but the very idea that they should have to pay even a fraction of the cost of their care never enters their heads. If medicine were a business this would be called theft. At least shoplifters know they are stealing and try to hide thier crimes which is not the case in the medical world where a family will boldy stride into the ICU and insist that we spend whatever it takes to squeeze a couple more days out of their demented, stroked out, septic, octogenerian grandmother. It’s somebody else’s time and money, what do they care?
On top of this, attached to the most technologically sophisticated industry in the world which performs commonplace miracles that would have been inconceivable just fifty years ago is a system of remibursement straight from ancient Byzantium. A nice system for a courtier, a eunuch, or a lawyer but as adminstrative costs alone are said to gobble up a third of every health care dollar, money that provides no medical care whatsoever, what exactly is the benefit to the public and how can doctors be blamed for the high cost of health care?
It’s not a problem that has an easy solution. The single payer zealots opine that making government the insurance provider will streamline things but all you’ll really get is a clumsy bureacracy looking for ways to not reimburse and holding onto every penny like it was a gold coin. Very similar to a private insurance company except that Aetna cannot kick down your door and raid your house. Insurance companies need to make money for their stockholders. Governments try to dole out scarce money to constituents to buy their votes and there is never enough to go around.
But hell, the public doesn’t care. They want medical care for free no matter how much it costs. We are already conditioned to not care about the price of health care. Very few people actually take out their wallet and pay for even something as simple as a routine doctor’s visit that in an ideal world would cost eighty bucks and, in a country where people pay twice that for a month of cable television, would be considered a good value for the price.
I don’t think we need to do away with insurance but we need a simple law forbiding hospitals and clinics from billing a patient’s insurance company. Especially if it is the government which, along with private insurers, currently pushes the greater share of their administrative overhead onto health care providers who receive no extra money for their troubles. In the old days patients paid their bill and then submitted their claim to their insurance company. Watch how fast things would tighten up if patients were refused reimbursement for the same reasons that doctors are currently refused. You’d have angry patients, angry both at the government and at doctors for not caring about how much things cost which is probably the greatest incentive there is to efficiency and reasonable prices.
(To Be Continued…)