The Gospel According to Schwab

This may be the best paragraph I’ve ever read…

There seems to be a very schizophrenic attitude about physicians. People want more knowledgeable doctors, ones that will listen better and explain more clearly. Docs that will fully enumerate and carefully explain all the issues and choices for any situation; who will be sensitive to their individual needs, who will both guide them but let them make all their own decisions. And, of course, doctors with comprehensively flawless knowledge and impeccably perfect skills. People criticize doctors — surgeons especially — for having a god-complex, but they want god-like perfection. To achieve it, they suggest flooding the market with doctors and spending less time training them. And, of course, after people flock to become these perfect doctors, to pay them less and less for their efforts. Highly qualified, well-motivated folks with altruism aplenty will fight their way to the front of the line.

P.S. Thanks for pep-talk Dr. Schwab, this FP intern is going to go read up…on everything…

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  • T.

    I was thinking that too when I read it this morning – what a GREAT paragraph that really says it all.

    I have had patients whose first words upon seeing me were, “So you’re the one that’s gonna kill me?”

    After the suffering of medical training, the years of lost time, the insults and put-downs, and also the daily renewal of a commitment to rise above it all and treat each patient with genuine love and kindness, a greeting like this is deeply disappointing.

    Somehow in our society it’s not okay to disparage a particular racial group because an individual from that group happens to commit some wrong, but it’s ok to denigrate ALL physicians because of some people’s bad experiences.

    I get the feeling people feel entitled not to the very best care that can be offered, but rather to PERFECT care. For free. I try my best, but there’s no way on earth I can get it “perfect” every time, ever day, even if I can get it “really good.” I guess I just gotta keep holding up my end of the commitment and effort and hope it makes a difference…

  • Anonymous

    Here is what I find schizophrenic:

    Do doctors hate the time and effort required to handle bureaucratic admin costs associated with multiple payors/hmos/ins cos/etc or would they rather defend them from attack from Michael Moore?

    Do doctors demand/expect the best information from drugs reps in order to make the most informed decision for their patients or do they just shrug their shoulders and/or defend pharma when it turns out they wsere purposely lied to and that adverse side effects were purposely withheld from them? Regardless of the broader question of whether drug x should be pulled or not, wouldn’t one expect to hear a bit more outrage from the meidical profession when it is revealed they were lied to?

    I’m just asking because it strikes as very disturbing the bed-fellows that the medicial profession has made on more than just a few of these issues. I can’t quite tell where their allegiance lies other than in protecting their own pocket-book from something (whether it is HMO’s one day or “socialized medicine” the next . . . Medicare when they are cutting reimbursement or pro-Medicaid when they are increasing enrollment).

  • Anonymous

    Like anyone else, our allegance is to those who pay us, treat us well, or otherwise indicate to us that we have some value.

    It certainly isn’t insurers or hopitals that make us feel like we have a right to exist, let alone earn money for our skills.

    More often than not, patients aren’t even saying “thank you” – it’s just “that’s it – I wasted my copay.”

    Our “bedfellows” are whoever can provide us with same quality of life that we believe our patients are entitled to. Be that concierge practices, hospitalist groups, the AMA (yea right) or anyone else.

    Doctors are like everyone else – they like stability. Let’s see what florists do if laws are passed that change how they get reimbursed.

  • Anonymous

    I don’t think I have ever, EVER, expected any doctor any where to treat me with “genuine love”. If one did, I would be apt to think there was something mighty wrong with him/her. I don’t want your love (I have family) I want your education, expertise and maybe a little compassion.

  • Anonymous

    Well, at the risk of pointing out the obvious, “doctors” don’t do anything. Like any group of nearly a million people, everyone has their own priorities and feelings. The AMA doesn’t even have half the doctors in America in it. Some doctors criticize Medicare while some embrace it, just like some politicians criticize the Iraq war while some embrace it. I don’t know why people expect doctors to be any more of a unified voice than any other group.

  • Anonymous

    >>”I don’t think I have ever, EVER, expected any doctor any where to treat me with “genuine love”. If one did, I would be apt to think there was something mighty wrong with him/her. I don’t want your love (I have family) I want your education, expertise and maybe a little compassion.”

    And you are welcome to it as long as you pay fairly for it and have the decency to recognize that you yourself are first and last the one to be responsible for that fair payment.

    If your Medicare or other underpaying insurer places you among the part of a practice census that gets a subsidized ride on the payments of those who aren’t, at least understand you aren’t pulling your weight and have enough decency to be grateful when your doctor treats you as if that didn’t make a difference.

  • T.

    A refresher on the Latin roots of the word “compassion,” as many people already know, reveal it to be a FORM of love – not affection, attraction, or any of love’s cheaper imitations, but the genuine respect for the worth and dignity of a human being that the word “love” should primarily signify. It is in this sense that I was using the term; not sure what Anonymous above was reading into it, but it seemed like an unnecessarily malicious interpretation. Just proves the point many have made about the deep hostility that exists against physicians even while those same physicians are expressing sincere good intentions and trying to offer expert care.

    As for our education and expertise, as Dr. Schwab has pointed out, people may say they want it, but they also resent it, and they are certainly reluctant to remunerate for it. I neglected to say that offering those was part of the commitment to service I alluded to, but I thought it went without without saying. My mistake.

  • Anonymous

    Anon 9:10, wow, thats a mouth full you just said. To bad you don’t have even a clue about reality.

    Here is some reality for you pal. I worked 40 years plus, I also paid taxes every one of those years. A portion of my taxes went to pay for folks medicare who had worked and paid their taxes before me. This is the way our system is set up.

    I also have paid more out of pocket in medical bills than I have ever paid for anything else in my entire life, and that includes what we paid for our home.

    In addition, what I pay for this “free” medicare is in excess of what my retirement check is for each month.

    Lets break it down for you OK?

    93.50 medicare part B

    267.00 AARP supplemental health ins.

    68.00 Medicare part D

    Over 700.00 each month for co pays, and meds, that aren’t covered.

    When you talk about free medicare just what is it you are talking about?

    Is it my fault that you sign contracts that medicare gives you to sign? Do you want me to pay you in addition to what medicare pays you? you and I both know you cant do that. Again, how is that my fault?

    Ive paid my taxes, worked my years, and still pay out more than I personally bring in, so just what is it you want?

    So I guess what you are telling me is you think I haven’t paid enough in medical that I deserve your education or expertise? Well screw you!

  • Anonymous

    Do they offer free mental health help for Physicians?

    If so, you guys need to check in, pronto!

  • KoKo

    A course in the first year of medical school should be offered, entitled
    “Why I shouldn’t become a physician”.

    In that way, at least students will have a better idea of what they’re getting into and can act accordingly.

    Then, they won’t end up in mid-life belly-aching on a Web site, about their terrible professional lives

  • Anonymous

    “More often than not, patients aren’t even saying “thank you” – it’s just “that’s it – I wasted my copay.”

    While I’ve never left a doctor’s office without thanking everyone, I’ve also had plenty of experiences that tested my patience — from waiting over 90 minutes past my scheduled appt with no apologies made or reasons given, to watching as the receptionists searched for my chart (which they admitted had been misplaced in the utility room), to being given a prescription for painkillers after an outpatient surgery that the doctor forgot to sign so the pharmacy wouldn’t fill it. Lots of things influence a patient’s attitude, and a lot of them are probably the same things that drive doctors nuts. If someone’s rude to you, it may just be because their experiences to that point haven’t been good.

    I sincerely doubt most patients want or receive “genuine love and kindness”…just professionalism from all people involved. And yes, if they get it, they ought to return it.

  • beajerry

    What I’d like is a doctor that is pissed at my sickness and wants it friggin’ cured, now!

    I want that surgeon to take that appendix out, throw it on the floor, and stomp it to smithereens!

  • Anonymous

    Anon. 3:46:

    You think you are the only one that has to pay taxes? And good for you that you got your home when you did, I’m sure it has appreciated nicely for you. The fact that you pay now for care sums that exceed what you paid for your house is besides the point. The same could be said of many current costs, new cars and new houses and new medical care.

    But you are wrong about my being clueless. I am in this business and I see self-entitled people who think like you do every day. You confuse the fact that you paid taxes while you worked (and now, probably) with paying your doctor. Of course they aren’t the same. And what you aren’t entitled to, which it appears you have not understood, its to believe that your having paid taxes and your Part B premium is an automatic entitlement to not be responsible for your bills, or to feel free to have whatever you want from whichever doctor you want. Hearing rude talk like “screw you” from people who think and write as you do is, sadly, no surprise at all, it is just another example of why Medicare will someday soon no longer be able to sustain itself.

  • Joe

    Anon 2:58,

    You are an absolute nut case!

  • Anonymous

    anon 2:58 – WELL PUT!
    joe – YOU are the nutcase.

    I too see the AARP crowd sucking up resources by the truckload, spending $100,000 of someone else’s money at-a-time for futile care that would otherwise vaccinate thousands of kids, or expand primary care to those without the means or motivation to seek it.

    medicaid only compounds the problem – I always cringe when I hear a new patient tell me “I’m fully covered, i have medicare & medicaid” as if they can even fathom how much taxpayers support their medical expenses.

  • Anonymous

    4:26, is there any evidence you have to offer besides the insult? Or is merely disagreeing with you sufficient to qualify?

  • Anonymous

    You Sir, Mr. Doctor, have just proved the point that NOTHING is good enough for you guys. You don’t even know what it is you do want. I’m convinced you want to bitch and whine, but beyond that, your arguments are weak to say the least. As for medicaid, that is not an option with me and my doc’s have never heard me say those words. I have always had ins. and paid my co-pays. We patients are not the ones who set the ins. rules that you have agreed to accept. Your anger is misplaced.

    You find fault with everyone and everything, no matter what ins. they have, and, no matter how much they pay out in medical expenses.

    Do you pay out more than you bring in on medical? So when you hear someone say I pay out more than I make in just one aspect of living, and it is still not enough for you, what is it that you are proposing? Are you thinking that once someone becomes ill they should not receive any medical care at all? If that is the case then we certainly don’t need doctor’s, do we?

    You want to talk of entitlements? You take the cake. you may be the most arrogant entitled person I have ever heard talk.

    If all you want to do, and deal with, is giving childhood vaccinations, well then why not become a pediatrician and vaccinate away, until your hearts content. And yes, I certainly made sure my own children were vaccinated and paid cash at that time for those vaccinations. How does this have one thing to do with my medical care now? Let parents get their children vaccinated, I hope they do ,but how does this effect me? Are you suggesting that instead of paying my AARP, So that you get paid, and my medicare, and buy my prescriptions, that I should just not get any medical treatment and donate my money to childhood vaccinations?

    Your arguments make zero sense and they are all over the place. You give your profession a bad name.

    I was not the one who suggested you receive mental health help, but now, I certainly agree with that recommendation. You are sick!

  • Anonymous

    Anon 5:42 –

    I am NOT the above poster, but I have one question: When you go to your doctor for a visit, does it matter, for the purposes of the expenses, costs, and time for THAT visit, how much money you have spent in the past? Once you decide to come in the door, your spending history is irrelevant, just as your spending history for groceries has no impact on the price of broccoli you will pay.

    You say you did not make the decisions that led to the insurance plans the doctor will accept, etc., similarly, the doctor was not involved in the financial deicisions you made in the past that make paying for your healthcare difficult today. You could have planned ahead and maybe saved a little more, had a smaller house, etc. I know it sounds crass, but these are the same arguments on this board that non-docs are using against docs who complain about expenses and reimbursement.

    So let’s agree that my service today has a value, today. How much I made yesterday, and how much you paid yesterday, are irrelevant. Unless I am you indentured servant, of course.

    And by the way, we are NOT the government, and do NOT collect taxes.

  • Anonymous

    Anon 5:42:

    No one on this thread has made a more disjointed post than you have. And instead of providing a reasoned argument why your case should make more sense than anything else posted, you have resorted to name calling and disparagement. All in all, you haven’t been very convincing.

    You seem outraged that you still have to pay medical bills after having paid federal Medicare taxes while you worked, something another poster reminded you does not make you unique, and your Medicare part B premium and supplemental premium. Tell me, how does that make you so aggrieved? Are you angry because your supplemental insurance is expensive? Are you angry because your medicines are expensive? Fine. I could understand why that might be upsetting. But you didn’t say that. Instead you seem outraged to read that doctors aren’t satisfied with what Medicare–not you, mind you–pays them for providing services to beneficiaries like you. Why does that seem unreasonable, if in fact the reimbursement does not adequately cover their costs? It wouldn’t be unreasonable in any other line of services. It wouldn’t be unreasonable to other professional medical providers, like dentists, who don’t by and large have to work under federally-enforced price-fixing. It seems you can’t grasp how a system could leave you with large residual bills and still underpay those who service you. Really, that isn’t all that hard to grasp, when you consider how many people are demanding services, drawing benefits at an age that when Medicare was set up was far closer to the natural average lifespan than it is today.

    You haven’t offered much here except calling doctors who post here “nut cases” and other similarly unhelpful statements. The statement by another poster, comparing the high cost of end-of-life care paid for mostly by Medicare to the cost of preventative medicine programs like childhood vaccinations (and obviously not paid from the same budget) was a rhetorical illustration on the present uses of public funds and their relative utility. No one suggested you be dunned to pay for vaccinations, or did you just not get that?

    Whether you like it or not, and whether you voluntarily change your expectations or not, the Medicare program in which you now participate will have to change. You may believe that cutting reimbursements is OK, but the harsh reality is that cuts of that kind will ultimately reduce access, and it will likely do so unevenly, affecting those who live where practice business margins are slimmest already. Neither you nor I have to like it, but that is the way it will be. There are alternatives, but those will require a willingness to accept that not everyone can have everything.

  • Anonymous

    Are you angry about what medicare pays you? Fine, I can understand that. but, why are you taking it out on your patients? It is not our fault. We pay them what they tell us to pay. We pay our supplemental ins. what they tell us to pay, we pay for our medications what the pharmacists tell us to pay. We pay “you” what you tell us to pay.

    Do you want us to tip you, over and above what you charge us? you know, give us good service and we slip a 50.00 in your hand on our way out? Maybe if we give your receptionist a 20.00 when we sign in, she will move us ahead so we don’t have to wait 2 hours in your waiting room? People do that often at supper clubs. I won’t tell medicare about it if you don’t. Would that put you in a good mood? it sure seems to make waiters happy. You want to be treated like a waiter? You want me to go to the grocery and buy 100.00 worth of groceries and drop them off on your door step, a couple times a year? fine, give me your address and I will go shop so you can feed your family.

    You get angry at us, and honest to God, we don’t know exactly what it is you want. I mean we pay all our co-pays, all our supplemental payments, we go to your office when YOU tell us to, and on the way out, I pay whatever they tell me, or when I get a bill I send you a check. What is your legitimate problem with me? It is because you are stuck with excepting what medicare tells you to accept. You want to charge me more than you have agreed to accept, and now you have some sense of entitlement to believe it is right for you to take that anger out on me. Your pissed at the entire program. Well, so am I.

    You hear us say that we are paying out 15K a year in medical expenses, and you only see a small portion of it. I would rather give what I have to pay for medications to you. I would rather give you the 5 K. a year i pay in supplemental premiums, but, this is the way our current medical system is set up. you sir, are a part of this system. It is your profession. Stop whining about it and work to change it.

  • Anonymous

    “Stop whining about it and work to change it.”

    That’s what the hell we’ve been doing every year when we’re threatened with fee reductions. Even if we drop out of Medicare (I personally plan on going non-par unless there’s a fee increase for 2008), we are limited in what we can collect to 115% of what Medicare allows. Collect anymore and it’s a federal CRIME. As non-par, the check goes to the patient. If we drop out altogether, which we all should (but, hey, docs arent allowed to unionize or strike), we have to sign individual contracts with each patient, and, you, my friend, get no reimbursement back from Medicare. The reason we’re grumpy is that we actually do give a damn about not leaving our seniors in the lurch and without medical care, but the only way this bullshit system will change is if we all do exactly that. We give a damn, but because of that, we soon may be out of business. So, hey, what the hell? At this point, the only way we will change things is to tell Congress to shove Medicare and Medicaid where the sun don’t shine, and JUST SAY NO!!! And, YOU also need to let Congress know, that as a Medicare recipient, you’re pissed as hell.

  • Anonymous

    Anon 10:11:

    Here is a solution: Medicare must lift its unreasonable restriction on allowable charges and doctors and other providers should be able to charge as they like and as they need. Medicare should offer the allowable payment and the patient should be responsible for the difference. If I can provide some services at the “allowable” rate but charge more than that rate for other services, then I should be allowed to do so. If I beat out the other providers on price for comparable services and get practice business that way, so much the better. If I don’t and others do, likewise.

    I shouldn’t have to enter into onerous contracts with patients when I want to charge more than the Medicare rate. Patients can decide if I am worth the difference. If my costs require I charge more, I should be allowed to do so without suffering penalizing exclusions from participation with Medicare, and my patients should not be cheated out of their benefits by the government for choosing to do professional business with me.

    I am sick of this system too. Remember, I also pay taxes. I also expect to have medical benefits in retirement. But I also have to deal with the government in ways you do not, and I think the system as it is cheats me by requiring me to provide money-losing services.

    If you have a better idea that has a hope of working, I am all ears.

    As for who gets to work changing anything, remember you can vote, because that is how this change is going to have to happen. Don’t whine to me about that, because neither I nor any other doctor nor the medical profession as a whole is going to change things for you.

  • Anonymous

    “If I beat out the other providers on price for comparable services and get practice business that way, so much the better”

    I live in an area where virtually all doctors, from adult med to family practice to all the various specialties, belong to one 300-doctor clinic association. They all conduct business according to the same rules. There is no competition as you describe, so in this instance, I don’t see how your plan would work unless patients accepting the burden of traveling to see doctors elsewhere. And if a member of my family is sick, I’m sorry, but I would rather get them local care than take them on a 2-hour drive.

    That same clinic has been turning away new Medicaid patients for several years. We do have a small clinic for low income residents, which does get some financial support from the for-profit one, but even after a recent expansion they have given up on keeping waiting lists due to the extreme demand.

    Currently the for-proft clinic is lobbying the community for permission to build a large cardiac care center. This would complement their existing cancer center, spine center, sports medicine center, etc.

    I agree that citizens need to be more aggressive with the government. However, I also think there are actions that the medical profession can take to cut costs of delivering care. One is to avoid bloated administrations. Our for-profit clinic has a list of vice-presidents, directors, and officers that is staggering. The more management-heavy any business is, the less effectively it operates.

    Another is to focus on providing good primary care rather than funnel so much money into the speciality centers.

    Obviously these comments are not directed at those of you in private practice, and I wish you the very best of luck.

  • Anonymous

    As for the comments pertaining to medicare people stating what they have paid in the past not being relevant, I think it is statements made in relation to the ever present complaint of “I am so sick of mine and other taxpayers money going to support people on medicare.”

    it was being pointed out that they also worked many years and paid taxes that went for others medicare. You are not doing anything they haven’t already done. Also as has been pointed out medicare is everything but a free program. It is not just they have paid in the past, but what they still pay. Anyone who believes this program is free just has not yet experienced it.