Doctors should work weekends, and how reformers alienate physicians

Peter Orszag wants doctors to work weekends.

The former director of the White House Office of Management and Budget wrote as much in this past weekend’s New York Times:

Doctors, like most people, don’t love to work weekends, and they probably don’t enjoy being evaluated against their peers. But their industry can no longer afford to protect them from the inevitable. Imagine a drugstore open only five days a week, or a television network that didn’t measure its ratings. Improving the quality of health care and reducing its cost will require that doctors make many changes — but working weekends and consenting to quality management are two clear ones.

And he’s right, to a point.

I’ve pointed to studies showing that mortality rises on the weekends, in part due to skeleton staffs that hospitals employ on Saturday and Sunday.  And, since Mr. Orszag is an economist, the cost factor is noted.  Tests that get pushed off until Monday cost the health system serious dollars.

The problem I have is that Mr. Orszag, like most health reformers, offers doctors little incentive in return.

Like most people, doctors like their time off.  In the United Kingdom, the NHS addresses the issue of after hours care by offering primary care trusts, which receives government funding for care at night and on weekends.

What does Mr. Orszag suggest to support American physicians working weekends, other than telling them they should?  Increased pay?  A reduced paperwork burden?  More support for beleaguered primary care doctors?

Instead, nothing.

Why not have doctors sympathize with your point of view by offering incentives?  Studies show that patients are heavily influenced by their doctors.  If health reformers want to sway public opinion, getting doctors on your side seems to be the ideal strategy.  Instead, more often than not, they’re alienated by Mr. Orszag and his progressive ilk.

The same can be said for physician salaries.  It’s no secret that most health reformers want to reduce physician salaries.  Fine.  I agree there’s a significant pay disparity between primary care doctors and specialists that needs to be moderated.  But in order for physicians — specialists, in particular — to accept that stance, why not offer something beneficial in return?  There are more than a few who would trade lower pay for, say, true malpractice reform.

It’s confounding how progressive health reformers continually antagonize the medical profession when, in fact, their job could made be so much easier with doctors on their side.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://www.BocaConciergeDoc.com Steven Reznick MD FACP

    Tried the weekend and evening hours suggestion several times. For the most part nobody came in. Most of my patients had personal time or sick time benefits and preferred to miss work then miss a weekend by being at the doctors. I had bunches of young retirees who enjoyed the evening and weekend hours because it didnt interfere with their tee times.
    I think incentives and alternatives for adjusting ones work schedule are great ideas. Its a shame Kevin Pho MD has to think of them not our policy makers which includes our organized medicine organizations.

    • http://www.aneurysmsupport.com/ Mike

      I agree. Few of the people who work for me, particularly the young people, would attend a doctors appointment over the weekend. Most prefer me to give them time-off from work so the appointment will not cut in on “their time off”.

    • Pharmer Joshua

      How long did you try this? Like any business, you can’t just change your hours and immediately expect consumers to adjust. If too many of your patients are Medicare, I wouldn’t bother, though. You SHOULD be able to be open when you want, charge what you want, and take advantage of a free market and competition. With Medicare and so much government meddling, you can’t.

    • Smart Doc

      I reluctantly offer every other Saturday hours: Guaranteed 30%-40% no shows.

      Evening and Saturdays are a waste of my time. I am considering dropping both.

  • http://evimedgroup.blogspot.com Marya Zilberberg

    As if doctors do not already work many weekends! And what about the predicted shortages of MDs, RNs, PharmDs, etc.? How do we reconcile the math? (Something I blogged about yesterday). I am not even sure that incentives will appease at this point.

  • stitch

    I read the article yesterday in the NYT, and my first thought was, yeah, good luck with that. We’ve spent the last 10 years reducing resident work hours and now even making them take “naps.” Now Mr. Orszag wants docs to work more hours, or at least outside of the regular hours? Sure.

    I agree with staffing up in hospitals on weekends, and perhaps having extended office hours on Saturdays for urgent needs, but there will be several issues that will need to be addressed, especially the ever-increasing physician shortage. But elective surgeries on the weekends? Come on. You won’t find support staff that wants to work those kinds of hours, either – and that will also be an issue for outpatient practices extending their hours.

    • http://www.aneurysmsupport.com/ Mike

      Stitch, you may very well find someone willing to work those hours. True, most people, at least those seeking full-time employment, will prefer Monday-Friday there are always a few willing and even choosing to work weekends. Most are people looking for part-time supplemental income but not all. The ones who choose weekends generally cite a more relaxed atmosphere that many businesses have over the weekend with fewer staff and fewer supervisors.

      • stitch

        Mike, I can tell you that in the offices where I have worked as a primary care provider, whenever the issue of expanding hours comes up the biggest problem is staffing.
        And that is just a primary care office. If you are talking about providing elective surgery (not emergency) you need to have a much greater support staff than you do for a primary care office. It’s just not that simple.
        Any time you add hours and have to add staff, you add costs: salary, benefits, insurance, etc. So at a certain point you have to ask if the benefit outweighs the cost, not only for the docs and the facility but also for the patients.
        And I’ll say it again, we are already facing a doctor shortage. Where are the physician hours going to come from to do this kind of professional staffing? Especially if we are talking about changing the fee structure from a fee for service model (which I generally support, btw.) We have raised an entire generation of young physicians to think more about the clock and less about the patients care, and that has been administrative rules coming from outside the medical profession. It is not a small issue.

        • http://www.aneurysmsupport.com/ Mike

          I agree with much of what you say stitch. As I mentioned in a previous post, most people will likely still prefer an appointment during the week, even if they must take time off of work. Many people, particularly young people, do not want anything to interfere with their days off.

          Now, I did not say they there would not be costs associated with hiring additional staff for weekends, just they there probably are people who would work those hours. As I mentioned, in my experience they cite a more relaxed atmosphere and less supervision. Something I did not mention, is that many, even part timers, will want a shift differentialm i.e. extra pay, for working the weekend. Personally, while it might occasionally be convenient, for me at any rate, I question if it would be economically feasible for the physician.

          People have different thoughts when it comes to physicians, for some odd reason they do not see a Doctor’s office as a business. They expect care whenever they need it without regard for the doctor, assume that all physicians are rich and do not appear to understand that a doctor’s practice has costs and overheads just like any other business.

  • Chris

    I grew up watching my father, who’s a mechanic, work weekends, nights, swing shifts, graveyard, the whole bit. It just seemed normal. In my third year of med school, not once have I ever felt it to be an injustice that I have to go to the hospital on a weekend. In the real world, people work weekends all the time. Their incentive? A paycheck. My wife, an RN, works every other weekend. Her incentive? A paycheck. Why is it that doctors feel they need EXTRA incentive, other than their relatively high pay, to do what most people in the working world do anyway? C’mon guys.

    • http://www.pacificpsych.com/ pacificpsych

      It’s true. Doctors, especially surgeons, don’t work enough. Lazy bunch. Why don’t they get up in the middle of the night and do surgery? It’s appalling to me that even though people are dying they just lie in their beds and sleep. As far as I know, general surgeons work 8-4 then go and play golf. What a life! Who wouldn’t want it?

    • Dan

      Nurses and tradespeople are paid extra for working overtime and weekends/nights (weekend differential anyone?). Docs are generally not. In fact, if the patient has no insurance and can’t pay, that overnight call is volunteer work for the doctor. Not so bad when it’s all shiny and new in your third year of medical school, but it might not be so fun 20 years down the line.

    • David

      Guess what, we are not mechanics or plumbers…like it or not, we are physicians and surgeons….most of us sacrificed damn near close to our whole lives to get the best grades in high school, college and medical school. As a surgeon, I risk my life and the life of my family immersing my hands in the HIV infected blood of my patients, as their families all have a knife at my jugular waiting for the slightest bad outcome to try to take every possession away from me in malpractice court…Yes, medicine is a wonderful and special profession—not a trade or a job. You, my friend, are just a student…and a naive one,at that. Wise up and shut up until you’ve experienced enough to know what the hell you’re talking about

    • Vox Rusticus

      Chris,

      How many times did your father let his clients drive off without paying? How many times did your father go in to work on major holidays? Did your father expect to be paid extra for coming in at night? Did he receive overtime if he was asked to work more than a standard workweek?

    • http://curbside.posterous.com Nuclear Fire

      Simple. I work because I need money. After a certain point, I don’t need any more money and I’d rather spend my time with my wife and my kids.

      I personally have no interest in working nights and weekends. I just won’t. I have a life to live. Medicine is just a job. My family is more important to me than my patients.

      • http://Www.Twitter.com/alicearobertson Alice

        I so enjoyed Nuclear’s comments above. They are raw honesty, and even posted with a link…..an honest doctor…..what a find…..no Pollyannish stuff…..no patients are driving me crazy, so crazy I may have to threaten to leave medicine (boo hoo hoo) just the truth……you work for the money…..just like the rest of the working stiffs. Honestly, this short post was refreshingly honest. I like IVF’s posts too!

        • CM MD

          Alice, what about after-hours phone calls and emails? As a rural physician in solo practice, I have implemented after-hours protocols that minimize interruption to my personal and family time. You blasted me for it in a previous article, but your ok with Nuclear?

          • http://www.twitter.com/alicearobertson Alice

            Hi! That’s a good question. I have no memory of blasting you, but if I did it must have been my evil twin! :) What I complimented Nuclear for was his honesty, not his opinion.

            If someone leaves a link I try to write privately, but I don’t know half the time who I am talking to. Honestly, I don’t bite….please refresh my memory because I am a bit clueless…and I apologize if I blasted you needlessly.

          • http://Www.Twitter.com/alicearobertson Alice

            I am sorry…I was rushed and did not answer your question. Elsewhere on this site I give public kudos to our favorite doctor. I gave his name and told him how much we love him (then dropped him an email with the link….which I have did more than once). Part of the reason I am so smitten with this doctor is because he answers email with knowledge and sympathy….such understanding to a heart broken mother dealing with cancer. His emails helped in our healing. He says he enjoys the correspondence, and would encourage me.

            After reading Dr. Atul Gawande I wrote to this doctor with an excerpt about residents. His quick response was so good I removed the doctor’s name and shared it with a medical student who writes here. He was so impressed he desired to be under this doctor’s tutelage at Cleveland Clinic (the doctors know I did this).

            I admit I am not objective. The last year has been so spirit crushing to me….but I have learned so much. If I blasted or was irrational please know it was not personal….I speak from the heart of a mother who at times desired a lobotomy just so her mind would slow down. But I remain deeply grateful for two of the doctors who encouraged communication….and took the time to see that I deeply needed answers and reassurance.

            Hope this explains a bit better why I get passionate….and both of these doctors answer emails late at night and weekends. They helped take my shaken world and gave me some calmness. A hurting heart cannot be scheduled, and words seem insufficient to express just how grateful I am to them…..but I try to impart it via email.

  • http://bakirita.blogs.com/xico EKB

    I wish you wouldn’t call Orzag and his ilk progressives. I consider myself progressive and certainly think he sounds more like someone who likes to issue orders from on high, rather than from the perspective of real people.

  • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

    Congress gives themselves 23 1/2 weeks off per year. Of course they use that time off to claim they are working to meet their constituents. I’m sure that’s it.

    Of course it is.

    http://thehappyhospitalist.blogspot.com/2010/08/how-many-weeks-of-vacation-does.html

    I’m not sure politicians who masquerade as economists carry much weight in their opinions.

    I have an idea. Why don’t patients just not get sick on weekends. Problem solved. That solution is about as likely to happen in this payment environment as it is for doctors to work more weekends.

    • http://www.twitter.com/alicearobertson Alice

      I’m not sure politicians who masquerade as economists carry much weight in their opinions. [end quote]

      But they do carry a ton of weight (whether they are qualified is something the voters need to get with the program about….surely, progressives and their bleeding hearts caused a ton of problems by inviting the government to cure the ills of society?)……and it would seem on the surface that being a government employee would be advantageous to doctors……but the patients would pay quite a price (not recommending this alternative for doctors either….the government does little well).

  • MassachusettsPCP

    I agree that doctors SHOULD work weekends. In fact, they should have late hours during the weekdays too. People do not get sick between 9 am – 5 pm. Much stress and demand can be taken off the ER (as our colleagues at the ACEP have noted) and it’s cheaper for patients and insurance companies for a patient to see his/her own personal physician, who knows him/her well and can reduce testing and total visit fees for the bulk of patients, by seeing them on demand 16 hours out of every day. Win-win.

    He has a point. Pharmacies aren’t 5 days/week. Neither are grocery stores.

    The difference is that pharmacies and grocery stores, and yes, even ERs work in shifts. A doctor cannot be present 16 hours/day 7 days week and not go through burnout, fatigue (compassion or physical), and divorce. We are not corporations with multiple interchangeable people to provide the same service, unless PCP offices contract to have “night” and “day” doctors.

    Even if some PCPs did offer such a model, what of their staff? Salaried staff do not want to work 7 days/week, and most do not want to work weekends on a VERY regular basis in addition to 5 day workweeks. So, most PCPs will need to hire additional staff … with their attendant benefits. So we go to the insurance company and explain we need more money to hire more staff to accomodate expanded availability as they finish their analyses of why physician pay needs to be cut or capitated.

  • Taylor

    Hahaha, @ pacificpsych and The Happy Hospitalist! Yep, doctors should work every minute they’re awake. No time off. And I agree Happy… working for their constituents, rightttt!!

    My parents PCP ALREADY works weekends. He is working weekends because his business is down 30%!! So what do you suppose a doctor in his situation does Mr. Orzag? He is already working weekends to make ENDS MEET, so I guess he should work nights too? And maybe no time off?

  • Max

    Double reimbursement on weekends. I have no doubt in my mind many physicians would stay open at least a few hours for that option. It would probably save the system money in the long run by reducing ER visits. Pay for email, phone calls, etc. Hell I’ll give every patient my personal number and email address to be able to bill for it. “Shoot me an email this weekend letting me know how you are. Me? Busy? Oh think nothing of it. Call me too”.

  • doc99

    The statists don’t want quality. The statists want control. What right does anyone have to determine how much anyone makes? Doesn’t this bother anyone here? Am I even in America anymore?

    • http://www.twitter.com/alicearobertson Alice

      “America” has become a relative term……sigh! Let’s thank the professors who don’t work weekends for creating a generation of progressives.

      • http://evimedgroup.blogspot.com Marya Zilberberg

        OMG, really? Seriously? The median income in this country is $50K for a family of 4! Do you really think that 90% of the people have the control over how much they make? Corporate bosses have the control, not an average person (or even one in the 90th pecentile). This is the reality of our “market capitalism” in the setting of elected officials who will sell the citizens to the highest bidder, with the consent of the Supreme court. This is really not at all what free market was meant to be.

        • Pharmer Joshua

          Take a moment and realize the complexities associated with policy. There is a reason why an ER visit for something as simple as a uncomplicated UTI is $500 in the United States and the blame can squarely be placed upon the government. The government claims to help the poor, but yet they enact policies with good intentions that crush them.

          • gzuckier

            OK, I’ll bite… what is the government doing that makes an uncomplicated UTI visit cost $500? Is there a breakdown of the components that go into this cost somewhere I can refer to? And where is it that these visits cost $500? Around here, which is a high cost of living area, outpatient UTI visits are typically below $100. What kind of government do you have, anyway?

          • Pharmer Joshua

            Major midwestern city. Cash patient pays about a $300 ER fee, plus around ~$150 for physician, and then whatever medications they decide to prescribe. Maybe not quite $500, but still way too much. MEDICARE sets the rates for reimbursement, in addition to licensing of healthcare professions, which restricts labor differentiation and thus increases costs. Hospitals then charge $$$ to “recoup” costs. Medicare and special interests utilize government programs to advance their own interests. That would be fine in the free market, but it is unethical and just plain stupid to do so through government.

  • docguy

    maybe he should work weekends to fix the depression going on in society, maybe have congress work every day, no weekends off, no vacation days, every year that we spend more than we take in no days off, every year that we bring in more than we spend as a country they can start taking vacation days..

    hmmm i wonder how long it would take the balance the budget then.

  • http://fertilityfile.com IVF-MD

    There’s nothing wrong with working weekends as long as it’s VOLUNTARY. Let those who choose to offer this service do so, but don’t force people. I work seven days a week to be able to accommodate patients who optimally ovulate on a Saturday or Sunday. But that’s the service that I choose to offer my patients. You don’t have to offer us artificial incentives. Just give us free market choices and some of us will willingly do what it takes to make our patients happy, even if it means that me and my entire crew sacrifice our weekends. Coincidentally, I blogged about this last month: http://fertilityfile.com/2010/09/19/those-sunday-morning-ovulations/

  • http://www.occampm.com/blog Michelle W

    I saw that article earlier and wondered when someone one comment on it. As some have already commented, it’s interesting that on the one hand we have called on doctors to stop thinking they’re godlike and get rest, collaborate with patients, etc, and on the other hand are saying they should be open at all hours. There is going to need to be a reason, a tit for tat as it were. If doctors work on weekends and longer hours, what makes up for it?

  • Primary Care Internist

    obviously free market forces are not in play here. If there was true “negotiation” between doctors and insurers (including medicare), i could offer e.g. to stay open every other weekend, in exchange for some increase in reimbursement rates after hours.

    But no such thing mostly. For medicare there is a billing code, but it’s not reimbursable (???)

    If there is a shortage of offices open on weekends, then clearly there isn’t enough incentive for it.

    Nurses, cops, and EVERYONE else get a differential for holiday / weekend pay. And during weekends I see most nurses just yapping about optimizing their vacation / sick time to milk their benefits maximally, rather than actually caring for patients, while I round on the 5 medicaid and “self-pay” admissions i got overnight who will earn me next to nothing.

    Orzsag needs to go learn something valuable – he (and obama) should follow around a couple of primary care docs for a day. Even michelle obama, former $300k/yr hospital exec apparently isn’t able to contribute any knowledge.

    This administration continues to alienate doctors, and I just don’t know when the AMA is going to grow some balls and be more forceful in defending us. First the tonsillectomy comment, then the blatant bed-sharing with the trial lawyers, and now this???

    This is still a free country, but we are rapidly moving towards a “take-it-or-leave” state, and most docs over about 55 years old are happy to just leave it.

    • Pharmer Joshua

      The AMA and state medical societies protect you every single day from free market forces. It’s called licensing. If other health professionals were allowed prescriptive authority, for example, do you think as many people would go see you for the same price? No. Our healthcare is inefficient because of anti-competitive laws such as these protectionist policies just as awful as union agreements that protect bad workers. Medicare is the same, as it controls disbursement of taxpayer monies. Medicare is both your savior and your downfall, but mostly a downfall for all, not just physicians.

      • Vox Rusticus

        Anyone who wants to go to medical schol can get a license when he or she passes the exams that the state requires be passed. Voters could decide anytime to change that and remove all restrictions on prescribing, even make all medicines over the counter, for that matter. Where is the public outrage that we don’t have that freedom now? Could it possibly be true that the public expects the government to regulate who can prescribe and what they can prescribe? The public seems to be O.K. with requiring prescribers attain a certain level of education and maintain that level by taking continuing education courses. They seem O.K. with licensing pharmacists who dispense drugs and requiring drugs makers satisfy requlations as to safety and efficacy of their product.

        Pharmer Joshua, you seem trapped in your extreme understanding of free-marketing and the body politic does not seem to be with you. Ever wonder why?

        • http://fertilityfile.com IVF-MD

          Pharmer Joshua is right. I’m one of those doctors who is (unwillingly) protected by those artificial rules and regulations and I would ask a question to Vox Rusticus. You speak as to the assertion that “the way things are” represents “what the public wants”. Not true. Under our CURRENT SYSTEM as it runs today, do laws represent the will of the public or more the will of the ruling elite? As evidence, remember the huge outpouring from the common people BEGGING the politicians not to vote for TARP and not to vote for the healthcare act. These policies are never ever put to the direct vote of us common people. That’s not how the current system works. The system is a representative democracy and can be rigged (and it is) so that we can only choose between two parties, neither of which serve our wants, in my opinion. We could debate the intricacies of our legislative system all we want, but it would be more appropriate for us to take that discussion elsewhere. For now, I’ll just stick to the topic at hand and challenge your assertion that people don’t want the freedom to buy their own medications without a prescription. I bet there are enough folks who want it that if it were left to a state-to-state vote or even a county-to-county vote, that there would be several places where people become free to purchase medications without a doctor. This is the way it is in some other countries and it serves them fine. I would rather the AMA fight to protect us doctors from lawyers rather than have them fight to protect us from healthy competition. Because if we do our jobs of providing quality care, there would still be plenty of people who choose to come to us rather than to buy medications on their own. I have a great story about this in my field in particular where people can and do buy medications without a doctor (via the internet) and the harm it caused to them. I might blog about it some day.

        • Pharmer Joshua

          Extreme? It is most certainly said that being a proponent of the free market is now extreme, as that was a vital component when our country was created.

          I would be fine if others could dispense medications, just as I would be fine if others could prescribe. You fail to realize that it was not the people that set those regulations. The public is complacent because it is just “how things are.” A very conservative position, I might add.

          You can bet the body politic would be with me if pharmacists and nurse practitioners could prescribe autonomously, because the cost of services would drastically go down. Why are people going to MinuteClinics? And why are many physicians railing against them? It is protectionist, statist, and for physicians, not in their interest to support licensing. Physicians give up their freedom and ability to charge what the market demands.

  • SmartDoc

    Memo to Peter Orszag:

    I am so glad Peter Orszag took time out from his busy career of utterly ruining the American economy, raising taxes, and wasting trillions in our now lost national treasure to offer these thoughtful insights.

    I would point out a small problem: the Fourteenth Amendment to the United States Constitution outlaws involuntary servitude.

    • http://fertilityfile.com IVF-MD

      I’m with you, SmartDoc.

      And allow me to add that although the Fourteenth Amendment to the United States Constitution outlaws involuntary servitude, the Sixteenth Amendment coercively demands it.

  • Winslow Murdoch

    Extended hours service doesn’t save money necessarily. I do see patients at my home an average of every other weekend and do meet patients at the office on weekends if need be for testing that I cannot offer at home.
    Primary care being available and knowledgable of a patients full history, for thorough phone and email consultation does save money and prevent ER visits but is not compensated at all.
    Again most times in adult primary care, having obtained a full history, the triage for office vs ER care is pretty straight forward but again no payment so default is usually ER referral.
    For complex chronic or acute care issues, weekday office visits (or email or phone consultations if they ever get paid for) are most appropriate and effective when we have full staffing and access to resources/samples/chart/staff to do preauthorizations and precerts etc at the office.
    The idea that off hours are by default patient centric when insurance lab hospital and radiology resources are absent is magical thinking in the real world except for the most straightforward medical issues.
    Winslow

  • ninguem

    http://www.cmaj.ca/cgi/content/full/167/5/530

    In 2002, Quebec tried to draft physicians to cover rural ER’s. Not to take on the subsequent care of the ER patient, but actually send a mountie to your house and drag you, willing or not, to a remote ER to provide medical services. They couldn’t find docs willing to work there. Heaven forbid they pay an attractive enough wage to motivate people to work there. No, use the power of the state to force the docs to work.

    So I’m not surprised.

  • Brian Loveless, DO

    Don’t we have weekend doctors? I thought that was Urgent Care/ED for acute issues (they are better equipped than most offices anyway for these things.) You don’t need to come in on the weekend for non-acute issues, make an appointment during the week.

    Brian

  • http://www.consentcare.net Martin Young

    In a perfect world anybody who needs help at any time should be able to get it, and there would be no abuse of the system nor of the provider.

    Wishful thinking indeed!

  • HJ

    “I’ve pointed to studies showing that mortality rises on the weekends, in part due to skeleton staffs that hospitals employ on Saturday and Sunday.”

    Of course working weekends is about money and not about saving lives.

    • http://fertilityfile.com IVF-MD

      HJ, I’m not sure what point you’re trying to make and I’d like to understand your viewpoint a little better. If what you say is true, then what would it look like if, alternatively, “working weekends is all about saving lives and not about money” and I’d be curious not only what it would look like but also what’s the point of arguing this?

      • HJ

        My point is the most of the comments in on this post show more concern about money than improving health care in our communities.

        • http://fertilityfile.com IVF-MD

          Fair enough :)

          Is it OK if I interject that in a true free market, the two would go hand in hand. A doctor who delivers the most desired quality of healthcare (in the eyes of the patient, not in the eyes of a bureaucratic planning committee) would tend to earn the best for himself and his staff.

          • Pharmer Joshua

            IVF-MD, we can only wish, but Medicare now essentially controls the entire market. People are afraid of “socialist” healthcare, but we basically already have it. Ask any private insurance company – they follow Medicare. For too many people, they seem to equate a “free market” with only money and evil, rather than securing economic and human rights. I might as well just change professions and go to law school. At least that way I can at least defend some good people and companies.

          • HJ

            “in the eyes of the patient”

            Since I don’t have a medical degree, how do I determine whether I have received quality health care?

  • imdoc

    A review of American history will show there was a time in the country in which licenses did not exist and there were no prescription laws. Our forebears put such laws in place not to protect the economic interests of trades, but to protect the public. You can’t even cut hair without a license. I would argue we have all benefitted from this.

    • Pharmer Joshua

      Ok, imdoc, let’s have this discussion. Not only does licensing of jobs such as haircutting hurt the working poor more than it helps, things like medical licensing also hurt more than help. I like to refer your argument to the “protect the public” part of the Constitution, otherwise known as the “It’s for the children” part of the Constitution. Requiring physicians to do tasks that can be performed well by less educated professionals is anti-competitive and increases costs and decreases access to care for patients. Your assumption that licensing is a good thing needs to be challenged, because it is an invalid assumption. First bit of reading for you here -
      http://j.mp/cVnC7z. Enjoy.

    • http://fertilityfile.com IVF-MD

      Imdoc, at first when you pointed out that you can’t even give a haircut without a license (and the latest I heard is that in some states it’ll be illegal to teach yoga without a license ha!), I thought you were agreeing with the nonsense of all this, but you surprised the heck out of me when you went on and said that you feel we have all benefited. What???

      There’s nothing wrong with VOLUNTARY licensing or ratings. That way I can choose freely if I want to go to a licensed haircutter or to (heaven-forbid) an unlicensed haircutter, but morally, that’s the choice of the people. It does not come under the jurisdiction of a powerful elite person in some state far far away, especially not according to the Constitution. Coercive licensing requirements only serve to help the providers by protecting them from fair and healthy competition.

      But to hear you out, when you say we have all benefited, I’m curious what do you think are the good things that come out of a heavily-regulated world and what are the BAD things come out of a heavily-regulated world?

  • http://hotmail.com Art

    Since we have a shortage in physicians, nurses and other licensed professionals, spreading them out over 24 hours does what?

    I would think they couldn’t see as many people as they do now! No?

  • http://fertilityfile.com IVF-MD

    Hmmm. In an above comment, I asserted that the quality of medical care is best judged “in the eyes of the patient” who’s getting the care.

    HJ asked “Since I don’t have a medical degree, how do I determine whether I have received quality health care?

    It depends on what you value. In the free market, the opinion of the customer/patient is what counts.

    I can’t pretend to tell you a one-size-fits-all answer to what constitutes quality health care in YOUR opinion, because I don’t know you and what you value. That’s the whole point of what makes a free market paradigm different from a centrally regulated one. As an outsider, I’m not meddling nor judging your transactions. I leave that to you and to your doctor.

    If you want me to, while I can’t know what you consider as “quality”, I can hazard a guess what other people might value and they might all be different. For example:

    I feel I received quality care because:
    “My excruciating sudden pain went away after my appendix was removed and it happened within a span of 2 hours from arrival at the ER to being in the recovery room” OR
    “It burned when I urinated and now it doesn’t any more” OR
    “My doctor’s office has convenient free parking. They always answer their phones on the second ring with no voicemail. They are so polite and pleasant and my doctor talks with me for 30 minutes unrushed and attentively. They gave me a copy of my labs and explained everything in detail, answering all my questions” OR
    “Even though I hemorrhaged and got an infection after my c-section and required a transfusion and a week of IV antibiotics, my doctor and the staff were really attentive and I felt really in the good hands of people who truly cared during all this. That was the best medical care I’ve ever had”

    And in contrast………………………..

    I feel I DIDN’T recieve quality care because:
    “I waited 5 hours in the ER waiting room before being seen and another 5 hours before having surgery for my ruptured appendix” OR
    “It really burns when I urinate and after seeing the doctor 6 times, he just keeps giving me the same ineffective antibiotic and I still have burning, worse than ever” OR
    “I pay $10 for parking every time I see my doctor, wait for four hours reading year-old magazines. Her staff is rude and incompetent and spend more time gossiping about their weekend plans than assisting me. The doctor sees me for 2 minutes and writes me a prescription for an expensive drug without asking me what my symptoms are or even saying good morning” OR
    “Even though my c/section went perfectly and everything post-op went perfectly, my TV was broken the entire time I was in the hospital and no matter how I brought it to their attention a dozen times, they just kept saying they would send someone and they never did. That was the worst medical care I’ve ever had.” (This was an actually told to me with a straight face)

    Of course this free market paradigm is just one option. There is always the other way if you prefer where even if you were to hypothetically wait four months for an appointment, spend 5 minutes with a nurse and 10 seconds with a doctor, remain uncured, end up in worse pain and suffering than ever. And when you legitimately complain about the lack of quality care, the central planners say to you “What do you mean you didn’t get quality care? The doctor is licensed by us. The facility is accredited by us. They exceeded federal benchmarks in % of mammograms ordered and average cholesterol levels of patients and your care was free and paid for out of tax money. So shut up and be appreciative. You got quality care because we say you did”

    HJ, you certainly don’t have to have a medical degree to determine whether or not you received quality care. It is based primarily on if you are happy and satisfied with it or not. I’m curious why you don’t ask questions about anything else you don’t have a degree for, like for example:
    Since I don’t have a culinary degree, how do I know if I’m being served quality food?
    since I don’t have an engineering degree, how do I know that the bridge I’m driving on is a quality bridge?
    Since I don’t have a cosmetology license, how do I know that I’m getting a quality haircut?
    Since I don’t have an educational degree, how do I know that my kids are getting a quality education? etc etc

    Even without an official degree, you are certainly free to do common sense research on any crucial matter or consult people you trust, ESPECIALLY in this day and age of unprecedented informational access. Thinking for yourself gives you more power to vocalize whether or not you are satisfied. Relying on a central planner to think for you takes away your power, and that’s even assuming that their judgment and motives are good for YOU and that’s a very dangerous assumption. Agreed? :)

  • imdoc

    Ok, I read the Cato Institute report. This is really just another rebuttal to the Flexner report which has been raging for a hundred years. Should ALL licenses be abolished or simply part of a private sector effort? Many people do not want to board an airline with a pilot who doesn’t have a pilot’s license. The answer to the post above regarding driving on a bridge: In the U.S. you have the comfort of knowing that there was a certified engineer supervising – something that doesn’t happen in every country. Pharmer Joshua are you in healthcare? IVF-MD what, without license and force of law, is to be done with a doctor with criminal conviction or substance abuse impairment?

    • http://fertilityfile.com IVF-MD

      imdoc, you asked “without license and force of law, is to be done with a doctor with criminal conviction or substance abuse impairment?”

      You asked a very good question. I never said to ban licensing, only to make it voluntary. Therefore, as a patient, I can choose to see “Seal of Approval” doctors and feel reassured to the degree that I trust the licensing agency, which is not to be assumed to be perfect, by the way. I strongly believe in enforcement and harsh punishment for people who falsely CALL THEMSELVES licensed if they are not truly licensed.

      But alternatively, as long as unlicensed individuals don’t profess to call themselves “licensed”, a patient can knowingly CHOOSE to enter into a patient/provider transaction with someone who was trained in a foreign school, who has a prior criminal record, who has a physical handicap that would preclude their being licensed or who just chose not to pay a license fee. It would be a big disadvantage to compete in the marketplace without a license, because you would have to prove yourself to potential patients by going above and beyond in other ways, and establishing some sort of reputation in other ways.

      For example, if I needed eyeglasses, I should be free to CHOOSE to risk going to an unlicensed, uncertified, untrained, substance-abusing non-optometrist with an extensive criminal background to get my refraction exam and get a pair of eyeglasses. That should be my free choice. It’s utter nonsense to ban me from engaging in a mutual consensual transaction with someone.

      Now, while it should also be my free choice to go to such a uncertain person for open-heart surgery, I know 100% sure that I’d choose not to and I would wager that someone like that would not be able to sustain their practice in an economically viable fashion.

      The moral principle is to allow people the freedom to take risks as they judge. You might make an argument that children and mentally-impaired individuals could fall prey here, but that’s where their family comes in. As a parent, or family member of a mentally-impaired individual, your love for them would make you take an active role in choosing their healthcare provider. Having the state take responsibility leads to the horrendous harm that comes to many children who grow up in the “the system”, for example.

  • http://www.healthscareonline.com Richard Young, MD

    For family physicians and other primary care physicians to expect the political and financial class to support our future, expanded coverage on nights and weekends has to be part of the deal. Though let’s recognize that this issue is a thorny one in many other developed countries as new payment approaches and a new generation of doctors make out-of-hours coverage more difficult to staff.

    For the good of the healthcare system, the most important first encounter of a patient to the system is that he or she sees a common sense primary care physician. People are frustrated when they have minor health issues that arise at nights and weekends, such as a small laceration, yet their primary care office tells them to go to an ER. This is a waste on many levels for the patients and the entire system.

    This doesn’t mean that primary care physicians should be expected to work 24/7. But it does mean arrangements for shared after hours work where all PCPs chip in should be part of our future.

  • anonymous

    You know, I am the wife of a medical resident. He works his butt off. Most days he works 4:30am to 8:30pm. He works most weekends. But when he is off for a weekend we enjoy it. I think it is ridiculous that this economist is who we have in the government making decisions for health care. Maybe the government should consider actually getting some doctors in the mix so that they can actually do reform that will work.

    Decreased Pay + increased hours (weekends) = doctors who do a horrible job because when they aren’t at the hospital or office working, they are moonlighting at another hospital to make up the money they need to support their families and pay back the exorbitant amounts of student loans. This results in doctors who cannot do the job they need to do. Tired doctors do not = effective doctors.

    Someone needs to understand that politicians and economists CANNOT make a health care system that will work for both patients and doctors. If you screw up health care reform, you loose doctors, then who is going to take care of the patients. It is ridiculous!

  • Mike

    “Studies show that patients are heavily influenced by their doctors. If health reformers want to sway public opinion, getting doctors on your side seems to be the ideal strategy.”

    Less and less so with each new exposé in the New York Times. I think the public has had a heavy dose of reality in recent weeks and sees doctors less as altruistic, champion fiduciaries and more as self-promoting, money-driven human beings.

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