Physicians the government wants to see

I was talking with a pre-med student recently.  He had completed his very first medical school interview and was, understandably, excited.  But he told me the interviewer had asked him what he thought would be the outcome of the current health-care reform measures.

I laughed to myself.  After 17 years in practice, even I don’t know the outcome, though I have my suspicions.  It seemed a loaded, almost unfair question.  After miring students in biology, physics, chemistry and every known application-padding activity, after expecting volunteerism and activism, I’m not sure why they would expect this young man to have any earthly idea about the reform measures from his current position in the medical biosphere.

But I wondered, since I’m not a medical educator, was there a right answer?  And I wondered even more, what do we want in our future physicians?

Since I can’t speak for the young man’s interviewer, I’ll give the benefit of the doubt.  I suspect that he was trying to see if he could think, if he had a courageous opinion, one way or the other, about a controversial topic. Like one of my residency interviewers who asked my opinion about giving abortions to minors without consent; which led to a brief disagreement … and to my attending a different residency.

I hope that the interviewer wouldn’t have doubted the young man’s capacity if he had said, ‘I’m for repeal!’  I don’t know the details of his answer, but I doubt if that was his opinion.  Pre-med students aren’t known for their valient, unpopular stands on social issues.  Pre-med students tend to follow the current that ends in medical school, and do their best not to rock the boat.  I know that’s what I did.

I do know that the pre-medical students I meet are very energetic, very savvy, very enthusiastic.  But what sort of enthusiasm do we desire to see in them?  In times past, we sought physician candidates who were self-motivated, independent in thinking, courageous in uncertain situations:  not always right, but always confident.  Is that what we still want?

Speaking from private practice, I would say yes.  I want future partners who are bold, who have solid opinions that sometimes fly in the face of government and culture.  I want partners who have their own set of moral values and abide by them, despite the trends and tendencies of society.

Is that also what we want?  Or is it better to have malleable students?  Is it better to have students who love rules and love following them?  Is it better to have students who adore government initiatives and are always willing to go lock-step into whatever reform, whatever ideal, whatever policy comes to them from on high?  Are they expected by admissions committees to be the kind of people who agree, or the kind of people who sometimes don’t?  Can they be admitted if they are politically at odds with their interviewers or future professors?

Maybe a better question is, what sort of student does the government want to see training as a physician?  I imagine they would like to see physicians willing to work more and cost less.  It fits budgetary priorities.

But I’ll bet they also want  physicians comfortable with that most horrible trend in American, and Western, culture. The trend of hyper-regulation.

I growl and grump against new rules all the time.  Against excessive time-outs, encrypted pass-words, too much data on charts and payment schemes too complex to understand.  Each new year seems to bring something else designed to cause me to retire early; as if I could.  But does it rankle the young?  Does it bother those who grew up with a surplus of rules the way some of us grew up with a surplus of heroes?

Does the country want physicians who find rules and regulations to be impediments to patient care?  Or does it want physicians who follow any rule if they’re told it’s a good one, and if someone (someone in authority over them) flashes a double-blinded, placebo controlled study to justify it?

I’m just asking; I don’t know the answer.  We used to choose physicians for their autonomy and individuality.  For their willingness to open their practices, do what they thought was right and serve within the context of their own morals.  The reward for their autonomy, and for their service to the sick, was their relative freedom.

What does the future of reform hold?  I don’t know.  But I do know it may require an entirely new species of physician.  Myself, I have a chilling sense of impending extinction.

Edwin Leap is an emergency physician who blogs at edwinleap.com.

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  • http://www.AllThingsBoys.wordpress.com Arnel

    Dr. Leap,
    What an interesting blog. Also being in medicine, my husband and I have noticed of late that the charging practices of the younger generation are entirely questionable. We all want to be paid for our services, don’t get me wrong. But when we hear that someone was called in for a 40.00 office visit simply for telling them their labwork was normal, we have to wonder. Likewise, a new current practice of charging 25.00 to call in a perscription seems also wrong. And it seems it is the younger generation–those only in practice for a few years–who seem to have no qualms about what they can charge for.
    The sad thing is, it seems to be spiraling out of control, with no end in sight, and eventually people will accept these practices as the norm, but will question and balk at 40.00 for a simple eye exam. I think people have their priorities mixed up.

  • family doc

    “…And it seems it is the younger generation–those only in practice for a few years–who seem to have no qualms about what they can charge for…”

    If we had the higher pay and the lower paperwork burden that the older generation of physicians enjoyed, we’d be happy to go back to doing lots of things for free. This seems a bit like Maddoff’s early investors wondering what the big fuss was about since things worked out well for them.

  • http://www.AllThingsBoys.wordpress.com Arnel

    Family doc,
    While I sympathize whole heartedly with the decline of reimbursements, (particularly with regards to those whose practices carry mostly geriatric clientele–my husband included) it doesn’t excuse some of the billing that goes on. I would argue that if you have time to call every patient back in for an appointment in which the only thing that happens is they are told their lab results are normal, then that doctor has a low patient load; ie, they can’t fill all their slots with regular patients, because if they could/did, they wouldn’t have time for these appointments, and the nurse would call the results. And there is the group that falls in between the “hey day” of insurance reimbursements, and the young group now that charges anything that looks at them. My husband has been in practice long enough to feel disdain for such practices, but not long enough to have enjoyed any of the “hey day” era. So you are wrong to assume that the docs that resent it made out like a bandit before the ship sailed.

  • anonymous

    “I would argue that if you have time to call every patient back in for an appointment in which the only thing that happens is they are told their lab results are normal, then that doctor has a low patient load; ie, they can’t fill all their slots with regular patients, because if they could/did, they wouldn’t have time for these appointments, and the nurse would call the results”
    not necessarily true. if you get paid the same for the visit, would you rather have this visit or a long one that will make you late for dinner?
    where is the younger generation learning these habits from?

    • http://www.AllThingsBoys.wordpress.com Arnel

      Well, as naive as it sounds, it seems as though you agree with filling your appointments based on how it cuts into your social life, and that your scheduling is based on monetary reward and how that jives with getting home for dinner. As far as learning these habits, it’s a little like mob mentality. It only takes a few to think up the idea and execute it. Then it catches on like wildfire. Doesn’t make it right. And I’m thinking that many people won’t want to see a doctor when they learn that said doctor chooses his scheduling practices according to reimbursement and ease of appointment. I also fear that these kinds of issues take away from what is really destroying medicine. Lawyers are pretty stupid if they are not happy when the focus shifts away from malpractice, insurance responsibility, and the government. That is where the reform needs to happen, but it won’t if doctors suddenly find themselves practicing in a less than honorable fashion, bringing the attention back to them.

  • Brian

    “I want future partners who are bold, who have solid opinions that sometimes fly in the face of government and culture. I want partners who have their own set of moral values and abide by them, despite the trends and tendencies of society.”

    And what of those future partners who, of their own accord, actually happen to agree with the government and culture? While I understand your point, your post seems to presuppose a virtue in those who disagree with government (in this case, health care reform) that is not possible in those who agree.

    Could you clarify?

  • Doctor Jones

    I am questioning along the same lines as Brian–why do you assume that people who choose to prioritize the public good rather than private gain (taking the government perspective rather than, perhaps, the private practice perspective) are incapable of bold, solid opinions, following their own moral code?
    Could they not be following their own moral code, that leads them to agree with government policies, rather than yours, that leads you to disagree?
    Equally worthy human beings, with different world views.

  • justin

    arnel,
    you seem to begrudge physicians who want to be paid for their time. if a doc was paid for the five minute phone call to report lab results they might choose to call the patient with the results. but what about the ‘ free’ phone call to deliver results that ends up requiring fifteen minutes because the patient has legit questions or symptoms to report. what you are saying is that a doc should work for free, and I disagree with that.

    • http://warmsocks.wordpress.com/ WarmSocks

      When you paid a fee to take the MCAT, did you then have to pay a second fee and return to the testing center to pick up your results? Of course not! People legitimately expect to be given their results as part of the original fee.

      That does not mean, however, that a doctor needs to personally phone every patient for whom tests are ordered. That’s what support staff and the postal service are for. For normal results on routine tests, it’s okay to drop a card in the mail. For abnormal results that need follow-up, let the office staff phone and set up an appointment. For tests that aren’t routine (the patient is anxiously waiting to hear the results), a phone call is appropriate whether the results are positive or negative – again, this can be done by the support staff.

      I’m lucky in that my doctors are willing to write “copy to patient” on the lab order slip and let the lab take care of mailing a copy of the lab report to me.

  • http://www.edwinleap.com/blog Edwin Leap

    Brian,

    I did use the word ‘sometimes.’ If those partners agree with the government, for the right reasons, then fine. But not just because ‘it’s the government and they say so.’ We need to be willing to confront bad ideas, bad science, bad government, bad care; and encourage the good in each in turn. Governments can certainly be involved in bad care, whether Nazi physicians or the US syphilis experiments, just as they can do useful things like encouraging and funding research, engaging in public health measures, etc. I just want us to think independently!

    • Brian

      Yes, governments can be involved in bad care, regardless of their motivation (i.e., “evil” a la Nazi doctors, or “good” a la Tuskegee). I am extremely skeptical of the insinuation that anyone doubts this, least of all aspiring medical students.

      I take issue with your post solely because it appears to me to be a stalking horse for your own opinions about health care reform. In so doing, you turn what is a regulatory and ethical morass into an easily-digestible, if simplistic dichotomy.

      Sentences such as: “Pre-med students aren’t known for their valient [sic], unpopular stands on social issues” assume valor on the part of those who oppose HCR (whether you intend them to or not), and in a general sense, rules & regulations in general. By implication, those who support current government efforts viz. health care reform are, in effect, mere sheep, comfortable with the “evil” expansion of government rules and regulations.

      But rather than go on at length about what I perceive to be your message, I suppose I should ask whether you believe government has any role to play at all in patient care, and if so, where the line is drawn.

  • David Helcel

    Justin,

    Part of the fee you collected when you ordered labwork is intended to cover the interpretation and reporting of the results, as it is a part of your examination of the patient. The phone call you make is not unpaid, then, because until you interpret and report, your examination is not complete.

    • justin

      Where are you getting this information? If we extrapolate your example to surgery, then when I decide to remove someone’s gallbladder, there is no extra payment beyond the initial evaluation. Because that is when I decided the gall bladder should be removed. Of course this is not the case.

      • David Helcel

        Justin,
        That’s a pretty bad extrapolation. Obviously there is a difference between being paid a fee to examine a patient and being paid a separate, higher fee to perform a surgical procedure. However, in your original post, you stated that you should be paid to speak to a patient about lab results (which I presumed that you ordered to further evaluate the patient based on an examination that you charged for). My point in that scenario was that since the diagnostic testing was related to the examination, part of your exam fee was to interpret and report the results for your patient. Admittedly, I did not specify the fee to which I was referring in my original post, and that may have led to your confusion.

        • justin

          David,
          Thanks for your thoughtful response. I think that traditionally physicians would call lab results, and they would not request to be paid for the phone call nor request another appointment. In my opinion these were the good old days when reimbursements were high and MD’s graduated from med school with $10,000 in debt. No one requires the doctor to provide the free phone call, nor is there a requirement to schedule a followup visit, so either option is a legitimate and appropriate choice by the doctor. You are supporting one choice where the doc calls the patient for free, while I support the other choice where the doc charges for the time on the phone or schedules another appointment. In the middle would lie doctors who only schedule appointments to discuss abnormal results. Neither your argument nor mine is correct in any absolute way; they are merely differences of opinion. This makes us both right/and wrong simultaneously.

          The suggestion about having the secretary call with normal results sounds good, as long as you have a secretary.

          What it really comes down to is patients choosing a doctor that behaves in the way they prefer. This will become challenging for folks who want the free phone call as all the baby boomer docs retire and the young docs with huge student loan bills enter the workforce and want to be paid for their professional services; the services they spent 11+ years learning.

          I think we will have to agree to disagree.

          Doctor: $250K in student loans. 4-5 years for bachelors, 4 years for MD, 3+ for residency. Entering the workforce at 30 years old at the earliest vs living your 20′s with a 40 hour week and making 6 figures by the time you’re in you early 30′s. Doctors are generally very empathetic people who put their patient’s number 1, but they also want to earn a good living. Residency sucks and you are underpaid. Paying for a phone call seems like such a petty thing for you to argue about.

          • David Helcel

            Justin,
            I know where you are coming from concerning education and debt.
            DVM: 4 years bachelor, 4 yrs for DVM, age 30, 130K in debt. Identical educational requirements and difficulty, sans residency (and ours suck as well, and the pay is laughable).

            At my practice we do most of our diagnostic testing in-house, I have a secretary, and I’ve always only ordered diagnostics for my patients, having previously examined them. The concept of charging someone for a phone call to explain a test result that I ordered is not something I would feel ethically comfortable with. A recheck office visit, yes, if the patient required it, but not a phone call. I suppose part of my bias is that we do not have to deal with insurance companies or Medicare, as our clients pay when services are rendered.

            I also hear what you are saying about getting tied up with some chatty person who will waste 15-30 minutes of your day. I don’t like it either, but in my opinion, it’s part of the job. I suppose we just have different philosophies.

    • anonymous

      The problem I often run into: when the patient has me on the phone, they take advantage of that to ask about new symptoms they didn’t mention during the physical. If I try to get them to make another appointment, they protest.
      My solution: I tell them during the physical that if all the labs are normal, my receptionist will call them to let them know. If there is something that needs attention, I will call them to briefly explain the issue but they may need to come in to spend more time on the full discussion. I also tell them if they don’t hear from us within a week after going to the lab, they should give us a call.
      The other method that works well with motivated patients: give them the lab form ahead of time so we can discuss the labs AT the time of the physical.

  • PAULMD

    I think you may be confusing diagnostic testing with ordered lab work. I do a large amount of diagnostic testing in my office and I am paid for the testing and the interpretation rolled into the single fee.

    Docs that order labwork do not get paid for the test but are required to avail themselves for their explaination for free??? Hardly seems fair to me.

  • PAULMD

    I personally did not think it was very “cool” of the government to NOT treat known cases of syphilis in Tuskegee…but that is my perspective.

  • Brian

    Paul,
    I think you may be confusing the intent with the result. The intent of the study was to demonstrate that African-Americans did need treatment for syphilis, contrary to the prevailing medical wisdom at the time. Goes to show that the road to Hell…

  • PAULMD

    My impression on what kind of person(s) the government wants in medicine…squids. Intelligent, yet spineless and maliable , cephalopods.

    I love to generalize…so here I go. Alot of Academic docs are squids as well. Sorry, it’s just the way you are. Since they control the particular individuals that will matriculate into their institution they are further motivated to bias towards those with whom they see “self”. Therefore the march of squids persists.

    I did admissions for a large medical school years ago. For the most part, the staff that has the time to attend meetings and steer policy were the squids. These meetings of all kinds are polluted with “good soldiers” who, if I had to guess, were mostly the last kids picked for dodgeball on a regular basis.

    The surgeons and surgical subspecialists were too busy treating people to attend these meetings. At least most of them were Chordates.

    Yes, I am and I wish to be in the company of honest, competent and aggressive doctors that will question the voracity of research results as well as the dictates of government and the insurance industry. People that can think critically and call a spade a spade. I like most, want more “self”.

    But then again, I’m probably just an angry squid.

  • http://www.edwinleap.com/blog Edwin Leap

    Doctor Jones,

    If physicians’ opinions are well formed and rational, and not compelled by their educators, then fine! I just want physicians to be independent thinkers. And I don’t think I suggested that either group was worthy or unworthy as human beings.

    I do think it’s interesting that you juxtapose ‘prioritize the public good rather than private gain.’ Here, in a sense, you do what you accuse me of doing. You imply that your opinion is morally superior because it holds forth that government is always for ‘the public good’ and anything opposed is base, and ‘for private gain.’

    We all, doctor, work for private gain. Even our politicians. And in point of fact, private gain frequently results in more general public good than government policies and intrusion.

    But that is not the point. The point is, I don’t care if one holds one opinion or the other; merely that they be capable of holding independent opinions.

    Medical students indeed have opinions; but can they express them and be accepted? Or will they be considered politically incorrect? If a med student says abortion is always wrong or fornication is a sin, will he be welcomed?

    I don’t know; as I said in the post, I”m asking.

    As to the limits of government in healthcare, the feds imposed EMTALA on my specialty and for 17 years in practice I have seen tons of patients for free. The average emergency doc has $160,000 in unpaid charges. But we receive no malpractice protection for being the safety net, and we receive no tax credit or anything else. In my world, the government goes too far. Even in coding, where not doing enough internal medicine review of system boxes results in a down-code so that payment can be denied and shifted in a vast shell game.

    Look, I get what I bill for; I am not employed by hospital, state, HMO or anyone else. The government consistently makes my job harder.

    Thank you for your comment,

    Edwin

    PS Of course this piece reflects my opinion; Reader Takes is an opinion forum.

  • imdoc

    “voracity of research results…” I expect that was a typo, but you know it actually has a meaning of its own given the authority studies of any type now seem to assume. I like it.

  • PAULMD

    VERACITY

    Damn I miss spell check on these blogs….but it would have slipped by because of my own ignorance. If only I had a more balanced eduacation in the Humanities, this could have been overted ;)

  • ninguem

    “…….The intent of the [Tuskegee] study was to demonstrate that African-Americans did need treatment for syphilis, contrary to the prevailing medical wisdom at the time…….”

    Which “time” are we talking about? It makes a difference.

    The Tuskegee study was from 1932-1972. Penicillin was not established as the standard treatment for syphilis until the 1940′s. Wikipedia says 1947. It may well have been earlier, but as a practical matter, not easily available in the war years.

    It started as an observational study at a time when there was no treatment for syphilis. Treatments in the 1930′s were minimally effective at best, and caused significant harm. The people in the study, back in the 1930′s, likely would have received no treatment at all, ineffective as contemporary treatment was at the time. State of the art was a retrospective study from Norway in the 1920′s.

    The original idea was to follow the retrospective study with a short observational prospective study (months), followed by a treatment phase with currently available treatments. What it morphed into over the years, is another matter.

    What they were thinking after 1947, I’ve always wondered about. By then, there WAS an effective treatment, beyond dispute.

    http://en.wikipedia.org/wiki/Tuskegee_syphilis_experiment
    http://www.tuskegee.edu/Global/story.asp?S=6377076
    http://www.tuskegee.edu/global/story.asp?s=1207598

    The study started out with help from n Rosenwald Fund, a Chicago-based charity which had approached the U.S. Public Health Service to consider ways to improve the health of African Americans in the South. They got the help of the Tuskeegee Institute, a historically black college.

    It’s too easy to make it off as an evil racist plot. It’s worse than that in a way. It started out with the best of intentions, and even had support of African-American leaders in the area.

    It sure morphed into something else.

  • Brian

    “It’s too easy to make it off as an evil racist plot. It’s worse than that in a way. It started out with the best of intentions, and even had support of African-American leaders in the area.

    It sure morphed into something else.”

    This was sort of my point, but I acknowledge I was a bit simplistic in my earlier comment.

    • ninguem

      Thanks.

      If anybody has any insight, heck I’d like to know. The part of the Tuskegee study that really bothers me is the phase from 1947-1972.

      When there was virtually no access to care anyway, and there was no practical treatment for syphilis, and the ethical protocols for human studies was more lax generally, you could argue the study made some sense.

      Penicillin was being tried for syphilis in the early 1940′s, but the treatment was not proven, and war shortages would make it hard to get. In the 1930′s they extracted the penicillin from patient’s urine to re-use it. I don’t know when production was ramped up enough that they could stop that practice.

      But postwar, there was plenty of penicillin, it was established as the treatment for syphilis in 1947.

      What was their reason for continuing the study from 1947-1972?

  • doctor

    As far as the original blog, ditto, Dr. Leap. I have been hearing that political correctness and “correct” (meaning liberal) political opinions were becoming requirements for admission to medical school- or at least that if one had dissenting opinions, he or she had better keep them to herself/himself. Could this be described as, “Don’t ask, don’t tell?”
    As far as reviewing lab results with patients, my partner has a reasonable rule: if the phone call exceeds (insert your own time, for him 15 minutes) then maybe it is reasonable to have the patient in for consult. I don’t think there is one right answer. After 15 years, I just accept that I will finish appointments and then spend another one or two hours on the phone uncompensated. (or without further compensation, depending on your viewpoint) The only thing I can say with certainty is the lawyers would never accept this!

  • sam reyes

    The goverment will be happy to see more doctors in family practice who will be more than willing to work hard for less. Come 2014 the law makers will come up with a law to import MDs from the third countries as it happened before. They will be willing to work hard for less.

  • PAULMD

    @ SAM
    If it was my job to destroy the american physicians, I would open the sluices to FMGs. I wonder though, how many of the good ones would seek fellowship training.