Progressive commercialization of American medicine

by Lucas Restrepo, MD

There is only one fundamental problem with American medicine: its progressive commercialization.

Every other problem derives from it centrifugally. Medicine, wrote William Osler, is “a calling, not a business.” Patients are not clients, nor physicians businessmen. People do not spend over a decade studying medicine ―living years in poverty or overburdened with debt― merely hoping to get rich. While it is perfectly legitimate to expect a salary that enables a dignified living and financial stability, any medical student who dreams a life of luxury is misguided. Even doctors or nurses in private practice rarely consider their call a conduit to personal wealth. People become health care providers for many reasons that can’t be encompassed with a neat word; however, altruism can’t be absent from anybody’s list.

Yet we have a medical system that admits into the doctor’s office only those who have money.

This must change. America has a long and uncontested relationship with market forces that have made her prosperous. However, not all human endeavors should become the object of greed. When did our society become persuaded that helping someone in need must generate financial profit? Or that good things in life only come with a price? Can a society call itself fair when falling ill, something that is inextricably linked to our human condition, frequently means helplessness, discrimination or bankruptcy?

Meanwhile, a few individuals become rich beyond our imagination. According to a survey of the American Medical Group Association, family practice physicians received on average a salary of $190.182 in 2008, while CEOs of the main health insurance companies received $24.300.112 to $3.241.042. William McGuire, a physician and legendary ex-CEO of United Health, earned more than 1.13 billion dollars from 1994 to 2006 (1 out of every 700 dollars spent in health care). In other words, executives whose principal preoccupation is to ensure that a company is profitable to themselves and a body of anonymous share holders, receive a salary that would pay for an army of doctors and nurses, whose main concern is to provide health care to their patients. Admittedly, the Patient Protection and Affordable Care PPACA will furnish more clients to these companies, but at least now they will be treated as patients.

Doctors are entrusted with the health of society. The “Charter on Medical Professionalism,” drafted in 2002 by the American College of Physicians and other organizations, declares that “professionalism is the basis of medicine’s contract with society.” This “contract” is the articulation of something essential to medicine: physicians become what they are not only because of their individual capacity and sacrifice, but because society permits their education and practice in the first place. Any physician can express satisfaction or vainglory about his or her skill, but in the end, every doctor learns to suture a wound only because of the selflessness of a patient that understands that medical proficiency must start somewhere. The contract is sealed with the studious efforts of one and the pain and patience of the other. Consequently, all physicians have a social obligation, requiring that the interests of patients are upheld above those of other individuals, including physicians themselves, setting professional standards of integrity, and “providing expert advice to society on matters of health.”

The fundamental principles of the Charter advocate the primacy of patient welfare, that altruism is the catalyst of the physician–patient relationship, and that “market forces, societal pressures, and administrative exigencies must not compromise this principle.” Physicians also must empower patients to make informed health decisions, acknowledging their autonomy. Finally, the charter advocates social justice: Physicians must “promote justice in the health care system, including the fair distribution of health care resources,” working “to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”

Needless to say, some disagree with these elegant principles, alleging they are “too nebulous.” No. There is nothing airy, ambiguous or utopian about them. Tendencies vulgarizing medicine to the level of the market place motto, greed is good, should be discouraged with vigorous investment in non-profit health care providers, public or private. If health care is deemed a right of every citizen (or more aptly, of every human being), it naturally follows that a legitimate government should protect fully the rights of its citizens and guests (invited and uninvited). “Medicare for all” is the logical and just solution to the argument, but this has not become law. Instead, we have the PPACA, which is a reasonable step forward.

Physicians need to defend such progress. To my silent colleagues, I propose studying, writing to elected representatives, fomenting debate, and healing the wounds inflicted by ignorance and cynicism. To those demagogues still slandering PPACA with Orwellian fantasies, I suggest that our anatomy endows us with two ears and one mouth; hence, we must listen twice as much as we speak.

Lucas Restrepo is a neurologist who blogs at Progress Notes.

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  • SteveSC

    Utopian progressive claptrap. When “health care is the right… of every human being” and the government “protect(s) fully the rights of its citizens and guests”, every doctor will be enslaved by the state. Don’t like the payment your receive for your work? Too bad, you take what the government gives you. Don’t want to participate in government-run healthcare? No medical license for you then, go find something else to do.

    The biggest problem with medicine now is that we have already gone too far down the path towards socialized medicine.

    • The Patient Factor

      A government-run health care system enslaves both patients and providers. Canadian patients are forced to pay for a health care system where politicians and health care bureaucrats make decisions regarding our access to health care and the type and quality of care we receive.

      Let’s talk about freedom of choice in health care decisions. My home province of Saskatchewan, Canada has a population of just over one million people. There are currently 28,188 patients on waiting lists for surgery. With a government monopoly on medically necessary services, the only option available to these patients is to wait on a list or leave the country.

      With health care expenditures now consuming around 43% of provincial budgets, governments are looking for more ways to cut costs. This includes centralizing the delivery of health care services. In the city of Saskatoon, Saskatchewan, there are three hospitals serving a population of 223,000. Labour and delivery is only provided at the teaching hospital. The doctor on call will deliver your baby. In many cases, this turns out to be an unsupervised medical resident. My friend’s father experienced a stroke and was rushed to hospital by ambulance. Upon arrival they were informed that he would need to be transported immediately to an alternate hospital that offered services in neurology and cardiology.

      The Canadian health care system is failing patients and providers. Please take some direction from those who’ve reached the end of the path to socialized medicine. It’s time to turn around.

      • Alice

        Bravo! A non-defensive, honest answer……….I wish more Brits would quit claiming to have the best healthcare in the world……while they die from easily preventable infections and waiting lists. I hope you don’t grow tired of sharing the truth, because some people think socialized medicine is their pie in the sky answer… a Barbara Cartland novel……she liked everything in pink and sometimes I envision posters with a pink keyboard, pink hair and lipstick, and pink feathers velcroed onto their monitor! It’s socialized medicine fairy land and no amount of truth will bring them out of their Peter Panish story hour.

        • pj

          Alice, if the infections are “easily preventable,” and yet so deadly, why don’t or can’t some “lower echelon” equivalent of our physician extender/midlevel provider (NP or PA), or even an RN, see to these problems?

          I’m sure you know more than I about the UK system, but a widespread prevalence of easily prevented infections that are otherwise deadly- frankly that sounds “utopian” to me….in that it would be such low hanging fruit that it would be absurd not to address it.

          • Alice

            Not really. It’s all over the British newspapers and they are screaming, and I believe with all the press it should improve. It’s a funding problem. Not enough money in the repository to wash all those sheets (that’s why it’s called the land of the dirty sheets…I experienced that firsthand). I think the reports are that it’s three times more likely to get an infection there than here, but I would suspect it will improve (of course, with the budget cuts……..sigh). . Just google it and put in “NHS + infections” or something similar.

            You probably already know doctors there are government employees and it’s extremely hard to sue. I could tell you what they did to my mother-in-law…caused sepsis…….then pulled the plug on her without any family permission. The family showed up to her dead body and they were told they waited for them to leave then pulled it. The doctor blatantly lied in writing about what happened. We tried in vain to get her medical records. A lawyer said she would go to court for I think 200 pounds, and she still doubted the judge would give us the real records.

            So, what’s the consequence in a government run system where doctors do not fear the consequences of their actions?

          • Alice

            PJ….sorry I type too fast. I wish more doctors like Paul would link to their e-mail and you could send them stuff you don’t want to clog up the boards with.

            Anyhoo……..I was rushed…..but your point is valid…it is much cheaper to prevent an infection than clean up afterwards. But sometimes cost cutting seems to make sense at the time. There is an NHS report from last year about the infections. And if ideas have consequences I will admit I worry about the prevention of what so many view “unnecessary” tests. They, too, can be preventative medicine…….but costly. Sometimes we follow an idea to it’s logical end……….

    • Claudia

      Medicare is “socialized medicine,” and it works well. And no, Medicare isn’t going broke in the near future – Medicaid is.

      • Alice

        Claudia: Medicare is “socialized medicine,” and it works well. And no, Medicare isn’t going broke in the near future – Medicaid is. [end quote]

        Alice says: I tend to disagree, although I will agree it’s government run, but doctors can still make choices. We want to keep it that way. If you want a better example use the Veterans…..of course, we could debate until the cows come about some of the poor care they receive. Again…….we have to stop looking to the government for answers..maybe a partner……but not King.

        No wonder Medicaid is going broke……’s a free-for-all without limitations and no co-pays and many completely abuse the system. The “system” isn’t serving the taxpayers or patients well, so I want them out of my hair as much as possible.

        • pj

          Actually, the medicaid system in my state has significant limitations as well as copays- admittedly , small ones.

          Many drugs are not covered along with most types of therapy and DME (orthotics, slings, TENS units, etc.)

          • Alice

            For those who enjoy reading about what the future holds with medicine and government (and the overlap) I was reading today about Rand Paul’s suggestions. And he really wants to make some cuts and considering he will be on the Budget Committee some of the “free” programs may be cut considerably.

      • pj

        To say “Medicare isn’t going broke in the near future” ignores a lot of ugly realities, and makes some very rosy assumptions, about the US economy. Medicare is only solvent as long as our creditors keep lending us money by buying treasury securities. And some very smart, honest people such as John Williams @ Shadowstats doubt very much that can go on for long.

        The sad part is, there are even US senators (Debbie Stabenow comes to mind) who are surprised to learn that our nat’l bills are funded mainly by the chinese and japanese govt’s…

  • John Lynn

    A really great post. Definitely provides some great perspective on it. Although, I think it’s also a mistake to divorce the idea of making money with providing good healthcare. I don’t think you intend this, but many people take arguments like yours and extend them in this direction. Point being that I know many doctors who provide phenomenal care and many times at a loss, but overall still make a very nice living.

    Of course, your comment about the insurance CEO’s should make anyone sick.

  • doc99

    The only contract I have is that between myself and my patient. That is the Signal. The rest is Noise.

    • Lucas Restrepo

      Dear Doc 99,
      Thanks for perfectly summarizing my post.

      • Alice

        It is an amusing comeback, but if we give the government more control as this author seems to suggest it will be more than background noise you can tune out. You may lose the right to have that opinion…..wish I could place a smiley face here.. It could become so noisy a real conversation will be hard to hear because………oh gosh I just can’t resist………yes, Alice….say it while you can….the thought police may be in the background! :) Ya’ know it’s not paranoia if it’s true! ha!

  • Ed

    Dare I say it?

    Docs are acting more and more like lawyers.

    • Lucas Restrepo

      Thanks for your comment. Indeed. The great physician Rudolf Virchow once said, “physicians are the natural attorneys of the poor.”

      • Alice

        The great physician Rudolf Virchow once said, “physicians are the natural attorneys of the poor.” [end quote]

        Hmmm…….Lucas could you place a “[some]” before the word physicians in that statement? Just as a matter of clarification.

  • JoAnne

    Wow! It is so nice to read this coming from the keyboard of a compassionate physician who is in it for the right reasons! Thank you for writing this post. I am slightly less cynical and jaded for reading it.

  • Jane

    You have got to be kidding. If i wasn’t paid very well to do this thankless job–forget it. This ‘Charter’ has to be a joke.
    I am not entrusted with the health of society. Individuals are responsible for their own health.
    If you want to see patients for free, be my guest, but don’t involve other doctors in your downward spiral.

    • Lucas Restrepo

      Dear Jane,
      No kidding. If you think you need to be “paid very well to do this thankless job,” I respectfully suggest that you consider an alternative profession. Thank you for reading the post, and hope sincerely that you start liking what you do.

      • Alice

        Hmm……..even if I don’t agree with Jane, I tend to think a good doctor is worth the money and I have to say I appreciate her honesty. How refreshing after wading through some of the narcissistic, altruistic back patting stuff from some doctors on this site.

        That said I appreciate charity and honesty from good doctors. Personally, I am not that concerned about what insurance execs make. Yes, it’s a great informative point to make, but didn’t recent regulation force the insurers to put more money towards the actual patient? And I say this with great trepidation….regulation should be a last resort……but sometimes it has to happen. I really worry about the strong arm of the government. I think if more doctors would just admit money is alluring we would see an honesty on their part, the same honesty a good doctor can hope to promote from their patients. I don’t see many doctors giving back to society (kudos to the few that do) or to the poor…….and where I live free care being donated is rare……yet a segment of doctors proclaim they want socialized medicine. If they feel that way donate your time to the poor in the interim, because you may find yourself doing just that under price regulation from government regulation.

        As far as whether healthcare is a right……..I do not see it as that……..I will admit I see a responsibility on the part of doctors and society as a whole to do what we can to help others……and at this point I don’t know anyone who has died from the inability to get care.

        We tread a fine line when we try to make healthcare a “right” because that right can be so far reaching, and there are consequences. I will concede to a “responsiblity” to help mankind and that goes beyond America. Yet, I believe America has been instrumental in helping those around the world and our innovations have helped other countries save lives.

        • Paul Dorio

          Nice comments, Alice. And several additional commenters gave some interesting perspectives on this subject. I’d like to say a couple of things here:

          1- “Honest” appraisals of ANY job include fair and acceptable remuneration. Most physicians went into medicine, dare I speak for others, to care for people, yes, but also to make a good living for their families. Doctors who discuss how altruistic we should all be and how health care should be divorced of all remuneration are living in a fantasy world unnecessarily. Getting paid for what you do is not a crime nor should it be an issue. I know very few doctors who get paid millions of dollars. Making money the sole focus, however, is not what physicians should be about and I think is the underlying valid comment to be made.
          2- Segue: Health care CEOs: why are they paid millions of dollars? Therein lies a problem with the industry that is not addressed. You have an entire industry — insurance — that basically runs health care as we know it. Those companies are for-profit entities, beholden to their shareholders. Their job is to pay little and earn lots. Don’t you think that our healthcare system could be improved if the main driving forces were more aligned with patient needs?

          • Alice

            2- Segue: Health care CEOs: why are they paid millions of dollars? Therein lies a problem with the industry that is not addressed. You have an entire industry — insurance — that basically runs health care as we know it. Those companies are for-profit entities, beholden to their shareholders. Their job is to pay little and earn lots. Don’t you think that our healthcare system could be improved if the main driving forces were more aligned with patient needs?[end quote]

            Alice: I am thinking about this. The government just passed regulation that says something like 85% of the monies need to go to the patient care. My mind is rattled…….nothing new mind you…….I just worry about posting something then having to sit and gather up a bunch of articles the ranter won’t read anyways. Is there a cure for blockheadedness? :) Don’t worry I’ll get my second wind and go on a posting marathon! Are you scared? You should be! haha

      • pj

        As a physician who treats vast numbers of uninsured pts (mainly thru CHC’s who in turn pay me fairly well from various sources including federal grant money), I say, there is nothing in the consitution about healthcare being a right, BUT I submit that it is the mark of a civilized nation to provide some measure of basic, essential services to all needy citizens…

        It’s too bad none of the politicians, idealogues or physician leaders have put the debate in these terms.

        • Alice

          PJ….. I tend to agree with your goal……and you seem really nice… I hope my diatribe here isn’t offensive. It is not meant to be…’s just a bit of rant about being able to see through all what the Brits would call sh*te…oh oh….I mean bollocks! Ummm…..well………..:)

          It may be a responsibility of society…..but clearly not a right. It’s an extremely hard issue, admittedly lawsuits are a huge part of the problem. All the unnecessary tests a doctor has to run……..but it’s very hard… because patients like the tests (it usually brings relief) and sometimes they hit a homerun…and when you are the recipient of that you appreciate it. This type of testing diagnosed cancer twice in my children…….so I am not objective when it comes to running the tests I had to fight a doctor for.

          On one level it’s bothersome because I don’t know anyone who has died from lack of care. I find it so curious that people claim to be so desperate, yet throw their hands up, blame doctors (never themselves)…..and when questioned they didn’t even explore the rudimentary steps it takes to get help. My friend did and she received all the meds, an operation, home care, hospice care and everything was paid for……yes, it took days on the phone, but her husband died with the best of care (he was a smoker….died from lung cancer…he had no insurance at all).

          Part of the problem is the patient’s fault to. We are unwilling to do the basics…take care of ourself…..we want, we want, we want and don’t want to pay…..then people come here and claim they don’t mind paying the extra taxes….and, yet, not one can admit (even anonymously) to donating that extra amount to a hospice or to help a patient pay their bill. It all seems so shallow to proclaim your dying swan act for the poor and your supposed willingness to help……..then do nothing. I haven’t found one person here who even goes to nursing homes or hospices (we do……..and I was berated for bragging…..forgive me:)) to give comfort to those who need it so desperately….yet claim compassion by desiring higher taxes? Sometimes I wonder if they are in the 40% who sit on their no-tax throne telling us about all they can’t wait to give from their paycheck (and how greedy the free marketers are) while giving nothing of themselves or their own money. Same with the docs who proclaim Berwick and his socialized medicine is a good idea. I have asked them how much time they donate each year. I haven’t received an answer yet. Be careful what you dream about….sometimes reality is a nightmare.

          The answer is not the government……..maybe in small doses….but can anyone name one government agency that is run efficiently? There are a few, but I would find the answers of others interesting. I was a civil servant……I would privatize everything from the schools down to our garbage being picked up.

  • Dr. Kene Mezue

    Thanks for the article Dr. Restrepo. The opposition to the Health Care Bill in the USA showed the ignorance of the American people and the selfishness of the doctors. However, it is correct that we make it clear that Medicine is not a trade, or a business…it is truly a calling…you don’t expect to find a doctor on Forbes 500…

    Here’s an excerpt of Sir Prof. Michael Marmot’s speech when he accepted the Presidency of the British Medical Association. It is hoped that this kind of thinking will pervade the medical scoiety…

    So close is the link between social and economic arrangements and health that we can see health as social accountant. Health and the fair distribution of health—health inequalities—tell us how we are doing as a society. The simple answer is: we’re doing well but can do better.

    “…Let me illustrate. In my review of health inequalities, Fair Society Healthy Lives, we emphasised not just the poor health of the poor, but that health follows a social gradient; for example, the more years of education the longer the life expectancy and the better the health. Those with university education have the best health. We calculated that if everyone over 30 had the mortality rate as low as those with university education we could prevent 202 000 premature deaths, EACH YEAR. Does anyone in this room think other than that should be largely avoidable?

    In the US, a similar calculation suggested that if African-Americans had the same mortality rates as whites there would have been 800 000 fewer deaths over a decade. When I spoke of this to the American Public Health Association one commentator asked movingly, how many times do we need to learn the same lesson? 800 000 times is too many.

    Let me go further: life expectancy for women in Zimbabwe is 42, in Afghanistan 44. By contrast, in Japan it is 86. There is no good biological reason why there should be a 44 year difference in life expectancy across the world. This 44 year difference arises because of our social and economic arrangements.

    To address these inequalities in health within and between countries, the World Health Organization set up the Commission on Social Determinants of Health. The director-general of WHO, JW Lee, invited me to chair the CSDH.

    Our report was published in 2008 as “Closing the gap in a generation.” Closing the gap? Are we bonkers? A 44 year gap in life expectancy between countries, an 18 year gap within countries, and we want to close the gap in a generation?

    It was a statement that we have in our heads the knowledge, we have in our hands the means, to close the gap in a generation. The question is: what do we have in our hearts? Do we have the political will?

    An illustration: we said in the CSDH report that one billion people live in slums. We estimated that it would cost $100 billion to upgrade the world’s slums. I thought: no on one will take us seriously. Who would find $100 billion for anything?

    When I last looked we had found $9 trillion to bail out the banks. For one ninetieth of the money we found to bail out the banks every urban dweller could have clean running water. Do we have the knowledge? We have the knowledge. Do we have the means? We have the means. Do we have the will?

    When I formulated this view, I was not aware that I knew the motto on the BMA crest—with head, and heart, and hand….”

    • Lucas Restrepo

      Dr Mezue,

      Thanks for your comments. I recommend that you visit “Progress Notes,” the Blog of Doctors for America:

    • Alice

      The opposition to the Health Care Bill in the USA showed the ignorance of the American people and the selfishness of the doctors. [end quote]

      How about the ignorance of representatives who voted on a bill they didn’t read and Pelosi saying they had to pass the bill so we could know what was in it. Our real ignorance was at voting time when we voted in representatives who voted on a bill many knew would need fixed.

      Overall it seems most doctors don’t like the healthcare bill, although, admittedly you battle a real PR battle as far as greed goes. That’s a mess that needs cleaned up, and the government may force you to. Just as the article implied, it’s far better to police yourself…..and somehow doctors are good are not clearing up blindspots with their own colleagues.

  • Killroy71

    This completely glosses over the radiologists, plastic surgeons and anaesthesiologists who make $500,000, compared to mid-range insurance CEOs who make about the same. The vast majority of insurer ceos are NOT making 7 figures, let alone 8 or 9.

    • Lucas Restrepo

      Great sense of humor, Killroy 71; thank you for reminding us of the many hardships of a CEO’s life.

      • Alice

        Could you help me out here? I am sincere. Why flip off the truth? If we cut the CEO’s down to size how will that help doctors and patients? I have a real sardonic sense of humor……so hit me with your best shot! :) Okay……..I’ll get serious……Killroy just clarified something your article missed…….so tell me what I am missing. You seem really nice, so I can’t resist asking.

        • Paul Dorio

          Alice, Alice, Alice,

          Why is it always about how much doctors make? Is there any report out there that says that a doctor’s ability to effectively, compassionately, and empathetically care for people DECREASES as his/her salary INCREASES? I think not. But it is my opinion that most people look at doctors as individuals who should only care for people and not get paid for doing so, as if it is their right and privilege to do so and any remuneration taints that purity. Obviously this is a fallacious perspective on the part of those individuals. Keep things in perspective. Their is nothing wrong with getting paid for a job well done, right?

          • Alice

            Well….Paul, quite frankly, i don’t care if your keyboard or toilet are made of gold….just freakin’ treat your patients well! Ha!

            As this board shares pay has nothing to do with your worth……and you did do the time for your crime….oh no did say that(?) ….um…er….no….no…no….what I meant was yes dear….. you deserve every dime! Ha!

            Okay…I’ll get serious… my post was to Lucas who again referred to large salaries of CEO’s. Honestly, I do not care what you make…..really…that much? H’s!

  • Muddy Waters

    It amazes me when someone trains for a profession for 12+ years, takes > $100K out in student loans in the process, and then feels any obligation to work for free. Hell, I didn’t even get a cafeteria discount as a medical student. Doctors are some of the most educated, intelligent, and HARD-working contributors in society. We deserve every penny we make. At least we help people in the process. When was the last time Best Buy or McDonalds did anything for free? America is founded on capitalism…deal with it. And, if anyone tries to control the physicians, America is going to truly realize a physician shortage (you thought it was bad now). And don’t think it can be filled by training new doctors, because the quantity and quality of the applicant pool is going to be slim.

  • Justin

    As a doctor, I’ve got years of training and lots of education debt. The government cannot fairly reimburse me for these investments, so I serve patients who can pay me. For these sacrifices, to be able to do a job I sometimes love and sometimes hate, I think I should be well compensated.
    the bottom line that no american is willing to accept.

    • Alice

      Justin…I am willing to accept it…but a tip…..patients struggle with student debt and job stress just like doctors. It is relatable….so…if doctors are diplomatic the message is received better when it is not overly defensive.

      • justin

        I appreciate your advice, which sounds like selling my sob story would work better if it carried a “hey we’re all in this together” sort of tone.

        • Alice

          And listen to the Beatles singing, “All Together Now!” Now…….once more with meaning! :)

  • Anna

    Compassionate? Sounds downright stupid to me.

    “Yet we have a medical system that admits into the doctor’s office only those who have money.”

    Gee, I’ve never been able to have a place to live, or buy food, or a car without money. All the basic things in life and I’ve had to pay for them? They should be given to me, no doubt. And since I need a place to live and food to eat more than I need to seek medical care, obviously food and housing should be free for everyone, too.

    I trust this doctor sees patients and never collects a fee.

  • NEMO

    The post highlights the difference in perspective from a physician in academic medicine (salaried) and those who have to practice and ‘count the beans’ to remain open to see patients (must realize enough revenue to pay overhead, staff and then self).

  • Jane

    Luckily for me Lucas I have made a very nice living and have no need to worry about money, but i certainly wouldn’t do it for free. Being a physician is a job–much like any other job. This calling stuff is for people who live in a dream world.
    Again, leave the rest of us to live in reality and make the very good living that we deserve. You may do it for free.

  • Jane

    Lucas have you ever thought about going home to help your native country and where you attended medical school. Did you have debt from that education?

  • Ralph

    So Lucas I pay for medical school myself, work long hours in primary care for unappreciating patients who think they are owed something ,work in a constant state of defensive medicine & I should be ashamed I make good money. I deserve everything I make and more.

    • Alice

      Yeah, but Ralph have you considered anger management?:). It’s one thing to make money…good on you…but hmmmm …..not so sure you like the patients who are providing you with that good living? The patient is owed something….they are paying for your time. But, then again, you were honest…..sure you don’t want to identify yourself? That way your patients could know you don’t like bellyaching…..hmmmm…..

  • Marc Gorayeb, MD

    Why does a “Charter on Medical Professionalism” include a requirement that physicians must “promote justice in the health care system, including the fair distribution of health care resources,” Who defines what is fair? What does wealth redistribution advocacy have to do with physician professionalism?

    • Alice

      Marc…this is a fair question…you ask who defines “fair” and I ask who defines “justice” and for who? Is there justice for the burdensome expensive elderly? Those with rare diseases? We are allowing the government to be the puppet master…yet, it is bothersome that Main Street looks out for Wall Street because of personal benefit? Representatives who want to constrict doctors while keeping their own ability to give themselves a raise or make money through not regulating or policing their own. Expecting one segment of society to contort while they retain their own freedoms. Lack of consistency…and yet….anyhoo…….

      Ann Coulter’s newest and usual tongue in cheek article starts out with this paragraph:

      It’s the Christmas season, so godless liberals are citing the Bible to demand the redistribution of income by government force. Didn’t Jesus say, “Blessed are the Health and Human Services bureaucrats, for theirs is the kingdom of heaven”?

  • JPB

    Well said Lucas! Check out Roy Poses’ new piece on Health Care Renewal which deals with these same issues.

    Some of the responses here are so predictable and really highlight how wide-spread this attitude is among MD’s. No one questions that a doctor should be paid for his/her services but equally, no one should have to face financial ruin because of a medical problem! Unfortunately, it’s only getting worse…

  • Unlikely Hospitalist

    First a word of caution. We as physicians and the rest of the general medical community do not provide healthcare! Sure we can handle most infections, manage most CHF exacerbations, prolong life with dialysis, mostly. We give advice, make diagnosis, and take off every diabetic foot we can find. But this isn’t health care. This is medical care, and with many exceptions, we do it pretty well! If you want healthcare provide it for yourself. Stop smoking, significantly reduce alcohol consumption, lose weight and exercise. At least for now, you can’t prevent people from making bad decisions.

    So let’s call it what it is, medical care.

    This health, um, medical care business is expensive and while I agree with your altruistic argument, I think you are being a little generous. After undergraduate chemistry, four years of medical school, three years of residency and the debt equivalent to a mortgage some other more pressing motivators rise to the top. Career, family, children, in-laws take their toll. There is only so much altruism to go around.

    Nevertheless, the truth remains, there are not enough doctors available in this country to provide healthcare to the masses, let alone nurses, hospital beds, nursing homes, rehabilitation centers, etc, etc . While many studies have indicated that physicians will flee the field with this new legislation (we already have a baby boomer problem), it does nothing to manage the costs that are ahead of us. Medicare, Medicaid, and Social Security are all unfunded by many trillions of dollars. This is fiscal suicide that exacerbates the problems and you are asking us to stick our head in the sand and rejoice that the government has everything under control.


    Please don’t take this personally. You sound like a nice contemplative guy, but your opinions about the role of physicians offends me to my marrow. Pass the huka back to Alice B. Toklas and join me and many others in the real world (as we know it.)

    Be honest with your patients that YOU have chosen to see and treat with MEDICAL care and do your utmost best work for them. Whatever the terms of the arrangement must be agreed upon by both parties. Other than that, the rest is crap. We, as physicians, have nothing to apologize for.

    Enjoy your California attitudes! We may purchase your state cheaply when it falls into receivership.

    • Paul Dorio


      I’ve always been astounded at how insulated academic physicians can be compared to the rest of us out in the community. And as a resident at an academic center I remember looking at community/private physicians as if THEY were the odd-balls!

  • elmo

    You are an academic MD at UCLA. Nothing wrong with that, but it also shows that you have little idea how to manage a practice. It is easy to ponitificate about how things “should” be when the nanny academic center is paying for everybody who helps you from the unit assistent who checks in your patient to the resident writing your notes for you to cosign, and yourself. A small practice doc does not have that luxury. The simple fact is there has not been a significant change in medicare rates since the SGR went into effect in 1997. Every doc can tell you about practices that folded that did not watch the bottom line. As an academic doc do you even know how much you bill? I take hospital call so I regularly see patients in the ER/hospital that will never pay me. Do you as an academic salaried MD…no. Please keep your lectures to yourself. I am not going to run a practice into the ground being medicaid’s handmaiden. If you actually had to live off medicaid payments as opposed to collecting a check from UCLA you might have some clue as to what I am talking about.


    What Elmo said.

  • Max

    Seconded. An employed academic telling us how it should be in private practice. How quaint.

    • Paul Dorio

      An employed academic from California no less. Does it get any more “rich”?!

  • labrat

    Seriously? What kind of medical care would there be without profit? Why stop at doctors? Why not rail against the whole industry? Why should anyone profit from manufacturing a drug or a bandaid or a needle or an MRI or Xray?

    Let’s take away all profit from this aggregious industry and see how eglatarian we can be providing “healthcare” with what we have left.

    • pj

      and yet- vaccines are still made even though profit is limited. ..

      • Alice

        Aren’t most made overseas to prevent lawsuits? I know some require a waiver that protects only the doctor.

  • ninguem

    The author came here, to the USA, from South America, according to his own website links. One would imagine the need for medical service is far greater in the home country. But hey, money talks. Funny how the ones preaching altruism always want someone else to be the altruist.

  • ninguem

    elmo – “……..It is easy [for an academic MD at UCLA]. to pontificate about how things “should” be when the nanny academic center is paying for everybody who helps you from the unit assistant who checks in your patient to the resident writing your notes for you to cosign……”

    And if UCLA is anything like my local academic centers, charges than I could for the same service, extracts higher payments from the entitlement programs, gets Medicare pass-through payments, not to mention charitable contributions, on and on and on. One center in my area got dinged a while ago when it was realized that their clinic fee tickets had only Level 4 and Level 5 visits on their checkoff. There was never a simple visit (level 2 or 3) in their clinic.

    Oh, and don’t forget the tort protections applied to the academic centers but not the community. And when all was said and done, our centers also got chided for providing less charity care than the Catholic hospital down the street.

    Which by itself did not really bother me, except they would also pontificate, constantly, about the greedy ignorant private community docs.

  • Margalit Gur-Arie

    Of course physicians should be paid for their work, and IMHO they should be well paid.
    The question, of course, is what “well” means and how this meaning is determined.
    In the olden days, it was whatever the “market” could bear, and sometimes it could only bear a couple of chickens. Somehow that was never equated to “slavery”. When tax-payers pulled their resources to pay for medical services for the elderly and poor (Medicare/Medicaid), and all they can afford to pay is maybe 50 to 100 chickens per visit, it somehow becomes “slavery”.
    Please remember that in addition to student loans, the same tax-payers (Medicare) are bearing a significant financial burden to provide medical education to graduate students.

    BTW, I don’t see how the OP’s country of origin or place of employment is relevant to the ACP charter or this discussion.

    • Paul Dorio

      Um, no. I don’t think it is a question of “what ‘well’ means and how this meaning is determined.”

      I think it is a question of why we continue to talk about how much doctors get paid. At all. Why does anyone care? I think the only reason people look at what a doctor makes is 1-it’s constantly being published by the media and 2-people think health/medical care should be free so doctors should also work for free.

      Under all the rhetoric, that’s a conclusion that makes sense to me anyway. Otherwise, get off the subject and focus on self-responsibility, improving one’s own health through one’s own actions, decreasing health care utilization through self-improvement, etc.etc.etc.

      • Margalit Gur-Arie

        Not really.
        The reason we are discussing doctors’ pay is because medical services are not affordable any longer for most people.
        Granted, doctors’ pay is only a small fraction of health care expenditures and I for one would prefer to concentrate on those extracting money from the system without contributing anything useful.

        The other reason for talking about doctors’ pay is because doctors are arguing that it is not adequate, and in the case of PCPs, it is not.

        As to health care being free, I think you are confusing “free” with “tax financed”. I cannot, of course, speak for 300 million Americans, but I can assure you that no one is expecting docs to work solely on a volunteer basis.

    • NEMO

      Perhaps a better term is “involuntary servitude”?

      Involuntary servitude is a United States legal and constitutional term for a person laboring against that person’s will to benefit another, under some form of coercion. While laboring to benefit another occurs in the condition of slavery, involuntary servitude does not necessarily connote the complete lack of freedom experienced in chattel slavery; involuntary servitude may also refer to other forms of unfree labor. Involuntary servitude is not dependent upon compensation or its amount.

  • Alice

    As to health care being free, I think you are confusing “free” with “tax financed”. I cannot, of course, speak for 300 million Americans, but I can assure you that no one is expecting docs to work solely on a volunteer basis [end quote]

    A distinction for some, because 40% of Americans pay no income tax, and often get free care without the burden of paying into the system. We pay bigtime into the system and pull little out (yes, I use the roads and have a representative in Washington, but refuse to use public schools, etc.)

    I think if people want government paid doctors, the non-tax payers will get free, get an entitlement mindset and want doctors to work for free. In the UK people call docs at midnight because they had to do housecalls. My relatives ran a few doctors ragged and they weren’t really paid. At that time a doctor received a monthly fee per patient on their list, and after-hour house calls were part of their performance……….commitment.

    But all of that said the problem is I would give up house calls and pay for minor care to have great catastrophic care. I will get over a cold or the flu usually, but socialized medicine concentrates too much on boo boo care and people think that justifies the whole bad system.

  • Christopher Gregory

    I enjoyed reading Dr. Restrepo’s commentary, as well as the varied comments, both supportive and critical.

    If I may, allow me to offer thoughts on what has taken place in medicine from the perspective of one who, for 30 years, has advised physicians on matters and management of personal wealth. I see so much of this in terms of personal wealth economics and as a reflection of what has taken place and what is taking place in the “system”.

    First, consider what is “fair”. And let us not lose sight for one second that the engine of our healthcare system is the physician and his/her patient. That said, is a physician, once he or she is ready to start earning a respectable living after years of substandard pay and the accumulation of substantial debt really being overcompensated for his or her work? Follow many practicing physicians around their work schedules and you’ll see that they do not retire into a cushy 9 to 5 life. (There are many easier ways to earn a fine living – just look at the business school grads who work on Wall Street or the health insurance industry and command huge salaries and bonuses.) Physicians must be consumed with their calling long before they earn a dime, and they must remain so for the duration of their practicing careers. I know because the demands of their lives make their schedules their masters – often resulting in delayed attention to matters such as personal wealth management and even family matters. I apply this observed perspective to the entire spectrum of medical professionals – from heart surgeons to primary care physicians. They are busy and their lives are consumed by the qualities of their commitments to their work. Sometimes that hurts them, but they remain “in the game” because in the vast majority of instances, they are dedicated to their calling as healers. For that, countless physicians have my greatest respect

    As a nation, we have sadly misplaced our priorities. We will easily tolerate the notion of actors, rock stars and professional athletes being paid millions (even hundreds of millions) because we gladly want to be entertained. Yet we somehow think that doctors get paid too much or that they are raising too much of a ruckus (or as some say “whining”) when their remuneration is slashed by profit-motivated commercial insurers or by government payers. The problem here is that too many fail to see that many physicians are businesses that are facing ever increasing costs of staying in business. Just look at the tremendous balance problem (and the looming crisis/catastrophe) with Medicare. How can $1 in physician services (or any business service) be delivered for just 65 cents in remuneration?

    The problem we have is that while we earnestly say we want physicians to have the time to be high quality doctors to their patients and earn a living commensurate with their sacrifices and that we want every citizen to have access to health care, the system is broken and continues to be torn apart by the special interests and agendas of many hands grabbing for a piece of the pie. Most of those interests and agendas are slavishly powered by commercial profit motives, e.g., health care systems, insurance companies, hospitals, drug companies, appliance manufacturers, etc.. Let us not lose sight of the fact that the great American “consumer” is also culpable in the deterioration of our system, due to lifestyles and expectations that cause our costs to increase dramatically. We as a nation are too fat, too lazy and we don’t eat right – if that isn’t a contributing factor to health costs, I don’t know what is. When the American consumer of healthcare is pushed into placing more of their “skin into the game”, we’ll see an improvement I our health care cost structure.

    How do we do that? Does GOVERNMENT present the cure? Does a government run healthcare system or a legislated system like PPACA provide the answer? To that I would say “absolutely not” because more government in multiple arenas is what has gotten us into the horrible economic mess we face in this country. Government and partisan politics have time and time again demonstrated that it is inept at formulating and executing effective solutions to fix problems. The legions of bureaucrats that will be spawned by PPACA will make this another government fiasco. It may have been conceived with a noble intent, but just look at the mess we have after partisan politicians got their grubby fingers on it. Study the diagrams of the bureaucracy this monster has spawned.

    What is needed, in my opinion, is a good hard look at what is coming, and a concerted, committed private sector initiative to address the problems that are on the horizon – they are visible. Just look at the millions of individuals who will be accessing Medicare in the coming years. Are we ready? Can we initiate a private sector initiative to allocate costs more equitably? To those who would say “good luck”, I’ll leave you with the mess we’ve inherited and the spoiled fruits which lie ahead.

    Look at the dwindling resources (both human and financial) that are being allocated to the front line needs of our primary care system. We need to fix those problems as a major national initiative to balance primary care and specialized medicine. The efficiencies and the numbers bear this claim out. We are just not running our system efficiently, and continually kicking the can down the road will not fix the disaster coming at us like an onrushing train..

    Government just isn’t the answer. A reasoned free-market approach is the only hope we have. Everybody has to engage in a spirit of sacrifice and equitability in the way our dwindling healthcare resources are allocated. Let there be no doubt that, in the words of David Walker” health care costs in this country are public enemy number one.

    • Mike N

      Christopher: very well said.

  • Mike N

    I don’t want to go under the knife of a doctor who resents my congressman telling him how much he and his nurses may make and hours they must work. Even more strongly do I not want to go under the knife of a doctor who does NOT resent it.
    I want to go under the knife of a completely free doctor who has the freedom to refuse to treat me if he so chooses. Such doctors will be plentiful when government regulations are all replaced with market regulations, i.e. laissez-faire capitalism.

    • Alice

      Mike are you recommending no-fault type of coverage for doctors?

  • Dorothy Green

    “No one questions that a doctor should be paid for his/her services but equally, no one should have to face financial ruin because of a medical problem! Unfortunately, it’s only getting worse…”

    Agree – Here are 8 basic factors causing our crisis

    1. Until recently the AMA has, in defending physician’s autonomy and income, opposed any kind of universal health care/insurance system. The only health care insurance was the blues – non-profit. GDP Healthcare Cost $ – patients without insurance/care XXXXXX.

    2. A trade of wages for employer health insurance was enacted in the 40s. GDP Healthcare Cost $$ Patients without XXXXX.

    3. Medicare/Medicaid compromise with physician as fee- for-service compensation (Part B). Both physicians and hospitals found Medicare to be a Bonanza – more patients, no limits on fee for service, increased hospital admissions, stays. – The Socialization of American Medicine and the Making of a Sovereign Industry – 1984. Paul Starr. More GPD Healthcare Cost $$$ patients without XXX.

    4. For- profit hospitals – Increased competition, overbuilt, more than enough technology in dense communities, duplication of services. Cost $$$$. Patients without care XXX.

    5. Pharmaceutical industry booming – high cost of Medicine, brand name preferred – GDP Healthcare Cost $$$$$, Patients without/denied care XXXX.

    6. CEOs of all businesses (ie health insurance) making way more than average worker. Income gap between rich and poor widens. So does income gap of primary physicians vs specialists.

    7. Medicare Fraud becomes an industry unto itself. CDP cost $$$$$$. Patients without care XXX/.

    “Someone paid $$ to investigate fraud can’t compete with someone who gets away with doing it who gets $$$$$$$$$$$$. Infectious Greed, Frank Portnoy 2003.

    8. The American culture of wanting “a magic” pill and “everything” to be done – even when the brain is dead persists – GDP cost – $$$$$$$$ patients without care XXX.

    8. Over this time most of our food has become industrialized and far less nutritious, unhealthy food is subsidized (corn feed, HFCS), 90% of food dollars are spent on processed food. There are more calories produced and consumed than needed. Salt, sugar and fat are the substances now known to be potentially addictive as the leading risk to the chronic preventive diseases that use the majority of healthcare dollars – GDP cost $$$$$$$$$$. Patients without care XXX.

    • Alice

      Dorothy this is interesting to read all the faults laid out. Is there a cure less than a few thousand pages long? The nutshell cure? There are a few items you mention that seem to be redflags, although admittedly they are all troublesome………it’s the vantage point the causes the right reflections and reactions.

      I realize you are advocating for change that is helpful to the patient. Socialized medicine will not help the patient, limiting doctor’s pay doesn’t help the patient……and I guess I am irritated that doctors don’t view their own colleagues as the culprits that led us to this point. They caused the government regulations because of ill treatment and greed. You are battling the bad PR and crimes of your predecessors.

      I sorta laughed when Ben Afflick mentioned high salaries of CEOS. I guess this means he is donating his future profits? Maybe the government should regulate Hollywood since they have such bleeding hearts. Looks like Americans behold their entertainment to the point we are being entertained to death and eat at the trough of popcorn haven, as long as it feels good. Hollywood has contributed more to our downfall than corrupt doctors……but Hollywood fuels Main Street.

      I don’t know……there is something wrong with the whole picture.

  • PharmDStudentGuy

    Interesting thing I noticed, just because I was curious.

    Restrepo’s “website”, Doctors for America, is one of the many facades of the Center for American Progress, a progressive think tank and propoganda organization.

    Neither site mentions the affiliation, but they share the same physical address, and the donations given to Doctors for America are processed by the Center for American Progress.

    Just sayin’

    • Paul Dorio

      Way to do your due-diligence! I also checked out his website and noticed similar tendencies towards polarizing perspectives/attitudes. Still, the topic is very interesting and useful to discuss, regardless of the original aim of the author, imo.

      Once again, I’ll state the obvious: fringe does not accomplish improvements. Only careful, educated thought between fair-minded people can result in improvements to a system that clearly needs some evaluation and adjustment.

  • Mike N

    No I wasn’t referring to a no-fault kind of insurance. I suppose though, that could be a possibility but I have not considered it yet. I mean that all government regulations need to be replaced by market regulations. I know the next question: who would enforce them? The market would.

    You see market regulations are all the positive and negative feedbacks everybody experiences every day while living their lives.

    Grocery store A charges higher prices that store B. Quality being equal, the higher prices of store A are a negative feedback to you, it’s costing you more. The lower prices at store B are a positive feedback to you, you are saving money.Conversely, the decreasing number of customers is a negative feedback to the owners of store A telling them they are doing something wrong. The increase in customers at store B is a positive feedback for store B owners telling them they are doing something right. And so it goes all through the market place including education, health care, everything.

    Government regulations interfere with those feedbacks distorting reality and and causing market disturbances. Politicians and pundits routinely blame the market for not functions properly and clamor for more government regulations which cause more economic distortions until one day we wake up in a totalitarian dictatorship where government can do anything it pleases and the people may act only by permission i.e. America of the near future. We need government in society to protect our rights but we don’t need it in the market place.

    • Alice

      Mike…I do understand your marketplace analogy…but we have a middle man…the insurers….and possibly someday the government. The government jumped into medicine because doctors were behaving badly……lots of it brings abuses. Just like the banks…and the abuse of customers…the government regulated them to the point most people can’t get any money…so the regulations helped some and hurt a lot…and the banks found another way to make money. We, also, have seen this with the automotive companies. The media focused on the salaries…and just like doctors the salaries are a minute part of the problem. The government became a competitor in the free market.

      It is bothersome that people in trouble now think their rich Uncle Sam owes them a way out of poverty…it is a lifestyle for many…and it was meant to be a temporal lifeline. Free lunches are not free…someone, somewhere sacrifices….but the mindset is not a gift, or help, it is now called a right. Where does it end? Is a house, car, food stamps, education, Head Start, before and after care with food, family planning, and now healthcare all owed to every human? From the cradle to the grave every aspect owed to others? Who will pay? No accountability on the receiver? No giving gratitude or service to give back?

      Mike..I should tell you I do not think no fault serves the patient…but if I were doctor I would be liken’ it!

  • BradMD

    Lucas Restrepo, MD, is completely wrong. What made American Medicine the best is the world was the free market. As the free market has been destroyed by socialism our medical system has gone into decline. ObamaCare is a disaster. It does nothing to reduce the runaway prices in medical care, which a return to the free market could have done. We must stop the progressive socialism of medicine if we want to empower patients, doctors, and nurses to work together on the same team again to save the most lives possible. The most powerful entity in healthcare should be THE PATIENT, not the government. The next most powerful entities should be doctors and nurses and family, not the government.

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