Why doctors and patients have turned against each other

“Where there is love of humanity there will be love of the profession.”
-Hippocrates

Reading some of the blog posts and comments on the Internet, you might get the impression that a majority of American doctors hate their jobs. Actually, according Family Practice News, only 35% of my colleagues are unsatisfied with their careers, but that is still a remarkable number.

Are Hippocrates’ words implying an answer to why some doctors today don’t like their jobs? Don’t they love being able to help their fellow human beings enough to overlook the imperfections of the health care system? Or, put another way, is the health care climate in some places so horrendous that some doctors and patients cannot find enough common ground for a caring relationship to develop?

I have read comments by both clinic doctors and concierge doctors that describe their patients as unreasonably demanding and next to impossible to work with. You don’t have to look far to see equally unflattering comments by patients about their doctors.

It seems clear that these imperfect unions are being poisoned by outside influences, which create prejudices or unrealistic expectations. If these unhappy doctors and patients were married couples, we might tell them to split up, get counseling or go on a vacation or retreat and get to know each other all over again. Staying together without changing the bad energy won’t lead anywhere. And just like unhappily married people, if they split up and start over with someone else without learning what part they themselves played in the failure of their relationship, they are at a very high risk for finding the same unhappiness with their next partner.

Who, then, has forced their way into the doctor-patient relationship and turned the two against each other? And why did doctors and patients allow this intrusion?

The intruders promised both of them freedom from responsibility to each other – for the patient, access to doctors without having to pay – for doctors, freedom from asking their client for money, freedom from patient judgments about the dollar value of their services.

The intruders also told doctors and patients what they deserved from each other, instead of letting them iron out their expectations on their own. Patients and doctors were seduced with images of perfect and pliable partners, no more realistic than romantic fiction.

Hippocrates’ words build on love of man and a sense that ours is a noble profession. First, if we imagine our patients at least as distant relatives, we are partway where we need to be in our relationships. Our job begins with finding the common ground that makes relationship building possible. Second, if we don’t accept that our profession has a higher purpose than to do technically good work and reap the financial rewards we deserve, we will never be happy.

If we cannot feel joy and satisfaction when we are able to move a fellow human being in the direction of better health and enjoyment of their lives, we need to return to our own source to feed our souls and renew our spirits.

Ultimately, this is about soulfulness in our work. Many doctors today seem to feel that their work doesn’t matter on some deep level to their own sense of purpose. Relating to our patients as fellow human beings is the very first step in finding that purpose. Without that foundation, everything we do turns too abstract to provide professional pride and satisfaction. It is not sustainable to work as hard as we do if the only ones we help are the insurance companies or the clinic bottom line. Our job is to help people, real people with real problems.

A Country Doctor is a family physician who blogs at A Country Doctor Writes:.

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  • Gerry Oginski

    Dear Country Dr.,
     You raise a very interesting point.

    “Who, then, has forced their way into the doctor-patient relationship and
    turned the two against each other? And why did doctors and patients
    allow this intrusion?”

    It is clear that there are outside influences that affect how doctors interact with patients. It is also clear that the landscape of medical care has dramatically changed so that now patients feel entitled and demand certain results and time commitments from their doctors.

    As a perfect example, years ago I was in the emergency room with my son in the emergency room. The physician refused to actually touch him until he had completed talking to my son. It appeared as if he had some type of phobia or fear about what might happen to him if he began to conduct his physical examination. I think the fact that I had some medical knowledge, being a medical practice attorney and him asking me how I knew such medical information, might have immediately turned him off. In any event, my son was fine but it was clearly evident that there was something interfering with the doctor patient relationship.

    Long gone is the expectation of a country doctor who is called to attend to patients in their home with their trusty medical bag. That type of medical practice no longer exists. Instead, patients have certain expectations and want immediate results. They also want things done cheaply. Physicians, on the other hand are highly trained and expect to be properly compensated for the knowledge and expertise.

    There is clearly a disconnect between desires, expectations and outcomes. Outside influences clearly alter those expectations. I also noticed that you carefully stayed away from identifying and confronting just which of those influencers are, in your opinion, most responsible for this situation.

    Thanks for a thought-provoking article today.

  • Steve Wilkins

    Physician-patient relationships, based upon strong doctor-patient communications, are the cornerstone of medicine. If the volume of comments from docs like “there’s not enough time to talk with my patients” or “I don’t get paid to spend time talking to my patients” are an indicator of the problem, I suggest that physicians look in the mirror for why patients are “turning” on doctors. Many doctors simply don’t do a very good job communicating, relating, empathizing, listening to their patients. As patients “compare notes” and read articles in the lay press talking about what they can expect from a good doc…they realize they can vote with their feet if they feel their physician is not giving them what they need. 

    Before physicians say there’s not enough time…simply check the research that shows that a patient-centered communication approach only takes 6 second longer than the predominant doctor-directed communications (practiced by 60% of physicians).  If you need to blame someone (rather than fix the problem) blame the patient’s desire for quality care and a satisfying relationship with a doc that thinks we are important.

    If you feel you need to be paid more in order to communicate with patients then you may be in the wrong business as soon you will be paid even less once Medicare factors the “patient experience” aka satisfaction, into provider reimbursement formula (soon to impact 30% of provider income). 

    The answers are out there if you look.

    Steve Wilkins, MPH ((patient and care navigator for spouse)
    http://www.healthecommunications.wordpress.com

    • Anonymous

      If you think that all the problems generated by the expectation that a doc can handle 3 chronic problems, 2 new problems, 2 referrals, 7 prescription refills, and the creation of a meaningully useful note in 15 minutes will be solved by adding 6 seconds to the appointment, you’re not being realistic.

    • Anirban Ghoshal

      It is not a sin for wanting a better  pay for a professional service. Everyone does that .  The Govt could drill this 30% cost cutting , only for the doctors  ‘cause , that doesn’t hurt the populace. Screw those doctors . No where Govt. could get away with these . Just wait to see how it is  going to bite them from the back , in the long run.
      Misguided idealists like you played their part , as usual.

  • http://secondbasedispatch.com/ jackiefox

    This makes me so sad. I never gave doctors much thought until I got a front-row seat to medicine thanks to a DCIS diagnosis and five related surgeries in eight months. I was incredibly blessed to have four great ones–my family doctor, my general surgeon, oncologist and plastic surgeon–all of whom could teach a master class in bedside manner. I will be grateful to all of them for as long as I live. It wasn’t until I wrote a book about my experience and joined the online community that I learned this sacred relationship is under siege from all sides. When I blogged about how I’m a patient and not a consumer for kevinmd, I couldn’t believe how hot some of the discussion got. I can’t believe my oncologist’s recommendations are challenged by insurance companies, but they are–regularly.

    We need to stick together. We need to look out for each other, because no one else will.

    Excellent post. Thank you.

  • Anonymous

    I am criticized for using my insurance and not paying cash.  I am criticized because medical school costs a lot.  I am criticized because Medicare doesn’t pay enough.  I am criticized because I don’t have an Ayn Rand view of healthcare.   I am criticized for looking things up on the internet and making my own choices. I am criticized for wasting the doctor’s time because I didn’t educate myself.  I am criticized for not having a “relationship” with a doctor who rarely has time for me.  I am criticized if I chose a nurse practitioner.  I am criticized if I don’t want to see the nurse practitioner.  I am criticized for needing urgent care.  I am criticized for using urgent care centers or the emergency room.   I am criticized for wanting to explore lifestyle over medication.  I am criticized for taking medication instead of making lifestyle changes.  I am criticized for wanting to enhance my health using alternative care.  I am criticized for being sick.  I am criticized because my doctors couldn’t diagnose my illness and I used the internet.  I am criticized because I have been misdiagnosed.  I am criticized for the trauma I experienced.  I am criticized for being in pain.  I am criticized for wanting everything done.  I am criticized for wanting nothing done.  

    • Anirban Ghoshal

      It is not your fault  for high Medical School Costs . It is also  not your fault that Medicare doesn’t pay enough. None of the instances you cite , makes you culpable. What  could be the problems is with the co-pays. That you should be paying.  Services come at a price . When it matters to your health. I think you should be able to be a bit compliant and help your doctor to help you.

      • Anonymous

        You clearly haven’t read the comments by doctors that blame patients for the state of our healthcare system.  I received one comment from a doctor that said I am stealing services because I don’t pay for them directly and used my insurance.  

        “Misguided idealists like you played their part , as usual.”

        I am criticized because Medicare doesn’t pay enough.

        “When it matters to your health. I think you should be able to be a bit compliant and help your doctor to help you.”

        More criticism?

        • Anirban Ghoshal

          Now I understand. Anything other than mollycoddling , is a criticism for you  

          • Anonymous

            “Now I understand. Anything other than mollycoddling , is a criticism for you.”
            Yet even more criticism.

          • Anonymous

            Really?   Really?

            Good point, e_patient! I agree with you.

            Patients have usually already paid for services covered by insurance. Insurance coverage is a wage/salary benefit, and wages or salaries are lower than they otherwise would be but for the insurance benefit (because of tax benefits for the employer). When patients use insurance, that insurance was paid for by deductions from their wage or salary (with the co-pays on top of that). This is particularly obvious in the deduction for family coverage. This insurance benefit is often part of taxable income, so the employee also pays income tax on that benefit. 

            My point is that the patient has paid for the insurance benefit, and therefore has already paid part of the cost of services before the service is scheduled. With respect to Medicaid/Medicare, all employees have paid for that through their taxes, in one way or another (a separate issue from reimbursement rates).

            So, I contend that Anirban Ghoshal’s comment that that patients haven’t paid for services is not valid for many, if not most, patients. 

            I further suggest that sometimes the service is not worth the price paid. A hurried five-minute exam session (with maybe 30 more minutes of prep and paperwork time for the doctor for that visit) often doesn’t feel worth the bill charged, especially when it’s clear the doctor is ignoring symptoms or is unaware of recent research suggesting better treatments (and woe to the patient who brings in articles from well-respected journals to support a request to consider more recent research findings). 

            Anirban Ghoshal’s point about compliance is well taken. However, I have on multiple occasions over the years experienced doctors wanting me to do something that was not in my best interest. At first I found out after the fact by reading the PDR entries on drugs and by reading research journals (the good ones). Now I read up on drugs and research myself before I agree to particular treatments (and I have an earned Ph.D. which helps in evaluating a research design and the statistics used to analyze the data; I am appalled at how frequently an inappropriate statistical analysis is performed or an inappropriate conclusion is drawn from an appropriate statistical analysis or conflicts of interest throw doubt on the whole study). After all, I have to live (or not live) with the consequences. I thought I was paying the doctor to be educated on the drugs he or she was prescribing and to stay current with research. Only once did I have a doctor react well when I questioned something (“Hmmm,  good catch! You really shouldn’t be taking huge doses of ibuprofen right before a major surgery; let’s switch you to something else for pain.”)

            It doesn’t seem that Anirban Ghoshal is willing to concede that the medical community has contributed it’s fair share to the downward spiral in patient/doctor relationships.

            Sorry for the rant. Somebody just stepped on a really sore and sensitive nerve.

          • Anonymous

            No. Completely wrong.

            When the cost of health insurance is deducted from the worker’s paycheck, all the money goes to the insurer and the worker has purchased insurance coverage.At this point, they have not purchased 1 cent worth of health care.When the worker enters into an agreement with a health care provider for services, the worker, now a patient, agrees to pay for that service. If the patient and provider (doc or hospital or whatever) agree to negotiate payment through an insurer, the insurer is now in the position of power and can overrule both doc and patient. To think that buying insurance is tantamount to buying health care is a serious misunderstanding of what is happening. 

          • Anonymous

            No, completely wrong.  I still pay…although indirectly…for care that doctors have signed a contract to provide.  If you think that I should pay all those premiums and deserve nothing, then that divide between patients and doctors will only get wider.

          • Anonymous

            You didn’t read my post carefully. I was objecting to the statement:

            “Patients have usually already paid for services covered by insurance”

            To say that when a patient buys an insurance policy they have already bought my services is completely incorrect.

            “If you think that I should pay all those premiums and deserve nothing”

            Straw man in excelsis. I never said anything like that.

          • Anonymous

            I suppose that you would argue that if a tornado strikes my house and my home insurance pays off on the claim, I have not pre-paid that expense. The fact that I have chosen to arrange payment in advance through a third party (who can negotiate a better price for me) is apparently irrelevant. 

            You are deliberately choosing to select only a subset of the entire system. Years of general systems theory research across multiple disciplines suggests that consideration of the big picture is critical to solving any non-trivial problem. In addition, years of research across multiple disciplines suggest that considering the perspectives of all stakeholders is critical to solving any non-trivial problem. 

            Seems to me you are not putting much value in the full perspective of your primary customer, the primary source of your revenue. Hmmm. Isn’t this the very problem the article presents?

          • Anonymous

            “To say that when a patient buys an insurance policy they have already bought my services is completely incorrect.”
            Considering you signed a contract to provide such services at a certain price, then I would say my policy buys your contracted services.

    • Anonymous

      Type your comment here.AMEN, AMEN & AMEN and after all that, the bottom line is always money.

  • Rebekahroxanna henderson

    Why I have turned against many doctors. Well, a surgeon told me that what I was telling him was a lie (well, he didn’t say lie, he just said it was a violation of the law of conservation of matter and energy), said that everyone was tired and so my saying I was tired all the time wasn’t a symptom of anything wrong. Well, one ovarian cancer later. . .
    Yes, I’m still angry. I have multiple graduate degrees, my father was a doctor, I majored in chemistry at one of the country’s best universities and some doctors treat me as if I’m an idiot. I’d settle for a little respect. Fired the surgeon and the primary care doc who kept saying when my thyroid straightened out then whatever was going on with my stomach would be fixed.

    I also grew up in a house where my father dissed his patients, particularly the elderly females ones as not really having real health problems.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    Physician – One upon whom we set our hopes when ill and our dogs when well.

    Ambrose Bierce (1842-1914)

    What makes you think this is a new phenomenon?

    • Anonymous

      “What makes you think this is a new phenomenon?”

      Because we no longer set our hopes on physicians when we get sick…

  • Anonymous

    You write, “Our job is to help people, real people with real problems.”  This is, more accurately, our professional responsibility.  One of the obvious reason for professional dissatisfaction is that, in this era where physicians are increasingly employees, this is simply not an accurate job description in the vast majority of corporate situations.  I have pointed out elsewhere that it is no wonder patients wonder about our loyalty when they find themselves on the outside looking in, with their noses pressed against the glass, as we sit having lunch with our friends in the insurance, hospital, and adminstrative/corporate sectors.  The simple solution to this, as this article suggests is for us to wrap our arms tightly around our patients so that there is no room for third parties to insert themselves in a relationship where they have no proper role.  Our relationship with employers, if we chose to have one is our business.  Physicians and their patients have individual fiduciary relationships with insurers that do not overlap – as even the courts have made clear.  If patients are confused, it is because third parties have worked hard to shift their responsibilities onto physicians.  There is no reason physicians should aid and abet that confusion.

  • Anonymous

    I find it interesting that I was just finishing up a blog post for my own new website on the very same topic when I checked my email and saw this come through.  I love synchronicity!  As an ER doctor transitioning into a professional coach for doctors and health advocate for patients, this issue is near and dear to my heart.  Whatever forces may be responsible for creating this situation (doctors not satisfied, patients not satisfied) it is clearly up to us (doctors and patients) to come up with a solution. No one is going to do it for us.  Many, many lives depend on all of us being able to communicate effectively and work toward a dramatic solution to this major societal problem.  This will require that we be completely open to understanding each others’ perspective. If enough of us are willing t to be part of the solution, and we commit to coming together in the spirit of partnership, with an “everybody wins” attitude, we can keep things from spinning even further out of control.  I’m dedicating myself to working with doctors (in the spirit of partnership) and helping them experience more joy and success in their lives, which will in turn allow them to be a more valuable resource for their patients and everyone they touch.  Simultaneously, I’m dedicated to being an advocate for the doctor-patient relationship, since I’m both a doctor and a patient, and I see what needs to happen here.  If you;re interested in joining the movement, feel free to contract me!  Thanks for letting me share!

    DrBob@DoctorsOnPurpose.com

  • SHARON CONNOR

    A lot of physcian are not takeing the time to chat with their patients so therefore there is a trust value that either is weak or non existant.

  • http://twitter.com/whatscorrect don peterson

    Physicians have every right to be critical of patients who abuse their health insurance benefits.  And by “abuse’ I mean those who make poor health choices and then expect the physician to cure them.  Often, the patient’s lifestyle has more to do with their illness than any external factor.  The epidemic of obesity for example and the risks that come with it, are often well within the patient’s ability to reduce.  Yet, when they get sick, they demand to be treated.  Those who lead a healthy lifestyle end up picking up the tab for other’s poor choices.  How does a physician feel about providing care to a patient demanding to be treated for whom insurers have said, “we don’t want to pay or pay much for that service because doctor, you’re not improving outcomes?” How does a physician improve outcomes with patients who don’t care because they don’t pay but a fraction of the cost of their care?  Being generally critical of patients gets us know where…but being critical of physicians does nothing to improve things either.  Turn your ire towards the established monopoly of health insurance fomented by the outrageous dysfunction of Medicare. Move responsibility for payment and outcomes to the patient-physician relationship and maybe things will improve.  We know the current system does not work…the only thing to do is go back to the days when patients made sacrifices to remain healthy and physicians would move heaven and earth to help you when you weren’t.   Do you know why doctors don’t make house calls any longer?  Because insurance won’t pay for it.  Just a year or so ago, Medicare finally decided they’d pay for a phone consult…$25.

    Rather than mandating employer health insurance, put most of the money being paid by the employer back into the hands of the worker/consumer and say…”look, you can spend this on anything you want, but you will need to use this for all of your healthcare up to a certain amount…say $10,000.  After that, your insurance will pick up most of the cost.  When a consumer has choice and doctors have to compete for those dollars, outcomes will improve.  Patients will still be protected with catastrophic coverage, but they will ration their own care for those things that they can control.  As an individual with a family policy I pay ~$1K per month.  If I paid only a few hundred a month for catastrophic coverage and had to decide how to use the balance, I’d find a doctor interested in keeping me healthy and I’d find ways to seldom go to him/her. I’d demand generic drugs and tell big pharma, make them affordable or we’re not taking them.  we’d tell hospitals, we’re not coming to your ER we’re going down the street where they don’t have 3 different physicians wander in and then charge us a butt-load for doing nothing.  The mass collaboration of physicians and patients is the only way to change the system…please stop bickering and work together.

    • Anonymous

      Nice stereotype of patients.

      If physicians have the right to be critical of me, I have the right to be critical of them, especially since I don’t fit into your stereotype.

      • Anonymous

        “How does a physician improve outcomes with patients who don’t care because they don’t pay but a fraction of the cost of their care?”

        If my employer gives me $10,000 a year to spend however I want on healthcare, and my insurance covers anything above and beyond, I don’t pay anything of my care.
        It’s not about what the patient pays, it’s about what doctors get paid.  We are having this whole patients don’t have any “skin in the game argument” because doctors didn’t get a big piece of the healthcare pie

        • http://twitter.com/whatscorrect don peterson

          You certainly do have the right to be critical…but that doesn’t make you right.  Sounds like you have a different problem than whether or not patients are getting value from their physician.  Sounds like you envy or resent that they make good money when many do not. Since I’m not physician I can relate but then I didn’t go to med school or work 12-18 hour days until I was almost 30 before starting my career of working 12-18 hour days.  In the Midwest, hospitals today pay family physicians with 5 years of experience about $200K per year.  Between undergrad and med school most shell out about $500K.  I make that much and I didn’t even finish college and I started my career at 24.  So I suppose you would resent me too but then you have no idea what I do to earn that money…as I imagine you have no idea why a physician should be paid that much.  Your not a stereotype, your a typical malcontent.  I haven’t heard your solution, only your criticism.

          • Anonymous

            I don’t resent that they want to make good money.  I resent being blamed because they don’t make enough money.  I resent being given substandard care because they don’t make enough money.  I resent being called entitled because they don’t make enough money.   I resent being painted as this mindless consumer that doesn’t consider cost when deciding whether something is valuable.
            Ten years ago I would have advocated for my doctors financial needs but after a decade of abuse at the hands of doctors who feel money is more important than a doctor/patient relationship, I really don’t care. So you are right, I don’t find a great deal of value in the care I have received.  I regret spending all that money…my copays and the money paid by my self insured employer…into my healthcare. 

            In my job, caring about people is not contingent on how much I get paid.

            So you can decide whether or not I am a typical malcontent.

          • http://twitter.com/whatscorrect don peterson

            Yeah..pretty typical…always the victim of everyone else’s misunderstanding, No clue how to fix it but happy to point your finger at those who make you the victim. You should never go to the doctor again! You’d have no one to complain about and just maybe, in time, your whining would suddenly stop.

          • Anonymous

            I am criticized for any suggestions I make.

  • http://www.facebook.com/people/Haleh-Rabizadeh-Resnick/1134586817 Haleh Rabizadeh Resnick

    You hit it on the nail when you talk about “relating” and “soulfulness”.  Ultimately the doctor/patient dynamic is a relationship and in today’s age, it is a relationship of equals.  From the doctor’s angle I think this relationship has become secondary as docs are wrapped up in their own expertise of a health situation while simultaneously fearing to ever admit doubt for a number of reasons including business concerns and training.  
    Any doctor who returns to “relating” and “soulfulness” is courageous and bound to become an ultimate healer.  
    Haleh Rabizadeh Resnick, Esq.  
    Speaker and Author of Little Patient Big Doctor

  • http://www.facebook.com/people/Jackie-Swenson/100000046998781 Jackie Swenson

    We go to a ‘country’ dentist who prefers cash to insurance claims.  He charges less than half of what the other ‘gilded’ dentists do in the city.  He’s in his early 60′s and is very efficient.  He uses the newest technology in dental work, but uses the old-fashioned paper files for his patients.

    The hospital we go to has an automated system for everything.  My doctors can turn on the screen in the exam room and show me all the lab reports and records.  At the end of the appointment, my doctor would filled out a form and have me drop a copy at the check-out desk.  It has information on the follow-up appointment and the prescription.  Most of my doctors need to write no more than 5-10 words on it.  It’s an easy way to take care of the billing/coding procedure.  I suspect it also cuts down time spent on dictating. 

  • http://twitter.com/PamelaWibleMD PamelaWibleMD

    Patients and physicians are renewing their relationships without burdensome third parties. Welcome to the era of disintermediation (removing the middle man – aka the “meddling” man):  America’s Healthcare Heroes – YouTube

    Exciting times. . . 

    • Anonymous

      The closest “Ideal Clinic” (from the map) to my home (an hour away) charges $900 a year for this “ideal care” with the third party insurance right in the middle.  

      The next closest one is a group of naturpaths…I already have a relationship with a naturpath and she accepts insurance.  I pay cash and I am grateful she doesn’t inflate her prices like medical doctors do for cash paying patients.  So maybe I already have an “Ideal Clinic” to visit without a real middleman.

      The third closest is a nurse practitioner.  She also accepts insurance.

      The fourth one…MD with no retainer fee but insurance.

      One of the testimonials on the “Ideal Medical Care” sight practices in my area.  She accepts my insurance.

      Seems to me that middleman is still there.

  • Anonymous

    I am criticized for making too much money (despite the fact
    that the average RN anesthetist with a fraction of my education makes far more
    than me).  I am criticized for expecting
    that I should be paid fair market price, like every other highly educated professional
    who has had as much training as I have had.  I am criticized and called irresponsible for spending
    several hundred thousand dollars on my education.  I am criticized and told I should have
    “shopped around” for my education because, you know, there are so many bargain
    basement deals to be had on the path to becoming a physician.

     

    I am criticized by my managing partner for not making enough
    money or seeing the high volume of patients.  I am criticized for booking 30
    minute appointments versus 15 minute appointments.  I am criticized by the medical school for not
    spending enough time educating medical students, something that I love to do,
    but which slows me down impossibly.

     

    I am criticized by patients for not spending enough time
    with them.  I am criticized by patients
    for spending too much time with the person before them.  I am criticized for not working in a person
    for a routine physical, because well, it is routine and therefore not deserving
    of a same day appointment which should be for sick people.

     

    I am criticized for withholding antibiotics for viral upper
    respiratory infections (“but doc, my $20 co-pay was for nothing!).  I am criticized when I give in and give
    antibiotics because I just don’t have the time and emotional energy to spend 30
    minutes arguing about this (“you are contributing to antibiotic resistance!”)

     

    I am criticized for not providing 24/7 email and direct
    phone access, despite the fact that I have 24/7 pager access.  I am criticized for charging $25 for the
    access I do give (less than the cost of co-pay and parking or bus fare!)

     

    I am criticized for billing two E & M codes for the
    mega-physical that covered the physical, pap, and every other medical condition
    over the last year and which took 45-60 minutes in the 30 minute spot.  I am criticized for making the person who
    showed up 25 minutes late for their 30 minute appointment wait until I was done
    with the next patient who arrived early. 
    Then I am criticized by patients for running behind, although I do not
    eat lunch nor take bathroom breaks. 

     

    I am criticized for being booked out, due to my good online
    ratings (I really do care about my patients!) 
    I am criticized and told I will be charged for running late so that I
    can talk to the person before them about their suicidal ideation, or cancer, or
    heart disease, or about entering hospice.  

    I am criticized for the actions of every other person in medicine who saw this patient before me for slights real and imagined.  

     

    I am told I make too much money (although we are struggling
    to make ends meet, pay tuition, etc), am too selfish (although I am “part time”
    and work routinely over 50 hours a week, weekends and holidays and provide
    thousands of dollars of completely uncompensated services), have the wrong
    “ethic”.   I am criticized by strangers and told I
    don’t care, although I have cried and laughed and shared a part of myself with
    everyone who walks in my door, leaving far less for my family.

     

    I am an endangered species. 
    I am a primary care physician.

  • Doctor Hire

    nice article…..

  • Anonymous

    A doctor has to earn my trust and respect and sadly, many have sold out to govt, profits and pharmaceutical companies. You have to ask yourself – why is she pushing this test? Is it for profit, defensive medicine or to reach a govt-set screening target? I think it’s time doctors remembered their first duty is to us: their patients.

    In my opinion, cancer screening has eroded the trust and respect some women had for the profession – doctors aggressively pushing and even coercing women into elective cancer screening and over-screening/inappropriate screening. In Australia our doctors also collect target payments for pap testing; most women are unaware of this potential conflict of interest.  Informed consent is a legal and ethical requirement for all cancer screening, yet its always been denied to women. Now many doctors serve screening programs and the government, not their patients.
    Individuals are not targets and we all have a right to make up our own minds about these tests and exams, that all carry risk to our healthy bodies – informed decisions are the best decisions.

    My brother-in-law has just had surgery to have his hip joints replaced AGAIN…his surgeon received royalties from the manufacturers of the hip joints and even though there was evidence there were problems with the joints, he continued to recommend them to patients. (and failed to mention his financial interest in the joints) The joints were leeching toxins into his system and so he needed to have them replaced…
    My BIL has joined a class action against the surgeon, but would have preferred to avoid a second lot of surgery and 6 months of physiotherapy. Has this shaken his faith and trust in the profession? Of course…

    In the States some/many doctors practice defensive medicine – they believe it’s safer to over-everything – they probably assume it’s more likely to be sued for missing that rare case of cancer than ordering an extra or unnecessary test that results in a false positive and over-treatment. Even when patients are left worse off, most walk away relieved they don’t have cancer and never realize the doctor took a risk with their health and tested without their informed consent. It can result in horrible outcomes like putting elderly women through pap testing, those terminally ill through mammograms and colonoscopies. Does any of this benefit the patient?

    I know whenever I mention target payments to my GP she looks embarrassed – she knows these payments are unethical and that it’s only okay if her patients don’t know about them….
    She’s wrong – unethical is unethical, end of story.
    Once patients knew their doctor had their best interests at heart, now sadly, that’s increasingly uncommon and dangerous to assume or you can end up in some very ugly places.
    Dr Margaret McCartney wrote, “Doctors should not support unethical screening programs” BMJ:2011
    Some doctors “get it”….

    • Anonymous

      OK, I hear you about a doctor having to earn respect and trust, but I had to clarify that here in the US there is no “target payment” for doing paps or making sure a woman has a mammogram. When I refer someone for a colonoscopy or a mammogram,etc I do not get any sort of kick back or payment for it, I read this type of comment all the time and I find it amazing that people think that is the case. I believe that would be a violation of the Stark Laws and illegal here.

      I can’t speak for every physician, like any other profession I am sure there are some bad apples out there, but as for me when I do a pap, I always review the data per ACOG and USPTF, I always bring up the issue of stopping screening. Guess what, in the majority of cases it is the patients (not me) who want the extra testing.

      As a second point to the “target payments” isn’t there some sort of preventative task force there in Australia who sets guidelines as to how frequently someone should be screened? Why on earth would the gov’t then reward an MD who was screening inappropriately?  Or is your objection to the fact that doctors in Australia get payments for (perhaps aggressively) following guidelines that the state-sponsored health system set up? I guess it is a moot point either way until P4P becomes more entrenched here.

      • elizabeth52

        MZMD, there may be no target payments in the States, but women face HIGH pressure to screen and coercion is very common. (You must have pap testing IF you want BC – if you refuse, I will not prescribe the Pill = coercion)
        Cancer screening is supposed to be elective, legally and ethically…screening guidelines do not make screening compulsory – every man AND woman is entitled to consider their risk profile, the risks and benefits of the test and decide for themselves.
        Dr Joel Sherman wrote an interesting article on this point: “Informed consent is missing from cervical screening” – on this site.

        This article discusses the impact of defensive medicine and the desire for high profits – a bad deal for healthy people and I’d say, bad for medicine.
        http://www.huffingtonpost.com/the-center-for-public-integrity/forty-percent-of-medicare_b_999653.html
        The medical profession certainly benefits from screening and all of the unnecessary follow-up. Screening leads to over-diagnosis/over-detection and over-treatment/biopsies and all of that is highly profitable.

         ”I always review the data per ACOG and USPTF, I always bring up the
        issue of stopping screening. Guess what, in the majority of cases it is
        the patients (not me) who want the extra testing.”

        Do you ask the patient whether they “want” to test? Is it presented as mandatory or an offer? Do you list the risks and “actual” benefits of the test? If patients decline to test, what happens then?
        I don’t think doctors can blame women for requesting extra testing – they’ve been pressured and misled into over-screening for decades.

        I feel doctors now have a responsibility to undo some of the damage – they should take the time to educate women – tell them the truth.  Doctors shouldn’t keep over-testing and risking their patient’s health and well-being.
        In my opinion, women have never received balanced information on cancer screening, so they can’t be blamed for making poor screening decisions, they’re acting on ignorance and fear.

         ”Or is your objection to the fact that doctors in Australia get payments
        for (perhaps aggressively) following guidelines that the
        state-sponsored health system set up?”

        Correct, most women are unaware of these target payments and the potential conflict of interest and women don’t receive balanced information – there is no respect for informed consent.
        The programs have targets and that is the focus, not informed consent. I believe these programs operate outside the law and ethical standards – our program also over-screens and harms and worries FAR more than it helps.
        Most women are unaware of the risks with breast screening as well and especially, over-diagnosis. The head of Breast Screen (Aust) appeared on the “News” recently and mentioned a study that supported breast screening and encouraged women to have the test on the back of that research. She failed to mention a later study that suggests the fall in the death rate is about better treatments, and not screening. A very biased and selective presentation of the facts and research. Breast Screen are chasing a 70% screening target – that political target is the focus, not informing women of risk and actual benefit and respecting their right to say yes OR no.

  • http://www.HealthcareMarketingCOE.com Simon Sikorski MD

    This sounds like a case of doctors who don’t know what Participatory Medicine is. The doctors I know and consulted on ways to manage their practices love working with their patients … and the “demanding patients” mentioned here are rather patients that want to be part of the Care Team, not treated as “cases.”

  • Anonymous

    1. I do not hold birth control pills hostage for a pap. Yes, I do need to see someone at least once a year to prescribe a medication however (but this does not necessarily include a pap, I offer them according to the guidelines).I am sorry, but I cannot keep prescribing indefinitely, an otherwise healthy woman needs to be seen once a year to (yes imagine it!) go over the risks and benefits of oral contraceptives. I think if you lived in the US you would find this was the case in many regions – this is a basic issue that was dealt with many years ago during residency training…

    2. Yes I specifically tell them about why the pap guidelines were changed (too much over diagnosis leading to problems with preterm labor, possibly infertility, no real health benefit for certain age groups, etc).

    I don’t blame a woman for wanting testing – what I object to is this mass characterization of me, a medical doctor, as some predatory person who is just in it for the bucks.  On this website, as on so many others, it always comes back to the doctor being at fault – to much testing, too little testing, always my fault ?!

    But you have to know, oftentimes the patients are the ones requesting the screening. If you do not live in the US perhaps you are not the best qualified person to judge standards here – I would certainly not presume to be an expert in cultural norms in Australia for instance.  You give the sweeping statement that “the medical profession benefits from over diagnosis” – but how do I as a specific physician benefit? I do not get kickbacks from those I refer to (illegal here FYI).  My only skin in the game is to advocate the best way I know how for my patients.  I am offended at the inference otherwise.

    As for breast screening, I am definitely not the right one that you want to have that battle with. I am an early stage breast cancer survivor myself. ER PR negative HER2 positive (google it if you aren’t familiar – it is not a good set of words to be attached to your personal medical history).  That digital mammogram with CAD probably saved my life.  Hey, it is a personal decision to get breast cancer screening. I tell my patients I recommend it, but I don’t condemn them for not getting screening – as long as I am sure they can understand the risks and benefits of screening or not screening. And BTW they are not aware of my personal issues so that does not factor in.

    I receive no kickbacks for mammograms, colonoscopies, etc that I order.  I might reiterate – that is ILLEGAL in the US.  I receive no target payments.  I can only counsel people on what I think they should do – that is why they come to see me…

    • Anonymous

      “I do not hold birth control pills hostage for a pap.”
      I’m hopeful more doctors will follow your example – my American friends tell me most doctors still “hold” the pill until their “requirements” are met. It means many women receive no medical care at all, they avoid doctors altogether and use the Internet to get drugs or pick them up when they’re overseas. Of course, I understand you want to see your patients and check their blood pressure, which is a clinical requirement for the Pill, but many of your doctors tack on unnecessary invasive exams or force elective cancer screening. We have issues here as well – there are many doctors who still use this consult to pressure women into pap testing – there is no respect here for informed consent for women either. We also have doctors that will tack on a routine pelvic exam when they’re doing a pap test or do a routine breast exam, although I hope these practices are declining…
      If you don’t have pap tests, these things don’t arise – it was only recently that my GP offered CBEs when I declined breast screening – after doing my research, I declined – I couldn’t find anything supporting the practice, they just seem to lead to biopsies.

      Personally, I believe the Pill should be off script by now – it seems unfair when men can buy Viagra literally everywhere! I feel it smacks of control – and making reliable birth control readily available, I believe, will improve the health and lives of women. The repercussions when women can’t get the Pill at all or easily are severe – unplanned pregnancies, abortions etc

      “often times the patients are the ones requesting the screening”
      I think many women have been scared to death or have been misled and some of your women have been brainwashed to believe they must climb into the stirrups every year of their life or they’ll die. I can understand why some women are now afraid to move away from the excess. I hope doctors and their professional bodies will take some responsibility here and come clean – educate these women to understand unnecessary and excessive exams are harmful for no benefit – more is not a good idea.
      If a doctor is aware that annual or 2 yearly pap tests carry higher risk for no additional benefit, shouldn’t they be ethically obliged to decline the patient’s request?

      Thank you for your response…you’re right, I’m probably not the best person to assess the US system, but I noticed my American colleagues all heading for the doctor when they landed in HK or getting their “supplies”  (you can get the Pill and other meds without seeing a doctor in HK). They told me they couldn’t get the Pill in the States unless they agreed to climb into the stirrups (which horrified me, I’ve never even seen a set of stirrups and hope to keep it that way!) Some carry trauma as the result of being forced into these exams – it felt like they were sexually assaulted – that doctors had the right to do as they pleased with their bodies. Some were damaged and traumatized by early cone biopsies or other treatments which are common when you screen young women. It’s been known for some time that young women produce lots of false positives and that testing does not change the tiny death rate in young women. (under 30)
      I now have lots of online American friends and their stories upset me…one woman has not seen a doctor in decades. This shouldn’t happen – women, like men, are entitled to have a trusted doctor in their life.

      • Anonymous

        Thanks for the reply. It is nice to have a measured reasoned discussion on kevinmd.  So often these things turn into flame wars unfortunately. I agree, it is sad to hear of women avoiding care for this. I certainly would never force someone to have this type of exam, even if she was due, or overdue for it. I counsel with risks and benefits and document this and we both go on our merry way.
        With regards to doing the pap test in a more frequent interval, while the data is against the ultra frequent screening, I am not sure the converse can be said – that it is unethical to screen in between these times.  Again, I talk about risks and benefits and possible outcomes and we proceed from there.
        At any rate, can men buy Viagra off the shelf in HK or Australia?  That isn’t the case here although I am sure it could be ordered online fairly easily.
        I do think that women benefit from medical counseling from the pill and disagree that it should be over the counter (although it would probably improve my liability profile for that to be the case I do think there are safety concerns).  We have a big obesity and hypertension problem here in the US, and OCPs often can contribute to HTN. Plus all the urban legends out there about how to take them, the risk of DVT/PE, high potassium in some cases, etc.  Plan B is however over the counter, very reasonably.
        As far as breast screening, that is a personal decision. Our rates here are 1 in 8 up until the age of 75 or 90 I believe. Having been that person already, I do advocate screening, but it is a personal decision as I obviously do not force adults to do things against their will.

        • Anonymous

          Men can buy Viagra literally everywhere here…I get about 8 emails a week asking me if I’d like to buy it!
          One of the men in the office spent a few hours in casualty after he overdosed and had a painful erection for over 24 hours. There seems to be more risk with this medication and I guess there is a temptation for some to overuse/misuse it. (the hazards of the much younger wife!)

          I know some countries have made the Pill available OTC and the pharmacist takes the woman’s blood pressure  – it’s argued that overall women have better health and there are fewer unplanned pregnancies if they have easy access to reliable BC. I’ve read there are some benefits with the Pill too – reduced risk of ovarian cancer.
          I tend to agree, that the benefits that flow from easy access outweigh the risks.
          I know others feel as you do though…you’re probably aware of the debate going on over this topic – I’ve read a few articles by your Daniel Grossman from Ibis Reproductive Health.
          I’ve never used the Pill…I refused to do the well-woman exam that was a requirement here when I was a young woman, so it was down to condoms and taking a course on the Billings Method. I resented not having the choice at the time, but have always enjoyed controlling my own fertility. It ended up working for me.

          I just cannot understand how a doctor could let a woman walk away with
          no birth control simply because she doesn’t want elective cancer screening or
          exams our doctors tell us are unnecessary and harmful. It’s like men
          being asked to have rectal exams before they can get Viagra or condoms. I
          see article after article in your newspapers that pap tests and pelvic
          exams are unnecessary for the Pill, yet these stories keep appearing.

          I saw a post last night at “Feminists for Choice” under the thread,
          “Birth control and pap smears: why do they go together?” – a woman with a
          6 month old baby – declined birth control because she refused a pap
          test and pelvic exam. I just don’t get that…if a doctor is concerned
          about her patients health and welfare, as she claimed, how could she let her
          walk away with nothing? How stressful to cope with that on top of a baby? She might end up having two babies to care for this time next year.

          The repercussions are severe, leaving a woman with no BC…and could
          even be life-threatening (ectopic pregnancy, childbirth) I hope this sort of thing
          becomes a thing of the past (an ugly past) before too much longer…

          The 1 in 8 figure scared me, that was mentioned here a few times, but then I found out that figure includes advanced old age and many of us will die before then…risk rises with age and the risk for my age group (53) was thankfully, not as high – 1 in 55 or 60 (from memory) BUT, of course, still concerning.
          I did find the decision not to have breast screening difficult, breast cancer is a serious issue. In the end we can only do our reading, speak to our doctors and make the best informed decision – whatever sits best with us.
          I hope things continue well for you – stay positive and look after yourself. Medicine is a stressful profession, remember to take some ME time.

          That post:
          “Just left the doctors office in tears. Had my baby 6 months ago. I just
          needed birth control. I was basically told either strip down and have
          the pelvic, pap-smear and all or leave without birth control. I asked
          the question what does one have to do with the other to be told ” I am
          your health care provider and I am looking out for your health. This is
          the recommendation.” If it’s a recommendation than why is it forced on
          me? No answer to that. I told her it is my body and I will not do
          something I am not comfortable with and is totally unnecessary. So she
          told me to have a good day.

          This is just out of control. What do I do now?”

          • Anonymous

            Perhaps this young woman should find another doctor.  If a med-mal case is the concern (i.e. pt given oral contraceptives without adequate assessment of cervical health, she shows up 5-10 years later with cervical CA, now Dr is on the hook for large judgement), appropriate documentation of risks and benefits should protect the physician AND allow the patient to get what she needed.

            Re: protection from Ov Ca, interestingly, even condoms and vasectomy of the male partner reduce risk of development of Ov cancer from what I recall reading last spring.

            Thanks for the well wishes, and perhaps I will see you elsewhere on the boards!
            cheers!

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