What happens when doctors lose their calling?

The field of medicine is one of the most rewarding occupations out there. Few occupations allow such an incredible opportunity to directly impact the life of a fellow human being and see the amazing results of something you did. Few occupations are allowed inside the most intimate and vulnerable moments of the human condition. In a word: amazing.

But medicine for people has quickly given way to medicine for business.

Business needs results. Business needs productivity. Business needs profit. And profit in the increasingly competitive world of medicine is getting harder and harder to come by.

To assure these business needs, medicine has hired legions of support personnel. These include administrators looking for ways to remain “value-added,” collectors to assure the cash flow, insurance plan negotiators to cut the best deal, quality assurance and safety officers (you can never be “too safe”), database operators adept in last-year’s technology, concierges to make it all seem happy, survey takers to under-sample opinion, and negotiators adept at keeping the price spread.

To lower costs, patients are made outpatients, personnel ranks are thinned, and beds are closed.

Yet for the most part, it has worked because doctors have stayed true to their calling.

But what if that calling dies?

What if the insurances hassles grow too great or the income doctors receive fails to cover the cost of their education? What happens?

In truth, little right away. Given the time commitment, it’s hard for doctors to pull the plug entirely. Many doctors don’t complete their training until their early thirties, and by then, they likely have families and kids, and if they are lucky, a home. So they hang in there. They do the best they can. Like most Americans, they cut back, budget, and make do.

But as their hours grow and incomes dwindle, some of the rose-color in medicine turns to grey. They still love what they do, when they can do it, but if there is less reward, there is less effort. For some, mediocrity will replace exceptionalism. For others unwilling to bow to mediocrity, the desire to stay late to squeeze another patient in dissolves.

The recent revelation of the latest physician cuts proposed by the insurance industry should give us all pause, because if it’s true, you won’t hear a word from doctors.

You just might not be able to see one.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • http://www.practicebalance.com/ PracticeBalance

    I love the first paragraph of your piece. Beautifully put.

  • NewMexicoRam

    I feel like I’m teetering on the edge of the cliff.
    I like my patients. I like helping them.
    I’m hating going to the office because I know I’m going to be bombarded with insurance hassles and multitudes of paperwork, or EHR computer buttons to push.
    I’m on that brink, waiting to see which way I fall.

    • Suzi Q 38

      How old are your children? If they are teens or young adults, ask them to come in and help you, if possible. My PCP does this.
      He has several employees, but his wife and college aged daughter also come in.

      Try to get some help with this part of your job.

      • querywoman

        Hee!

        Child labor, Suzi Q? It’s legal for parents to do that!
        What these doctors really need to do is enlist a few patients, like you and me, who know how to fight insurance companies.
        It would also help if doctors made a blog and shared tips with each other on ways to win the insurance battles.

    • querywoman

      Try and identify stalling techniques your insurance companies use. Then petition your state to make it illegal.
      They are holding the money in the bank and drawing interest while withholding it from you.

  • Dr. Drake Ramoray

    I make the case that the calling of medicine is to the patient. Previous generations sacrificed time, energy, and family for the patient. The key part is for the patient. Most of my toil these days is for the insurance company, beuracratic hospital administrator, or government official. This doesn’t take into account the millennial generation of doctors who tout themselves and claim everything will be better when they are in charge, all the while avoiding primary care and looking for cushy 9-5 corp med jobs.

    My late nights and early mornings have little to do with patient care anymore, nor do my practice meetings that have to calculate what cut has occurred this month (See ultrasound guidance reimbursement for thyroid FNA but over 50% by Medicare). It feels that I spend most of my time “devoted” to patients dealing with documentation, prior authorizations, EMR requirements, and letters of appeal to insurance companies.

    My plan is to position myself for the future so that I can continue the calling to those patients I can care for without undue restrictions or beancounters that extend the hours of my day. I will either diversify my practice with research so I can devote fully the time I have for patient care to the patient’s for whom I am caring, or if it gets bad enough (and with a little more groundwork laid) strike off in a concierge model.
    But if none of these strategies ultimately result in that option, the calling to provide the best possible care to my patients, then quite frankly I will find something else to devote my time.

    I will do my best to avoid corp med and the conflict of interest to an employer that that represents. I will not place myself in an environment where I cam certain to be labeled a “disruptive” physician. It is possible tat my call to care for patients pushes me to leave the practice of medicine. I haven’t reached that day, but my crystal ball beyond 5-10 years is cloudy. My Magic 8 Ball says “Outlook not so good”

  • buzzkillerjsmith

    I saw how loss of autonomy and morale can play out in family medicine years ago at Kaiser. There were of course some very dedicated docs and smart docs, but they were always punished for doing a good job with more work and the worst patients. Several of them went admin and, curiously, several of them got disability for one thing or another in their fifties. Several of them because hospitalists.

    Most docs who worked 8 to 5 and really tried to get out on time. That was their main concern.

  • http://euonymous.wordpress.com euonymous

    We can see the results of this already… schedule a sick person to see a nurse practitioner, not their doctor. You want to see your doctor? It’ll be 2+ weeks at the earliest. Sorry. As for the doctors themselves, there are medical-related alternatives: work inside big pharma or a med dev company, in the government, in the media, or surrender to being part of a hospital staff. Physician “jobs” have changed from the days of physician “vocations” by a considerable amount, and it’s all about the Benjamins. Right? I keep hoping that Obamacare will morph into Medicare for everyone in the US, but the Republican Party monsters are trying to prevent that. They thought FDR was a “traitor to his class” also, remember. We need to rethink capitalism, healthcare, and democracy. What are our values as Americans, anyway?

  • Suzi Q 38

    I am so sorry. Try to get some help with the insurance.
    Can you also get the patients themselves to call the insurance company on their own behalf?
    I do, and most of the time it works.

  • southerndoc1

    “if they prove too much for any doctor, and the doctor cannot give quality care because of it, then that doctor should find a new career.”
    Those doctors are frequently those who are committed to providing care to their patients at a level of excellence that is no longer tolerated in today’s dumbed-down medical culture. You seem quite complacent with running them out of the profession.

  • southerndoc1

    Agree that stress is pervasive in today’s work environment, but I think we have to acknowledge that something very bad is happening in medicine these days.

    If 60% of primary care docs are clinically experiencing burnout, 30% are depressed, and a good number should be on 24-hour suicide watch, I don’t think “get a grip” and “it’s up to you to figure it out” are going to solve the problem.

    Something is very, very wrong with the work conditions that doctors find themselves in. I am a patient too, and it scares me that I may have to rely on physicians who are depressed, exhausted, and uncaring. I’m sure that concerns you also.

    • DoubtfulGuest

      Not sure where exactly to post this reply…I am very cautiously taking doctors’ side on this one, I agree it’s just a terrible unsustainable situation and the public needs to get some perspective. I think it’s likely that Karen’s wonderful current doctor is one of those under less pressure for any number of reasons, or may have an optimal support system to balance it out.

      I’d say the same of one of my doctors, he IS wonderful! Patients and staff just luv-luv-luv him…but I think he has a particularly supportive family and is salaried at a teaching hospital. Also, i’d guess he is very good at compartmentalizing, i.e. leaving work at work. Some of the best most passionate caring doctors canNOT do this. Their health suffers and patients get mad…which brings me to my next point: Patient harm. We know that Karen was harmed by a serious medical error. So was I. How would you all like us to handle this? Lots of patients here are trying hard to see the big picture. “Suck it up” is not a good answer. There must be some way we can actually help change things. Understanding needs to go both ways.

      • guest

        The best way you can “help change things” is to listen and take seriously what good doctors are saying about what needs to change in our profession, and then look for ways to support that.

        However, when our comments and suggestions are met with scornful or dismissive or angry (or all three) responses, it does not exactly support the contention that patients are here “trying hard to see the big picture.”

        It seems to me that if a lot of doctors say that they are overwhelmed by dealing with third party payors and that those activities don’t leave them with adequate time with their patients, that should be thought about by everyone, including patients.

        Comments like “that doctor should find a new career,” do not exactly move the discussion forward, and they do not leave anyone feeling inclined to offer a sympathetic response about someone’s experience with medical errors. As I’ve said elsewhere, we’ve all been the victims of those.

        • DoubtfulGuest

          guest, speaking for myself, the whole point of bringing up medical errors is to think about how we can reduce the frequency and the suffering that results from them. I don’t like what happened to you, I don’t like what happened to me, I don’t like what happened to Karen. I think the discussion could be more productive if we were not assumed to be whining or navel-gazing. I also don’t think a competition of “my experience is worse than yours” is ever helpful…not saying you are doing that, it’s just the overall atmosphere in discussions sometimes. We never really understand the entirety of what someone else is going through.

          I explicitly disagreed with some of Karen’s comments. The whole point of my participation here is to listen to doctors (and patients and nurses, really everyone), but specifically to learn about doctors’ perspectives, which are the most foreign to me. I am taking all of it seriously. What I’m uncertain about is how to apply what I’m learning.

          For example, what you say about third-party payors. Long ago, I was one of those who didn’t think much about health insurance, just was glad to have it. Had no idea of the headaches involved for my doctors. Now, I’m starting to understand and I care very much. What specific steps should patients take to support their doctors on this? This may be a stupid question, but it’s easy for patients to take the wrong steps when we’re not fully informed. In our day-to-day health care and doctor/patient relationships, a lot is kept hidden from us and it’s very confusing. I specifically offered to pay cash for a visit to talk with a doctor after he harmed me. I wanted him to know that I supported him being paid right away and being paid *closer to* what he is worth (I found out his practice is gravely impacted by Medicare/Medicaid cuts). Given what I know about how the problems w/ my care started, a thoughtful conversation would be a complete remedy for me, and should also help this doctor in the long run. I’d had insurance on file with the doctor before, but that was a few years ago. Unfortunately, my offer seemed to make the doctor angrier, although no one will explain to me why. I’m not sure if what I proposed is illegal since I had PPO insurance? This is not your problem, but please understand how confusing it can be for patients. There has been a lot of anger and disdain expressed on both sides here, and it is not productive.

          • guest

            Ah, I see. It was nice of you to offer to pay your doctor out of pocket.

            I think this leads us to a couple of other problems with our healthcare system, both of which are related to how doctors are socialized in their training. The tradition is for us to pretend that we don’t care about getting paid, that we are just doing our work purely out of altruism. This, of course, is silly. Doctors have personal lives; we are not monks or nuns and so we have material needs (like sending our kids to college) that need to be met by being paid for the work we do. But doctors like to feel self-righteous and so it’s considered icky for us to talk about money or payment, especially with our patients. I, too, have had docs reject my offers to pay them cash in order to sit down and talk with them about something. I see the cultural reasons that this occurs, but I agree that it’s a little frustrating.

            Second, medical training involves a tremendous use of shaming when mistakes are made and so doctors who have made a mistake are generally ashamed. They don’t want to talk about it, they just want to move on. Obviously this is not at all the way mistakes should be handled. And in a hospital setting, it isn’t. A medical mistake results in peer review to try and determine what contributed to the mistake being made. But in private practice, there’s no equivalent to that, and most doctors have enough shame that they are resistant to processing mistakes with their patients, even those who truly just want to figure out what happened in a noncritical way.

            To fix this, we need to make fundamental changes in how we educate doctors. Such changes have been under way for about as long as I’ve been a doctor ( a pretty long time) but as in any entrenched system, old habits die hard. I think it doesn’t help that in a lot of places the use of shame to modify behavior has not been identified as a fundamentally flawed way to educate people when you want them to relate to their patients in a non-shaming way later in life.

          • DoubtfulGuest

            Thanks for your kind thoughts, guest and I agree with you. I wish I knew how to fix these problems. I DO try to share with people (friends, acquaintances) what I’ve been learning lately whenever medical topics come up in conversation… as much as I can without being overbearing since that would have the opposite effect than I want. Seriously, if you or any doctor could give me something to do, assign me a task, that could actually help things, I’ll do it. I work and I have a life, but I spend a fair amount of time just spinning my wheels trying to understand what happened to me.

            I don’t want my doctor (actually there were several involved but I’m talking about the one at the center of the chaos) to suffer or feel shame. I do want him to think about this, and care about me. His office actually sent me a termination letter in response to what I thought was a nice letter from me. My letter said things along the lines of “If X mistake/mix up occurred because you were tired, stressed, or hungry it would have been okay to tell me. I was happy with your care apart from your anger at me”. I don’t mean to dump this on you, guest. I just hope doctors here will understand how hard some patients try to work things out with you all.

          • querywoman

            If they reject your offer to pay cash, perhaps it is because they have plenty of insurance patients scheduled and just want to zip on through.

        • DoubtfulGuest

          I thought of something else that *might* be important here. It’s understandable if it’s hard to read about our bad experiences when doctors spend day in day out listening to and caring about patient complaints. I can only assume many of you are logging on here with empty emotional/spiritual gas tanks, and responding accordingly. We should all keep this in mind when we talk to one another. The notion that patients should care about what doctors are going through is very new and unfortunately not the norm.

          I think our (patients’) intentions, taken in the aggregate, are more constructive than it might appear. Even if we let you all take the lead and we sit passively while you teach us, we still don’t fully understand what you need us to do. Your profession has a historical precedent of secrecy/lack of transparency (I’m sure you’ll correct me if I’m wrong) that is not conducive to the kind of change we seem to agree is necessary.

  • guest

    Unless you do the work that a doctor does, it is, in fact, highly disrespectful to make statements about what kinds of work stress doctors are under.

    • querywoman

      Guest, are you a doctor? Do you make presumptions about stress in the lives of your patients? When my mother had carpal tunnel surgery, I asked her hand surgeon what he thought of doctors who dismissed, “carpal tunnel,” as emotional stress?
      He said, “The same thing I think of doctors who dismiss everything else as stress.”
      I have never had to have surgery, but I spent a small fortune on neck spasms from overwork on computers in the 1980s, and I was told the neck pain was, “stress,” and no one ever asked what kind of work I did.
      Furthermore, the doctors took the money I earned as cash and also from my job-related insurance.

      My father worked as a short-order cook and many other things because he left home young, I asked him, in my early twenties, when job stress was killing me, if there was stress on a short-order cook.
      He said, “Oh, yes. Stress to get things cooked, etc.”

    • Suzi Q 38

      I don’t think this is disrespectful.

      Physicians make assumptions about patients, and others, but that is O.K.?

      We don’t know the actual kinds of stress physicians are under, but we can be empathetic and guess. On the other hand, this sometimes is not necessary, as many physicians have revealed what is stressful in their work.

      • DoubtfulGuest

        Good points, Suzi Q 38. While I disagree with some of Karen’s statements, she’s here on this blog trying to engage with others and understand things. I have NOT seen any doctors here show compassion for her situation. You, I, and others have also been down-voted when bringing up our misdiagnoses that resulted in substantial harm. In order to become aware of what doctors are going through, we have to be able to talk about it, including how we as patients are affected.

        Assumptions are much more dangerous when they’re unspoken and unexamined. Best to admit we all make assumptions, and go from there.

        • querywoman

          Very good, Suzi Q and Doubtful Guest!
          When a person has a real job with health insurance, how many doctors appreciate the job stress their patients endure to pay their salaries?
          I’m not the only one who has paid my doctors out of money I earned from overwork on computers.

          • DoubtfulGuest

            Most doctors I know bend over backwards to help with payment plans, and/or they have a high proportion of Medicare/Medicaid patients, for which they are paid only twenty-something cents on the dollar. Furthermore, they wait months to be paid by third-party payors. I don’t think that’s the problem here. It’s the way they talk to us, complain that we don’t understand, while keeping us in the dark about many things we need to know.

          • rbthe4th2

            Or saying that its all in my head, when I’ve complained for several months on bleeding issues, and when a Vitamin K was finally run and the level didn’t register, not ONE word. Nada. Nothing. Zip. I’m sorry, I understand docs problems, but its hard when you’ve got a couple of docs in RL who help and the ones here do, but the rest … there’s not an excuse. If you do sloppy work, the patients are going to blow you off.

          • DoubtfulGuest

            Yes, we usually give them multiple chances since we know they don’t get much time to think. I went back to mine and very nicely said “Uh, yeah, hi, I’m concerned we’re missing something here and here’s why…I wonder if we could please…” which resulted in him biting my head off and promptly handing it back to me. (No, doctors, he didn’t just disagree or refuse to follow the whims of an entitled patient. Sigh…)

            I hope they’ll figure it out this time, R, so you get to feeling better.

          • rbthe4th2

            Oh ye Gods … I’m sorry DG! That was how I was taught to approach them: ask and wonder about things. I’ve taken the direct approach also. I’ve had the same experience as you, from the original “problem child” Dr. Ego. Funny, we walk more about the docs’ attitude and reaction, than we do that they’re wrong. Again, docs on here: you’ve seen our predicaments. How can we take care of them and help you all out?

          • DoubtfulGuest

            Would triple-like this if I could!

          • rbthe4th2

            Ta.
            I think I missed one: if you expect us to trust you, then you trust us. It goes both ways. I had the new internist be fine until the GI destroyed me. You know why … because he was wrong. Its not so much as being wrong and not educating yourself, but going out of your way to sabotage someone trying to find better help … what does that say about the medical professions’ ethics?
            While I’ve got a lot of sympathy for the docs here, this does about the same things as frivolous lawsuits does for our side.

          • querywoman

            I’ve been through that garbage umpteen times. It took me years to get the decent set of doctors whom I use now.

          • rbthe4th2

            I’m sorry. I can feel for you, quite clearly. I’m sure the good docs are probably wincing …

          • querywoman

            Ha! You know as well as I do that the past doctors aren’t wincing. But some of my current ones are celebrating along with me, especially my dermatologist and endocrinologist!
            Those two are jewels, and I deserve them!

          • rbthe4th2

            Yes you do!! I don’t know, I have a few doctors who are wincing because, in a roundabout way & they know it, they got pinpointed for a sloppy job.

          • querywoman

            Doctors who apologize are less likely to get sued, or maybe not.
            Who knows?

          • rbthe4th2

            I think the issue comes down to the doctor coming off as being human, and willing to take responsibility. Like a Marcus Welby type (I’ve only seen some reruns.) The other is that the bigger issue is how are they going to work to prevent it in the future? So far, I see a lot of denial, but no real change happening in the medical establishment. Patients need to see some effective change. That says a lot more than someones’ words. Its called we help you and you help us when that happens.
            Randy

          • DoubtfulGuest

            I think there’s a lot of research showing that patients mostly sue *because* their doctor stonewalled them and refused to apologize. Lawyers know this, of course — it’s more billable hours for them if they help make the patient as mad as possible.

            I also feel it’s a self-perpetuating thing, how med mal lawyers make themselves indispensable by playing on doctors’ fears of litigation:

            Treat harmed patient unkindly –> patient does something adversarial & stupid in response –> Lawyer says: “There now, that’s exactly why you need us. Aren’t patients a$$h*les?” –> doctor becomes more suspicious & defensive with future patients –> doctor makes error –> patient is harmed –> treat harmed patient unkindly….and so on.

            Lather, rinse, repeat.

          • querywoman

            I researched this point the other day and saw, yes, of course, some people sue after an apology.
            I talked to a woman privately recently who has given up on the idea of a lawsuit and simply so desperately wants an apology.
            At an activist-type awards dinner a week ago, I heard a speaker, on another matter, state that it was a victory when a city finally apologized for a tragedy after many years. He called an apology a basic human dignity.
            I have given up on apologies, though I have had an occasional one from the medical profession.
            When I was a state employee, a union official said these words, “If you want an apology, forget it. You’re not going to get one. When big companies settle class actions, they always say they do not admit guilt.”
            I settle for being amused at some doctors, kicking up a ruckus in various ways, and going on to get a better doctor.
            I sued an insurance company once, in a state system, outside of court, that was run like a court. It was only for about $200. I did not win, but a lawyer friend assured me that I had made them spend more than $200 fighting me, and brought about a policy clarification.

          • DoubtfulGuest

            You’re right, apology is a basic human dignity for both the person giving and the person receiving an apology. I can’t imagine not apologizing to someone I’d harmed…I think it would mess me up pretty badly, particularly if they had made it clear an apology would help them.

            Yes, some people will sue anyway, but many just want an apology, so this should reduce the overall rate of med mal suits. Your friend should join us on this blog if her situation is medical. I bet she could add a lot to the discussion. Some patients of course want and need compensation, too, but they’re not trying to ruin anyone’s life. They just need money to recover from the harm. In my case, I don’t feel I need money because I have excellent career prospects and the financial harm I suffered was on the low-middle end.

            I think I could also help this doctor I want to talk to. I think I could help him psychologically, kind of help him recalibrate his thinking in some ways. One reason I’m so intensely interested in these issues, is there were a lot of indications that his misdiagnosis and other mistakes were actually *caused* primarily by his fear of lawsuits. He dropped some hints in conversation during those early visits, and he seemed quite jumpy and fearful even when he was being really nice. I think he has some law background and knows lots of people in it. That seems to be a very strong influence on his end. Whereas I just needed him to do his regular doctor thing. The disease i have is weird and the diagnostic process was a big intellectual exercise…about as far removed from lawyer stuff as you can get. I don’t know whether to laugh or cry, it’s so ridiculous.

          • querywoman

            The friend is on and off this site. I just shared with the friend my union rep’s bit about forgetting about an apology.
            All the apologies in the world won’t bring me back years of suffering, nor will it give the children I was not allowed to have.
            However, longevity runs in my family, and I’m getting better.
            My way of winning is through my survival and hopes that I will eventually be an activist for atopic eczema.

          • DoubtfulGuest

            Another good point. Sometimes apologies won’t fix it. The harmed patient is the best judge of that. I’m sorry for your bad experience and that is understandable. I’m glad you’re getting better. A couple of thoughts about the union rep’s statement…”forget an apology” is one of those things people say, that spreads by word of mouth and no one really looks at it critically. I’m just saying, sometimes we accept things we shouldn’t. Lawyers take advantage of this resignation. Also, I think it’s different with doctors and patients. Like it or not, it’s a very personal interaction and the betrayal of trust is chilling if we really think about it. Even when we’re not particularly attached to our doctors, we still sat there in a flimsy gown and told them about our bladder and bowel habits. None of us really know what we might be getting into when we agree to that.

          • querywoman

            Yes, a doctor-patient relationship relationship is intensely personal, and demands an apology moreso than a large company or employer settling a class action.
            Many cops who have killed in the line of duty apologize, and that includes ones who have been convicted and served criminal time.

          • querywoman

            Never forget, there aren’t many medical malpractice suits. I just read that, of the few that make it to trail, 80% are settled in the doctor’s favor.
            Politician John Edwards lost most of his cases.

          • DoubtfulGuest

            That’s a good point. I’ve read papers saying that doctors’ fears are way out of proportion to actual risk of being sued. Even when they win, it can cause a lot of problems for them, even when they’re innocent, so that’s part of it. Some say most real malpractice is settled out of court? The whole system is messed up.

          • querywoman

            Valid malpractice is usually settled out of court, eg, obvious cases like a sponge left in surgery. Most people sue because they need medical care. More equal medical care would reduce the need for that. I understand that medical malpractice can be prosecuted in Britain and Canada to a more limited extent.
            Most of us agree that a doctor who intentionally hurts or kills is criminal. Britain convicted Dr. Harold Shipman of murder. However, medical negligence lacking intent is not that simple.

          • querywoman

            Where I live, most doctors don’t take Medicaid. Texas reimbursement rates are the worst. Most doctors do take Medicare.
            See, I can be flexible. I realize that Medicaid may be more wildly accepted in the rest of the country.
            The Medicaid patients around here are well-served at the medical schools and larger hospital systems by doctors on salary who get most of their pay elsewhere.
            Decent doctors who take Medicaid limit it to a small percentage of their practices. Some of the higher paid specialty docs, like OB/gyns and surgeons do take Medicaid.
            My personal opinion of most private Medicaid doctors around here, from my welfare years, is that they are awful and do other stuff to make money. I would not use a private Medicaid doctor unless the practice were limited to a percentage.
            I also do believe that Medicare pays more reliably than private employee-related insurance, which, as I am learning here, constantly invent new ways to stall payment.
            My remedy is to hold private insurers to the letter of the law!

          • DoubtfulGuest

            Interesting perspective, thanks!…I actually don’t know that much about this. :/ I know about Medicare/Medicaid cuts because I found out they have badly affected this doctor I’m concerned about, among many others. I don’t want to get too specific, but it is extra-bad for certain procedures in certain specialties, to the point that some of these doctors may have to close their practices. I don’t think this doctor limits M or M to a percentage. I think he just lives modestly. His behavior after he made the mistakes w/ my care just doesn’t add up. Before that, he was really good and there were no indications that he was doing anything unseemly on the side. I have mostly been focused on this one situation…the overall issue is very confusing to me.

          • querywoman

            Most local doctors limit their Medicaid, not their Medicare, patients to a percentage of their practices, especially in the large urban areas.
            In Texas, they lose lots of money on Medicaid.
            However, there all kinds of ways to make money on Medicaid. Texas dental services on Medicaid are limited to children. The reiumbursment rates are awful.
            After substantial expansions in Medicaid for children, many new dental clinics serving children on Medicaid opened.
            The Medicaid dentists put braces on a ton of children. One person in Austin or somewhere was supposed to approve all braces. Of course, way too many unnecessary braces were slapped on Texas children!
            Another fun way to make money is baby root canals!

            There is no need for me to go in detail about how private Medicaid doctors exploit their patients and the government. I know lots of little numbers they do.
            Now, before I get all of my routine thumbs down, I’ll point out that these unethical Medicaid doctors are a small subgroup of Texas doctors.

          • querywoman

            DoubtfulGuest, I have also made posts stating to the effect that I know insurance companies play even dirtier games with doctors than they do patients, and even got thumbed down for that!
            Here’s the truth: nobody ever stuck private health insurance companies in charge of American health care!
            It evolved as a way to spread the risk, to help certain classes of people. Then it started being assume everyone had it, but a large percentage of the American population has never had health insurance!
            I’m not much a fan of medical malpractice insurance either! Any insurance, for that matter!
            The existence of insurance bloats car repairs excessively, too!

          • DoubtfulGuest

            I actually don’t know that much about the insurance thing, or how they got to control so much! I do agree with many of your points elsewhere, and am sometimes mystified by people’s rationale for down-voting. A few folks around here are quite trigger-happy. :(

            I’m not a fan of med mal insurance…I suspect the insurance company for this doctor I keep mentioning is one of those still stuck in the dark ages, who prohibit disclosure/apology maybe under the threat of losing the policy? I have not and will not file a claim, but I have still been treated very poorly by the doctor’s office and whoever else is behind the scenes.

          • querywoman

            DoubtfulGuest, I have known of private insurance companies stalling much longer on paying doctors than their “subscribers.” Yet, the doctors here don’t seem to like it when I point out that I know insurance companies mistreat doctors.
            Sadly, some doctors don’t seem to admit that a “lesser” person has any real knowledge of anything.I didn’t create their insurance problems. If they want and they can afford to do so, then they can refuse all insurance completely. That’s hard to do in private practice.
            Doctors aren’t the only ones who have some miseries.
            If you haven’t already done so, google, “Dr. Annette Ciotti,” to see what her very few online reviews.
            I’m sorry that my truthful statements cannot improve her morale and/or understanding. I’m more concerned with my own attitude.

          • DoubtfulGuest

            Let’s not slander anyone, okay? Five online reviews, at least two of them by the same patient? Not impressed… Happy patients are usually off enjoying their lives and rarely sit down to write reviews. She tried to tell you your remark was hurtful. Given that this blog is specifically about medicine and health care, I don’t see that doctors should have to think or talk about the morale problems of other kinds of workers. They DO have unique stressors that they are facing pretty much alone. It won’t kill us to listen to them and stop making comparisons. Just like we feel very bad when doctors say “I have this other patient with your same disease who just soldiers on and handles it sooooooo much better – why can’t you?”

            The whole direct pay vs. insurance thing confuses the heck out of me. It does seem we are between a rock and a hard place when our offers to pay cash instead are viewed as offensive, because of a weird medical culture thing that makes no sense. Doctors will need to tell us what to do about that…

          • querywoman

            I don’t want to slander anyone. Just pointing out what can be easily found.
            What’s sad is how so many of these doctors who post here personally attack anyone with an opposing view.
            It’s also sad that they don’t realizing how hurtful it is to their own cause to act like that.
            I didn’t create all of their problems, and they didn’t create all of mine.

            I can feel for some of their problems, but I want the same courtesy.

          • DoubtfulGuest

            We wouldn’t like it if someone pointed to other “evidence” on the internet about us that didn’t make a good impression. There is no way this is a representative sample of her patients and it tells us nothing useful about her.

            It can be very hard to come across the way we mean to, in a written format. Sometimes, I need to work on my tone. Maybe you could try this also, and see what kind of response you get? There are also some unreasonable downvoters on here as I keep pointing out. The comparisons are just not helpful…guaranteed to make people feel terrible. You come across very well when you’re talking about your personal experience, so more of that would be great. I really enjoy the variety of perspectives here. :)

          • querywoman

            You are polite. We don’t even know if this is that Dr. Annette. If it is, then she should realize what else is freely available on the net.
            I don’t get tacky unless someone gets tacky with me.
            Sometimes I think about going to a more patient friendly site, like some of my friends have done, but I keep getting drawn back in this one.
            Now I have some errands.

          • DoubtfulGuest

            It can be very hard, but I try not to get tacky no matter what. Sometimes I fail, but being “the big person” in a difficult situation can be such an asset in the long run. I actually took her comment to mean she *would* be interested in what you have to say but you keep saying you pay Drs. salaries, which is not really true. It comes across like snapping your fingers like they’re your servant. I am sorry you were talked to this way in a previous job. I bet it didn’t feel great. People don’t say “that does nothing to improve my understanding” unless they would like to understand you!

            There is a lot of opportunity here to make this a more patient-friendly site. Unfortunately, because we are discussing such heavy, stressful issues, everyone’s nerves are raw a lot of the time and we need to be sensitive to that. Have a nice evening. :)

          • querywoman

            As for everyone pays everyone’s salary, they do. But look at all the posts on KevinMD complaining that government expansion into health care means we are paying for someone else’s health care.
            True, but medical school grants and loans come out of tax dollars. Medical schools and other universities get tons of government money.
            The universities get richer (endowed) all the time and charge students more.
            Medicine and education used to be associated with religion, now they are both strongly associated with government.
            For some reason, public health care, like food stamps, is a love-to-hate cause.
            I don’t like spending money on NASA.
            I point out that doctors make their money off human misery. It’s true. Accept it and merge the thought into your practice mentality.
            Do the defense contractors celebrate when the US enters wars? It’s hard to believe that they don’t. Look at the scads of money they make off human destruction.

            I can look at the whole picture. Some doctors who post here don’t want to.
            A large segment of the population no longer pays income tax, other than in the cost of goods and services they buy. Many lower income people get very large Earned Income Credits, which are a kickback on their taxes, a reward for not working. They get much more back than they paid in.

          • DoubtfulGuest

            You make some good points…there are a few nastily condescending drs. on here and we can either ignore them or try to find some common ground with them. It’s just, the Drs. pay into the system to and they are patients, too. Unfortunately, there will always be sickness and suffering, the corollary to your statement is, if not for them, who will take care of the sick? Just like with your welfare work, if not for you and people like you, who would help those on welfare? It is what it is, I just think the way we talk to them about it is very important. There are a lot of external forces pushing us into adversarial relationships with our doctors. I have learned to watch out for this kind of thinking at every turn–it is so easy to fall into it. Lawyers and insurance people will be happy to take advantage! If Dr. Ciotti is still around, perhaps she could give us a bit more of her perspective? I wish there was a way to post a reply to more than one person.

          • querywoman

            This was apparently the first post Dr. C had made. I think she had been reading me awhile and then she blasted me.
            Apparently, most of the doctors who post here are practicing under an insurance system with small patient copayments, then they have to get the rest from an insurance company. This system has become their
            daily bread-and-butter, and insurance stalls constantly with new games.
            Oddly, no one ever comments when I post about the old fee for service system,
            which ended for me in December 1980. We routinely paid in full out of
            our pockets for outpatient services.
            The standard was a $200 deductible, then 80% reimbursement to the patient.
            Most doctors here would not take insurance assignment. Sometimes fees exceeded reasonable and customary charges.
            I was quite ill in the late 1980s and had to put a ton of office fees on credit cards, and that caught up with me. I paid a gynecologist $300 out of pocket for an in-office procedure. He had wanted $375. Then I had to pay an outpatient lab about $200 for blood work. The hospital did take
            my insurance for day surgery.
            He did not even come back and talk to me after the surgery before dismissing me.
            This was a preventive medicine type surgery.
            Within a month, I became ill with other problems with symptoms and had no money for doctors.
            In January 1989, my employer went to a PPO type system. I could pay $5 for
            a generalist or specialist visit, without a referral, to a preferred provider.
            That expanded my choice and the ability to easily go to another doctor. However, when I was paying only $5, the doctors felt free to run whatever lab work they could. Sometimes it’s needed; sometimes, not.
            Many doctors have exploited this system, making it very hard for the others.
            Copayments go up all the time. I am on Medicare and, after I pay my annual deductible, most doctors ask for my 20%.
            My derm is in a large clinic, and I hear what the other patients pay as copayments, on up to $50. I think, between Medicare and me, my own visits are about $80.
            Most of the employed uninsured want to go to a doctor for a low copayment. Who can blame them? I haven’t seen ACA plans that work that way.

          • DoubtfulGuest

            I have a hunch that Dr. C. is alright. I understand it’s startling to be the recipient of her first comment. I don’t think she meant to blast you. :)

            Your story is really interesting…were these in-house labs your doctors were running? Thinking in terms of 1980s money, that is quite a lot, yes. They do need to decide what would be workable for them these days and then tell us very clearly. I know I’d be willing to pay cash for most of my medical care, but then we’d need to know how much things cost so we can budget accordingly.

          • querywoman

            Yes, he owned a portion of the lab that he used. I thought that become illegal shortly after that, for a doctor to won a percentage of a lab.
            I already discussed that with someone else here, and it may still be legal.
            Ownership is a complex issue. There is a reason why the eye doctors attached to places like Walmart have a separate door outside the main building.
            Annette C didn’t upset me at all. I only tell the truth.
            And I have paid plenty out of my own pocket for health care!
            Surely there are some “mature” doctors here who practiced under the $200 deductible, 80% reimbursement system here. They never talk about it!
            They probably would not advocating to returning to that system. If a patient really needs a lot of blood work, it’s easier to do it when the patient only has to pay a copay.
            I was just talking to someone privately who likes a doc having a bunch of expensive new equipment. I don’t, but unlike her, I mostly need blood work.

          • DoubtfulGuest

            I agree that you deserve more thoughtful responses from doctors here. I for one am interested in your experiences under the old direct pay system. :) I think it’s helpful to go back and consider how and why things changed, what worked and what didn’t, when we’re trying to figure out what would work best now.

          • querywoman

            So doctors should not have to worry about how the stress in the lives of the workers and nonworkers who pay their salaries?
            I’ve had insurance costs increase many years when I was not getting a raise.
            And when I worked in welfare, I had clients tell me that they were the reason I was there.
            They were!
            I made my living off human misery!

          • DoubtfulGuest

            I think it’s better to focus on the third-party payors causing the problem. It took me awhile to see this, too, because doctors are out there, visible, in their white coats (and, apparently, with bulls-eyes on their foreheads), so it’s easy to blame them for everything. Insurance companies and lawyers are probably thrilled to keep it that way. If we want to solve problems, we need to address these behind-the-scenes people. It would help if the doctors could tell us the best way to do that, since we often don’t even know who those other people are.

          • querywoman

            I see a lot griping about the insurance companies, but I never see any alternative offered. They don’t come out and say they want patients to pay out of pocket.
            So what do these doctors want?
            The insured do pay for their insured, and their insurance companies in turn pay the doctors for a large portion of their bills.

            I say a lot of what insurance companies do is blatantly illegal and should be addressed.

            I also maintain that most of the problem starts in medical school with the massive debt.

          • DoubtfulGuest

            Good points, yes. They could do a lot better job of telling us what they want. And they’re not even a united front which makes it harder. I mean, of course they are individual people, but it makes it even harder to know what we as patients should do in any given situation. Personally, I have no trouble adjusting to the idea that doctors need groceries and toilet paper. I actually agree with them making a *comfortable* living to offset the long hours and stress. This means a decent house, regular vacations, paying for kids’ college, etc. I don’t know any doctors who live excessively. But yes, they need to tell us what the heck we are supposed to do about their weird “can’t talk about money” tradition. I understand why they feel that way, because most of them really don’t put money first….but what are we supposed to DO?

          • guest

            The fact is that you don’t really pay your doctors. You pay your insurance company, who then makes it as difficult as possible for the doctor to be paid for seeing you, meaning that the doctor has to hire additional staff in order to collect for your treatment. If you stop to think about it, you can probably see that this means that doctors are getting paid less for seeing you than they did a generation ago, since paying salary and benefits for administrative workers comes out of the pocket of a doc in private practice.

            It is true that your insurance premiums are high (as are ours, we need health insurance, too), but I think it’s a big mistake for you to believe that we see your high insurance premiums as being equivalent to you paying us for what we do for you.

            And therein lies one of the bigger problems with our healthcare system…

          • querywoman

            If you think I am not aware of the abuse that insurance companies inflict on doctors…I don’t live on Venus. I know a lot, actually probably a small bit, about insurance abuses.
            Insurance company abuse is staggering.

            I have paid plenty of doctors out of my own pocket. I have written about the heydey of fee for service in the 1980s when I repeatedly had to pull out a credit card in advance and pay large new patient bills in advance because the doctors would not bill me or accept insurance assignment.
            I last had that kind of insurance in 1988. In January1989, my then employer went to a PPO system with $5 copayments for its preferred providers. Then doctors felt free to run any and all blood work when I was only paying $5 a pop.

            I have also written that I know insurance companies pay even more games reimbursing doctors than they do patients.
            Nevertheless, doctors do not have to take insurance assignment to see patients. The ones where I live who don’t take insurance charge more than average insurance billed rates. Somehow they manage to stay in business, too.

      • rbthe4th2

        Oh my yes!!! Its ok for docs to meet me and 5 min. later, we took the previous docs’ word for it they’re crazy (without any simple investigation) but we can’t ask what basis that judgement was made on?
        Trust works BOTH ways guys. Yes, there is a difference between being wary and doing an incomplete job so badly than when the testing is done, its proved there was a problem.

    • querywoman

      Guest, I used to be a stupid lazy welfare worker with an, “attitude.” It was stressful for the clients to come in and deal with us to get their food stamps, Medicaid, and cash benefits.
      So they’d come in and “perform” for us. It usually looked like they were enjoying it, too.
      One man told me his wife didn’t like to come in the office. I didn’t know that. She talked my ear off every time I had her.

  • Nancy

    What you succinctly describe here is a future in the practice of medicine in the US very similar to that I experienced and lived with, in Africa and a couple Marxist/Socialist countries.
    It grieves me to no end to see this happening here, where many of us fled those systems to the only haven left. America is not perfect by any means and with many problems. However I know of no other country where millions clamor to move here and are willing to pay very high personal price for this privilege.

  • guest

    “DeBakey, a famous stress generator himself…”
    Doctors who deny their own stress and adopt an attitude of “if you can’t stand the heat get out of the kitchen” are typically also hard on those around them, as you observe of DeBakey, whose first wife died of a heart attack. Such doctors have an unfortunate tendency to be brusque and unempathic with their patients, and to dismiss their complaints as “stress-related.” It’s exactly that type of bedside manner that our patients are objecting too most loudly so I suggest that we listen, and think about taking better care of ourselves as southerndoc suggests.

    • querywoman

      Everything in life is stressful!

  • buzzkillerjsmith

    And yet…. Docs have the highest burnout rate of any comparably-educated group and we are in the midst of a severe and worsening shortage, especially of primary care docs. Docs are bugging out whenever they can and some have even suggested that non-physicians–patients, let’s say–have some stake in all this.

    Of course one way to approach this is to put one’s fingers in one’s ears and say, “La, la, la, I can’t hear you!” Consider yourself in generous company there, Karen.

    Another option might be for you to go to med school and residency and then come and show us how it’s done. And no complaining allowed.

  • Suzi Q 38

    Interesting, Decent point.
    There are ways of changing your stress.
    If it your career or job, maybe think about being in the same field but changing your daily routine or work in some way. This may mean getting paid less or having a concierge type of practice.
    Maybe going into teaching, which is far less lucrative but more rewarding.

  • rbthe4th2

    Karen,
    You have some excellent points. I am hoping that between your points and some of the docs, we can get a happy medium, as Doubtful has pointed out. I’ve clearly seen doctors blow things off, once one claims “mental issues”, you can expect a total lack of helping on your physical health. I had a doctor who saw a level so low it didn’t register say everything was fine and claim it was because I was crazy. So one of my points here is to get docs to understand that behavior is completely unacceptable. It is items like that that cause the rebound “sue mentality” and “govt. interference” and getting non physician involvement in “policing” the profession. Protecting each other is simply not the way to go. It undermines respect for the profession, not just the docs. While I will do all I can, when I’m informed/asked, of how I can help docs out, I expect professionalism in return.
    Randy

    • Karen Ronk

      Amen, Randy. Like everything in life, it is a question of perspective. There has to be give and take and there will always be unreasonable people and difficult situations. I grew up having almost blind respect for many “professionals”, but after the reality of life sets in, you realize that having a degree in something does not make you good at it and that respect needs to be earned. I also agree with you about good docs needing to speak out about bad ones, but of course they are always afraid of things coming around to bite them. And if some of these doctors are really that stressed out and suicidal, as some on this post have claimed, then they definitely should not be treating patients.

      • DoubtfulGuest

        That would be an awful lot of them…maybe some of your good ones now, or some of mine. They just hide it well. I agree with many of your other points, but mental illness is not this rare thing that only affects the weak. You or I might also crack under the same stress…anyone could.

        I agree we must find some way to address the behavior of individual doctors who harm us. But if we start saying people with such and such stress need to leave their profession, there will be like three left. I know my disease can’t be treated by a dermatologist in SoCal. :/

        • querywoman

          Do you have a skin disease? I have a marvelous derm in Texas. Perhaps I can find a derm he trained in Southern California.

          • DoubtfulGuest

            Oh, thank you. :) No, I don’t…it was another one of my stupid jokes…I have a weird metabolic disease that a dermatologist would have no idea how to treat. I am getting the care I need for it. I was making a silly generalization about derm often being more of a lifestyle specialty, although indeed there are many very serious skin diseases. I’m way far away from SoCal, too. I was just saying, if we ignore Drs. stress and mental illness brought on by stress, eventually there will be few Drs. left to take care of *anything*. Very thoughtful of you to ask, though. Your Texas derm sounds like a keeper!

  • querywoman

    Such tunnel vision, Annette Ciotti! If you read all my posts, you’d see I have a flexibility. I know that insurance companies abuse doctors.
    Doctors aren’t the only taxpayers and voters in America. Show me that you care about the morale of the rest of America.

    Other workers and nonworkers have morale issues.
    Doctors aren’t the only ones in America who have morale issues.
    I have worked with the poor and heard their sob stories.
    I live in an area with a lot of engineers, programmers, and another technical types. They work horrible hours, and do not have the prestige of doctors and lawyers.
    I knew one man, about 40 years old, who worked 100 hours a week for in a high tech job. He had a master’s in math, and said he worked similar to an engineer.
    One day he cracked up on the job and was taken to a psychiatric hospital, where doctors and other medical people assisted in his recovery.
    I find that those technical types don’t know much about laws, fair labor, and even voting. The work too hard and don’t have the mentality for it. He was astonished when I told him about the Americans With Disabilities Act and that he could request reasonable accomodations under that.

    His coworkers longed for a union, something “professionals” usually don’t have. He didn’t know that Worker’s Compensation laws also cover job stress, though it is hard to prove. He didn’t understand that overwork was his real problem, and that the Worker’s Comp law covers even if he’s not covered under hourly laws.
    I told him that the hospital filed his emotional hospitalization under his employment-related health insurance when it really was a Worker’s Comp complaint.
    These bleary-eyed tech professionals could do a lot more about their job conditions if they could force it in the court system!

    I’ve heard engineers talk about what their hourly wage works out on their lengthy work weeks. I’m not sure, but overtime laws may not apply to engineers and programmers, unless they supervise. I think their have been exceptions written in the law.
    Do you think about the morale of the brilliant tech people who designed your sophisticated medical equipment? Do you think about them every time you pound out a note on a computer?
    The techies seem to lack the sense of “exclusivism” that so many doctors have. With modern communication systems, the gap between the doctors and patients has started to close.
    Think what you want of the rest of us, and we’ll think what we want of you!
    If you want to work together with us and appreciate us, you’ll agree that we have our morale problems too!
    You don’t have to read me!

  • querywoman

    You need to try and improve your methods to get it all done in 3 months.
    The 3 month window is weird. Most insurance claims, at least in Texas, may be filed up 18 month after the event.
    An insurance claim for a doctor in normal practice is not like other claims, since it’s so much strongly tied to your daily income.

    • psychomd

      Just requires more and more admins to pay on my part and does not fit my practice model as a solo practitioner. THe trouble is more on their end, slowing down paying claims,so there is usually no point in calling weekly because they will repeat what they are waiting for or you get several different stories from them since they are careless.

      • querywoman

        Their stalling techniques are probably illegal. Those of you who rely on them for your bread and butter are probably too scattered and fragmented to present an organized front with arguments.

        • psychomd

          Actually do sometimes end up calling myself and confronting but there is really very little I can do. No lawyer is going to get involved for small claim stuff. Eventually they pay but it’s aggravating. and costly from a time perspective and admin.

  • DoubtfulGuest

    I don’t think of medical care in customer service terms, but I’m with you on the Golden Rule, absolutely. Even for those of us who do want to help them, they haven’t actually told us what we can do. I AM very concerned about the way medical errors are generally (not) dealt with honestly. Their own ethical codes give them a basis for how to handle things, but then they say weeeeeeeell, we have all these funny cultural and psychological things that make it hard, so, we often just don’t do what we’re supposed to! Um…that ain’t gonna work, folks. How do you even look in the mirror anymore? What I would LOVE them to explain, is how does a patient go from being someone you want to help, to someone you just throw under the bus and don’t care about at all, at the drop of a hat? What’s the point of medicine at all, then? What about the time you spent examining and talking with the patient, supposedly wanting that trust and connection and caring, blah blah blah, all down the toilet when a mistake is made? I’m obviously not smoking the right stuff because I don’t understand. Anyway, sorry to vent, I actually agree with you about quite a few things.

    • Karen Ronk

      It seems you and I have experienced the same situation when it comes to a doctor just not caring (or trying to get rid of you before their mistake is discovered). I am trying not to let that mistake change my life anymore than it has to, which is a learning process I would have been quite happy to avoid. I am with you on wondering how these doctors can behave this way with no remorse. No need to apologize for venting – I am sure, like me, the people in your life who care about you are not always able to understand how you feel.

  • DoubtfulGuest

    Hope you are having a better day, Dr. C. I’d be interested to know more about what you think of this whole mess we’re discussing. :/

  • Shirie Leng, MD

    Wes, it’s hard to hear this from you, since I know from following your writing that you love your job and are committed to your calling. If people like you are discouraged, medicine is in big trouble.

  • querywoman

    A medical doctor should be able to apply for an Income Based Repayment plans for the student loans just like anyone else. Many doctors graduate and already have children. I understand that can be hard, as you struggle to find secure work.
    Contact your financier as soon as possible if you are having trouble.
    Currently, you could stretch out repayment over 25 years, and then the loan will be forgiven you will be issued an IRS form for forgiven income.
    Obama is shortening the period to 20 years to loan forgiveness. If you get issued an IRS statement for $100,000, then you will probably owe about $10,000 tax. The IRS will work with you.

    This is just an example. It’s not an insurmountable problem.

  • querywoman

    Hmm, I could fire off a letter to my federal officials that Medicare payments to doctors go down as the cost of a federally financed education goes up!
    Most universities are sitting on fat endowments and charging their students more all the time.