A culture of contempt has led to medicine’s downfall

“Doctors are crooks.”

“They’re getting worse than lawyers.”

“I don’t go anymore. They’re just out for a buck, and they don’t really do anything for you anyway.”

“I stopped getting checkups when my old one retired. He was good, took his time. I haven’t found anyone like him since.”

“They always think they know everything … a bit too much self-importance there, without ever walking in my shoes.”

“They all say the same thing; it’s all ‘canned’ advice, and some of them don’t even realize that.”

“I just pick any name off my insurance company’s website. It really makes no difference.”

“Every time I go to the doctor, I get four or five bills or statements. Some say ‘do not pay’, and some say ‘pay this amount’. I ask my doctor, and he says he doesn’t know anything about that side of it, even though the bills have his name on them. I don’t understand why I can’t just get one bill. Are they purposely trying to confuse me, hoping I pay all of them by mistake?”

I’ve heard all of these comments in the last several months. Some of these statements were uttered bitterly by patients, some were shared in confidence by friends and family, and some came from random, mildly inebriated guests at a cocktail party I recently attended. The emotions, the frustration and misconceptions voiced, are themselves not new. And, honestly, they are occasionally well deserved. But I can’t help but feel the prevalence of these sentiments is increasing.

After one too many drinks at the aforementioned gathering, my head spinning a bit from both the alcohol and the mind-numbing small talk, I came to a conclusion. Physicians, particularly primary care physicians, are now bearing the consequences of so many misguided decisions, so many inane policies, so much discordant marketing and misinformation, that the profession’s image is taking an unprecedented beating. I know what you’re thinking — “So what else is new, Einstein? After all, this isn’t some brand new phenomenon, some new, unexpected development.” I thought the same thing.

But then I looked around the room, well-dressed guests toting drinks to and fro as they passed judgment on the many quacks and charlatans they or their family members had encountered in their lives. And it struck me that this is, in fact, new. There’s something happening to the profession, something insidious, something that’s spreading more quickly than one might assume. Namely, physicians are no longer in a position to control their own image. The way patients, our fellow citizens, feel about the profession is mostly governed by forces beyond your control. And with regard to pervasiveness and extent, it is indeed a new phenomenon.

Consider this. A tiny, almost insignificant portion of your patients’ impression of you, of physicians in general, is based on the few minutes you spend with them in your office or examination room. The rest of their impression, aside from some time in your waiting room or on your website if you have one, is formed by a diverse collection of forces that lies outside your sphere of influence. And, with the combination of more insured patients and decreasing reimbursement exerting its paradoxical influence, the time allowed for direct contact with your “customers” is decreasing rapidly.

They spend ten minutes with you, but they spend hours interacting with all of the other components that collectively comprise the current healthcare behemoth. They spend much more time watching pharmaceutical industry and malpractice attorney television commercials, arguing with their health insurance companies, waiting in line at the pharmacy, surfing medical websites of varying credibility, listening to the advice of celebrity physicians, formulating an opinion on the Affordable Care Act based on the musings of cable television pundits, empathizing with friends and family members wronged by the system. Their friends tell them they also had the flu, but their doctor is amazing, and the antibiotics he gave them patched them right up. And they often hear much worse from sources offering the illusion of legitimacy.

In most industries, a tightly controlled marketing message is critical to an enterprise’s success. The tighter the control over that message, the fewer the parties allowed to disrupt it, the easier it is to create a clear, compelling value proposition in a customer’s mind. But as physicians, particularly in today’s environment, your personality, your training and expertise, represent only a fraction of society’s collective opinion of the profession. Your message is, in fact, primarily controlled by external forces and is increasingly drowned out by industry “noise.” Your image is bad and only getting worse; it is increasingly undifferentiated, bland, and unremarkable. The profession simply does not receive or, in fairness, deserve the respect it once did.

Why? The simple answer it that healthcare is like no other industry. Nowhere else in our economy can one find another example of such great and growing separation between a “business” and its “customers.” In no other industry are there so many parties tangibly disrupting the relationship between a profession and those that seek its guidance. And we simply haven’t done enough to adjust. We haven’t allowed the profession to evolve fast enough to meet the demands of our time. We’ve allowed the government, the insurance and biopharmaceutical industries, contract research organizations, pharmacy benefit managers, hospital and health system administrators, and all of the other players in this industry to fundamentally change the profession’s image.

You provide patients a service, but they aren’t the ones that pay you. You are paid by insurance companies or other payors to whom you don’t provide a direct service, yet they have tremendous influence on what you are allowed to do for patients. Those companies, however, do not have the same fiduciary responsibility to your patients that you do. You are frequently visited by pharmaceutical sales representatives who are eager to sell you things you don’t purchase. (Interestingly, the biopharmaceutical industry does obsessively control both its message to you and the message it presents to the public, and the two are often quite contradictory.)

You increasingly prescribe and treat according to algorithms that, in most cases, you had no part in developing. And, in truth, other than a trusting glance at the “unbiased literature,” you often really can’t be sure one drug or therapeutic approach is better than the next. (Assuming that a brief analysis of a study’s results and known conflicts of interest is sufficient to untangle the intentionally complex and perplexing relationships yielding the vast majority of medical research today is simply intellectually dishonest.)

You frequently order tests, prescribe drugs, and recommend consults, but you have little control over your patients’ experience while procuring those products or services. You enforce policies that aren’t yours and operate within a system you have little say in designing or managing. You, necessarily, offer therapies patients often can’t afford. Your therapeutic decisions, which are increasingly tied to the skillfully packaged information in professional journals and databases providing only the illusion of scientific rigor, are scripted and predetermined. You are increasingly providing a commodified service that lacks a unique signature and which more mid-level practitioners are being allowed to provide. And being paid by third parties has conditioned your true “customers” to believe your services are worth little more than a twenty-dollar copayment.

Moreover, patients regularly receive multiple bills or statements in the mail, most with your name plastered all over them simply because you are the PCP or PMD of record, which reinforce the image of the “greedy, uncaring physician,” even though none of that money ends up in your pocket. “Hey, she ordered this stuff; we didn’t do it, but pay us.” Virtually every player in this crowded field uses our profession to lend credibility to their own endeavors, yet we bear the responsibility solely and silently, often having no real opportunity to dissent.

It is truly a bizarre industry composed of disparate, nonsensical policies and ludicrous interrelationships. When patients are confused or angry or hurt, you’re the scapegoat. And all of the other parties involved in healthcare, while they publicly empathize and call for change, love it. And you can’t blame them; they’re in business to make money, and they know image is crucial. If someone else is willing to take the heat, why not go with the flow?

So why am I so concerned about what patients think? Why should we care about the profession’s image? Am I saying physicians need to emulate celebrities and politicians, scrambling to hire image consultants and public relations specialists to help them develop and protect their brand? Do doctors need to be liked? After all, physicians aren’t in the “image business;” they’re in the “helping patients business.” Why should image be of any concern? Well, the answer is it’s not just about image. The perception problem is just a symptom of the disease, an easily observable one. The declining image may be little more than a metaphor, but it is a powerful one that allows us to recognize and visualize a trend – the medical profession, as we know it, is in decline; its relevance is dwindling rapidly.

The point of all this is that the distance between you and your patients has grown in the last twenty years, it continues to grow, and the rate at which that chasm is widening appears to be increasing. The ability for patients to see real value, truly differentiated, unique value, in your services is quickly diminishing. Your services are now mundane, common. You are not physicians; you are “providers”. You are not providing an invaluable service; you are providing something that others can provide equally well at a lower price. You are selling things that can be found lying around on the web or being sold on street corners.

A patient can get both advice and the flu shot from pharmacists; psychologists can now prescribe drugs in some states and more states are jumping on board. Prescription pads and the ability to legally give medical advice are being handed out at an unprecedented rate. Despite once being the central, indispensable figure in the delivery of healthcare, physician compensation represents significantly less than 10% of all healthcare expenditures in this country. Physician influence on healthcare policy, physician ownership and control of the business of medicine, are likely even more negligible in scope. And this was all made possible by one of the most successful marketing ploys ever attempted in this country — the introduction of the word “provider” by the insurance industry.

“Physician” is a unique term with real meaning; “provider” is a word without meaning, a term without history or consequence. Its introduction sought to change the psychology of healthcare, to reorganize the system, to establish a new, conveniently flatter hierarchy, and it was an astounding success. Similarly, “primary care” is a hollow phrase also imposed on the profession. “Family doctor” was a specific term, a warm one that unambiguously conveyed information about level of training, specific role, and accountability. “Primary care,” when coupled with “provider,” sought to completely eradicate that clarity and replace it with vague insinuation, professional anonymity, and an overwhelming sense of transience, a sense of “anyone can do this.”

The next ploy, the current iteration of this brilliant approach intended to reorganize the system, is to drive a wedge between you and your patients, to reach beyond the psychological and into the practical, using every legal administrative hurdle, internet connection, traditional media outlet, government agency, pharmacy, and supermarket to accomplish the task. Hey, maybe Starbucks is next – one free digital rectal exam from a trained barista with the purchase of your next latte.

Using virtually any other industry as a model, the ideal situation would be one where you see patients, and then those patients reach into their pockets and pay you, acutely aware of the value of the service just delivered. You would control as much of a patient’s experience as possible while under your care. You would have the ability to apply at least a modicum of creativity and independence, breaking free of nonsensical, biased algorithms without the fear of malpractice lawsuits. You would not be required to repeatedly pay organizations to “prove” your knowledge by passing tests with little relevance in the real clinical world. You would not be consistently forced to undergo additional training, while others are given more freedom to operate independently in the same fields with significantly less training and accountability.

No document with your name on it would find its way into a patient’s hands if it did not originate from your office. You would have legal recourse to swiftly claim fees left unpaid for failing to comply with arbitrary administrative exercises that play no role in improving patient outcomes. And you would not be forced to complete tomes of useless administrative paperwork in the first place or would, at least, be compensated for doing so. You’d possibly even have some control over what you and your specialty are called. However, none of this legitimately earned courtesy, none of this professional respect, none of this deference for your expertise currently exists.

Instead of a clear, unified message, misinformation and poor policy continue to flood the system. Patients still believe that most physicians are “rich.” Many see physicians as “greedy,” as profiting from human suffering. Many don’t even know what type of training their “provider” has, often assuming that anyone with a white coat can do the same thing, leading to the belief that there is very little room for physician autonomy in developing a unique, well-differentiated service or novel therapeutic approach.

And perhaps rightly so, since breaking free of the almighty algorithm, actually applying any of the knowledge and training in biochemistry, pharmacology, physiology, anatomy, and many other disciplines that physicians possess, is discouraged by the system in the name of a uniform, “evidence-based” approach, no matter how unscientific and biased. If you read the comments following any online articles about the profession, you will quickly find these assertions about the public’s increasingly negative opinion of physicians are accurate.

But the profession hasn’t done enough to reassert its independence and relevance in the modern marketplace. Reimbursement is declining, but medical school tuition is increasing at an unprecedented pace. Residency training, fellowship training, and board certification are all becoming either more difficult to complete, longer, or more expensive, and medical hyperspecialization is touted as necessary, an inevitable trend given the increasing complexity and pace of scientific discovery. Yet others with significantly less medical training are being allowed to do more to meet the growing demand for healthcare services.

Every new strategy is rife with contradiction; every trend diminishes the profession, limits it, and, frankly, puts patients at risk. Each new policy, whether initiated by the government or private insurance companies, every new pharmaceutical company commercial goading patients to seek the latest, equally ineffective, hot drug from you, every new guideline governing professional development or certification, every duplicitous, ineffective attempt at increasing access, only serves to add more complexity to an already tenuous relationship, to create more distance between a physician and his or her patients. Even social media and other emerging technologies, technologies that should hold great potential for the profession, are being used much more effectively by other players to further their own agendas.

I felt compelled to write this piece simply to point out that the way the system is organized and the direction in which it is headed are increasingly breeding what I refer to as a culture of contempt, contempt for the medical profession. Most of what patients find distasteful and unjust about their healthcare experiences is not your fault, yet patients attribute it to you. You bear the brunt of their frustration, despite being increasingly stripped of the ability to control your own practice, to truly be independent, to even compete in an industry you created. And every attempt at correcting the problem only seems to make it worse. Is it a conspiracy? Is it an attempt to completely eradicate the profession? I don’t think there is some master plan to accomplish that, but competing interests and ill-conceived policies are effectively accomplishing the same unfortunate result.

This culture of contempt is spreading, growing in intensity, and the results will be catastrophic. Our current direction won’t just lead to patients not liking or trusting us; it will lead to patients viewing us as insignificant and irrelevant. More importantly, while greater access to care, public health education, and the dissemination of medical information are necessary and beneficial in the right context, the propagation of the message that sound medical advice is a cheap commodity that may be procured anywhere, from the internet to the local pharmacy to the grocery store on the corner, is dangerous.

I understand these opinions may not be popular or politically correct. But the system, in my opinion, is so broken, so dysfunctional, that nothing short of completely restructuring it will do. And this article is intentionally unfocused, little more than a collection of loosely cohesive observations, to reflect precisely the lack of focus and cohesion present in our approach to medical education, professional regulation, and overall healthcare policy. My next piece in this series, however, will outline five strategies the medical profession mustimplement if it would like to remain relevant in a system that has repeatedly shown contempt for it, if it wants to survive.

For now, though, I hope you understand I am not trying to be overly dramatic or alarmist in my characterizations. And perhaps I only see this trend so clearly because I spent eleven years working in other, more traditionally operating industries before joining the profession. But the truth is that without major change I will be writing an article in a few years entitled, “How Physicians Became Clerks – The Downfall of a Once Great and Noble Profession.” Honestly, I could start writing that article today.

Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Dr. Collar, let me interject here before you write the next article, which is something I wanted to write for a long time, but restrained myself because it must be written by a physician, and preferably by lots of physicians at the same time.
    First of all, this is not contempt. It is bitterness. Whether you are willing to acknowledge it or not, the fact remains that medical doctors are the top paid professions in this country, and this includes primary care. If you think from the inside, so to speak, that “doctors are not rich”, just imagine how everybody else who never ever made it to the best paid Forbes list must be feeling about their own financial situation. By comparison, doctors are indeed rich, because the meaning of rich has changed in America.
    So when every gripe and every conversation and every “open letter to congress” begins and ends with physicians money problems, it becomes a bit more obvious why every one of those essays accomplishes the exact opposite of what it means to accomplish.

    Second, there is definitely a well organized and well financed campaign executing out there to downgrade physicians social and professional status, and with it the fees that are paid for a doctor’s labor. Once venerated professions that exist no more (and some that still exist on distant shores), went through the same process before you. I don’t recall doctors complaining when that happened to millions of Americans, and when thousands of thriving small businesses got swallowed by giant corporations.
    Guess what? It’s your turn now. Why? Because your “industry” makes up one fifth of the “economy” and there is no way these entities will allow so much money to flow down to individual persons. Your 10% is 10% too much. And your ability to control spending for patients (your proverbial pen) is unparalleled in any other industry that has been assimilated into this enormous financial engine of extraction.

    I doubt very seriously that there is much you can do at this point as a profession. As individuals, some of you may be able to continue the tradition, just like here and there you find a true family farm growing wholesome food. If you look at your young ones, by and large, all they want is a job that allows them to maintain a balanced lifestyle. The mindset has changed (not by accident either). They accept (seek) employment, shift work, and give up empowerment and control, in return for debt relief and “hassle free” job security. I don’t know how you change that.

    The America where doctors rose to preeminence was a different time and place. There is now contempt for each individual in this country, not just doctors. You need to understand that no matter how high the medical profession was raised by the people it serves, doctors are still part of the people, and as the people are being increasingly marginalized, impoverished, exploited, taken for granted, dumbded down, and pretty much robbed of the fruits of their labor, so go their doctors. Fix the former, and the latter will take care of itself.

    • John Hunt

      Please excuse the mixed metaphors, but collectivism is a contagious intellectual disease that a large number of pushers are on the street trying to force down the throats of the innocent and naive. Collectivism is waging a war on human dignity, because dignity gets in the way of acceptance of the “greater good” mentality–the mentality that is so wonderfully effective at turning citizens into servants of the politically powerful.

      End collectivism by kicking the bums from both parties out of congress and the presidency, bringing in folk who are humble and libertarian into political office, take on collectivism at the local level, recognize evidence based medicine and JCAHO and ACGME and AMA CPT codes as full evidence of the infection of collectivism. Recognize that making laws to fight obesity is just one insane component of medical collectivism groupthink

    • Luis Collar, M.D.

      First, let me say I actually agree with many of the issues you raise. I do believe this is only one part of a larger societal trend. I try, however, to limit my discourse to things with which I have direct experience (in this case, medicine and some aspects of business). But I definitely feel similar issues are present in education (e.g. the plight of teachers), for example, and other professions.

      The point of the article was not to make physician income the central issue here (though it should be part of any discussion about any profession). It was simply to point out that much of what is said or felt about individual physicians and healthcare in general, much of the frustration expressed by patients, is, in fact, related to policies or other forces that physicians do not control. Because of the way the system has been organized (which is what the culture of contempt was intended to allude to), policy is, for the most part, governed by parties with no medical training or, in many cases, any idea what it is like to be ill and navigate the very policies they create. Raising that issue in one industry does not imply that it does not exist in others.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        This is exactly right. If we draw that line between rich and everyone else, physicians are in the everyone else camp. And this is why, you cannot surgically address the physician problem, without addressing the systemic problem that is attacking the “everyone else” body.
        Trying to stay away from melodramatic narratives about small pox and metastatic cancer, if you have poison ivy spreading all over your body, you can’t just treat and cure the left foot. The sooner you realize that, the better your odds for effecting change, and the odds are microscopic.

        • Luis Collar, M.D.

          “…if you have poison ivy spreading all over your body,
          you can’t just treat and cure the left foot.”

          Agreed. Likewise, in an “outbreak” of poison ivy, the plight of each individual afflicted is worthy of discussion, along with a realization that it has a unique impact on each of them. Intellectually, discussing the unique aspects of one individual with the disease does not negate its existence in others. Indeed, epidemiologically speaking, it is often identifying its presence in one individual, studying its unique origin, course, and resolution in one person, that can help elucidate possible solutions to the larger “outbreak.”

        • Luis Collar, M.D.

          “…if you have poison ivy spreading all over your body, you can’t just treat and cure the left foot.”

          Agreed. Likewise, in an “outbreak” of poison ivy, each individual’s struggle with the disease is worthy of discussion. Intellectually, recognizing the illness in one person does not negate its existence in others. Indeed, epidemiologically speaking, it is often identifying the disease in one individual, studying its origin, course, and resolution in one person, that can help elucidate possible solutions to the larger “outbreak”.

    • buzzkillersmith

      Bitterness is a good word here. We all know that when people are unhappy with a system they hammer that part of the system that come into contact with, not the drivers of the system.

      You doubt there is much we can do as profession to change all this. Well done. Good to see you embracing the hopelessness. It is what reality requires.

      Maybe the new docs coming up will like CorpMed. People can get used to a lot.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Yeah… I’m coming around to the hopeless side of things… takes a while, but I do eventually learn from my betters…

  • Ed

    “You provide patients a service, but they aren’t the ones that pay you.”

    With all due respect, I disagree. My W-2 for 2012 shows $17388.72 in employer provided health insurance; that’s deferred compensation in my book. Add in approximately $2400 in annual premiums for a family of four and the co-pay for each visit and prescription; yes, we absolutely do pay for the services you provide!

    • Luis Collar, M.D.

      Patients do, obviously, pay for the care they receive to varying degrees (e.g. medicaid vs. private insurance vs. self-pay). But, in most cases, they don’t pay physicians directly. That was the point. They pay insurance companies or other payors who, in turn, take their cut plus expenses, and pass only part of it on to patient care. The point isn’t that patients don’t pay physicians, rather that the relationship between the two parties is different than in other industries.

      • Becky

        I appreciate my doctor. I hate to go, so I’ve already tried everything else I can to fix the problem by the time I go to the doctor. As far as the system, I don’t think it will ever get fixed. The pharmaceutical industry and the insurance companies make too much money with the the way it is currently.

        • Luis Collar, M.D.

          I agree that changing things would be exceedingly difficult given the number of deeply entrenched, competing interests involved. But a good start might be to ensure that new policies don’t further compound the problems. Thank you for your thoughtful comments.

      • querywoman

        When I had Kaiser Permanente briefly in Texas, my copays were zero and the meds were a dollar a pop. What they did and/or didn’t do to me subsequently cost other insurance companies and me at least $20,000.
        I often thought about showing my sorry @ss Kaiser family doc my pay stub and circling the premium for my health insurance.
        A contemporary American doctor chooses whether or not to take insurance. The very existence of a third party payment system has enabled the American medical profession to live significantly better financially enriched lives than their predecessors 100 years ago.
        I often write about how a third payment system corrupted the university as well, which graduates doctors who have already been raped and gouged for the cost of a medical education.
        I agree that the health insurance industry is viciously corrupt and exploits the doctors more than the patients. But we do pay for our health care. Any doctor who doesn’t like dealing with insurance can set up a direct pay practice. Not many doctors are financially stable enough to that, and continue to take insurance because it gives them a better income.
        I’m on Medicare which works very well for me. At my derm’s office, which is a large practice, I often hear patients making copayments as much as $50 per visit. The privately insured get gouged every year with higher premiums and copays.
        The medical profession should go after the insurance companies to stop their stalling techniques against payments. You won’t get much sympathy from patients.

        • Luis Collar, M.D.

          “The very existence of a third party payment system has enabled the American medical profession to live significantly better financially enriched lives than their predecessors 100 years ago.”

          I would argue the exact opposite is true.

          “I agree that the health insurance industry is viciously corrupt and exploits the doctors more than the patients.”

          I believe patients, whether they realize it or not, are even more adversely affected by insurance company policies than physicians.

          “You won’t get much sympathy from patients.”

          The article was not a call for sympathy at all. Rather, it was simply an attempt to point out that a large portion of how physicians are viewed is more a result of the policies and contradictions within the current system than their own training, practice habits, or outcomes.

          Thanks for contributing to the discussion.

          • querywoman

            Dr. Collar, I just got dismissed from the hospital after being locked up for 2 days for pneumonia. I spent 8 days in hospital for more serious pneumonia in late 2012. Not as bad this time, my care seemed good.
            That’s why I’ve been silent. I get traditional Medicare, which works well for me.
            The standard of living has risen for us all. Most of the poor now have big TV screens and expensive cell phones. That’s what’s important to them. A lot of them rent those TVs.
            When I worked in public welfare, even the poor children had lots of toys. My clients said they got them from the charities.I forget what kind of doctor you are. Will have to look it up. You’re in some subspecialty, aren’t you? So you may not even bill or charge in the same way many doctors.
            But you take a lot of interest in general med.
            I never accuse you or trying to get sympathy. Is Sapphire Equinox your blog?
            I researched you once and you seemed like a fairly young guy, too. 30s?
            I discuss with some people privately about how what we know as modern medicine is socially new,

            It’s hard to believe that most doctors before the 20th century could just bleed a person, purge ‘em, and treat pain.
            Hospitals used to be dread places where you went to die. The early 20th century brought diabetes, antibiotics.
            Morphine helped Civil War surgeons immensely. Alcohol and opium are the oldest and best drugs.
            Insurance was designed to spread the risk and reduce costs. Unfortunately, it’s become very bloated, and forced doctors, who aren’t good bureaucrats or paper pushers, into a nightmare.

            A young doctor graduates in the US already having been raped by one 3rd party system, and then, unless you get a salaried job, you are forced into dealing with insurance companies until you can save more money and get rid of some of the insurance problems.
            I don’t see people on this blog discussing the cultural/societal changes in medicine much.
            Most modern doctors get more respect than a barber/surgeon. rightfully so.
            Most people in the 1918 flu epidemic died of the pneumonia, and now we have strong antibiotics for that, which just benefited.

            I got out a few hours and am back to normal some, researching on the net. I slept very good in the night.
            I faced one problem with medical changes. I have a hospital-attached internist. She sent me to the ER from her office. Shortly before I got sent to my new, another doctor came to my room.
            I didn’t know, but he is a hospitalist, and I was put in under his name. The next morning I heard her soft sweet voice, and I was surprised. I said look at my bracelet and the name up there. She said, “That’s a mistake.”
            So maybe I’ll google you again before I nod off.

          • Luis Collar, M.D.

            Hi QW…

            First of all, I hope you’re feeling better. Glad you’re back.

            Your points are well understood. I agree the standard of living for most has improved, particularly as compared to several decades ago. But that is not the case for everyone, nor does it apply to every facet of our lives. I think much of what you are referring to (e.g. flat screens) can be attributed to technological innovation. Wages, however, have remained relatively stagnant for many Americans. Specifically, although doctors standard of living by that measure (ease of technology, etc…) has improved, I just don’t feel it can be attributed to the insurance industry. In fact, in recent years it has had the quite the opposite effect, in my opinion.

          • querywoman

            Much stronger today. Looking for the new eggless flu shot.
            If you have been practicing medicine about 15 years, I counter that I have spent a huge amount of money on medical care since about 1980.
            And insurance practice has changed dramatically over that period!
            I have been on traditional Medicare about 10 years. It works very well for me. I refuse to do Medicare managed care. I cannot have my access to dermatologists and endocrinologists restricted.
            My derm has a large clinic with several other doctors. I hear what other patients’ copays are. I’m astonished to hear $50 now.
            The panic in the medical world is pandemic!
            I’m always hearing people fearing what Obamacare will do to Medicare.
            Obamacare does not effect Medicare. Some doc on the kevinmd site was hoping that Obamacare will bring up the Medicaid reiumbursement levels.

          • Luis Collar, M.D.

            Not sure anyone can predict how the PPACA will affect different groups with any accuracy yet. But some trends are disconcerting and merit further analysis / modification.

          • querywoman

            Wages our awful in this country. In my parents’ time, some people really got raises.
            When I worked in welfare, I looked at a lot of paychecks. Raises are hard to come by these day.
            Some places like banks and insurance companies give raises.
            Walmart does, if a worker stays long enough. Then Wally World cuts the hours and the worker is still making the same amount of money.

          • Luis Collar, M.D.

            Agreed. Wages in many industries seem to have been stagnant or in decline for years. That’s a problem when cost of living continues to increase.

    • SarahJ89

      Yes Ed. I’m always insulted when people make statements that indicate an unawareness of what we pay in insurance premiums or Medicare taxes. When my insurance company pays a bill it comes out of the money I’ve paid in so no, I’m not irresponsible about making claims. More claims = higher premiums. It’s simple math, folks, and lots of people actually get the connection.

      This kind of thinking underlies silly (IMO) statements such as “If people have skin in the game they’ll use the medical system less so let’s charge those poor people a fee that’s negligible to us but may well serve as enough of a barrier as to prevent them from getting care.”

      • hawkeyemd1

        Doesn’t seem to me anyone said patients don’t pay for their care. I think the comments were more transactional in nature (like, how the money gets moved around in several steps before it makes its way to physicians). Also, when premiums go up, they don’t go up in direct proportion to the claims paid, that’s not how insurance works. If you’re in the hospital for two months, premiums may go up but not by $100,000.00 (which is probably what it costs).

        • Luis Collar, M.D.

          Precisely. Thanks for helping clarify that.

  • CouldSleepAMillionYears

    Standing ovation!

    I feel like you wrote out my thoughts. Truly excellent article. Agree, agree, agree.

    There is no one, to my knowledge, fighting for physician’s rights or our image. No one to counteract all the forces against us.

    I always wonder how did it come to be that all the rest are in charge. Why is a nurse calling me in to her office to diss me? Why is the ‘clinical director’ a Social Worker or someone with a B.A. in something or other? Why are they the bosses? How did this happen?

    Thank you very much for writing this.

    CouldSleepAMillionYears – not a provider, not a cog, not a number.

    • hawkeyemd1

      Physician’s rights? Who cares about those? lol. Great points.

      • DoubtfulGuest

        Aww…:(

        • Luis Collar, M.D.

          I suppose your reply implies that either physicians have no rights or that things that affect them are unimportant or unworthy of discussion? I don’t agree with the implication, but still respect your right to voice the opinion. Thanks for commenting.

          • DoubtfulGuest

            I guess you haven’t seen my other comments here? I meant to be supportive, sorry…

          • Luis Collar, M.D.

            There’s no need to apologize or edit your post. All points of view are welcome and necessary if we want to truly address the real issues in healthcare. If I misinterpreted the implication, I apologize.

          • DoubtfulGuest

            Okay, thanks. I meant it more as a “virtual pat on the shoulder” but not so familiar? I’m actually glad to know if it came across poorly.

    • Luis Collar, M.D.

      Thank you very much for your contribution to the discussion and your kind words. I appreciate them both.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I’m sorry if I wasn’t clear enough, but it seems that you misunderstood my comment.

  • NPPCP

    Ms. Gur-Arie has an excellent finger on the pulse of what is going on in this area. It seems this may be the first time you have read one of her posts. Stick around – there is a lot to learn. And very respectfully, the bitterness you display would make one want to recommend your family find a different career. I can promise you she is on your side. Heck, I own a private NP practice and she doesn’t even think I should be in business without a physician and here I am still speaking up for her. Re-read her post – again, she is on your side.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Thanks NPPCP. For the record, I think the time for arguing about you being in practice or not, has long passed. I wish you well :-)

    • Luis Collar, M.D.

      Even when we disagree, I always love reading Margalit’s comments…they challenge one to think about things differently, to leave one’s intellectual comfort zone. That’s precisely why I like to write, so her feedback is always welcome and appreciated. Yours too! Thanks for your comments.

  • NPPCP

    Come on kjindal – apologize for the snarky nurse comment. I can promise you misunderstand simple math at times as well. No hard feelings. That just wasn’t needed.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    This was intended to explain the *perception* of the public nowadays, and the key word was “by comparison”. The McDonald’s worker in your waiting room, thinks the 4th grade teacher sitting next to her is rich, and the teacher considers you rich. Rich is a relative term, and as Americans grow poorer, more people regard doctors as being rich, again by comparison. There really isn’t much you can do about this, since it boils down to simple math.
    You are correct that most folks don’t know much about the trials and tribulations physicians undergo in order to obtain a license to practice medicine, and while they do practice medicine. Someone needs to do a much better job with public relations….

    • docswife

      Thank you for the clarification. My apologies for the misunderstanding. This is a very sensitive topic for my family as we sacrifice time with my husband I hear so much of this “contempt” and “bitterness” from people on a daily basis. I would not wish for my husband to have chosen a different profession, as he is an incredible doctor, and that is not bias. He loves what he does, and puts so much heart into it. I just wish those receiving care would see and appreciate that prior to making blanket statements.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        No problem. If you want to know where I stand in a nutshell, read this kevinmd older post: http://www.kevinmd.com/blog/2011/03/ehr-solo-primary-care-physician.html

      • DoubtfulGuest

        docswife, I understand what you’re saying. I know of at least one specialist whose practice is struggling terribly for the last few years due to Medicaid/Medicare cuts and other factors. Having read up on this a bit, I’ve become aware that this is not unusual. I’ve also learned that physician salaries may not be so high when you break it down to hourly wages. I think it’s reasonable to expect the public to absorb factual information, instead of having the knee jerk response that all doctors are well off and stress-free.

        • docswife

          Exactly. As soon as my husband graduated from medical school I heard many people saying, “Oh you are rich now because you are a doctor.” I was shocked at how truly ignorant people were at how long it takes to actually get to the point where you start making money that is adequate to pay off the massive student loans acquired through training as most residents and fellows make an average of 50K or less per year. On top of that, we are losing physicians and less are applying for med school because every time you turn around someone is being sued for a complication that the patient signed off on as a “known complication” and they don’t want the risk. You can’t practice medicine without feeling like you have to be watchful of everything you say and do to a patient or fear being sued. This is why patients get less face time with their doctors and nurses. We have to spend hours documenting what we did rather then spending time with the patient to protect ourselves if we get audited or sued. “If you didn’t document it, you didn’t do it” my nursing school catch phrase.

          • DoubtfulGuest

            My perspective as a patient is that lawyers and administrators take advantage of us. I had a pretty serious medical error in my care, on top of which the doctor deceived me about what went wrong. Most of the harm to me came from the deception, not the original well-intentioned mistake. All I’ve wanted is to talk with this doctor. Everything I’ve learned is a result of trying to understand his side of things. This is all with no help from him or his “people”. I don’t have a lawyer. I agree that there is a huge cultural barrier, and I can only imagine what it’s like for you to deal with neighbors and casual acquaintances. It’s so disturbing how easily people say “Well, you could sue”. Or “Of course he won’t talk to you, he’s afraid you’re gonna sue ‘im”. All rational thought stops at these kinds of statements. It seems like Alice In Wonderland kind of craziness to me…this is someone I trusted with my life, personal information and physical exam, and it apparently means nothing. Mistake is made, wall goes up, and that’s it. I wonder how many other patients feel the same way — they liked their doctor but they’re angry/hurt when something goes wrong, then they defer to another authority figure (a lawyer) to try to fix it. I can tell you I’ve looked for every alternative. Tried about 20 times to get this doctor to talk to me. I still don’t have a lawyer, I just want to say how hard they make it for patients who only want an explanation, apology, and conversation about how to do better.

          • Luis Collar, M.D.

            I’m sorry to hear about your situation. When this occurs, I don’t think physicians or patients “win”. I hope you are doing well now (medically) and that you are able to resolve the issue.

          • DoubtfulGuest

            Also, given your discussion with Randy on this thread, I’d like to clarify that this doctor I’m speaking of is in private practice. Any QA/QC would come from him alone. That’s what I want anyway. He’s a grownup professional — I’d rather he handle this himself. I understand he’s probably in survival mode. All I’ve asked is for him to take about an hour out of his life to talk with me about what went wrong. Not only have I never asked for financial compensation, but I offered to pay cash for his time to talk to me. I also said, in writing, that I could wait months for the visit to make sure that other patients’ needs weren’t shoved aside. I received silence for a long time, and then finally a nasty termination letter. I have another doctor and am getting the care I need. But I thought termination letters are supposed to be for when the *patient* did something bad, not to pile on after the patient is harmed by the *doctor’s* actions. I’m still semi-new here, but I can tell you Randy has shown a lot of support and concern for doctors, more than he’s ever gotten in response. I always appreciate a balanced conversation.

          • docswife

            I understand your perspective, and I’m sorry that you were harmed and have not been rightly heard. Doctors are humans, and humans make mistakes and have misguided judgment. I’m not at all defending what was done to you, because it was inappropriate and should be handled professionally. I also know that often times people will make a judgment about a group of people and assume that all of those types of people are the same way based on a bad experience. We stereotype everyday in our society. Medicine is not an exception here. My response to Randy was to demonstrate that what you see/hear on the internet, from a friend, etc is not always the case and unless you deal first hand with these areas that your information may not be completely accurate. I am not interested in arguing with anyone as that is never productive, just simply trying to point out that everyone has their own experiences from which they gain their own viewpoints. I think it’s important that everyone discuss their feelings about their passions and the efforts that are being made to improve quality of care in medicine is a passion of mine. Hospitals do not do a good job of advertising all of the outstanding work they are doing to improve safety and quality of care, and we really should change that.

          • DoubtfulGuest

            Thank you. I don’t have a problem with anything you’re saying, in fact I appreciate your viewpoint. I just wanted you to know that Randy is another patient who’s actually trying to be an advocate for doctors. Neither he nor I have made much headway in trying to get some here to tell us how we could actually help. Sometimes doctors here are quite critical of us, and I suspect we’re bearing the brunt of some redirected frustration at the kind of patients you mention. Those who do not care to learn what it’s like for medical people. Don’t get me wrong, there have been lots of enlightening discussions and some encouraging gestures on both sides, but we keep getting stuck early on in the process. It’s frustrating. Anyway, I’m glad you’re posting and I look forward to hearing more from you. :)

          • rbthe4th2

            Agreed DG. I have listened to doctor comments, and am willing to work with them. However, I don’t find the same response, as you’ve said, in trying to help us out in areas. First and foremost is the #1 cause of med mal suits: missed, delayed, incorrect diagnoses. Getting rid of those would seem to take a big chunk out of doctor stresses. Hospitals paying for nurses and not more admin would be another area. It can’t be just help docs out, they have to reciprocate and that support is not there.

          • DoubtfulGuest

            Excellent points — it’s just that the system sets up medical professionals to make the errors, in many cases. We have to address that or we’ll keep going in circles. The time constraints, the lack of sleep, the paperwork, the misdirected reimbursement (i.e. they don’t get paid to think or to coordinate care).
            All the same, I get the impression that docs here want us to passively accept medical errors, as sort of a pressure valve on a screwed up system. That’s where I can’t agree. Explanations, apologies, and occasionally compensation (not in my case), are needed to restore our dignity and recover from injuries. If the individual patient doesn’t matter at all, then why go into medicine? What’s the point? The “deny and defend” tradition of dealing with medical errors is based on certain assumptions about patients. That we’re essentially self-absorbed, useless blobs who drain society’s resources and we don’t care what happens to other patients or to doctors or their staff. We have to do something about this and address the system problems all at the same time.

          • Luis Collar, M.D.

            More often than not, lawsuits are the result of poor communication on the part of a physician or his / her representatives. Missed / incorrect diagnoses do occur, but quite often discussing these honestly with patients can prevent a lawsuit and resolve the patient’s health issues. When there is injury to the patient, or there is inadequate communication, then the likelihood of a lawsuit does increase, though. And in the case of truly incorrect (not just a difference of professional opinion) diagnoses or negligence, those lawsuits are appropriate and not frivolous.

          • rbthe4th2

            I don’t think this website allows it, otherwise I would put up my sources for the information I have about salaries. The main one I had, I used in a post above.
            I understand that you believe there are efforts made to improve quality care. I’m pointing out, with all due respect, we don’t see the improvement. Again, google Texas Medical Boards. That is the most recent example of a medical board being taken to task (I think Cal. is having the same issue) because they are not putting efforts into improving quality of care, and where doctors were allowed to keep on operating after they really shouldn’t have been.
            I don’t see where hospitals are improving care because I myself have requested to work with at least one local hospital chain and they’ve completely shut down on the efforts. I’m not the only one that has spoken out publically about the attempts to “blacklist” patients for that, from this very same group.
            I’ve seen doctors “attack” some of the advocates for patient care. First comes to mind is Dr. Leana Wen. I can name others.
            If the efforts to make things better aren’t being advertised, my question is why? So far, again, the efforts I’ve seen have not been condusive either from the medical profession OR from hospitals, groups, etc.

          • Judgeforyourself37

            How easily this situation could have been remedied. Fifty or sixty years ago this would have been handled differently, and you and the doctor would have discussed the error and if it could have been ameliorated the doctor would have done so, if this was possible. You didn’t mention the scope of the error or how severely it affected you. In the last forty years litigiousness has escalated exponentially, to the detriment of all concerned, albeit, not the legal profession. Even thirty or more years ago, and certainly today, most RN, RTs, LPNs and other medical personnel, carry their own malpractice insurance, as we are only human and can make errors, although we try valiantly to check everything, prior to the administration of a task. Short staffing and myriads of documentation has complicated the situation. No, we do not depend on the hospital covering our malpractice insurance as if we deviated, even slightly, from protocol, we are no longer covered by the hospital. I know of one excellent RN who was literally “thrown under the bus” by the hospital as she “didn’t act quickly enough,” although the patient had been admitted on another shift and the parents kept refusing to allow the doctor to treat their child appropriately and when the child died, the parents sued the nurse assigned to that patient at the time of death, the doctor and the hospital. They won, or rather the hospital and doctor settled for an undisclosed amount, as they had as legal representation a member of their family. This excellent, and knowledgeable RN left the profession and it was a loss to the profession. I am grateful that I was never sued, I am now retired, but I advise anyone in health care to carry their own insurance, but not to necessarily broadcast the fact that they carry such insurance.
            No, not everyone sues, and not all presumed errors are errors on the part of a medical practitioner, as the above scenario shows. However, you are right, doctors, in a perfect world would discuss the error with you, but due to our litigious world they are afraid to do so. This make medicine very expensive for all, and destroys the trust between physician and patient.

          • DoubtfulGuest

            Thanks for your kind thoughts and perspective. I’m little informed as to how this messed up system affects nurses. I don’t like what happened to that RN — that’s horrible. Yes, how is it that someone always gets thrown under the bus, but attorneys come out ahead? I am glad that you were never sued. My situation is odd in that, to me, it seemed slightly below the level of harm that anyone would think about suing in the first place. So, I was pretty shocked when this doctor stonewalled me. I had some moderate financial harm from which I can probably recover on my own. Unlike others who post here, I MAY have no permanent medical injuries. The thing is, there’s no way to tell yet. I had a substantial delay in diagnosis for a progressive inborn error of metabolism. I really needed to start treatment as soon as possible. I’m getting excellent care now from other doctors, so I’m feeling about as well as anyone can with this disease. I’m still ambulatory, able to work, etc. I am afraid of what the future holds, but again, how could anyone prove that the doctor’s actions shaved years off my life? I thought all that through myself, without ever consulting an attorney. There were a series of mistakes in my care, but the first was a mix up with a referral, that snowballed into a bunch of other problems. This referral mistake was made with the best of intentions. I wouldn’t be surprised if sleep deprivation on the doctor’s end played a role. It’s SO stupid, because I really liked this doctor. When I realized he had messed up the referral, I wasn’t mad at all. I actually laughed at the absurdity of the situation. I AM angry about the mistakes he made as a result of trying to cover that up, but even that could be remedied with a sincere apology and a full explanation. This is why I feel that lawyers play a big role in stirring up conflict between doctors, nurses, and patients where there wasn’t necessarily any before. It’s really in the best interest of medical professionals to offer patients a meaningful alternative that is not adversarial. It’s my understanding that the law doesn’t trust patients to be competent to decide not to sue their doctors. I offered to sign away my right to sue and got nowhere. Why must all roads lead to an attorney’s office?

          • Luis Collar, M.D.

            Very well put…thanks for contributing.

          • Luis Collar, M.D.

            Very insightful comments. Physicians and nurses often don’t receive the support they should from hospitals when things “go wrong.” As you say, this is often not due to a true error, but rather a financial decision on the part of hospitals to mitigate losses. Thanks for contributing.

          • Luis Collar, M.D.

            Hadn’t read this comment, but I’m glad you are seeing a doctor you are more comfortable with and your medical needs are being addressed.

        • rbthe4th2

          I don’t know any one who thinks a docs life is stress free. Well off, yes, well if they don’t live in the lower or middle income areas, that should tell you something. That’s what myself as a person sees. The relative I have in medicine lives in a “rich” section. The physicians I know can have the spouse work out of the home. For the same salary, both husband/wife couples have to work in the IT industry. There is only 1 person I know not like that, and he’s one of kind. That’s not true for MD’s.

          • DoubtfulGuest

            I don’t disagree with the income trends, it’s just that I’m personally aware of specialists who are struggling. The one who I keep mentioning, and others in the same specialty that I’ve read about. In my part of the country, that 400K/yr (that people say about specialists) was probably not happening even in better times. Not even close. Sure, they probably have an okay house and a nest egg, but then we’re talking no paycheck at all for six months at a time? Who knows where they’re at with student loan payments? And working ~16 hour days? I think these individuals matter in the discussion, too. Just like patients’ diseases, there are common ones and less common ones and they’re all worth talking and caring about.

            I DO know a lot of people who assume patient care is not that hard, and they imagine doctors mostly golf and go on vacation. :/ I used to think that way long ago (*ducks and runs for cover*).

          • rbthe4th2

            I’m a bit confused. Only the surgical subspecialties would make in the $400K range in our area. Doctors are getting bonuses and pay raises in the range of 1% or more every year, while everyone at my work place has had a 2% raise one time in the last 4-5 years. No bonuses. A 1% pay raise on the $300-$400K range is a LOT more than what our 2% bonuses are. Another friend had a 10% paycut. Not true here with medical professionals.
            As for student loans, I’ve seen the pay off times from 8-20 years, depending on how the loan is structured. Its also not unusual for me to see people in the $80-90 range working 10 hours a day in my profession. So making 1/2 the salary but not 1/2 the working hours.
            We have different friends. I don’t know any one that thinks patient care is easy. I don’t think they go on vacations and play golf all the time. I’m actually one of those who complained and was for restrictions in interns working hours because I believe in work/life balance for them. I have always been critical of one doctor I know that bragged about how many patients he took care of in a specified number of hours. However, I got flak for that from the medical profession. LOL.
            Randy

          • DoubtfulGuest

            I don’t disagree with you. I’m just showing some data points at the other end of the range. I’ve been purposely vague for anonymity reasons but my understanding is that this specialty I refer to:

            1) has low overall reimbursement because it’s a “cognitive specialty”.
            2) most of their income comes from this one diagnostic procedure
            3) Medicare/Medicaid cuts have drastically decreased reimbursement especially for this one procedure over the last several years
            4) and it is getting worse
            5) this doctor I refer to (the one who misdiagnosed me) has a much higher than normal proportion of Medicare/Medicaid patients. This is his choice, as far as I know. It’s also a function of geographical area and the diseases he treats.

            I don’t know all the math, but M/M pay 20-odd cents on the dollar for this procedure. Then there’s staff pay, electric bill, all the overhead. Whatever’s left over goes to the doctor’s income. For months at a time, this may be zero.

            I’ve just been trying to make the point that it is in fact possible in our current healthcare climate for a doctor to be kind of poor, for reasons not their fault. This doctor, even though he won’t talk to me, kindly put some of this financial information in a public sphere and I found it. I only know what he’s chosen to make public, but it’s pretty shocking. I did some background reading, with professional organization websites and such, and found that many other [insert type of specialists here] are having the same problems. Some have had to close their practices. Others are on the brink of doing so. It’s really bad.

        • Luis Collar, M.D.

          Well said…thanks for your comments. They are appreciated.

          • DoubtfulGuest

            Thanks for your kind words, I just saw all your other responses. I sometimes go on too long, but with too few characters, one’s intended meaning is lost. Have to work on that…

          • Luis Collar, M.D.

            Again, I enjoyed reading your comments so there’s no need to explain. When we communicate in writing, our intended meaning is often lost or misinterpreted. (That’s part of the trouble with text messaging, for example.)

  • rbthe4th2

    Hey docswife,

    I can think of a lot of doctor-doctor couples who are pulling down about $500K a year or more. Google mortarboards to millionaires and look at mdsalaries, its a .com website. 30% of kids in medical school are from medical families. None of them live in the middle class neighborhood we do. How many of those doctor/doctor couples can make a good dent in that $200K education loans?

    I can think of an engineer (my cousin and best car buddy) and at the most they make/made $70K a year. I have a slew of IT people who make less than $90K a year. The only ones above $90 are in management and have been around 20 years or more.

    Those IT people? They have worked shifts the same way at times. I am in IT and I’ve done 3 day stints before, sleeping in a cot or a chair. A buddy did 4 days by bringing in their sleeping bag. Again, at the time this happened, these people were making $50K range or so. As for working holidays, computers are a 24/7/365 business. I had to fix a job on New Years Day so I didn’t party the night before. I missed out on a scheduled vacation day at Christmas because of a network upgrade I needed to be present for.

    State Medical Boards and JCAHO have been known as “jokes”. I can provide a number of links that show that state boards allowed doctors to practice even though they had issues. The word is out that JCAHO is the same way.

    When it comes to complaining, maybe we need to be on the same webpages. I see a lot of complaints about patients, the work load, regulations, lowered salaries/reimbursements, etc. I don’t see that many doctors (this site has about the most I’ve seen) are willing to talk about patient safety and missed/delayed/incorrect diagnoses and how to fix that problem.

    As for insurance, I’ve got stats that hospital docs have it paid for them. I think if you look, its the lawyers and insurers who make out, because the stats I have is that patients aren’t seeing the money.

    Randy

    • docswife

      Randy, Do you work intimately with accrediting bodies? If no, then I would not be so bold as to say that these accrediting organizations are jokes. I work in quality in a large institution and we start preparing a year in advance to have documentation aligned, run practice surveys, educate staff, etc for Joint Commission. There is a very realistic expectation that a hospital can and will be shut down temporarily, if not permanently, if they do not meet “standards.”

      I could name a few non-doctor-doctor couples that are making well over what most of my physician friends/coworkers make. I bet you could identify many in your IT profession as well. To say that you know some, does not mean that is the standard. And just for clarification, we are not a doctor-doctor couple. I am a nurse, my husband was a BSN graduate and went on to medical school. We put ourselves through college through hard work and dedication working 3 jobs at times to pay the bills and school loans, so do not assume that those med students you speak of are coming primarily from middle class families that are paying everything for them. We came from middle class families that didn’t put a dime towards our education. Regardless, this was not my point in my initial post. The public views physicians as “rolling in the dough” and does not take into account what they put into a days work. You speak of sleeping at work for 4 days, doing the “same thing at times.” At times, is key here. Most hospital based physicians spend an average of 80 hours per week in the hospital. This does not account for the time they are catching up charts at home, consulting with patients and other providers on their phone on their “time off.” So your “at times” is their “most times.”

      Malpractice insurance MAY be paid for by a group that a physician practices with, but that is not always guaranteed. How many people have you killed by making a mistake on the computer? People die everyday because of errors in the hospital. Being any kind of a medical provider (nurse, NP, MD, RT, etc) comes with a huge risk that we do not take lightly and should be rightly compensated for.

      As for discussing the many broken practices in medicine, “patient safety and missed/delayed/incorrect diagnoses and how to fix that problem” you clearly do not have an understanding of what is going on in a medical setting. I could list about 15 different projects that I am involved with, each of which has multiple physicians that are participating or leading to improve patient safety and quality. Mistakes are reviewed as soon as they happen to prevent reoccurrence. No medical provider is perfect and goes their career without making a mistake, but to say they are not doing anything to improve care is just not accurate. I voiced my opinion initially on this board because I had the time with my job where I make an honest wage working a typical 9-5 workday, while my husband was sleeping after working night shift, trying to be his advocate. He does not spend his time defending his plight on webpages as I would assume most docs do not because they are busy providing patient care or recovering from a long shift and need to rest so they can go back to work and provide safe patient care.

      • DrTWillett

        I have an MD, a PhD, and even with the ‘subsidized’ training carried $90k in debt out of the ivory towers. My husband is in IT, with a bachelor’s degree, but a lot of confidence. He will ALWAYS make more than I do as a pediatrician. He is more offended than I am at the injustice, since his errors may delay product launch, while my errors can harm children and/or get me sued. Actually, I can be sued without making any errors. So the income is indeed only a small piece of the imbalance puzzle.

        • hawkeyemd1

          Amen!

        • Luis Collar, M.D.

          Great point. Thanks for contributing.

      • rbthe4th2

        DG made a comment, and he’s right: “Randy has shown a lot of support and concern for doctors, more than he’s ever gotten in response.” I believe in working together, but given the response I’ve gotten from most (not all) docs (I would hazard a strong guess docswife, that you are not in that genre), its not working. I’ve seen it happen on other lists, to the point that docs will even say they don’t want to discuss errors but are willing to complain about patients, workloads, pay, hours, etc. We all know docs aren’t perfect, and would be nice if they were? Yes. Not every mistake needs a lawsuit. They do need education, and there are many patients who are willing to partner. Doctors aren’t. That is a major area where contempt comes in.

        Contempt also comes in when honest complaints or even suggestions are met with negatives on the side of the medical profession and admins. Even after saying we’re not looking to sue but for improvements in the process or in this group, for the patients. Once you are stonewalled on that, people do have contempt and the lack of credibility goes down.

        No, I don’t. I have several friends that do and a relative who works at a “name/famous” institution. I know of a number of patients who have complained to JCAHO and saw nothing change. There is a similar “body” to JCAHO for a few of my friends in accounting/finance, and they spend a lot of time doing documentation, same as JCAHO. From what I understand, most they get is a fine/hand slap, and keep on working. In the IT profession, you can be out of a job and a career for the same level of mistake.

        That being said: how many complaints does JCAHO receive from patients and how many have actions taken on them? How many hospitals has JCAHO shut down? If a person dies or is harmed, is it only a fine and the hospital and/or doctor keep on practicing? Same for the medical state boards? Recently Texas Medical State Board has been in the news for allowing doctors to operate, move to other hospitals, without action taken. Look up Charles Cullen, allowed to keep on killing patients at various institutions for years while Risk Management blocked/stymied efforts to stop him. There are lobbying efforts for tort reform that does more to hurt patients than doctors.

        I had a complaint about a nurse who gave me the wrong amount of medication and requested that she give me the rest of the dose. She had given me too little. I was literally chewed out and heard a doctor come to her after I walked out of the exam room saying, ‘You can’t treat a patient like that’. Was anything done to her? Nope, she’s still practicing. Admin didn’t even want to listen to my story.

        As for salary, again, I don’t think its permissible to list the links here on the website, but people don’t go into medicine without taking a look at the money to be made. Someone coming out of residency can start at more than $125 a year in PCP, higher salaries for specialists/subspecialists. That’s not possible for any one in IT, finance, etc. and even management doesn’t make that sort of dough in their late 20′s. I’m not referring to New York City or other major areas, I’m talking places like Cincinnati, Charleston, etc. Also, the surgeons I know in the area leave work before the nurses do, right after the clerical people go (and sometimes before). Those same surgeons get a $1K bonus for doing on call and they get either the day off or a half day in the office. We don’t.

        As for $50′s in residency yes that is true. They make that in this area. That is equivalent to what IT makes in this area. Once residency is done, you go to over $100K. That doesn’t happen in the IT world. I use IT because that is what I’m in and that is a money maker. CEO’s are not getting that sort of money right with a BS but go the MBA route to make that sort of money.

        Have you seen what happens when you “IT” mess with people’s finances? I can assure you, the upset that comes with that is not pretty. It can be very devastating, just as much when a missed/delayed/incorrect diagnosis happens. It can leave lasting damage to their ability to get a job, get a security clearance, and things of that nature.

        Actually a lot of us know about the time and effort taken for MD’s since we hear a lot about it. If doctors didn’t want to do it, then go into another profession. How many docs end up in the millionaires categories vs. how many of us IT people do? Finance? Etc.

        As for med school applications, all the data we have is that they are opening more medical schools and there are more applications for medicine than there have been in previous years. The same hasn’t been true for Americans in IT.

        Again, it boils down to the fact that a number of times I have suggested a patient/medical approach to errors that would work with both sides, and no one on the medical side (whether it be a single entity, this website, other AMA level orgs, hospitals, medical boards) has been willing to work on that level.

        Randy

        • Luis Collar, M.D.

          Your experiences with physician reluctance to recognize or admit to medical errors is truly unfortunate. Most of the physicians I know do not fall into that category. If a real mistake (not a legal maneuver / insurance company policy / scientifically invalid interpretation for administrative expedience) takes place, most physicians I know just admit it and move on. I do recognize this is not the case with all, but my own experience tells me the majority of physicians are trying do their best and are generally honest with patients. Your point is well taken, though, and definitely something the profession should be sensitive to avoiding.

    • hawkeyemd1

      Not sure anyone is questioning how hard others work. Seems like they were trying to point out that doctors work hard, the education is extremely long, and the compensation isn’t as high as many think it is. I have two friends in IT (one is a director at a biomed company and the other a VP for a large bank. Both could buy and sell me three times over. I do understand your point, though.

      • Luis Collar, M.D.

        Thanks for your comments. You are correct that the focus here was not to complain about physician compensation. It was simply an accurate representation of the truth: that much of what physicians are “blamed” for is, in fact, beyond their control.

    • Luis Collar, M.D.

      Thanks for contributing to the discussion. The article simply sought to make the point that, in many instances, a physician’s image suffers for things that are beyond his / her control. This is primarily due to the way our healthcare system is organized. Obviously, in isolated cases, physicians’ image may suffer for good reason. But this is true in any career (there are some unethical people in all of them).

      Although physician compensation was not at all the focus of this piece, I will make one comment. Because I worked in other fields (finance and IT) for over a decade before going to medical school, I can tell you that (at least in and near major cities), there are many people working in those fields that make significantly more than primary care physicians (I was one of them). And the hours I worked (as much as I liked to think they did back then) did not come close to the hours I worked in residency.

      Again, though, the focus was not on money or hours worked, but rather the disconnect between what physicians actually control and what people feel they control in our healthcare system.

    • Rita Chobanian Swisher

      Randy- let me start by saying that I fully believe what you’re saying, and let me propose that your situation is specific to the southern states. There is a VAST difference in requirements/level of accountability for professionals of ALL types between northern and southern states, generally speaking. My husband, practicing in northeast Ohio, is treated like an indentured slave and with entitled sneering and little respect (as all doctors in primary care are in this geographic area). When my great aunt used to have encounters with physicians in the south, you would think she was having appointments to talk to God Himself. Mistakes abounded, patients were blown off, and even people in the waiting rooms trembled from being chewed out by the receptionists! This is only slightly exaggerated… but yes, there are pockets of the country where your observations are quite relevant.

      • Luis Collar, M.D.

        Very true. Though many of these healthcare issues are universal, there are many geographical differences in how physicians are perceived. I think the overall direction is one that doesn’t bode well for the profession, though. Thanks for the thoughtful insights.

  • DSAiANP91870

    The US health care system as a whole is a national disgrace.

    Yes, there are pockets of excellence but there are also swaths of glaring incompetence. For every anecdote of a life-saving or pain-eliminating procedure there is another of malpractice and utter indifference.

    Unlike other industries, however, health care gets paid outrageous sums of money even if it kills its customer. Health care can bankrupt you, ruin your life, destroy your family, maim you or even kill you.

    Is there any other industry that sends its customers an unreadable bill for, say, $10,000 and then reduces it and rewrites it and settles for $2,000 without ever explaining what the charges are for? Have you read the bills? They are laughable if they were not so large.

    We are the laughing stock of the rest of the world. Other countries shake their collective heads at how stupid and pathetic Americans are to put up with this mess. We can no longer say that we have the best of anything, we are just limping along until we simply implode from the weight of all this greed.

    • PoliticallyIncorrectMD

      I think the point of the article is that, like patients, physicians are cogs (though better payed ones) in the big game played by the hospitals, pharma, insurance companies and politicians. When patients are told that doctors are greedy and incompetent, and doctors are told that patients are ignorant, lazy and non compliant the war starts that destructs the attention form the real enemy – the CorpMed.

      • DoubtfulGuest

        Agree. Any ideas about what we can do? I hate to keep asking this — it’s just that patients aren’t allowed to see much of what goes on, so it’s easy for us to mess up when we try to fix anything. I know…I stepped in it several times with previous doctors, making me ignorant, lazy, and non compliant in their eyes.

      • Luis Collar, M.D.

        Very good points.

    • Luis Collar, M.D.

      “For every anecdote of a life-saving or pain-eliminating procedure there is another of malpractice and utter indifference.”

      I respect your opinion, but the implied ratio here is inaccurate. The assertion that for every patient a physician helps, he or she hurts another is simply false. Mistakes and indifference do exist, but by no means occur in a 1:1 ratio.

      Thanks for the comments.

  • Bob

    First some perspective: Physicians, Nurses, Pharmacist and Elementary Teachers are, and have been for some time the most respected professionals in America, but certainly not the best paid, by far; while they are required to or tend to spend the most years and money to obtain and maintain their skills.
    As to the medicine they prescribe, most of it is now generic, except for the biologicals that TV ads constantly promote, verbalizing as is required all those warnings that appear with BLACK BOXES around them on their written information required by the FDA and aren’t seen when patients are infused in doctors offices. These are twice the price here and end up costing tens of thousands of dollars a year, but are rarely seen at PCP offices and aren’t dispensed in pharmacies.
    What is dispensed in pharmacies now are mainly generic that pharmacist nor doctors know where they are made, in fact neither does the FDA or State Boards of Pharmacy, since nobody asks. If they did and tracked the manufacturers back to their manufacturing sites they would find, many are in India and China and GAO reports few can be verified as being inspected by the FDA, as they all have the same generic name. Will anyone ask the simple questions?

  • Karen Ronk

    I think you can make an analogy to the availability of medical information from sources other than doctors to the translation of the Bible into English.

    When the mystery is broken down and examined, there will be questions about the validity of the people and the practices behind the mystery. That is not to diminish the years of education and hard work that those in the medical profession dedicate to their craft, but I do think it puts more pressure on you to get it right. Whether that is fair or not, it is the world we live in now.

    Somewhere in your rather lengthy (but worth reading) piece, you talked about “guidance”. That is the simple thing that most patients are looking for when they go to a doctor. Not perfection or answers to questions that are not answerable, but just guidance. I think that patients and doctors need to work together to get back to a place where that interaction can happen.

    • Luis Collar, M.D.

      “I think that patients and doctors need to work together to get back to a place where that interaction can happen.”

      Very well said. I believe the more we do to limit the number of unnecessary parties present between patients and physicians the better.

      Thanks for the thoughtful comments.

  • Sharon

    As a nurse on the sidelines, observing the changes in this profession over the years, I would have to say some excellent points have been brought up in this article. I’m sure you speak for many, Luis.

    • Luis Collar, M.D.

      Thank you very much for the comments and kind words. I really appreciate it.

  • rbthe4th2

    BINGO! I find no other profession that “hides” mistakes like the medical profession. That “blacklists” or has millions of dollars to lobby for efforts for “tort reform” that hurts patients.

    • querywoman

      They hide mistakes because there has never been an effective enforcement system.
      Any system that is heavily government subsidized follows the same general US complaint system.
      The government has not taken proper enforcement action against the medical profession in the past. That is changing.
      Parkland Hospital in Dallas has been disciplined for not providing a written answer to a complaint made in the hospital as per Medicare regulations.

  • MannyHMo

    It’s a business. There one thing that the U.S. health care system has that other developed countries don’t have – SHAREHOLDERS ! Read the book “The Healing of America” by T.R. Reid.

    • SherryH

      Yes it is a business. And as a business they have a right to make a profit. They do not, and should not, have the right to gouge people. Nor should they have the right to keep keep prices invisible. No other industry is allowed such a thing.

      • MannyHMo

        Lots of people undergo a lot of treatment who die ultimately but has to declare bankruptcy. No other developed country has this kind of phenomenon before death wherein hemorrhages happen on both sides – the body and the pocketbook.
        My wife had a lot of treatment. I found out that the hospital is billing us for treatment that Medicare actually covered. Watch out for that ! I totally agree with you that bills should be itemized, clear, and transparent (disclosed totally).
        I have the advantage of being a retired MD and the thought that elderly Mr. Joe Public has to deal with these bills devoid of doubt would just pay and pay so as not to be a trouble to hospital that entrusted his life to.

        • Luis Collar, M.D.

          As I alluded to in my piece, those practices do a disservice to patients and contribute to the declining image of the profession, despite physicians often having little say as to what gets billed, how the information is presented, or how the money is collected. You are quite correct in advising patients to carefully review their hospital bills.

          Thanks for the thoughtful comments.

        • querywoman

          Bankruptcy usually isn’t even necessary for medical bills. People get scared and file.
          That depends on your state though.
          Texas is the best state for deadbeats on money. They can’t get our homes.
          In Texas, paychecks may be garnished for 3 reasons: child support, income tax, and student loans.
          Not surprisingly, child support is the most important debt.

  • Dorothygreen

    Dr. Collar: I see that physicians are taking the heat for a lot of the problems in health care, when it is really is a much larger problem than just physicians. However, there is a reason for this.

    It is unique to the US. You won’t find other countries spending all this time discussing health care or health care costs at cocktail parties or elsewhere. A few pundits here and there, a grumble about this or that, not making enough, even an occasional protest, but nothing like the US. And the
    populations of other countries respect their physicians where prices are transparent, costs are affordable, no one is left out.

    Their systems maybe run by the government (single payer) or like in Switzerland where the government sets the parameters for prices or has negotiations with players. Insurance does all the administration. But there are regulations, price control. The US will never have a health care system without them and until we do all the players (except physicians) will continue as corporations to play medical industry monopoly.

    To understand how this all came about you have to go back,
    way back pre 1965. Read Paul Starr’s The Transformation of American Medicine – the rise of a sovereign profession and
    the making of a vast industry 1984. This is the history. There is no account comparable to truly understand how the AMA prevented universal health care from becoming part of the American culture. It is they who invented the term “socialized
    medicine” as a scare tactic akin to “reefer madness” to scare folks about the dangers of marijuana. It was not because they thought folks would receive poorer care in a universal health care system but rather that they could not achieve the status and monetary compensation they thought due them. Enter Medicare. A terrible compromise under a democratic
    administration and Congress. A compromise that gave physicians and hospitals the ability to determine prices
    and lengths of stay – so scared they were the AMA would boycott their accomplishment. As it turned out, it was a bonanza – status and financial compensation for the taking. It was milked and some milking continues to this day (McAllen, Tx is a most documented recent account). When the government (uh hum! Representatives of we the people), try to put some regulations in place they get beat up. That is continuing to happen. Do you really believe the free
    market will make health care affordable?

    All the other players are really corporations who have
    benefited from your original physician organization’s stand on not having a universal health care system with government regulation. Now, it has all come back to bite you in the
    form of “bitterness” from patients (we the people). Maybe it is time to join a physician organization that cares about we the people. Seems there are a few out there. You probably
    wouldn’t be invited to a lot of cocktail parties but I guarantee you will have a lot more respect from a lot of people.

    • Luis Collar, M.D.

      interesting point of view. I agree that many professional organizations do a poor job of effectively representing the interests of their constituents. Thanks for contributing to the discussion.

  • Rob Burnside

    A strong piece of writing, with many valuable comments. There’s little I can add except an observation that we’ve endured a nasty recession and years of foreign conflict. These things color the national mood and indirectly affect our perception of everything else. Instead of working together to improve our lot, we argue and lay blame. More than ever now, we need to begin to restore faith–in ourselves, in each other, and in the future. Faith rearranges many mountains in the path we cannot remove. We succeed–or we fail–together. I prefer to believe we’ll succeed, and I hope you do as well.

    • Luis Collar, M.D.

      Thank you for the eloquent and thoughtful comments. I hope we succeed as well.

  • sparkee

    Get the government out of the health industry and let the free market do the rest!

    • SherryH

      The free market approach cannot work without prices. Until costs are transparent, there is no real choice or free market.

      • Luis Collar, M.D.

        Thanks for commenting. I don’t disagree, though the opposite assertion is also true. Specifically, until true market forces (not third-party payment / govt intervention) are allowed to act unobstructed, there can be no real prices set. We’ve let the system become so unnecessarily complex that moving in either direction too quickly will have significant repercussions.

    • hawkeyemd1

      Unfortunately, I don’t think most people realize the truth in that.

    • Luis Collar, M.D.

      I agree that free market principles, with government oversight, not intervention, to prevent abuses, are what is needed. Thanks for contributing.

  • DSAiANP91870

    Unfortunately, there are no easily accessible reliable resources with sufficient data for the customer to make a rational decision.

    When you see someone for 15 minutes once a year for a checkup, how do you make a decision about competence and trustworthiness? I suspect most of the decisions about a practice are based on the decor of the waiting room and the pleasantness of the receptionists.

    As for politics that is absolutely correct. Vote in those who will vote for single payer before we are completely run over by conglomerates.

    • Luis Collar, M.D.

      “Unfortunately, there are no easily accessible reliable resources with sufficient data for the customer to make a rational decision.”

      Great point. That’s part of what I was trying to say with patients only being able to rely on a short visit to draw significant conclusions about a particular physician or the profession in general. The rest of their opinion is formed by many other things, most of which are not under the physician’s control.

  • DSAiANP91870

    There is lots of discussion about the pillaging (pummeling?) done by insurance companies. Insurance companies are banks aka financial intermediaries. Would you want Citibank or Lehman in charge of your family’s health? Neither would I, let us go to single payer.

    Aside from eliminating the private insurance company, the other reason for single payer is the changing landscape of pillaging and pummeling (financial) and who is doing it. Only single payer is big enough to take on this:

    http://www.nytimes.com/2013/12/03/health/as-hospital-costs-soar-single-stitch-tops-500.html

    We pay double or more than people in other countries and our results are the same or worse. We should be appalled at how poorly our hard-earned dollars are being spent.

    We should feel ashamed that people in other countries are frightened of our system and pity us. Maybe if we feel ashamed enough, we will do something about it. Write your representative and lobby to lower the age of eligibility for Medicare to 0.

    • Luis Collar, M.D.

      Interesting article…thanks for sharing it.

  • Suzi Q 38

    Thank you for your honesty, doctor.
    I had a couple of bad ones, so I told one off and got rid of both of them.
    Patients are human. Treat us the way you would like to be treated.

  • DoubtfulGuest

    I sometimes think I need my head examined, but I’m a patient and I’d actually support tort reform to some extent. It’s my understanding that what doctors are pushing for hardest would be caps on non-economic damages (i.e. punitive damages). In our current system real malpractice is rarely compensated appropriately, if at all. I’d prefer to be taken care of by a doctor who does a good job for the sake of doing a good job, and because my life is worth something. Not because s/he lives in constant terror of being sued. Fear is a poor motivator long-term anyway. It’s one thing to yell at kids to keep them from running out in front of cars, but how many of us could perform well at work under a constant threat? It’s not even proportional to their actual mistakes…they can be sued and reported to the NPDB after one innocent mistake or even no mistake at all. Also, what makes us think that doctors and their insurers are on the same side?!?! I’m almost certain that med mal insurance companies just pass settlement costs on to doctors in the form of higher premiums. Their attorneys are happy to get billable hours to defend cases. They want to protect themselves, not doctors.

    • DSAiANP91870

      IIRC the chances of a doctor getting sued has much to do with their bed side manner. Treat customers (patients) rudely and arrogantly and they are more likely to sue.

      I do not think it is that easy to sue and win against a health care provider. That is a myth. There is nothing like being the injured individual crushed between a couple of corporations.

      http://www.nytimes.com/2013/01/25/us/even-with-counsel-texas-amputee-is-hindered-by-state-tort-laws.html

      Reducing the consequences of bad behavior does not reduce bad behavior. What would happen if there were laws against any malpractice claims? Would that reduce the incidence of malpractice?

      If there is a cap on medical malpractice, why should the health care profession be so blessed? Why not make all malpractice across all professions and industries capped at a low number?

      Why should a doctor get financial protection while a car manufacturer does not?

      • DoubtfulGuest

        All good arguments. I do not agree with what happened to that lady. With your first point, agree completely. Stonewalling when mistakes are made has also been shown to increase chances a patient will file suit. I think attorneys know this which is why they push doctors not to talk.

        As far as being easy or not, to sue and win, you’re right that people who should get compensation often lose cases. I can’t help but view this issue through the lens of my own experience, which I’m aware hardly covers all the bases. I’ve never talked to a lawyer about my own case, but one of my other doctors blurted out that I could sue easily and win, on a technicality for sure and possibly for the delayed diagnosis itself. The reason? Sigh…they changed my records. This was *probably* a well-intentioned effort to correct some typos, but they failed to document it properly. It feels weird to be in this position, because from day one I picked up on signs that this doctor was terrified and that’s likely the main reason he made mistakes in the first place. I’m not going to sue him, for the same reason I don’t kick puppies…A car manufacturer is a company, the risk is spread out. I didn’t mean that there should be no accountability in medicine — for the most part I agree with you. I just think about this other stuff as well.

    • Luis Collar, M.D.

      Again, very good points.

  • RocK8Doc

    Taking money out of the equation will solve nothing as money is one of the many factors and is not a significant determinant.

    The significant determinants are all those factors that acts as barriers to establish a “Connection” between patients and their physicians.

  • hawkeyemd1

    Couldn’t agree with you more… Great points, but most people won’t understand just how right you are.

    • Luis Collar, M.D.

      This is why physicians need to do a much better job of elucidating the challenges they face in caring for patients. From a public relations perspective, the public needs to understand that much of what they dislike about the system is due to the layers of administration, bureaucracy, and politics that increasingly make it more difficult for physicians to deliver quality care.

  • hawkeyemd1

    We definitely have a lot of “glitches.” lol

  • hawkeyemd1

    How could money be taken out of the equation?

  • hawkeyemd1

    Physicians don’t control much of anything anymore. I don’t think the majority of the public understands that. And you’re right that most mistakenly still think we’re all rich. Great post!

    • Luis Collar, M.D.

      Thanks for the feedback. I appreciate it.

    • querywoman

      I don’t consider most doctors as rich. Most of them have a reasonably high income, but work hard to earn it.

  • hawkeyemd1

    Great point. That’s just another example of how not “rich” most physicians are. Most people on boards are the real “rich,” but most don’t understand that. If physicians were that rich, they’d be on every board.

  • hawkeyemd1

    Great point. Amen.

  • hawkeyemd1

    Nothing better than a good “doctor bashing” story to draw media attention and dollars.

    • Luis Collar, M.D.

      That, unfortunately, is often very true.

  • anne vinsel

    Although I work in health care, I am speaking now as a patient. The only person I have ever heard tell a group of MDs something like this is Anna Deveare Smith (Nurse Jackie actress/playwright/NYU professor and MacArthur award winner, my kind of speaker!). And because I knew most of the audience and I could see their faces, I could see they weren’t hearing her. So, one more try from someone with no credentials other than being in my late 50s with some genetically based problems and normal aging.

    Your (MDs’) big problem is that there is no longer any incentive to go to a physician. If I feel miserable and manage to get an appointment before my “flu-like” symptoms are gone, it’s likely to be anywhere between 35$ (copay, never optional) and $100 (visit co-pay plus lab co-pay plus over the counter meds). You don’t have anything for flu-like viruses, you tell me that in two minutes, bang, i’m out of pocket 35$-100+$ plus lost wages/sick day to get to you. In the event I have a strep throat it’s a race between getting the (100$) labs back and the thing just going away on its own. I might get antibiotics then, another 5$-more like 70$ depending on my drug plan, if any). Allergies? You might be slightly useful for prescribing prescription meds, which will cost me less than the over the counter version if I have drug coverage. Hypertension, cholesterol, and other initially asymptomatic conditions. I didn’t feel anything when I came in, I”m out of pocket a lot for labs, visits, meds, and if I’m lucky I don’t feel anything when I’m on them. If I’m unlucky, I have nasty side effects, and cascading other problems (GI, skin, etc.) from the meds themselves. So I feel worse and again am out of pocket a bunch of money. Generally speaking, primary care is expensive, I don’t feel better, and I’m lucky to get out of it without getting broke or feeling worse. It’s a gateway, though, and if I actually do need meds I have to get them through you. In the meantime, I’m lucky to avoid inappropriate and annoying nagging in the guise of education. It still gives me the creeps that my PCP can’t remember that I had my PAP removed decades ago (including the cervix) and always tries to charge me for a PAP smear even though the actual MD and I laugh about it and skip it. Gee, why would I think you’re just out for money? How about very little face time w/the MD, insane billing practices that take hours to “resolve”, and imaginary actions and procedures? I have very good insurance at a large academic medical center. I shudder to imagine what bad insurance is like. And then the 100$ for two minutes with the PCP who refers me to a specialist. You get the idea. There’s nothing in it for us. You all have a real problem.

    Surgery is an exception. Something actually happens that hopefully will improve matters if I don’t get PTSD from standard inpatient care.

    Um, people, it is contempt and bitterness, both. Deserved.

    • PoliticallyIncorrectMD

      “Your (MDs’) big problem is that there is no longer any incentive to go to a physician.” So why exactly one has to wait weeks before being able to see their PCP ( who is, by the way, is forced to see a patient every 10 minutes)?

  • Luis Collar, M.D.

    Truly interesting story. Thanks for contributing.

  • Luis Collar, M.D.

    Thank you very much for your thoughtful contributions to the discussion. I know you represent an opinion that may not be popular, but it is one that is quite valid. Though not everyone is privy to the real-life experiences of physicians and their spouses, I, personally, can certainly appreciate many of the issues you raise. Many of the responses reinforce my assertion that, due to an unnecessarily complex system with many conflicting interests, the general public has a fundamental misunderstanding of the role physicians play in our society, including what their education, work, and compensation actually entail. Additionally, despite the opinion of many, what someone’s income may or may not be in relation to another person’s in no way makes their concerns or the challenges they face any less worthy of discussion. Just as disease does not discriminate based on income, empathy should not be limited to a particular income bracket. Thanks again for your comments.

  • Luis Collar, M.D.

    Very good advice.

  • Luis Collar, M.D.

    Interesting articles…thanks for sharing them. Those would be examples where the “poor image” is well deserved. As you implied in your post, however, I don’t believe that the two pieces are indicative of the majority of physicians or their ethics / values. Thanks for the comments.

  • Luis Collar, M.D.

    I’m sorry to hear you had trouble with your doctors and suffered as a result. I’m glad, though, you seem to be getting better care now. I hope that continues.

    I would only clarify that I was not “whining” about money in this piece. I’m not sure how that issue took over the comments when it represented a tiny portion of the actual piece. I do think physician income (particularly primary care) is sorely misunderstood, but that was clearly not the focus of the article. I simply wanted to point out that physicians increasingly have less control over their image and how they are perceived by the general public. Income (decreasing reimbursement) is only one manifestation of their growing lack of influence within the healthcare system and limited ability to determine how it operates. And, despite the tone of many of the comments, the problem is that this not only affects physicians’ incomes but also their ability to serve the patients that seek their help.

    I do appreciate your contribution to the discussion, though. Thank you.

    • Suzi Q 38

      Thank you, Dr. Collar.

      i have observed that when any given patient is important to the physician and if the physician views his/her lifework as caring for others, the patient is well-served.

      Simply put….as in any profession, there are those with good attitudes and those with bad attitudes..the positive and the jaded….the complainers and the doers.

      Physicians have less control over image because there is little control on the Internet. If a physician is good, the public will know, quickly and decisively. Conversely, an unhappy patient may also express h/her dissatisfaction with their doctor’s service.

      Income reimbursement for primary care is ridiculously low. My hairstylist gets paid more than my insurance company pays my GP. They will keep on paying them this as long as the doctors keep accepting the pay and doing nothing about it. You also do not see their colleagues (the specialists), offering to lower their pay so that the GP’s pay can be increased.

      For all the intellect locked in your individual and collective brains, your leadership (The AMA or whatever group) and fighting spirit for a just cause is sorely lacking organization and “intestinal fortitude.”

      I truly admire the low percentage of GP’s who have said:
      “No more. I will NOT accept $30.00 a patient and medically be responsible for h/her.” I think it is called “direct pay,” or a concierge medicine.

      It is getting hard for them, but they are the brave ones.
      If my GP asked me to go private pay, I would.

      • Luis Collar, M.D.

        You make some great points. Thanks for the thoughtful comments.

  • Luis Collar, M.D.

    Well said. Thanks for contributing to the discussion.

  • Luis Collar, M.D.

    Very well said. Thanks for commenting.

  • Luis Collar, M.D.

    Thank you very much for the thoughtful comment and kind words. I appreciate it.

  • Luis Collar, M.D.

    Thanks for commenting. I’m not sure that money can completely be removed from the equation in our country, nor that doing so would have the intended effect. Rather, I think we need to reevaluate the unnecessary complexity that has been forced into what should be a relatively simple process / relationship (particularly in primary care). Good luck with your career; I wish you the best.

  • Luis Collar, M.D.

    Thank you for contributing. The fact that many people view you this way, despite your clearly ethical and laudable practice habits, was precisely the point of the article. I also agree that some physicians contribute to this phenomenon. In fact, in other pieces (my book, A Quiet Death, for example), I have been highly critical of physicians for some of the very practices you reference. I do feel, however, that the unnecessary complexity of the system and competing interests of the non-physician players in this industry do more to harm the profession’s image than the relatively few (although, admittedly too many) physicians that engage in those activities.

    Again, thanks for the very insightful comments and honesty. They are both appreciated.

  • Luis Collar, M.D.

    I agree that much of the problem can be attributed to the unnecessary layers of complexity and “third parties” that exist between patients and physicians. Thanks for commenting.

  • Suzi Q 38

    “….Overbooked clinics. Running 2,3, even 4 hours behind in clinic as a result. Spending little time with patients. Not answering patients questions. Not admitting their medical errors to patients and doing the necessary steps to correct their errors. Putting an enormously large workload on the their office support staff. Treating the their office support poorly, resulting in a high rate of employees quitting. Nickel and diming patients (i.e. no show fees, late show feels, Rx refill fees, etc). Not wanting to spend a dime on upgrading old equipment that would improve patient care because they couldn’t afford it. Even though they make $500,000 a year and drive a Cadillac Escalade. Ordering medically unnecessary tests in clinic that would generate revenue. I could go on and on. I can totally understand why so many people hate doctors these days…”

    Interesting and boldly honest that you have observed the same behavior. I tread very carefully with my health care now.
    If I don’t like what I see or how I am being treated, I leave.

    • querywoman

      Suzi Q, you know how to properly evaluate the office procedures and the greed, in some.
      Do you need costly equipment and procedures with your spinal stenosis? All I really need is occasional blood work, so I’m not interested in shiny new equipment.
      I have an internist who uses a laptop, but she’s never just sat there and stared at the laptop. It’s documentation. I think her husband is an IT type.
      I’ve always hated it when docs treat their office staff like doggie dung. Luckily, I haven’t had that type of doctors in years.

      I at least used to have contempt for some nurses for just taking that humiliating treatment off doctors. I’ve seen a change in treatment of staff in my life for the better.
      There was a time when nurses wouldn’t even tell you your blood pressure. They’d take it and wait for the doctor to tell you.

  • querywoman

    Dr. Collar, you are some kind of pathologist? But you are taking the time out to look at general medicine, etc.? That’s very important. That’s being a new wave doctor, sort of an activist.
    Every doctor is supposed to be a GP, but many of them aren’t.
    You seem like a competent GP.

    • Luis Collar, M.D.

      I have training in both internal medicine (primary care) and anatomical / clinical pathology. Even though I’m not active in primary care, I still take an interest because I think that specialty is critical to the delivery of quality healthcare in our country.

      • querywoman

        I told a psychiatrist once that she was a general practitioner. She said, “I’m a doctor, dear.”

        You are too.
        So many specialists get too far into their specialists. And that’s bad medicine.
        You are on the fringes, but with an interest in primary care and are making cogent evaluations and can contribute a lot.
        Keep it up!

        • Luis Collar, M.D.

          Thank you, QW. I appreciate it.

      • querywoman

        So do you analyze stuff cut off a body? Can I send you some stuff I cut off from my skin?
        Can you explain why it’s so hard to get a skin lesion biopsied?

        • Luis Collar, M.D.

          Pathologists diagnose disease by analyzing the body’s tissues. I’m afraid you can’t send me anything, though. Tissue requires special preparation before it is sent anywhere to be analyzed, and pathologists work with other physicians to analyze those tissues in the appropriate medical / patient context. You should definitely see your primary care physician if there is anything on your skin that concerns you. It’s a good idea to have your PCP take a look at it first.

          Getting a skin lesion biopsied usually isn’t hard at all, unless its a highly vascular lesion, etc… But dermatologists are generally very good at doing even complicated skin biopsies. If your PCP feels it is required, he or she can send you to a dermatologist that will definitely help you.

          • querywoman

            It was partially a joke. I already have an excellent dermatologist, who is a training, research dermatologist.
            One hospital told me they don’t do skin biopsies in the ER. I didn’t ask if they did genital biopsies! You have to do some REAL WORK to get to that part of the body.
            My PCP knows nothing about skin.
            I’m staggered at the docs who don’t. And I can’t believe they can’t cut a few cells off an external part of the body! Yet women get corralled in for Pap smears,
            My derm is an activist in his profession.
            You can help me out personally be being an activist for skin biopsies!
            Love ya!
            Get that book. Order it online. It’s the most valuable finance book I’ve ever read. My deceased mama loved the pearls from it.

  • querywoman

    One of my all-time favorite books is by a British prosperity-type writer, Stuart
    Wilde, “The Trick to Money is Having Some.”
    He wrote that the only reason to be in business is to turn over the money. Example: Mother Theresa was a sharp old bird who sent more money to HQ Rome than she ever spent in Calcutta. She was parsimonious and wouldn’t spend the money on basic medical supplies for her clinics.
    I’ve had greedy doctors and I’ve had generous ones. I don’t have any problem with greed, as long as people will admit it. And that goes for people other than doctors!
    I used to be a registered patient at a county clinic. The doctors got a reasonable salary and job security. It’s public info. I never got around to asking my doctor if he liked money.
    I have one doctor who lives in a 2 million home. He’s a very generous kind man. I doubt he made all that money working as a doctor. Some of it may be inherited.

    • Luis Collar, M.D.

      I think the “greed” issue is a separate discussion (as you say, being deceitful, etc. can exist in any profession), and it’s also a general term that requires context (who was greedy, how so, what did the person do that makes him / her greedy, etc…). In general, though, I don’t feel there is anything wrong with “making money.” I think people that earn their money honestly have no reason to “feel bad” about what they’ve earned. I agree honesty is key, especially since there is no reason to hide the fact you are earning money for providing people a service and acting in good faith. That applies in any industry, including healthcare.

      • querywoman

        I prescribe that you get the book and read it. It’s humorous.
        Stuart Wilde also states that the real purpose of American and British politicians is to vote themselves in for life and get that income and benefits.
        He’s right. Surely both nations have similar political types. None of the political parties are all that distinct.

        • Luis Collar, M.D.

          Sounds interesting. As soon as I have some time, I’ll pick it up.

  • querywoman

    Yes, medical debt is the number one cause of bankruptcy, but that does not mean it is necessary to file bankruptcy to stop harassment.
    The threatening phone calls are what drive most people to bankruptcy.
    The harassment can be stopped with a cease communication letter.
    I don’t need to go into the legalities of this here. It depends on your state. In Texas, we can’t get our checks garnished for medical bills.
    The reason I bring it up is to point out the fear associated with medical debt. The fear is not good for us medically or culturally.

    • MannyHMo

      You don’t have to declare bankruptcy however it is bankruptcy that prevent these collection agencies from hounding you and making your life miserable.
      OK, I’m very curious now. If what you said is true, nobody in Texas declare bankruptcy because of medical bills or nobody should really declare for one. How does the hospitals and doctor offices go after those who are unwilling and perhaps unable to pay ?

      • querywoman

        In Texas, it’s very difficult to collect unsecured debt. It’s mostly scare. They can sue and get a judgment to collect from a bank account, but then they have to go an extra step and locate resources to try in collect.
        They usually don’t bother with a judgment. The cost of suing is high. A person can have a high income, a nice home, and very little in the bank.
        Now if someone like Ross Perot didn’t pay a bill, they would sue him, get a judgment, and find a bank account.
        A wealthy person who refuses to get a judgment can get tossed in jail.
        I read a bizarre account of a Lutheran medical system in another state suing people and garnishing their wages. That included garnished the wages of a very low income woman over a miscarriage. Very strange! Medicaid covers miscarriages and pregnancies with very generous income allowances.
        The info about debt collection cease communication letters is freely available on the net. Bud Hibbs had a great site, but he passed away.
        Infomercial media wh0re Kevin Trudeau even got into it, rehashing the same info that others had already done better.
        After a cease communication letter, the debt collector may only make one contact with the debtor, which could mean a notice to sue. It’s illegal to threaten to sue with no intent to file. They can still sue, but most of them just drop it.
        If a debtor carefully records, monitors, and lists all credit harassment, it’s easy to catch them at a federal law violation. They all do it. Some people file small claims suits in their states for violations of federal debt law, and that’s a $1000 penalty per violation.
        Most people seem too frightened or lazy to send a cease communication letter. Repeated phone calls can also be turned in to the phone companies as harassment.
        There are other agencies that address collection harassment.

      • querywoman

        I doubt that a hospital would even sue the average doctor or lawyer for nonpayment.
        They would sue a known wealthy eye surgeon or personal injury lawyer.
        FYI, Dallas prominent personal injury lawyer apparently keeps his home in his wife’s name.
        I need to google him. I heard he got in a bad accident himself.

  • querywoman

    I got up off the couch from my pneumonia-recovery sleep this morning and reread the original article again.
    Regardless of the payment system, the real reason doctors don’t spend too much time with patients is that they have more than they can handle.
    With the decline in dearly deaths from infectious disease, malnutrition, and poor hygiene, patients live longer. With longevity comes degenerative disease, and they know how to do stuff. Diabetes treatments are socially new.

  • querywoman

    And you know that some of the opthalmologists, the cataract and lasick surgeons, are the rich ones. Also some of the dermatologists.
    Arnie Klein has made and blown vast fortunes.
    Here’s what I think of new technology:
    I traveled on the bus in the Texas summer heat to a dentist. When I got to the office, I was sick. Their computerized Xray machine was out, and I could not been seen.
    I refused to return.
    I made dang sure my next dentist had a manual Xray machine.

  • DoubtfulGuest

    The physician is defended by an attorney hired by the malpractice insurance company. Sometimes the physician has a personal attorney also. An insurance company lawyer is going to act in the insurer’s best interest. It’s my understanding that any settlement must be reported to the National Practitioner Data Bank. This is not public info but certainly can limit doctors’ hospital privileges and employment opportunities. Even if the doctor did nothing wrong or made a non-negligent error, sometimes the insurance company will push doc to settle to avoid a bigger payout in court. Which can happen over a technicality or a jury sympathy issue, even if the doctor is innocent. Lawyers work on billable hours, so they probably don’t mind losing if they can drag things out for a long time. It’s a racket, from my standpoint as a patient who’s chosen not to sue.

  • Luis Collar, M.D.

    Fear of lawsuits may certainly be contributing to that reluctance. Interestingly, the doctors that tend to get sued the least are the ones that have the best relationships with their patients. And that often involves simply being honest. Thanks for contributing.

  • Luis Collar, M.D.

    Very true. The increased patient volumes being generated by several forces currently impacting medical practice (decreasing reimbursement, corp med model, etc…) are, in most cases, detrimental. Thanks for commenting.

  • Luis Collar, M.D.

    Great observation. Although there are other dynamics at play here, I agree physicians are the “face of medicine,” despite often executing policies that aren’t theirs, so they bear the brunt of the dissatisfaction. Thanks for the insight.

  • Luis Collar, M.D.

    Thank you very much for the feedback. I appreciate it.

  • Luis Collar, M.D.

    We need to reform the way we deal with medical malpractice. I don’t have all the answers on this one, but it certainly seems that the current system doesn’t serve patients (all patients) or physicians well.

  • Luis Collar, M.D.

    That is quite true. However, their interests are not completely aligned. For example, in order to protect their financial interests, malpractice insurance companies and hospital administration often decide to settle a case, despite there being no evidence of wrongdoing on the part of the physician in question. This is done simply because the costs (legal fees, experts, etc…) of moving forward with a case are higher than offering a modest settlement which the patient will often take. This may have an adverse impact on the physician’s reputation, yet he / she often has little choice in the matter. Your point is well taken, though. Thank you.

  • Luis Collar, M.D.

    I absolutely agree on the need for “reviewer friendly” bills. My parents often show me their hospital / medical bills and statements and, embarrassingly, it usually takes me quite some time to figure them out myself. We need to strive for simplicity, honesty, and transparency in these bills. Honestly, there is not good reason not to do this. Unfortunately, physicians often have little say in hospital billing practices. But, when they can control the process or have an opportunity to offer feedback, that message must be delivered. Thanks for the insight.

  • Luis Collar, M.D.

    Again, great comments. The legal profession, despite dealing with their own image problems, has done a better job of protecting their interests and retaining control over their profession. With so many parties disrupting the relationship between patients and physicians (e.g. insurance companies, corporate administration, government), physicians have lost a great deal of control over their profession. And their image (since the public is often not aware of the overly legislated and administratively burdensome environment physicians are forced to operate in) has suffered considerably as a result.

  • Luis Collar, M.D.

    On many of the issues raised in the post, you are correct. Physicians do not, in fact, control much of their own practice environment anymore. There are some exceptions, and some geographical differences, but the trend is definitely there.

  • Luis Collar, M.D.

    I think there is some hope, but, in many ways, I agree with your assertion.

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