When doctors complain: How to resonate with the public

There is a dark cloud of discouragement, dejection, disheartenment, and all other synonyms of despair, hanging over the medical profession. It’s not that all physicians live in constant gloom and doom, although quite a few do, particularly those still in private practice, but the profession itself seems to be losing its luster.

Some doctors seem content to pragmatically adapt to the new and duller definition of their old profession, but in other quarters there is deep seated anger stemming from the perception that this is something purposely inflicted on physicians by a power hungry government, greedy businesses and an ignorant and ingrate populace. No matter how the conversation starts, the question seems to always be whether there is anything that can be done to turn the tide.

And no matter what is said and done, the exchange of opinions always devolves (or evolves, depending on your position) to money — cash, payment, reimbursement, fees, compensation for long years of learning and training, and for performing arduous work that is really (or at least should be) beyond monetary valuation. And this, my friend, is the most counterproductive narrative of all. This is where you shoot yourself in the foot, albeit with undeniable gusto. Regardless of its merits, this is a nonstarter.

The hurricane hitting health care today can be traced in its entirety to money. We would not be having this dialogue if medical care was affordable for the average American, and if the sum total of national expenditures on health care would be hovering around 10 to 12 percent of the inadequate measure called gross domestic product (GDP). You can engage in the futile exercise of splitting hairs trying to allocate blame for runaway costs away from doctors, but you would find yourself outgunned, outnumbered, and late to the game.

The mass media is chock full of randomly chosen inflammatory examples of the small fortunes charged by physicians and hospitals for stitching a pinky finger. The shining bright lights make every pharmaceutical hotdog cast a shadow the size of the Keystone XL. Large insurance companies are providing interviews to anyone willing to listen, on their strategy for keeping premiums affordable for the working man by expelling “low value” providers from their “high value” networks.  And Medicare just announced that it will be releasing information on how much money it pays to individual physicians, because the “public has a right to know.” How do you fight that?

The same way George Washington fought the war of independence — you redefine the battlegrounds and meet the enemy at a time and place of your choosing; a time and place where your inferior force is actually an advantage. So first of all, you don’t discuss money, and you certainly don’t go into endless tirades about your accounts receivable and accounts payable over the last 30 years. Why? Because complaining about the frosting on your cake while your audience is starving is not a very endearing or effective method for garnering support and sympathy. There is no way you can convince the nine out of ten Americans who would gladly trade places with you, that your work is hard, your life is hard, and your six figure income is inadequate compensation for lack of joy at the office.

There is no way you can explain to a nation that makes on average around $50,000 a year, that $150,000 is not good enough. And bluntly telling them that they are too stupid and too lazy to do what you do, and that’s why they are deservedly worse off, is not going to get you much applause either.

The second rule of engagement is that you should never confuse your arguments with political partisanship. Why? Because, the moment you do that, you lose half your audience, and it doesn’t really matter which half. If you are ever going to win this battle, you need all the hearts and souls you can get. You don’t discount half the country by calling them irresponsible moochers, and you don’t throw out the other half by labeling them heartless disciples of Ebenezer Scrooge.

Your best, and arguably only, weapon in this fight is that both halves still trust your professional voice. You don’t further diminish that trust by descending into the political swamp to meet your enemy. You pick your time and place. You choose to fight on the moral high ground.

You took an oath to help the patient in front of you, to the best of your ability and judgment. Whatever modern enlightened technocrats think about ancient oaths, potions and incantations, there is an implied promise here to conduct one’s professional life in an ethically responsible manner, which is more than can be said about any other secular profession. So what happens when your ability is harnessed by entities whose sole raison d’être is to increase shareholders profits by any means necessary, and your judgment is subordinated to agencies that live and die within political election cycles?

Your ability is steadily crippled by diluted training and limited practice, and your judgment is shelved in favor of shiny fly-by-wire instrument panels (medicine is like aviation, remember?), configured by invisible and unaccountable hands. This is what the public needs to know and thoroughly understand.

If you are going to speak up, make public statements, write blogs, start a movement, or just post an anonymous comment somewhere, you should stick to your high ground, your guns and your strategy to inform the public about health care issues that matter to individual people, their children, their parents and anyone else they hold dear. You can write stories, relate experiences, compose elaborate treatises, sponsor studies and do research, and all of these things need to be about the one patient in front of you.

When people come to you for advice, they should understand that it’s not necessarily your advice they are getting now. When the frightened ask you what you would do in their place, they need to know that you may not be at liberty to give them an honest response. They need to know that advocating for your patients, may draw disciplinary actions from your handlers, and financial retribution from your masters. They need to know that medical ethics are largely outside your control now, and subject to lobbying and political patronage arrangements. They need to know that the archaic words of Hippocrates are turning into a largely empty exercise before graduation parties begin. But most of all, they need to know that you are asking them for help.

And next time you lament the loss of joy and the diminishing status of your profession, you will have to give old Hippocrates some credit, because two and a half millennia ago he forewarned all doctors of the fate awaiting them, if his moral prescription was ignored: “If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.”

What’s your lot look like these days? And what are you planning to do about it?

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • Doug

    As one about to begin his residency, and one who at least weekly (at some point) wades through the stagnant waters of jaded physician fatigue, I thank you for this. We may be in medicine, but some virtues know no professional boundary – interpersonal communication and leadership paramount among them in this instance.

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

      Thank you, Doug, and best of luck.

  • Thomas D Guastavino

    Im curious. What is your business or career?

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

      Health Information Technology, a.k.a. HIT, a.k.a. horror story :-)

      • Thomas D Guastavino

        I agree. HIT has become a horror story. Interesting. It sounds like you have a lot of complaints about your career as well. I wonder how your complaints would “resonate with the public”

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

          I have no complaints about my career, and even if I did, they need not resonate with the public.
          The problem with your career is that if it gets obliterated, lots of innocent people, mostly poor, in this country will suffer. This is why I am advocating for the traditional medical profession.

          • Thomas D Guastavino

            But…. you just said HIT, a.k.a horror story?

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

            It was a joke, since everybody is complaining about EMRs and all that….

  • guest

    In my experience in following these conversations, it seems that very, very few discussions of doctor’s income are ever started by doctors. Doctors are, for the most part, complaining chiefly about the matters that you suggest above: unreasonable governmental and corporate intrusion into the work we do, and the subsequent dilution of care that we are able to offer our patients.
    Unfortunately, it’s a pretty common pattern for these expressions of concern to be met by the public with a response along the lines of: “Well, you make plenty of money so it’s up to you to figure it out and not bother the rest of us with your whining about how terrible your job is.”
    It’s at that point, most commonly, that you see doctors speaking up about their diminishing incomes, growing educational debt and plummeting job satisfaction.
    I am not sure what you could suggest about that. Most of us are very much trying to write about our concerns about the changing landscape of healthcare delivery, and how it affects patient care, which after all is what we care about the most. But if those warnings are met with responses from patients which focus on our compensation, how exactly do you think that we should respond?

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

      Well, I don’t know that it matters who starts the debate. I agree that many articles are written in response to accusations, such as the NYT article, (Dr. Wes, right here today). I also agree that some of those responses are excellent (certainly the one from Dr. Wes is). But you can’t win hearts and souls with just good defense. And you can’t win at all if you let the opponent dictate the terms of engagement.

      Whether you guys like it or not, there is a full fledged war waged against your profession, because your sheer existence stands in the way of fully industrializing medicine. However, unlike many others before you, doctors are in a much better position to fight for survival and independence, precisely because you are the ones that touches each patient, literally and figuratively. If you are going to win this fight, you have to educate folks about what’s at stake for them. For them, not for you, because you cannot win this alone.

      I am not oblivious to inadequate third party payments, but this doesn’t make good copy. Telling patients that you can’t spend time with them because Medicare doesn’t pay you enough to care, is bad messaging, because a) you are talking about your problem, not theirs, and b) it sounds mercenary. And yes, this is about spin and public relations.
      So why not try something else: “Medicare is creating all these rules and regulations, and forms in triplicate, and hurdles and mandates about what I can or cannot do with/for you, so I have to spend an inordinate amount of time and resources on administrative bureaucracy and there is very little time left for you, Mr. Patient. Furthermore, Mr. Patient, Medicare (or whatever payer) is now insisting that I become more “productive” and see even more patients per day to accommodate increasing membership, so assuming that there will always be 24 hours tops in each day, chances are Mr. Patient, that next time you come in, we will have even less time together, or maybe no time at all, and you will have to talk to my assistant”.

      And when the NYT posts funky, animated salaries on their front page, maybe someone should post equally funky and also animated graphics about how often one will be able to “see” a real doctor in the not too distant future (TV doesn’t count), let alone have one listen to what they say.

      • guest

        You know, I sort of thought we were educating folks about what their medical future will hold when we talk about how no bright, motivated, compassionate students are going to want to go into medicine the way things are going. the problem is that no one appears to want to believe us.

        Also, I still don’t see what is bad about educating Medicare patients about the fact that it costs a doctor money to see them. To me, that’s something that, as a patient, I always want to know, so I can adjust my expectations accordingly.

        You make good points. Thanks for trying to help.

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

          This is actually a great example of being too vague. Anyone who does not live in health care day in and day out will have one of two reactions to that warning: 1) give me a break, why wouldn’t people want to go to medical school and make “tons” of money… don’t they have a gazillion applicants for each spot anyway… my nice is the smartest kid in her class really nice girl too…. she wants to be a doctor… and what’s his name … Joe’s boy also wants to be a brain surgeon or something… weird kid…. we’ll be fine…. these guys have no clue…. or
          2) huh? what is this 34.95 from Amazon on the Discover… you guys think I’m made of money….. maybe you should go to medical school if the rich kids don’t want to anymore… and get your own Discover….

          • guest

            Ha! Very funny! I do see your point…

        • NewMexicoRam

          An approach I take is that I believe all of my patients deserve the best from me and my staff, and we are still providing that level of care in the best ways we know how. But, when reimbursement from insurances and Medicare does not keep up with costs, we can only provide that type of care for so long before it starts to unravel. Then I ask them if they would be able to provide the same level of work for their employer if their boss expected more work, requiring more hours, while being paid less for it? My patients quickly relate.

  • karen3

    Every time I hear a doctor complain about how expensive medical school was, I think, I wonder how much that guy down the street invested to open that 7-11, or the five guys, or the grocery store, or whatever small business comes to mind. Because I guarantee that the guy who is in the tacky polyester 7-11 uniform who owns the place and is working 80 hours a week at the register probably spent more on his franchise than you did for your medical degree, with no subsidized federal loan, and with less guarantee of a return and certainly isn’t making what the docs are making. The amount spent on medical school is really not that much and the rate of return is quite certain and fast.

    • Steven Reznick

      I agree that the investment and risk taken by a businessman may be significantly higher than the $150 – $250K a physician makes on a medical education today. That physician , if he decides to open an office and then practice then has to raise and make the same type of investment if not more than the businessman to start his practice while paying down those educational loans.. While the doc is doing this , insurance companies and the government are determining the reimbursement levels and raising overhead and the physician , unless they are in a direct pay model or concierge practice , have no way to pass their costs on to the consumers like any other business would.. Despite this, if you wish to be a doctor it is a risk well worth taking. I do believe that Margalit is correct that this is a losing argument to raise.The real argument is that the rules and regs and bureaucratic dogmas are taking physicians away from devoting time and attention to the patient care. You as a patient are the ones who ultimately suffer and that is the major tragedy of all this..

      • NewMexicoRam

        Good answer. So true.

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

      Thanks for saying this. I think it illustrates the point perfectly. Lots of people out there are risking capital and working hard. The doctor problem is very different, and the existence of practices like Dr. Reznick’s, I think prove that there is also a possible solution. Now we need to summon the will to scale it.

    • M Aviles

      “the rate of return is quite certain and fast” – Not sure this holds true, especially for Family Practitioners who open their solo private practice in this uncertain and broken system. A lot of my female colleagues who are solo in my area, make way less than the national average! And they are not only taking a business financial risk (which is separate from medical school costs) but the most important one: the life and wellness of those who come and look for our expertise and compassion. Of course, you can argue against this by looking at physicians who have chosen to be employed by Hospital systems to avoid the business risk in itself.
      I kindly ask you to keep these other things in mind. I love being a doctor! I love caring for those who have entrusted their health to me! I try my best every day to give choices, listen carefully, counsel and cry with the afflicted even when I should probably take some rest! So apart from these responsibilities (which I gladly accepted when I took the Hippocratic oath & which do not have a price tag) we are still responsible for being good “business people” under our “magical White Coat”.
      Thanks for sharing your view Karen.

  • guest

    Well that’s a problem, too, and of course not at all justified.. Not to sound paranoid, but I am sure it’s just what the powers that be want to see; all of us turning on each other like rats in a cage.

    • Patient Kit

      It’s a classic strategy — divide and conquer — that has been used all too effectively by many powers that be. Patients and doctors must stay on the same side. Once that relationship and trust is lost, it won’t be rebuilt easily, if at all. And the war, not just the battle, will be over. Yeah, I don’t think you’re paranoid if you see doctors and patients being pitted against each other.

  • Luis Collar, M.D.

    Hi Margalit…

    Great piece, but I have to agree with some of the other comments here. No matter how one frames the discussion (assuming one wants to deal with real issues, not just the politically correct ones), the structure of our current healthcare system leads to many misconceptions. My recent post (http://www.kevinmd.com/blog/2014/01/culture-contempt-led-medicines-downfall.html) is a good example of this.

    In what was a lengthy post that barely mentioned physician income (and certainly didn’t attempt to compare it to other incomes), a disproportionately large percentage of the comments were related to that topic. Any honest discussion about the lack of physician influence on current policy seems to devolve this way. And I don’t think the public or the medical profession can be blamed for this phenomenon. Instead, it is due to the competing interests in healthcare that like to create the illusion they deliver tremendous value benevolently, while minimizing their role in its shortcomings (e.g. insurance companies / policy makers).

    I also think it is dangerous to assume that the challenges facing any particular group (e.g. physicians) are any less worthy of discussion than those facing any other group. It may be politically correct to do so, but that sort of “stifling” doesn’t help solve issues, and it certainly doesn’t help patients. When cancer afflicts the wealthy, it is no less worthy of empathy or diagnostic effort than when it afflicts the poor. And other than the individual suffering from a given illness and his or her family members and friends, I know of no other group in this system that has patients’, rich or poor, interests in mind more than physicians do. To truly solve problems, they need to be looked at from all angles, without allowing political correctness to play a role.

    I did enjoy the post and feel you make some great points, but preventing open, honest discussion for the sake of political correctness doesn’t help anyone, despite providing the illusion of fairness.

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

      Dr. Collar, I am not suggesting that honest discussion should be prevented. I am suggesting that this open discussion as cathartic as it may be for the participants, is not advancing the ball for you, and it may even cause it to go back 15 yards ever so often.

      You need an organized effort, professionally run, to counteract the millions of dollars pouring into the very organized and purposeful campaign to drive you into irrelevancy. I was merely suggesting a strategy for such effort.

      BTW, I wrote this post precisely because of the multitude of comments you mentioned. I do understand the frustration in those comments, but if you want to actually make a difference, you will have to reach out to people who may not grasp, or be able to sympathize with your frustration, simply because they cannot connect your current hardship with what is happening to them. It may seem obvious to you (and me) that if primary care docs don’t get paid double of what they are paid now, the public will suffer (is suffering), but this is not at all obvious to the man on the street, and it actually looks pretty much the other way around. It’s up to you to fix this faulty perception.

      • Luis Collar, M.D.

        Funny enough, I wasn’t even advocating for higher pay in that post (probably just poorly communicated). I was trying to show how little influence physicians have on policy and how their declining image is relevant to patients (because physicians, nurses, etc… are the ones that actually deliver the care, their lack of control over the process puts patients at risk). I do understand your point, though.

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

          I know you weren’t, but on many occasions I suggested just that :-) and I didn’t mean “you” personally…. I just want someone to do something big and bold before it’s too late, and buzz will probably it is already too late….

          • Luis Collar, M.D.

            I’ve got it… Let’s start “Gur-Arie & Collar Medical PR Solutions, Inc”… We’ll be rich. Wait, I just mentioned money again…oh no! lol… Just kidding. Your point is well understood.

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

            You are funny… Love it… :-)

          • Rob Burnside

            I think he’s serious, Margalit…

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

    Thank you, and yes, it is very difficult and it is getting harder by the day.

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

    Ah… I knew you would say this…. :-) I could hear it in my head before I actually read it just now….
    Seriously though, do you think there really is no point in giving it one more shot? I mean, there are lots of variables here… Things could change somewhat.

    • NewMexicoRam

      Please name some.
      Most likely what will happen is a HUGE public outcry when ObamaCare starts affecting multiple millions of Americans in a very negative way. The politicians will act, national funded healthcare will start, the specialists will take a large paycut, primary care will see a measly increase, and 2 levels of healthcare will result, one for everyone, and one the rich can buy into.

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

        Well, isn’t this what we should try to change? I don’t believe that things are preordained at this point. I may be wrong, and overly optimistic, but we won’t know unless we try.

    • buzzkillersmith

      Hi M, I don’t know what will happen in the long run, but the short-term prognosis is bad. I have given up, but, oddly, it doesn’t bother me all that much. It’s interesting kinda in the same way as watching a volcanic eruption or a tsunami. Not good, just interesting–if you know what I mean. Now if the Seahawks lose, then I’ll be depressed.

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

        Yeah… I know what you mean seeing how the Rams can’t get their act together this century.. I sort of like Peyton, but Seahawks are fine too.

        • NPPCP

          Reading between the lines here – M is a Broncos fan. And that is good to hear (speaking for her, of course).

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

            I just like the Mannings (both), but I am a Rams and Bears fan. Sadly, there’s not much left for me in the post season, so I’ll go with the horses to make it interesting on Sunday :-)

      • NPPCP

        Um, wait a minute. I get irritated by some of the conversations on here for sure. Buzz you are one of my favorite kevinmd devotees and I would really like to meet you in person – please PLEASE don’t ruin it all by mentioning the Seahawks. I can’t deal with that in this medical forum. I think we both know you are about to double down on your primary care depression with an easy Hawk loss to the Broncos. Nothing seems to be going your way – perhaps a consultation with the PCMH psychologist? There is an opening on the 12th of Never. :)

        • buzzkillersmith

          You could be right.

  • Duncan Cross

    Thanks for this, Margalit. I agree mostly, but wonder whether it’s necessary to resonate with the broader public. If physicians as a profession offered a compelling vision to patients to ensure they have access to high quality care, us patients would set the world on fire (figuratively) to see that vision realized. People who need medical care want happy physicians — the morale issue affects us, too. It’s not that we love the ideas that come out of Washington, it’s that more often than not when we look to physicians for an alternative, we get hand-waving about “markets” or diminishing status. I would much rather get care in a health care system designed by physicians than politicians, as long as the point of the system is to ensure we get the care we need. Patients and physicians ought to be natural allies; maybe reaching out to sick people would be a good intermediate step before taking on the general public.

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

      I think things are at a point where just doing the right thing in one’s little square of the map is no longer enough. I think we need the voters to become informed and subsequently outraged and then go out and vote their interests.

      • Duncan Cross

        Sure — but nearly half of all adults in the U.S. have a chronic illness: that’s hardly a ‘little square of the map’. If doctors can’t get the sick half of voters to support them, why would the healthy half line up behind them?

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

          They need to get everybody, including the sick, but being a good doctor to the sick is not enough at this point. First because they can’t be the best they want to be in this system, and second because people don’t understand why it is so. They need to set facts straight and ask people to help them take on a system that is quickly moving towards a broad and inequitable solution.

          • Duncan Cross

            I’m not talking about doctoring, I’m talking about advocating — a big difference. Nobody has at much at stake in this problem as sick people do.

          • DoubtfulGuest

            I think given the urgency of the situation, they need to target everybody all at once? That said, I really like your statements in your first comment. I hope they’ll keep us posted on whatever they get started, and let us help. Surely there are lots of smart, healthy people who know they could get sick at any time…and would do the right thing once they know what’s going on?

            A logistics question getting back to “Where is everybody?” – might there be a point soon that we patients could help get the word out to our own doctors that there’s actually something getting organized? Or would it be more efficient for docs to just spread the word themselves on Sermo and other venues? Not to jump the gun, but it would be nice if we could help you all somehow, and not just to make us feel better. Please think about ways that we could save you time and support your efforts?

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

    Well, we can accept that we lost our democracy and call it a day (or a night). But if we still believe that voters can influence the system, or that some day they may, then I think it’s worth getting the public to understand the real reason behind the indignities soon to be inflicted on them (and for some already being inflicted), and how they can go about addressing the problem.

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

    Thanks. I will….

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

    By screaming really loud….. before there’s no one left to scream.

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

    I’m glad you brought this up, since this is a perfect example of the massive disinformation campaign going on now.
    The sum total of pharma payments, or Dollars for Docs, as Pro Publica calls it, is $2.1 billion over 4 years. Most of the money went to research institutions and big hospitals for research projects.
    But even if you want to count legitimate research, the numbers are ridiculous. There are approximately 1 million doctors in the US. This amounts to $2000 per doctor on average over 4 years, or $500 per doctor per year, or less than $1.50 per doctor per day.
    Now take the inflammatory NYT headlines, saying that doctors make $800,000 or $500,000 per year, and tell me what would a person making so much money be willing to do for $1.50 per day?

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

    That’s exactly the point. I offered before to do the grunt work, but this MUST be physicians founded and led, if it is to be successful, preferably lots of physicians from many specialties. It’s not that difficult either, but it will take some commitment.
    According to the latest AMA survey, 60% of doctors own or work in private practice. Where is everybody?

    • M Aviles

      I would like to contact you directly. My e-mail: maravil12@yahoo.com.
      Would it be possible to exchange a good talk and see what comes out of it? And I really mean it… don’t have much time to waste… Thanks Margalit.

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

        I will email you directly. Thanks.

  • T H

    BKS – like MGA, I heard your reply in my head well before you had actually posted it.

    I agree with everything but the last statement: people who go into primary care are NOT fools… as long as their eyes are open and they have a clear understanding.

    • buzzkillersmith

      I can agree with that.

  • Rob Burnside

    A simple, honest, and well-intentioned question, Dr. B.: If the greatest physician shortage is in primary care, why wouldn’t PCPs be able to command top salaries per supply/demand? Is it the increase in number of NPs and PAs, a lack of PCP labor organization, or the persistent Norman Rockwell archetype? All the above or something else? I tried to be my own PCP for thirty years and it worked fine, until I became ill. Maybe patients like me are partly to blame.

    • buzzkillersmith

      The proximate cause is the “rent control” phenomenon. In a free market, as I’m sure you know, price and quantity are determined by where the supply and demand curves intersect–at least that’s the simple, first-order model. But if the price is capped at a level below the intersection, then there is unmet demand–a shortage. They tell me this is what can happen in places like New York which has (or had, I don’t know) rent control. There was a shortage of rental units.

      We family docs, have our price (our income) capped at a level too low to induce adequate supply.

      What are ultimate causes? It’s multifactorial, of course, but the RUC’s decisions might be the biggest direct cause. And the RUC’s structure and function is a direct consequence of our lack of effective organization in family medicine and the fact that we are outnumbered and out-earned by proceduralists. We bring our little knives to a political ax fight. Another huge factor underlying all of this is that America is freaking out about HC costs and rightly so. So there is only a certain amount of money for us docs, and, you got it, the proceduralists eat first.

      The increase in numbers of NPs and PAs in primary careis a consequence of primary care medicine spinning down, not a cause. The archetype and patients are not to blame. This is really about how the business of medicine is structured.

      • Rob Burnside

        Thanks, Dr. B, this completes the picture for me and ties it up in a neat package although, of course, things aren’t so neat in another sense. Looking back over fifty years, PCP encapsulation began with the demise of the house call, or so it seems from my perspective. I think it was Robert Frost who first said, “The best way out is through” and I wonder if it doesn’t hold true now. It’s becoming more apparent to me that physician-supplied primary care won’t survive in the long run without congressional intervention in the short. As I freely confess to being a Norman Rockwell devotee and a member of the Best Foot Forward school, I hope it happens soon.

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

          I agree. Something really bad happened in the late seventies early eighties (and not just to doctors), but I think specialists need to realize that PCPs are just the canaries in the mine. It won’t take long for the powers to be to realize that the big “savings” are not in the PCP compensation, but elsewhere, and by then we will have “proof” that medicine can be managed without doctors, so why not dermatology or OB or anything else?
          Either they all rise up now as one, or it’s game over in twenty years or so….. game over for us, that is.

          • Rob Burnside

            A grim forecast, Margalit, but certainly possible if no course corrections are made.

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

    They say that if you don’t take care of yourself first, you can’t really take good care of others. So for the third group you mentioned, which is the majority, I would suggest that they put on the gloves, and gear up for a fight. The sheer knowledge that you are no longer cowering down, taking indiscriminate blows to the head, should do wonders for stress and burnout problems. Win or lose, there may even be some joy associated with the exercise.

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

    Thank you for this brilliantly phrased perspective.

  • DoubtfulGuest

    Or rotten eggs. We don’t want that.

    • head_and_brain

      For example, the patient’s adherence to taking prescription. A physician could criticize the patient for being “complicated”, but your goal was to “get patients to take medication”. Some physicians took this path and still not understanding why patients didn’t comply.

      • DoubtfulGuest

        LOL, yes, I’m not arguing there. I’ve experienced reactions from doctors that, seriously, who acts like that after the age of five, much less in a professional setting? That’s the “rats in a cage” in action, as someone mentioned above. Docs feel outside pressures and instead of standing up to those, some have turned against individual patients. Many of us blame doctors for the high costs and not having time for us. But these are problems of the whole system. I just meant that for doctors to save their profession from total industrialization and corporate interests, they will have to push very hard. But they may yet be successful in the end. They should keep repeating their message and not be too concerned about a negative response. It will sink in eventually. Most people I know like their doctors, or want to like their doctors. If they do what Margalit suggests, it should also restore much of the public respect and appreciation for their profession that is sorely missing these days.

        • guest

          Let’s not forget about the patients being turned against the doctors…at a time when doctors have less and less time to talk with and think about their patients, due to the regulatory burdens that Margalit references, isn’t it odd that there’s this huge volume of literature appearing about how patients should “advocate” for themselves and “insist” that doctors spend more time with them?

          Naturally, a doctor who knows that he or she is going to spend two or three hours on the phone or completing paperwork that day in order to get the patient’s insurance company to pay for the patient’s medication, or treatment, or radiology study, or whatever, is going to be offended by the patient “insisting” on more face time with the doctor. But someone continues to crank out all these pieces encouraging patients to antagonize their doctors by doing just that.

          • DoubtfulGuest

            Sure, I see that and agree with you. I bet some of the literature is from well-meaning “patient advocate” types, but quite a bit is likely planted by CorpMed folks taking advantage of patients’ fears? I was vulnerable to this kind of thinking for a few months at a real low point in my medical situation. Then I started to be honest with myself about why I felt that way — it’s intimidating to have to place your life in someone else’s hands. People get a little charge out of declaring “You work for me!” and going around insisting things. You all are right to feel antagonized. It does nothing to address our underlying feelings about being sick, anyway. I’ve had some fun trying to get people to think differently about this. For example, a relative was having some medical problems shortly after I got my diagnosis. She wasn’t getting anywhere with doctors, and I was describing how I learned to be more assertive. She said “I need to do what you did, and *demand* the *services* that I *deserve*.” I said “Oh, no! No, no, no, no, no, no! It’s not ‘demanding…services’. There’s your trouble….”

          • DoubtfulGuest

            Also, I think a big part of the problem is patients have no concept of everything doctors do for them behind the scenes. There’s an “information vacuum” which fuels anxiety about medical care. In earlier days, people had more caring, trusting relationships with their doctors. We feel this loss and can’t explain it. I think it makes people more suggestible to the kind of propaganda you mention.

  • NPPCP

    I have a thought – I have actually always believed the following: a powerful force together would be all primary care providers together. NPs (I am one and own a private practice) are already practicing almost all of the time (more than not) without family physician involvement (not specialist, family physician). The greatest way to achieve the goals of BOTH of our professions is to join forces. We would be unstoppable together. The AAFP should stop fighting against NPs attaining full practice authority. Once it is achieved, what will change? NOTHING. NPs will still work in teams with physicians and will still be employed by large institutions. A few of us will open private practices. But, all in all it will stay the same. Once both professions realize this is the way it is going to be, there will be no more antagonism, toward each other from the AAFP and AANP. We will have no “beef” with each any longer. Then we can join forces against CorpMed. That one little “captain of the ship” issue keeps us from forming the greatest coalition of primary care providers in the world. I believe it.

    • buzzkillersmith

      I myself have no problem with NPs working independently or running PCMHs or whatever. But I really don’t think working together is going to happen much, to a great extent because we are abandoning the field.

      Do you know what the med students are up to? Physicians are going to hand primary off to you all almost completely and you all will be running the show, if you’re willing to do so. Medical students have virtually no interest in practicing general medicine.

      • NPPCP

        Buzzkiller, you will enjoy this. I recently had a family practice student about to start residency in a NE state come to my NP practice for a visit. He wanted to know about all my numbers and demographics, etc. He started lecturing me about the “PCMH” and how it is the “wave of the future” and it is what they are teaching in primary care. Well, little did he know what I knew. So for the next 30 minutes I commenced to REALLY educating him about primary health care delivery and the realities of the real world. He had NO IDEA that NPS practice independently and literally wanted to know who was responsible for my clinic and who led my PCMH. I told him “me, my wife, and our 401K were responsible.” What’s the point? New FPs have no clue about the real world and how primary care operates. It’s a sad state of affairs. They won’t know what to do when they are finished and will automatically gravitate toward CorpMed because that is what they have been taught. Just as the time we need more PRIVATE FPs and NPs. The whole discussion was a sad sad deye opener for me.

        • buzzkillersmith

          Well, I guess if this guy is dumb enough not to know what’s going on there is at least one doc dumb enough to go into primary care. I’m not sure if that’s good or bad….

  • Rob Burnside

    Very well put. I knew some of this but couldn’t quite connect the dots, and it’s been a long time since Econ 101. Even so, I doubt I would have been able to fully appreciate decoupling without your help. Thanks, and best wishes!

  • Rob Burnside

    Thank you. It’s so simple when stated this way, and it’s easier to see where much of the “overhead” comes from.

  • http://www.myheartsisters.org/ Carolyn Thomas

    Glad you weighed in here, Dr. D. I too cringed at this “battle” metaphor, particularly “meeting the enemy” and “weapons in the fight”.

    Margalit, when you write: “There is no way you can convince the nine out of ten Americans who would
    gladly trade places with you that your work is hard, your life is
    hard, and your six figure income is inadequate compensation for lack of
    joy at the office”, it reminded me of this comparison from Lauren Collins in The New Yorker last month:

    “… like business-class passengers lobbying for more leg room…”

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

      Hi Carolyn, yes, it does sound petty and insensitive. That’s why the issue needs to be reframed to what it really is.
      They should lobby (fight for) a larger plane so that coach passengers don’t asphyxiate in their crammed quarters.
      First it’s no fun to fly with dying passengers behind the curtain, and second, a proportionately bigger plane will by definition increase the legroom for business class as well.

      And since, other than incessant empty rhetoric, nobody is currently inclined to do anything for coach passengers, and since coach passengers are encouraged to believe that their shrinking accommodations are due to business class greedy passenger’s expansion, I think those who want to maintain a place in business-class ought to lead the fight for better conditions for all passengers.

    • DoubtfulGuest

      I actually see “battle” as apropos… isn’t it in medicine that the word tends to have the most positive connotations, i.e. battling disease or fighting for one’s life? We might like the outcome: happier healthier doctors with more time to actually take care of patients.

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

        Yeah… I wasn’t calling for muskets in the streets :-)

      • http://www.myheartsisters.org/ Carolyn Thomas

        You bring up an important point, Doubtful. It’s true that medicine perpetuates combat metaphor, but you may be shocked to learn that many, many patients do NOT see this labeling as “positive”. In the world of metastatic breast cancer, for example (the cancer that’s essentially ignored by all that happy cheerleading pinkification of fundraisers who don’t want us to look at the messy reality of breast cancer mets), to adopt this offensive “battle” metaphor assumes that somehow you didn’t quite battle hard enough or in the correct way if/when your cancer metastasizes and you die. Just look at the public firestorm from breast cancer patients worldwide that recently greeted the NYT’s unfortunate Bill Keller when he dared to call Stage IV breast cancer patient Lisa Adams a “cage fighter”. Do some homework – read “The Language of Cancer” http://www.breastcancercare.org.uk/news/vita-magazine/language-cancer

        • DoubtfulGuest

          Thanks, Ms. Thomas. Re: “Do some homework”, I agree that a combative tone can be counterproductive :) Not shocked at all…I agree that social pressure to “win a battle” is harmful for many cancer patients. I previously read and concurred with a similar article to the one you linked. However, “many, many” is not all patients, I’ve personally known some who preferred and adopted the “battle” metaphor. I also didn’t focus specifically on cancer or any other category of disease. I was thinking in more general terms of disease — “been there, done that”, thanks. I really don’t care what language doctors use here – especially not less than a week into starting something. They don’t want to hurt or kill anyone…quite the opposite. Any major social change is going to have stumbling blocks early on. I just want to see what they come up with and if I can do something to help. If I disagree with steps they’re taking, I’ll say so, but in the meantime I prefer to give them the benefit of the doubt. I want well-rested, mentally healthy doctors who care about me, spend time with me, do their jobs well, and if they make a mistake, to deal with it honestly and responsibly. I want you to get better care as well.

          • http://www.myheartsisters.org/ Carolyn Thomas

            You are correct, Doubtful. “Many, many” is not “all” patients. It’s “many, many”.

          • DoubtfulGuest

            Ms. Thomas, what would you like to happen? What improvements could you suggest and what might you contribute to get things moving in a direction you’d like to see? You’ve already said what you don’t like – that’s the easy part.

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

    Hi Dr. D, I think you are more interested in helping individuals to make the best of a lousy situation, while I am more interested in the macro view.
    I am not suggesting that people should complain more. I am suggesting that instead of complaining, they should organize and fight back. Yes, fight, because it is a fight. Pretending that it isn’t and trying to find a little place out of the way where you can survive a bit longer, won’t change reality, just postpone it.
    Doctors don’t live and practice in a vacuum. Large corporate interests are stripping the people in this country of both wealth and hope, and health care is just one aspect of it. There are 300 million people soon to be relegated to second tier health care, where good doctors will be a rare luxury, particularly primary care ones. I think doctors have an obligation to stand up against that, and it is possibly the only way for them in these turbulent times to maintain trust, leadership, respect, status and all that comes with those attributes.

    One question though: who is that “supervisor” that doctors ought to negotiate with? And where did it come from?

  • buzzkillersmith

    I agree with M. below. You two are really talking about two different things. Complaining to the sick person in front of you is foolish in the extreme.

    I agree with you and her that the strategy that is most likely to be effective is organizing, but it is still unlikely to be effective. Not all problems can be solved.

    One thing I have been interested in is employee doctors organizing unions. This seems to be so simple, and, with the shortage, would seem to be a good way of improving negotiating power. I wonder if it will come.

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

    Hey Dr. D. Yes it’s fine to disagree, although I’m with Buzz, and I don’t think we necessarily disagree, other than the serenity thing. I want to see the courage, because sometimes trying and failing can be very beneficial to the long run…

  • DoubtfulGuest

    True…I’m encouraging them to do something, and reminding them they have some basis and precedent for it. I’m quite forward when I disagree with doctors. For those who are working hard to make things better, positive reinforcement seems like a better approach to me.

  • head_and_brain

    “Argument 1: Costs are outrageous.”
    Each time patients ask why the price is so high, the usual answer is, the cost is high. Then patients ask why the cost is high, cough, there is no answer anymore.

    “Argument 2: It’s mismatch of patient and physician that brings complaints”
    Phehaps physicians and patients should fill out a self-report personality form, and let professionals and computers determine the best match. Some patients might prefer physicians with multiple offences of insulting patients.

  • PamelaWibleMD

    Study happy doctors to see what is working. I stopped complaining long ago and opened an ideal clinc. If doctors are victims, patients learn to be victims. If doctors are discouraged, patients learn to be discouraged. If we want happy, healthy patients, why not start by filling our clinics with happy, healthy doctors. There are many of us out here.

    http://blog.oregonlive.com/health-care/2013/07/the_ideal_medical_care_movement.html

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

      Hi Dr. Wible, I have been a fan for quite sometime. The problem is that you practice outside the system, so to speak. There are others that do as well, and they seem happy too. There are even some that found a way to make peace within the system. But, by definition, the majority cannot leave this behemoth system, and if we want the silent majority to be happy, we have to somehow change the entire thing.
      I also find it inspiring that what you did in the micro, (i.e. brought the patients in and asked them to help you design your/their practice), is really what I want to see on a macro level. Have all doctors ask all patients to help them shape the “system” to better serve the people it was intended to serve.

  • DoubtfulGuest

    No, I see what you mean now. Good point – thanks.

    • Patient Kit

      I still trust doctors way more than I trust insurance companies or the government. But that’s not a very high trust bar and my trust in doctors is eroding. Another example: As a patient, I feel increasingly caught between wondering whether insurance is denying necessary tests to save money and whether doctors are ordering unnecessary tests to make money. I’m thinking of the Choosing Wisely campaign, which really has me wondering much and trusting less. I mean, it’s saying that so many routinely done things in medicine are unnecessary. What am I supposed to think? I want doctors as a group to start doing a few things that will help me trust them again. All this eroding trust undermines the idea of building a good doctor-patient team to rage against the machine.

      • DoubtfulGuest

        Yeah, I apologize for being a little slow on the uptake. You make good sense. As far as what’s happening, I think it’s some of both? Insurance companies want to deny benefits wherever they can. Doctors could make money from tests, but only if they have at least part ownership of a lab or imaging center, as far as I know. Defensive medicine is a huge factor in wasteful unnecessary testing. Lots of workup is done for butt coverage, to put it indelicately. Lawyers have too darn much power and we have weaker relationships with docs than in years past, so we’re all giving one another the side-eye. Then there’s quality mandate stuff (which I know nothing about), under which doctors can be penalized for not running certain screening tests on “appropriate” populations, regardless of patient preference. And the paperwork headache – I read somewhere about a doctor who had to justify why a female patient wasn’t given a PSA test, or something equally ridiculous.

        I have trouble trusting them, too. Honestly sometimes it’s more of an intellectual exercise — how do you build something out of nothing? We shall see…it’s worth our while to try.

  • head_and_brain

    Good Housekeeping is a magazine. Imagine the house as health profession, the host as regulation body, residents as doctors, neighbors as patients. Doctor A noticed his roommate, Doctor B, started to acting strangely and might pose dangers to others and to him/herself. Doctor A chose to tolerate and not report to the host. Days went by and Doctor B started causing disturbance in the neighborhood. Neighbors complained to the host, but the host also took no action. As Doctor B caused more disturbances, and the host plus doctor A still took no action. Eventually the neighbors regarded the house disorderly, and most residents causing disturbances. There are a few residents who are behaving well, but neighbors view those as “survivors”.

  • th3o6a1d

    “”If you are going to speak up, make public statements, write blogs, start a movement, or just post an anonymous comment somewhere, you should stick to your high ground, your guns and your strategy to inform the public about health care issues that matter to individual people…[Patients] need to know that advocating for [them] may draw disciplinary actions from your handlers, and financial retribution from your masters. They need to know that medical ethics are largely outside your control now, and subject to lobbying and political patronage arrangements..”"

    Brilliantly said. This is indeed a “battle” for the soul of medicine, and the old tactics aren’t working. And they won’t work. Changes are coming, especially with the advent of new technologies, that will further strip doctors of their status and challenge their usefulness. The only way doctors will come out looking like the good guys is if they center all of their efforts (especially in an organized manner) on actually improving the health of nation. This means more preventive medicine, more primary care and less end-of-life care, alternatives to fee-for-service, killing evil insurance companies with the flaming sword of righteousness. Hopefully, the new world order that doctors create won’t resemble the system we have now.

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