Medicine is like blackjack: Physicians need to count cards

Medicine is like blackjack: Physicians need to count cards

In the game of blackjack, players will attempt to increase their odds of winning by using the frowned upon method of counting cards. Then basic principle is to add or subtract points to the cards dealt under the believe that the cards remaining in the deck are more or less likely to give the player a winning hand. Not a guarantee, of course, just trying to tip the odds in the players favor.

Over the past several years in has sadly become more clear that providers’ survival will depend on a similar strategy. The last straw is currently being thrown on providers’ back in the form of reimbursements tied to nebulous quality measures. Those of us who have been in practice for many years have discovered that outcomes are more often then not dependent on factors over which we have little control.

How then do we count the cards to tip the odds in our favor? The answer: The simple realization that the more complex the problem, the more likely there will be a poor outcome. The more complex medical issues tend to occur in those patients who are the most uncooperative, cause you the most stress, take up most of your time, have the most comorbidities, most litigious, and least likely to have adequate insurance. Add to this the added new burden of these patients being the most likely to give you poor quality marks and you have a recipe for disaster.

Nowhere are these issues more obvious then the emergency room. Among the numerous issued involve in taking ER call, how many so-called quality surveys ask patients how long they had to wait to see their physician, not taking into account the fact that the physician may be responding to an emergency? Fortunately for providers, there is one card we can play, the fact that the more common problems tend to be the simple ones.  It is far less stressful, and now more lucrative, to deal with ten simple wrist fractures in children, even if all of these children have Medicaid, than one uninsured drunk with an open tibia fracture at 3 a.m.

Also, the more common a problem, the more experience and comfort you have in dealing with it. In other words, although patients with complex problems may be only 5% of your patient population, they take 30% of your time, cause 40% of your stress, be 50% of your litigation risk, and be 60% of your uninsured population. At the same time they actually may cause us to lose money in the form of poor reimbursement and time lost for other patients: especially with reimbursement tied to poor quality marks. Is it any wonder we no longer wish to deal with that 5%?

I recently read another in a long list of studies trying to explain why more complex patients are being transferred to tertiary care hospitals when it is felt they could be treated locally. The conclusion always seems to be that more studies are needed. Really?

Although it will be frowned upon,  providers’ survival now depends on counting the cards correctly.

Thomas D. Guastavino is a physician.

Image credit: Shutterstock.com

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  • Dr. Drake Ramoray

    Excellent article. While only a microcosm of the practice of medicine as a whole this is one of the reasons why endocrinologists are looking to get out of diabetes care. Thyroid is more straightforward, still requires our expertise, and their almost never prior authorizations for medications or testing.

    I would expand on the article further and make the case that these pay for performance schemes will also have physicians gravitate even further to wealthy suburbs and other affluent areas. Think of it as stacking the deck in your favor. Rural and underserved care will be hurt by these “incentives”.

  • HJ

    I have complex medical issues and for the past 15 years, I have mostly been brushed off by my doctors. During this time I had a Cadillac insurance policy that paid well for an office visit.

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

      This is a very important observation, and I would like to try and address it. It’s been said that the current fee for service system creates perverse incentives for doctors to to do “more”, and this is largely correct, but not because of the model itself. The problem was and still is that we have a uniform fee regardless of service.
      So a physician gets paid the same for treating a moderately complex patient and one that is very complex and extremely difficult to treat. This has always created a tendency to “refer” the most difficult patients out, and it also caused doctors to stop going to hospitals, and generally it caused the much lamented “fragmentation” in the system. This is also at the root of the complaint that there isn’t enough time to spend with patients.

      Unfortunately, it seems that new reforms are just going to make things worse for the most underserved patients, because physicians will be asked to assume risk for their patients, and because so called quality measures are like removing splinters with a chainsaw.

      The simple solution of paying doctors for time spent with patients, although it fails to resonate well with the bureaucratic powers to be, would actually make it much more likely that people with serious conditions will not be “brushed off” by anybody. Couple that with properly measured quality of care, which is extremely difficult, and we could most likely see some serious benefits to patients.
      But, since benefits to patients is not the goal here, we’ll just have to settle for saving job creators and their shareholders some more money.

      • buzzkillerjsmith

        because physicians will be asked to assume risk for their patients.

        Bush “Fool Me Once…” – YouTube”Fool me once, shame on you. Food me twice, won’t get fooled again.”

        • Suzi Q 38

          “Fool me twice??”

      • Dr. Drake Ramoray

        I know a direct pay doc who bills with a stopwatch. No set fees for appointments. Start the watch and go. He is no longer amazed at how prepared his patients are for their appointments.

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

          Fantastic idea :-)

      • HJ

        Unless the doctor is paid an hourly wage, there is still incentive for the doctor to brush off patients with complicated issues. That $500 an hour my insurance allowed didn’t provide any incentive to think outside the box.

    • Patient Kit

      I’m really sorry that you’ve been treated — or not treated — so badly. Your experience highlights that this dumping of complex patients by doctors is not some brand new unintended result of the ACA. It’s been happening for a long time before the ACA ever became law. And, while the ACA may have some huge problems and flaws, I think it’s extremely important to remember that healthcare reform/the ACA would never have happened if our healthcare system pre-ACA wasn’t such a heartless souless mess. Sure, it was working for some patients and doctors, maybe even for most doctors. But those “good old days” left far too many people out. Our pre-ACA system wasn’t working either for many. And that remains true with the ACA. So, this work in progress must continue until we get it right.

    • Suzi Q 38

      It may get to a point where we will be treated by the NP, PA, or “Watson” the diagnostic computer. The patient App by Apple may assist also.
      We will then be forced by process of elimination to seeing only specialists after the initial visit by the PA or NP.

      Where else would we go?

    • DeceasedMD

      Sorry to hear that. Did you ever try going to an academic center?

      • HJ

        I relied on Dr. Google and some very nice alternative care providers.

        • DeceasedMD

          well glad it helped. sorry that the other visits were of disappointment to you.

      • rbthe4th2

        Even there I could be stymied and not all can go to an academic center, either financially, too far away for drive/flight, etc. or can’t take time off work for it.

        • DeceasedMD

          oh I agree. It is tough because they will take tough cases but often test too much and waste your time as well. it depends. Plus not everyone can go as u said.

          • rbthe4th2

            Well so far I’ve had good and bad luck with those. They have tested but at least they do rule everything out. The problem is that they still have the mentality that if the blood test doesn’t go way off the scale, things have to be fine.

          • DeceasedMD

            how true. It is an art not a pure science.

          • rbthe4th2

            LOL the problem is that I supply the science, and the art only colors in between the lines. ROFL …

          • rbthe4th2

            LOL the problem is that I supply the science and the art they provide only colors between the lines. ROFL.

      • Suzi Q 38

        I used to do this regularly, when trying to educate a doctor or two. You see, some just don’t have the time….especially the surgeons. They have no time to look up something obscure or weird like a “borderline proliferating tumor, or giant cell arteritis.”
        They would rather just cut first and ask questions later.
        Surgeons like to cut.
        I like to go to the nurse’s library and access medical sites and studies (like Up to Date and others) at the teaching hospital.
        Remember it is your body. Be informed before you agree to any surgery or complicated procedure.

        • DeceasedMD

          I completely agree. I think that is even a problem in direct care. It may be a solution for the physician but not for a pt with complex issues who may need a referral to a tertiary center. I am not sure of any place where docs talk to each other. The best that seems to happen is an email exchange on EPIC which is a far cry from collaboration and that seems highly uncommon everywhere as well.

  • DeceasedMD

    Great article. These kinds of pts have always been challenging. The joke during residency was to put them on bus therapy so they would travel elsewhere. But seriously now, they may have new ACA insurance but no doc willing to treat them. With more and more cherry picking the straightforward cases, the less care the difficult pts will get. Even if they are seen they will be shunted through the system rather than treated. When the system is set up to make as much money as possible it becomes like a Ford factory producing the same mediocre cars. And when there is no incentive to treat these pts, they will sadly be abandoned. Only in medicine, the more difficult the job, the less you get paid. And the more residents don’t get to work with these challenging cases, the less skilled they will be at handling them.

    • Patient Kit

      “…there is no incentive to treat these patients, they will sadly be abandoned…”

      This is very disheartening and scary, to say the least. Inhumane, to say more. And while I’m not a particulary complex patient myself (and am actually a very “good” patient), any one of us could be relegated to the complex patient trash bin at any moment, with one stroke of bad luck. But for the grace of God.

      By incentive, you mean financial incentive, right? Is there no way, even inside Corp Med, to find a non-financial incentive to do the right thing? Starting with the awareness that none of us are immune from becoming complex and abandoned in such a system?

      If this is really where we are headed, I guess my next question is whether it is an unintended or intended consequence of [fill in the blank]? And are we going to just accept it? And if not, what are we going to do about it?

      Personally, I cannot accept abandoning any portion of the population to that trash bin….especially those who are sickest, because they are sickest. If we are at a point where most doctors will accept doing this, we are in even deeper trouble as a culture than I thought.

      • PoliticallyIncorrectMD

        Cannot agree more! Luckily, one of the unintended consequences of changing healthcare landscape would be forsing those who shouldn’t practice medicine to look for alternative means to get reach fast. True professionals who practice medicine for right reasons would stay and provide exceptional care.

      • buzzkillerjsmith

        “If we are at a point where most doctors will accept doing this, we are in even deeper trouble as a culture than I thought.’

        You’ve almost gotten it. Substitute species for culture and you will see the light-or darkness. Whatever.

        Soon you might enter the gates of buzzkillerland. Another soul lost to the recognition of the horror, the absolute horror.

        Not that bad really. Kind of interesting in a dog lab sort of way.

        Dog lab interesting: This is med school jargon for a situation that ends horribly but is actually kind of interesting. It comes from anatomy lab where you put dogs from the pound under, mess with their cardiovascular system by giving them various drugs and cutting or clamping various parts and then just kinda seeing what happens. Things don’t end well for the dog.

        Hurricanes, volcanic eruptions, gigantic bi-concave asteroids hitting the earth and reintroducing an Age of Reptiles, only this time they’ll get it right ( I think a fair amount about this one, way too much if truth be told), financial crashes, etc.

        Of course dog lab is not interesting at all if you’re the dog.

        I think I’m going to watch Apocalypse Now now -not for the first time.

      • DeceasedMD

        I agree. The pressures in CorpMed are to perform tests not really to diagnose. And you are on a clock. The average PCP visit is I believe 12 minutes. Anyone can correct me if i am wrong. That is not enough time to deal with anything complex. If a pt is fairly straight forward and their treatment requires a procedure, you are probably in luck. But if your treatment requires a lot of thought or discussion kind of like Drake’s diabetes pts, the pay is lousy and the time required to spend is not there in CorpMedland.

        • Suzi Q 38

          I know older family members and friends who tell me that they are having a lot of difficulty finding a physician who takes Medicare.
          They also tell me that they are only allowed to talk about one problem with each office visit.

          • DeceasedMD

            exactly. i was just going to say that. And these are not necessarily “difficult” just have multiple problems. Sad that medicare works that way. And this has been going on a long time way before ACA.

          • Suzi Q 38

            This conversation happened two weeks ago, in Honolulu, Hawaii.
            The seniors there are used to it and laugh about it.

          • ninguem

            Some people, retirement allows you more time to obsess over things.

            I’ve had Medicare patients walk in with three pages of “problems”.

            Both sides.

            Single spaced.

            Typewritten.

            And they really do think all of that will be addressed in one visit.

            How many problems should you discuss at one visit?

          • Suzi Q 38

            “……How many problems should you discuss at one visit?”

            I type up a list of my medications and vitamins, plus any unusual symptoms or questions that I have.
            I want you to consider that I only see my GP twice a year, and certain specialists once a year.

            I thought that the best way to handle a patient like myself is to send the nurse in first. This happened at one of my visits with my neurosurgeon in the last year. She was quite knowledgable, so she answered most of my questions. By the time the doctor walked in, I only had one question for him.

            I have a “touch” of OCD, so a list is mandatory for me. I like lists.
            As far as how many problems I would discuss?
            One prominent problem and then one or two lessor problems before I let you out of my patient room.

            My PCP knows how to handle me and allows me two or three questions. My insurance only pays him $45.00. I try to make the visit a fast one, but I make sure that I have the information that I need.
            He is usually quite curt and direct. With that tone, I am the same. If he tries to rush out too fast, I ask him to “wait one minute, please.” Then I ask my last question.
            I also bring him and his staff 2-3 trays of Fuji apples from Costco. He likes them.

            I figure one for the doctor and his family, then one for the nurse who processes my insurance, and another for the receptionist who makes my appointments and calls in my prescriptions to one of two different stores, whichever is cheaper (I can also get in to see the doctor whenever I want, even the same day that I call…the doctor has no idea that the receptionist does this for me and has done so for 10 years, LOL).

          • SarahJ89

            ninguem,
            I have to agree with you that some people really do seem to focus way too much on what I’d think of as minor annoyances. Frequently this feels like a manifestation of anxiety to me. But I’m more the type to tough things out, which can cause problems in the other direction. It pretty much takes a broken arm or the need to have a prescription renewed annually to get me into a doctor’s office. (Seriously sprained skiing accident ankle didn’t do it. I just rented crutches and borrowed a walking cast from a co-worker until 7 weeks later when I knew I needed PT.)

            I have two questions for you:
            1) What do you think you could do to get people to sort out the wheat from the chaff in their list of problems? I was a special ed teacher and discovered the inability to pull out relevant from irrelevant information is pretty widespread. It can be a case of the way the person is wired or, again, anxiety at work. You may be seeing this phenomenon in your office. Also, you probably have superior skills in that area (very helpful in academics) without realizing it.
            2) How do you assess the functioning of a system as a whole if you are only looking at one part? That’s what “one problem per visit” translates to me. I realize you have not said “one problem only” but would love to have your take on that concept.

            Lastly, Bette Davis was right: Old age is not for sissies. I’m only 66 but after the aforementioned skiing accident and broken arm, plus a bonk on the ice which caused me to see stars and have a bump that lasted for months… I find myself becoming quite the little squirrel about walking around in winter, especially if it’s an open winter (little snow, lots of ice). I feel vulnerable in a way I never did before and at what I consider a relatively early age.

            Lists are also good for those of us with abysmal memories. I usually have 5 or 6 items (none very long or hard to describe) on my annual visit, rattle them off like a buzz saw to get them in, then let my doctor prioritize them. I can’t. I lack a medical degree. This seems to be okay with her.

          • SarahJ89

            Being able to talk about only one bodily system at a time ensures poor care. The whole reason primary care MDs are so valuable is their unique position of being able to look at the whole picture. (That would be the one with more than one bodily system, striving as a whole for homeostasis.)

        • SarahJ89

          So far my sweetie and I have been in pretty good health. But he’s developed some cardiac problems in the past two years (electrical, not plumbing). This has ushered us into the Wonderful World of Specialists. Yikes.

          What we’re finding is that the thought process of younger doctors seems to end in Text X or Test Y, not in a diagnosis. Also, there’s a huge rush to medication, with no effort made to put symptoms in context, find out what’s causing them or try non-medication approaches first. Actually, it really seems in the past few years that the definition of symptom and diagnosis have become conflated. Treatment is always medication and always directed at the symptom, with no desire to think about possible etiology.

          I find this all quite puzzling.

          • DeceasedMD

            I can sympathize. I have an older family friend who just walked away from cardiologists that were insisting on invasive tests, that were no doubt lucrative- but I think in all fairness, the guidelines are just not clear. Some believe in stents for all elderly pts-or at least seems that way. It is quite puzzling as a pt. The friend in the end was right that no stent was needed.

            I hope your sweetie is comfortable with whatever he decides upon. It is not easy being a pt.

      • Suzi Q 38

        What ailments are you talking about??
        There are specialists who treat cancer and cardiac problems.
        I have not had a problem finding a doctor to treat me at all, and I have had a myriad of problems.

      • rbthe4th2

        I have that now. Thanks to a surgeon who had a personality/attitude/ego problem it was made worse.

  • Patient Kit

    I sympathize with the pressures doctors are under, but I’m trying to understand what you are advocating as a response to those pressures. Are you saying that, in order to survive, doctors should refuse to treat complex/problem/’bad” patients and should instead dump (or refer) those patients — into other doctors’ hands?

    How do you choose which docs to unload those patients on? Do you see this as a strategy mostly for primary care docs or for specialists too? I’m not quite clear on where you are advocating sending those patients that you don’t want. Are you saying that private practice docs should send those patients to hospitals/Corp Med?

    Believe me, I intimately understand what it means to be in survival mode in more ways than one. But identifying a whole chunk of the American population as too risky or unworthy to treat sounds like a very slippery slope to me.

    BTW, with all the medical care I’ve been through recently, I’ve yet to receive one of those much-lamented patient satisfaction surveys.

    • Thomas D Guastavino

      Thank you for your response. The purpose of this article is not to be an advocation. It is a warning. If current trends in healthcare continue then some patients, especially those with complex issues, are going to find it increasingly difficult to obtain the care they need.

      • Patient Kit

        I’m glad you’re just warning, not advocating. That was actually not clear to me while I was reading your post. Together, we need to somehow do something about this. Routinely abandoning our sickest people is totally unacceptable. And really bad for our collective karma.

      • rbthe4th2

        We already are.

      • PoliticallyIncorrectMD

        “[It] is not to be an advocation. It is a warning.” You are speaking as if we are just bystanders. It will ONLY happen if our profession will let it happen. Sounds very much like you are asking for forgiveness or excuse before doing something you know you should not do.

        • Thomas D Guastavino

          You still have not answered my question.

          • PoliticallyIncorrectMD

            Look under one of your other comments. I thought I gave very specific answer. In short, it will be too much to bear only if it directly puts my or my family’s life, health or basic needs at risk.

          • Thomas D Guastavino

            Le

          • PoliticallyIncorrectMD

            I thing this is demagoguery. What is your point? Here is mine. This is free country. You are free to choose your lifestyle. You are free not to provide services if you feel that you are not adequately compensated. You are free to do other things than medicine if it is not lucrative enough. I am free to practice medicine even if it does not make me top 10% of high earners. I am not alone. There are many people in the field who are motivated by other incentives than $$$. Long term, we will provide better care because we put the patient first. Good luck with your business endeavors!

          • Thomas D Guastavino

            First, I am not trying to make a point. Since you are setting the parameters (“As long as out basic needs are satisfied we should put up with the inconveniences” ) I was simply asking you to clarify as to what you define as a basic need? If you are unable or unwilling to do so, so be it. You call it demagoguery, I call it avoidance.
            Second, if you admit that there is freedom of choice then how can you belittle those who make choices that may disagree with you? Believe it or not we care as much for our patients as you do and we feel that the road we are on now is not going to end up well for providers or patients. Your “if you don’t like it then just leave” attitude is not only insulting, it is counterproductive.
            Finally, I too wish you luck with your future in healthcare. If nothing changes you are going to need it.

          • PoliticallyIncorrectMD

            1. There is no avoidance: I was clear about what my needs are. I cannot define it for somebody else, though as I mentioned basic needs are usually similar. You were trying to provoke me to say something so you can accuse me in trying to redistribute wealth. I am not for it. You could have asked me directly, avoiding being intellectually dishonest.
            2. Having freedom to make a choice does coexist with possibility of good and bad / right or wrong choices. Stating that I think your choice is wrong is not belittling anybody. It is simply stating my opinion.
            3. Stating the truth no matter how hursh

          • PoliticallyIncorrectMD

            1. I stated what my basic need are. I cannot decide this for someone else. Although, as I stated earlier the basic needs are usually similar. The way you word your questions makes me believe that you are trying to accuse me in trying to redistribute wealth. If you think so just say it – it will be more intellectually honest. Just for the record – I do believe that anyone is in titled to keep the fruits of their labor.
            2. Having freedom to choose does not imply that all the choices are right. I happen to believe that your choice is wrong. This is not belittling, just my opinion.
            3. When you call something “counterproductive” it bags the question “to what?”. To the great monetary benefits physicians always enjoyed – perhaps, to good patient care – not necessarily.

          • Thomas D Guastavino

            To Quote You:
            “Perhaps the supporters of “counting cards” approach should leave medicine altogether to become professional gamblers”
            “Sitting in your cushy office and complaining about your collections going down or about having to make an extra call to the insurance company is inconvenience! ”
            Sounds awfully like belittlement to me.
            And since you brought it up:
            “As long as our basic needs are satisfied we should put up with the inconveniences”
            Sounds awfully like “From each according to their ability, to each according to their need”
            Judges??

          • PoliticallyIncorrectMD

            1. Belittle (verb) – make (someone or something) feel unimportant. If I recall correctly I did not make a single remark about your personality or behavior. I simply stated that in my opinion patients are better served by physicians whose actions would not be swayed by the level of their compensation. If it makes you feel unimportant, I apologize.
            2. I did not say “we should put up with inconveniences”. I said I choose to do so because it is my belief that it is the right thing to do. You are free to choose the way of actions you see fit. Our patients will be the judges.

          • Thomas D Guastavino
          • Thomas D Guastavino

            First, I never thought any of your remarks were directed at me personally so there is no need to apologize.
            Second, You state that “in my opinion patients are better served by physicians whose actions would not be swayed by their level of compensation” Are you now stating that physicians should continue to work no matter how much reimbursements get cut?
            Third, you state that it is your belief that we should put up with the inconveniences because it is the right thing to do. I would like to go back to my original question that I asked you that started our conversation. Is there a level of “inconvenience” that even you would have to admit is to much to bear?

          • PoliticallyIncorrectMD

            Should physicians continue to work no matter how much reimbursements get cut? “No” in a sense that in a free society physicians ( or anybody else) should not be forced to do anything. “Yes”, in a sense that many physicians would continue to do so on their own accord as they feel that it is the matter of their ethical and professional responsibility to the society. Not to say that they should not continue fighting for better pay at the same time. As far as my own case, I would continue practicing medicine no matter what. If I have to do something else to support my family I will and then would practice medicine as a hobby ; ). Is that straight forward enough answer ?

          • Thomas D Guastavino

            Interesting. So you would work no matter what? As well as not being paid how may other inconveniences are you willing to accept? How many hours would you devote to your “hobby”? Would you take ER call? How would you handle being sued for malpractice? A bad patient review ? What about a Medicare audit? A drug seeking patient?
            I could go on but the point is made.

          • PoliticallyIncorrectMD

            Medicare audit? Who needs to follow Medicare rules if I work for free! Malpractice? What malpractice! Who would care to sue if they cannot make any money off me? I can go on but the point is made. You, sir, are trying so hard to catch me in making some kind of logical error in my argument. There is none! I honestly want to do Medicine for the sake of Medicine. That is how generations of physicians have done it around the world and in this country. There are many who continue to do it now. I know it may be hard to comprehend coming from the perspective of seeng medicine as a job, source of income, business. You just have to trust me that people are different, and for some of us not everything rotates around $$$. Ironically not only we provide better care as there is no impartiality in our intentions, but also we avoid many stressors someone with your perspective has to endure.

          • Thomas D Guastavino

            WOW! Are you saying you intend to practice without malpractice insurance?? Maybe your state does not require it. Are you not concerned that they will come after your home, your car, your kids college fund? Do you intend to continue refilling the drug seekers prescriptions? What about ER call, or the bad review? Do you truly believe that you provide better care ( a level of care that you have yet to define) then the rest of us?????

          • PoliticallyIncorrectMD

            Bad review ??????!!!!!!!! Show your patients this dialog, see how many will stay ; ). Better care is easy to define: the one that puts the patient first! Not the rest of you, just some of you who entered Medicine for any other reason than to help those sick and suffering. “Yes” you are impartial by definition. And “yes” I am not stressed at all. You on the other hand… just look in the mirror.

          • Thomas D Guastavino

            Again….WOW!

          • PoliticallyIncorrectMD

            I would consider those inconveniences to be too much to bear if and only if they put my and my family’s life, health and basic (and I do mean basic) needs at risk.

          • Thomas D Guastavino

            I am glad you included as one of the “inconveniences” not putting ones life at risk because that actually happened to me. Would be please define “basic need” for me?

          • PoliticallyIncorrectMD

            I think basic needs are pretty generic: food, shelter, healthcare, utilities, transportation (fancy cars excluded : ) )…

          • Thomas D Guastavino

            And who decides how much food, shelter, healthcare, etc.. ?

          • PoliticallyIncorrectMD

            Most of people’ basic needs are same: you can only eat so much food or need so much space to room… Where are you going with this?

          • Thomas D Guastavino

            Everybodys idea of what constitutes a “basic need” is different. Who decides?

          • PoliticallyIncorrectMD

            Perhaps … How is it relevant to this discussion ? What is your point?

          • Thomas D Guastavino

            You have made it clear that you feel that as long as our “basic needs” are satisfied we should just put up with all of the “inconveniences”. So I ask again, if it is not us, who decides what is a “basic need”?

    • RuralEMdoc

      I see this all the time. In my ER the orthopod’s won’t touch certain fractures because the outcomes are so bad. I almost always have to transfer out certain fracture types, especially in the pediatric population. They have to be sent to a pediatric orthopedist.

    • buzzkillerjsmith

      Are you saying that, in order to survive, doctors should refuse to treat complex/problem/’bad” patients and should instead dump (or refer) those patients — into other doctors’ hands?

      How do you choose which docs to unload those patients on? Do you see this as a strategy mostly for primary care docs or for specialists too? I’m not quite clear on where you are advocating sending those patients that you don’t want. Are you saying that private practice docs should send those patients to hospitals/Corp Med?

      Very well put, Kit. What we are saying is EXACTLY that. Not that it should be done but that it is done more than you think.

      Years ago I worked in a practice in Roseburg OR. (Never, ever go there.) I took almost all comers, many many disasteromas, train wrecks. These folks took a lot of time and the money just was not there. The attitude of a lot of the pts was bad. They had been abused by this society and by themselves and often took it out on the people they would meet, including docs. The threat of a malpractice suit was palpable. The practice went belly up in 2 years.

      When they heard I was leaving the other family docs in the area decided they would start to be honest with me. “You take Oregon Health Plan?” They shook their heads sadly.

      Where to send these pts? Wherever. The hospital? Fine. CorpMed. If you can, although CorpMed is pretty smart. A community health center is probably more likely. You don’t have to choose a doc. You send the AMA boilerplate letter giving the pt 30 days to find a new one and you’re done.

      Some practices make pts fill out a questionnaire before letting them into the practice in the first place. Too many grammatical errors are a red flag. A comment like ” I have had pain everwhere for years and the docters don’t know why.” Too many medicines, too many medical problems, too many consultants.

      Practices do”wallet biopsies.” Cash on the barrelhead. No checks or credit cards. One of my OR partners said you must get cash before doing a circumcision on a little guy or the parents will stiff you.

      • ninguem

        Agree about Roseburg.

        When I moved to Oregon, it was a tort reform state.

        The tort reforms were overturned, thanks to then-Judge Kulongoski, who went on to become Governor Kulongoski.

        We worked for tort reform by Constitutional Amendment, in 2004. We lost.

        The people of Oregon had a choice. You could SUE doctors, or HAVE doctors.

        It was more important to sue doctors.

        So be it.

        But don’t expect any sympathy from me, if a complex patient in Oregon can’t find a doctor.

        • buzzkillerjsmith

          Three words: State of Washington.

        • buzzkillerjsmith

          Have doctors or sue doctors. Very well put.

        • Suzi Q 38

          The state of California chose to have doctors. There is tort law, and a cap on rewards for patients of $250K.
          Consequently, it may not be worth it to sue, especially if the injured party was a stay at home parent who did not work outside of the home.

          Add to that the fact that you have to prove negligence.

          I think that the situation in California is mainly to protect the doctor, rather than the patient.

          Move on down to the state of California. You as a doctor can totally screw up, still get paid, have a maimed or dead patient, and not get sued.

          • DeceasedMD

            so true Suzi, that each state is so very different and most people even doctors don’t realize this. You are so right but few know this. In general regardless most doctors are hypervigilant about legal issues, regardless of how unlikely it may be.

          • Suzi Q 38

            I think that a medical law class should be mandatory in medical school.
            At least have a lawyer who is a physician come and talk to all of the residents and attending docs.

            I had to put my surgeon’s mind at ease:
            I told him what the statute of limitations was in our state, how I allowed it to already pass. Even the tougher “discovery” statute date had passed, so it was better that he treat me to get me better, rather than ignore me, stall my referrals and delay care. Now I can sue him for delay of care rather than for the surgery itself having the bad outcome.
            (Not that I would. That would be “circus.).

            I told him that a person like me who only works part-time has far less to sue for than a person like his wife, who is also a physician and makes far more.

            Also, the insurance company would want to be repaid for paying for my surgery that was botched and my care.

            Another point is that all of this is very hard to prove, even though it makes him look very bad to his colleagues and the CMO.

            The doctors in California and other states with tort law and low monetary award caps need to seriously calm down a bit.

          • DeceasedMD

            Very true. plus the Boards are pretty lame as well for these kinds of issues.

          • Suzi Q 38

            The State Medical Board in California would probably take a year or so to get to your case, and when they finally did, they probably do nothing.

            I have thought of the state medical board in my case, but I decided not to file for now. Actually, I think that the statute to file is longer for the state board than it is for regular medical malpractice cases.

            I would have to look that one up.

            The thought of disliking a couple of doctors so much that I file something with the state board would surprise even me.

            Believe it or not, that surgeon that allowed me to yell at him for a couple of hours had an effect on me.

            After our conversation, I don’t hate him anymore.

            Now, if he had not called, I probably would have still been angry and taken it to the highest level that I could.

            I might also have at least filed a lawsuit and served it to him during work hours with a friend of mine as a witness. I thought of that, but then I remembered that recently, I YELLED at him for 2 hours…..and the yelling did not improve my medical condition. The young lady across the street is an unemployed lawyer. I would have simply given her some work.
            What would this have done?
            Gotten the attention of the CMO, who would have at least asked the doctor in question if his malpractice insurance was current.

            If I didn’t want to use my own money, my expensive PPO insurance (based on my medical history since my surgery) would have hired lawyers on my behalf. How do I know?
            They (the largest insurance company in California) have sent me not 1, not 2, but 3 letters asking if I thought that this could be the result of a malpractice error. Normally, I would have said YES!!

          • DeceasedMD

            It’s a hard decision. And you have been through a lot. I never heard of insurance providing medical malpractice for pts? Well sounds like you probably for the board have around 7 years for most states I believe.

          • Suzi Q 38

            My guess is that the insurance company’s interest is not to pay the hospital and doctors for my injuries and medical care claiming that it was the surgeon’s fault. Once the MS was ruled out, why did I sustain this type of injury so soon after my surgery? They could look at my records and find it not that extraordinary….but if you look at my records after the hysterectomy, I sustained the cervical spine injury that was allowed to go undiagnosed for way too long.

          • DeceasedMD

            my goodness you have been through so much plus not only the emotional toll. I am so glad you say you are stable. Unethical to not have you see a covering MD when you were so unstable and neurologically compromised. But I have witnessed this sort of thing with sloppy vacation coverage etc. and it is at best inappropriate and at worst harmful and careless.

          • Suzi Q 38

            Thank you, Doctor.
            You are right and are very kind.

          • Suzi Q 38

            Some of them, especially in the state of California for now, need to truly relax and just be good doctors.

          • DeceasedMD

            Agree. A pretty sad state of affairs. BTW if you don’t mind my asking, how are you doing? I have read your other posts and know you had a delayed diagnosis etc. I wondered if with time and proper tx you might be feeling better. At least I hope so.

          • Suzi Q 38

            Thank you, Doctor…obviously you are not deceased….why the sad name?

            I am doing better!

            As of May 2014, the MS physician has told me that “He did not think I had MS.” Inside, I knew that this was true, but both teaching hospitals made such a big deal about it being a possibility that I also wanted to make sure before I agreed to cervical spine surgery. Why have the surgery if I am “going down” with primarily progressive MS at the age of 57?
            Interestingly enough, I also tested negative on several tests, one of which was really risky for me to take. I was negative on the lumbar puncture, all blood tests, and the brain, thoracic, and lumbar MRI’s. The cervical MRI displayed a bright light spot, that they were sure was injury, but not sure it was MS.

            While they were all deciding about what to do with me, my walking ability began to rapidly decline.
            I tried to get down from a bar chair and put my foot down on the floor….I didn’t feel anything…it was as if it “melted” to the floor.

            After that incident, my new neurosurgeon was on vacation for the winter holidays and no one cared, LOL. I almost went into ER of the tier one hospital where my daughter worked, or took a flight up to San Francisco to see the brother of my son’s friend (both M.D.’s) The one in S.F. was a orthopedic neurosurgeon. I was so close to panicking and flying up there, husband and daughter in tow. The problem was that teaching hospitals are basically shut down on elective surgeries during the holidays, which is why I considered him. He worked for a private hospital…I decided to rest up, do nothing, and stay put.

            January came, and I finally got to see my new neurosurgeon again. I got in his face…nicely.
            I told him that I almost lost function in my right leg while he was on vacation. His nurses were no help, and the receptionist stalled me and did not refer me to another neurosurgeon on call.
            I have had nerve tests that determined that my right side is already damaged. Does he want me to not be able to walk at all??? What is he waiting for? Can his nurse and receptionist stall me like that when I needed help during a bad time?I told him that I really didn’t think I had MS, but I am not the MS doctor.
            I guess he checked with them, and I got my surgery the following week.

            To make a long story short…..I was in “limbo” with regard to the MS diagnosis for about a year and a half. The MS doctors were so nice, but they wanted me to take MS meds for my condition.
            I refused. I challenged them to prove to me that I had MS. Both sides were doing the “wait and see.” The neurosurgeon examined me at 6 weeks, 3 months, and 6 months. By 6 months, he told me that “You don’t have MS.” The MS doctors were still not convinced until this past May, when I told hime that while I still had numbness and pain in certain areas, that I have not declined since the early January 2013 foot episode and my symptoms and pain are alleviated with low doses of Nortryptiline or Doxepin, which are tricyclic antidepressants. I didn’t want to be on Oxycontin or Norco long term, so I tried these two generic drugs. They worked.

            I was told that I would not improve after a year post surgery. It has been a year and a half. I would say that I slowly stabilized (with the plate in my neck) the first year. I was slowly healing. After the first year, with the nortryptiline and Doxepin, I improved, as it lessened my pain and I was more free to move without as much pain.

            I could not blame those other two doctors (the gyn/surgeon) and his undergrad friend/roommate the neurologist) until I was sure that I did not have MS.

            Now that MS has been ruled out, even by two MS specialists, I am free to ponder that this was a bad outcome after my surgery of some sort.

            Thanks again for asking!

          • DeceasedMD

            I am so glad you are feeling better. The incompetence of how your case was handled is well.. pretty bad to say the least. If the MRI showed the lesion in your neck and an operation to boot, it is mystifying why they thought there was MS on top of it all? Just thank your lucky stars you feel better! So glad. Oh my name is meant to be a joke from practicing in the current state of medicine.

          • Suzi Q 38

            Thank you, doctor.
            The incompetence was alarming and made me angry. I realized that my state of health was being played with….doctors who did not want to admit wrongdoing or incompetence, so they hoped that my symptoms would magically go away without medical intervention.
            The MS symptoms mimicked the symptoms that the cervical spine injury exhibits, so I understood it a bit.
            I read in “up to date” that unfortunately, 5% of the patients with MS test negative. They thought that I was possibly in that minority population, so they did not want go give me a cervical spine surgery that would not help me if I indeed had MS.

            They had seen cases where the doctors and surgeons felt sure their patient had a cervical spine injury, confirmed by cervical MRI, yet the injury spot highlighted by a white area was instead MS. The patient had had the cervical spine surgery for nothing, and continued to decline clinically due to MS.

            I thought: “What next???” “What else can happen to me??”
            Thank goodness that my symptoms dictated to me that I had an injury rather than MS.
            I had to take my own “leap of faith,” and all worked out for me.

          • DeceasedMD

            That’s ridiculous taking a chance with a cervical lesion that could injure the nerve. Glad you are better. Sad to hear how unnecessarily painful this has all been for you.

          • Suzi Q 38

            Thank you!
            Your good wishes and empathy mean a lot.

          • DeceasedMD

            your welcome. I know it can be very disastrous when people are not treated appropriately. I don’t think enough has been done about these kinds of issues and esp. in light of HC problems in general it goes under the radar. In fact I think this will only get worse as HC itself is really sinking. Oh and my name was a joke I made up, but I suppose the serious part of it feels like I am conveying the decline of medicine as I knew it. I think we can all relate. i think pt’s that have more uncommon dx are going to have a harder time in this new world. When I was trained which was not all that long ago, physicians were really made to think and do full evaluations and physical exams. that day is gone sadly.

          • buzzkillerjsmith

            Wow, Suzi, you really ought to get up to speed on what docs think about practicing in CA. See my note above.

          • Suzi Q 38

            How do I see your note?

          • Suzi Q 38

            Where are the links?

          • rbthe4th2

            Your last sentance is why I disagree with tort reform. I’ve seen too many times that patients are shafted.

          • buzzkillerjsmith

            CA is an absolute nightmare for family docs. This is all over the internet. Worth a look.

          • Suzi Q 38

            Really???
            Send me some links.

          • buzzkillerjsmith

            Google California doctor shortage and Google Medi-Cal to get started.

          • Suzi Q 38

            Thanks.
            This is not what I was talking about.
            I was talking about tort law and the state of California.
            Your articles are talking about the primary care shortage and not enough GP’s and FP’s.
            This has been an ongoing problem, especially for the medicare and medical patients.
            By the time I am old enough to qualify for medicare, I might very well be seeing a PA or NP instead, as my doctor will retire before I will.

    • Dr. Drake Ramoray

      I took the post to be a warning, although again as if often the case the article is woefully mistitled. That being said this sort of game is already happening. The neurosurgeons in our area don’t actually do neurosurgery preferring to focus on spinal and back procedures, I presume for reasons as listed in this article. Although I could stand to be corrected on that.

      I have several patients who we’re dismissed from their PCP’s for being “too complicated”. I have had several patients who have been sent to a tertiary academic center for a procedure as they were felt to be complicated by the local surgeon. It already happens to degree, in some cases but the elephant in the room in this post and discussion is Medicaid. Almost everybody in private practice limits it, and as I posted earlier in some areas of the country I couldn’t find any private group that even took it at all. Medicaid patients on the whole are sicker, more complicated, and I’m not aware of any data (I have never looked) but certainly carry the stereotype of more likely to sue. They are also known to have worse outcomes (in some studies worse than people who actually have insurance.

      It is already happening more than is being let on. That being said the point of the article is that it will become more common with pay for performance schemes.

    • guest

      In order to survive in medicine, you have to:

      A) Derive at least some sense of satisfaction or enjoyment from what you do for 9-12 hours of your day (come to think of it this is true of all jobs)

      and

      B) You have to make enough money to keep the practice open and hopefully take home enough money to enable you to compensate materially for what you can’t do personally for your children (you can’t EVER make it to any of their basketball games but maybe you can afford to send them to a good basketball camp).

      These days, in order to treat a complex patient and not lose money, thereby eliminating your chances of achieving goal B, you have to spend so little time with the patient that you don’t get a sense of satisfaction, because you know you haven’t given them the best care possible. Thereby you don’t achieve goal A.

      I agree with Margalit that by far the most elegant and sensible solution to this problem would be to pay doctors the same way we pay lawyers: by the hour.

      • Suzi Q 38

        How much should that hourly rate be?
        Twice or three times as much as a nurse or NP?

        • guest

          Honestly, although I don’t make that much, and never will, I do not see what’s wrong with people getting paid that kind of money for a career in which you have to go through years of grueling training for which you are paid peanuts and then spend the rest of your working life staying up all night every few nights and performing work where, if you make a mistake, people can die.

          The stress of that type of work is incalculable and the fact is that people won’t sign up to do it just out of the kindness of their hearts.

          Now, if you’re talking about dermatologists and ophthalmologists making that kind of money I have to say I tend to agree that their current compensation structure is not equitable.

          • Suzi Q 38

            How about a radiologist, neurologist, endocrinologist, gastroenterologist, or a rheumatologist?
            There are a lot of specialists who make that kind of money. The surgeons make even more.

          • guest

            It always amazes me how people don’t know this about doctors. When you are a doctor, you take call, usually about once a week, if not more. When you are on call, you get called all night. When you are called all night, you don’t get to sleep. The, after a night when you have not slept, you get to go into work and work a full day, just like normal, except that you are utterly exhausted. Wash, rinse, repeat.

            It’s pretty simple, really. I don’t understand how it is that patients are so unaware of this aspect of our jobs. Clearly, we are not doing a very good job of explaining ourselves.

          • Suzi Q 38

            Thanks. Now I know what you are talking about.

            The nights you are “on call.”

            That would be rough, just as any job would be when you are used to using that time for much needed sleep.

            Do ob/gyn’s or ER surgeons fall into that category?

            While I am sympathetic, isn’t that aspect part of the “job?”

            Is this one or two nights a week, and does this vary depending on who you work for?

            I try not to call doctors at night or utilize the doctor on call during sleep hours.

            I have known doctors who will take less pay and do other work rather than take a job that requires too many nights on call.
            My friend is a pediatrician. She does not have to do on call work at night.

            Are firemen/women and police officers exempt from working late hours if there is an emergency?

          • guest

            These are all good questions. Here are some answers:

            Firemen and police officers work in shifts. Some of them work overnight shifts, and then have the next day off. They do not go in and serve extra time for emergencies without pay the way doctors do. They have the option to schedule themselves for extra shifts and get overtime pay for that, but that is at their discretion.

            Almost all OB docs and surgeons take call which means that they have to go in for emergencies, then work a normal day the next day, and there is no extra pay.

            If you are an emergency room doctor, you work in shifts, like a police officer or fire fighter. This is why this is a popular specialty to go into.

            Not every doctor has the ability to avoid taking call for less pay. Lots and lots of medical jobs are just structured so that you take call, because the coverage is needed. I think almost any doctor would like to have a job in which they took no call, but there aren’t enough of those jobs to go around. Someone has to be taking care of the patients at night.

            I suppose you could say that “taking call is just part of the job.” But then we should think about the fact that other parts of the job used to include a lot of professional autonomy and the ability to make a decent living. As both of those are eroded by a public who believes that we are overpaid and under-regulated, many of us wonder about the fact that we are expected to continue with the “bad” parts of our jobs without complaining about them, at the same time that the “good parts” are eliminated.

            If the public insists on pushing forward with these “reforms”, we will continue to see a trend for our brightest graduates to either not go to medical school, or to do everything they can to go into specialties where there are more reasonable expectations of them.

          • Suzi Q 38

            I understand.
            That would be a truly difficult part of any job.

            You can still change your life and ask to be paid.
            if you and your other physician co-workers ask for extra payment, maybe the management will figure out that it is important and give you some extra money.

            What would be fair?

            My husband used to hate his management position at a cleaning company when he was in college. The police used to call him up and get him to come to the building to open the doors so that they could inspect the building. Sometimes this occurred in the middle of the night. For whatever reason, the alarm went off and this was part of his job.

            My point is an oversimplification of your complaint.

            Either complain about it to change it, or look for another job that pays less but does not involve “call.”

            Don’t keep doing a job that you hate.

          • rbthe4th2

            I’ve actually told nurses in the hospital to not page the doctor. They thought my kidneys were shutting down. I am like … go find the hospitalist. They paged the doc. He said he wasn’t worried about it yet. I’m like me either because 5 hours later they had me hooked up. I sort of had that figured out, but the poor nurse was in state. I’m sure she would have been blamed.

          • Suzi Q 38

            It took me a few days to figure out that my mother’s GP could not come to the hospital, that there was a hospitalist. The hospitalist had no knowledge of what “Giant Cell arteritis” (located in the forehead area) was. We eventually had to call in an internal medicine doctor who had this condition listed on his CV as an “interest.”
            The hospitalists had no idea about how to prescribe mega doses of steriods to an 85 something year old woman then slowly rather than abruptly titrate the dose down in order to save her eyesight and then minimize paranoid behavior and delusions.

            We probably wasted a week figuring out that her medical problem was so rare and complex that the hospitalists weren’t working out……

          • rbthe4th2

            You have a point on the rare things, but for kidneys, a hospitalist should have been able to deal with that vice waking up my doc. This, btw, is teh same doctor who hoosed me over. Now if I can act that considerate of him, why is it I couldn’t get him to do that in RL?

            Any ideas from the HCP’s here?

          • Patient Kit

            I agree. We patients don’t really know how “on call” works. You need to educate us, raise our awareness. Is regular (at least weekly?) “on call”a part of all doctors’ realities — both hospital-based attendings and private practice docs? Please educate us. I’m genuinely interested in knowing.

          • rbthe4th2

            Actually some of us do, but when we ask for help for the docs, they dump our care and give a reputation for helping out. So why should we do anything?

          • rbthe4th2

            YES! I can see spending a bit of time on something, but I dont want an OCD doc. The one I had who was a huge problem, I got the very distinct impression that they needed to learn to disconnect so that they became one with the human race again, and NON MEDICAL friends needed to be a part of that.

          • rbthe4th2

            I see no reason for derm and opth. to get paid that, especially from what the female half got when looking at her skin problems.

        • buzzkillerjsmith

          What hourly rate?The hourly rate required to induce medical students and primary care physicians to do what we think they should be doing. This rate would be found by trial and error. Right now the rate is below what it should be.

          I would submit that lurking for answers is a victim of this. I would submit that it he or she had a doc that was adequately compensated for the work involved in taking care of him or her, things would be better for lurking. And for many others.

          Nurse, PA, NP? They want our jobs? They can have them. That’s what the med students are telling us by their actions. That’s what family docs are telling us when they bail out.

          We have a practice in a neighboring town that is tough gig. Four complicated pts per hour. Three young (<40) female docs are leaving, one to do naturopathy or some such nonsense, one to do bariatrics, and one to train up in pain medicine–procedures of course, not a narcotic mill.

          These docs will not be replaced.

          Look up Just Price Theory, its defects in particular.
          I'm not telling you how the world should be, just how it is and shall be.

          • Suzi Q 38

            ….Nurse, PA, NP? They want our jobs? They can have them.

            With the ACA, the hospitals, clinics, and the drug stores, the NP’s and PA’s et al have already made their plans on taking some of the jobs.

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

          My lawyer bills $350 per hour, which includes overhead for a rather luxurious office. So I would say $500 per hour for primary care is fair, and this should be the middle of the road for medicine, considering variability in overhead, intrinsic value, complexity and length of training.

          But the exact number really doesn’t matter that much. The important thing is to shift the paradigm, so spending more time with one patient is not considered a loss of revenue. Oh, and insurers should just shut up and pay what they are billed. They can do periodic audits, and automated checks for fraud (like billing for 20 hours every day or billing time for the same patient every day for a year), but that’s about it.

          • buzzkillerjsmith

            Very good idea, and I’d do it for 250 per hour, maybe 200.

    • Suzi Q 38

      I get those surveys regularly.
      I was wondering if the doctor or staff had some control over this.
      It seems as if they decide which patient gets the survey.
      The private doctors don’t have to do the survey at all.

      I always fill them out.

      • SarahJ89

        And I never fill them out. I don’t want to give the rapacious “non-profit” hospital that has sucked up every PCP practice in a 30-mile radius anything to work with. Plus, the information a patient would need to know (how many X procedures per year, morbidity and mortality rates, etc.) is withheld from us. About all that’s left is the doctor’s bedside manner and the quality of the curtains in the examining room. No thanks.

    • guest

      You probably haven’t received one of those patient satisfaction surveys because you’ve been going to well-run hospitals which have managed to maintain a respectful stance towards their doctors and nurses.

      This is not to say that I think patient satisfaction surveys aren’t a good idea. But as with anything else, their usefulness and the extent to which there are unintended consequences depends both on the quality of the survey (the current one in wide use, the Press-Ganey, has significant methodological issues) and how the results are interpreted and used by hospital administration.

      • rbthe4th2

        We asked to be put on the “do not survey” list.

        • Suzi Q 38

          Why? Wouldn’t a survey be your chance to evaluate the good and the not so good of any your doctors?

          • rbthe4th2

            NO. I ask for the practice managers and higher ups. For review/$$$ dollar time, they use that because patients may fill out surveys & it may get back to them as generalized set of data, but someone who is taking the time to go to the bosses and say hey I want to give you specifics of good docs’ care, you betcha your bottom dollar its going to be noticed a lot more than those surveys. It stands out. Big time.

            Plus, I’ve known when I’ve hit the practice managers that several have said they’ve sent it up the line to 1 or even 2 managers above.

            If you do good by me, I’ll make an impact.

            If you don’t, I just tell everyone until the cows come home.

          • SarahJ89

            Totally agree. Those surveys are just part of a shell game. When someone does an excellent job I make a point of telling their immediate supervisor, not some anonymous bean counter currying favour with JAHCO.

          • rbthe4th2

            You got it! I actually asked one how do you want a good review because I have things I want to tell you. They told me can you give it to us in writing because we’ll use it at yearly performance reviews and raise time.

            You best believe I had one to them in 3 days. I do the online surveys but its not unheard of for me to put in my EHR or whatever and to ask that the admin see it.

            NOTE TO ALL HCP’s!!! LOL.

  • PoliticallyIncorrectMD

    Perhaps the supporters of “counting cards” approach should leave the medicine altogether to become professional gamblers. Patients deserve to be treated by those who value patients’ interests more than own inconviniences. I am astonihed how many here are emphatic toward physicians but completely ignore the fact that patients are those suffering the most.

    • ninguem

      Is bankruptcy an inconvenience?

      • buzzkillerjsmith

        Bankruptcy is a strong word. I pulled the plug when it was clear that profit would never get above zero. So there.

      • PoliticallyIncorrectMD

        Are you referring to personal or practice? How common is it? I am not being facetious! Most of the physicians I work with (including primary care) have no problems keeping roof above their heads or feeding their families… though I do hear lots of complaints.

        • ninguem

          How common does it have to be?

          No, it’s rare to go into bankruptcy, the docs just leave and do something else. The unprofitable practice with unprofitable patients, is closed.

          What are those? Inner-city and rural of course.

        • Patient Kit

          Many patients, on the other hand, actually do lose everything they have and have to file for bankruptcy when medical bills mount as they try to save themselves or their loved ones when serious illness strikes.

          • Suzi Q 38

            So true.
            All of what you worked for for decades can be “wiped out” by a single, unfortunate, but complicated illness. Your health is your “wild card.”

            When I see articles on how simple it was for so and so to save for their retirement, I want to scream….I do , however, I see some common components to their success stories.

            They stayed married to the same spouse (did not lose assets and retirement in a divorce), possibly chose or did not have children to pay for and educate, did not spend a lot of money on large houses or other things, (like travel, restaurants, clothing),had few student loans (or paid them off early), were savers and stayed healthy or had few health concerns throughout their lives.

        • Suzi Q 38

          “….Most of the physicians I work with (including primary care) have no problems keeping roof above their heads or feeding their families… though I do hear lots of complaints.”

          Some may be frugal and have valid complaints, but others are not. I imagine it is difficult for anyone to be frugal, especially physicians.
          No one likes to be on a budget. It takes time, and sometimes physicians do not have the time to do so.

    • Dr. Drake Ramoray

      http://money.cnn.com/2013/04/08/smallbusiness/doctors-bankruptcy/

      It’s more like the private practice independent physician will cease to exist and everyone will get Walmart care at higher prices at the hospital based ACO/PCMH

      http://www.publicintegrity.org/2012/12/20/11978/hospital-facility-fees-boosting-medical-bills-and-not-just-hospital-care

      • Patient Kit

        I get that hospitals are the most expensive way to access medical care for both individuals and for the system.. But the constant rap from private practice doctors that hospital-based docs and hospital-based medical care is so inferior to private practice just has not been my experience at all. And frankly, if private practice docs are going to refuse to see me because there isn’t enough in it for them, the hospital-based, salaried docs who do see me and treat me very well are earning my undying respect, appreciation and loyalty.

        • rbthe4th2

          and the other half’s home baked goodies.

      • PoliticallyIncorrectMD

        I feel your pain… I really do… But lets call spade a spade. It is still possible to take reasonably good care of fairly complex patient. The thing is – a solo private practice may not be the way to do it. So, join an academic center or ACO (not all of them are evil) or talk few of your colleagues into joining forces. Unfortunately, if you are a businessmen more than you are a physician and the solo practice is the only business model you embrace you may indeed suffer.

        • Dr. Drake Ramoray

          For the record I have never dismissed a patient for being complex. I have referred patient’s who required a service that I could not provide (which is different).

          Personally, economics is not m y driving force but autonomy and freedom which is what I hold against ACO/PCMH model.

          As for limiting Medicaid, three points. 1.) We do take some Medicaid, any pregnant patient. 2.) It’s not the pay or risk of litigation that dissuades us it is the hassles. In my under represented specialty it’s already a 2 mos. wait to see me. It’s not a zero sum game when you are above capacity. That 60 minute appointment to help a complex patient could be 3-20 or 4-15 minute appointments to help more people. And sometimes that “simple” thyroid nodule case turns out to be cancer.

          As I pointed out above, it is the hassles and not the pay for Medicaid and I have never dismissed a patient. Furthermore, business man implies money and I calculate a 25-50% pay cut to have a low cost direct pay practice. While not presented clearly I this piece (the title and analogy certain doesn’t help). Is that current reimbursement does not take into account the amount of work required for more complex patients. When we see patients like that in our office we joke that their should be a level 7 outpatient visit (oddly enough you can bill for time spent and complexity of coordination of care in certain settings as an inpatient.

          The bottom line is current pay doesn’t take into account these difficult management issues, and the current solutions to healthcare reimbursement are likely to only exacerbate this problem. If all patients and pay are equal in the eyes of docs, I wish it were only so, I would be happy to see a few more specialists in certain fields in my local area. They just don’t exist. I’m rural, we have too much Medicare, too much Medicaid, and not enough affluence for many docs to move practices here. It might be wrong, but it doesn’t mean it’s not true.

          • HJ

            Doctors don’t dismiss you for being complex…they just ignore your complaints, tell you to come back next month, tell you your symptoms are normal aging, tell you that you are overreacting to you problems, tell you that nothing can be done, and then offer you Prozac.

          • Suzi Q 38

            I agree.
            Ask them if you can record your visit because your memory is not good, on your iphone, video style.
            I wonder if the doctor would put you off then.
            Also, bring in a friend or a relative, and the doctor will be more attentive.
            I used to bring in my husband or my sister, who knew NOTHING about medical conditions.
            The doctors would actually be more attentive and helpful.

            Go figure.

          • rbthe4th2

            I had a surgeon who is “pretty” in front of others, but put us alone and he could be sarcastic, nasty, rude, etc. Not all of the time but anything that wasn’t yes sir was met with an issue. Even down to asking how much experience do you have with X?

          • Suzi Q 38

            I believe it.
            I used to think that the surgeon I had was” high strung and wired” with coffee, when in actuality he needed to appear to be calm and patient.
            All of mine were arrogant, but I guess they have to be in order to be a neurosurgeon or similar.
            I know that a lot of the specialty selections not only go by personal choice of the doctor, but their testing ability in school. The surgeons supposedly test the highest.

            Please correct me if I am wrong. Maybe a surgeon, resident or fellow in training can enlighten us.

          • rbthe4th2

            No, they don’t have to be. That’s the point. Just because you are X specialist does not give you the right to not learn manners or respect for other humans. Actually this surgeon didn’t ever make any 1 star marks or schools. The sad part is they have a partner who gets more complaints than they do.

            Any takers who can help us out here?

          • rbthe4th2

            They do dismiss you for being complex in other ways also, but you are right. I’ve seen it where they just get mad at you and take it out on you.

    • DeceasedMD

      It’s really not completely a matter of not looking at pts interests. I have dealt with a lot of challenging pts I am sure like the rest of us. But the system is working against us and i have no clue how that will ever change. There is only so much sacrificing one can do or one will be swallowed up by this corrupt system. I actually am complaining to my congressman like that is going to do a lot and they keep canceling the town hall meeting. They really do not care and there is no time apparently for lip service either.

      • rbthe4th2

        I wish you would be willing to share your complaints to the congress people. I have done so to one of them and intend to hit the rest up. I would happily partner with doctors in what I believe they could use in reimbursement: EHR time, phone calls to patients/other docs on patients/peer to peers.

        • DeceasedMD

          How sweet. I will keep at it. They really don’t care. This is the third time they cancelled a “town meeting” -simply a conference call to a bunch of constituents. Doubt I will get a word in edge wise. I honestly think one needs to donate say a half a million and then they may call you up just to listen and likely pacify you..

          • rbthe4th2

            Dump that verbal stuff. I put it in an email or letter. Always in writing. I just keep asking. LOL. The other options is publicizing on Twitter, Facebook, MySpace, you name it.

            You are right – either be a big corporation or you are screwed.

            Oh, btw the other option I ask about is mandatory nurse to patient staffing ratio laws.

          • Patient Kit

            There is an alternative to being either a deep-pocketed corporation or one little unpowerful individual with a tiny voice — that would be an organized doctor-patient movement with many individuals speaking and acting together. Like a huge school of little fish forming a wall together when a big predator barracuda is in the area. It’s an amazing thing to witness.

          • rbthe4th2

            What doctors would be willing to partner with us? I’d speak for them. I just actually have a note I want to send on behalf of one of my doctors for the work they did. Maybe its normal for them, but I feel they demonstrated willingness above and beyond to help me, and I intend to get his admin and let me send them a copy on it.

    • Patient Kit

      If we’re going to deal gambling analogies, going to a doctor should not be such a crapshoot for patients. It shouldn’t be a roll of the dice to see whether a doctor is going to care about us or consider us not worth their time.

      I do empathize with many doctors’ deep sense of betrayal as our healthcare system moves through major change. A bunch of demoralized docs isn’t good for any of us. I get that they sacrificed a lot to become doctors and this is not what they signed up for.

      But this is an even harder time to be seriously ill in America than it is to be a doctor here. And our sickest can not be just left without care as some kind of statement against the changes. We all need to get involved and insist on having a voice in how these changes take shape.

      I agree with you that if one of the consequences is weeding out the doctors who, at this point, care first and foremost about preserving the incomes and lifestyles they’re accustomed to at the expense of many patients’ health, that’s probably a good thing.

      • guest

        I don’t disagree that weeding out doctors who care only about their income is a good thing for medicine and for our patients.

        At some point, though, (a point at which we have already arrived I think) you also start weeding out bright, compassionate doctors who would like to help people but also have some degree of self-respect and wish to pursue careers in which they will not be abused by a system which is increasingly gamed to maximize profit for administrators and executives at the expense of decent working conditions for the people who actually deliver the care.

        We still have lots of applicants to medical school, but increasingly, once those applicants are through with their training, they look hard for ways to avoid clinical practice or to go into specialties where their lifestyle will be reasonable.

        Also, as someone who teaches medical students, it is my impression that they are not as a group as bright as they used to be even just a few years ago. I am regularly quite shocked by how unintelligent many of them appear to be. It seems to me that we have a situation in which our brightest college graduates are avoiding medicine altogether. The fact that they have been replaced by an equal number of not-so-smart students is not really very reassuring to me.

        • Suzi Q 38

          I agree with you.
          I am seeing this as a patient.

          Not every group of students will be the brightest.
          Of course there are other profession that will appear to be more desirable than being a physician. The day to day job has changed so much, that some people are re-thinking its desirability as a future career.

          Also, we as patients don’t know who was the brightest in their class. For all we know we could be a patient of a physician who was the last in h/her class.

          I still say I would rather have any doctor, last and otherwise, who would just LISTEN and had good empathy skills. At least h/her mind isn’t closed.

          When my doctor could not figure out what was wrong with me, I knew I had to start figuring it out myself.

          • rbthe4th2

            You said a mouthful. The surgeons, as a group, are the ones that have the most paternalism and the least amount of listening to the patient. They pretend to, but once they’ve made up their mind, especially if its pointed out their wrong, its impossible to budge them. Then other docs believe them rather than giving the patient the chance. That’s bogus. Completely.

        • SteveCaley

          I fear that I am being weeded out, sorry. I may move and work for months away from home. I may live in a trailer. I drive a 1992 Ford Taurus with nearly 400,000 miles on it. None of these makes me ashamed, and I do not care much for my status and standing. But I would dearly like a job that doesn’t require me to move, and I am seeking one outside of medicine.

          • DeceasedMD

            Ah that is a loss for you and all your pts. You clearly are a very bright man with a lot to offer. Anyone that would give you up …well is downright stupid. Before you leave, is direct pay even an option for you? Autonomy is key. Is it possible that you need to leave the bad experience behind, not the whole of medicine? Well if you decide to leave, you must write a best seller book. You have a lot of talent but I know the problems you write about must factor in to your decision.

          • SteveCaley

            Thank you, but in our society, people only really WANT what what are willing to pay for, not what they “say they want.” Miley Cyrus albums are massively wanted – early childhood education is not. Primary care is not. Good MMORPGs, yes; better-than-horrible public education, no.
            I think that reviewing disability applications might be fine – it certainly is more richly rewarded in my state than primary care. The people in the line positions with a high school diploma are paid about the same as physicians doing contract services. I’ll take the benefits.

          • DeceasedMD

            Well I have to agree with you about the screwed up values. And all the hard work that can seem taken for granted.
            Tell me more about disability applications. Seriously. i live in a different state but it is nice to know there is something to fall back on. Is it directly working for the state or is it through one of those awful third party who take a cut? I am unfamiliar with this but i would go directly to the source since as you well know these third parties take a huge cut. But I know it must almost feel like you are doing your time as your skills are way beyond this crap. I have a buddy who lost his practice in psychiatry and the most lucrative job is-where else- in prison so that is where he has been working. I don’t think I could ever stomach that. Best of luck to you as you are wise beyond your years.

          • Patient Kit

            I’m so sorry, Dr Caley. I hope that’s not true (that you’re being weeded out). We need more docs like you. As you may remember, I’ve reacted to some of your posts by wishing you were my doc. What are you doing that has you moving around so much? I’ve just been through the worst couple of years of my life but never lost hope. Now, I think I see some light at the end of this lacuna. I like to think I had to go through this difficult transition in order to get to what’s next for me in this world. I wish you the same.

          • Suzi Q 38

            I am sorry, Dr. Caley.
            I hope that you find a job close to home.
            Do you mind if I ask why?
            What state would you like to work in?

        • Karen Ronk

          I so agree with your last thoughts. I have had many encounters over the last several years with physicians, and I find myself wondering what the heck is going on in medical schools. But, in truth, the “not-so-smart” phenomenon is a malady affecting most levels of our society today.

          Despite, or maybe because of, the vast amounts of information at our fingertips, we are becoming less intelligent and more importantly, less able to comprehend facts and situations. And I am not just speaking of “book smarts”, but also common sense that tells you 1+2 = 3.

          Of course with physicians, the lack of intelligence can lead to terrible outcomes for patients. And it would seem that the ongoing dysfunction of our healthcare system is certainly not going to be a breeding ground for change. As for working in abusive systems where profit is the overriding goal, welcome to corporate America. Millions not served.

      • DeceasedMD

        I think this particular blog is a cry for help with a SYSTEM problem. If in your job, you were regulated as to how much time you can spend on the most complex piece, could you do your job? If one is not given the tools they need to practice medicine, does not matter how much you may wish things were different. It is not exactly docs, it comes from the way the business world handles these pts. We alone cannot fix that problem.

      • rbthe4th2

        I would add it shouldn’t be a roll of the dice to find out if a doctor will work with you in terms of you being a partner in your healthcare or not. Those doctors that I’ve had just do a do as I say and can’t explain their magic, or won’t discuss my research, if you feel that way, then it should be known BEFORE we ever make an appointment with you. That way, we have a better idea if we will “jell” or not and not waste doctors times.

    • Thomas D Guastavino

      I guess we as physicians should just expect the beatings to continue until morale improves.

      • PoliticallyIncorrectMD

        Not being able to get your medication when you need it is too much to bear! Waiting months in pain to see a physician is too much to bear! Dying in your 40s and 50s before your kids graduate from high school is too much to bear! Sitting in your cushy office and complaining about your collections going down or about having to make an extra call to the insurance company is inconvenience!

        Should physicians be compensated well? Absolutely! Should they be left alone by bureaucrats and administrators? Of course! We should fight for our freedom and our independence! However, WE CANNOT TAKE OUR PATIENTS HOSTAGES. Not only because it is a wrong thing to do, but also for a simple practical reason that we are not going to win this war if our patients will not fight on our side.

        • Thomas D Guastavino

          You did not answer my question.

          • PoliticallyIncorrectMD

            I did not answer your question or I did not answer it the way you wanted me to answer? Let me try
            to be more explicit. I would consider those inconveniences to be too much to bear if and only if they put my and my family’s life, health and basic (and I do mean basic) needs at risk.

          • Suzi Q 38

            “….And “no”, physicians should not accept the beating. They should fight. But they should choose the target appropriately. It is silly to take it out on patients, just because they are easy target.”

            My point exactly.
            I have had several doctors tell me that Their attitude is not good because I (the patient) do not pay them enough. I pay $500.00 a month plus a $6K deductible. My husband’s employer pays another $1K a month on our behalf. I feel that between the three of us, we pay a lot.
            I realize that some physicians are resentful at the $15.00-$20.00 co-pay that we pay at the time of the office visit, but THAT AMOUNT IS NOT THE ONLY FEE WE PAY.

            Also, we have to have insurance, because if not, we can lose our house with the first major heath challenge and extended hospital stay.
            The insurance not only helps us to pay for our medical bills, but it also helps us with a more reasonable price to pay for a hospitalized catastrophic illness.

            Any doctor that treats me badly because of the insurance is not going to have me as a patient for long.

            If you have a complaint, complain to the insurance company directly.

  • PoliticallyIncorrectMD

    Even if it is true, we cannot hold patients hostages.

  • guest

    Actually, your insurance company is choosing your doctors for you.

    • Suzi Q 38

      True, unless you have PPO insurance and pay big bucks for it. This year I have the same PPO, but I have a large deductible of about $5 or $6K. I have been paying what the insurance says to pay the doctors, but I have been paying cash directly to the doctor. Maybe this method of payment will work out better.
      I can choose any doctor(s) I wish, at any office, clinic, or hospital in any given city or state.

      I have found that some doctors don’t know where to start if you have a complex issue. Maybe they know deep in the depths of their psyche, but don’t want to take the time to treat you if you are a patient with complicated conditions.

      As you get older, sometimes there are more medical problems. We older patients joke that “You better be able to tell the doctor what you have and have an idea of how to treat it, or you are out of luck.”

      • guest

        Even with PPO insurance, your insurance company pays a certain amount for a certain service. Any doctor, whether they are on your panel or not, then makes rational decisions about how much time they can spend with their patients before they start losing money based on what they are being paid for the visit.

        Your insurance company controls the care you get in many different ways.

        • Suzi Q 38

          Yes, I agree.
          There were a couple of years (recently) that I was not aware of this.
          All we patients know is that things have changed.
          We blame it on the doctor and think that the younger doctors are just being lazy and not friendly. This is complete contrast to the Marcus Welby type of doctors that we had in prior decades.

          • rbthe4th2

            I’ve seen too many that are frankly lazy and not friendly. If I do the work for you, then I can tell who is willing and who isn’t. I have no problem talking to the insurance so the docs don’t have to, as I know they don’t get paid for it.

          • Suzi Q 38

            I have figured this out as well.
            The insurance company has denied several things for me in the last year.
            Sometimes, I agree with them that we need to proceed with my care with caution.
            Most of the time, though, when my mind is made up, and the doctor concurs, I get approval with one phone call…mine.
            I talk to the insurance company and persuade them to approve it.
            I speak English, and more specifically, their medical English. Also, I am very persuasive.

          • rbthe4th2

            What made me mad was that I knew I could back up my stuff with medical research. I probably got the insurance mad because I caught them in a few ??common sense?? “mistakes” they should have caught.

            LOL the new docs I think prefer to me at them. :)

      • rbthe4th2

        and then they get mad because we are telling them how to practice. Did I miss something but when I have several years worth of research that I say here is what I’m concerned about and why I think it fits this, what is the problem of asking me about it? I dont care that a doctor doesn’t know everything but I do want them to tell me how their knowledge backs up to research. If they don’t have it, check it out. Ask for the important points. I’d rather have a doc with an open mind than one without. They cost me more.

  • QQQ

    “In other words, although patients with complex
    problems may be only 5% of your patient population, they take 30% of
    your time, cause 40% of your stress, be 50% of your litigation risk, and
    be 60% of your uninsured population.”
    —————————————————————————————————-

    Hospital inpatient admissions are going to collapse in the near future.
    The U.S. government is promising insurance coverage to the public but is
    going to pay the physicians and the hospitals next to nothing.
    Hospitals are planning to stack up the patients in the Emergency Room
    instead of being admitted due to cost. When the public cries about it,
    the corrupt U.S. government will simply force the private hospitals and
    their physicians to admit patients regardless of payment.

    The private hospitals will go under…. but the U.S. government will
    step in to run these facilities. Don’t worry… you will get the same
    great care that our veterans receive at the VA hospitals. The
    politicians and the elite will not be caught dead in one of these
    government run hospitals. But if they did, they would be DAMN sure they
    would make it work right!

  • PoliticallyIncorrectMD

    Is something intrinsically wrong with this? Look at Mayo. I think they are able to take care of complex patient fairly well : )

  • doc99

    Would this even be an issue if physicians were paid for their time as other professionals are rather than paid by CPT codes?

    • Suzi Q 38

      They are paid for their time.
      Many receive a sizable SALARY for the difficult work that they do.

      I don’t think that Medicare or Medicaid pays enough, but that has been an ongoing problem for decades.

  • guest

    Darn. I am sorry to hear that. Maybe see my response above about medical students not being as smart as they used to be? Perhaps the doctor is intimidated by complex problems…

    • rbthe4th2

      Or doesn’t have the experience to handle it and can’t or won’t look at research to find out about it.

  • W. X. Wall

    This is a standard business management theory. Just google “fire your customer”. The idea being that some small percentage of your customers are responsible for a large part of your costs / management headaches / staff time and resources / etc. And that therefore, if you get rid of them, your business will improve (not just monetarily, but will run smoother, etc.)

    While the business logic makes sense, I do think it’s harsh to apply it to patients who are complex. IMHO, what makes a “bad” patient is someone who refuses to do what you ask them to, blames you for problems of his own doing, has secondary gain issues, etc. OTOH, patients with complex problems may be some of the most cooperative patients who truly want to get better. They both will require more of your time, and ultimately you will take a loss in treating either one, but I still make a distinction between the two patients. FWIW, I’ve fired patients of the former type, but still take care of patients of the latter type.

    I understand that seeing too many of either type of patient can be financially nonviable, so I understand others who don’t wish to see either one, but regardless, I think the distinction between the two types of “unprofitable” patients is useful…

    • Suzi Q 38

      Interesting……In other words, unless we are healthy and easy, compliant patients, we don’t deserve care?
      Get a clue.
      The world is full of difficult and imperfect people.

      Maybe some physicians should have a sign at each of their offices that is similar to what restaurants display: ” We reserve the right to refuse to serve anyone.” If I found such a doctor, I would applaud him/her for being honest, and “vote with my feet.” I would walk out the door.

      Didn’t most physicians go into to medicine to help others, easy and not so easy? Many patients did not visit these conditions on themselves. They are what they are. Some are unlucky, others develop poor conditions beyond their control.

      Maybe doctors should have prefaced that idea with a statement like: ” I will care for others only when they are easy to treat and/or compliant. Difficult patients with difficult conditions need not come through my office door.”

      I imagine if physicians had this attitude when applying to medical school and residency and verbalized it to admissions, they would not be selected as a student.

      Maybe being truthful would be stupid, but a good thing.
      Some doctors, just like those in all professions, do not deserve to do what they are trained to do. They are able to pass the courses and rigors of medical school, but are unable to endure the difficulty of treating patients who need help on a daily basis.

      • PoliticallyIncorrectMD

        Unfortunately some physicians don’t go into medicine to help those sick and injured, at least it is not their primary motivator. Prestige, financial stability, status, tradition are other motivators. My answer to those advocating “we reserve the right to refuse to serve anyone” would be: ” than don’t complain when you are treated as fast food place, not as professional and pillar of the community “.

        • Suzi Q 38

          Thank you for your honest thoughts.
          I wholeheartedly agree.
          Doctors don’t want to admit it, but they love the “adoration” and admiration that comes with being a doctor……back when many doctors wanted to help the very sick and needy. Now they truly good doctors are dwindling.

          • PoliticallyIncorrectMD

            There are still some good doctors left. My prediction that in spite of overall negative changes in healthcare delivery, one of the unintended consequences would be compete change in motivation (to the better it is) of those who enter medicine. Or maybe I just want to see the glass half full ; )

          • Suzi Q 38

            I am with you.
            I think that now that we are aware that there are some resentful, jaded doctors who really shouldn’t be treating unsuspecting patients, we can be more aware of the signs and fire them.
            We need to replace these doctors ASAP, before our health suffers.
            I was not aware that this was happening, so I got a “raw deal.”
            No more.

            I am more careful with who I trust with my care.
            Right now I have PPO insurance that allows me to choose any doctor and any specialist I want.
            I will enjoy this advantage for as long as my husband and I are still working and can afford it.

            I no longer will pick the doctor that the receptionist at the teaching hospital recommends, I do my research first.

            I take my time.
            When I do find the right doctor, I will drive an hour or so if need be.
            Convenience used to be really important. Now, having a really good doctor is far more important.

            The good doctors are still around, but they are harder to find and in the minority.

      • W. X. Wall

        Wow. Not sure where your venom is coming from. I specifically stated that I gladly take care of complex patients, regardless of the fact that they will require more of my time and effort than an easy patient. How do you get “difficult patients with difficult conditions need not come through my office door” from that??

        But I *won’t* take care of someone who refuses to comply with my treatment recommendations, or who blames me for their condition, etc. To take your “fat” example, if someone is fat and genuinely tries different treatments but fails, that’s one thing. No one believes losing weight is easy. But if you don’t want to even try what I recommend, then quite frankly, why bother continuing to come to me? Find someone whose recommendations are more to your liking.

        Similarly, patients who have secondary gain issues have a much less chance of actually improving with any treatment. You will waste endless hours trying to help solve their problem when what they really want is for you to help them win their personal injury lawsuit.

        At any rate, actually, every doctor *does* have the right to refuse service for whatever reason (except in emergencies and except for patients you already have a relationship with). Just because you don’t see it on the office wall doesn’t mean that right is forfeited.

        • Suzi Q 38

          It is not venom.

          It is “direct talk” from a patient who finds your opening paragraph sadly lacking in compassion and very short-sighted.

          Yes, you explain in more detail later, but it is still rudely annoying just the same.

          My guess is that you probably have your share of non-complaint patients. Rather than assist as many of them as possible, you quickly separate them in two categories and fire the ones you see fit.

          Nice that you can do that.
          Have you ever thought about what do so does to your patient emotionally? Not to mention that h/she has to start all over and explain why you have done the ultimate “pass off” and patient “hot potato” to the next doctor that she tries to see. Do you give h/her a good recommendation should the new doctor call you, or do you bad mouth the former patient?

          No guts.

          You may have before you a patient who just can not lose weight, is chronically obese, has back pain and a borderline diabetic.

          Have you ever asked h/her how long h/she has had arthritis and numbness? Do you think that h/her meds like Lyrica, doxepin, and NSAISDS have contributed to h/her excessive weight gain? How about h/her cholesterol meds and steroids?
          Could these meds be contributing to h/her diabetes?

          Consider who prescribed these drugs for her in the first place. Doctors, just like yourself.

          Helping patients is what you and many other doctors have signed up for, good and bad.

          As arrogant as you sounded….about firing your patient. I would have to agree that

    • rbthe4th2

      I’ve been fired because the doctor gave me instructions, changed them, or forgot what he told me and blamed me for not following his instructions. How do you feel about the docs who blame the patients when they got conflicting instructions and then were fired because of that?

  • Suzi Q 38

    So true….
    Thank goodness that scenario has not happened to me yet.
    My doctor is the same doc that I have been seeing for more than 12 years.
    Once he tried to do that, as he probably was having a bad day.
    I am somewhat embarrassed to say that I got in his “face.”
    I basically told him: “Look. A lot has happened to me medically in the last couple of years. I need your help today and I need you to listen to me.”

    He immediately stopped and sat down and we talked. I got the help that I needed.

  • Thomas D Guastavino

    I would to thank everyone for the spirited debate. On one side, near desperate patients trying to find answers, and on the other, frustrated providers who have seen their altruism used against them.
    There is a scene from the movie “Dr Zhivago” that every time I see it sends chills down my spine. After the revolution, Yuri returns home to find it taken over. He then meets his half-brother who tells him he is “assigned” to work in a certain hospital. We all know what would happen if Yuri refuses. I have to wonder. Is this the natural endpoint of the entitlement attitude that has become pervasive these days. By entitlement attitude I don’t mean social security or medicare because (at least theoretically) these are prepaid, but the belief that if someone needs something someone else is obligated to provide it. This “Vote for Me and I will Give you More Free Stuff and take It from these Evil people over here” attitude has become the cornerstone of modern politics.
    Like many things, health care started out with the patient being able to freely choose their provider, and the provider freely choosing what patients they would treat and what type of treatment. Most providers were more then happy to provide some pro-bono care as long as they were not told how much. As healthcare became more of a “right” providers “obligations” steadily increased. How long will it be before some state legislature demands that providers accept Medicaid (and ACA) patients as a requirement for licensure? Our tacit approval has only made things worse.
    This is not a sustainable situation. In the long run, no amount of belittling or crushing regulations is going to provide one more ounce of high quality healthcare. It did not work for Yuri and it will not work here.

  • SteveCaley

    Oh, but that is the game since day one. Once physicians were told that they were playing cards at the table – perhaps in the seventies – and their earnings were measured in “chips” – then it became a struggle about earnings, a struggle that has continued to this day.
    Go ahead, play the house, go ahead. But in the long run, the house never loses. Count the cards, learn a trick – and they change the rules.
    This has been the game for decades. And the patient will always lose.

  • PoliticallyIncorrectMD

    Which insurances reimburse. I am not defending it, just pointing out there are ways to care for complex patients … if that is why one entered medical field to begin with. Claiming it is not possible and dumping it on someone else just because it does not fit the business model we prefer is wrong.

  • rbthe4th2

    I posed that to a risk manager and have yet to receive an answer. LOL. The pat response is go to the ER. I said and they’re supposed to do what?

  • rbthe4th2

    Story of my life – I do have some good ones, but yep, that’s about it. I get sicker and will have permanent problems from the lack of reading research and just treating the problem ages ago.

  • SarahJ89

    I’m not optimistic. How long have we gone with millions with no insurance whatsoever? That didn’t seem to bother the government a whole lot.

    • Patient Kit

      The Clintons attempted healthcare reform in 1993 that would have helped those millions of uninsured Americans gain access to healthcare 20 years ago.. I’m not saying that the Clinton universal healthcare plan or the ACA are perfect. Far from it. But I don’t think we can say that nobody tried. I sat in a conference room with about 40 other people and listened to Hillary Clinton explain her plan and answer our questions about it.

      The Clinton plan was defeated by politics, by the corporate powers that drive healthcare and, to some extent, by the public (patients and doctors) who resisted change and wanted to hang on to the evil they already knew. In the 20 years since that Clinton plan was defeated, those profit-driven corporate powers that control healthcare in this country have only grown more powerful.

      People say they don’t want government or Corp Med or employers involved in healthcare. Well, this country is never going to an “each individual gets whatever healthcare they can personally afford no matter how sick they are” system. Just not going to happen, especially with so many Americans living on the bottom.

      So, if not government or Corp Med or employers or individuals, where who is going to pay for and provide healthcare to 300+ million Americans?

    • rbthe4th2

      Until they found that medicine was controlling in a field they hadn’t overtaken completely yet.

  • DeceasedMD

    You know sometimes they say it is research but often ther eis someone in the world that will treat the problem without you having to be a so called guinea pig, I am not sure I now believe in all of these studies, especially from an ethical standpoint. But not all necessarily.Many academic centers are so research focused that they miss diagnosis and encourage studies rather than care.

  • DeceasedMD

    sorry to hear that. i think there are more what many refer to as “orphan dieseases” than we realize and there are more conflicts in diagnosing and treating amongst MD’s unfortunately. I wish you the best.

  • Suzi Q 38

    So do certain teaching hospitals in California.

  • PoliticallyIncorrectMD

    Stand by! I am trying to come up with a little patient’s guide for people like you. Hopefully Kevin will publish it. For now I would suggest trying to connect with a teaching hospital or a university if there is one in town. Their motivation is usually completely different and they don’t mind taking care of “complex” patients.