Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
Join us on this episode as we discuss the changing landscape of medical practice with guest Edmond Cabbabe, a plastic surgeon with over 30 years of experience. We delve into the impact of corporate medicine on the patient-physician relationship, the challenges faced by medical graduates in terms of education costs and practice settings, and the emergence of numerous specialty societies. We also explore the drawbacks of hospital employment for physicians and the importance of organized medicine in protecting physicians and patients from threats such as insurance companies and regulators. Tune in for a thought-provoking conversation on the state of modern medicine.
Edmond Cabbabe is a plastic surgeon.
He shares his story and discusses his KevinMD article, “The fall of the patient-doctor bond: How corporate medicine is changing health care.”
The Podcast by KevinMD is brought to you by the Nuance Dragon Ambient eXperience.
Ambient intelligence augments human capabilities to make our lives easier. The applications are many, especially in health care. Ambient clinical intelligence is offsetting the most pressing challenges in health care today, such as burnout, physician shortages, physician and patient dissatisfaction, and underperforming financial outcomes, by applying the technology to clinical documentation.
The Nuance Dragon Ambient eXperience, or DAX for short, utilizes artificial intelligence and natural language processing to automatically document care. It securely listens to and captures the natural, clinician-patient encounter conversation unobtrusively, and turns that conversation into a clinical note for the clinician’s review and signature directly in the electronic health record. You just talk naturally, and DAX does the rest.
DAX is being used by thousands of physicians across 30 different specialties nationwide. It has already won the Silver Stevie award in the health care technology category and was ranked #1 for improving clinician experience in KLAS’s top 20 emerging solutions.
VISIT SPONSOR → https://nuance.com/daxinaction
SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast
RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended
GET CME FOR THIS EPISODE → https://earnc.me/XAzekl
Powered by CMEfy.
Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today on the show we have Edmond Cabbabe. He’s a plastic surgeon. His KevinMD article is titled “The fall of the patient-doctor bond: How corporate medicine is changing health care.” Edmond, welcome to the show.
Edmond Cabbabe: Thank you very much, Kevin, and it’s a pleasure to be with you.
Kevin Pho: So we’ll go to the article in a little bit. Just first off, briefly share your story and journey to where you are today.
Edmond Cabbabe: Yes. I was born in Aleppo, Syria, of all places. I went to medical school at Damascus University and came to the United States in 1973 after graduating. I did a surgical internship, followed by four years of general surgery training at the University of Tennessee and two years of plastic surgery at Saint Louis University. Following that, I stayed on the faculty at Saint Louis University as an employed physician, an assistant professor, for six years, and then went into private practice with nine other plastic surgeons in the St. Louis area. One or two years after that, I became the president of the group, of all things. The group continued until 2005, when it broke up for financial reasons, as usual, with the younger people joining us wanting to work less and make more.
A couple of years after that, my son graduated from the plastic surgery residency in Birmingham, Alabama, and joined me. He’s been with me now for about 15 years. He’s my partner. We call him 49. And I am very busy with organized medicine. I currently chair the delegation from Missouri, I’m the chair of the caucus for the Heart of America, and I’m also the chair of the Council on Long Range Planning and Development at the AMA.
Real physician voices, twice a week
Free, and one click to unsubscribe.
Kevin Pho: All right. So before we get into the article, I just want to ask you a question about private practice. As you know, there are fewer and fewer private practice physicians now. Tell me some of the challenges that you’re facing in a private practice environment today.
Edmond Cabbabe: Well, you are always fought by everybody, including the employed physicians of the hospitals and the insurance companies. They try to cut you down, because they can probably leverage their influence on you and on everybody else, and that’s why I’m frustrated. I am working part-time right now, but still, every day I face a challenge. For example, the hospital recently hired a plastic surgeon who has not done any surgery in three years, even though if I do not do a procedure in the last two years, they take that privilege away from me. Now explain that.
Other things: harassment by the administration. At the least occasion, they try to harass you for not washing your hands in front of the nurses, while you washed them, probably, before the nurse came in. It’s a plethora of problems. And they moved us from our office to put the Mercy clinic in the office where we belonged. They were going to bring in two plastic surgeons, but COVID hit, and they had to fire people. And then we had the problem of having poor staff for years, until we finally got permanent staff, because they were bringing in travelers who had no interest in the place and no interest in helping you. They just wanted to make their money.
So there are a lot of things that are happening, and that is the cause of my frustration: the weakness of the patient-physician relationship. It started out first with the managed care programs that steal patients who are in a plan that we did not participate in. To participate in those plans, we had to accept much lower payment, and that is frustrating, because our overhead keeps going up and not going down, and our employees are paid more, and they want more benefits. So things like that really bother everybody. Now, you and I probably feel this more. The newcomers to the practice of medicine did not experience the good days, so they don’t see the difference, but we do, and that is the biggest area of frustration we face.
Kevin Pho: Sure. So you talk more about that in your KevinMD article, “The fall of the patient-doctor bond: How corporate medicine is changing health care.” Now tell me, how did your article come together?
Edmond Cabbabe: My frustration is that right now we have in St. Louis many hospitals, probably about 20 big hospitals, and they’re divided into three major networks: Mercy, SSM, and BJC, or Barnes-Jewish Christian. Now, if you try to belong to one without the others, and you stay out, and you fall out of their favor, then you have nothing left. If you’re employed by those networks and you decide to leave for any reason, you have to leave town, because the restrictive covenant covers the entire metropolitan area, and it has happened to many people. Other changes, like trying to schedule cases in the OR: It’s more difficult for me as a private practitioner than for an employed physician. They have block time; they can share it together. So it’s one problem after another.
And how can we fight it? We’re powerless, really. The reason is that we are weak. We are not cohesive. We have no good representation that covers all of us. And that’s why I put down in my article how it was in the old days, when everybody had to join organized medicine at the state, local, and national level, and in those days we decided what to do with the practice of medicine. Now, throughout the years, what weakened this is essentially physicians themselves. Physicians looking for leadership broke off, and organized medicine started going into specialty societies.
In my specialty society, my specialty of plastic surgery, we have probably 15 different organizations, and they have heavy dues, much more than what we pay for all of organized medicine, for just one of them. And then what kind of power do they have? They really don’t have any power in the practice of medicine. They promote the specialty, they allow you to present papers, maybe take some courses, and try to defend your turf against other specialties. But they have no power to go, for example, and ask to repeal the SGR. That has to be done through organized medicine, because Congress and the Senate cannot sit down with every specialty society and discuss things. So that’s the problem, and we’re suffering because of that, I think.
And that’s why I brought it to the attention of the readers that becoming part of organized medicine at all levels probably costs less than $1,500 a year, which is probably a lot less than what people pay for their specialty society. But the AMA now only having maybe 17 or 18 percent of physicians paying dues leaves it with a small chest to lobby. They do have lobbyists, but their capacity to convince congressmen or senators of their causes is weaker, because they don’t have the money for it and the staff for it.
Kevin Pho: Now, give us an example of some of the frustrations that you just talked about, whether it’s time in the OR or some of the private practice frustrations. Why should patients care about that? Because patients see this, and they see a lot of physicians squabbling among themselves. Tell us, how do all these issues that affect us as physicians affect patients?
Edmond Cabbabe: Well, it’s affected me in many ways, as an example. Right now, I’m telling you, I was the main plastic surgeon in multiple hospitals, and I was a chief in at least three hospitals. We had taken a lot of consults and took care of the patients, and our rating, when the hospital went over the patients and complications and everything, was excellent. Yet they brought in somebody who’s weak, who probably failed in private practice, and they gave him all their referrals. That’s because most of the ERs belong to the hospital, most of the hospitalists belong to the hospital, and most of the internists and primary care doctors belong to the hospital. And the funny thing is, when those doctors get sick, they come to me. They don’t go to the employed one, unless they have no benefit outside their network. So that is frustrating, and of course we still have to take care of them when they seek our help.
And now in the OR, right now, if I have cases to schedule, sometimes I have to wait six weeks to get my cases on, while the employed physicians have a quota where they can have block time. They can share it together and put the patients in. Now, if my son and I have block time and we don’t fill it, for a reason like travel or whatever, they take it away from you, while they conserve it for the others. Go to the executive committee of a hospital: It’s mostly employed physicians now. Go to the bylaws: They keep changing them, because they have the vote for it. So I don’t know what else to tell you, but it’s frustrating. I’m glad I’m toward the end of my practice. I still enjoy working, and I’m still good at what I do, because I’m sure there are many eyes over what I do at work from the hospital employees.
Kevin Pho: So you’ve been involved with organized medicine for decades. Now give us an example of how organized medicine, the organizations that you’ve been involved in, has moved the needle and improved the practice of physicians.
Edmond Cabbabe: OK, so let me start at the local level. At the local level, one time we had a hospital ID doc, infectious disease. He criticized Mercy Hospital at one point for having a smaller ratio of nurses to patients, and he made a statement to the press that this affected patient care. He was fired. We came together and demonstrated, and we returned him to the medical staff, and he became the medical staff president.
On the state level, in Missouri, for example, we are fighting hundreds of bills every year to allow nurse practitioners to be independent, CRNAs to be independent, physical therapists to be independent, pharmacists to be prescribing and doing things. So it’s endless. And the state medical society in our state is fairly good, because we have legislators who are also conservative, so we protected the reimbursement, for example, for workers’ comp, which is still good. Many other states, because of a lack of interest by the physicians in the state in supporting the state society, now pay them for workers’ comp at Medicare rates, and Medicare is pitiful, especially for hand surgery. I am also certified in hand surgery, with an added qualification.
And of course, at the national level, the AMA is behind everything that we gain, like trying to remove the cuts that were imposed on us this year, and now they’re working on changing the whole formula for how Medicare reimburses, based on inflation. We repealed the SGR. There are countless issues that come up nationally where the AMA intervenes on our behalf.
Kevin Pho: Now, as you know, we live in a very polarized society, and the physician community is no exception. Physicians are along a spectrum when it comes to their worldview and their political views as well. Given that context, how do you expect a single organization to represent physicians when physicians, as you know, can’t even agree among themselves?
Edmond Cabbabe: You know, the AMA right now, as you probably know, has a House of Delegates. If you are, let’s say, an anesthesiologist, and you are a dual member in the AMA and the anesthesia group, then for every 1,000 of you, you get one representative in the House of Delegates. OK? So even if your specialty is fairly small, if you have a good dual membership, you get more representation. And what the AMA will do is, the representatives in the House of Delegates present resolutions, and they’re discussed, they’re approved or disapproved or whatever, and then the lobbyists carry on. No other organization has the capacity to do this as of now. Maybe the internal medicine group is a large group, but its power in the House of Delegates is by the number of people who have dual membership in the organization.
And if you look, for example, at the hospital association, almost all the hospitals are in it. The lawyers: They’re all members of it. What do they do? They have the power. They push for lawyers to become members of Congress and the Senate, to pass the laws that please them, and to allow them to have more business. And the hospital association always asks for increased reimbursement. They lead with the idea that without them, the uninsured will not be taken care of. Physicians always forget, and I’ve raised this before, physicians forget that the hospitals are given federal and state money to take care of the uninsured, and most of them are also tax-exempt. Well, we are not, and they require us to take care of the patients who have no insurance for free, and if you lack enthusiasm for it, they can punish you.
We have an organization, and it’s good. Right now it’s healthy, and in the AMA we have a very good house of representatives and good lobbyists, but they are not powerful enough, and they don’t have enough funding to have more leverage.
Kevin Pho: Now, how would you convince physicians who may not necessarily agree with all of the AMA’s stances to join the organization? Because, as you said, the organization is only as strong as the number of its members. So how do you go about convincing physicians who traditionally may not have agreed with what the AMA stood for?
Edmond Cabbabe: OK, so let’s say we now have two parties in the United States, right? Republican and Democrat. If you are not participating in the election, how can you leverage your ideas and push for them? You have to participate. If you don’t like what the AMA is doing, and I don’t like many other things that the AMA is doing, and that’s mostly because it’s pushed by the newer generation of students and residents and fellows, and even the young physicians, but if I don’t participate, then I have no input, and the rug will be pulled from under my feet. So I would tell those people: Join in, if you want your ideas to be the policy of the AMA and of the practice of medicine.
The students and residents, unfortunately, first pushed a lot of bad things, I think, from shortening the hours of work to shortening the years of work, and now they’re trying to shorten the years of medical school, and it’s going to hurt them. I used to be in a group of plastic surgeons where we had people who had the five years instead of the traditional seven years minimum. They were weaker. They did not have the experience. They were not able to tackle all parts of the body. They made less money, but yet they wanted more.
And the same goes for the students and residents. They’re coming out of residency now with a lack of exposure. They sometimes make bad choices, joining a residency or a program that is not good, or they try to avoid working the longer hours to get more experience. In general surgery, for example, if you don’t do the five years and do the chief year, they would not let you do any big surgeries. They think you’re going to be a lost cause. So that’s what it is. People don’t think about the impact that their decisions are going to have on their future.
Kevin Pho: We’re talking to Edmond Cabbabe. He’s a plastic surgeon. His KevinMD article is titled “The fall of the patient-doctor bond: How corporate medicine is changing health care.” Edmond, tell us some of your take-home messages that you want to leave with the KevinMD audience.
Edmond Cabbabe: I would say that if we don’t organize, we are going to continue to fail, and everybody’s going to take advantage of us. Join organized medicine at all levels, because through it you can have more leverage in the practice of medicine.
Kevin Pho: Edmond, thank you so much for sharing your time and insight, and thanks again for being on the show.
Edmond Cabbabe: Thanks, Kevin. Have a great day.
Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
