I have only been able to make it back to my hometown once a year for many years now, but I recall my father having a very friendly dog many years back, a black Labrador mix named Abby. She was well behaved, would stay in the yard if you let her outside, didn’t cause problems, and was great with children.
Then about ten years ago, another dog was added to the household, a small (at the time) miniature pinscher named Ginger who I would hardly characterize as a good dog. She made a mess on the carpet, barked incessantly at new people, regularly ran away from home, and seemed uncomfortable being petted by strangers.
There was one occasion in which Ginger was friendly to all comers, namely when someone walked toward the kitchen or make any sound that indicated food could be near. This would result in extreme begging and jumping in an effort to get any bit of food available. When Abby and Ginger were fed, Ginger would first try to secure Abby’s portion before turning to her own. Freud would say that this dog was purely driven by an unchecked id, a desire for self-satisfaction without control.
As I would visit each year, Abby remained friendly and lovable, essentially tolerating the smaller dog’s antics while maintaining her own personality. Ginger also remained guarded and selfish, but her jumping for food became gradually limited by worsening obesity. It didn’t stop her from trying, though.
It occurred to me that these two dogs mirror relationships in modern health care. Most patients want an affable doctor willing to be the most ideal health care companion without a lot of hassle or added stress. We want our health care providers to be less greedy and more approachable. We want the Labrador doctor.
In the United States, reimbursements for health care come from “doing stuff” to patients rather than preventing illness. There is probably no way around this. The result is that health care agents emphasize the best reimbursements and view aggressive billing and efficiency (i.e. not spending time with patients) as means to maximize profits. Have you ever wondered why there is such a thing as a “heart hospital” or a “bone and joint” center but no “abdominal hospital?” The answer is quite simple. There is a packet of money involved in every chest pain patient being monitored to rule out a heart attack. Abdominal pain is less likely to be deadly than a heart attack, and there is furthermore no standard battery to rule out life-threatening causes of abdominal pain. Cardiologists have further capitalized by taking over single-organ imaging such as echocardiography, nuclear medicine stress testing, and in some cases, cardiac MRI. If you own the patient referral base, why not own the imaging, too?
Hospitals have had to become the miniature pinscher. Let’s say you have a large inner city hospital in downtown close to large amounts of uninsured patients. How do you expand revenue? Build an independent ER in the suburbs (where more insured people live) that is not physically connected to any hospital and charge standard emergency room fees while knowing full well that no significant trauma or seriously ill patient is going to be brought there by ambulance. For the one in twenty patients who actually needs to be hospitalized, he or she can be brought into the flagship hospital. Better yet, staff these places with cheaper mid-level providers and/or hire traveling emergency physicians who increase speed and billing by ordering extra tests before a physical exam is performed while trying to keep the rest of us as ignorant as possible as to what is going on. Rinse and repeat.
Doctors are becoming the greedy dog, too. An emerging theme in radiology is for private practice doctors nearing retirement to sell stock in their practices to private equity companies. Newer doctors, now often relegated to the role of employee when partnership used to be the norm, are no longer afforded the opportunity to invest in their services at the same rate. In this way, radiologists risk harming the new doctor in exchange for an easier immediate payout. This is detrimental for the specialty since radiologists do not have their own patients and can thus not “feed themselves” in the analogy above.
The problem is that once the dominoes start dropping, you have to become the greedy dog to survive. Somebody is going to take your food from you if you don’t bark back and eat as quickly as possible, and this is what has happened to us. When your doctor rushes you out the door hurriedly or brings up an acne treatment when that is not why you came in (which actually happened to me once), there is a reason.
I am sad to say that Abby died a few years ago, leaving my dad’s household with only an angry overweight barking dog that never stops leveraging to get more food. I’m even sorrier to say that it seems like the Labrador in all of us is quietly dying too.
Cory Michael is a radiologist.
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