Dr John M

cardiac electrophysiologist, cyclist, learner

Doctors in the crosshairs…

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Let’s start with a disclaimer:

I am not complaining; I’m just stating the facts.

Honest fact: The morale of doctors in the real world is low–and sinking lower.

I know what you are thinking. “Come on Mandrola, you are nuts if you expect us to feel sympathy for doctors–of all professions.”

Well…you can think that if you wish, but I’m calling it as I see them. And here is why it matters:

Because when you are sick, an available, rested, un-rushed and talented doctor is really important.

You know this: quality health care–real quality, not spreadsheet or Internet quality–stems from basic human-to-human interaction, between patient and doctor. Healthcare reform, with its emphasis on metrics, prevention of fraud and cost-cutting measures has forgotten the basics. Namely, that humans, who have dedicated their life and committed their self-esteem, practice medicine. To take care of people well, doctors need things:

  • We need face time with the patient–not with a computer screen.
  • We need time to listen, to examine and to treat.
  • We need to feel trusted.
  • We need our self-esteem.
  • We need leeway to be human.
  • And of course, we need to be paid a fair wage for the years of training that it took to acquire these skills.

In support of this view, I’ll call your attention to four posts from real doctors:

–My colleague Doctor Wes Fisher talks of the growing culture of hostile dependency towards caregivers. Wes is rightly disturbed by a sensational and one-sided book review (WSJ) of surgeon-author Dr Mark Makary’s Unaccountable. Agree or not with Wes, his words come from the heart of a man who hangs a lot of his self-esteem on the doctoring peg. Wes is a guy I would want to have as a doctor. If healthcare reform keeps going in this direction, patients will have fewer Wes Fisher’s around to pull them out of fires.

–Here’s a quote (via email) from an esteemed colleague–another guy you would want as your doctor.

We doctors are absolutely being demonized.  Every day something new is written pinning our healthcare crisis squarely on our shoulders.  It’s really affecting me emotionally.  I’ve actually started to think it might be a good idea to take a media holiday for a while.  I appreciate that you still have the energy to fight.  I’m getting pretty tired.

–One of the most obvious unintended consequences of cutting healthcare costs on the backs of doctors providers is the flight of good primary care doctors to concierge medicine. One of the best posts I have read on the topic of Dropping Out comes from Dr Rob Lamberts. Dr Rob is a beautiful writer and another passionate practitioner of Medicine. I’ve been reading his stuff for years, and it is clear that Dr Rob has unequivocally mastered the obvious.

–Finally, there’s me. I wrote an In the Prime post today about the two sides of the canvas of healthcare reform. It was in response to a nicely written opinion piece in the Courier-Journal. A local doctor pointed out that we must not settle for anything less than universal insurance coverage. He’s right; but there is also the important question: What good is universal coverage if there are not enough caregivers?

Doctors don’t expect sympathy. That’s not what we want. We want the people–our patients–to know the consequences of hostility towards caregivers–be it in mistrust, hyper-regulation or lower pay.

We welcome reform, but we can’t sit still and watch it destroy the practice of Medicine.

JMM

Concierge medicine makes everyday a snow day. Implications for impending health care reform…

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The interview, such as it was, happened on the walk in from the doctor’s parking lot.  As early morning approachability of doctors varies widely, one is especially cautious about starting conversations at this time of day.

He had recently changed his very busy Internal Medicine practice to a concierge style practice.  Maybe because of this, he looked happy and rested enough to ask the question.

“How is your new practice?”

“It’s really good,” came the reply.  Now the pause came, the brief ‘y’ in the road in which a mutual decision is made to talk more–have real conversation–or just move on to the morning duties.

He offered.

“It’s amazing how good it (his new practice) is…we (his other partner) went from over 3000 patients to about 700.  We no longer worry about making enough money….I see about ten patients a day, and if someone needs to be seen it’s never a problem working them in that day.  You have to be on call at all times, but this weekend, I only had a few calls.” 

Here came the zinger. He thought for a moment and gave it to me…

“You know, the medicine is way better, like it should be.”  

As we parted ways, I couldn’t help but to think of how much fun I had practicing medicine on this winter’s only real snow day.  That is, snow in a southern state halves the number of patients to be seen.  Concierge medicine seems to have succeeded in creating a snow day every day. Fewer patients equals better doctoring.

Fortunately, our family has little need for the services of an internist.  But if we did, couldn’t I justify the cost of a daily designer coffee for the availability of a well-rested and happy doctor?

The purpose of publishing this impromptu interview with a recent convert to concierge medicine, is not to say retainer fees to doctors are the end all answer for our health-care delivery woes, but rather, to further illustrate this obvious conclusion: society cannot expect more care, better quality care and less expensive care. These are incongruent triangles, never to be justified.

I wonder what the future of health-care holds.  Fewer young people will choose medicine as a career.  Training doctors takes longer as the complexity of medicine expands exponentially.  More middle-aged doctors will retire early.  Doctors are increasingly moving to shift work, as the incentive to work themselves into an inflammatory haze are removed.  All this while more patients enter the health care arena. And for some unclear reason, many seemingly intelligent people expect to pay less for more care.

I am not sure how Ivy league colleges teach economics, but at Hobart, we learned that if demand (of health-care) is on the rise, and supply is diminishing, the price does not go down.

Like parents in Harlem who enter a lottery in hopes that their children will be selected for admission to the best charter school, will there be lotteries and wait-lists to see the few-in-number best qualified doctors. Sure, like there are other schools in Harlem, there will be other health-care available.

But what kind of care will it be?

We will see.

JMM

Why is paying a doctor so different?

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Doctors going to a cash only system of payment is steadily increasing, and these changes are garnering much attention.

Practicing medicine is a skill honed over many years of training and education.  Like any good or service, “doctoring,” has a value.  What this value is, has become a matter of much debate.   The payment for these services has evolved into a convoluted web, with monopoly-money-like charges submitted and third parties paying some widely disparate fraction of the bill.

What other economic system in society works like the healthcare system?  Lawyers, accountants, architects, barbers and so on, all get paid in the “normal” manner with a credit card, check or cash.

At the bottom of any invoice for a good or service is the “balance due.”  In real life, the balance due is usually the same as the sum of the charges.  In medicine, the balance due is some fraction of the charges and the formula varies widely.

Doctors employ many just to help navigate this web of confusion, and the navigation of this complex system is a source of much dissatisfaction by doctors and patients alike.

More and more though, many doctors are moving to the root canal system of payment –one in which payment is in cash, like everything else in society.

Right or wrong,  expect more doctors to move to this system.  In my medium sized pond, many good doctors have already done so.

JMM

Not complaining, just stating the facts…

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The phone conversations are overheard.  The other doctor is new to the game of private practice and she meticulously explains the illness to a daughter.   This persists for about twenty minutes and at the end of the phone call the daughter suggests the doctor needs to talk with the son who is a surgeon in a far away state.  Soon, the phone rings and the same material is discussed for another 15 (low estimate) minutes.  An agreement is reached and there is a third conversation to the nurse taking care of the patient.

The newbie doctor turns to me and says, “Whew, that was a long time on the phone. Do I get paid for my time?”    Of course, most know the answer is NO!

With bias acknowledged I am certain good patient care was achieved, but yet there is no payment.  In that same time spent, a defibrillator is installed, a simple ablation performed or numerous ear tubes inserted, all of which are well compensated.

And, yesterday an announcement of yet another primary care doctor moving to concierge medicine where people of means will pay for the aforementioned attention.

Just the facts…

JMM