Community General MedicineJuly 7, 2014

The battle to care

By James Salwitz, MD

Doctors have become a profession of whiners.  Meetings, dinners, doctor’s lounge and blogosphere are flooded with physician complaint, tirade and anger. The volume of pained voices suggests that health Armageddon is only a few moments away.

It was not always so.  Medicine is a career where idealism runs rampant.  In medical school interviews young students really do answer that they want to help their fellow man.  Nonetheless, in recent years that has changed.

Instead of espousing the latest breakthroughs, preaching preventative care or carrying on collegial disagreement about research direction, doctors harangue about insurance company dominance, the intrusion of dehumanizing electronic records, ridged evidence-based-venn-diagram treatment regulations, lost autonomy, malpractice assault and of course plummeting reimbursement.   Why has the mantra of the doctor moved from; I am here to help, to I am here to be harassed?

Pundits blame doctors for much that it wrong and therefore justify broad attacks on the profession.  Doctor’s over-diagnose, over-treat, and over-charge, all resulting in massive cost overruns. They fail to use objective analysis and best standards, depend too much on pharma sales data, and rush lemming-like toward the next glittering breakthrough.  Physicians are accused of making income their primary drive, with overblown salaries and even fraudulent billing.  The power of the doctor’s order drives chaos.

Are physician complaints simply the response of a failed profession as it is bludgeoned with reality?  Should we hear their frantic words as bombastic, hubristic self-preservation, or is it a warning?  Whom are they trying to protect?  What are they trying to achieve?

Doctors deeply sense that the despite the need to modernize and rebuild major parts of healthcare, many elements of change threaten the ability to communicate with patients, make therapeutic decisions and may inappropriately limit treatment choice.   Intrusions can penetrate and disrupt the physician-patient relationship.  In other words, what frightens doctors the most is transition that destroys their ability to care and give care.

Doctors defend not themselves.  They perceive that the litany of assault is not just annoying, insulting, confusing and at times ridiculous, but a direct attack on patients.  Physicians rant not for treasure or personal glory, but for those who entrust their bodies to the medical profession.

Change is critical if we are going to achieve the quality of efficient healthcare we need.  Physicians understand this more than any other healthcare advocates.  As is their calling, doctors on both side of each argument and idea will have impassioned opinions.  What is vitally important is how we hear physician invective.   Whatever the validity of their complaints, each must be understood to come from the most positive of values and goals.

The practice of medicine is a complex, exhausting and demanding profession, which requires passion and life-long drive.  Doctors will continue to the struggle against disease and for health, with voices loud.  They are fighting for all of us.

 

 

 

 

 

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33 Comments

  • Jo
    Praises to all the good doctors! I hope that they will be listened to and heard..they are on the front lines of the battle for health. Recently when I told a couple of people that a doctor had ordered an MRI on my husband's brain, one of them said to the effect, I guess the doctor needs money for his golf game, and the other said something similar. It really upset me because I believed that a doctor would only do something that would benefit a patient and hopefully lead to better health and not be motivated solely by money. Sure they have to make money, but to me, to order tests or treat the patient solely for the money they could make off of them would be highly unethical! Perhaps these people were half joking, I don't know, but, it really bothered me. Your articles are very insightful Dr. Salwitz.
    Reply
    • Tom Koby
      By law doctor who orders MRI is banned from owning MRI, therefore the profit from MRI goes to someone else, who by law is forbidden to give kickback to referring doctor. Doctors order expensive tests from fear of potential lawsuits. This suits medical corporations and insurance companies just fine.
      Reply
      • R. M. Osborne
        Thank you for your accurate reply
        Reply
  • Margaret Fleming
    Thank you. I would only add that doctors, at least in L.A., were already feeling the burden of all this in the early 90s.
    Reply
  • Liz
    I would guess it is the loss of autonomy, increase in time consuming paperwork (be it billing, getting approvals…) that drives many doctors nuts. This kind of stuff drives people nuts in other professions too, although idealism is not why people enter some professions (it is for more professions than just for medicine though)… If bitching about aspects of their jobs they hate help doctors cope with those stresses, then have at it. Others in other professions bitch about what they don't like about their job, employer, profession, etc. The problems begin for the patient when the down side of the job pulls the doctor down such that the patients have to deal with a jaded doctor who is just putting in his/her hours, is burned out, etc. or when the "paperwork" side of the job overwhelms common sense and the patient can't get a test they need, is forced to be discharged from the hospital too soon… due to a gatekeeper who is a fool. As far as the attacks on the profession - the problem is that the research has documented that if an MD practice or a hospital buys an expensive piece of equipment they order tests using it more than they did before so there is some justification for some of those complaints. Another problem is that this profession is like any other - there are people who are ethical and don't deserve to be attacked and those are not ethical and fit the shoe being thrown. The problem is that they way our brains works we remember the rarer events and presume they are more common than they really are as so as a result presume more doctors are "corrupt" than really are (just as we presume more CEO's are working only on their own self interest than there really are). When the government heavily regulates something that always adds a layer of complexity to whatever it is that goes on. Since most legal bills are those involving compromise whatever is passed usually has flaws, unintended consequences, etc., sometimes pretty significant ones. Unfortunately doctors often get blamed for that fall out (especially the unintended consequences). The reality is that in any profession there are things people don't like, things that you don't need to be an Einstein to know what is going on is stupidity, etc. and those practicing in that profession need to learn how to deal with the down side so that it doesn't drag them down. The trouble is we are human and so we do get dragged down on occasion.
    Reply
  • Greg Bowman
    It would be nice if physicians were able to do their profession without all of the outside distractions. A lot of the stress issues confronting physicians today are the product of outside sources interjecting their thoughts and opinions on how Medical Practices should deliver care. However, most of these outside sources are not qualified in the field of medical care. Because time is finite and non-renewable, every second a physician is required to spend on these non-productive issues takes away his/her opportunity to care for patients. Physicians need to be allowed to maximize their time with patients so they can deliver quality care to their patients. Delivering quality patient care is the number one concern for virtually all of the physicians I work with.
    Reply
  • Judy Roebuck
    I hate seeing a doctor down on himself or health care in general. I want you all to be supermen/women, never complaining and getting on with what you do best, helping other people have a better life. That is what you do and I thank you for it. You went through too much, go through to much, not to feel good about what you do. As we would say in Texas, "Cut yourself some slack." You basically do good, no matter the storms around you. And you have given the best years of your life to doing good. What better could a person do? God bless you and your family and those around you who do the same thing. Keep you eye on the prize. Your posts are enlightening and encouraging. Helps keep everything in perspective. I have Waldenstroms Macroglobulinemia (ah...that takes you back to medical school, I bet!) and would not be here without the expertise of several good oncologist/hematologist. Be strong and of good courage. The tea cup is half full...although there is a tempest there!
    Reply
  • janice mancuso
    Dr. Salwitz, your message in today's essay reminded me to listen again to Lawrence O'Donnell's poignant (spoken) essay about his gratitude for doctors & nurses. (http://www.msnbc.com/the-last-word/watch/lawrence-returns-discusses-his-accident-287481411836) It touched me as deeply today as when I first heard it on June 23rd. Following a serious auto accident - and near death experience - in April, Mr. O'Donnell found himself for the first time in his life "living among the medical community." It proved to be a huge revelation for him At approx 13:00 he said: "The doctors and nurses I have met have something that most of the rest of us don't have, the absolute certainty every time they go to work that they're going to do something important today - something invaluable for someone else." Thank you for doing at least two meaningful-somethings - exquisitely caring for your patients and writing words worth reading. PS This very liberal "anchorman" even had kind words for David H. Koch and his philanthropic contributions, especially to the Hospital for Special Surgery in New York. He cited a pertinent F. Scott Fitzgerald quote to make his point. A good lesson for all of us. "The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function."
    Reply
  • J Antonucci MD
    Whining is defined as a plaintive cry. Here in primary care we are desperate to be heard ,we spend 1/3 of our scant resources on administrative checkboxes which have no efficacy and distract us.It is hard to be constructive and organize and speak up But it needs to be done.
    Reply
  • Bobby Gladd (@BobbyGvegas)
    I will be citing this on my blog. Been thinking, reading, and writing a lot lately about what I call "psychosocial toxicity" in the healthcare workforce culture. At its worst, it poses patient safety issues. Beyond that, it's enervating and counterproductive for everyone involved. While there may be a (negative) "publication bias" (only the angry and frustrated docs get attention; happy ones don't blog or comment as much), the problems are significant, and need remediation.
    Reply
  • cclarke
    Physicians are busy working and rarely have time for much introspection...I have never had a position where I was free to sit and whine, or figure out that I could cheat the system and make more money by ordering an MRI of the brain...I do know if I failed to determine that an MRI was indicated based on the patient's history and physical examination and it turns out that the patient actually had a condition in which a MRI as early diagnostic intervention would have ensured an outcome without end-organ-damage there would be grave consequences for the patient and possible damage to my professional practice.
    Reply
  • pat m
    The public has really soured on health care in recent years and do blame doctors for excessive tests, etc., when in fact most doctors get no money for the tests they order. So many of these sophisticated tests, CT scans, MRIs, and now Pet scans have eliminated the need for many exploratory surgeries, painful biopsies, and decrease the chances for infection. The technology should be celebrated because it saves patients so much pain, saves the system money ultimately because they have decreased the need for hospitalizations. Much of the reason hospitals are sitting half empty is because technology has made it possible to do so much on an outpatient basis. We in health care should be out defending the great state of health care as it moves and adjusts to so many changes but still millions get moved through the system in a safe and careful way. That is because they have physicians and nurses who are great advocates, unafraid to question and constantly poke the system to improve. But improve it is and at a very rapid rate.
    Reply
  • Bariatric Help
    Hmmm I would agree with a few things in here. "They fail to use objective analysis and best standards" is tops of the list. I have seen time and again that with some training, I can interpret bloodwork results better than doctors. As in interpret it to the patient, not just "oh the computer said its fine, patient is just malingering". I find a lot of doctors rely way too much on their own personal experience vs. some research. Frankly, I can't take doctors who complain about getting their info from Oprah or Dr. Oz, but then go off their own experience like they have a basis for their opinion. I've had too many missed diagnoses or failed to follow up because they simply aren't doing any science behind their guessing.
    Reply
    • Doc TH
      If you can interpret your test results "better than doctors", why go to a doctor? Just go to a CVS "clinic", ask for a CBC and chem panel and ask them to mail you the results. Then you can prescribe your own drugs from Mexico, and learn how to do surgery on yourself,
      Reply
      • Bariatric Help
        The insurance won't pay for it, nor will you be able to get the testing that I need from a simple CMP type of thing. Nor can I get treatment covered either. Let me add that your attitude comes through. The doctors I have, teaching ones and MD/PhD's, who are science & evidence based, have agreed that what I ask for is logical and not just some pie in the sky stuff. Time and again they've seen me choose based on evidence, not just Oprah or others. Time and again, they've seen me proven right in terms of diagnosis. One exception is when I had a value that went off and asked for another test for something. The doctor, who didn't know the research, said no. When I spoke about it to another doctor, they didn't understand why I asked either, until I told them if they looked up a high level of X, they would find that can be due to disease Y. Its in the research. They understood my concern. Its those who blew me off and didn't listen to the science, but said things like 'I've been a doctor for 20 years", who have missed and delayed diagnoses. For those people who have learned and gained the knowledge, why do you find it so hard to work with them? I work with people younger than me and if they have something great, I go with it. I don't have a problem that I have a degree they lack or experience they don't. What matters is what is best for the project, or in my case, the patient. Not my ego or whatever.
        Reply
    • h l morgan
      I take it you're not doctor. Training and personal experience are key to making a correct diagnosis. Tests are performed to confirm the diagnosis. Medical references which we rely on also help in cementing the diagnostic impression. That's why its called the art and practice of medicine. Too many young MD s order tests then are stumped when conclusion is not obvious. A good physician listens, examines, then forms an educated opinion. Your ability is based on past successes as well as failures. This takes a number of years. Some learn faster than others.
      Reply
  • briarcroft
    Dr. Salwitz, you have once again written such wisdom and truth: "what frightens doctors the most is transition that destroys their ability to care and give care." I am and have been there for some time and the fear and frustration of not being able to do well what I was trained to do weighs heavily every day. I look for those small moments of knowing I have made a difference in someone's life, and that keeps me going back to work. It isn't so much about whining as it is about weeping, no longer silently, over what we have lost in our battle for caring. The wounds we and our patients bear are deeper and slower to heal. thank you, Jim, yet again.
    Reply
  • Kieran Cross
    Just to be clear, most doctors do not make any money from the tests they order, including imaging and labs, as they are not Radiologists or Pathologists. We Radiologists cannot order any imaging tests because the Stark Laws prevent that. We can only perform studies on patients that are ordered by their physicians, like Internists or Family Practice doctors. It is highly insulting to hear people think their doctors are taking financial advantage of them when actually it costs most doctors' offices a full time staff member to get authorization from insurance companies to order any test and that doctor gets no reimbursent for his staff's time from the insurance company or the Radiologists. It would be considered a kick-back, which is illegal. KG Cross, MD
    Reply
    • Bariatric Help
      Dr. Cross, I don't believe the issue is that doctors make money from it. I think one of the issues I've seen is the lack of thorough H&P, instead relying on basic bloodwork. If docs did a good H&P, you may not need any bloodwork. Or use the bloodwork to back up. I ask for targeted bloodwork - or a full round - all depending on what may be found in an H&P.
      Reply
  • Cartón Rojo
    The medical professions have been selected, by the lawyerly professions that dominate our political elite, to absorb the body blows that will emerge from the “need to modernize” healthcare. Unfortunately, such selection is typically reinforced by a process of stigmatization, which will be felt as unfair punishment, if it hasn’t already been. Health professionals will remain frontline enforcers of modernization’s more onerous side-effects, and will very likely see their compensation stagnate if not decline. In order to achieve “efficient healthcare”, the concept of ‘bending the cost-curve’ is inevitably, eventually, bound to the concept of ‘bending the Hippocratic Oath’. All of this “bludgeoning” will likely take an emotional toll on practitioners of what is traditionally the best-motivated profession to be found, overall. It’s difficult to imagine that the net result won’t be damaged motivation and a diminished talent pool attracted to the profession. Much of this has been contemplated by the author of this generally well-considered article. To scold those who accurately identify decline in their professional independence and prestige, and who rationally wish to limit the deterioration, is the reflex of an idealogue. I’ve seen plenty of this reflex, and to me, it presages a form of the Stockholm Syndrome being adopted, to which the well-intentioned are always the more susceptible.
    Reply
  • Craig Gordon
    It is the ability to care for someone who needs it and knowing that a job well done is going to offer immediate "positive" reinforcement that helps me to continue to do what I do best. Seemingly, almost everything that I am trying to do over the recent past has limited my ability to do just that...care for my patients. I have not seen a physician whine...ever! I have seen doctors speak passionately about their ability to care for patients and to practice their skills. I see this ability continuing to erode and wonder where it is we are going to be in the near future. I am worried and concerned and with good reason. Whine...I think not. Recognizing a problem and fixing it; that is becoming remarkably more difficult. Calling it a whine seems to be an inappropriate attempt to suppress an important noise.
    Reply
  • Giorgio
    Get the insurance companies out of the way and let us take care of the patients. It will be faster, better and cheaper than hearing: "doc, you can do what you want but we are not going to pay for it" or: Going forward you will need pre-cert for an echo" and a pre-approval for that new medicine that is not on our formulary" .
    Reply
  • Ms. Judy Rosner
    What wasn't mentioned was a major cause for physicians' problems: malpractice insurance costs thanks to the country's moronic legal system. If congress were composed of real people instead of so many lawyers, tort reform would be passed and physicians wouldn't have to order so many CYA tests.
    Reply
  • S Curtiss Mull M.D.
    As a physician who practised 30 years in private practise and who for the past 12 years has continued to work as a part time Locums orthopedic surgeon, I would agree with much of what you say. We have, to a great extent, ourselves to blame. I went into medicine because I thought it would be an interesting, challenging profession and have never been disappointed in that reguard. Unforfunately, many physicians have forgotten that the financial aspects of medicine are really secondary if you really think about it. Not many laymen are going to feel sorry for any physician who had to reveal his or her yearly income. Sure there are a lot of hassels with insurance, billing, and now medical electronic records. If you can put the negaives behind you and concentrate on the many positives, your life becomes much simpler and rewarding. I have found that as a Locums, I can treat all my patients without reguard to ability to pay (at least me) and have the time to spend with them, a luxury that the full time MD dosen't always have in these days of rushing thru the day. I always advise any student who is considering medicine as a career, to consider it a calling, not a way to financial sucurety. On final note. Many in our profession burn out early, espescially if they don't have a balance in their lives, with family, hobbies and outside interests playing a very important role in our mental stability
    Reply
  • Danial
    Such a silly article. Why do they over diagnose and over charge? Because they get sued and get threatened to be sued all over the place. Physicians who don't practice anymore should not be allowed to judge others, nor should they be allowed to make policy decisions that won't impact them. This is where I can give you multiple examples even this week where I felt frustrated because I couldn't help my patient but I won't. Because someone out there will mistake it as more whining.
    Reply
  • D Someya Reed
    It's sad to think how many doctors spend more, sometimes most, of what precious little time they have with their patients not discussing their patients' actual care but rather how to traverse the system to get them that care...sometimes ANY care. If you really want to test the "caring" resolve of a doctor, find out or listen to where that doctor's advocacy lies. If you're hard pressed to find a beneficial patient connection then it should give you pause. If the doctor spends more time telling you (as patient) what his list of needs are then you are not utmost on his (list). There are powerful forces above most doctors driving medical care today and it's not all about patient care. A good reason to be further impressed by those doctors who push back for the benefit of their patients when pushed upon by these forces.
    Reply
  • Wigpicker
    We have the worst health care system of all developed countries. Think about what our health care would be like without the insurance companies sucking every possible dollar of profit. The more they profit, the more we lose. Why the hell do they still control our health care? Do doctors in England experience the same frustration as ours do?
    Reply
  • Paul Kempen
    Get Real! Medicine is 18-20% of the Gross national product and doctors are no longer in charge. We have politicians, corporations, and hucksters out there pushing their brand of product line on "medicine" including nonsense and unproven junk science to be bought and sold. Even the "leadership physicians" are finding corporate boards to hide on and gross millions while never seeing any patients. People like Christine Cassel (at ABIM for years and now National quality forum) and many CEOs of the ABMS and affiliates are "top earners" pushing this unproven and "new product" MOC on physicians after pushing through Congress legislation to require their products of every physician. Patients don't know that this also means they become guinea pigs for the MOC products and will never even be told!
    Reply
    • Bariatric Help
      Actually, not every patient is in favor of the MOC stuff. We support continuing education, but have seen far too often that it may not help us get better care. Some of us patients do support docs getting paid for doing peer to peer with insurances, EHR work, phone calls to patients and to other docs on behalf of patients, emails for/to patients. Telehealth too. The problem is how we patients can make a dent in trying to get that to happen.
      Reply
    • h l morgan
      AMEN!
      Reply
  • Haindmaidenofhippocrates
    What a tragedy. Keep in mind that most patients are on your side, but doctors and their so-called advocates have done a very poor job of linking the corporatization of medical care to its decline. By failing to stand up to the naysayers, you have put your patients at grave risk. Medicine has been bombarded by negative propaganda for at least two decades. There have been few who have publically defended the profession. Corporations, insurance companies and the government have relentlessly demeaned physicians with few rebuttals, so that they can push their agenda for profits or power. Even among the educated readership of the WSJ, commentators often rail against what doctors 'must' earn from procedures. It never crosses their minds that while a GI specialist is doing procedures in the hospital, his overhead back at the office diminishes his profits, sometimes by as much as 80%. Combined with the pittance that Medicare or insurance companies pay him, he keeps a fraction of what he charges. Very few people understand this. Doctors have behaved as if they have taken vows of silence. But the independence of thought and action required for top notch medical judgment must be defended. It is difficult in an era of increasing government intrusion into every facet of people's and businesses' lives almost to the point of fascism. Businessmen are very jealous of the independence that doctors' have enjoyed. They are happy to smack them down and guzzle the money they generate. Government loves power and control If you can't speak out publically, do it one patient at a time. They vote. And most hate what is happening to medicine, because they instinctively know that you are their most ardent advocates. Tell them what is happening to you and your practice. Remind them that insurance companies have contracts with them and they must demand care. Explain to them the terrible conflict of interest that results when doctors become captives of insurance companies. Educate, then educate some more.
    Reply
  • sterlinghaynes
    I agree but we are not much different than the average Canadian.
    Reply
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