Random Thoughts from a Restless Mind

When did I become the bad guy?

Dirty Rotten Scoundrel, M.D. Apparently that’s me, and for the most part pretty much all of my physician colleagues if you listen to the President, Members of Congress, and various and sundry pundits from all sides of the political spectrum. There is a over-riding assumption of ill-will and mal-intent when the public is asked about doctors and how doctors behave in our modern medical system. Everyone talks about bad behavior, how doctors are at the root of many (most?) of the “problems with healthcare” in the United States, looking out for themselves first and always, rather than looking out for the best interests of their patients.

The stories told and the statements made are really quite amazing. Mind you now, there are really never any statistics offered that stand up to scrutiny, but the stories are just SO good and SO important that they just must be told. And told again. And again and again until through the sheer volume of the telling they just MUST be true. Like the recent statement by President Obama that Pediatricians would much rather remove a child’s tonsils than treat an infection with antibiotics because they, the pediatricians, would be paid so much more for doing the surgery. This one is pretty hurtful for countless reasons, none the least of which is the fact that neither the President nor any one of his minions is aware of the fact that pediatricians do not perform ANY surgeries, and that pediatricians do not garner any income whatsoever when an OTOLARYNGOLOGIST  removes a child’s tonsils. Recent discussions in pediatric, infectious disease, and otolaryngology circles about the fact that childhood infections have RISEN in the decades in which tonsillectomies have declined, and that perhaps we are doing TOO FEW tonsillectomies now seem rather quaint and pointless in the face of such blatant political pandering. After all, how important can decreasing childhood infections be, really? We’ve got a healthcare system to save!

Is it really true? Do all doctors, or even most doctors, or even a measurable minority of doctors REALLY put their own economic well-being first? Is the first level of decision making in the office truly “which treatment will make me, the doctor, more money?” Could this possibly be the case? I really don’t see it.

In the U.S. becoming a doctor has always been a rather difficult task. American medicine has always been a true example of America as a meritocracy. Our doctors have traditionally been among the brightest of our citizens, students who excelled at every level of their education simply in order to qualify for the privilege of suffering through the pain of a medical education. Those who excelled in their medical school and post-graduate years started out with the best jobs in the nicest locations, or became the academicians who did the ground-breaking research that produced the dazzling array of medical advances that serve us today. A very large percentage of each town’s best and brightest became physicians.

Why? Why did so many of our brightest young people go into medicine? The men and women who are in the primes of their careers right now, did they do so in order to become rich? Was that a reasonable expectation, and were they told how to do this in school? Not to my memory.

Once upon a time, around the time that most of our doctors now in their prime were in grade school, the doctors in a town were held apart from other citizens–seen as different for accepting the calling of medicine. There was an assumption of goodwill born out of the experience that the doctor would be there to take care of you whenever you needed him. A high degree of respect and deference was granted those doctors, whether they were pediatricians or otolaryngologists  or any other type of doctor. Physicians were well-off but they were not wealthy unless they were born to wealth. Being a physician was actually considered one way for a child of wealth to give back to the community. The wealthy in town were merchants or the owners of the factories. Doctors lived in nice houses in nice neighborhoods, but they did not live in the NICEST houses or THE neighborhoods. They often belonged to a country club, but not THE country club.

Doctors of that time, and indeed doctors up until relatively recently, had two very powerful incentives to work hard. In a free market where one is paid for doing work and for doing it well, the more hours you worked and the better you worked the more money you made. It has always seemed that it is easier to find the private practitioner, the doctor of any specialty who works for himself, when an emergency arises at 3:00 AM don’t you think? But more than that, the harder a doctor worked, the more he put aside his own time (and that of his family), the greater was the respect he earned in his community. Hard to value in dollar signs, but clearly valuable enough to create the archetypical American doctor, on call for his patient night and day. In return for devoting your talents to medicine, and in return for devoting years to the toils of becoming a doctor, and in return for placing your time at the disposal of your patients, your doctor recieved a very comfortable living as well as uncalculable respect.

With the exception of the 1980’s during which a small minority of doctors did, indeed, become truly wealthy from practicing some kind of medicine, doctors really did NOT, and do NOT get rich from their jobs. Some time  in those 1980’s things started to change as more and more of our nation’s healthcare was purchased by the government or by insurance companies that took their cues from the government. All of a sudden the doctor was suspect, guilty of gaming the system at every turn. The medical record was no longer a tool to be used in the ongoing care of a patient but was now a legal document, the trap in a perpetual game of “gotcha” as third party payers and malpractice lawyers started to grind away at the reputation and goodwill of our doctors.

Why? Why did this happen? What am I NOT seeing in my offices and in the offices of every physician I have ever known that makes this so? The short answer is that I am not really missing anything at all. There really is no greater incidence of greed and graft on the part of physicians than ever in the past. It’s a ruse, a strawman.  What is greater now is the benefit to be gained by individuals and institutions when all of that goodwill, that assumed respect accorded our doctors is slowly eroded, when doctors can then become a target that diverts attention from any number of more culpable groups.

Might this trend bear fruit? Might this, in fact, be the route that we take to controlling the healthcare economic problems in America? Aye, perhaps, but this is likely to be yet one more instance where we have the opportunity to see the genius of Heinlein,  There Ain’t No Such Thing As A Free Lunch. Or perhaps this, from the Esteemed Physician in ‘Atlas Shrugged’: “Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and operating wards that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it…and still less safe, if he is the sort who doesn’t.”

You might miss me, the eye surgeon Dirty R. Scoundrel, M.D. and my colleagues Snide Lee Whiplash, M.D. the otolaryngologist, and Boris and Natasha Karloff, the husband and wife pediatricians. You will most certainly miss our children and the rest of the best and the brightest of their generation, none of whom are likely to be there to answer your sick call at 3:00 AM. They will most likely be home asleep in the NICEST house in THE neighborhood, tired after an evening at THE country club.

For they will not have become doctors.

This entry was posted on Tuesday, September 22nd, 2009 at 8:12 pm and is filed under Health Care, Healthcare Economics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.