Wednesday, July 02, 2003

I submitted this to Medpundit about a year ago and Dr. Smith published it. Things haven't changed much.

Sometimes find myself ashamed and guilty of how I feel some times about such matters. One the one hand physicians are told that medicine is a "calling" and that we should devote ourselves above all to our patients. Medicine is somehow "special" in this devotion when compared to other professions. On the other hand physicians are described as "greedy" when issues of declining reimbursement or high liability costs are discussed. As my partner states, "No other business works solely on credit". When I perform a cholecystectomy I cannot demand payment up front ( as a plumber or even a lawyer can do), I am at the mercy of the patient's insurance company or Medicare/Medicaid (if they have coverage) to receive payment. If I am not paid, I cannot very well put the gallbladder back in. This is described as providing a "service to the community". However the community cannot and will not help me in paying my rent, salaries for my staff or my liability insurance. Society has forced physicians to look at their practices through the lens of a business model but then criticize us severely when we do.

The coverage of the closure of the trauma center in Las Vegas provides a case in point. When local circumstances cause the cost of business to rise to where expenses rise income, you have three options: 1. Work harder (see more patients) 2. Raise your fees or 3.Close and relocate. As you well know fees are set by the payors and do not rise at the appropriate pace. ( or as in the case of Medicare, they are falling). So physicians can either run a volume business or relocate. Seeing more patents means less time for each patient and again more dissatisfaction for the patients you do see. If you are an OB/GYN you pay a higher premium for seeing more patients. Thus the rise of "retainer" medicine as DB's med rants puts it. But if you leave you "just wanted to terrorize the community" by denying a service. I also find Assemblyman Perkins's statements, comparing the closure to a strike, to be amusing.

The public continues to demand that physicians act as selfless protectors of the public. But their actions have made being a doctor like having any other job. Residents, medical students, and those interested in medicine can see this. I feel that is why medical school applications are down, slots in general surgery remain open after the match, and resident work hours are under scrutiny. Survey after survey reveal that physicians retire as soon as they can and they are not encouraging their children to go into medicine. Soon the lines will meet and the fixes will have to be more painful and expensive.

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