The battle for the soul of medicine….

Interesting essay in the NY Times. As usual devil’s advocate comments required especially when discussing issues of the soul (see inserts)…

A Doctor by Choice, a Businessman by Necessity

By SANDEEP JAUHAR, M.D.
Published in The New York Times: July 6, 2009

To meet the expenses of my growing family, I recently started moonlighting at a private medical practice in Queens. On Saturday mornings, I drive past Chinese takeout places and storefronts advertising cheap divorces to a white-shingled office building in a middle-class neighborhood.

I often reflect on how different this job is from my regular one, at an academic medical center on Long Island. For it forces me, again and again, to think about how much money my practice is generating.

A patient comes in with chest pains. It is hard not to order a heart-stress test when the nuclear camera is in the next room. Palpitations? Get a Holter monitor — and throw in an echocardiogram for good measure. It is not easy to ignore reimbursement when prescribing tests, especially in a practice where nearly half the revenue goes to paying overhead.

Economic theory would predict that economies of scale would reduce your overhead burden as opposed to the current average physicians adopted response of driving increased utilization potentially abusing your domain knowledge over the patient as he has no idea he doesn’t “need” the extra tests. The Devil suggests that the typical small scale physicians practice is outdated and consolidation would allow you to lower your overheads per provider. Implementation of IT systems (which you may already have though many doctors don’t) though heavy on the upfront costs may provide you greater insight into you practice’s financials and allow you to identify inefficiency. My main point is that physicians themselves have been the biggest hurdle to implementation of innovation in healthcare delivery. Of course this requires a loss of autonomy and we are talking soul here…

Few people believed the recent pledge by leaders of the hospital, insurance and drug and device industries to cut billions of dollars in wasteful spending. We’ve heard it before. Without fundamental changes in health financing, this promise, like the ones before it, will be impossible to fulfill. What one person calls waste, another calls income.

It is doubtful that doctors and other medical professionals would voluntarily cut their own income (even if some of it is generated by profligate spending). Most doctors I know say they are not paid enough. Their practices are like cars on a hill with the parking brake on. Looking on, you don’t realize how much force is being applied just to maintain stasis.

Can’t argue with this one except it implies incomes should be protected and never disrupted. There are examples all over of protected industries being subject to disruptive technologies which upset very comfortable income arrangements. Whether it be broadband and Skype for telecommunications, Napster and itunes for record label companies, internet news and blogs for the newspaper/print media industry, and even, hopefully, investment bankers no one is immune to readjustments in income. I’m sure doctors have benefited from the previously listed innovations which must have been quite painful to others in society. According to the Devil, what is required is anticipating and embracing change and reorganizing your “business” to enable it to adapt to a new inevitable reality.

I recently spoke with a friend who dropped out of medical school 20 years ago to pursue investment banking. Whenever we meet, he finds a way to congratulate me on what he considers my professional calling. He often wonders whether he should have stuck with medicine. Like many expatriates, he has idealistic notions of the world he left.

At our most recent meeting, we talked about the tumult on Wall Street. Like many bankers, he was worried about the future. “It is a good time to be a doctor,” he said yet again, as I recall. “I’d love a job where I didn’t have to constantly think about money.”

Are you kidding me? This guy is truly a work of art. After the investment banking industry has just raped and pillaged the world’s economies and put America on the pathway to bankruptcy, he wants to now join our altruistic calling. Actually the Devil would get a kick out of that. I’m sure your friend has saved plenty from the last few year’s bonus distributions to retire to Practice Wonderland; meanwhile you dear doctor must continue to worry about falling incomes and rising overheads.

I didn’t bother to disillusion him, but the reality is that most doctors today, whether in academic or private practice, constantly have to think about money. Last January, Dr. Pamela Hartzband and Dr. Jerome Groopman, physicians at Beth Israel Deaconess Medical Center in Boston, wrote in The New England Journal of Medicine that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” And they added, “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms.”

Price tags are part of everyone’s daily life. No reason to exclude docs.

The rising commercialism, driven in part by increasing expenses and decreasing reimbursement, has obvious consequences for the public: ballooning costs, fraying of the traditional doctor-patient relationship. What is not so obvious is the harmful effects on doctors themselves. We were trained to think like caregivers, not businesspeople. The constant intrusion of the marketplace is creating serious and deepening anxiety in the profession.

Not long ago, a cardiology fellow who had been interviewing for jobs came to my office, clearly disillusioned. “I was naïve,” he said. “I never thought of medicine as a business. I thought we were in it to take care of patients. But I guess it is.”

I asked him how he felt about going into private practice. “I’ll be too busy vomiting for the first six months — I won’t have much time to think about it,” he replied.

Rising commercialism, deepening anxiety, busy vomiting…please. If you are really into it to take care of patients then the commercial aspects are irrelevant. The deepening anxiety is due to the threat to incomes and thus standards of living. A “real” doctor would do it for the barter as in the old days. Of course I exaggerate , as the Devil is apt to do; ok, yes, we all want and are entitled to earn nice cars, a decent roof, and to put our kids through college but this is the source of the anxiety. Physicians need to be an aggressive part of the evolving solution and not try to protect and preserve their old turfs and their previous oligopoly. Only in this manner can physicians recognize and identify future opportunities to add value and capitalize on them.

Of course, there has always been a profit motive in medicine. Doctors who own their own imaging machines order more imaging tests; to take an example from my moonlighting work, a doctor who owns a scanner is seven times as likely as other doctors to refer a patient for a scan. In regions where there are more doctors, there is more per capita use of doctors’ services and testing. Supply often dictates demand.

Supply only dictates demand when the consumer of the services is ignorant and is not required to pay for the service being provided (the famous Moral Hazard). Caveat emptor or buyer beware need not apply in this example. You need the holter and echo. Yep I do. My doctor says so and I always do what my doctor suggests because he knows best. Plus, the insurance company pays for it…so what the heck. If I suggested to you as a Chrysler car dealership owner, I build 3 more dealerships because you will buy more cars I would be insane although that is exactly what the automotive industry in the U.S. did and now are extricating themselves from. It’s called oversupply. The usual response to oversupply is decreasing prices…not in healthcare. We got a protected industry and an ever-willing (at least in the past) payor.

But financial considerations have never been as prominent as they are today, probably because so many hospitals and doctors, especially in large metropolitan areas, are in financial trouble. More and more doctors are trying to sell their practices, or are negotiating with hospitals for jobs, equipment or financial aid.

At hospitals, uncompensated care is increasing as patients suffering from the economic downturn lose health insurance. Admissions and elective procedures — big moneymakers — are declining. Hospitals are cutting administrative costs, staff and services.

Is it possible that there is an oversupply of hospitals? Just as dealerships go out of business, albeit after government intervention, maybe a reduction in the number of hospitals is required. Maybe we don’t need so many CT scanners. Remember your previous argument, “Supply often dictates demand”. This is a lethal recipe when mixed with a dose of moral hazard. Any maybe, physicians selling their practices is just the consolidation we need. Just throwing it out there as the Devil.

“More and more you’ll see people in medicine get M.B.A.’s,” a doctor told me at a seminar, in a prediction borne out in my experience. “We are in a total crisis, and I don’t know the answer.”

Ooops. I am one of those doctors with M.B.A.

I must admit that part of me wants to see doctors master the business side of our profession. When I hear about executives at health companies getting tens of millions of dollars in bonuses, I am nauseated by the blatant profiteering. As a loyal member of my guild, I want to see doctors exert more control over our financial house.

It’s sad to see you bemoan others’ incomes as you defend your turf. Imagine the outraged blog entries insurance company executives could write. Society asks them to distribute risks. Society asks them to ration care so that all can have access. No love at all.

And yet the consequences of this commercial consciousness are troubling. Among my colleagues I sense an emotional emptiness created by the relentless consideration of money. Most doctors went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income. There is a palpable sense of grieving. We strove for so long, made so many sacrifices, and for what? In the end, for many, the job has become only that — a job.

Don’t cry for me Argentina. A lot of people suffer. A lot of people sacrifice. If you have ever started your own business in an industry where there is real competition (NOT medicine), no price fixing (NOT medicine), no virtual guarantee of being paid (NOT medicine), and a real risk of loss and bankruptcy (NOT medicine), you would understand sacrifice. A job is an honorable thing…don’t knock it. >9% of your population doesn’t have one.

Until I went into practice, I never had an interest in the business side of medicine. I sometimes yearn to be a resident or fellow again, discussing the intricacies of a case rather than worrying about the bottom line. “You need to learn a little of the private-practice mind-set,” a doctor friend recently advised me. “You can’t survive with your head in the clouds.”

The Devil agrees with last sentence for sure…

But something fundamental is lost when doctors start thinking of medicine as a business. In their essay, Dr. Hartzband and Dr. Groopman talk about the erosion of collegiality, cooperation and teamwork when a marketplace environment takes hold in the hospital. “The balance has tipped toward market exchanges at the expense of medicine’s communal or social dimension,” they write.

How this battle plays out will determine to a great extent what medicine will look like in 20 years. This is about much more than dollars and cents. It is a battle for the soul of medicine.

Sandeep Jauhar is a cardiologist on Long Island and the author of the recent memoir “Intern: A Doctor’s Initiation.”

Physicians need to embrace the inevitable upcoming upheaval and adapt. Maybe the AMA has recognized this already when they signed on to Obama’s reform. Who knows the real political considerations? Patient’s will always need care. You are the caregiver. The real battlegound is in physicians’ souls.

Tej Deol, M.D.