Think about how medicine came about. There was a person in your village or tribe who, when something went bad you went to them and he/she evoked the power of the gods through prayer, chanting, herbal remedies, or crude surgery in order to bring about cures. This was before the randomized, controlled trial was invented, so really we can’t say if this was effective or not. But this was the way of things, there was a healer, who was also a holy person probably. Then at some point there came a decision that people should go see their healer in a specified place, sometimes a temple, sometimes what we might now call a clinic. And later people would stay in these places where the healers dwelt and they become hospitals which really started to come on around the end of the 1800s. Doctors starting having their offices elsewhere and when you got really sick, they’d put you in the hospital, but often times the doctor owned the hospital or he and his partners did.
Then the whole thing got big and out of control and now doctors aren’t even allowed to own hospitals even though it was our idea to make them in the first place. It reminds me of the movie “Tucker” though when The Dude gets voted out of the presidency of the company that he created (a nice film on crony capitalism if you get the chance to waste 2 hours). So there was a time when hospitals existed with doctors as sort of free agents bringing in patients to one hospital or another, but having privilages at other hospitals to change it up now and then. That time is passing.
Hospitals make a lot of money off of lab tests, radiographic imaging, operating room utilization, bed utilization, and ancillary services (a word for “everything else that supports the main operation”). But hospitals know that they can’t use those services unless a physician orders them to be used. Trust me, if they could get around that they would. So they are willing to give some of the profit from those services to the physicians in order to guarantee patients will use their hospital instead of someone else’s. The other issue aside from that is that hospital payment is tied more and more to certain “quality” measures which in the end rely on the compliance of the physicians with the quality standards. And trust me, many physicians see quality measures as pure and simple bullshit (largely they are, more later). Hospitals employ compliance and quality officers (nurses who are burnt out on cleaning shit out of bedpans) in order to boost their numbers, but ultimately they need the buy in of the physicians.
A physician who sees patients in the hospital full time and bills E&M codes (evaluation and management – what we get paid for seeing you, talking to you, and making you turn your head and cough) and does very few procedures will work hard and net between $150 and $200,000 a year, and that’s really busting their hump. The hospital can offer them somewhat more than that and guarantee a shift-work like schedule with bonuses and incentives tailored to the hospitals quality measures. They get a good salary, the hospital gets a compliant employee, and what’s more the hospital gets all of the patients the doctor would see to come to their hospital. Also, the doctor becomes a “brand” that the hospital can market to patients as an expert (which benefits both hospital and doctor).
This is great right, everyone is happy, right?
Here’s why it is the end of civilization:
1.) Work Ethic – Being a doctor is hard. Traditional wisdom says that when you try to take something hard and make it easy that something gets lost. Why does handcrafted furniture command better prices than those made by machines? You sit on them just fine, they may be aesthetically pleasing, they do their job. But nothing more, they have no soul, no character, no passion. And that applies to physicians who do the 9 to 5 thing. It takes everything about being a doctor and makes it sterile (not in the good way) and passionless. Getting a salary to work a certain number of hours regardless of patients seen, etc is a way to make doctors feel like their work is unimportant. Underworked doctors will become entitled and lazy. Overworked doctors will burn out.
2.) Specialists – Hospitals want to market their specialists. Primary care makes no money for the hospitals. They don’t operate, they don’t order high volume tests, and the diseases they treat opreate under “DRGs” which determine payment before the patient is ever treated – so the incentive is to do less for the patients. But specialists make a lot of money because the opposite is true. The more they do, the more they get paid – and the money goes to the hospital.
But specialists come in varying quality and ethical standards. The ones that take the big dough are the ones that didn’t want to have to work in the community to get their own consults, build up a reputation among their colleagues, and climb their way up into the money. They decided to suckle the fat teat of the hospital in exchange for easy referrals, easy hours, and a fixed call schedule. Again, that sounds nice. But if they don’t get paid to see an emergency patient, maybe they won’t come in at 9pm to do so…admit, wait until morning. Raise your hand if you know someone who was admitted to see the specialist in the morning. Does that sound right? And then if it isn’t an emergency, if its a matter of convenience or courtesy, that doesn’t exist in the employed model. If you know you get the referrals from the hospital, why show extra courtesy and stay late or come in on a weekend or during lunch to see a patient as a courtesy to a colleague. You don’t have to show off! The check’s in the mail, baby!
Finally, the hospitals market these guys like crazy, but they aren’t usually the best physicians in their field for the above reasons. The good ones are out there making mad cash and working really hard. So your media gets inundated with b.s. about the best people providing the best procedures and it is all untrue and so you suffer. Think this doesn’t happen? Read this.
3.) Prison - Not like federal jail, but like the hospital is a prison for physicians. They sell their practice to the hospital literally. They sign over their insurance contracts and medicare benefits to the hospital and then promise that they will not compete against the hospital if they leave. That means most of the time that if they leave, they can’t practice medicine within like 50 miles of the hospital for 5 years, or maybe even 1 year. They can’t call or write their patients to say they are leaving and they want to remain their doctor. The hospital has them, the doctor is now just an agent of the hospital. It doesn’t matter if the time lapses and the doctor comes back and practices there legally, the patients now have new equally douchebaggy doctors and they aren’t switching back just because you got a conscience and stopped being a medical whore.
4.) Buying in to Quality – I believe in quality medicine, but in our police state of hospital care, it is defined somewhat arbitrarily based on unproven standards. You can prove that in a subset of patients who have CHF that discharging them on an ACE Inhibitor or ARB is good for them. I don’t argue that. But forcing the whole world to do it and then calling that quality medicine – making it one of like 10 standards by which all quality is measured…what does that do? I don’t know, and no one does. Quis Custodiet Ipsos Custodes my friends. In other words, how do we know that this massive quality measure is actually going to improve healthcare.
Aside from picking arbitrary measures and deciding that’s what quality healthcare is, what about, oh, say, meeting the expectations of the patients? I mean, hospitals want you to be happy and come back for more tests, surgeries, etc. BUT they don’t care if you’re really truly satisfied or have gotten an excellent outcome. What I’m getting at is that what if the whole quality effort is completely misguided and won’t really make patients feel happy, feel trust for their caretakers, and have a sense of health and wellbeing, isn’t that what it should be about? For instance:
Is that quality healthcare? The government thinks so. And so does your hospital employed physician.
So, I know, TLDR, but to sum it up:
Doctors are all stupid and lazy, BUT
Doctors who work for the hospital are the true whores of the medical system.
Thank you, that is all.