Physicians

PHYSICIANS: Dr. Mom sounds off

Angela Heider is no longer practicing as an OBGYN, and has written a book about why not, called The Rise and Fall of Dr. Mom: Women, the Health Care Crisis, and the Future. What went wrong? Well she starts to explain in this piece:

Wanted.  Part-time.  Private practice seeks obstetrician and gynecologist.  Forty hours a week, some nights and weekends.  Pretax income $70k/yr and falling.  Life-altering medical malpractice claims average only 1/3 years.  Electronic medical record – partially functioning.  Administrative skills required.  Medicare, Medicaid, self-pay, and dozens of insurance plans accepted – billing, coding and prescribing proficiency needed for above plans.  Keep up with this ever-changing medical field and all technical skills on your time.  $80k exit fee due at termination of employment.  Expect childcare expense approaching $35k/yr.     Fortunately, I vacated the above position before the required $80k in malpractice tail coverage took effect.  Unfortunately for all of us, many female obstetricians are forced to make the same choices.  In my practice alone, five of nine female partners elected to retire within the past two years.  I left the practice after only three years when my inability to balance work and family life became obvious.  I was clearing less than $20k a year – and money wasn’t even the biggest problem.  Clearly, my case is only one example; my concern is that it is not the only example, but a nationwide trend for women in private obstetrical practices.

Much has been said about physicians and the part their greed plays in the current health care crisis.  Admittedly, many examples can be found of physicians who have milked the system, over-billed, over-treated, and committed outright insurance fraud in order to make more money.  On the other hand, some physicians have been praised for their utter selflessness, physicians who devote all of their time and resources to charitable care.

Most, myself included, do not fit the description of either extreme.  Like many Americans, we want to excel professionally, enjoy our work, have others appreciate the contributions we make, and raise our families comfortably.  As a physician, I would have been happy with my salary minus the bureaucratic nightmare the practice of medicine has become, the constant threat of catastrophic legal action, the ingratitude, and the long hours away from my young children.  Some physicians long for the honor that once accompanied the profession.  Others miss the joy associated with personal doctor-patient relationships.  Still others enjoy their work, but also want to enjoy their families.  Money is not always the bottom line.

My current job – wife, mother of three small children, new author of the book, The Rise and Fall of Dr. Mom: Women, the Health Care Crisis, and the Future, and advocate for health care reform – doesn’t generate any income, but the benefits are better.  I hope to be a part of needed change in our health care system simply by telling my story.  The compensation is not important; the fact that I can enjoy and am proud of what I am doing is.  We can raise awareness by examining the effects the system has on individual doctors, patients, and communities.

We all depend on our physicians to provide quality medical care, to take our lives into their hands.  If for no other reason, should we strive towards health care reform so we can restore their job satisfaction?  Do we not want them to be happy when they are guarding our lives?  Do we not want the best and the brightest to continue to sign up for careers in medicine?  And how much should they earn anyway?

In my opinion, reform will be required in order to retain a qualified, diverse pool of primary care obstetricians and gynecologists for women across the country.  Such reform must include medical malpractice reform, as current rates make the cost of less than fulltime practice prohibitive.  Changes in the training of obstetricians and gynecologists could be made to allow for women to focus on either obstetrics or gynecology, thus improving their odds of being able to keep abreast of changes in practice patterns.  Finally, the enactment of a national health care plan with health care coverage for all would reduce the administrative costs and barriers to practice and improve physician job satisfaction.      

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  1. I agree. The problem with the med mal system is not so much the direct cost of jury payouts alone. It has a far greater impact on physician attitude. First of all, when a case is tried, the physician is expected to drop whatever they are doing and sit in court for the entire trial (which could last weeks). They experience loss of income, along with loss of control over their lives. Almost half will describe symptoms consistent with major depression, which clearly has a negative impact on everyone around them. Furthermore, physicians practice defensive medicine on a daily basis at considerable cost, estimated at at least $70 billion a year. And, like you said, the med mal insurance companies have to make a profit.
    First, I think we as a society need to answer this question. If a woman comes in at term expecting a healthy baby and through a horrible turn of events ends up with a baby who is severely handicapped and will require considerable care for the rest of their lives, should that woman receive extra help from us as a society? After all, to care for the child will be a full time job consuming resources the rest of the family may have needed. Do we want to help? When we phrase it like this, I think the answer for most of us would be yes. That is why juries are sympathetic. However, in medicine, this gets tricky, because bad outcomes are inevitable. How do we decide who deserves help?? We don’t want everyone who has something bad happen to them to expect the government to come fix it. That type of expectation results in entitlement, ingratitude, and ultimately loss of sympathy for all people who need our help, resulting in a cold society, not a caring one.
    None of this has anything to do or should have anything to do with whether the bad outcome was caused by negligence, in my opinion. That is a separate issue. This woman had a horrible outcome, and if a doctor caused it, we should be aware of the problem and fix it. Sometimes that will mean changing systems or adding layers of protection and sometimes it will mean that the doctor’s practice should be limited or terminated.
    Here are the things I know from experience: Doctors make mistakes on a regular basis, just like anyone else. Fortunately, we are a resilient species, and usually no damage is done. Sometimes though, the results are catastrophic. Generally, the doctor then experiences deep remorse and self-deprecation. Only rarely (in my experience) is damage the result of malfeasance. Unfortunately, damage as a result of gross negligence is more common. (Good doctor, good person makes a bad decision and patient suffers the consequences; outdated doctor who should quit performing surgery continues to do so, none of his colleagues are willing to call him on it, patient gets injured; doctor performing outside of his knowledge base makes an error in judgment; baby should really be delivered right this second, but that can’t be done due to human constraint – nurses aren’t fast enough, doctor has to drive in, the or is full, and the list goes on).
    Several changes could be made to improve our system. We should be willing to help patients who have experienced catastrophic outcomes – at least with medical bills. Universal health care would accomplish this. We can also help by providing subsidies allowing moms (or dads) to care for sick children, and providing families with education, resources, etc. Certainly, if we are going are going to have juries deciding malpractice cases, those juries should consist of an educated panel of people – including nurses, hospital administrators, doctors, lawyers, etc. Lawyers should not be able to retain 30-40% of uncapped damages. Damages should be capped. Arbitration should be the first step and we should improve systems for this. Each case should be considered in terms of negligence by ethical committees and this should be separate from payment to the inured party. That would help restore quality of care and our confidence in the system.
    That is my take on med mal. Any comments?

  2. Those are the numbers I remember, Peter. It’s clear that our malpractice system needs cleaning up, but it is not the culprit driving high health care costs. Malpractice insurers are allowed to increase their rates to offset losses in other industries (9-11, Katrina, etc), and the medical profession could eliminate that cost-shifting if they’d just form a malpractice coop that cuts the insurers out.
    What is really driving the costs up is well described in Maggie Mahar’s “Money-Driven Medicine” and in my own book, Politicians – Owned and Operated by Corporate America.
    It’s not a pretty sight.

  3. Jack, I found this which has some interesting comparisons.
    Johns Hopkins Bloomberg School of Public Health study:
    The U.S. also logged 50 percent more malpractice claims per 1,000 people, at 0.18, than the United Kingdom and Australia, and 350 percent more than Canada.
    But the study’s authors found malpractice payments in America are lower on average than in Canada and the U.K. The U.S. average as $265,103 per settlement or judgment to Canada’s $309,417 and the U.K.’s $411,171. The U.S. average was higher than Australia’s $97,014.
    Those dollar amounts were adjusted to account for cost of living differences between the countries. There were also figures on lawsuit out of court settlements, dismissals, wins/losses.

  4. The malpractice issue is interesting, especially since claims take a bigger percentage of the Canadian health care dollar than in the US, but their overall costs remain at 50% less than ours.
    Claims in the US have remained at about .5% of health care costs for the last 5 years, but they are increasing at the same double-digit rate as is HC. As well, physicians cite malpractice as the reason for overordering tests, and if they didn’t get a piece of the profits I suppose I would feel sorry for them. They must also start getting the bad doctors out of the system so these costs could be mitigated.

  5. Canadian doctors are paid by rates for each procedure that are set through negotiations between the provincial governments and the physicians’ organizations. I’m not sure what the situation is now but in the past docs could strike, although they did not fair well in the public opinion arena. But at least they know up front exactly what they are going to be paid for each procedure. The patient also knows what their costs are – nothing, except for the taxes collected. Docs also only deal through one insurer and one set of rules in which they are guaranteed payment – no bad debts or collections. The offside for docs is they aren’t compensated as much, but they also don’t need to phone an insurance company to get authorization for payment of treatment. I’ve never seen a poor doc in Canada. As for malpractice in Canada, I went online to see what I could find. I do know that malpractice is not such a big issue there. Anyway here’s what I found, sorry for the length but see how this over view fits with your overview of the U.S. situation;
    “Medical malpractice lawyers take legal action in only a very small percentage of the potential claims for damages for mistakes caused by those who provide medical care. Most people who are injured either do not know that their condition was caused by negligence or do not bother to make a justified claim and as a result less than 10% of those who are entitled to claim actually do so. Healthcare professionals including specialists, doctors, nurses, pharmacists, dentists, medical technicians and alternative health practitioners including chiropractors are negligent if the treatment of a patient, under their care, has fallen below the minimum standard which the medical profession regards as acceptable.
    Doctors are required to stay current in their knowledge of treatment methods and to meet a reasonable standard of care and failure to do so may make them liable to pay compensation for any injuries that result from their sub-standard care. The courts maintain that doctors have a duty to conduct their practice in accordance with the conduct of a prudent and diligent doctor in the same circumstances, and that specialists have a duty to exercise the degree of skill and knowledge of an average specialist in that field. The effect of this is that there are no absolute standards and a healthcare professional will be judged by average competent standards assessed on the basis of what was known or should have known at the time of the alleged negligence.
    In addition to showing that there was negligence it is also necessary to show that the negligence actually caused some injury or harm to the patient. It is usually necessary to establish the natural progression of the illness and the likely outcome if non-negligent treatment had been given in order to compare the outcome following the negligent treatment. If injury and damage are proved by medical malpractice lawyers to be as a result of the negligence by a health care provider then compensation may include; pain and suffering, loss of past and future earnings, medicines and medical fees, travelling expenses, assistance for household chores, special care aids and equipment, adapted accommodation and transport, care and assistance, general expenses.
    There are a number of potential defenses under medical malpractice law available to those who represent allegedly negligent healthcare professionals which include the doctrines of “accepted practice,” “respected minority” and “error of judgment”. If the person providing the treatment can show that the actions which caused the injury were errors of judgment as opposed to negligent actions, that the practice followed was accepted by other competent physicians and that the injury was merely an unfortunate result, or that a body of respectable doctors would act in a way which deviates from the standard practice, then the doctor may avoid liability unless negligence can be proven. There are time limits within which a claim must either be settled or issued in a court of law and failure to take action before the expiry of the statute of limitations may mean that the chance to obtain damages is lost forever.”

  6. It is a delimma, Angela. I like the idea of salary based on the quality of care, but you are right. How is that determined? What about the doctor that is (un)willing to take on the more difficult cases?
    Perhaps the issue of the patient needing care at the end of the day can be addressed with a fair rotation system, as can the difficult cases be equally distributed.
    Part of where we want to be years from now must include a good universal IT system. It should be centralized, and I like the VA model because it avoids the protectionism that prevents competitive hospitals and physicians from sharing critical data. Patients, of course, could opt out.
    As a patient I’d like to see my yearly physical begin with a session in front of the computer, maybe even from home, filling out a thorough Q&A about my aches and pains that the physician can then use for assessment. Treatments would be logged and contraindications flagged for the physician. Hopefully this could reduce practice variations and prescription errors.

  7. Several comments have addressed physician compensation mechanisms and the government’s ability to control cost. As I began to outline a plan for national health care in writing my book, these were the questions I did not find great answers for.
    As to physician compensation, compensation based on production (number of patients seen and procedures performed) could encourage physicians to hurry through patients or order unnecessary tests. Both could be bad for patients. Pre-established annual salaries could encourage lassitude. Not that most doctors would be outright lazy, but the practice of medicine is often inconveniently packaged.
    For example, I worked on salary and had set hours. My partners were all on production. When a patient arrived unannounced at the end of the day and I had to see them, it was uncompensated work on my own time. My partners were at least paid to be late to pick up the kids or get to soccer practice or whatever they had to do. Of course, if physicians are paid on salary, they are going to be less likely to want to see you when you walk in at the end of their day with a bladder infection. They are human. If you pay them Y dollars to work X hours or see Z patients, that is often all they will want to do.
    I guess the best answer is salary based on “quality of care” given. However, it is very hard to establish “quality of care”. Is quality care inexpensive and noninvasive? Is quality care ordering any available test or procedure so that no diagnosis is ever missed? Is it taking the time to talk to patients? Is it performing operations faster or less invasively? Or is it performing them cost-effectively? Is it based on patient satisfaction? That is clearly flawed. Many people would be most satisfied with whatever physician gave them an antibiotic for every viral illness they had (not good medical care).
    I haven’t thought of a perfect answer? Has anyone?
    As to cost control, a national health plan would have to include some protocols for care and limit some procedures. For example, we wouldn’t want doctors ordering expensive tests like MRIs for problems that should or could be diagnosed less expensively. We wouldn’t want doctors choosing the most expensive medications for simple problems, which could be solved more inexpensively. As patients, we also wouldn’t want to worry that the government was cutting corners and providing poor care.
    It would be difficult to establish national guidelines for the diagnosis and treatment of disease, but not impossible. The problem is many patients just don’t fit the guidelines. We don’t want doctors to be blind pathway followers. So, there would have to be considerable laxity. I haven’t figured this out either, but can it be worse than having someone with no health care knowledge on the phone at an insurance company telling doctors what tests, procedures, or medications to prescribe? Or worse than doctors who are going to choose whatever option creates the most revenue? If we have to give up control to someone, I would rather it be a national board of experts who create treatment guidelines which have to be either followed or an application has to be made to take another route.
    People ask me these questions all of the time when I speak, so if anyone has answers, I would love to hear them.

  8. I agree with Peter on using retired nurses to judge malpractice awards. They have long been critiquing patient care with the patient’s best interest in mind, though they may need the ability to consult specialists. Payment of the attorney can be approved by the panel after review of the hours invested (though this can be fudged significantly).
    Not unlike most of us, physicians have a tendency to prefer total control with zero accountability, and somewhere in the middle is where I think we should be.
    At this point my preference is a Medicare-for-all system, but there is still opportunity for physicians to order inappropriate or unneeded testing because it is the most profitable. A VA-type of system (where physicians are salaried and well paid) would certainly eliminate that possibility, but I am concerned that government pressure to reduce costs would push physicians to avoid even needed tests. Does anybody have experience in this area?

  9. Peter said doctors long for a time when they had more power. I can admit to the truth in that. Doctors are often independent and opinionated. I must admit that I did not enjoy insurance companies telling me what drugs I could prescribe, administrators telling me how long my patients could stay in the hospital, or patients telling me what I would do if I wanted to avoid a law suit.
    I think with a national health plan with clearly established guidelines some of those issues would be less central to the practice of medicine. In some ways we would have less control, but it wouldn’t be so frustrating. For instance, if the national health plan covered a certain drug or procedure as opposed to an alternate, at least we would know the rules in advance -we being doctors and patients. For example, if the plan covered a certain mehtods of contraception, doctors would most likely prescribe from that group. (Patients could opt out and pay for different methods, but most would not.) The doctor and patient would have several options to choose from and would select an option together, without concern as to insurance copays, deductibles, or allowances. Currently, the physician will likely select somewhat blindly (as it is impossible to know which methods will be covered by each of the hundreds of insurance plan with which the doctor deals). Doctor and patient will both then be frustrated to find that with the patient’s insurance, the cost of said treatment is prohibitive. The doctor will then prescribe an alternate, but everyone will end up feeling disempowered.
    So, yes the lack of power required to manage a simple issue is frustrating…Who enjoys doing a mediocre job at something they might actually do well without so much “help”?

  10. Ms. Heider’s piece is heartfelt but I do disagree with her point, “Some physicians long for the honor that once accompanied the profession.”, I think they long for the time when they were not questioned and they held more power than honor. I also mostly agree with Jack Lohman. On malpractice, once the cost to the injured patient is covered by a universal health system, the amount necessary in malpractice awards would be greatly reduced. His wish to have the punitive award go the system sounds Ok, but where will the money come from to pay the lawyer? Prosecuting these torts is expensive. The problem with random selection of juries is inconsistant judging and lottery wins/losses. Why not pick a random selection of past healthcare plaintiffs to be on the jury? Nurses might be the best answer, they see docs work every day from behind the scenes, and can cut through the crap. Nurses are also better patient advocates.

  11. My take on this is a little briefer: I’ve never understood why Democrats oppose sensible reforms to the malpractice system.
    Sure, there are greedy docs. But there are greedy people under almost every rock you care look under.
    My personal view is that docs are demonized because a lot of people view them as the most convenient targets at which to vent their wrath. Administrators are tucked away in their offices. Drug companies are off in New Jersey. Insurance companies are bland and anonymous and by and large boring.
    Every time I hear a speech about how bad physician behavior is: I think of doctors I know who’ve already voiced the same complaints ..

  12. I’m sure Angela Heider’s experiences as a physician are not unique, but I must say that I think physicians have painted themselves into a corner. Many have been lulled into thinking that the free-market approach is going to be their savior; that if they’d just turn the business and administrative chores over to the MBAs they’d be much better off.
    Nothing could be further from the truth. The MBAs are smarter than physicians when it comes to business, and with them running the show they want all of the profit they can muster in this medical/business relationship going into their own pockets. And they’ve done everything possible to convince physicians that they can’t make it without them.
    The truth is, physicians will fare much better under a universal health care system (i.e., Medicare-for-all with proper funding and reimbursements) than under one run by profit-seeking CEOs. I’ve written more about this at How doctors are yielding their profession to the CEOs, and I’d welcome feedback (though I know some will oppose, 60% of physicians prefer a single-payer system).
    Also, on the malpractice issue physicians have again shown their inability to beat the CEOs at their own game. Why have they not formed a national self-insured cooperative that leaves the insurance companies out of the loop? They just hike rates to recover losses in other parts of the market that have nothing to do with the rate of claims. Look at Canada’s solution.
    They should also lobby congress (yes, that means giving more campaign contributions than the lawyers and insurance companies) to reform the malpractice system.
    Instead of a 12-man jury, which is appropriate in criminal trials, malpractice cases should be judged by a three-person committee of randomly picked retired physicians and nurses. Economic damages are determined by this panel, as are appropriate attorney fees. But punitive damages, if any, would not go to the plaintiff and attorney, but instead would go into the fund to pay for the universal health care system.
    Another approach to determining awards, once guilt is determined by the panel, would be “final offer arbitration,” which seeks from both sides their bottom line offer or demand. The panel could not make any changes, but must select the more reasonable of the two proposals, which becomes the final settlement. This discourages either side from making outrageous offers because that would then exclude their offer from being the one selected.
    I know physicians will not police their profession, but perhaps this panel could also decide when a physician’s license should be suspended or revoked.

  13. I so agree with her- this current “bureaucratic nightmare” is helping nobody- except the health plans-unhappy patients and unhappy doctors make the practice of Medicine sad and denervating. This is one of the main reasons a mother like me is avoiding full time medical pratice.The idealist in me hopes that health care for all will come soon. The realist in me, however thinks I may be delusional- every political gesture in the US has been cosmetic and what is needed now is a change in paradigm-but I doubt anybody is brave enough.

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