Monday, September 5, 2011

The Death of Professionalism in (Internal) Medicine

     I have been in the practice of internal medicine for 30 years, starting with my internal medicine residency for 3 years  in a big city medical school hospital and then 27 years of the solo practice of internal medicine. I was taught to go into the waiting room to greet each individual patient, escort him/her into my office to discuss the presenting problem(s), then take the patient into the exam room and have the chaperone help the patient into an exam gown. During the exam, I would ask additional questions. I would then tell the patient to get dressed and come back into my consulting room so we could discuss my diagnosis and possible treatments. During all of my training and practice I was always aware that medicine was a mixture of art and science, as well as a gestalt of the patient's medical belief system. One develops a "feel" for illnesses of various types, for the presence of stress, for histories that don't quite match the physical, for the inconsistencies in the way that the patient answers certain questions, and how to recognize when the patient resists (consciously or unconsciously) when  I steered the post-exam conversation in the direction of certain diagnoses and treatments. All of this and more is contained in the professional practice of medicine, which is a mixture of medical knowledge, science, art, psychology, and empathy.

     The concept of professionalism encompasses respect for your patients, respect for yourself, a desire for the respect of your peers, a feeling of collegiality with your fellow physicians, and, I personally believe, always placing the patient's needs first, without appearing shocked at anything the patient says. Too often we doctors forget that we define what is "normal" for the patient. (The old saying that an alcoholic is any patient who has two drinks a day more than the doctor does still holds.) You should also feel personal disappointment if you do not give the patient as much time as the patient needs (within reason), or if you ever make the same mistake twice.
You should also be able to spend the majority of your time in direct patient contact and care, rather than filling out forms, calling HMO's  and drug plans, and writing letters to Medicare. And if you find that you are getting angry during your work day or telling your personal or professional problems to your patients, you should either take a vacation or change your profession.

     When I started practice I felt proud of my practice and my professionalism. I charged more than most physicians in exchange for which I gave my patients much more  time than they did,  and all my patients were happy with this arrangement. I also treated poor people for free in my office(I allowed an hour for the initial visit, and didn't charge extra  if more time was needed), I ordered the blood tests and Xrays that  I determined that the patient needed and also made  referrals to other doctors that I thought was indicated. I also made house calls and charged my patients my usual fee for the time I spend at their house, plus $25 for making the house call,. I generally was following 8 to 10 patients at home, who I saw at intervals varying from weekly to monthly. I also had patients in 2 different nursing homes.

     Then along came Medicare, and managed care (HMO's) and drug payment plans. Suddenly I could no longer take the best possible care of my patients. Medicare began by not permitting me the $25 house call surcharge to patients, so I stopped house calls and explained why. Then I had the problem of an Oxford patient needing shoulder surgery when the best shoulder surgeon I knew was part of Cigna. Then one of my two admitting hospitals had a payment argument with Blue Cross so that my BC patients could not be admitted to that hospital. Then I had to spend time explaining to a drug plan that although Nexium was their preferred PPI to suppress stomach acid, Nexium did not work on my patient and only Prevacid did. Then Medicare asked me why I did more of a certain procedure to test for cancer than other internists did. When I wrote them back asking why more internists didn't look for cancer, I never heard from them again on that subject. The final straw was when Medicare D, which pays for drugs, decided it would only pay for generic and not brand name drugs. In some of my patients, generic Ativan, or Prozac or Wellbutrin, for instance do not work. I have now dropped all HMO's and insurance plans as well as Medicare. I still have to argue with drug plans, but that is all. It is a problem for my HMO patients, because they had to find another primary care doctor for referral to specialists, but I also got tired of telling patients that I could not recommend any surgeon in their HMO. As a final note, if I saw two Medicare patients the same day in a nursing home then Medicare paid  me less for seeing the second patient and even less for the third, so I stopped seeing nursing home patients.

     I could no longer take care of my patients in the manner in which I was trained, and so I was forced to switch to an all cash billing system. This had immediate advantages. Since I no longer submitted any bills except to the patients, I did not need an electronic billing system. And one of my staff no longer had to spend half of her workday on the telephone with drug companies and HMO's.

     But to return to the problem of the death of professionalism in medicine. The insurance companies feel that all doctors are fungible and interchangeable. Anyone would agree that the best doctor (plumber, lawyer accountant) should be allowed to charge more, but no one knows how to measure them. All admissions to hospitals have to match a computer diagnosis, so I can no longer say:"This patient looks so sick that immediate hospital admission is needed". Medicare patients whom I see still have Medicare paying for their  lab tests. I cannot say that " in my experience I think this patient needs a particular blood test",  but rather I have to invent a diagnosis to justify ordering the test. The Joint Hospital Committee invented a rule that all patients with pneumonia in the ER must get antibiotics within 4 hours of ER admission or else the hospital would be sanctioned. I got used to writing in the ER chart that the patient refused antibiotics at the 4 hour mark  after I told the patient that I was unsure of the proper antibiotic at that time. I resented the fact that I had to "game" the system to obtain what I thought was the best possible care for my patients.

     In line with the anti-professionalism trend I know of two large internal medicine practices which have installed a 900 number for after-hours and weekend telephone calls. The recorded message tells callers to either go directly to the ER, or to stay on the line where they will receive a bill for each minute they spend on the phone. This has generated some additional income and cut down a lot on after-hours  phone calls.

     I cannot help but feel that patients are not as well served if doctors cannot afford to spend a lot of time with them, even if there is not a negative result in the mortality statistics. It takes much less time to order a test when a patient has a complaint than to take the time to take a proper history, but the doctor makes more money the former way. And I detest the practice of the PA going into the exam room to obtain a history and take the blood pressure.

     There is something wrong with the practice of medicine when the most competitive residency is dermatology, since  dermatologists can charge whatever the practice will bear since neither insurance companies nor Medicare pays for cosmetic dermatology. At a typical teaching hospital, the top grossing dermatologist takes in almost twice the fees that the top cardiac surgeon does. Plus we have the old saying that one advantage of dermatology is that (barring cancer) "the patient never dies, never gets well, and never calls you in the middle of the night".


  1. It's easy to complain about Medicare, Yes, it has rules and regs that are time-consuming, often appear unreasonable, perhaps under-value the practitioner's time. But it has brought reasonable health care to millions of adults who otherwise would have had little or none...and probably died. The system should be improved. What does Dr. Thomas suggest?

    As to HMO's, what is their benefit to the patient? To the doctor? To society? Again, what does Dr. Thomas suggest?

  2. As to the above comment:

    1) The main problem with HMO's is that they are not (legally) health insurance companies,and hence do not fall under the jurisdiction of the State Health Insurance Regulator, unlike, say Blue X/Shield, so that they can be untrammeled in their treatment of patients in their drive for profits. And none of their doctors, who make pay/non-pay decisions about a patient ever examines the patient in question.

    2) Medicare is good in that the more people who have private doctors (see Canada for instance) the less they use the emergency room for medical problems, which is a great savings in the overall health expenditure. The problem is that in trying to reduce costs (e.g. in having a precise diagnosis for every drug test) they cause the doctor to spend more (unreimbursed) time, and time is the one non-fungible thing that doctors have. For instance if a patient comes into my office complaining of dizziness, I know the 21 questions I will ask him/her, and I only write down the positive or useful answers. Medicare requires me to write down all 21 questions and their answers. I could go on, but that is the general idea.