Where have all the doctors gone?
I’m at wit’s end. In the last couple of weeks, I’ve had to practically beg physicians to accept patients referred or transferred from our emergency department. Not indigent, intoxicated patients, mind you. But paying patients, with real medical problems. A very nice young man from Charlotte, NC (about 3 hours away from here in little old Seneca, SC) had an open finger fracture with a tendon injury. He wanted to have it taken care of as soon as possible. Our orthopedic surgeon wasn’t comfortable with the hand injury. The hand surgeon in the next town, Greenville, said, ‘I don’t want to operate on someone who will follow up in Charlotte!’ And the ultimate insanity? The hand surgeon in Charlotte told me, with remarkable snottiness, ‘You know Doctor Leap, it isn’t rocket science. You clean it out and close it and send it to us this coming week.’
Problem is, it was a bad wound, and too swollen to close. It was hard to get good analgesia/anesthesia. And the patient wanted to either have it taken care of immediately, or have someone in Charlotte accept him. At least 10 phone calls and four hours later, one hand surgeon (bless his heart!) said, ‘just put wet to dry dressings on it, cover it, splint it and I’ll see him in the morning!’ It was so easy. That’s all the first guy had to say; I guess it was too simple. And for some reason, the fact that the paying patient was in another town just violated some unspoken territorality. ‘More than 30 miles away? Not in our clan, not in our pack. Someone else’s job!’
We had another very similar patient with a Workman’s Comp injury who wanted to go back to Gwinnett, GA, near Atlanta. No one would take him. He finally left, knowing he could arrive at a hospital there and be treated. They called back. ‘Why did you send him here?’ No doubt hoping for an EMTALA violation. ‘We didn’t. He got tired of waiting and left.’
A few days ago I cared for a lovely older lady with jaundice and an abnormal liver and pancreas on CT scan. Not too uncomfortable, she needed an outpatient ERCP (for the non-medical, that’s a procedure to look up into the ducts of the liver and pancreas). The gastroenterologist in Anderson, the next town, said, ‘You know, they do those in Greenville too. I’ve taken enough from Oconee this weekend.’ Even a local doc, and friend, when asked to follow up on an uninsured lady with an artificial bladder and fever, said ‘You know, I’m getting a little tired of these uninsured patients.’ Well guess what, it’s just reality. And I see them all the time, so what’s the problem?
I know doctors feel put-upon by the uninsured, and by the volume of patients they see week after week. I know that insurers and regulators wear us all out. I know that we somehow believed gold would fall into our laps as doctors. At least some folks thought so, apparently. But some stark realities remain:
None of the patients I mentioned wanted to be patients. They needed care, they needed surgery, they needed medicine, they need procedures. They’d have been just as happy to stay home and never darken our door. We went to medical school to take care of them. I know it isn’t a perfect system, but it’s what we have. What if it was our child, our son, our mother?
Next, even though we lose money on some folks, and even though I’d like to see everyone pay their bill (so everyone would pay less), we still make money. The problem seems to be, it doesn’t fall from the sky as big bags of free gold. If you want to make money, and you decline a paying patient I send you, then you are simply out of touch with reality. Sickness or injury in insured patient, plus trained medical doctor, equals money. Or am I doing the math wrong? I always had trouble with simple math…
And here’s one last reality. This is America. It isn’t the Communist block with bizarre borders and border guards. If a patient needs your care, but isn’t from you community, why does it matter? I’d keep them if I could, but I can’t, so help me out! I know you may have financial incentives, or you may be overwhelmed already, but I’m not sending them by the bus-load, only rarely, and one at a time. And only when I can’t do it myself.
Attention Doctors…step up to the plate! Let’s be the professionals, heal the sick, treat the wounded, comfort the dying. The money will come, I promise, if we act like the heroes we can be, the heroes we should be. Let’s reclaim medicine! But we can only do it if we take care of those ‘pesky sick people.’ After all, they need us.
Pass it on!
Edwin Leap, MD
This is very depressing! Someone needs to point out to these doctors that they might have trouble getting care for themselves someday. We joke about this alot in our community because there is an extreme shortage of primary care docs so many of us really do wonder who will care for us in our old age.
Our hospital developed a community call system to rotate the care of the uninsured/unassigned patients across a large group of generalists, including the hospitalists, if people have to be admitted. I picked up 2 admissions one time through this system; both weren’t uninsured, they just didn’t have a doctor who could admit them. I think the community call is also used to get patients a follow-up from the ER, but it doesn’t include specialists.
Yet another example of why we need some kind of single payer system. Financial incentive is destroying medicine.
Thanks for responding! I understand what you’re saying, but I doubt it it will be that easy. While financial incentive has it’s downside, there’s no question that a lack of financial incentive will be dangerous as well. And I’m not sure it’s about money entirely. As I said in the post, the people I was trying to refer actually had insurance. The doctors would have been paid! So there are other dynamics at work that a single payer system probably won’t fix, and may exacerbate.
Edwin
Having private insurance does not necessarily mean the consultant will be paid. In the office setting, say a hip replacement is anticipated. The insurance is checked, the anticipated surgery is preauthorized. If not preauthorized, the person does not get the surgery. The patient has motivation to pressure the insurance company to authorize the surgery. In the ER, the procedure is done, the insurance may find the surgeon is out of network, payment may be denied for any number of reasons, legitimate or not. Many a time I get payment denied for no reason at all, and on appeal the clerk just says “computer error”. There is no penalty for such denials, and sometimes they get away with it. Then, of course, there is the increased medicolegal risk of emergency work versus elective surgery.
I certainly understand those frustrations. Our group actually cancelled our relationship with BC/BS for similar reasons; consequently they still have to pay, but send checks directly to the patient, knowning that many will cash the check and spend the money without paying the medical bill.
Nevertheless, what do we do? When people have legitimate medical/surgical problems of an emergent nature, we can’t predict the future of denial or reimbursement. I guess specialists can take one of three paths: 1) always leave the problem for someone else to deal with and escape the cost/risk of emergencies(this is basically what surgeons do when they open outpatient surgery centers and stop taking hospital call). 2) Do the right thing and deal with the risk later. 3) Leave medicine altogether, because after all, someone will do it, right? 4) Dodge the problem and let the ER deal with it.
I know there are risks, and I know there are nefarious schemes by insurers to abdicate responsibility for payment. I know people sue, and people refuse to pay. But I can’t help wondering, when my children get sick someday, and need urgent or emergent care, what if no one wants to do it? Or if the only people who will are only barely competent to do it? There’s no easy answer, either in nationalized care or pure market schemes. But the one thing we have to hold onto is our desire and commitment as professionals to do the right thing when people need help. The rest? I confess, I just don’t know. I feel sympathy for every doc, and every patient, caught in this increasingly complex web.
Edwin
I think we are seeing the result of the insurance companies not being willing to change their reimbursement to doctors. If a doctor is held in a long term contract he may be paid the rates that were established five years before. If you look at the cost rises in all aspects of care in the last five years you will soon see that there is no incentive for the doctors to even accept insured patients. In Charleston WV our ENT doctor is reimbursed $8.00 for seeing a child under the Medicare system, so he has to rely on the other patients insurance to compensate him for the difference in his costs for this service, which he gladly does. As far as I know he has never turned anyone away and actually went into healthcare because of his own infirmities. Our insurance BC/BS, which Keith’s own group has ceased using, reimburses him such a small amount that it is embarrassing to us as patients. Several doctors in our area have actually stopped doing business for health care and begun doing business in plastics since this is more of a cash and carry business with little insurance involvement.
I am not sure a single health payer system is the way to go though. That would involve government regulation/involvement, and as such government decision making, on our health and well being; which has not been proven to be effective in other countries. The way the government works today would result in many people without proper care and many waiting too long for necessary procedures and medicines; just not a good prospect if my opinion matters.
My state has no tort reform. Ballot initiatives to create tort reform have been voted down.
If this is what the public thinks of doctors, why should we extend ourselves for them?
Oh, and speaking of single payer, wasn’t it Quebec that tried to force their physicians to work in provincial ER’s? That was about five years ago, as I recall. And I don’t mean cover the ER’s, but take shifts when they could find no one else.
You think the consultants hate taking the call, what do you think they’d say about a draft card?
I have to say that I can’t figure out why some are so entranced by the single-payer idea. At best some party independent of the govt will administer it, but how is to be funded? Sure there’s some funds to free up I guess if the insurance industry is scaled way way back, but not enough to fund everyone’s care by a long shot, so we are left with taxes to pay for healthcare, which means government/political influence on healthcare delivery after all. Whether the federal govt is the single payer, or it provides the funds to the single payer-administrator, is a small difference to me. Whoever holds the purse strings will control medical care provision.
We’re talking about professionalism, vs market behavior. I call a plumber and he’s busy or has an excuse, I call another. He might kindly suggest another provider(contractor) or just wish me luck. The pattern I detect in in the last 15 years is the lack of respect for other “doctors” when calling for a consult. A month ago the receptionist at an Ortho office wouldn’t let me talk to the Ortho on call about a follow up for a patella fx….I always thought in the “fraternity” we treated each other with respect and professionalism.
I don’t think who pays us will change that. It might change the depth of cynicism I sense…Even on these pages…
http://poemd.blogspot.com/2007/10/wisdom-fraternity-11.html
“My state has no tort reform. Ballot initiatives to create tort reform have been voted down.
If this is what the public thinks of doctors, why should we extend ourselves for them?”
What other industry in your state has liability caps? Do you expect those people to extend theirselves for you if they don’t have it?
girlvet –
you think a single payor system wouldn’t have financial incentives? How would that payor “enforce” it’s thoughts about the way medicine would run? It would say “do this, or we don’t pay you.” That’s the way Medicare works right now. “Pay for Performance” they call it. Not in every way a bad thought…as long as the performance they’re looking for is reasonable.
A bit different a concept of the one you’re talking about (being paid to see the patient at all), but still financial incentives driving medical care, nonetheless.
It’s sad that you have to BEG people who entered a profession of caring for patients to care for patients. Luckily the EM physicians are legally bound to treat whomever comes through the door. If only your hand surgeon and orthopaedist were bound by EMTALA.
One afternoon, I was in the backyard hanging the laundry when an old, tired-looking dog wandered into the yard. I could tell from his collar and well-fed belly that he had a home. But when I walked into the house, he followed me, sauntered down the hall and fell asleep in a corner. An hour later, he went to the door, and I let him out. The next day he was back. He resumed his position in the hallway and slept for an hour.
This continued for several weeks. Curious, I pinned a note to his collar: “Every afternoon your dog comes to my house for a nap. ”
The next day he arrived with a different note pinned to his collar: “He lives in a home with ten children – he’s trying to catch up on his sleep.”
I cried from laughter
Sorry, if not left a message on Rules.