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Grand Rounds for January 6th: Profit in medicine and other cool stuff!

This is the location for Medblogs Grandrounds, January 6, 2008.  Our topic?  The value, or detriment, of financial profit in health-care.  From doctors to pharmaceutical companies, universities to insurers and everything in between; is profit good or bad?

Well, obviously not everyone wants to write on my topic.  So here are the submissions.  Lots of interesting posts from very interesting writers, writing from many different angles; nurses, patients, insurers, lawyers, therapists, students and all the rest.

So, since it’s my turn to host, I go first.  Here’s what I have to say about profit in medicine.  Every difficult, life-changing, dangerous, critical, exhausting job requires reward.  In fact, every kind of work requires some reward, but that’s not what we’re discussing here.

Physicians have to be paid well in order to continue to practice medicine.  It wasn’t always this way.  Because, there was a time in modern medicine when the rewards of the practice of medicine were considered higher than mere cash.  Why did early physicians expose themselves to epidemics and death?  Why did they go to battlefields and learn surgery?  Why did they labor with the miserable and poor?  Because they sensed the value of human-kind.  They were taught, and believed, that every life was valuable in God’s eyes, and that if they ignored their calling, and ignored suffering, they would face God’s wrath.  They also believed that if they did right, if they endured under hardship, if they died of the diseases they fought against, they would be rewarded by their Creator.

We are too modern for all that, now, aren’t we?  We don’t need mumbo-jumbo, irrational, anti-scientific theories about human worth.  We’re post-moderns!  We will do right, because it’s good for mankind and good for society and because our reward will be…well, it will be science and knowledge…I mean, it will be the survival of all the fittest for the collective good of mankind in a few eons…it will be…a good review from my boss and a nice retirement with a boat…it will be a vacation and a car and….well, some money will do nicely, if you please.

Reject transcendence if you will.  But if you do, prepare large boxes of cash.  Because doctors without a sense of temporal and eternal purpose will have to be rewarded financially in order to stay in a long, arduous educational system, in order to work all hours, in order to expose themselves to risks physical, emotional and legal and in order to come back day after day to a job that is sometimes amazing but often quite tedious and frequently quite maddening.

It’s cute that medical students and pre-med students like the idea of working for less if their educations are paid by the government.  But that attitude won’t last.  Ask folks who went to medical school on military scholarships.  And ask them how long they stayed in the military.  Eventually, the realities of this job in a post-enlightenment world catch up, and everyone wants money.
All that aside, medicine is a valuable profession and valuable professions are simply worth a good living.  Should doctors be stingy thieves?  No.  Should we be fair?  Yes.

Are we fair?  Yes, I think for the most part we are fair, and good and compassionate.  I’ve met very few physicians, in emergency medicine at least, who wouldn’t bend over backwards to help someone who was truly sick and truly dying.

Now, you’ll also need money to get physicians and mid-level providers to continue seeing all of the nonsense we see; the lifestyle-choice based diseases, the ridiculous midnight requests to do sports physicals, the insane ‘I’m out of my MS Conin, Percocet, Klonopin and Fentanyl patches’ complaints.  Of course, that sort of ridiculous abuse of the system should probably be the topic of another Grand Rounds.

So be careful about re-ordering the existing ‘natural order,’ in medicine.  Because if we decide that profit is inherently bad, we’re going to have a tough time getting things like new medicines from companies, new procedures from surgeons and open office slots from any doctor on earth.

Until we re-discover Hippocrates, and what he was saying all those years ago, we’ll just have to do one of two things:  keep paying people lots of money, or learn to do without care.

That’s the way I see it, anyhow!

Now, read on and enjoy today’s Grand Rounds.

First, a technical note about subscribing to Grand Rounds, from Walter Jessen of Highlight Health http://www.highlighthealth.com

Don’t forget, Grand Rounds now has subscription options – you can follow by email or RSS feed: http://feedproxy.google.com/GrandRoundsBlogCarnival

An aggregated feed of credible, rotating health and medicine blog carnivals is also available: http://feedproxy.google.com/HealthAndMedicineBlogCarnivals

On to the show:  (Of course, unlike Grand Rounds in medical school and residency, you’re all here because you want to be, no one has worn the same clothes for three days and it’s doubtful you’re passing out on the computer, spilling your coffee and praying that your faculty doesn’t call on you.)

Kim at Emergiblog boldly suggests that profit motive isn’t the
problem, that primary care is something we desperately need more of,
and that the plan out lined by Physicians for National Health Care may
be just the ticket to maintaining incomes and encouraging doctors to
be doctors.  Go Kim!  Thanks for an excellent, well-articulated post.

http://www.emergiblog.com/2009/01/primary-care-profit-is-not-a-dirty-word.htm

At medschoolforfools, we have what I consider a reasonable,
well-thought defense of the profit motive in medicine.  My advice?
Hire this young doctor when he finishes training.  He’ll work hard and
do the right thing…you can bank on it.  Pun intended.

http://medschoolforfools.blogspot.com/2009/01/success-money-and-medicine.html

Medical librarian Laika discusses the merits of evidence based
medicine vs. web 2.0 based resources in a well-thought post that also
addresses one of my questions, that is ‘is everything we do, and
recommend, really evidence based and in the best interest of our
patients?’  Laika is clearly very intelligent.  After reading this
post I felt like I needed to join the other hominids and go touch the
monolith.  Well said, Laika!

http://laikaspoetnik.wordpress.com/2009/01/04/the-web-20-ebm-medicine-split-1-introduction-into-a-short- series/

Liana reminds us, in photographic eloquence, that medicine is far, far
more than profit.  Thank you for the gift of your camera and your
compassion.

http://medvalleyhigh.blogspot.com/2009/01/belated-post.html

Colorado Health Insurance Insider suggests that primary care would be
more attractive if it were a government-salaried position, without all
of the hassles of the current system.  We may just get to test that
hypothesis…

http://www.healthinsurancecolorado.net/blog1/2008/07/28/attracting-more-docs-to-primary-care/

Scalpel illustrates with absolute transparency the reasons that ankle
sprains cost so much in the ER.  He’s right, most people don’t
care…but we should.

http://scalpelorsword.blogspot.com/2008/12/1000-sprained-ankle.html

At allergy notes, a discussion of anti-fungal therapy in asthma.
Don’t start inhaling Lotrimin…read the post first, OK?

http://allergynotes.blogspot.com/2008/12/60-of-patients-with-severe-asthma-with.html

A Roger Ballens photograph and search for a genetic diagnosis at the
‘Clinical Cases and Images blog.’

http://casesblog.blogspot.com/2008/12/roger-ballens-photograph-and-search-for.html

Dr. Rich discusses the coming ‘Battle over Universal Healthcare.’  But
not like you might think.  With typical wisdom and foresight, he
offers strategies for flanking the encroaching government limitations
that will likely accompany a national plan.  Take notes, boys and
girls; this is a primer on civil disobedience combined with ‘guerilla
tactics’ that we may all need in a couple of short years.

http://covertrationingblog.com/new-business-models-for-healthcare/strategies-for-the-battle-over-universal-healthcare

Kerri, at ‘six until me,’ discusses her experiences with CGM, or
Continuous Glucose Monitoring.  A topic I’m interested in, since my
soon-to-be 12 year old is, like gracious Kerri, a card-carrying,
pump-wearing type I diabetic.

http://sixuntilme.com/blog2/2008/12/dexcom_pros_and_cons.html

My friend Emmy at ‘The pink teeshirt’ is appropriately frustrated by
her oncologist’s rescheduling of her follow-up and by physicians
pushing crazy-expensive drugs on her.  I don’t blame her!  She reminds
us to keep patients first and do the right thing.  Keep reminding us!
We forget…sadly, we forget.

http://thepinkteeshirt.blogspot.com/2009/01/physicians-and-profit.html

A review of health and medicine in 2008, collected by award-winning
medical journalist Amy Tenderich, awaits us at diabetesmine.com.

http://www.diabetesmine.com/2008/12/2008-the-year-in-health-medicine.html

Dr. Val Jones takes on the idea that for profit companies are
inherently less ethical than not for profit ones, and boldly suggests
what I’ve always suspected; that even academic centers can exhibit bad
ethics.  I know, I know…heresy.  But guess what guys and gals, the
truth hurts.  Deal with it.  Thanks to Val for a great post.

http://getbetterhealth.com/are-for-profit-healthcare-companies-inherently-less-ethical-than-non-profit-organizations/2009.01.04

Mudphudder reminds us of something Val was saying.  Academia is not a
synonym for ethical.  Thanks for the warning!  We need to hear it.

http://www.mudphudder.com/2008/12/season-of-giving-comes-to-a-close/

Here’s a quiz:  What do sushi, shampoo and poker have in common?  Go
to this post and find out.

http://www.howtocopewithpain.org/blog/295/jobs-that-cause-pain/

At Code Blog, read about the way even the best nurse can feel
overwhelmed.  I understand.  I feel that way almost every day that I
work.  It’s a testament to all that overwhelmed doctors and nurses
keep coming back for more, in order to do the right thing.

http://www.codeblog.com/archives/tales_from_the_ccu/my-brain-is-overwhelmed-with-info.html

Nancy Brown, PhD is truly poetic when she speaks the truth:  we cannot
analyze the cost-effectiveness of child-rearing.  The joys are too
wonderful for mere fiscal computation to make any sense at all.

http://www.healthline.com/blogs/teen_health/2009/01/h-p-p-y-n-e-w-y-e-r-welcome-to-2009-i.html

Happy Hospitalist offers us a succinct, biting, deliciously sarcastic
but absolutely genuine view of the real barriers to effective care and
efficient medicine.  As we say in the South, ‘It ain’t what you think
it is.’

http://thehappyhospitalist.blogspot.com/2008/12/american-health-care-in-nutshell.html

I’m only two hours from Atlanta and Grady Hospital.  Here’s
fascinating reading about Grady’s financial losses, and ways to stem
the loss of cash, at Insureblog.  Sometimes, it seems, people actually
abuse a hospital’s higher impulses to charity.  Can you imagine it?

http://insureblog.blogspot.com/2009/01/gradys-new-year-resolutions.html

Bongi talks about a triage system we can all understand, but which we
hope never to use.  I thought drunk rednecks were bad to cut each
other!  Turns out, they’re rank amateurs.  Let me here convey my
utmost respect to a doc doing the best for the most, in a situation
where profit is unlikely to raise its head.

http://other-things-amanzi.blogspot.com/2009/01/new-year-triage.html

Speaking of profits, Fitness Fixer Jolie Brookspan may cut into some
orthopedic ones with her post here, about the idea that cruciate
injuries can successfully rehab sans scope.

http://www.healthline.com/blogs/exercise_fitness/2008/12/anterior-cruciate-ligament-acl-surgery.html

David Williams at the Health Business Blog explores a world a little
distant to my emergency department; the difference in compensation of
egg donors and reproductive endocrinologists.  Yikes!  I’m just
excited to get paid a couple of hundred bucks by Medicaid for
resuscitation.

http://www.healthbusinessblog.com/?p=2004

Here’s another great post, offered by Chris at Aequanimitas, reminding
me to quit my whining and remember all the great men and women who
sacrificed to advance modern medicine in some of the most remote,
‘unprofitable’ parts of the world.

http://precordialthump.medbrains.net/2008/12/31/the-cretin-and-the-pharoah/

David Harlow, former Certificate of Need attorney in Massachusetts,
covers quality, cost, regulation and competition in Boston’s ongoing
Partners Healthcare saga.  He asks ‘should healthcare resources be
developed in an unregulated manner?’  Read on and enjoy his
intelligent analysis.

http://healthblawg.typepad.com/healthblawg/2008/12/partners-healthcare-competition-regulation-and-the-redeeming-virtues-of-robust-quality-and-cost-data.html

Robin at ‘Survive the Journey’ gives us her take on healthcare reform
and suggests something I’ve advocated before:  tax breaks for those
giving indigent care.  She also asks why we expect charity from an
industry like healthcare, but not from the auto industry.  Very good
question!  Answers, anyone?

http://survivethejourney.blogspot.com/2009/01/in-october-i-wrote-about-our-healthcare.html

And in a fitting finale, Nurse Keith points out the obvious but hard truth: despite all our worries over profits and policies, many people are still really suffering.  We have to remember them, care for them and keep our perspective clear.  Thanks for that gentle reminder, Keith.

http://digitaldoorway.blogspot.com/2008/12/economy-and-its-discontents.html

Next week’s Grand Rounds will be hosted by Barbara Kivowitz at In sickenss and in health.

http://insicknessinhealth.blogspot.com/

So start sending those links!

May God bless you richly and wildly in the coming year!  Thanks so much for your contributions and patience.

If you have a problem with links or if I spelled your name wrong or anything else, e-mail me at [email protected].

Edwin


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Edwin

15 Comments

hgstern

2009-01-06 14:32:42 Reply

Nicely done, Edwin!

Happy New Year, and thanks for including our post.
 

Kerri.

2009-01-06 16:23:12 Reply

Thanks for including me, Edwin. And are you and your son thinking about trying out a CGM? I found that even wearing it for a few days a week has helped me reign things in a bit. If there’s anything I can do to help, please let me know!!

Great edition of Grand Rounds. :)

- Kerri.

Kim

2009-01-06 20:44:48 Reply

Wow, Edwin! I wish I had written what you had written!

Thanks for a great edition that will keep me busy for a few days!

The Happy Hospitalist

2009-01-06 22:43:33 Reply

Great job. Doc. Excellent commentary as well.

Happy

Toni Brayer, MD

2009-01-07 03:25:47 Reply

Great way to start the new year with a wonderful Grand Rounds. Thanks Dr. L.

Physasst

2009-01-07 05:02:54 Reply

Excellent grand rounds. Loved the commentary, and it wouldn’t be complete without a mention of the soon to be mass exodus from primary care…..at least according to recent surveys…OH, and a survey of 1200 medical students revealed that only 2% plan on practicing in primary care…..Nice.

medaholic

2009-01-07 20:57:26 Reply

Interesting topic to think about, profit in medicine.

I wrote a similar post for my blog called the Taboo of Medicine and Money.

http://www.medaholic.com/2008/12/17/the-taboo-of-medicine-and-money/

Peter Lucash

2009-01-08 19:18:59 Reply

No job done well is all about money. The million dollar physician reflects the cultural shift that belittled “doing good” and helping others, replaced by the idol of the marketplace. The latter doesn’t always work, as October demonstrated rather well, and people who chose to serve others were belittled and scorned as though something was wrong with us.

People have to have a passion to work through the years of training until they are out in full practice. Yes, many do opt for salaried positions because of the security and stability, versus the uncertainty of having to spend time on the business side. There is always a way to make more money – until recently, investment banking was a great way to make a lot of money, and drug dealers can make a lot as well. But we make choices in careers pursuits for many reasons.

Long time management theory, I believe from Hertzburg, suggests that money is NOT a motivator, but lack of money (pay) can be a de-motivator for employees. Simply throwing money at employees will not make them more productive, and it creates false and sometimes poor incentives. Physicians need RESPECT first, and then FAIR compensation. The compensation problems are a reflection of the lack of respect.

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