I just gave this lecture in Indianapolis, at the annual meeting of the Indiana Chapter of the American College of Emergency Physicians.  Thanks!   Edwin

Money and Medicine:  A sharp, double-edged sword



I’m here to talk with you about money.  Money lies in the background of all that we do.  We know it; we expect it.  And yet somehow, we like to pretend that we’re above it, or that it sullies our activities.  We disavow financial connections; we remind one another that our decisions aren’t financial.  I recently called a cardiologist in order to ask him to do a cardiac cath on a patient.  ‘Not only does he need it,’ I said, ‘He has insurance!’  ‘No, no don’t tell me that.  I don’t want to know that,’ he replied.  In what other business (for we are in business) do we act that way? 


Well, I’m here to offer some encouragement to all of you, and to remind you that it’s OK to be motivated by, and actively pursue, money.


I’ve been thinking about money a lot lately, as we all have.  Every news story tells us more about America’s financial struggles.  Unemployment is rising and your stocks are in the toilet.  My retirement has tanked.  After my medical career, I’ll probably be looking for work as a mall cop. 


But retirements aside, what’s worse is that we may be facing a dramatic restructuring of the healthcare system in the United States.  Guess what.  That includes you.  Rest assured, when Congress or the people think of the cost of healthcare, they aren’t ruminating on insurance executives, layers of inefficiency in government, nefarious trial attorneys, unfair taxation or the cost of research.  Even though it’s wrong, even though it’s a false assumption, your face and your bill pop into their heads.


The constant mantra is that health care is simply too expensive, and everyone seems to look over our bills and nod; ‘yep, that’s true.  This is ridiculous!’ 


These days, when I hear that, I think about my life.  And I think about the rule my wife and I have.  It’s called the $200 rule.  That is, the entry fee for almost every activity in daily life is around $200.  Take your stupid, snake-bitten hound dog to the vet.  $200…for starters.   Fix that weird sound in the car?  $200 for Goober to look it over and tell you how much the actual repair will cost.  All the kids gett sick, need shots, need glasses?  $200 is on the low end.  Shopping for a large family for groceries?  We have one teen, and three others.  $200 covers the pop-tarts, milk and cereal.  Life starts at $200.  Oddly, no one is worried that they’re charging me too much for groceries, or vet-care or heater repairs.  No one else is the least bit concerned about their own bill, or being told that they make too much for the system to bear; well, OK, no one except executives in companies bailed out by the feds.



To come back to the point, then, I believe that life is simply expensive.  Date night with your wife, school books, tuition, fees, computers, computer repairs, mortgages, airline travel; airline travel with luggage; all of it is expensive.  What that means, by association, is that someone is making money on all of those activities of human life.  Your builder, your lawyer, your plumber, your landscaper, your vet, your dentist, your cable guy, your computer guy, the people who sell you clothes and all the rest.  Some make a little; many of them make a lot.  But the one place America, and those pesky American politicians, seem to fret the most is health-care.  We are the only ones expected to be apologetic for the cost of our particular industry.  Witness the fact that government isn’t actively reforming legal care or Hollywood. 


We need a return to a fundamental truth.  Much of the misery and lunacy of history has been tracked to false ideas.  So, what ideas do we need to address?  That income represents greed; that wealth represents theft; that self-interest represents blind ambition.  The truth is that we have to remember what income is.


Income represents effort.  It represents time spent in education, in preparation, in investment, in days and nights away from the wife or husband or children or friends or dog or forest you love.  It represents your physical activity, your risks of injury and infection, your intellectual struggle to do the right thing.  All of those are things worth compensation.  You deserve…watch this, as Baptist preachers say…you deserve a lot of money for what you do, if indeed you do it well. 


What do you do when you get your money?  What do you do with this gross excess of wealth that the world assumes you possess?  Do you, as some seem to believe, order caviar at pricey restaurants?  Gamble in Monaco?  Jet to Brazil for Carnival?  Do you take extended vacations and wear only tailored clothes from the finest stores in Italy? 


No, you’re workers.  I speak to you; I know you; I am you.  You save for the future; you pay your mortgages (sucker!)  You provide for yourself and your children.  You take bologna sandwiches to eat at work.  You don’t ask for a handout.  You don’t ask for a bailout.  You pay taxes to support all the madness Washington sends your way.  I personally pay property taxes to educate the children of others, and then homeschool my own.  And I’m OK with that.  Your money, my money, our money isn’t wasted.  It’s earned, used and reinfused into the economy.  Not trickled down, like chocolate sauce on a Sundae.  It’s spent on the everyday business of life.  It benefits our families, our charities, our local and state and federal governments.  It allows us to avoid needing assistance from anyone else.  But that, of course, is no longer deemed virtuous, but grasping.   



Nevertheless, despite the effort we engage in, the necessity of what we do, the thrift and work-ethic we employ, the excellence of it all, we are often reminded that healthcare in America is just too expensive. 


We doctors and all the things we do are breaking the bank.  We hear it over and over; 16% of our GNP is devoted to healthcare.  But I want to ask a stunningly insensitive question:  So what?  If we read, tomorrow, that entertainment constituted 16% of the GNP, would we fret, or celebrate?  Would we be cranking down the controls on Hollywood or professional sports?  Unlikely.  We would feel that, as a culture, we had arrived, at last, at the good life, the beautiful life, La Bella Vita.


Now, granted, I know that we could probably be more efficient.  I know that some costs are out of control.  I know that there are those who can’t afford care.  The market could repair most of this, if unimpeded by deluded government functionaries.  But I also know that all over the world, people envy our dysfunctional, allegedly broken, innovative system; from Arab princes to poverty stricken African tribesmen. 


And I have come to a conclusion about the cost of American healthcare.  It is expensive because we believe that humans are valuable, and deserve the latest science and the best medicine.  It is expensive because excellent minds drive it, and excellent minds practice it, and because Americans want excellence.  It is expensive because you are those excellent minds, and though only a small part of the cost, you deserve to be well paid.


Our patients desire long lives.  They desire (at least the rational ones) health and function.  And we have delivered it!   The chaos of our system is probably the outgrowth of doing so much for so many, and doing it so well.  We aren’t perfect, but the level of care available in any one of your ER’s, large to small, would seem stunning to anyone in a third world country.  We have, like the good capitalists we are, given our customers what they wanted!  And we have, like good inheritors of the highest morality, probably applied our science and medicine more equitably than any other culture in history. 


Do you doubt that?  When was the last time you turned away a badly injured, or truly ill, drunk, addict, drug dealer, criminal or anyone else?  You haven’t and you won’t.  Because you are good; technically and ethically.  The only way you will, is if government, in it’s devaluation of health and therefore humanity, instructs you to do so under penalty of law.


Let’s not miss the point.  Healthcare is about human beings.  Not abstractions or statistics, not international ratings or cost-savings.  Healthcare is not a liability or a problem to be solved.  It is a gift; a gift of God to mankind, a gift from each of you to your patients.



But, having attained it all, Americans have discovered that the latest, greatest and best is a little pricey.  They don’t like that.  They want it on the cheap. Worse, they want to believe the lie that it can be free.  They like to delude themselves that insurance is something in addition to their salary.  They like to imagine that if the government gives a thing away, it’s free.  These delusions allow them the financial discretion to spend on other things, less mundane than medical bills or prescriptions.  Someone once said to me, ‘do you realize I had to pay for my medicine out of my own pocket?’  I doubt if she ever said the same thing about her cell-phone.


See, people will spend what they want, cheerfully, on desires.  But necessities are a problem.  And healthcare is something they perceive as a necessity.  Sometimes it is, sometimes it isn’t.  With an MI, it is.  With a cold, for which patients routinely come to the ED, healthcare is a luxury, pure and simple.  But either way, spending ‘my own money’ for healthcare is way down the list of desires.


I understand.  My insurance is expensive.  My child, Seth, is 12 and has been diabetic since he was five.  If I didn’t pay for insurance, I’d have more money.  But for what?  For fun?  For travel?  Sure.  But he is the priority. His health is the priority.  His life is my priority.  And shockingly, my own responsibility, since he is my child.


There are far too many people who will buy new trucks and ask for free samples; who will smoke 2 ppd, smoke crack and drink a case of beer per weekend, who say ‘I can’t afford to see a dentist.’  And all too many who could have insurance, but don’t, and who then come to us with the line:  ‘I can’t see a doctor, because I can’t afford it.  So I came to see you.’ 


It’s an issue, in many instances, of priority.  Mind you, I’m not made of stone.  I know plenty of patients trying their best, who simply can’t afford much of anything.  That’s one of the reasons the demon EMTALA was conjured up from the 7th circle of hell.  Because, rightly, sick people were being turned away.  EMTALA, however, is a classic example of the law of unintended consequences. 


Is there more available for the poor now? Or is there less?  Do you have greater access to specialists now, or less?  I know the answer.  It’s less all around.  EMTALA, designed to make us fair, to show physicians and hospitals how to be nice, caused pain all around; and gave trial attorneys an entirely new avenue to pursue in their own financial safari.  EMTALA, ultimately, devalued medical care by making it seem free of cost.  And in the process, devalued every last one of us.


EMTALA robs us every day.  In our group, our collection rate is about 25%.  Because everyone knows, you just go to the ER and get what you want.  Payment for services, according to the Federal government, is rather passe’.  An old ideology from a crass, capitalist dark age.  EMTLA is the government moralizing about compensation; then dodging any responsibility for it. 


It has reduced payments all around, since it called for effort but rewarded none of it.  Therefore, hospitals have closed, specialists have stopped taking call, transfers have become more difficult and we have been tasked with working for free. 

And now, there are talks of reducing payments.  Whispered discussions of provider fees; of ‘pay to play.’  Of government control to bring costs down.  I’m not sure how much further costs can fall than zero.  That’s the amount many of my patients pay me, and pay you. And frankly, I’ve ‘paid to play’ for years through EMTALA.


And yet, in that mix, some dare to say that I’m one of the immoral rich, responsible for the problems of the economy?  You’re the filthy rich?  The greedy?  The selfish?  The ones who stole first from the great money tree?  Here we are, a room of grasping, evil problems, who have spent our careers caring for the citizens of the country and are now being told to give back.  Rest assured, ladies and gentlemen, you have given back.   You all deserve a tax holiday for the rest of your natural lives, based on what you have already ‘given back.’


Who else would do what we do?  Who would do it for what we’re paid?  Who would do it for less, or for free?  We saw, yesterday, the incredible injustice that we bear the brunt for uncompensated care.  Not surprising.  Who else would wrestle spitting, demented, HIV infected patients?  Who would argue and cajole and struggle to get care for the patient who isn’t ever going to be able to pay, since he is young and sick and has no insurance?  Who is going to respond to the pandemic?  Who is going to put his face by the face of the tuberculous illegal immigrant and struggle with the airway?   Who is going to go back, day after day, and do as much as we do for free?


NO ONE.  That’s who.  How do I know?  I know humanity.  And I also know that if you go to the workplace of a patient who explains that they can’t pay you, and then take their labors and explain that you can’t pay, they’ll be furious and say you’re a rich doctor.  They just lack the understanding that doctors only get rich when people pay them.  As if we were given a great truck of gold upon graduation, that we then live off of for life. 


Actually, that’s a better description of congressional benefits.  Be certain that your representatives in Washington don’t do their jobs for free. They just like to believe that because their payment comes from your taxes, it’s more ethical than the money paid to those of us who sully ourselves in actual commerce and gainful labor.  Those of us whose blood-covered hands ultimately write the checks that support their wasteful activities. 


So don’t surrender your power, and don’t underestimate your worth.  Money is power; money is influence.  Entertainers understand this clearly, and rush to attain as much of both as possible.  So do lawyers, politicians, lobbyists and everyone else.  So please don’t ever stop lobbying and striving to be recognized as a professional whose efforts, time, knowledge, skill and compassion are extremely valuable. 


And feel no shame about your income.  Money is simply a neutral, transferable, commonly held way of giving tangible reward for the immense, intangible quality of what each of you provide to the world.


And yet:


Money is always a double edged sword.


Have you ever met a rich physician who is miserable?  Some physicians seem to grow angrier with every added dollar!   The wealth they desired, and were gifted to accrue, ultimately leaves them increasingly unhappy.  Why is that? 

Of course, it isn’t just physicians.  Many very wealthy people have attained vast material riches only to realize, to their dismay, that they remain lonely, sad, angry, dissatisfied and frustrated. 


But with physicians, a group I know well, I think I understand why.  See, money is a well-deserved and appropriate reward for what we do in medicine.  But money is also only a thing.  And what we do for humanity is so enormous and so difficult, that we cannot continue without motivation by transcendence. 


Unless we see ourselves as part of a greater effort; the healing of fellow humans, the provision of comfort to the suffering, the defeat of sickness and death, all the money in the world will not give us the ability to come back to work day after day and do well.


Money cannot provide the meaning we need. 


Furthermore, money can harm us and harm our families.  I have two partners who worked so hard, for so much, that their marriages collapsed as they became romantically involved with co-workers.   I know that divorces are multi-factorial, and always involve both parties.  But time away from home must have been a factor.


Money, or the pursuit of it, can lead us further and further from our beloved spouses and children; who can only look out the window, wondering when we will have enough, at last, to come home and play, to come home and live. 


You see, money enslaves us in its pursuit.  We want, so we get.  We get, and we want more.  We move from true need to wanting to the false perception of need.  Then, we need more money, and more, and because we aren’t dermatologists or ophthalmologists, we have to work more and more hours to meet our financial needs, to pay our debts, to cover two houses, four cars, three wives and the cost of days lost when we finally have that stroke or MI.


To be happy, we must use our time wisely to make what we need, but also learn to recognize and honestly assess just how much we actually do need!  This is an individual decision.  Before long, the government will probably start delving into the question of how much we need.  That will be a tragic day.  But until then, all I mean is that we should exercise our freedom and assess, with honesty and love in our hearts, how much money we require, and how much we can get by without.  In so doing, we chart a path to freedom.


We ought to stop living like doctors and start living wisely.  And we should probably remind the younger generations of emergency physicians of the equation we all learned so quickly:  Money equals time working with sick people.


So, to summarize what I want to say about money:



Be proud of your place and your calling.  No money can substitute, or ever truly compensate, for the risks and sacrifices, the hard decisions and hard situations you face. 


Be so proud of what you do, so convinced of your own worth, that you insist on being treated as the very valuable commodity you are.


Act as if money is less important, all the while knowing that is necessary and appropriate.


Bless your family and friends and favorite causes with your money.  Use it well.


When someone tells you the care you provide should be free, ask what they’ll give you for free.  Watch the puzzled look.



Be proud of what you do, and never ashamed of what you make.  No one else is; not even politicians who make millions on consulting work.  They just want you to be ashamed.


Just don’t ever believe that money will give you meaning, or replace the time you spent away from your loved ones, or doing things you hated, or living or working in a place you detested.


It’s a fine balance, but if you can find it, money will be your friend.


The Bible says ‘don’t muzzle the ox while he is treading the grain.’  That is, make your money.  But it also says, ‘The love of money is the root of all kinds of evil.’  Keep both in mind, and you’ll be able to navigate the weird finances of the future with peace in your heart.

Edwin Leap, MD

Copyright, 2009

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