As we try to apply various economic and social formulas to the cost of medical care, we inevitably come down to the public perception that much of the expense lies in doctor’s fees.  Although that’ really only a small part of the equation, it’s the doctor everyone sees.  Patients rarely meet pharmaceutical executives, insurance company board members, their representatives in Washington or (most elusive of all creatures) those who create the rules and policies for government programs like Medicare and Medicaid, and in so doing set the tone for the nation in terms of the cost of health-care.

As I signed off my verbal orders last night, and signed forms for this and forms for that, it occurred to me that one of the reasons physicians are paid more than some other professions is the degree of accountability expected of us.  I know, other professions have their own accountability.  I’m not trying to say we’re all alone in this.  But the thing is, we are responsible for many potentially life-altering things from minute to minute, day to day, year to year in the courses of our careers.

Even our EMR system reflects this, as ‘physician aware, physician notified, Dr. Leap at bedside, Dr. Leap gives verbal order,’ etc. populate the fields of the nurses’ computer screens.  And of course, paper records require our signatures; the medical chart must be signed physically or electronically.  The transfer form must be signed, verifying stability.  The transfusion form must be signed.  The psychiatric commitment papers (in SC) have to be signed twice on the same form!  The restraints have to be ordered and signed-off…by the physician.

A nation accustomed to forms, this seems natural to us.  But why is it natural?  Why does the MD or DO signature have to follow everything?  Because someone has to be willing to assume responsibility and be accountable.  And whatever else we are, or are not, paid to do, accountability is something for which we are compensated.  Now, no bill will ever say, ‘$200 accountability fee.’  But it’s there, hidden in the subtext.  We certify that we did the right thing, we sign forms that we bill honestly, we sign forms that guarantee our insurance, we sign forms that we signed forms.  We sign to say, ‘this was my decision, right or wrong.’

All of it so that, if something goes afoul, someone can be blamed.

Fair enough.  For these nearly 17 years of practice, I’ve been accountable. Sometimes it was a drag.  Sometimes, I was accountable for something bad.  But I accept it.  In a culture of shifting blame and a foggy sense of duty, I’m honored to be the guy who is to blame…since it was often for something good!

But I’m also unapologetic that accepting blame costs something. And since our society, unlike so many other countries (whom we seem bent on emulating) is in love with blame, with lawsuits, with punishment, this won’t stop anytime soon.

As we move forward and try to involve more people in the health-care system to extend care, let’s never forget that at some point, when you take care of patients primarily, you’ll be responsible.  This is a cautionary note for those PA’s and Nurse Practitioners and Doctors of Nursing who may be filling in the primary care role.  It’s a great honor, and I wish you the best.  But please don’t expect someone else to sign the forms behind you.

At least not if you want the big bucks.  Such as they are or will be.  Because when it comes down to brass tacks, it’s down-right expensive to get anyone to take the blame.


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