The \”empowered patient\” movement (which I think is a good thing) strives to take the doctor out of the center of care and put the patient at its focus.  The role of doctor is not to be the star of the show, the quarterback, the superhero, but the advocate and helper for the patient to accomplish their goal: health.  Many rightly attack doctor prima donnas who want the exam/operating room to be about them instead of the patient.  This is health care, not health performance. They want doctors who care more about the people they treat than they do about money, praise, or status.


I get it.  I get the message that doctors have to adjust to this new age of patient empowerment and patient-centeredness.  I get the fact that making patients wait is a bad thing, and that communication is as essential of a skill as is medical knowledge – remove either one of them and you don\’t have care.  I hear the message: doctors should care about patients more than they care about themselves.  That is what we are paid to do, and that is what we have neglected at our own peril.

So why is it, then, that those of us who try to be patient-centered in our care end up getting penalized?  If the days of the doctor-god are over, then why are we still paying premium dollar for those huge egos?  Why do we pay more for technology than humanity?  When I face the continued threat of declining reimbursement (don\’t forget, then next SGR battle will be over a 30% drop in Medicare reimbursement) I feel angry.  I am the point of care, not cost.  I am cheap. I spend my day trying to keep people well, trying to find cheaper medications for them, trying to avoid expensive procedures and consultants.  How am I rewarded for fighting the tide of spending?  With increased expectations, increased fear of the future, and decreased pay.  I see the gratefulness of my patients, and that keeps me from fleeing altogether; but I also face the callous cuts by CMS, the increased micro-management by the insurance industry, and accusations of being a \”greedy doctor\” for not wanting my pay cut.


Why is this?  Why is a system that is growing more and more expensive seeing cutting my pay as a means to saving money?  Why not focus on the durable medical goods that solicit business from my Medicare patients, suggesting that they can get \”free\” commodes and scooters?  In the past few weeks I have done three \”mobility evaluations\” for people who are trying to get scooters.  They have done this in response to the commercials or direct phone calls from the companies that provide these devices.  Beyond that, I have seen a huge increase in the number of ludicrous requests by these companies who prey on innocent and ignorant patients.  They are leeches.  They are bloodletters removing the life-essence from a dying patient.  Yet their presence is growing.

Why not focus on the generic drug manufacturers who are still able to charge premium prices for their drugs?  It used to be that when a drug went generic, it got cheap.  For some reason, however, things have gotten far more complicated.  I now need to know which are the \”cheap generics\” and which are expensive.  I need to remember which medications that were inexpensive have been forced off of the market by more expensive competitors (cough syrups and colchicine, a drug used for gout are two examples of this)?

\"\"Why not focus on the hospitals who are buying physician groups so they can order more tests in their facilities?  The pendulum has swung now back to the hospital-owned physician groups, with doctors fleeing the fear of SGR and other reimbursement debacles for the \”safety\” of a salary from a hospital.  The problem with this is that the hospitals are huge consumers of healthcare resources.  Hospitals hire doctors because doctors can send them \”business.\”  In case you forgot, \”business\” is another word for \”spending.\”  Hospitals are things patients should avoid, but doctors are hired to be a turnstile into the land of medical spending.  I have lived in both worlds, and I am far more patient-focused and cost-conscious than I ever was when owned by a hospital.

We have a bunch of hands being plunged into the coffers of healthcare, and yet we are penalizing those who are too busy caring for patients to do so.  I honestly get depressed when I see all of the waste around me and yet face huge cuts to my reimbursement.  It shows people don\’t understand.  It shows people don\’t care.  Do you want doctors who care?  Then put your money where your mouth is.  Stop rewarding the parasites.  Stop throwing money at the turnstiles.  Stop rewarding the spenders.

There are some of us who still care, but it\’s getting harder to stay that way.

15 thoughts on “Caring”

  1. Awesome, AWESOME post. I can’t add anything on the payment front other than to thank you for educating us. It’s all too easy to believe that the focus is being misplaced. I take the empowerment movement with a pretty hefty grain of salt–perhaps it’s the “movement” aspect. Some people are as militant now as some of us were back in the day of the feminist movement (remember the “Women Good, Men Bad” spoof on Saturday Night Live?), and that makes me uneasy. If you read some of the blogs and comments out there you’d think doctors were the enemy. I touched on this when I wrote about how I’m a patient, not a consumer on and boy did that generate a bunch of comments. Some people now seem to equate the word “patient” with “doormat.” Because I respect and trust my doctors and yes, like being their patient, these people assume I never asked a question or stood up for myself. And people talk about being patient-centered as though they just invented fire. I never doubted for a second during my treatment for DCIS that my four doctors were fully focused on me. Example: My surgeon never talked about himself while he was treating me (we’re talking three surgeries and at least a dozen office visits). I’ve had occasion to see him several times since then and he’s opened up about his life and his family. And it’s nice.

  2. Dr. Rob, you are dead on, as usual.
    I do have to say I am surprised the scooter companies are still so aggressive. Medicare cracked down on them several years ago when the number of scooters in one county in Texas increased by something like 300% in one year. The MD churning out those certifications was indicted and convicted of fraud. They simply never learn though, do they? However our government resources are limited. It is like trying to fight a tidal wave with a roll of paper towels.

    And as a result people like me, with my mobility diminished by MS, have a hard time getting a legitimately needed power chair. There is no justice in this world.

  3. Shoot, I believed those free scooter commercials and didn’t realize it’s just another racket (again, thank you Doc Rob for shining a light on this.)
    Marie, I am sorry you are having trouble getting what you need.

  4. I wonder how the points in your post, and everywhere else, will impact on college students who are contemplating a medical career. Will they head toward engineering or into the technosphere? Will the academic caliber of medical students decline? Does this matter?

  5. “Hospitals who are buying physician groups”? Really? I’d be interested to know more about this. That’s not a criticism, but an honest statement.
    On the other hand…”Hospitals are things patients should avoid…” Really? What an irresponsible thing to say! Some of us (with chronic conditions) don’t have that luxury. If I “avoided hospitals” every time I felt sick, I’d probably be dead by now. I will grant you that if a so-called “patient’s” major complaint is the common cold, a hospital isn’t what they need. But your statement may send a message to some that if they’re really sick, hospitals can’t or won’t help them, so they’re better off “toughing it out” on their own. I don’t think that’s the message you meant to send, but that may be how some people will interpret it.

  6. I don’t know about “racket”, necessarily. But what they don’t tell you on the commercials is that Medicare will pay for only *one* durable medical device. So if you have a lot of problems, or your condition is likely to worsen over time, you’re better off really weighing your options and making sure that the device you choose is the best one to meet your needs. I learned about that after my maternal grandmother had a stroke. Medicare paid for one power scooter. She decided she wanted another, smaller, portable one to use on outings with my mother. That’s when they found out that Medicare wouldn’t pay for the second scooter, so my mother and uncle had to come up with the funds to pay for the portable scooter themselves.

  7. You want to avoid hospitals because if you are in them it means you are sick. My job is to keep people away from hospitals by keeping them well. It’s like my auto mechanic; I try to avoid him as much as is possible. Now, when I need him, I go to see him. That’s what I mean by avoiding hospitals. Not by avoiding them when you need them, but instead not needing them in the first place. I wrote this post assuming my readers knew where I was coming from on this (that they’ve read my writing before and understand the context of what I said). Obviously, as a doctor I wouldn’t recommend people avoid hospitals when they need them.

  8. They are not doing things overtly illegal, but they are often calling seniors and offering them all sorts of “free” stuff that they may not need. Most seniors will say that they’d like a free scooter, so the vendors are VERY aggressive in this. Scooters have a valid place in patient care, and can really help some people, but they are not appropriate for everyone. The scooter distributors and manufacturers don’t care if the shoe fits, they just want to make as much money off of Medicare as possible. It’s not illegal, but it is very, very bad for our system.

  9. We learned that when my husband had a severe event with his post polio. No improvement was expected, so they were in the process of ordering an electric wheelchair (or scooter not sure which) for him for discharge, when he took a turn for the better and suddenly was able to walk 2 laps around the floor without tanking his SATs or falling.So then, they looked at ordering the scooter for when he needed it, and a walker, we ran into the 1 piece of equipment issue. They would not pay for the scooter (that he needed most of the time) and the walker that he could get away with part of the time.
    He choose the walker, in hopes that being forced to use it would just increase his mobility (it did).
    Now, because of increased falling, we’re looking back at the scooter (haven’t decided) but we’re not sure if enough ‘time’ has passed … and then there is the possibility of medicare saying “oh no, he said he could get by with a walker …so …”

  10. ive seen big hospitals in my area buy out practices………….. but i dont know how to stop rewarding the greedy ones when i have to abide by the rules given to me as a patient……. i know what you say is true but i have no idea how to reward the good without know ing the behind-the-scenes stuff patients just dont know about………… a lot of the time i wish doctors themselves would speak up more……. i cant know who the shiesters are really………… but medical people do. but often no one ‘on the inside’ speaks up, and the primary doctor is getting hit the hardest because everyone involved wants the status quo …………. so lets say i need something, im not going to get it unless i go by the rules that i know of………. there are lots of rules depending on who you talk to………. its very confusing………. but if i saw more doctors or nurses and such speaking up i could make better decisions so that it rewards those who are doing their jobs…………… part of the empowering patient is rewarding those who are trying the best they can to help but if we have no criteria then we cant do that…………hope it makes sense …………………

  11. Agreed! My daughter has special medical needs and sees 8 or so specialists, but in reality, it is her primary pediatrician who does most of the work and is in charge of her care. I’D pay much more for her services, but the insurance company rewards the specialists for doing much less work. This is also going to lead to fewer and fewer graduating physicians going into primary care, which is a growing problem already.

  12. Our pediatrician saves the day time after time with little to no reimbursement. Who steered us away from a not so great GI group and sent our dtr where she really needed to be? Her pediatrician. He saved money by avoiding a useless visit to a group that is all about procedures and testing anything testable. Not to mention how much better efficient, quality treatment is from a patient perspective. Who manages school 504 forms, medication forms, and referal letters/orders for OT and PT? Her pediatrician. Again, I can’t see any way the group is reimbursed. Who calls every now and then when she hasn’t been seen in a while? Yep – her pediatrician. Specialist visits are big bucks for a little time and debatable results. Too bad primary care doesn’t get the respect or money it deserves.

  13. When a cock-eyed optimist like Dr. Rob gets this bummed out, it means things are REALLY bad. I don’t see any quick solution coming down the pike. I do have to say that the primary care professional societies (AAFP, ACP, etc.) have been completely worthless in terms of addressing payment reform.

  14. It already has. My son (who’s father is a thoracic surgeon) decided to become a PA rather than accrue loans for medical school that would take forever to pay back in this insurance climate. He loves working in a busy NYC Emergency Department, getting a salary, having a schedule that is flexible and allows him to pursue his sports and social life, while still seeing a variety of patients and having a pretty high level of autonomy. More pluses are no malpractice insurance, no office overhead, no employees to worry about. He’s not the only one who made this choice and I think he made a good decision. His degree and certificate are more portable too – most states reciprocate so he can move if he wants to. Smart kid I raised!

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