A post I wrote nearly three years ago has recently gone viral, bringing tens of thousands of readers and a huge number of comments. It\’s a letter I wrote to my patients who do something that all but guarantees a bad relationship with many (if not most) physicians: they don\’t get better. There are basically two responses I get to this post: either readers are grateful to have a doctor admit to our flawed humanity, or they are furious that I would suggest that patients, the ones with the disease, should see physicians as needy and flawed humans and therefore watch how they act around them. If you haven\’t done so, read the comments to this post and hear the deep frustration and anger brought out by a letter that sympathizes with their pain and (apologetically) tries to help.
Amidst the dichotomy of reactions, both of which I understand, is the obvious question: why has a relationship that exists for the purpose of healing and helping become one of frustration and anger? The corollary to this question is perhaps more important: what can be done to heal this broken relationship? A reader of my last post (about viewing patients from a different perspective) asked me point blank: \”Dr. Rob, for the 99.999% of us who do not have a primary care doctor who is thinking as progressively as you, what advice can you give so that we can get our doctors to be treating us in the manner in which you are treating your own patients?\”
I must admit, I get a bit uncomfortable with this, as it sounds like I am putting myself above my colleagues morally. Ironically, it is my deep understanding of my own huge flaws, coupled with an upbringing that scorned conformity, that rips me away from the survival self-centeredness most docs eventually adopt. Putting myself on any moral high ground only invites a very public (and deserved) fall back to the low ground I usually inhabit. No, I\’m also not putting myself down out of false-modesty; I\’ve made peace with my flaws, embracing them for what they are: a lens with which I can understand my fellow human scum-bags. Of course, as my best friend (and best man) used to remind me: \”remember, I am doctor scum bag to you.\”
Now, I don\’t lay the whole problem at the feet of the fallen nature of mankind. I believe that our system of \”health care\” doesn\’t just fail to counter the flaws of our nature, it actively promotes bad relationships. It does this by:
- Reducing patients to \”problems.\” The payment system requires we use \”problem codes\” to classify patients and justify visits. The problem-oriented approach is not just a byproduct of the payment system, though, it is at the very core of medical education. Despite a 100% ultimate failure rate, we are still taught that death and disease are the opponents we need to outsmart or out-procedure. Perhaps its analogous to the public infatuation with the tawdry and grotesque (the more gruesome the murder, the more news shows cover it), but we physicians love \”interesting cases.\” But nobody ever wants to be an \”interesting case.\” Ask any of the people who commented on the blog post. Boring is better.
- Rewarding sickness. Having a full office pays the bills. If everyone got healthy, the system would collapse. This means that anything that would help patients get healthy stands against the financial wellbeing of doctors and hospitals. If doctors communicate poorly with my patient, they will be less likely to get well, and will hence be more likely to need their services. I don\’t think docs actually use that sickening logic, but it is the ugly truth about our system. This is why tools that should make care better are not adopted: doctors are penalized when they improve care.
- Making doctors targets. I am not talking about patients, I\’m talking about payers targeting physicians (and hospitals) as the cause of the problem. It would seem that the best strategy to fight unnecessary cost would be to simply stop paying for unproven, unnecessary, and/or harmful procedures. Better yet, why not pay docs like me who are motivated to keep patients well and happy? But payers instead target doctors through small financial rewards and huge sanctions. \”Quality measures\” are not out there to reward high quality, their purpose is to expose and shame the bad doctors and hospitals. Am I exaggerating? Perhaps; but I can say that one of the best parts of being out of the insurance-oriented system is to no longer feel the passive-aggressive eye of big brother waiting to catch me not following their rules. All docs feel this, and it puts them in a position of defensiveness, which is not good for patients.
- Killing time. One of the most remarkable differences in my new practice is the amount of time I can give each patient. I can answer the phone and handle their problems. I can sit and chat with them if they stop by to pay their bill. In the old system I was always late, always pressured to move on to the next patient, and rarely had time to do the most important thing: communicate with my patients. Good care takes relationship, and relationship takes time. Nobody has time any more because the system seeks and destroys time, either by filling it with meaningless clerical tasks or by punishing those who take extra time with lower pay.
In our health care system we have a business where both ends of the transaction are miserably unhappy. 99% of doctors hate the health care system, and the 1% who like it are the ones to avoid. Patient dissatisfaction is nearly as high, skewed downward by people who have grown so used to the terrible system we have that they now see \”terrible\” as \”average.\” Is there any other business where both consumer and those providing the product are so unhappy? The reason for this is that someone else is shaping the system: the payers.
I must admit, I am not sure how this can be fixed in any way other than a total disruption of the current system and replacement with one that is centered on people, not problems, on communication not documentation. Until we have a system that doesn\’t reward sickness, sickness will be the reward we reap. I left the system because I didn\’t think there was any way to continue practicing good care in it. While my new practice is far from perfect (consider the source), at least I am rewarded for taking time with people.
To have any chance at building better relationships between doctors and patients, we need to face the painful reality that our system corrupts even those with the best intentions. So, I guess that would make it a \”scum-care\” or \”health-scum\” system? The sooner we face our ugly reality, the more the chance of bringing the focus back to where it should be: caring for patients.
Dr. Rob, as one of the “incurables” with multiple chronic conditions (some of which you may have never heard of, or only in med school) I see both sides of the comments. Honestly, if many of the comment makers knew that you accepted NO insurance, their attitudes would change in less than a heartbeat, and earned praise would turn to vitriol, even if they knew your pricing structure! I applaud and agree with your new practice model; it removes a monstrous “middle man” from between you and your patients: the insurance companies. That system is great for the healthy, or those in need of obvious acute care, but those of us with chronic, often strange illnesses are maligned. Doctors have no time or no training to think outside of the decision tree that they have been taught, if there is any deviation, it must be the patient. We come in with diseases so rare that most doctors would not even consider the diagnosis because of its very rarity. Even more than “caring for patients,” I believe that doctors need to re-taught to THINK! You were bombarded with comments because you dared to expose “the little man behind the curtain,” instead of being our “Great Oz.” Many of us are simply wanting some semblance of a normal life, and see doctors as the ones with “The Cure.” No single doctor can possibly know or be versed on the diagnosis and treatment of all our zebra conditions, but we still hope to find one. Honestly, the best doctor I’ve ever had was one who was willing to say “I don’t know.” Instead of pinning on a wrong diagnosis, he was willing to find a doctor that might know…and get me to the proper care.I still applaud your efforts and hope that more caring doctors will follow in your footsteps.
A brilliant post. However don’t self-immolate…You are spot on about it all.Glad to hear you are ‘viral’ Catching up to Gangam ? or Paris Hilton?
Catching up with Paris Hilton would give reason to self-immolate. No, this is not about getting down on myself; it is about viewing my own faults as part of who I am. It’s a big step to become comfortable being a flawed person while not accepting my flaws as anything but what they are: proof that I am like everyone else.
Rob, thanks for the quick reply: No, your appraisal is correct. a humble servant, sometimes not appreciated. Remember we do it for ourselves in the long run….I too am terribly flawed. Hope all is well with your new practice….quite a leap
Not sure why folks would be against a doctor stepping out of insurance to focus on patient care, but I am sure you are right. That is sad for me to hear. In reality, I’ve gotten pretty callus to the attacks. Most folks haven’t read my other stuff enough to understand my perspective. They are just wanting to vent their rage at the system, which is OK. I don’t take it personally.
Dr. Rob,
Have you heard of One Medical (https://www.onemedical.com/)–a concierge practice that is similar to your practice? Do you have thoughts on them?
Similar to what I am doing. A step in my direction – hybrid approach. My big difference is the abandonment of office visits as the center of the care universe. I think care needs to be done on the continuum, not just at set intervals. Others are Qliant and MedLion. Lots of movement in this direction, for sure.
[…] http://more-distractible.org/2013/06/03/doctor-scum-bag/ […]
More likely Bruce Cockburn and Monty Python. A balm for the wounded soul.
dr rob, i think i love you…if you had boobs id be stalking you…lol, jk jk, some levity for you , on a serious note, I love your care model. wish I could find a neuro with your outlook lol
i feel very strongly about your point #2. very cynical about a health “care” industry that wants to keep it’s consumers just sick enough that they have to keep buying the overpriced drugs and overpriced treatments. we need a complete overhaul, involving both providers and consumers, but where/how to start?
I recently read your 2010 post “A Letter to Patients with Chronic Disease” after someone posted the link on Facebook. I am the parent of a child with a chronic disease and I read your letter with interest and I took your words to heart. It was very insightful to read a physician’s perspective. You see, several years ago, I wrote a letter – as the parent of a chronically ill child, to physicians letting them know my perspective and what I needed them from them. My letter is titled “Dear Future Physician” because I wrote it in response to a request by a first year medical student as part of her “Reflections in Doctoring” course. My letter became the impetus for a physician education program I established called “Touchstones of Compassionate Care”. http://www.touchstonesofcc.blogspot.com
I thank you for your letter. I truly do take your words to heart and I will try and remember them in my future encounters with the physicians caring for my son.
Ann Schrooten
http://www.jack-schrooten.blogspot.com
I was thinking about that today – as it happens I’m having yet again a reaction to a drug I was given to counter the unwanted effects of another one, and I’m taking now a plant mixture supposed to stir up adrenal glands, and I was wondering WHY we weren’t investigating something which would work at the root instead of something which only cures the symptoms. There’s one obvious answer: a cured patient doesn’t buy meds. And I think in France, there’s only one thing which functions reasonably well for patients, so far at least, and it’s the national health insurance. I only pay for what’s not related to my disease, the rest is 100% paid for, I just have to give my electronic card, which is a blessing – my monthly infusion alone costs around 5000 dollars. I think nationalizing the whole health system – big pharma and medical research most particularly – should be considered. But of course this won’t happen, so the system will stay as it is, in a race for money which is absolutely not compatible with general well-being and which also perverts doctors’ jobs, since hospital budgets are cut everywhere here. But I do think it’s not limited to the medical system, it’s the whole system now which has gone corrupted.
Dear Dr. Rob,
Just wanted you to know that I’ve linked your blog to mine, with great pleasure I might add.
Be well and thanks again for putting so much good mojo out there!
: J
Dr. Rob, Your letter was just passed along in one of my chronic pain support groups on facebook. I found it to be a refreshing look. My two main diagnoses are syringomyelia (which may make you go huh?) and fibromyalgia. My primary care doctor seemed to care less… so I’m on the search. A neurosurgeon minimalized my conditions and reduced me to tears on both visits. I found a very flippant neurologist. And I finally found a pain neurologist that sat down with me and we had real conversations about what I needed and what he did and didn’t know about my conditions. He was straight and honest with me, but said he would do what he needed to do to help. But all those other doctors almost made me give up on finding treatment… and I might have if the pain wasn’t so unbearable and I did not have my daughter to care for every day. Our system is broken.