Saturday, April 22, 2006

Customer or Patient?

One of the silliest things to happen in medicine in my 10 years of practice is the turning to a business model to improve what we do. Now I am a big free market guy and I believe that competition leads to decreased costs and incresed efficiency. So why would I be against learning from business to improve what we do. I wouldn't be if medicine were a business.

With the advent of medicare/medicaid medicine inched away from being a fee-for-service business to a heavily subsidized and endlessly intricate mystery wrapped in an enigma (apoligies to my hero). Used to be a doctor could hire a secretary and a nurse and open an office and do well if he was good and his patients liked him. Okay, that's business. Now I would challenge anyone to show me this Horatio Alger MD. I know there are boutique practices that cater to those with great insurance or great bank accounts but these are more a curiosity than an alternative to the current system.

As I have stated elsewhere, in the Emergency Department we collect about 30% of what we bill. Recent statistics show that each Emergency Physician in the country gives away about $150,000 in free health care a year. This is because of the unfunded federal mandate called EMTALA, and ED physicians are not the only ones affected. If you are a surgeon, for instance, and you want to practice surgery, then you have to have priveleges at a hospital. This is not true for all surgeons, oral-maxilofacial surgeons can skirt this, but let's just speak about your genergal surgeons, vascular surgeons, chest surgeons, trauma surgeons, neurosurgeons, orthopedic surgeons, hand surgeons, urologic surgeons, gynecologic/obstetric surgeons, and pediatric surgeons. These folks have to take call for the hospital at which they are priveleged. When they are on call EMTALA impacts them too, for if any patient comes into the ED with an emergency surgical condition... appendicitis or an open fracture for instance... that patient is now theirs.

Never mind that with many of these patients the surgeon will not see a red cent for their 3am call to the hospital for emergency surgery. Never mind that they are forced to give hours of their valuable time in these patient's care. Now understand also that these surgeons have practices and have scheduled elective procedures for which they will be reimbursed. Now these reimbused procedures are cancelled for the emergency procedure. No wonder they hate the Emergency Department. I'm not saying, nor would they, that the emergency patient should not receive their operation or should not receive care, I'm simply pointing out that this is not a business model.

It grates on me therefore that the business-minded amonst us are still trying to fit a square peg in a round hole. Believe it or not the administration of most hospitals and ED groups care most about postitive customer feedback (see the prior posts on "Press-Gainey Scores"), and less about good outcomes.

So in medicine, which already resembles a huge ponzi scheme run by the government and insurance companies, the physicians themselves are daily bombarded with ways to improve ''customer service''. Never mind that 70% of our ''customers'' are not paying a dime for their care... they still get to fill out surveys about whether their care was timely and caring. A single angry patient, even one in the country illegally, can get a physician called to the carpet because the physician was ''rude'' or ''didn't explain things'' or a host of other complaints having nothing to do with whether they were treated correctly for their complaint.

Here's another wrinkle, if you are a ''customer'' whose sole purpose is to obtain a prescription for narcotics which you can then use or sell on the street at great profit, and you don't get it because you are proved to be a liar and have 30 prescriptions at the local Walgreens for oxycontin written by different physicians at different facilities within the past year, and you receive a randomly distributed ''survey'' you too can get your treating physician in trouble. Physicians have no counter to this, instead we are treated to lectures on improving our "customer service".

For what purpose? In a fee for service environment where we were truly compteting for dollars that would go elsewhere okay! I get it! When half my salary is going into a deep dark hole anyway why the hell should I care about this? When all our beds are full, the waiting room is full, the hall beds are full, and three patients are dying how am I supposed to give warm fuzzies to the mom who brought in her healthy kid for a ''fever'' that we can't document and a ''rash'' that I can't even see?

Most physicians do not organize, picket, or complain outside their professional circle. We are a beaten bunch. My solution is to never look to see whether a patient has a job or insurance... I treat everyone the same. If I'm not slammed I will hold your hand and explain things to you, if not, you may see me for two minutes. Still, it is painfully obvious many times that the arrogant SOB/DOB who is not sick is in the ED simply because we are ''free'' has no intention of ever paying for their care nor any means to (though they can still afford their cigarettes because 'my husband buys them for me'- no shit!). I challenge anyone to point to another profession where its practitioners are forced by federal law to provide their unique skills for free. Sure, lawyers are expected to do some pro bono work, but they are not required to do so unless their firm demands it.

I challenge you to go to a grocery store, gas station, department store, lawyer's office, mortgage company, or utility company and demand their products or services because you ''have to have them to live'' and see if you get them if you do not pay.

Solution? I don't have a viable one, but I do know that, as I have mentioned before, the country as a whole will eventually get what they pay for. If medicine, perhaps the most intellectually, emotionally, and physically demanding profession that exists, ceases to be attractive to our best and brightest then the quality of our healthcare and physicians (currently at least equal to the best in the world) will plummet. It's not rocket science, if you want to increase use and demand for a sevice then just mandate that it be free.


  1. I always thought those surverys went straight into the garbage. I had no idea anyone looked at them. I make a point to write a letter to an actual person when I find an amazing doctor or get wonderful care, but I almost never send back the surveys. Maybe I will start if I think someone is reading them!

  2. Sorry for the late comment, I recently found your blog, and it is great reading. For radioactive girl, many, if not most hospitals use their PressGaney scores as one of the measures for bonus/incentive payments to their staff. This can range from senior management (who clearly benefit big-time in this area), employed docs, all the way down to environmental service workers. So, you should complete those surveys honestly. As far as EMTALA goes, this certainly can be improved upon. I think the ER docs truly take a beating in this area. And a topic about which too much can never be written...I believe most of the general public do not fully understand the financial and clinical impact on physicians and hospitals due to this law. (I've worked in financial management in hospitals for many years, so I'm pretty tuned in to such matters).

  3. ER docs still make more on average than PCP's. So even though you give away so much free care, you still do better than PCP's. And ER docs at my hosital do twelve 12 hour shift a month = 144 hours. PCP's do usually 40 hours a week x 4 wks plus weekend coverage > 160 hours a month, So its less per hour.

    So don't feel so bad.

  4. mike,
    two things, and no offense intended.

    1. i believe we make more because we routinely do high rish procedures and manage critically ill patients. also, while you are correct about the number of hours worked between pcp and er i would argue that the circadian disruption of all manner of different shifts makes our 140 hours a lot harder than those hours workded on a regular schedule.

    2. i don't make this argument because i don't like my salary. i do. i don't care so much about that though i would always like to make more. i care about working in a madhouse run by clowns with "customers" who have learned how to abuse, and routinely abuse our so-called system.


  5. I considered medical school for a long time; I like helping people and I'm good at math, bio, and chem. Because patients are treated as customers, EMTALA, and frivolous lawsuits I've decided not to go. Society certaintly is forcing out many of our brightest. Right now I'm a senior chem major, I can think of at least 6 others who have opted out of medicine for the same reasons.

  6. i sympathize with your decision. i think it is wise. at the same time i do think medicine is a great profession and can not continue in it's current state. it might be a great counter-intuitive or contrarian play right now. when i finished me school the word on the street was that anesthesiology was finished as a specialty and none of their programs filled. now it's one of the best specialties to be in in terms of remuneration and lifestyle. still, i think you are wise. best of luck.

  7. I accept your challenge. Utility companies are required by law to provide certain services (heat in mid winter for example)so that their customers wont die even though the customer isnt / doesnt / cant pay.

    Get off your high horse

  8. ya, but i bet it is not a commonality. Some poor souls have been known to accidently burn down their houses, apartments, trailors by lighting candles because electric is shut off. too sad.

  9. true story:

    so I am caring for an illegal in El Paso at a government hospital and he had been in a wreck while driving here. He had no insurance. Furthermore he had not a pot to piss in nor a door to throw it out. So I asked him (he did speak English)what would have happened if he had been at fault. He said that the other guy "had insurance". I asked if he knew the guy's premium would go up. He looked baffled. After a few minutes he said..."shut up, you Americans have it so good over here you don't even know how good"...after all of the expensive stuff was done finally another civilian hospital took the guy. We were not even allowed to call the Mexican authorities on the guy.

    So that is how the rest of the world views us I believe. They hate us until they need us. It is like that too with the people that voted for the president. The young crowd will love the system until they get placed in que at the end of the line when they are older.

    To answer the question as to whether they are customers or patients let me leave you with this...a customer pays for services rendered. In my opinion if you are not paying then you are not a customer. Also, since the ones that aren't paying are likely the 40% of the population not paying taxes then they again can't say they paid for it in their taxes.

    Remember the adage "those that can do; those that can't teach"...whether true or false it speaks of the academics that sit in their offices teaching medicine and maybe rounding once a quarter while they suck their hospital paycheck and work on their next publication. Don't try to steal from those of us out their that actually work for a living...Problem is that the government is asking those pukes how to fix the issue. They need to ask guys like me and you, with boots on the ground, how to solve it.

    Youtube "Reagan on Socialized Medicine"...he says it best and he says it all...

    Nope, they are not customers....they are patients...and since they are patients your model of not caring about the bill is the most ethical in my opinion would however be nice if those we "served" had some respect for the man or woman who holds their lives in the palm of our itty-bitty hands...

    Maybe we can some day soon realize that this holding hands nursing model of caring for patients and singing ballads over marshmallows and coco is not appropriate. Let's get back some good old fashion tort reform and bring back paternalism in medicine! Nice!

    Thanks again...