Extortion

Becoming a physician, thirty years ago, did not involve subjecting yourself to extortion. First with Medicare/Medicaid, now with EMTALA, and  soon, whatever bezoar is eructated out of D.C., a generation of physicians is being extorted. Furthermore, the impact of the extortion is not limited to physicians, rather, the impact is on all who need health care in America.

First, let me be clear that I am not one of these physicians, but I know lots of them. I know plenty of physicians who signed on the dotted line to commit themselves, body and soul, to medicine. They did it based on one of the fundamental principles of a market economy (and, doubtless, for many other reasons), that a fair price would be paid for excellence, and that their reputation and the price of their services would be determined by the most efficient distributor of resources known, the market. Also, they did it based on the belief, historically accurate in our country, that as a professional’s professional, they would have power over their careers.

It may be incredibly naive for them to have done that. In retrospect, my decision to join the service and have Uncle Sam pay the tab for medical school ($180,000 in 1992 dollars) seems like a genius move, but at the time there was no shortage of folks telling me I was making a big mistake. I joined for reasons other than money, but money was one of the reasons.

Coming out of medical school debt free has allowed me to avoid the trap in which many find themselves. *  It seems to be a trap that caught PandaBear and one that has caught many of my friends. The trap is extended and expanded through residency training by paying residents, per hour, minimum wage or less. During residency it is therefore impossible, especially if one has a family, to pay down your loans. Think about the interest over four years, or eight years, on $180,000 and then the size of the trap becomes clear. But the trap is only partially financial. The trap is cruelly protean.

Over the last fifteen to twenty years a quiet coup has taken place in medicine, with decisions regarding physician reimbursement, schedule, responsibilities, and the shape of a physician’s practice being co-opted by all manner of clipboard carrying administrative drones and academicians. Understand, I don’t believe the drones to be evil per se, they are simply doing what we can not… working to support themselves and their families to the BEST possible extent within their comfort zone. But their ‘normal’ existence and the laws, rules, and regulations which have allowed their rise, has come at the direct expense of physicians, and of patients.

The expense to physicians is in money lost from paychecks, but, more importantly, in confidence. The monetary loss is one thing, and it’s not hard to see how it happened… EMTALA and other government redistribution programs are unfunded, medical care comes at a cost, someone must pay, and the people paying the most are providers of the service (physicians), nurses, and taxpayers. Strangely, this redistribution has not only given to the poor (both deserving and underserving) and illegal aliens (by the hundreds of thousands), but has also given, from our pockets, cash to the new drone class in medicine. After all, there has to be a drone class to file the papers and hold meetings about how other people’s resources and money should be distributed. It has to be done with a semblance of “fairness” even though the act is unfair on its face.

Physicians have been a quiet bunch as their stuff has been taken, their time at the hospital increased, their power quashed, and their ability to practice medicine like they trained severely limited. Here is where uncertainty has replaced confidence. Here is where a whole generation of academicians and older physicians have given into bullying, or, worse, encouraged it.

I guess this is not surprising. It’s disappointing, but not surprising. It is one of the essential points of Panda’s post… what choice does he have at this point but to go perform at the carnival even though he belongs on Broadway (my words, not his). And the commentors either deride him for not liking the carnival, deride him for wanting to change it, or deride him for  'not being carnival material’. They say, “Well, leave already!” And go where? And do what? And pay his $3000- in school loans per month (for ten years) with what?

The Queen of the drones understands this calculus. The Queen demands more from the physicians, but the Queen does it in increments. So we physicians, and much of this IS our fault, have never recognized that once we surrendered to an emotional plea to implement price controls on some of our services that the DEMAND to give them away would surely follow. The funny thing is that, as a profession, we used to give away plenty of our services (perhaps more than we do now by law) prior to the rise of the Queen and her drones. Why do you think there are many hospitals called ‘Charity’? All that has happened is that we no longer get to experience the good feelings of providing charity care AND we have taken a pay cut so that tens of thousands of billers, coders, quality control folks, and ‘medical administrators’ can hold endless and pointless meetings which, ultimately and practically, become rules by which we must work. Guess what has happened to medical school tuition in the same time?

There are those who would say the medicine is greatly improved by the meticulous charting requirements and codes etc… I think medicine was better when your good family doctor could see you in his office, spend time with you, take care of you in the hospital, tell you ‘no’ or ‘you are too fat’ without fear of firing, keep your chart on an index card, hire a nurse and a secretary, AND be financially secure by doing this.

Patients complain that their interactions with physicians are limited and unsatisfactory. They are right, but they are unsatisfying for us too. We mightily wish it were otherwise; that we didn’t HAVE to see so many patients so quickly. We are operating in a perpetual crisis mode, but there really is no crisis. A crisis is not running-out of your Lortab. The ambulance is not needed to bring your child in for fever. A crisis is war, famine, drought, tornado, hurricane, heart attack, flood, severed limb, etc… In these circumstances it would be expected (and sensible), for all providers to have to scramble and keep moving, but the crisis is one of perception, and to the extent there is a crisis it is because responsibility for one’s health care bills has, for a segment of our population (which includes those in our country illegally) been eliminated by fiat. It didn’t take long for this to filter through, and now a certain class of patient (including illegals) EXPECT the best care for free. Obamacare seeks to cement this entitlement and it is going to, let me put this gently, KILL a lot of people.

I am not going to be participating in this dance, but I have an easy choice... I have an out now, for real, and I’m taking it. **  I’m taking a pay cut, but taking a lifestyle raise. I will be trading money for sleep and family. I can’t wait. I believe that once my colleagues get to a financial position where this choice is open to them, that most will make the same one that I have, that ‘Cat has, and that an increasing number of Emergency Physicians have. If you don’t believe me simply google “Emergency Department Closures” or “physician shortage” and see what you get.

The ultimate result of the dunderheaded and Machiavellian EMTALA/Obamacare power play will be, unfortunately, to hurt the very folks it was alleged to help, for the rich will always get good care, but when there are too few doctors to go around, the ER will be where poor people and illegals go to die. Through the looking glass, down the rabbit hole.


* For those of you thinking that medical school should therefore be ‘free’, please stop reading and go throw yourselves from a building more than 45 feet above pavement.
** I am going to work a 9-5 job which involve a little medicine and a lot of handshaking. More when I start the job.

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