Observations on Practicing Medicine in the United States
Most individuals who go into medicine do it because they want to earn their living in a field where you can help people and because they find the subject matter interesting. Once one begins their training, they find reality, especially in the United States, is often very different from the ideals which caused them to pursue a career in medicine. Here are some examples:
- A health practitioners primary responsibility is doing the paperwork. Taking care of the patient is secondary. One spends far more time on the paperwork than actually talking to and examining the patient. Now, with the electronic medical record mandate, this has gotten even worse. You can take perfect care of the patient, but if you do not complete the mountain of paperwork associated with that care, there will be trouble. There will be less trouble if the patient does not do well or is dissatisfied with their care, but all the paperwork is good.
- Most of the piles of paperwork, revolve around money. The patient completes lots of paperwork, because they want the insurance company to pay for the visit and services. The doctor has to write enough in the chart to justify the fee he/she is charging for the care they just rendered. The insurance company does not want to pay for the services, so they do audits and require unending forms and conversations to justify the treatments prescribed.
- Medicine is the only field where you are expected, in fact required, to offend your customer. Every other business does everything in their power to give the customer whatever will make them happy, so that they will buy more of their services or products. While healthcare entities attempt to give good customer service, the regulators and insurance companies demand that physicians assume all of the patients are liars, who are trying to get something to which they are not entitled. This is the reason for the mountains of paperwork, whenever a service is ordered. No one goes into medicine, so they can be a police officer. However, this is the position in which the American system has put physicians. It starts with school and work excuses and includes the affidavits connected to almost any service today. I am supposed to discern who is or has been legitimately sick. In the first place, that is an impossible task. Then, if I somehow conclude they were not really sick, I am expected to call my customer a liar, but hope they will keep buying my service. Then, just to add insult to injury, when the patient complains, the doctor following the insurance company rules, is portrayed as the one in the wrong.
- Only field where you are expected and required, to provide a service, even when you are not going to be paid for that service. If someone wheels their shopping cart out of a grocery store without paying for the items, they are arrested for shoplifting. On the other hand, many people expect doctors to provide them services and have no intention of paying for that service. The insurance companies and government have even gotten on this bandwagon. They constantly change the rules, expecting the doctors to do ever more work for the same or less money. There is also a list of diagnosis which doctors and hospitals are required to treat, but which Medicare and other insurances categorically will not pay for and the patient cannot be billed. Patients who present to the emergency department for even non-emergent complaints have to be cared for, even though a large percentage will never pay for that service.
- For a physician, perfection is not good enough. Everyone knows human perfection is not possible, but in medicine, not even perfection is good enough. We are expected to get every diagnosis correct. We have to choose the correct treatment every time. What becomes especially difficult is that we are also expected to correctly predict the future. We are supposed to know, in advance, who will have an adverse reaction to a medication. It is expected that we can accurately predict who will benefit from a given treatment or procedure. How long will someone be sick? Who is going to have a relapse? I have often said that when I graduated from medical school I missed the table where they were giving out the crystal balls and that has tremendously hindered my medical career. As a patient, I can certainly understand that one wants their doctor to always be correct and doctors certainly strive for perfection as well as to accurately predict the future. Nevertheless, it is extremely difficult for doctors when they are not only chastised for being incorrect, but run the risk of being sued when things do not turn out as they said they would.
- The process is more important than the result. There are now all kinds of rules and regulations controlling how medicine is practiced. This first creates the practical problem, that it is humanly impossible to keep track of all the rules. Secondly, the goal is no longer to find the solution that best meets the needs of the individual patient. The goal is to find the solution that follows all the rules established by the central planners. A doctor gets in bigger trouble for breaking the rules, than he/she does for providing poor quality medical care.
- Up until recent times, physicians were taught problem solving, innovative thinking and individualized solutions. This approach is rapidly being replaced by protocols and population based treatments and central decision making. It is argued that this approach provides the best outcomes for the most people. The problem is that human beings are not all the same. They are complex entities with very individualized needs and require individualized solutions. Today’s approach to medicine is making individualized treatment impossible.
- The patient is not the doctor’s customer. In the traditional sense a patient is a doctor’s customer. In reality, the patient is not the doctor’s customer. The real customer is the government agency or insurance company who is paying the bill and the government entities creating the regulations. The patients are just the widgets which are manipulated between the doctor and the payer and the government. Everyone wants “free” health care, but the moment someone else is paying the bill, the patient is no longer in control. Patients routinely get very angry at doctors because they are unable to get that which they think they are entitled, but the doctors are not the ones making the rules. They are, unfortunately, the messenger.
- The patient has no personal responsibility for outcomes. I certainly believe physicians have a responsibility to take care of patients to the best of their ability and to keep up with medical knowledge as it advances. It is just as important for patient’s to take responsibility for their own health as well. The majority of bad outcomes are not a result of poor quality doctors, but rather because patients have unhealthy life styles, do not take the prescribed medicine, fail to follow-up as recommended. The current emphasis on paying for quality, totally ignores the fact that patients have every bit as much responsibility for their health as do the doctors.
- Computers are not the fix. I love using computers and have used electronic medical records since 1998 and computers can be a very useful tool. Unfortunately, the government is now controlling how medical software operates and the result is inefficient, time consuming software. The focus of a doctor visit is no longer the patient’s concern, but rather data entry and dealing with the concerns the central planners think are important.
There are also many positive aspects of practicing medicine in the United Medicine, but unfortunately with the ever increasing dominance and control of government and insurance companies, the negatives are rapidly overshadowing the positives. Anyone want to add to this list, both good and bad?