No, not April Fool’s Day.
March 30 — National Doctor’s Day, a day designated by the senior President Bush, in 1991, to honor the contributions of physicians to the general good of American society. This day has been celebrated at different times of the year around the world since as long ago as 1955.
Given what we *think* we know about doctors (they’re all rich and arrogant), we might ask why they deserve their own special day, especially when many of us don’t get a day set aside to celebrate what we do.
Well, imagine this…
You’re on call for the emergency department and have been hanging fire all day, expecting the phone to ring or the pager to go off. (You just can’t relax when you know disaster can strike at any moment.) And eventually it does — as usual just as you’re sitting down to dinner with the family you haven’t seen for the past 48 hours. Back you get into the car – at least this trip is still during daylight, not at 2 a.m. as sometimes happens – to find waiting for you a patient whose skull was used for batting practice by his drug dealer. It’s now up to you to pick the bone fragments out of the patient’s brain and repair what damage you can.
Or imagine this…
A patient in your pediatric practice needs a particular antibiotic for an infection. Your years of experience tell you that this antibiotic is the one that will do the trick, but the patient’s insurance company will tell you to prescribe a different antibiotic first before they’ll cover the cost of the one you know will work. Your choice is to follow the insurance company’s directive, wasting both the patient’s time and money for a drug that won’t work, or prescribe the effective drug and help the patient fight the insurance company to cover the cost. (Or a third option – tell the insurance company that you already tried the first drug, to no avail, so they’ll authorize the effective one.)
Here is what it takes these days to function as a physician in the United States:
You’ll need as many as 16 years of training beyond high school (4 years of undergraduate work, 4 years of medical school, 1 or 2 years of fellowship or internship, and up to 6 years in a residency program). Most people manage to begin a career by the age of 25 or so. You will be about 10 years behind the curve of earning power by the time you finish training, and will have an average school debt ranging from $75,000 to $250,000.
Once you’ve finished training and passed all parts of the rigorous exams for board certification, you’ll spend up to 60 hours a week working (or more if you include taking call on nights, weekends, and holidays). And some of that time might be spent on the road, as a “circuit rider” traveling to several outlying clinics, or driving between your office and a hospital.
Increasingly, more and more of your time will be spent learning and keeping up-to-date not just with new information in your area of practice (through your own interest and mandatory continuing medical education), but also with the codes used by billing departments when figuring invoices for patients you treat. This year, it’s the update of the 68,000 codes incorporated into the ICD-10, the code system used worldwide to designate a patient’s diagnosis. And every year, it’s the updated CPT codes used to describe procedures for billing.
And now, of course, there’s the mandatory move toward electronic medical records. If you don’t get on board with this trend by January of 2015, you won’t get fully reimbursed for your services. But the various systems used by hospitals and clinics aren’t always compatible, which means that you may have to learn more than one system if you work in more than one place. And using them means you’ll likely spend more time looking at computer screens and less time at your patients’ faces.
Beyond all these requirements, you also need to understand the rules of the Health Information Portability and Accountability Act (HIPAA) and the continuing changes and updates to the law. Although the HIPAA legislation was originally intended to allow patients to carry their insurance with them if they move, its implementation has been more about privacy, and that legislation has increased the paperwork your office staff has to manage to comply with the government.
You can bill for the hours you spend treating patients, but you know that the amount you bill will never be fully reimbursed. Private insurance companies have formulas to calculate how much of any given charge they will allow (usual and customary payments). Medicare has its own way of calculating what it will reimburse doctors, using something called RVUs adjusted for practice and geographic conditions and then applying a “conversion factor” of (currently) about $34. This calculation formula shows why so many of our healthcare dollars go toward increasing amounts of time spent on paperwork and other bureaucracy. Medicaid is also notorious for its low reimbursement rates, paying about 61% of what Medicare pays a physician. (And Medicare never pays the full amount.)
So a question you’ll think about often is — how long are you willing to work at a job that pays you less than it actually costs you to do the work? With these numbers, you might decide to join the ranks of other doctors who have stopped taking patients covered by Medicare and Medicaid.
Given the litigious society America has become, you will eventually realize that every patient who comes for care represents a potential lawsuit. And so, your profession requires that you have malpractice insurance, which can cost you anywhere from $20,000 to $300,000 per year, depending on your specialty and the city or state you live in (Ben Carson, America the Beautiful, page 84). A recent report by the Rand Organization notes that “By age 65, 75% of physicians in low-risk, and 99% in high-risk, categories will have at least one medical professional liability claim.”
In other words, if you’re going to practice medicine, you should expect to get sued. And even if you win the case, there is still the cost of defending yourself and preserving your reputation.
In your daily rounds, you’ll also have to be aware of boundaries and turf wars of various sorts. These occur between different specialties (general surgeons and breast surgeons, for example, for patients with breast cancer) and as restrictions set up by clinics or hospitals that control which doctors are allowed to see which patients and at what site. For example, more and more hospitals across the country have employed hospitalists – doctors who specialize in treating patients only while they’re in the hospital. So, although you may be the one to send patients to the hospital, you might not be the one to continue seeing them once they’re there.
Keeping up with changes in insurance coverage and regulations, and devising new ways to work with (or around) those regulations, will require a lot of paperwork on your part. And all of these gyrations will only increase with the Affordable Care Act now in place. As the influence of business and insurance companies grows, you will need to increase your productivity, seeing more and more patients, which means spending less and less time — maybe only 10 minutes — with each one, regardless of their need. And if you’re a surgeon who works for a hospital, you will be discouraged from seeing the patients you operate on while they recuperate in the hospital. The hospital administrators want to keep you in the operating room as much as possible, because that’s what generates dollars for them.
Amid all this activity, you’ll also be subjected to unfair blame for errors and mistakes that you are not responsible for – whether it’s an appointment snafu by one of your front desk clerks, or a horrible outcome for a patient you only assisted with. There are many players in the disturbing number of medical errors that occur each year in the US – physicians, yes, but also nurses, physician assistants, technicians, pharmacists, and hospital administrators, too. But people like to see bad news about a doctor in headlines, even if it’s for something totally unrelated to medicine.
And somehow, in all of this, you still will want to serve your patients and do what’s right for them. Every day, you will try your best to be like Dr. C.
OK, OK, I hear the complaints already. Someone reading my previous post on this site commented that doctors aren’t always the good guys in the white coats, and that plenty of them are in it for the money or other material rewards.
Are there greedy or incompetent doctors out there? Absolutely. I’ve seen a few, and maybe you have too. Just as there are corrupt or incompetent accountants, executives, auto mechanics, and even hair dressers, there are some doctors who are out to make money or see their name in lights. No single profession is free of greed or ego. And yes, people in other professions face equal, maybe greater, challenges (imagine the police officer summoned to a domestic violence dispute) and lots of people carry pagers now in our 24/7 culture.
But we hold doctors to a higher standard of behavior and competence, and we do so because they hold our lives in their hands, and we expect them to save us, make us feel safe. A student can likely weather a bad teacher in second grade or a college statistics course. But one serious error by a doctor can kill you.
And yet . . . and yet. I believe the vast majority of people who go to medical school to become physicians have their heads and hearts in the right place, and most of them do a pretty good job, given their shrinking influence on the current state of health care in this country. Certainly, they’ve earned the right to a special day.
Next topic to come: In Defense of Patients