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Some of My Best Friends Are Doctors

Steven Pearlstein actually wrote that in the Washington Post on Wednesday, right after (another) long rant against physicians.  At the end, he offers doctors an olive branch.  Or maybe its an offer he thinks doctors can’t refuse:

The choice for doctors now is quite clear: They can agree to give up a modest amount of autonomy and income, embrace more collaboration in the way they practice medicine and take their rightful place at the center of a reform effort that will allow them to focus more on patient care.  Or they can continue to blame everyone else and remain — stubbornly — a part of the problem.

After reading Pearlstein’s columns, I’m still sure not why he has such a problem with doctors.  I am beginning to think it’s because he just misunderstands them.

Pearlstein is convinced that doctors go into medicine for the same reasons investment bankers go to Wall Street: to make money.

Docs seem to take it as a given that physicians in the United States should earn twice as much as doctors in the rest of the world — and five times more than their patients, on average.  Mention these facts and you are guaranteed to get a lecture about the crushing debt burden that young docs face upon completion of their medical training.  Offer to trade free medical education for a 20 percent reduction in physician fees, and you won’t find many takers.

Pearlstein has no source for these claims, but let’s assume they’re true, and do the math.  The government says that there are 633,000 doctors in the United States, and they earned median salaries between $135,000 and $320,000 a year.  If we take a number in the middle — say $200,000 — that means that American doctors earn about $125 billion a year.  A big number, but total health care expenses in the United States are over $2 trillion, which means doctors represent about 5% of the total.  Can physician salaries really be driving our health care problems?

It seems unlikely.  But Pearlstein is desperate for it to be true, so he keeps trying to discount all of the other possible causes of our problems as examples of conspiracies or arrogance or sloppiness:

For example, medical malpractice litigation is a problem…

But one of the reasons malpractice suits are still necessary is because doctors have transformed local professional review boards, which are supposed to protect patients, into nothing more than mutual protection societies

The “infelixible bureaucratic processes” that insurers impose are a problem….

But given that there is overwhelming evidence that doctors tend to order up tests, perform surgeries and prescribe treatments whose costs far outweigh the benefits, you can hardly blame the insurers.

We think it is good to have  “clever and creative” doctors…..

but . . . we could all have better health at a lower cost if docs were less inclined toward the medical equivalent of the diving catch and simply were more disciplined about kneeling down for routine ground balls.

Doctors should be applauded for embracing evidence-based medicine…

however, practicing  physicians still think that nothing should interfere with the sacred right of doctors and patients to make all medical decisions, even when they are wrong.

Pearlstein’s views on how doctors think are fundamentally flawed.  He thinks of them like stock brokers, pushing questionable stock to make commissions for themselves.  He’s thought of all the different ways doctors are abusing the system to their own advantage, but he doesn’t seem to have thought that maybe, possibly, he’s wrong.

So, yes, some doctors abuse the privilege of being asked to help their patients.  But the overwhelming majority don’t.  They want to spend as much time as they can with their patients, collecting information, thinking about their problem, and offering good, sound advice.  They are bothered by the involvement of the insurance company or the government or the plaintiff’s lawyer not because they believe they have a “sacred right” to total independence.  Or because they think the way to fix health care is to give them “free rein to treat their patients . . . run the hospitals and set their own fees.”

No, it is because these things actually interfere with the doctor’s ability to think, process and decide with their patient on the right things to do.

Pearlstein and other would-be reformers of our health care system need to reconsider their assumptions on what motivates doctors.  Maybe it’s something Pearlstein should ask some of his friends about.

*This blog post was originally published at See First Blog*

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2 Responses to “Some of My Best Friends Are Doctors”

  1. bat says:

    The major culprits for the unaffordable costs of medical care are undoubtedly doctors fees.
    If we truly want to make health care affordable for everyone, the govt has to put a cap on doctors fees. Can somebody explain to me why doctors think that they are entitled to absurd amount of cash to examine a patient?

  2. bat says:

    The major culprits for the unaffordable costs of medical care are undoubtedly doctors fees.
    If we truly want to make health care affordable for everyone, the govt has to put a cap on doctors fees. Can somebody explain to me why doctors think that they are entitled to absurd amount of cash to examine a patient?

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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