What's the minimum wage for lawyers? Half a million, according to Chief Justice Roberts.
Jan 03, 2007 Filed in: Medicine &
Science
It will
be very interesting to see what the media and the
public make of Chief Justice John Roberts assertion that $160,000 a
year is slaves’ wages and
that anybody with any sense could make much more
than that in academia or the corporate world. In
medicine, the massive rewards to be had by ceasing
to actually work with people and become a
corporate shill are not seen as a major cause of
brain drain. Any doctor can multiply by a factor
of 10 his or her salary by becoming an
“adviser” to the drug companies,
product manufacturers, congressional lobbyists, or
trial lawyers suing other doctors. But only a few
choose this route, because we do what we do not
for the money but because it’s who we are.
(See
Millionaire Doctors? for more
on that sore subject.) I would have thought the same
thing would be true for lawyers, that the chance to
have such a tremendous influence over the way this
country operates as to be a federal judge would
outweight any monetary concerns. So far, the public
has reacted with a big yawn, which works heavily in
Roberts’s favor: no complaints=no
controversy=easy amendment to massive spending
bill=big raise for him and his cohort. Prediction for
2007: Lawyers’ pay will rise, doctors’
pay will fall.
Doctor or Waiter?
Ask any doctor, especially those who have been practicing since before the insurance giants ruled the land, what the biggest loss to his practice has been, and the answer is likely to surprise you. The predicted answer is dramatic salary reduction, but actually that is far less troublesome than the loss of autonomy. First it was the HMOs that said, You must prescribe this not that, or No this patient is not a candidate for surgery. (If you ever wonder why doctors are sometimes seen as icebergs, imagine the emotional stamina that it takes to have spent 16 years, working 80-100 hours a week, to become an expert in subspecialty surgery, and after examining a patient, reviewingthe chart, discussing the case with colleagues, and consulting current literature, all in agreement that the patient needs surgery, only to be told by a 23-year-old MBA who just fell off the beer float that the patient is NOT a candidate for surgery.) Next, hospitals, which having much more bargaining power (dollars, lawyers, congressional lobbyists), get a very large chunk of cash for its services, turned around and said that as a cost-cutting measure doctors must ONLY use certain drugs, products, or devices. Never mind that other devices, drugs, products work much better. And to complete this Sisyphean triad, doctors are now being told how to practice medicine by their patients. Thanks to direct advertising and our short-sighted Entitlement Society, patients now come in and demand certain drugs, procedures, tests, or equipment: Don’t bother with the physical exam and I don’t care that you went to medical school thank you very much, this is my body and your job is to do as you’re told. “It’s just like the waitress job I had in college,” says one Denver pediatrician who asked not to be identified. “I used to go from table to table, ask them what they want, hint at a few suggestions but never contradict them act like I knew more than they did, and then make it happen just the way they ask. Now I go from room to room and do the same thing with my patients.”
Case Files
Fine, except that waitstaff are not asked to make life or death decisions about their patrons. Case in point: A patient comes to my clinic with abdominal pain. I perform an exam and order tests. The result is that the patient’s pain is caused by a stomach condition, but one that will heal with medicine not surgery. A prescription is given to the patient for the appropriate medicine (after checking with the patient’s insurance company, to make sure the medicine is covered, of course). Additionally, the patient is given a prescription for a narcotic pain medicine, and advised that the narcotic is just a temporary stopgap, that if the pain persists, it means the insurance-approved stomach medicine is not working and we will have to discuss other options. A followup appointment is made for three weeks later, with the standard admonition that if things get worse to call or come to the ER. Two weeks later this patient, having not communicated any problem since the office visit, shows up unannounced in clinic and demands of my secretary that she page me out of the OR to write a refill prescription for the narcotic pain medicine, because the patient still has some pain and is going away on vacation the next morning and has no time to be seen in clinic or the ER.
Nevermind what we talked about at the first visit about the possibility of needing other treatment. Never mind that the patient is quite capable or reading a calendar and knowing about her vacation ahead of time. Never mind that the patient is quite capable of counting pills in a bottle and noticing when they are running out before reaching the very last one. I should mention that this was not a drug-seeking patient, as in, someone who is addicted to pain medicine trying anything and everything to get more pain medicine. Those patients are not that hard to spot and referred to addiction specialists. This was rather the more common entitled patient who figured she knew better than her doctor and just wanted me to do as I was told. Let me also mention that I bend over backwards for my patients, seeing them between cases in the OR, early mornings, in the middle of the night in the ER, wherever, and my pager is always on. I get pages at three in the morning from patients wanting to know if they can reschedule an appointment that is still three weeks away. But I draw the line at them sacrificing their own health through ignorance.
No more Mr. Nice Guy
The end result for this patient was a stern lecture, a change in medicine, and close followup by phone while she is away on vacation. To some degree I am lucky, in that I can get away with this. As a surgeon, I already have fewer patients than an internist or pediatrician, since I have to spend a lot of time actually doing the operations, and with a smaller pool of patients, the number of headache-causing patients is smaller. Plus, as a subspecialist in a tertiary-care center, I’m the last stop. If they don’t like what I have to say, there aren’t a whole lot of other options. Which is not the case for most physicians. For most docs, patients see things they like on television or in a glossy mag, they show up for their 15-minute appointment and demand it. So now the doc has a draconian choice: Give them what they want and speed them on their way, or spend 30 to 60 minutes arguing with and educating the patient. The textbook answer is that the ethical thing to do is educate the patient. Except that there are forty more patients to see, and every hour spent on a “problem” patient makes everyone else that much more late, and adds another hour to what is already going to be a 60 to 70 hour workweek. And even if you opt for spending that extra hour with each and everyone of these “problem” patients (and there are many of them, believe me), they will then just go to another doctor, and another and another, until they get what they want, adding additional burden to an already overwhelmed medical system. And they will call their insurance company and complain about that “insensitive” doctor and you will get a snarling phone call from the MBA frat boy, telling you that if you’re going to continue to irritate “his” patients, he will remove you from “his” group.
An impossible task
I watched this scenario play itself out many times as a medical student, and fought this uphill battle many times myself as a resident before conceding the inevitable. (Sissyphus had the advantage that when he rolled the rock up the hill, at least he was able to get out of the way when it ran back down the hill. Every boulder I tried to strongarm out of the valley just ended up rolling over me and crushing me like a bug.) This had a lot to do with my chosen career, in that being the “last stop” I had a little (a very little) more freedom to fight back against this grim trend away from medical practice and into “service excellence.” Emphasis on service.
What can be done to stop the assualt on health care? Patients can try to see their physicians as equal partners. If the aura of “doctor knows best” is long-gone, at least trust that your physician, with decades of very arduous training, might know something worth listening to. Would you try to tell your plumber how to fix your pipes? You might try, knowing that the worst result will be a wet floor. But are you likely to ignore your electrician’s advice and wire things any which way? Not likely, because the results could be deadly. Same thing with your health.
As for what physicians can do to stop the erosion of good healthcare by the tsunami of know-nothing CEOs, we will continue to fight Big Insurance and Big Pharmacy and Big Government, so that we can always get you the best medicine, product, treatment or device. And we’ll do it with a smile, and for a lot less money than your average lawyer.
Return to Home Page
Doctor or Waiter?
Ask any doctor, especially those who have been practicing since before the insurance giants ruled the land, what the biggest loss to his practice has been, and the answer is likely to surprise you. The predicted answer is dramatic salary reduction, but actually that is far less troublesome than the loss of autonomy. First it was the HMOs that said, You must prescribe this not that, or No this patient is not a candidate for surgery. (If you ever wonder why doctors are sometimes seen as icebergs, imagine the emotional stamina that it takes to have spent 16 years, working 80-100 hours a week, to become an expert in subspecialty surgery, and after examining a patient, reviewingthe chart, discussing the case with colleagues, and consulting current literature, all in agreement that the patient needs surgery, only to be told by a 23-year-old MBA who just fell off the beer float that the patient is NOT a candidate for surgery.) Next, hospitals, which having much more bargaining power (dollars, lawyers, congressional lobbyists), get a very large chunk of cash for its services, turned around and said that as a cost-cutting measure doctors must ONLY use certain drugs, products, or devices. Never mind that other devices, drugs, products work much better. And to complete this Sisyphean triad, doctors are now being told how to practice medicine by their patients. Thanks to direct advertising and our short-sighted Entitlement Society, patients now come in and demand certain drugs, procedures, tests, or equipment: Don’t bother with the physical exam and I don’t care that you went to medical school thank you very much, this is my body and your job is to do as you’re told. “It’s just like the waitress job I had in college,” says one Denver pediatrician who asked not to be identified. “I used to go from table to table, ask them what they want, hint at a few suggestions but never contradict them act like I knew more than they did, and then make it happen just the way they ask. Now I go from room to room and do the same thing with my patients.”
Case Files
Fine, except that waitstaff are not asked to make life or death decisions about their patrons. Case in point: A patient comes to my clinic with abdominal pain. I perform an exam and order tests. The result is that the patient’s pain is caused by a stomach condition, but one that will heal with medicine not surgery. A prescription is given to the patient for the appropriate medicine (after checking with the patient’s insurance company, to make sure the medicine is covered, of course). Additionally, the patient is given a prescription for a narcotic pain medicine, and advised that the narcotic is just a temporary stopgap, that if the pain persists, it means the insurance-approved stomach medicine is not working and we will have to discuss other options. A followup appointment is made for three weeks later, with the standard admonition that if things get worse to call or come to the ER. Two weeks later this patient, having not communicated any problem since the office visit, shows up unannounced in clinic and demands of my secretary that she page me out of the OR to write a refill prescription for the narcotic pain medicine, because the patient still has some pain and is going away on vacation the next morning and has no time to be seen in clinic or the ER.
Nevermind what we talked about at the first visit about the possibility of needing other treatment. Never mind that the patient is quite capable or reading a calendar and knowing about her vacation ahead of time. Never mind that the patient is quite capable of counting pills in a bottle and noticing when they are running out before reaching the very last one. I should mention that this was not a drug-seeking patient, as in, someone who is addicted to pain medicine trying anything and everything to get more pain medicine. Those patients are not that hard to spot and referred to addiction specialists. This was rather the more common entitled patient who figured she knew better than her doctor and just wanted me to do as I was told. Let me also mention that I bend over backwards for my patients, seeing them between cases in the OR, early mornings, in the middle of the night in the ER, wherever, and my pager is always on. I get pages at three in the morning from patients wanting to know if they can reschedule an appointment that is still three weeks away. But I draw the line at them sacrificing their own health through ignorance.
No more Mr. Nice Guy
The end result for this patient was a stern lecture, a change in medicine, and close followup by phone while she is away on vacation. To some degree I am lucky, in that I can get away with this. As a surgeon, I already have fewer patients than an internist or pediatrician, since I have to spend a lot of time actually doing the operations, and with a smaller pool of patients, the number of headache-causing patients is smaller. Plus, as a subspecialist in a tertiary-care center, I’m the last stop. If they don’t like what I have to say, there aren’t a whole lot of other options. Which is not the case for most physicians. For most docs, patients see things they like on television or in a glossy mag, they show up for their 15-minute appointment and demand it. So now the doc has a draconian choice: Give them what they want and speed them on their way, or spend 30 to 60 minutes arguing with and educating the patient. The textbook answer is that the ethical thing to do is educate the patient. Except that there are forty more patients to see, and every hour spent on a “problem” patient makes everyone else that much more late, and adds another hour to what is already going to be a 60 to 70 hour workweek. And even if you opt for spending that extra hour with each and everyone of these “problem” patients (and there are many of them, believe me), they will then just go to another doctor, and another and another, until they get what they want, adding additional burden to an already overwhelmed medical system. And they will call their insurance company and complain about that “insensitive” doctor and you will get a snarling phone call from the MBA frat boy, telling you that if you’re going to continue to irritate “his” patients, he will remove you from “his” group.
An impossible task
I watched this scenario play itself out many times as a medical student, and fought this uphill battle many times myself as a resident before conceding the inevitable. (Sissyphus had the advantage that when he rolled the rock up the hill, at least he was able to get out of the way when it ran back down the hill. Every boulder I tried to strongarm out of the valley just ended up rolling over me and crushing me like a bug.) This had a lot to do with my chosen career, in that being the “last stop” I had a little (a very little) more freedom to fight back against this grim trend away from medical practice and into “service excellence.” Emphasis on service.
What can be done to stop the assualt on health care? Patients can try to see their physicians as equal partners. If the aura of “doctor knows best” is long-gone, at least trust that your physician, with decades of very arduous training, might know something worth listening to. Would you try to tell your plumber how to fix your pipes? You might try, knowing that the worst result will be a wet floor. But are you likely to ignore your electrician’s advice and wire things any which way? Not likely, because the results could be deadly. Same thing with your health.
As for what physicians can do to stop the erosion of good healthcare by the tsunami of know-nothing CEOs, we will continue to fight Big Insurance and Big Pharmacy and Big Government, so that we can always get you the best medicine, product, treatment or device. And we’ll do it with a smile, and for a lot less money than your average lawyer.
Return to Home Page
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