The pleasures of medicine; or not.

UPDATE: Nearly half of all physicians plan to quit if Obamacare passes. Many will phase out but it will be a disaster. I’m sure Obama has plans to fix it.

I have been a physician for almost 44 years. I graduated from medical school in 1966 and finished my residency training as a surgeon in 1972. Since I began medical school in 1962 (For the second time but that’s another story), I spent ten years learning to do what I did until I retired from surgery in 1994 after back surgery. I have gone on doing medical things since then but I had to give up surgery. The 27 years I spent as a surgeon (including my training) were the best years of my life. Had I not injured my back in college, I would still be practicing, even at 72. The early years of my career as a surgeon were the golden age of medicine in this country. We still could not cure some diseases and we especially were limited in our ability to deal with infection in some cases but the life of a physician or a surgeon was the best it would ever be.

About 1987, things really began to change for the worse. Some of it was the fault of the profession, some the fault of politics and some the fault of human nature. In 1978, the first political reaction to the rapid growth in the cost of medicine appeared. It was called PSRO, or Professional Standards Review Organization. Of course, it had little relationship to professional standards and everything to do with cost. We all had to participate like some Red Guards self examination in Mao’s China. We learned how to analyze care for what were purportedly quality issues but we all immediately recognized as cost. All the doctors of the hospital staff had to attend these classes and learn how to do this. Then we had to “volunteer” for committees to review cases to see if they met the standards. The standards always seemed to focus on cost issues, such as length of stay. Length of stay is an American obsession. A few years after this first experience with self examination, we began to have demands from Medicare and insurance companies for AM admissions before surgery.

AM admission is one of the examples of the lunatic aspect of government intervention in medicine. People who were to have major operations were expected to get up at 4 AM the day of surgery and come to the hospital at 5:00 for a 7:30 surgery. They were given instructions about not eating or drinking after midnight or whatever. Why not just have them come in at 6 PM the night before and be prepared then. ? They would sleep better with a sleeping pill, we would know for sure that they hadn’t had a late snack in spite of instructions and the hospital staff would know they were there, ready for surgery.

When this began, I asked what I thought was a logical question. Why are we doing this ? Cost, I was told. Why charge for the admission day before surgery? We could just make that a free day since the patients came in after 3 PM anyway. Nobody ever answered. The hospital had to add staff for the early morning shift. Sometimes a patient would not show up or arrive too late for their 7:30 case. Then we would scramble around to see if the next patient could come in early instead of the 10 o’clock they had been told. The schedule would be shifted around and the charge nurse would call the next surgeon to see if he could come in early, only to find he was doing surgery in another hospital at that time. I was sure, and still am, that the costs were no different and the aggravation and even the danger was increased for no good reason. It’s a bit like the Army. “Why are we doing this sir?” “Because I said so !” “Thank you sir.” A stint in the Army is helpful in understanding how government works.

That was the beginning. Next came calling the insurance company for permission to do surgery. In 1987 came the new way of being paid for care. It was called Resource Based Relative Value Scale, or RBRVS. A Harvard professor came up with a new way to pay for care. The methodology was supposed to account for the value of inputs in determining what Medicare (and quickly all insurance companies followed suit) would pay. It is related to the “Labor Theory of Value.” If you follow the link, you will see who thought this up. The original Relative Value System was developed by the California Medical Association in the 1930s. It was constructed by doctors to rate services, relative to each other, on what the price should be. I have previously covered some of this in a post on “How we got here.” Now, we have arrived at a system that is so onerous and counterintuitive that doctors have lost a lot of the pleasure of private practice. As usual, Thomas Sowell has something to say about it that concisely summarizes the foolishness of the present situation. If that is not enough, there are numerous examples of what government medicine eventually looks like. If you remove the pleasure, pretty soon everyone turns into the DMV or the Post Office employee. I mean no insult to those people but psychology has rules about behavior. Read the Thomas Sowell article. He always has something worth while to say. This is even better than most.

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17 Responses to “The pleasures of medicine; or not.”

  1. I blame the docs, doc.

    You folks have it within your power to talk sense to the politicians and if necessary back up the talk with the threat of… taking a walk.

    It wouldn’t take all of you. If even half of you had the balls to put the fear of God into the politicians then that would be that.

    As to a unified platform… surely the vast majority of doctors understand the basic economic flaw of the employer based (tax subsidized) “pre-pay” aspect of the modern American health care system.

    As you know, I think quite highly of my own wisdom, but compared to your average doctor I’m a dummy. So… are you seriously going to tell me that a dummy like me “gets it” but that your medical peers by and large don’t?

    Doc. You and I have done this dance before. I’ve gotta tell you, over the past few days I’ve really been thinking that large scale political violence is going to break out sooner rather than later.

    The Left has basically come right out and said – from in front of the curtain – that they’re going to turn this nation into a “Europeanized” welfare state.

    I greatly fear that the American People – or at least a large enough segment to create real havoc – susceptible to calls for armed opposition to federal mandates.


  2. Bill, a lot of older doctors, especially in primary care, are just dropping out of the system, including Medicare and even private insurance. They have avoided Medicaid for many years, which is why Obamacare will do nothing to reduce ER use. The ER is the resource for Medicaid patients who cannot find a private doctor to see them.

    The doctors who support Obama and show up in white coats, are young just out of training, many of whom are left wing anyway. Others are long term salaried types who know nothing about the economics of private practice. In fact, fewer and fewer doctors know anything about business because they work for large groups which have administrators to run the business.

    Those of us who oppose it are dinosaurs.

  3. cassandra says:

    How awful. My doctor of 20 years or so dropped in and out of private practice for years. Her last private stint was in a big house she had renovated down next to a hospital. She practiced a couple years there with about 1000 patients, and finally gave up and became a hospitalist across the street. I know for a fact insurance hassles were getting to her.

    I felt like a motherless child and still do in ways.

  4. “Bill, a lot of older doctors, especially in primary care, are just dropping out of the system, including Medicare and even private insurance.”

    Yep. I know it doc.

    But as often happens, all we’re doing is trading info each of us is already aware of.

    You’re a good man, doc. Unfortunately… you’re the exception.

    At this point all we can do is hope that a meaningful fraction of those who have gained combat experience in Iraq and/or Iran over the past near decade will save us from ourselves.

    I doubt it… but at least it’s a hope.

    I’m convinced that if a few “names” had the courage to call for confrontation that Americans would flock to Washington and their state capitals in the hundreds of thousands to make their voices heard and to present a credible physical threat.

    I fear that’s what it’s going to take if we’re to have any hope of saving this once great nation from the clutches of the incompetents “running” the system into the ground.


  5. Non-gullible Mike says:

    Oops! The “New England Journal of Medicine survey” wasn’t published by the NEJM and is a self-serving promotional tool of some physician recruitment service:

    You lose again.

  6. The NEJM used the physician survey of the recruitment company. Who would know more about physician’s plans than a recruitment company ?

    Your ISP gives you away. I’m just wondering if you are Craig Mises. I can’t think of anyone else with the motive to do what you are doing. For those who might wonder, he is younger doctor who was briefly a partner and who declared bankruptcy owing me $120,000.

  7. Non-gullible Mike says:

    The NEJM didn’t publish it, you idiot. Learn to read.

  8. Craig, tell me what the heading of the linked page says. It says it is the NEJM Career Center.

    I am getting tired of your anonymous spam.

  9. Ann says:

    UPDATED EXCLUSIVE: New England Journal of Medicine says it didn’t publish or produce health care “survey”
    March 17, 2010 12:50 pm ET by Julie Millican

    Right-wing media have seized on a dubious, three-month old email “survey” that purports to show that physicians are concerned about health care reform and that 46 percent of the primary care doctors surveyed “indicated that they would leave medicine – or try to leave medicine – as a result of health reform.” Many media figures have falsely attributed this survey to the New England Journal of Medicine. For example, on Fox & Friends, co-host Brian Kilmeade said: “The New England Journal of Medicine has published a report and did a survey, and they said the impact of reform on primary care physicians, 46 percent, they say, feel reform will force them out or make them want to leave medicine.”

    This is false.

    Media Matters for America contacted the New England Journal of Medicine, which confirmed it neither conducted nor published the “survey.”

    NEJM spokesperson Jennifer Zeis told Media Matters that the study had “nothing to do with the New England Journal of Medicine’s original research.” She also made clear that the study “was not published by the New England Journal of Medicine,” and said that “we are taking steps to clarify the source of the survey.”

    The “report” that right-wing media are citing actually appeared in Recruiting Physicians Today, which is an employment newsletter produced by “the publishers of the New England Journal of Medicine.” According to Zeis, that report actually “was written by the Medicus Firm,” the medical recruitment firm that conducted the “survey.”

    Here’s how The Medicus Firm describes the “survey” methodology:

    “The survey sample was randomly selected from a physician database of thousands. The database has been built over the past eight years by The Medicus Firm (formerly Medicus Partners and The MD Firm) from a variety of sources including, but not limited to, public directories, purchased lists, practice inquiries, training programs, and direct mail responses. The survey was conducted via emails sent directly to physicians.”
    The Medicus Firm’s clients include hospitals and physician groups.

    More to come…


    Following inquiries from Media Matters, the “NEJM CareerCenter” website has now posted the following statement, making clear that Recruiting Physicians Today is a “free advertiser newsletter” whose content is “produced by physician recruiting firms and other independent groups involved in physician employment” and that Medicus was responsible for conducting and publishing the “survey” in question. (NEJM tells Media Matters that The Medicus Firm “did not pay” to run the report.) From the statement posted on the NEJM CareerCenter website:

    Recruiting Physicians Today is a free advertiser newsletter published by the Worldwide Advertising Sales and Marketing Department in the publishing division of the Massachusetts Medical Society. Each issue of the newsletter features research and content produced by physician recruiting firms and other independent groups involved in physician employment.

    On December 17, 2009 The Medicus Firm, a national physician search firm based in Dallas and Atlanta, published the results of a survey they conducted with 1,000 physicians regarding their attitudes toward health reform. To read their survey results at The Medicus Firm website, click here.

    The opinions expressed in the article linked to above represent those of The Medicus Firm only. That article does not represent the opinions of the New England Journal of Medicine or the Massachusetts Medical Society.
    Indeed, The Medicus Firm’s write-up of their “survey” touted the supposed importance of physician recruitment firms “[a]fter health reform is passed and implemented”:

    “What does this mean for physician recruiting? It’s difficult to predict with absolute certainty, but one consequence is inevitable. After health reform is passed and implemented, physicians will be more in demand than ever before. Shortages could be exacerbated further beyond the predictions of industry analysts. Therefore, the strongest physician recruiters and firms will be in demand. Additionally, hospitals and practices may be forced to rely on unprecedented recruitment methods to attract and retain physicians. “Health reform, even if it’s passed in a most diluted form, could be a game-changer for physician recruitment,” said Bob Collins, managing partner of The Medicus Firm in Texas. “As competitive as the market is now, we may not even be able to comprehend how challenging it will become after health reform takes effect.”

    So, in sum, the right-wing media has seized upon what appears to be essentially a promotional document from a physician recruitment firm in order to argue that health care reform will cause physician recruitment and retention problems in the future.

  10. Ann, you are trying too hard. You might try reading some of my previous posts on the phenomenon of doctors dropping Medicare, and even all insurance, and practicing for cash. Media Matters is a well-know Soros funded leftist site that has misstated other reports.

    Nice try, though.

    At least you aren’t spamming me like Craig who declared bankruptcy owing me $120,000. His ISP is in Texas. What a surprise.

  11. Ann says:

    Is the NEJM Career Center also funded by Soros? It states: The opinions expressed in the article linked to above represent those of The Medicus Firm only. That article does not represent the opinions of the New England Journal of Medicine or the Massachusetts Medical Society.

    Wouldn’t it be easier to just admit you were wrong?

  12. And so the physician recruitment firm doesn’t know as much as you do about physician’s plans if Obamacare passes ?

    As I said, you are trying too hard. My own information is that doctors will try to retire or will reduce their participation in government programs. Do you know how many physicians accept Medicaid patients ?

    Do you know how many physicians refuse new Medicare patients ?

    Enlighten us.

    Or not, as the case may be.

  13. Ann says:

    I think — and you could, too, if you’d try — that a firm that has a direct financial interest in creating the impression of a recruitment “crisis” is not a credible source for this information. Think about it.

    The ability to quickly scan information and correctly gauge the credibility of its source is a helpful trait among competent adults. It sounds like you’re no longer practicing. That may be as well. Some older docs have difficulty keeping up with information and understanding how to use online resources. You get credit for trying, but try to use a little more care and responsibility in future.

    Now here’s a survey of physicians that really was conducted by the NEJM:

    It shows 63 percent supporting private/public options, with only 27 percent supporting private options only. In surgery, that’s 59 percent for public/private and only 33 percent for private only.

    Of course, the bill that will pass on Sunday is even less ambitious than what was polled here — no public option, and only minor tweaks to the existing system. So the majority of doctors clearly won’t have a problem with it. There will always be a few of us who don’t take their oaths seriously, but we’re used to that and the rest of us do our best to make up for the harm they do.

  14. The recruiting firm may have a “financial interest” but it is in determining physician career choices. I get two or three solicitations a week for general surgery jobs that have excellent starting salaries. There is a crisis now. A woman surgeon I know told me several years ago that there was no general surgeon practicing in San Francisco under the age of 50.

    The survey you refer to asks about an ideal proposal, which we could have had if Obama had not been so determined to go as far left as he possibly could and if he had prevented Pelosi and Reid from larding the bill up with corrupt attempts to lie about the costs.

    The present bill has absolutely no cost control at all. The one weak attempt, excise tax on “Cadillac” plans, has been gutted to please the unions. There is no cost control and it will be a disaster if enacted. The physicians who responded to the survey I linked to know this and are thinking about their future. They are not being asked in a survey about a theoretical concept.

    There is a physician-only web site called If you are a physician, as you claim, you could join and look at their survey of real physicians and what they plan to do. It would be an education if you are a physician, as you say. It tracks quite well with the survey I linked to. The site also has far more members than the AMA.

  15. I thought I would post the comments of the CEO of, which has more members than the AMA.

    A Squandered Opportunity

    Like so many physicians and citizens, I find myself frustrated, saddened, and more than anything scared by what is playing out in the healthcare reform effort. While I believe people understand the concept that the ends justifies the means, one cannot help but wonder what the ends are at this point.

    The subversion of our democratic system violates every lesson we learn as school children about separation of powers in the government. If this bill is so good for the public, then why do opinion polls overwhelmingly say that the public is not in favor of this and why are some legislators doing things that can only be described as extraordinary?

    The worst thing? I hope this bill passes.

    It is our last best hope at ANYTHING meaningful occurring. That being said, I think the damage is done. This is no longer about the goal, it is about the process. The proponents HAVE to pass the bill. It has become a self fulfilling prophesy. Rationality and what is “best” for our country have long since left the conversation. Unfortunately, true healthcare reform will be just the first casualty here. The healthcare system, the broader economy, and ultimately our nation will pay the price. We have squandered the opportunity of a lifetime for the benefit of a tiny number of special interests. On this point, I truly hope that I am wrong.

    Almost two years ago, the Sermo community called for healthcare reform with over 12,000 physicians signing the open letter. This community went on to predict that the AMA would fail physicians in their moment of need, pointing out that the AMA’s business model made them beholden to the government and insurance companies, not physicians. Finally, this community consistently pointed to the key elements needed in meaningful healthcare reform (not one of which is in the bill). Lately, this community has been making perhaps the most alarming prediction of all:

    * Physicians are opting out of medicine in alarming numbers.
    * We are opting out of Medicare/Medicaid in even larger numbers.

    Ultimately, it will be our patients that pay the price. As our nation holds its collective breath on the eve of this historic vote, we all should all remember that.

    Daniel Palestrant, MD

    Founder & CEO

    Sermo, Inc.

  16. Bonnie from OC says:

    Is that you writing in the Washington Monthly comment threads about this topic, Doc? I know you like to hang out there sometimes and it sounds very much like you.

  17. Bonnie and Ann share an ISP, just like Mike and Econmetrics, or whatever he called himself, did. The other troll has an ISP in Richardson Texas which is the town that Craig Mizes came from (I believe) who, after doing very well as a junior partner (I paid him the same salary I took) declared bankruptcy, after my back surgery when I was disabled, owing me $120,000 . I note he seems to have disappeared.

    I should add that I was banned from Wash Monthly months ago because I was discussing health reform with a bit too much logic and experience.