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.