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PUBLICATIONS
EXIT INTERVIEW
David C. Anderson, M.D.
General surgeon in private practice
leaves for Arizona
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David C. Anderson, M.D.
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Interview taped December 29, 1997
Transcribed from tape on December 30, 1997
Transcriber: Twila Brase, R.N.
Edited for clarity and length
Q: Why are you leaving Minnesota to
practice in Arizona?
D.A.: If the practice of medicine had stayed the same, there's
no question, I would've stayed. I enjoyed the practice environment
here as it has been over the last 20 years, but the enjoyment
factor of the practice has diminished as the business aspect of
the practice has become the overwhelming driving force in medicine
in Minnesota.
Certainly the reason to go to Arizona is not to make more
money. My income will drop--maybe 30-40%. On the same hand the
income factors in Minnesota are so driven by non-patient oriented
mechanisms that my idealistic mind doesn't allow me to continue to
practice that way.
Q: Can you talk about what those
mechanisms are and how they affected your practice?
D.A.: As the control of patients went into the insurance or
payment program, patient care was no longer driven toward the care
of people with illnesses. Patient care is now driven by the people
who control the reimbursement factors.
My training was to take care of the people who were really
sick and really needed to be taken care of, and those people are
finding more and more barriers in trying to get into the hands of
the people who can really do something about their care. This has
led to a tremendous waste of both fiscal resources and human
resources.
Q: Can you site personal or profession
examples?
D.A.: I can site a personal example first and then I can cite
innumerable surgical examples. My wife has diabetes insipidus - a
pituitary insufficiency. A year ago she developed a new onset of
headaches and one of the things that diabetes insipidus is
associated with is brain tumors. The acute onset of headaches in a
woman in her mid-forties is highly suspicious of brain tumor.
When she called her primary care doctor--an
endocrinologist--to have an appointment, she was told that the
first time she could see him was in three months. Obviously the
person who was making the appointments had no appreciation of the
medical potential of that new symptom complex. That's just
inappropriate. A three month hiatus for a patient like that is
wrong. Somebody with those symptoms and history needs to be seen
in the office in 2-3 days.
But the system is now set up to maintain strict office hours;
to maintain the office being busy throughout the day. There's no
time to work in people who have a medical illness--unless you run
them into an emergency room or an urgent care. And as soon as you
do that you're using medical funds at the absolute highest rate
with the least amount of control over how things are ordered.
My wife told me and I pulled the strings. Most people out of
the street would have no way of dealing with that problem other
than just waiting the three months and if there is something bad,
they wind up with a disastrous end result. That's not the way the
system should work because the vast majority of people in the
system are not in that kind of situation.
There should never be a time where you have to pull strings to
get sick people into medical care, or demand that you go to
emergent or urgent care where the cost is going to be way out of
proportion to the benefit; where they'll spend tons of money on
unnecessary work-up. The vast majority of those people would be
much better treated in the office with a physician who knew them
who could ascertain whether any workup needs to be done or not.
The last weekend I worked I had three patients that I had to
take to surgery for acute appendicitis. All three, without any
question--when you talked to them, when you examined them, when
you had their white blood count--were appendicitis. There was no
room for any question. They were straight forward, almost textbook
cases of appendicitis.
All three of the patients were seen through the emergency
room--on a weekend, that may be the only reasonable way they can
be seen. All three of them needed to be seen by a surgeon to
decide whether they needed surgery or not. Before I arrived, all
three had a CT scan which is not necessary for someone with a
clinical diagnosis of appendicitis. It's a waste of time, energy
and money to do that. All three of the patients could have been
seen and out of the operating room by the time they were initially
seen by a surgeon, if they had just called somebody who could have
done something about the problem when they were first seen.
Q: So they wanted to diagnose them
technologically before they brought you in.
DA: Exactly. And that is the biggest problem that I perceive
happening in Minnesota right now. Doctors, trained in business,
can run people in and out of their office in very short order, can
stick to their office plan, can make sure they see 10 or 12
patients an hour or whatever it is that they need to see, but in
the process they have lost their skills to become quality clinical
diagnosticians.
And if the primary care doctors lose their ability to become
physical diagnosticians, they wind up spending their time and
energy ordering expensive tests, tests that they don't even know
for sure how to understand. They have no idea what to do and in a
panic they either order more tests or inappropriate tests, or they
put the patient into the hands of a specialist without any plan as
to why they are going to see the specialist--except that they have
a technological answer that says that something needs to be done.
A very classical example of this would be the fact that in the
last 8-9 years we've developed the technology for much simpler
surgical interventions. That has allowed primary doctors to do,
almost ad lib, ultrasounds of the abdomen to look for gallbladder
problems. Because of it, people with symptomatology totally
unrelated to their biliary tree are getting operated on for
gallstone disease just because they have gallstones. But because
it wasn't the cause of the problem they came in for, there is very
little hope that it's going to make any difference in how they are
going to do. Many of those patients would probably live their
lives out with gallstones and never have any problems.
Because the primary doctor is locked into seeing so many
patients a hour, so many patients a day, the only way they can run
the patients in and out of their office--rather than spending time
finding out exactly what's going on in the patient's life, doing
some reasonable history and physical examination that comes up
with a reasonable working clinical diagnosis--is by ordering blood
work and an ultrasound on patients with a bellyache. If the
ultrasound comes back positive, they send the patient to a
surgeon, and yet nobody ever sat down and talked with the patient
to figure out why they came to the office in the first place.
And the truth of the matter is that once you have the positive
diagnosis made, people lose focus of what brought them to the
doctor. When I, as a surgeon, see these patients secondarily,
after they've already had the diagnosis made, even though I may be
convinced in my heart that it has nothing to do with their
gallbladder, if I don't take the gallbladder out, they've got to
go back to their primary doctor who will then send the patient to
somebody else to take their gallbladder out.
This is going to change the doctor's referral pattern because
he doesn't like to be one-upped. He will send the patient to
somebody who will rubber stamp his diagnosis. This makes not only
the primary care doctors poor diagnosticians, but it also makes
specialty doctors poor diagnosticians.
As the reimbursements have gone down and when you're only
reimbursed for what you do, not for the thought process, the only
way you maintain an income is to do more and more procedures. We
wind up giving diagnoses that don't need to be made, or at least
don't need to be made at that time. And that's like an open siphon
on the medical reimbursement pool.
And another problem occurs when you evaluate doctors, clinics,
or health plans on how they're performing. The only evaluation
that is accepted is something that will fit into binary -
numerical - logic process. If it won't fit into a computer program
where you make a system of binary choices then there's no hope of
an honest evaluation. There's not even an attempt at making
subjective evaluations in the process. It has to be a procedure or
a lab test that generates a number.
A classical example is the evaluation of pain on a scale. When
people come in for surgery, patients are coached on how to
evaluate how much pain they have relative to a scale of 0 to 10.
But, a person's pain at any given time is perceived in a vacuum as
far as where the scale would be. And so the patient gives out a
number and pain control is then based on that number. Concurrent
with that, many patients are now giving themselves their own pain
medication. If it's not adequate, the staff will ask them what
their number is. We're probably allowing some people to abuse pain
medications because we aren't paying nurses to sit at the bedside
and spend some quality nursing time taking care of that patient
and relieving their anxiety.
Oftentimes, if you can relieve somebody's anxiety, you get
much better pain control with much less medication than just going
in and asking somebody what their pain is. And many times, the
person now asking what the pain on the pain scale is, has almost
no medical background. They are somebody who has come in and been
given 2-8 hours of training and then work as a nurse extender.
Q: Do they call them nurse
extenders?
D.A. : They call them patient care technicians. They are the
old nurse's aids but they aren't called nurse's aids anymore. They
got a new name for them. I just became livid with that. I had a
hard time living with the fact that the only calls I ever got at
night was somebody asking whether a patient needed more for pain
or not based on the pain scale. When I would ask the nurses what
physical parameters indicated that this patient was having more
pain, there was never any clinical evaluation of the patient. It
was just a number.
The problem with that is, as I've explained to numerous nurses
on the floor, the business people in the hospital love it. Because
as it now sits, you don't need to be a nurse to ask somebody what
the number is. So then we can have even fewer nurses.
Alot of this is based on the business premise that the
customer is always right. That's why the business people in
corporate offices running medicine today no longer talk about
patients. They talk about customers. But in reality the customer
is not the patient. The customer is the company who's going out
and contracting with the plan. And the company's desire is to
control costs. They'll say they want quality care but they want it
for the cheapest cost.
The thing that will win out every time in the business world
is the cheapest cost. And that's the driving force behind the
people who are running the hospital and health care services. They
want the cheapest cost and they realize that it will have to be
real bad before it statistically makes a difference. And since
business is controlling things in Minnesota, I can't go on like
that.
And to top that off, they believe that if it's a technological
thing--a CT scan, an MRI--the answer is always absolute. The
interpretive factor of the equation never gets evaluated because
they have no way of evaluating that. If they did, they'd have to
admit that technology isn't the bottom line.
Q: Can you say something about what the
hospital environment is like for surgeons and patients? I've heard
about Patient-Centered Care.
D.A.: Patient-Focused Care. I could go on forever about that.
From my perspective as a surgeon, this is a system that would fall
apart completely, if it weren't for some incredible nurses just
breaking their back to make a very obtuse system work.
It's removed R.N. or L.P.N. care from the patient despite the
fact that there's just as many R.N.'s and L.P.N.s in the system,
maybe more, but they have been given chores unrelated to direct
patient care. Much of the task of primary care is given to these
woefully undertrained individuals who are allowed to do what they
do by programs, such as the pain scale or other things like that
that are accepted as fact, although there's a tremendous amount of
non-fact in what they're doing.
The mechanics of the physical environment in the situation at
United is a disaster. Millions of dollars were poured into
renovation of the system and physically, the plant is a disaster.
It's accepted by the people there that it was poorly thought out.
It's an architectural dilemma that is beyond the capabilities of
being solved short of completely destroying the hospital and
starting over from scratch and building up a new hospital, which
would still be locked into the whole concept of how they are going
to deliver care with paraprofessionals.
I think for the families of patients--there is a tremendous
amount of appreciation for the new system. It allows them to stay
at the side of the patient right up to when the patient goes to
the operating room for pre-op.
Q: How did they redesign the whole
hospital?
D.A.: On the floors, they've moved the old ward secretary, the
person who ran the floor, to a centralized location away from
where patient care is. Phone calls have been abysmal, disastrous.
They finally went to having cellular phones for the nurses, but
every system that they've tried has had major flaws.
Q: Where are the nurses?
D.A: It's a good question. You don't know.
Just an anecdotal story that raised alot of ire and drew alot
of anger from the administration. When they first put this program
in, I went in on a weekend on rounds, at 10:00 on a Saturday
morning on a surgical PFC, with 54 rooms. I was out in the halls
and I could not find anybody. There was nobody to be found. Since
I needed to talk to somebody for some equipment, I paged overhead
for any employee of surgical PFC. The vast majority of times, it's
just per chance that you run into the patient's nurse because
there's no centralized area that you can go to find them.
As they removed the centralized storage areas, they placed
more minuscule storage areas outside every room or every other
room. Oftentimes they're not stocked appropriately or if you need
something that's less likely to be used frequently, they don't
have it at all because they have a minimal amount that they can
store on the floor. Or it may be something that you use every
week, but because you aren't going to use it in every room once a
week they just don't have that, or if it is available, it's hidden
off someplace and nobody has any idea where it might be.
Q: Do you hear any complaints from the
patients?
There are nurses in the halls frequently during the day, but
when you ask patients, they say that there seems to be an
inordinate amount of time, after they ring a buzzer, before
somebody comes to answer. There seems to be an inordinate amount
of time before somebody will respond when they need to be seen or
ask for help.
When patients have complained it's generally been
care-related. They perceive that they needed to get their bandage
changed or they needed to get their bath. When patients compliment
the system, they like the isolated room. They like the fact that
their families can be in with them. They like the hotel features.
And since the care features for most people don't make too much
difference--it's only the occasional patient that's having medical
problems--that statistically doesn't make the hospital want to
change the parameter.
It's why they can drive people out of the hospital so fast
because most of them are going to do OK.
Q: Why do you say "since care features
don't make much of a difference"?
D.A.: Because the vast majority of people -- once you've
gotten through your operation--are going to get well. So the the
business type people say we can't spend alot of time babying these
people. We've gotta just say we know we aren't going to get sued.
We aren't going to lose a lawsuit because somebody perceived they
weren't treated nice. We're going to get sued because they have an
untoward result and the business people realize the untoward
results are unlikely to happen.
Q: If this is the case, that the
majority of people are going to get well, and that people like the
hotel features, and that most people don't have an untoward event,
then what's wrong with the system?
D.A.: You've spent at least $35 million, and if truth were
known, probably $50 million, to design a system that, not only was
money put into the building features, but it created a higher
echelon of administrative type people who are making inordinately
high salaries compared to the work load that they're doing. It's
allowed them to pay the people really doing the hands on care at a
lower rate by hiring these undertrained individuals to do the
hands on care.
And it's driving out the career nurse. The old career nurse
doesn't exist in the hospital anymore.
When I did my residency over at Miller, every station had a
senior head nurse and that senior head nurse was a career nurse
who had developed tremendous clinical acumen over the years which
she passed on to all the younger nurses. All of a sudden we don't
have those people around anymore because they are driven out of
the system. They are driven into administration or they're driven
into home nursing or they're driven into something that will pay
them more and give them hands on, because most nurses still want
to have some kind of hands on relationship to patients. That's why
they became a nurse. By driving them away from the hospital and
keeping a constant turnover of young nurses, who will go into any
kind of system and work for awhile till they get frustrated and
then they can move on, they wind up losing the very best thing
that they had going for them before.
Q: So who really knows what's going on
with the patient?
D.A.: Hopefully, you'll have a nurse that will have some
degree of following along on the patient, who will be able to give
you some idea. If I want to find out about a patient, I'm very
much locked into trying to read the laboratory data that's off the
chart. If it's not on the chart, it's almost impossible to find
somebody who can find it for you now. Unless you can call the lab
yourself, and that's almost a disaster because they want to put
everything on the computer so that they don't want to even look up
a number.
Clinically, nobody reads nurse's notes anymore. The reason for
that is that they got away from narrative nurse's notes where
nurses generally documented a long thorough note about the
patients condition. A note which really told you how the patient
was doing. Now they are suppose to 'chart by exception.' They are
responsible for evaluating every organ system of every patient for
every shift. There is a checkoff for "Within Normal Limits" of
each system. What that actually means is that they didn't check
the system, but that there were no problems or abnormalities noted
during their shift.
This means reams of meaningless paper are generated every day.
I didn't like the name of the new system. Calling it
patient-focused care made it sound like the patient had not
previously been the focus of care. In an open meeting, the CEO of
United said, and this is a direct quote, "We had to give it a
catchy name so that people would buy into it."
One of my nursing friends had an incident that she wanted to
report to the state, but she was afraid that she might lose her
job. The ER had to hold 3 acute MI [Myocardial Infarction (heart
attack)] patients all day because there was no room in the
hospital.
This is the position alot of older well-trained nurses are in.
They know what good medicine is, but they're stuck.
Q: What do you think about research?
According to a recent article in the New England Journal of
Medicine, Mayo Clinic researchers want access to rich clinical
data, but when you talk about the generation of reams of
meaningless data, what will the impact be on research?
D.A.: I think rich clinical data is a figment of the
imagination. There are some reasonable reasons to do clinical
research. I think the clinical studies that have any significant
meaning at all are the prospective studies. I realize that we have
to have some retrospective studies just to give us an idea--a
clue--as to what we should do, but my biggest concern is that
there will be no research except what's funded by for-profit
companies.
I'm sure that the HealthPartners, the Blues, the Allinas are
going to want to publish research data that will support things
that look good for their record. I can guarantee they will not be
reporting anything that looks bad on their record, and I can
guarantee that, just as with any human system, there will be bad
results in any kind of system, but we'll never ever see that in a
publication.
But the more frightening thing than that is what's happening
with what I call the "businessization" of medicine. Research, pure
clinical research, pure scientific research is going to be gone if
it's not already gone now, because there is no one to fund it. No
one is going to pay to do a project that doesn't give them the
answer that they want to have at the end.
And, since drug companies, or instrument companies, or
technology companies are going to want a given answer and are
going to be willing to pay billions of dollars to get the answer
that they want, there's going to be a tremendous desire to have
skewed reporting, or reporting that's going to be based on who it
is that's paying for the project. And it doesn't take alot of
skill to design a project to give you a designed outcome.
Q: What do you think about the
for-profit/not-for-profit debate?
It's sad to see that the University of Minnesota Hospital has
been taken over by the Fairview System. I hate that they're called
not-for-profit, because in reality, they're all for-profit. It's
just whether they're tax-exempt.
And in fact, for the leaders of those tax-exempt corporations,
there's a tremendous reward for making a huge profit. They
probably have a higher likelihood of being able to bonus
themselves out at the end than they would in a proprietary
business because in a proprietary business, you'd have
stockholders that would be interested in making sure that the
upper echelon are not skimming off too much of the profit. Whereas
when you have the good old boys system of appointing your friends
to the board, and then giving them the information you want them
to have, they're going to have no desire at all to look into this
to make sure you're not ripping the system off.
Q: Unlike primary care, are surgeons
able to have flexible schedules?
D.A.: Surgeons are fairly independent with their schedules.
There's a real pressure from the Allina Medical Group (AMG) and
everybody to contract out care. HealthEast is trying to contract
out all their surgical care so that they will have control of it.
Doing so would allow them to tell you when they want you in the
clinic; how many patients they want you to see. They would make a
contract that would allow them to bill for the patients that we
saw. There would be an understanding that we would see most of the
patients, but they would not write it in that we would see all the
patients. I think there is some legalistic things that they find
to be unsavory about that.
Q: They would do the billing?
D.A.: They would do the billing and then they would pay us
back a percentage of what they billed out--or what they collected.
We could bill the patients that we don't see in the clinic, if you
have to see an emergency at night or somebody that comes in at a
time other than the clinic.
Q: Let me clarify. They want you to see
their patients only in their clinic?
D.A.: That's what they wanted to do. They wanted to drive us
into their clinic. This is where I had my biggest argument with
them. I said that's totally inefficient care. If a patient comes
in with a surgical diagnosis on Monday morning at 8 o'clock and
sees the primary doctor, is the doctor going to wait till the
surgeon comes Tuesday afternoon? Even if it's a simple problem
like a breast lump or a hernia, something that one or two days is
not going to make a huge amount of difference, wouldn't it be much
better if you were going to contract, for the proceduralist to
say, 'Listen we'll keep somebody in the office. We'll open up
time. We'll make a contract with you that if you send the majority
of your patients to us, we'll guarantee that from the time they
come in our front door, we'll have them seen by the surgeon within
an hour'?
Q: And they didn't want that?
D.A.: No.
Q: Because it's easier to claim rights
to the whole billing process with you in their clinic?
D.A.: I believe that is what they thought.
Q: And the billing process, how is that
going to work? In the case of Medica, the Allina physician group,
the AMG, would bill Allina's health plan, Medica, and then the AMG
would charge you for the AMG's billing services for Medica
patients? Would that decrease your overhead?
D.A.: I can't see that there was any realistic way that we
were going to be able to cut our overhead at all. However, my
concern--since they had control of the patients--was that alot of
those patients on their own are probably not going to come in at a
time different than when they were told by the office to come back
to see the surgeon. The vast majority of them are going to wait
until they can be seen by us again at their office.
Again, my concept of what specialty care should be would be
that you have somebody seeing a specialist when it clinically is
sound for them to go see a specialist, not to rule out that they
might have coronary disease, but that you have a clinical
diagnosis when you're done. That's what primary care ought to be.
Primary care ought to be differentiating who's ill and who's not
ill. And once you've ascertained that Joe Blow is ill, then Joe
Blow gets in to see the appropriate person who can continue the
work-up to more precisely define what the diagnosis is, and to
start a more appropriate therapeutic action.
Q: About the billing. How much were they
going to charge to bill their patients for you?
D.A.: Well, basically, it was going to be based off of our
charge portfolio that we currently use. We were going to get
roughly about 24% of what our charges were for a given procedure,
whereas our average is 40% now across the board.
Q: You were going to get only 24% of the
charge you billed? They were going to take off 15% for billing?
(roughly the difference between 24% and 40%)
D.A.: Yes, plus they're establishing what the payments are
going to be. They're establishing whether they're going to pay x
or x minus 10. When it's Medica, Medica decides what they're going
to pay. It has nothing to do with what we decide to charge.
Q: So, if you charge $100, and Medica
decides to pay $45?
D.A.: They'd pay $45 to the Allina Medical Group (AMG) and
then the AMG would pay us $25 or whatever it would be. It looked
like it would be about 24% of what we were charging.
But the key thing, it's even more important than that, is that
they're doing that because the AMG is paying the AMG primary care
docs more than what they can generate out by reimbursements from
Medica for their primary care. And that's a decision that Medica
made. That's a decision within the Allina group. They said, we're
going to ask you to work this hard, but we aren't going to be
willing to reimburse you for it so we're going to take it away
from the reimbursement from the other doctors and give it back to
you, but in reality it's a shell game.
Q: So Allina said to the AMG that they
were going to cut the payments to the AMG, but that they would
increase the AMG payments by sending the surgeon's reimbursement
to the AMG and allowing the AMG to subtract a billing charge from
the reimbursement which then the AMG can keep?
D.A.: Actually, what they were going to do, with what was left
over, 50% was going to go to the AMG and 50% was going to go to
United.
Q: Of the $15? What was their
rationale?
D.A.: The hospital thinks they're in trouble and needs money
too.
Q: Tell me about your individual
experience trying to give surgery to a person that really needed
it.
D.A.: There were hurdles that had to be jumped to get certain
people in. It was mostly in situations where there was some degree
of clinical controversy in the diagnosis--diseases that there
might be some differences of opinion as to what is the optimal
kind of therapy; patients who do not fit the textbook definition
for the given procedure. There was the simple fact of requiring
second opinions for things like hernias or elective type of
surgical procedures.
For a healthy person, particularly males, to drum up enough
courage just to go into the doctor with the problem in the first
place, like the hernia, it takes awhile. Once they come in, if you
tell them they have to get a second opinion in order to have that
taken care of, a lot of those guys just won't go out and get the
second opinion. Alot of them will live a long time with a hernia
without any problems. It's a great boon for the insurance
companies.
There was always the disaster of retrospective denials. It was
difficult to function when somebody could retrospectively say that
what you did was not OK. You used your best clinical judgment to
make a decision and you operated on someone and maybe found out
something was different than what you thought. Then when you come
out and tell them about it, you are told the procedure is not
going to be paid for.
Q: But the only way you, or anybody,
knows that is because you did it.
D.A.: Exactly.
Q: So how does that affect
practice?
D.A.: It was a nuisance. It created additional paperwork,
writing letters. It was certainly not a reason for me to think
about abandoning ship.
It was not as big a problem to me as the philosophical
problems of driving ourselves to doing procedures that probably
weren't indicated. And not dealing with people from what was best
for the patient clinically. It's so easy to do operations today.
People are doing things because you can get by with it. There's
very very low risk and somehow there's a perspective in the
general public that you really were more sick if somebody did
something to you and that you're going to be better if you do
something as opposed to just talking.
Q: Why are doctors willing to not talk
to their patients anymore; to take 10 patients an hour?
D.A.: There's tremendous pressure from the business
organizations that own these primary care doctors. Primary care
doctors in the Twin Cities are all owned by somebody now. These
business people have told them they bought their clinics for any
exorbitant fee--they bought them beyond what the clinic was ever
worth--under the assumption that they were going to buy the
patients. They really didn't buy the patients because the patients
belonged to whoever they had their insurance carrier with. You
can't buy Dr. Jone's office and then buy his patients because if
the patients don't want to see Dr. Jones they're not going to see
him except by their insurance plan, and then only if that is the
only choice they have.
They bought sky.
And then they also, as part of buying that, contracted with
these doctors at a salary that the purchasers realized the
physicians were not going to be allowed to make. These doctors
would have never signed an agreement to sell their practice if
they would have been told that there was no way that they could
make their salary, or that they were going to take a big hit in
their salary. Therefore, all of these primary care offices are
losing money because they're reimbursed on a scale set by the
payer--a scale higher than the revenue coming into the office.
Let's just take the Allina Medical Group. The reimbursement
wing of Allina is not willing to pay the AMG primaries for their
clinical expertise. So the only way that these doctors can
generate more income is to see more patients. And so if Dr. x only
sees 4 patients an hour, then they will come in and say, 'Well Dr.
x, here's the choice, you either take less income next year or you
agree to see 10 patients an hour or whatever the number is.
I just happen to know one physician that I think that has gone
from 4 to 10, because her style was to see 4 an hour and they said
you can't do that anymore. There are very few of us willing to
take a big hit in pay.
Q: Ten patients an hour? Do you realize
how few minutes you can spend with a patient?
D.A.: Six. That's assuming you can "phase" yourself between
patients. Any numbers that I've used here are taken with a grain
of salt. They're for demonstration purposes. But what I'm telling
you is the pressure is on these doctors to turn people in and out
of their offices in short order.
And the truth of the matter is when somebody has a complex
problem it's going to take time.
And when somebody comes in and they perceive that you're
trying to push them out of the office, the only way you're going
to get out of the room with that patient is to give them a
prescription or order some kind of a test This creates a
perception on the part of the patient that you really care.
It's a huge joke to me, because oftentimes they'll order these
tests and then they'll tell the patient that they have to call
back on Friday or two weeks from now to get the report. But the
truth of the matter is that the report is instantaneously
available. Within 2 hours of any procedure the report's done. And
now with most offices, they're faxed back to the doctor's office.
Patients buy into the concept that they can wait 2 weeks to get a
report on something that's been sitting on the doctor's office for
2 weeks.
Q: Why does the doctor do that?
D.A.: To give him some kind of control. He no longer has
control over his pay. He no longer has control over his schedule.
The one thing he does have some control over is how he can report
back to these patients so he doesn't get backlogged in making
phone calls.
What business wants, is to control my finances and control my
work schedule. And they're very effectively able to do that right
now.
Q: So, do you think it's going to be
better in Arizona?
D.A.: No.
Q: How would you classify the morale of
your physician friends here in Minnesota?
D.A.: It's at an all-time low. The only physicians who might
have some optimism are the ones who are primary care, because
they've gotten more money in the last few years than ever before.
They like it that they have more expendable income than they've
ever had before. But most of those are very young doctors who've
never seen it done any other way.
The primary care doctors who really took care of patients are
realizing that the things they did that made patients love them,
they can't do anymore. Because they're no money in that. And alot
of the older ones are really disappointed. They're distraught even
if they're making more money. They are made to practice in a way
that is very, very distasteful to them.
Q: And why do you think they give up
their Hippocratic Oath to practice this way? Why have physicians
allowed it?
D.A.: Financial reasons. The rewards to physicians have
probably always been greater than they should've been--at least
since the Medicare Act. In a boom economy, to be made the goats of
a system that we had really no control over, and to be made to pay
a huge financial price, and still take the media perspective that
you're the one that's responsible. And then, what's left? I think
alot of doctors would like to do something different, but if
you're 50 years old and you've been doing this all your life, and
you really enjoy the direct one-on-one patient contact, it has
become your life. You can't change it.
Q: The new physician won't know that or
have it. The new physician will be an employee.
D.A.: Clock in. Clock out. And very unlikely to be talked into
seeing somebody early just because they might have a brain tumor.
I think it bodes bad for medicine as a whole in America for the
next several years. It'll take a generation to rectify the
problem. And the only way it will be rectified is the public
realizing they have tremendous vested interest in this whole
thing.
There's some rumblings that in California business has backed
away from medicine because they no longer can generate the kind of
dollars that they need, and business experts are getting into
other fields where they can make a profit.
The American College of Surgeons has a practice accountant, a
business advisor, who puts on business programs for surgeons. He
says what's happened is these health plans in Southern California
have lost their profitability. They are selling their clinics back
to the physicians for 30¢ on the dollar. But, it was an
artificial dollar when they were bought out and it's an artificial
dollar when they're buying them back because in reality they
aren't buying anything. They're buying equipment and office space,
but they aren't buying the patients.
These doctors, who've maybe had 10-15 years in a controlled
salary environment, are now having to run their own offices. They
are going to have to practice like they did when they were 28 or
30 years old, except it's a very difficult thing to do. It's very
difficult for a 55 year old physician to rebuild a practice like
he did when he was younger. But I think that will happen.
And when it does happen, I think physicians will realize that
they have to charge for professional work. They can't just let
that slide. Our professional work is worth money. Our clinical
diagnoses are worth money. And we have to charge. We have to make
people pay for that.
At the same time I think we have to start rewarding people for
more quality health parameters. Patients ought to have rewards in
an indemnity type of environment for having an annual physical
examination that they pay for out of their pocket. Maybe they pay
$100 for a physical exam, or $250, but they get rewarded by an
indemnity policy that charges at least that much less.
I still believe we should make health care taxable. If health
care is a routine taxable expense, then it's not going to be to an
advantage for 3M to buy health care. Then individuals will own
their own policies, and they'll make more responsible decisions.
Q: Tell me about the new doctors; the
young doctors.
D.A.: There's a huge difference. They're raised in an
environment of outpatient care, making sure that everybody's seen
and moved through the system quickly. They're customer, not
patient, oriented, and their perception is to take care of the
vast majority of people who are not ill in a way that gives them
some kind of a sense of feeling better about themselves. Be it
ordering of tests or ordering prescriptions, I believe there is a
real lack of desire to understand clinical disease.
I think there's a real lack of concern about patients who are
really ill. And I think there is a tremendous lack of desire to
practice medicine beyond anything that they do. Medicine is just
one of the activities that they want to have as a part of their
overall lifestyle, and they don't really want that marriage to a
very demanding partner.
Q: Is there anything wrong with that? Is
it surprising that we've moved to a McMedicine mentality in our
society?
D.A.: It's more than medicine. I think it's a cancer that's
invaded the whole environment of our civilization of the United
States. We're caught up in the profit end of the business. It
really runs our government as well. But it will come to roost very
quickly. We cannot maintain the exponential growth we have
experienced. We can have one or the other: Desire of quality,
employee satisfaction and limited profit, or we can have the
cheapest work force, an adequate product line and suck off the
biggest profit we can get.
Q: How about
doctors who have become HMO executives?
D.A. They're the worst of the lot. They have turned from
patient care as their driving function. They have managed to
leverage themselves into a position without expending any
resources of their own. Most feel it's a dog-eat-dog world, so
it's OK.
Q: What about the Hippocratic Oath to
put the patient first?
D.A.: Most likely it meant little to any of those people even
when they took it. They are enamored by statistics which show that
the death rates aren't going up. Without objective data they won't
believe we have a system that's worse than before. And as I said
before, it has to get really bad before it will even show up in
statistics.
Q: Thank you for your time. Keep in
touch.
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Citizens' Council on Health Care
1954 University Avenue West, Suite 8, St. Paul, MN 55104
Phone: 651.646.8935 / Fax: 651.646.0100, e-mail
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