President's Page

By: Daniel M. Lieberman, MD

It just feels like it’s harder than it should be to be a good doctor these days.

Part of the issue is definitely the changing landscape. Many of us are transitioning to an employed practice model. Healthcare continues to cost more every year while we get paid less for doing the same work. Even the hospitals - which we depend on for the care of our patients - are clearly in financial trouble due to cuts in AHCCCS enrollment. The Supreme Court may throw out legislation that will transform how we do our job every day. Unless, of course, they don’t. Or unless the other political party does it first. It’s reached the point that the only thing that is certain about healthcare is uncertainty. This kind of turbulence doesn’t fly very well with most of us doctors.

But the real issue, in my mind, runs deeper than the uncertainty. It feels hard to practice right now because we are under attack. They keep adding insult to injury. Every time you turn around, the government, media, or even individuals seem to be questioning our integrity.

On July 22, 2009 President Obama said, “Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. ... The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid's tonsils out.’ Now, that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change; maybe they have allergies.”⁽¹⁾ Really?

That quote was part of a news conference regarding the Patient Protection and Accountable Care Act, which was subsequently passed by Congress and became law two years ago. The Act creates two new panels to determine appropriate preventative care, as well as reimbursement. As Doctors we’ve spent the last several hundred years trying to arrive at this information on behalf of our patients. The U.S. Government employs over 10,000 physicians at the NIH in Bethesda to help develop care algorithms which have been working throughout this century. How are these two committees going to do it for us in a matter of months?

Politicians aren’t the only problem. Mr. Peter Fine, CEO of the largest healthcare system in Arizona, met with our Maricopa Medical Society Board last year. During his remarks, in describing the public’s attitude toward the physicians who serve them he said, “The bloom has clearly fallen off the rose.” One had the sense he was speaking more about the hospital system’s attitude toward physicians, rather than that of the public.  That type of comment is particularly alarming when one considers that hospital employment is becoming the new normal for medical doctors in Arizona. It’s hard to work for people who don’t like how you smell.

It’s also become routine for the media to depict physicians as dysfunctional. House is addicted to Vicodin (so is Nurse Jackie). On Scrubs quirky J.D. has to deal with psychotic surgeons and internists. The doctors on Grey’s Anatomy have beauty, brains, and personality disorders. While it is all done in the spirit of entertainment, the depictions of physicians are not favorable.

Well, we’re all grownups, who take care of patients for a living. Do these petty insults even matter? I think the real picture is mixed. Every year Gallup asks the public to “rate the honesty and ethical standards of people in the following fields as very high, high, average, low or very low.” The good news is that the public’s opinion of Medical Doctors has been essentially unchanged for years (see Table 1). The bad news is that in 2011 we were third, behind pharmacists and nurses. A full 30% of the public believes the honesty of Medical Doctors to be average or low. Wow!! That means on average if you see 20 patients in your clinic tomorrow, 6 of them think you are not really very honest. If they don’t trust you, why would they follow your advice?

We need to start responding. Our great shield against these types of attacks, and their ultimate erosion of public confidence in physicians, is our professionalism. We all know what should have been said right after the President’s remarks. “With all due respect, Mr. President, ENT surgeons train for years learning the proper indications for surgery, including tonsillectomy. As is the case with all surgeons, patient selection is monitored by referring physicians, colleagues in the hospital Medical Staff, and by the State Board of Medical Examiners. Review of practice patterns is also part of a national Board Certification process in which surgeon’s practices are reviewed by their peers. As an attorney, you probably know that they also have the highest level of personal liability for their work. Notwithstanding all of that, a good reputation is one of the most valuable assets for any practicing physician, and no one wants to ruin theirs by doing an unnecessary surgery, which by the way would be immoral.”

To their credit, the ENT surgeons did respond the next day. It would have been better if all of organized medicine had a response as well. The frustrating question on the national level right now is whose voice should this be? Each specialty has a national society; however, their numbers are never going to be large enough to gain much traction alone. Historically we doctors have been represented nationally by the AMA. The organization has been critical in supporting medical staff in dealing with the hospitals, as well as preserving the integrity of medical practice for national issues. In the past the AMA could have been this voice.

Unfortunately, the AMA now receive so much of its funding from the Federal Government for maintaining the CPT codes, they are not in a real position to disagree with Uncle Sam. In addition, the AMA is no longer representative of the plurality of physicians. According to the AMA⁽²⁾ there are 710,599 physicians in the U.S. who have completed residency, and are under age 65.  In that group there are 82,240 AMA members. Thus, before endorsing the Accountable Care Act, the AMA represented around 12% of practicing physicians. The AMA admits to losing 12,000 members since supporting the Accountable Care Act, potentially representing around 15% of its active membership. So the AMA has become too small, and likely too conflicted by its own secondary gain, to truly represent most of us doctors on a national scale.  

As doctors we are closest to the patients, and therefore have the best understanding of what is wrong with the current system and how to fix it. We have traditionally helped our patients navigate the healthcare system; it is now our responsibility to change the system for the better on their behalf. In order to ensure our patients’ needs are taken into account in the legislative process, we need a seat at the table. The issue now is who is going to represent the concerns of practicing physicians? I’ve joined Docs for Patient Care for that purpose. I am hopeful that this organization will make a positive difference in the direction our government has been headed with regard to healthcare reform.

In any event, the public doesn’t seem to mind the way we smell. In these cynical times medical doctors are still ranked as the third most ethical and honest professionals (Table 1). Although not saying much these days, we did score ten times higher than congressmen. While the public thinks nurses are more ethical than doctors, it’s hard to compete with people whose full time job is to act like angels left on this Earth to comfort the sick.

While we need to respond to media misrepresenting us as dysfunctional, I’ll have to just give Grey’s anatomy a pass because the producers did make Dr. McDreamy a Neurosurgeon.

We need to catch up to the pharmacists, who the public rank as the second most ethical profession. We also need to reconnect with our patients, our office staff, and even ourselves about why we do what we do every day. In other words, we must find ways to inform the people we work with of our professionalism that goes beyond the diplomas on our walls.

That’s where Simon Sinek comes in. If you Google his name you can catch Mr. Sinek on Ted through Youtube. He points out that there is a pattern that is followed by great communicators. Great companies (Apple), leaders (Martin Luther King), and inventors (the Wright Brothers) don’t go around telling you what to do, or how to do it. They start by telling you what they believe. Great communication begins with; Why, then progresses to Who then What.

I challenge you to have your own Simon Sinek moment. Watch the piece on Youtube, then put your own Why, Who, and What in writing. I’ll give you mine as an example. I believe that science and technology, artfully applied, can overcome pain and suffering. I am part of a multi-disciplinary group who specialize in the treatment of spinal disorders. We offer therapeutic exercise, medical pain management, targeted spinal injections, and (when needed) the most minimally invasive surgery available for the treatment of spinal disorders.

Once you have your Why, Who, and What, make it available to your patients. Be sure your employees know it as well. Print copies for your waiting room. Post it on your practice’s Facebook page, and Tweet it as well. But first, send it to us at MCMS. We will review all your responses and possibly publish them in an upcoming issue of Round-up magazine. Send your lists to mcms@mcmsonline.com or by mail to our offices.

So, Doctor, what do you believe?

Daniel M. Lieberman, MD
President-Elect

References:
1)  http://www.youtube.com/watch?v=ZhNeGYYPgIE
2)  http://www.ama-assn.org/resources/doc/clrpd/clrpd-report-1-a11-demographic.pdf