American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, February 10, 2010

It's Not Our Fault

This post by Rob Lamberts, ACP member, originally appeared in Musings of a Distractible Mind in September 2008.

Dear Patients:

I know you get frustrated with our office. We make you come in for visits when you think we should handle things over the phone. We seem more focused on your chart sometimes than on you. Sometimes you may even wonder if money has become more important than patients.

To this, I say: I'm sorry. It's not our fault.

We are part of an insane system that requires us to do things in a way that makes life harder for us both. We would love to practice medicine differently, but we simply can't. Here are some examples:

1. Making you come in all the time

I would love to handle your simple problems on the phone or via e-mail. The problem is that if I do this, I am giving free care for which I am liable. People are being sued for nearly everything. If we give you a medicine without seeing you, we are actually more at risk than if you come in. Plus, the only way we can get paid is to bring you in. Insurance won't pay me for handling your problem any other way. Even if we both agreed, we couldn't have you pay for a phone call or e-mail, because we would be breaking our contract with our insurance company.

2. Not ever giving discounts

If I choose to give you a break and not charge you for a visit, I am being nice. Right? Well, according to our government, I am actually committing fraud. That's right, fraud. You see, I can't offer anyone a discount that I don't offer to Medicare patients; and not charging you would mean I have to not charge my Medicare patients. Ridiculous, isn't it?

3. Getting lost in notes

Why do we spend so much time taking notes and not talking to you? Is it so that we can do better medicine? No, we actually think that all this charting is stupid too. The problem is that we don't get paid to see you, we get paid to chart about you. We are paid based on a complex set of rules of documentation and if we are able to document more, we are paid more. If we cut corners so we can spend time with you, we are again viewed as committing fraud.

4. Obsessing about money

When you get your bill from us, you may wonder what all those charges are. And why are we forcing everyone to pay up front and sending people to collections? The problem is, while health care insurance premiums have gone up and inflation has raised everyone's cost of living, our reimbursement has dropped. We get paid less and less for taking care of you, so we have to become much stricter in how we run our business. The practice of medicine has turned into the business of medicine. We didn't do that, nor do we like it. But we have to stay in business, so we do what we must.

5. Not seeing you in the hospital

It seems like the time you most need your primary care doctor is when you are in the hospital, yet we don't see adult patients in the hospital. Believe me, we hate that as much as you do. It is very hard to give your care over to others who see you as "another patient." They don't know your history like we do and are often too busy to answer your questions. We try to communicate with them, but it is just a hard thing to do.

The problem is that we can't afford to see patients in the hospital. The amount of time it takes for the money we get is just not worth it. It came down to what was the least-bad thing to do: stop seeing patients in the hospital, see our families less or see our salaries drop. As primary care providers, we are not paid enough to let our salaries drop, so we chose our families. It was one of the hardest choices we ever made.

6. Acting paranoid

Why does the nurse always tell you to go to the ER when there is even a small chance there may be a problem? Why are you treated like a criminal if you ask for pain medications? The answer? Lawyers. Lawsuits are so rampant in our culture and so it makes us practice "defensive medicine." This means that we can't do what makes sense, we must do what minimizes risk.

And if we are ever thought to be giving pain medications too liberally? We can lose our licenses and even go to jail. It's a dangerous business we are in, but we don't want to do anything to make it more dangerous.

I am truly sorry for the state of things as they are. Perhaps better days are ahead of us. Some politicians are actually talking about paying primary care doctors more. Some people are suggesting that they stop paying just based on charting, but actually reward better work. And some people are even talking about limiting malpractice rewards.

These all sound promising, but remember who it is that is making the decision: It isn't the doctor or the patient, the two people who the whole thing is about; it is the politicians, bureaucrats, and insurance companies controlling this stuff. Unfortunately, with them in charge it is probably not wise to hold our breath.

Stay healthy, and have a great day!


Dr. Rob

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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Blogger medicine girl said...

This post should be required reading for anyone who suggests medical schools should shift their focus to primary care (e.g.,

Thank you for offering a clear explanation of why many medical students decline to pursue careers in what is otherwise one of the most varied & intellectually challenging fields of medicine.

February 10, 2010 at 10:07 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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