Blog | Monday, September 25, 2017

The salaried employed socialized physician versus the private physician, and why you should care

“Hello, Dr. Payne, thanks for calling back, there's a consult I'd like you to see”.

“What's going on?”

“Well there's a patient up on 7 east who …”

“Wait a minute, 7 east … isn't there some other specialist covering there?”

“No, Dr. Payne, the schedule says you on Wednesdays.”

“Oh, I'll check that.”

“Okay Dr. Payne, well we have this 72-year-old, Mrs. Jones, who originally got admitted with pneumonia. She now has unusual inflammatory changes in her hands. She's having significant pain and has never had this before, and we haven't got a diagnosis yet.”

“Well if that's not why she came in, maybe you could just discharge her and get her to follow up as an outpatient. My clinic is full, maybe give her the details of another local specialist?”

“But the nature of her pain and swelling, it's somewhat unsettling, and she really wants to see a specialist before she leaves.”

Dr. Payne then goes back and forth for a while, trying his best to avoid what he believes to be a non-urgent consult. In the end though, Dr. Payne of course has to see the patient after the consult is placed, but is begrudging having to do this. Dr. Payne is thinking: I've got a very hectic day, and don't need another patient. I'm an employee of Hope Hospital, and it makes no difference to me if I see 15 or 20 patients, I'm going to be paid the same anyway.

Dr. Sweet however has a very different mindset.

“Dr. Sweet, well we have this 72-year-old, Mrs. Jones, who originally got admitted with pneumonia. She now has unusual inflammatory changes in her hands. She's having significant pain and has never had this before, and we haven't got a diagnosis yet.”

“Okay, is she doing alright, I'm in clinic now but can come over and see her right after?”

“Sure, she's otherwise stable, just in a lot of pain.”

“Thanks so much for consulting me, and she's welcome to come see me in the office in follow up too. Let me give you my cell phone number if you have any questions.”

Dr. Sweet races over to see Mrs. Jones after clinic. He assesses her, orders some tests, and starts her on a new medication. He leaves his business card with her, follows up again in the morning, and tells her she's welcome to follow up in his office nearby.

What Dr. Sweet is thinking: I run my own private practice and want as many patients as possible. I am willing to work long hours every day in my own business and will strive to give the best possible service to all my patients.

My take: The above is of course a very crude example, and does not intend to discount (or cause offense to) the hard working employed physicians in socialized systems. However, every doctor who has worked in different health care environments has probably experienced something similar to the above extremes if they've been around long enough. Similar principles apply when any physician is employed by a health care organization on a fixed salary, which is increasingly the case nowadays in America (although I don't want to confuse two separate debates).

Speaking as someone who came from a socialized system in the United Kingdom, as good and noble as the concept of free health care may be, I'm very wary of the United States moving further away from the traditional private practice model (with fee-for-service), to a 100% employed or even a future socialized model where there is absolutely no incentive to be more productive and efficient. I remember in the United Kingdom what a struggle it was to get things done, with physicians blatantly giving pushback for consults, not wanting to do more scans, or work any harder than they had to (again, this isn't to belittle the efforts of the excellent doctors over there, but merely to state human nature). Who in their right mind would ever do more work than they needed to as an employee unless there was some kind of motivating factor? In any field of work, there have to somehow be the right incentives in place. The traditional fee-for-service system may be flawed, unsustainable, and need significant changes—as most reasonable people agree upon—but the other extreme is deeply problematic as well.

When I first arrived in the United States and started working in a hospital, one of the first things that hit me was what a great “customer service” mentality there was here. I was stunned when I heard doctors say the words: “Thanks for consulting me.” My jaw dropped at the sheer speed of getting things done in American hospitals, whether it was a scan, procedure or a consult. People who live here may not appreciate it, but I speak as someone who has worked in health care systems in the UK, Australia and even have experience when relatives have been unwell in India. American health care has an awesome service mentality that should be retained and built upon. So as we move towards an employed model for all doctors and reimbursement structures become increasingly complex and focused on “quality”, while other folk also debate a future single-payer system, we have to retain some of these previous incentives that existed for physicians, rather than abandoning them completely.

Why patients should care: If we're talking about socialized entirely government-funded health care, this may sound appealing to some—but actually comes at a cost. Firstly, if it's primarily funded through taxation, it's hardly free anyway. Forget having so much choice over which doctors you see, expectations of their availability, and also getting what you need quickly. Waiting lists, rationing and a more paternalistic approach are the norm.

Why physicians (and other health care workers) should care: Imagine working in a system whereby the government dictates absolutely everything. You may not be so keen on European-style socialized medicine when you realize that in an instant, whether you are a doctor, nurse, physical therapist or any other frontline health care professional—some random government bureaucrat can decide that the country needs to save money and slash your salary by half and completely renegotiate your working contract. However bad you think the health care environment is in America, a completely centralized government system would be far, far worse to work in. If you want any evidence of this, look at what's happened in the UK's National Health Service (NHS) over the last couple of years. Morale was decimated across the board when the government forced through new contracts for doctors. The NHS basically functions on the kindness and goodwill of its staff, despite the widespread belief that the government doesn't support them. In America, if you don't like your job, you will likely have a choice to go across town to another institution and work in a completely different environment, with its own unique pay and benefits package. In a monolithic system, no such options exist—it's the same everywhere and you are at the mercy of a sole employer.

Why America should care: As health care continues to change rapidly, we must ensure that patients receive the best possible care and that physicians are incentivized to deliver that great care with a service mentality. My own thoughts for an ideal health care system rest somewhere in-between the two extremes, as I've written about previously in this article. Be careful what you wish for though if you think government run health care is the answer. You may be sorely disappointed with what you end up with.

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. This post originally appeared at his blog.