When You Go to an ER and There's No One There to Take Care of You

Recently, I’ve been reading less-well known health care blogs—and finding some provocative stories.

Below, Edwin Leap--who is a physician and a blogger--tells a story about trying to find a specialist for a very sick child in the middle of the night.

Let me preface Dr. Leap’s story by explaining that, in the past, specialists who had “privileges” at a hospital (to treat patients there and to use the hospital's very expensive equipment and operating rooms) were routinely “on call” to treat emergency patients. But these days, more and more entrepreneurial doctors are refusing to fulfill what was once seen as a traditional duty—unless they are paid.

In Money-Driven Medicine, I quote the chief operating officer of a rural community hospital who recalls a conversation with a young doctor who walked into his office and informed him that he would no longer be willing to be on call for the ER. When the doctor had signed on with the hospital, he, like all of the other physicians, had agreed to be available to treat ER patients one week a month. Typically that might mean coming into the ER two or three times during that week. But now, he explained, he wanted to spend more time at home with his children. He was not willing to continue answering the calls unless the hospital would pay him $80,000 a year.

The COO was nonplussed. He knew that an additional $80,000 would work out to $2,200-$3,300 each time the physician came in ( He did not ask how the doctor had calculated that quality time with his children was worth $80,000).

“But we have a contract,” he protested.

The doctor nodded: “Times change,” he said easily.

The COO knew that he had a legal and moral responsibility to cover his ER. He also knew that if he paid
this physician, he would have to pay all of the other physicians.

But he didn’t even try to negotiate. Because he also knew that if he refused to pay the amount asked, he risked alienating not only this doctor, but all of the others who practiced at his hospital. In response, they might well begin referring some of their most profitable business to a hospital in a city just an hour and a half away. He had no choice but to agree.

This is not an uncommon situation; covering ERs has become a problem nationwide. A report by the California Senate Office of Research offers an example of what can happen, citing the case of a man suffering from internal bleeding who came into the ER of an unidentified California hospital. Over the next three hours, six gastrointestinal specialists refused to come to the hospital to treat the patient. Finally, the director of the emergency room lured a specialist to the hospital with the promise of $500 cash. The specialist then performed the needed procedure, and the bleeding was stopped.

Below, Dr. Leap’s post. I will be very interested in your comments.

You won’t help a critically ill child? Is this how low we’ve fallen?
Dr. Edwin Leap, April 4th, 2008

One of my partners recently took care of a child with a retro-pharyngeal abscess.  For the non-medical, this is a serious infection behind the throat that can easily result in loss of an airway.  The child, some 20 months of age, was obviously very ill.

We frequently don’t have an Ear Nose and Throat physician on call at our hospital, and the night that child presented was typical.  So, the only viable option was to transfer the child.  However, when my partner tried to find an ENT surgeon to care for this child in a nearby town, he was met with this response:  ‘I’m not on call for your hospital.’

Now, I understand not wanting to have ridiculous referrals.  I understand not wanting to increase your already busy workload.  I understand that being a surgeon is very time intensive already, so the doc in question probably didn’t need more work.  But the thing is, it wasn’t a drunk with a broken jaw, an elective tonsillectomy, or even a fish-bone stuck in the throat.  It was a child who might have died.

Well, I guess Hippocrates didn’t cover that scenario.  You know, sick child from another town.  After hours, and all that.

Is this how far we’ve fallen?  See, we don’t have endless options for transfer.  We practice in a semi-rural area.  It isn’t Manhattan. There aren’t surgeons on every corner.  Trust me, if we could have handled it, we would.

Is this what doctors have become?  Technicians who feel no sense of urgency or obligation to the sick, in fact, to the most vulnerable of the sick?  Is this how we want our children, or grandchildren, treated?  Dismissively?  With a ‘good luck’ and a hearty pat on the back?  With a ’sorry, but you know how business is these days?’  I hope to heaven not.

That sort of behavior makes me feel angry, and a little sick.  It makes me see how malpractice litigation could get out of hand, or how national health care might slip in the back door.  If we’re so unprofessional that we can ignore a critically ill child on a technicality, then maybe we’ll deserve whatever happens.

Fortunately, the overwhelming majority of docs I know would never behave that way.  Like the intensive care docs who ultimately accepted the child, they do the right thing at the right time, the way we were taught.

We need to call this behavior what it is; childish and unprofessional. And we need to remind ourselves, every day, of why we do our jobs.  And that we have a duty to the sick and injured, convenient or not.

Comments

[bingo]

Maggie:

Did you read Jeff Goldsmith's piece on April 14 on the Healthcare Blog? Some well-spoken thoughts on the issue of ER coverage in point #3.

[Maggie Mahar]

Bingo--

I wasn't saying that a public school teacher is your peer in the marketplace.

(I don't live in the marketplace. As economist Rashie Fein once put it, "we don't just live in an economy; we live in a society.")

I simply was saying that a public school teacher could be your intellectual peer in the world (unlike some of the people who graduated with you from college who you didn't feel were your intellectual peers.)

I'm glad you like your work so very much--I suspected you did.

[bingo]

And yes, Maggie, I am very, very fortunate to be a physician. As testimony to that, were I to win an enormous lottery I would continue to do just what I am doing today, providing specialty care for my patients. I would just have better retirement planning and liability shielding!

And I would still cover the ER...

[bingo]

Maggie:

Thank you again for your thoughtful replies.

Barry Carol accurately points out that it is not the compensation of CEO's that is the applicable comparison, but the compensation of lower-level executives. While I do, in fact, have several peers who are now running Fortune 500 companies or large investment companies, none of my peers were doing so while I was in medical school or training. However, a significant number of my peers did have 6 and 7 figure incomes in our 20's and 30's, a significant head start which no physician can hope to overcome. It is THIS disparity that I reference.

I will continue to posit that teachers are not my peers in the marketplace. May we agree that simply doing so leaves my open to the impression that I am insensitive to the charge that I am insensitive to the challenge of teaching and the lack of value placed on teaching in our society, but that this is not the case? While all of your points regarding your daughter are true I continue to hold that they are not germaine to this discussion. She is not my peer in the marketplace. While she could have chosen, on her merits, to become a physician she did not do so, choosing a career with a significantly lower barrier to entry, with a significantly shorter and less arduous entryway. (Incidently, I attended a highly selective, small liberal arts college with a very rigorous academic program. I am skeptical that McGill is any more selective or rigorous than my alma mater) I continue to contend that comparing teaching and medicine is not a valid comparison given the premise of this thread. I agree that lumping teachers and plumbers on my part is equally invalid.

Your observation about my age is accurate enough, and your observation about the priorities of my younger, more recently trained colleagues is quite accurate. As I mentioned in earlier comments the change in training (shift-based) coupled with a seismic change in the prestige afforded physicians due to their sacrifices both while training and while in practice make the original story quite understandable. Simply saying that it shouldn't be this way, without offering any other rational objective solutions targeted at the cause of this behavior, seems to me to be taking the easy way out.

[Barry Carol]

Maggie,

I hear you on both the “calling” aspect of being a doctor as well as your point about European doctors able to live an upper middle class lifestyle on their income.

I suspect, however, that there may be significant differences between the U.S. and Europe with respect to lifestyle expectations generally, how an upper middle class lifestyle is defined, and what it costs to support. For example, Americans generally live in larger houses than most people in other countries. Americans have to pay more for college educations. Americans also have to save more for their retirement to supplement Social Security. For a doctor who wants a nice house in an upscale suburb with a good school district or an upscale condo in a full service building in a major city like NYC, Boston, SF, LA or Chicago, a couple of better cars, expects to be able to take his or her family on a nice vacation each year, send the kids to camp in the summer, maybe have a modest vacation home near the beach or in the mountains, pay for college at a selective, competitive school (if the kids can get accepted), and save enough for a secure retirement, it will probably take a considerably higher income than European doctors earn and find acceptable.

The good news is that assuming about half of doctors’ gross practice revenues go for expenses for staff, office space, equipment and malpractice insurance, their net income only accounts for about 10%-11% or so of total healthcare spending in the U.S. Our challenge is to drive the wasteful excess utilization out of the system, not to drive doctors’ incomes to European levels.

[Jenga]

People compare salaries of physicians in Europe and the US, but also compare how hard they work as well. US physicians work alot more hours on average than their EU counterparts.

[maggie mahar]

Bingo--

I should add that I recognize that you were probably a member of a generation of med students caught in a transition that people didn't see coming when you were in med school.

In other words, I suspect that you are a member of my generation--folks who graduated from college in the mid 1960s to very early 1970s, in large part because you and your partners, do see uninsured patients. That's part of what people who chose medicine back then assumed was part of the profession.)

Thus, you've experienced the worst of both worlds.
When you were a resident, you worked extraordinary hours--no one expected to just go home at the end of a shift.

But it was assumed that when you became a doctor, money would never be a problem.

These days, med students and residents are concerned about "life-style issues"--having a family, spending time with their children, etc. (The number of women in the profession has had an effect here.)

And they are
much more willing to work on salary, at a place like Kaiser, where there will always be a cap on how much they make.

So I definitely understand how physicians of your generation feel that you were blind-sided. But I still think you're lucky to be a doctor, adn I imagine that, despite the state of healthcare today, you derive real satisfaction from your work. I certainly hope I'm right.

[maggie mahar]

Barry--

You write: "I don't expect them to ever work for anywhere near the level that European doctors are paid even if they come out of medical school with no debt. There are just too many lucrative opportunities to earn a lot more money in other fields with less education and less effort. We have to be able to compete with that."

Here's what I think you are missing. Many very bright people would simply find business or finance too boring.

(For many bright people, finance is, of course, fascinating. Think Warren Buffett. But even though I have been offered potentially very lucrative Wall Street jobs, it just isn't what interests me.

Being a doctor is creative and fulfilling in a way that business just isn't.
I know entrepreneurs can be "creative"--but they just aren't dealing with the same mysteries, the same degree of ambiguity, the human body and the human soul.

And we definitely don't need doctors who don't see a difference between being a physician and running a hedge fund.

We need doctors who are drawn to medicine by their deep fascination with the science and mystery of the human mind and body, and/or a deep desire to help people who are suffering.

It's a profession, not a career.

I'm extremely impressed by many of the students going to med school these days. They're bright enough to easily get an MBA and very likely make more money in another area. They are well aware of all of the problems in our health care system. Still, they choose medicine.

Of course, I think that after all that their education entails, they should wind up earning upper-middle class incomes. But doctors in Europe earn upper-middle-class incomes.

And when I was at the INternal Health Care Conference Europe for 3 days, I didn't hear a single person talk about doctors pay--not in the all of the speeches and panel discussions.

It just an issue.

Some doctors there are definitely unhappy with the paperwork, some of the
bureaucracy, and things that get in the way of doing the by their patients.

Like us, they are very concerned about chronic disease management, better preventive care, better systems and fewer errors.

But absolutely no one was saying "I have to see too many patients--that's the only way I can make enough money."

[Barry Carol]

Maggie,

I don't think comparing doctors' compensation to CEO compensation is especially useful. At any given time, exactly 500 people in the entire country are working as a CEO of a Fortune 500 company. Of the many people who may aspire to be a CEO someday, very few make it.

With respect to CEO pay that started to surge in the early 1980's, there were two primary reasons for it. First, the stock market took off. As you well know, between 1966 and 1982 the stock market as measured by the Dow Jones Industrial Average made no net progress in nominal dollar terms and lost significant value in purchasing power terms. Second, in the early 1990's Congress passed a law that limited the corporate tax deductibility of compensation to $1 million per year per individual unless the additional compensation is "performance based." The law of unintended consequences led corporate boards to increase awards of stock options and restricted stock whereas they probably would have paid higher salaries and much less generous option packages in the absence of that legislation. Besides, even if the top five executives of every one of these companies worked for free, the prices those companies would charge for their products would probably not be reduced by more than a fraction of 1% at most.

That all said, smart people who are primarily interested in making money have many more avenues open to them here than in Europe or Canada. Most of professional Wall Street pays well. There are plenty of mid-level investment bankers, traders, sales people, and analysts who make $1 million per year or more with no stock options in the mix. There are also a lot of highly paid people in corporate law, real estate and the executive level of most large industries. Doctors who decide to go to Wall Street to become drug analysts or to insurers to become a Chief Medical Officer can make a lot more money that they could have practicing medicine.

Within medicine itself, the retail drug chains tell me that they pay about $80K plus benefits for pharmacists and slightly less for nurse practitioners to staff their clinics, and there is a widespread shortage of both. I'm all for paying doctors a good salary as opposed to the current fee for service system, but the salary would have to be high enough to induce bright people to go through the rigors of medical school and residency and to ultimately be able to provide at least an upper middle class lifestyle for themselves and their families. I don't expect them to ever work for anywhere near the level that European doctors are paid even if they come out of medical school with no debt. There are just too many lucrative opportunities to earn a lot more money in other fields with less education and less effort. We have to be able to compete with that.

[maggie mahar]

Bingo & Lisa--Thanks for your replies . . .

Bingo--I think you make two important points.
First:
"Many of my classmates in college made enormous amounts of money while I was toiling away at my schooling (at a cost of $50K/yr) and training (for a salary of $30k/yr). The fact that my peak salary was substantial in no way will ever bring me to par with those who are at best my intellectual peers. The perception is that I am undervalued."

I'm guessing that peers in college who made so much money went into business --probably some became CEOs.

And you're right, by and large they are not your intellectual peers. While I was at Barron's I interviewed many CEOs of companies like Disney
It is remarkable how dumb many of the most successful are.

When I began writing about medicine, and interviewing
doctors, the contrast was striking.

But the problem here, I think ,is that CEOs and other executives are way overpaid. This began sometime in the 1980s. Before that CEOs did not make six or seven times what a surgeon makes.

Once CEOs became so grossly overpaid, that threw a lot of things out of kilter in our economy and in our society. And I can understand why it would contribute to a doctor's perception that he is not valued by society.

Your second point is more troubling. You wrote: "Comparing me with a teacher or a plumber is a strawman argument--they are not my peers and it is not a valid comparison."

As it happens my daughter is a public school teacher. She spent three years teaching first grade in the South Bronx a few blocks from Yankee Stadium and is now teaching first grade at a middle-class school in Brooklyn. (After a year or two, she plans to go back into the trenches. Teaching middle-class kids just isn't as challenging. But first, she wants to have a baby. Too many teachers at her school in the Bronx were having miscarriages--terrible environment--mice dying in the walls, some rats, windows that don't open, and overall terrible air quality up there. )

She's particulary good at teaching kids with severe emotional problems. Some live in homeless shelters, some are physically abused on a regular basis, some . . . . you name it. Often they are very bright (one reason why they're so angry, I think) and she's particulary good at getting through to the boys--kids who other teachers just won't/can't handle.

She's also brilliant at teaching reading. By the end of first grade all but three or four of her 22 kids will be reading at or in some cases well above grade level--including, in one case, two kids from Africa who knew only one word of English at the beginning of the year: "toilet."

I say all of this, not to brag about my daughter, but to point out that she is your intellectual peer. And she is adding at least as much value to society; she, too, is trying to rescue people.

The reason she chose first grade is beccause it's one of the most challenging greades(teaching kids to read) and she feels that if they learn to read--and to like reading--they've got a much better chance of making it through school and getting out of the neighborhood. She also knows that after about 4th grade, it's too late,

In fact, some of the them are so damaged when they come to her that she wishes she could teach them when they're 3 or so.

She went to McGill, a much tougher university than the most prestigious in the U.S. (more requirements, more writing, higher standards) and did extremely well. Had she wanted to, she could have gone to med school--or done anything.

To equate "teachers" with "plumbers" is to point out that teachers--especially public school teachers--are, far and away, the most under-valued professionals in our society.

It is not just that they are not well-paid. They are not respected because Americans place so little value on learning. (By contrast, the parents of her African students have taught their children to have great respect for a teacher.)

Finally, in terms of adding value to a society, see Dr. Steve Schroeder's excellent editorial in the NEJM
http://content.nejm.org/cgi/content/full/357/12/1221

Schroeder writes: "When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these deaths could be prevented . . ."

Health care is not the key to good health, Scroeder argues:
"More fundamental is the recognition that social policies involving basic aspects of life and well-being (e.g., education, taxation, transportation, and housing) have important consequences . . .

"When public policies widen the gap between rich and poor, they also have a negative effect on population health. One reason the United States does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism. Our willingness to tolerate large gaps in income, total wealth, educational quality, and housing has unintended health consequences.

"Until we are willing to confront this reality, our performance on measures of health will suffer."

My conclusion: If we addressed poverty, providing education and healthcare to the poor (as you and your partners do) that would do more for the health of the nation than if everyone had insurance. You and Emily are in the same profession. And just as I'm very proud of her, you should be very proud of being a doctor (however some in society may view doctors).

Lisa--It's true that most doctors are never sued (though this varies widely by speciality.) Here I think Bingo's emphasis on "perception" is useful.

If they perceive or believe that they are in danger of being sued this does undermine the doctor/patient relationship. And the fact is that there a certain number of people out there who think that, when something goes wrong in medical care, that means they have won the lotto.

[Lisa Lindell]

The original posting was about a physician who had a contract with a hospital and didn't honor it, but instead held the COO hostage.
Physicians may very well have a legitimate beef with covering the ER, but is this really the appropriate method to resolve it? Are physicians supporting reniging on contracts?
I agree with Maggie, we're ALL working a lot harder for a lot less, and paying a lot more for things like gas and food... and healthcare! How about the service industry workers...Starbucks barista's, casino dealers, et al that have to share their tips with their managers. That's no fair, either.
If we can't have good discussion on the internet, then where?
And finally, again it's only my own opinion and observances, but I don't think physicians are less respected or valued by society. Personally I had great reverence and respect for the physicians that treated my husband from the minute I walked in the door. By the time our ordeal was over I had a pretty low and dismissive opinion of one, which was self-inflicted by him, but it contributed to my great disrespect for the entire institution as this is who they hired to treat their patients. To this day I still have great respect and gratitude for his treating physician. As far as a generation of litigious society, this too applies to society beyond just healthcare. I again will refer to Michael Townes Watson's book " America's Tunnel Vision: How Insurance Companies' Propaganda is Corrupting Medicine & Law." How many of the physicians reading this blog have actually been sued ? I can tell you we never sued anybody or attempted to sue anybody or threatened to sue anybody involved in my husband's care. It never crossed my mind...yet we were treated as plaintiffs from day one...The Enemy. And this wasn't just my "perception" and if you want to debate that it was, I will ask, what did they ever do to try and change my "perception?" Nothing. I will tell you, after my husband was discharged from the hospital the insurance company sued him. This ridiculous and expensive litigation dragged on for years. My former employer was sued on a regular basis, not by customers or individuals, but by corporations...ridiculous and baseless lawsuits. The Great Third Party With Deep Pockets gets tagged every time.
Speaking of litigation, the insurance company lawyers dragged that treating physician into depo after depo after depo, asking the same inane and irrelevant questions, it was humiliating and infuriating. Granted, he was paid for giving depo's, but that's not the point. His business is taking care of burn patients (and he's very good at it). Many a day we desperatly needed him on the burn unit, and now here he was, missing from some other burn patient's bedside because the insurance company lawyers want to grill him again. Once should have been enough. Even though we had no responsibility for this, I didn't go to those depo's because I felt awful that this physician was being taken from his patient's and it was because of our issues. Issues manufactured by insurance company counsel. Additionally, there was a news story here locally that indicated physicians will no longer treat auto-accident victims. Reason? Somebody comes in with a broken wrist from an auto accident, an army of lawyers aren't far behind. Insurance company v insurance company. The doctor's office becomes burdened with depo's, litigation, document copying, mailing, often in triplicate or quadruplictate, etc etc etc. I wrote to the reporter and supported their decision. I'm getting way off-topic now.

[bingo]

Maggie:

Points well taken, and your most polite tone is much appreciated.

A significant problem is one of perception. One's personal perception is reality for that individual. In my generation even those of us in relatively benign residencies worked 80 hour weeks and received pay that came out to much less than minimum wage. The unspoken understanding was that we would be compensated downstream both financially and by being held in esteem for our sacrifice as well as our expertise. Many of my classmates in college made enormous amounts of money while I was toiling away at my schooling (at a cost of $50K/yr) and training (for a salary of $30k/yr). The fact that my peak salary was substantial in no way will ever bring me to par with those who are at best my intellectual peers. The perception is that I am undervalued.

ER coverage, and the sacrifice of time, family time, sleep, etc., and the increase in stress and risk was once part of the reason why physicians were held in high esteem. That and the rather common practice at the time of providing services for patients at little or no charge if they needed the care and could not afford it. (While my partners and I still routinely do this we are in the minority, dinosaurs if you will.) The perception is that the sacrifice of the physician covering the ER (uncompensated care, impingement on non-work time, dramatically increased liability risk) is not valued by those we serve, and is certainly under-valued by those who run and own hospitals.

While you have little sympathy for the specialist who is making less, our perception is that we are working harder and making less (it's also the reality, sadly). Comparing me with a teacher or a plumber is a strawman argument--they are not my peers and it is not a valid comparison. We add different value to society. Making that comparison solidifies my perception that my training, skill, experience, and dedication is undervalued and underappreciated.

You or your other readers may consider this nothing more than whining. Be that as it may. But my hope is that this will shed some light on the psychology behind these occurances, not to justify them. YMMV.

[Maggie Mahar]

bingo--

I think you make an important point when you note that: "In response to the Libby Zion case in NYC in the late 80's, work-hours for residents were restricted. . The "law of unintended consequences" came into play.

"Residents once left their training with an ingrained reflex to simply get up and treat each and every patient whenever and wherever they might be. We now churn out wonderfully trained young doctors who are accustomed to regular hours and schedules, trained to pass off responsibility at the end of the shift."

I think this has a lot to do with why many of today's younger doctors don't want to be on call in the evening. They are accustomed to more regular hours and feel that when their shift is over, it's over.

At the same time, I'm not entirely sympathetic to the issue that specialists are reluctant to be on call because they earn so much less than they did.

Some specialits do earn less --and many pimary care docs, pediatricians earn less. But
many specialists have watched their total income rise faster than inflation over the past 10 and 20 years.

In some cases this is because they have increased volume, in other cases they've become more entrepreneurial, invested in clinics, diagnostic equipment or become consultants for device-makers.

I wrote a post on doctors' pay a while ago http://www.healthbeatblog.org/2008/01/health-care-spe.html
and the disparities are so great that it's impossible to make a generalization about doctors' income.s

But I would say that if a physician is earning $300,000 or $400,000 a year--or much, much more (after expenses)-and he says that this compensation makes him feel that society just doesn't value him sufficiently . . . . well,
it's hard to be sympathetic.

You write: "My world is hard, Maggie, and not getting any easier. "

In fairness, many people live in a world that is hard--and getting harder. The average workers' income has declined significantly, after inflation, over the past 20 years. And while the average workers' job does not require as much skill as yours, many people work just as hard--if you measure the physical effort, emotional and even psychological stress involved .(Especially if they are not working for themselves, but working for a boss who makes life very, very difficult.

Or, imagine being an 8th grade teacher in an inner-city public school. If you don't think society gives doctors respect . .

So while I'm sympathetic to many doctors, I do think some are sometimes inclined to feel a little too sorry for themselves.

This may be because, in the past, society put doctors on such very high pedestals and they were all but guaranteed that their salaries would just keep on going up year after year.

Understandably, if one becomes used to having a certain place in society--and a certain amount of wealth and then your income ceases to rise at the same rate, that is bound to be disconcerting.

MOre importantly, I do think that the loss of trust between patient and doctor is an enormous loss. Some patients have contributed to it with frivolous and simply greedy lawsuits; some doctors have contributed to it be thinking of themselves as "businessmen"or "etrepreneurs" rather than as professionals who put their patients' interests first.

Finally, I don't think that "The dialogue necessary to understand both sides is well nigh impossible on a blog."

Certainly issues like these cannot be resolved in one exchange between two people, but over the course of this thread, we've seen some extreme positions here, as well as very reasonable points made on both sides of the issue (including yours.)

By the way--I think it is good that residents' shifts are shorter--and suspect that they still may too long (in terms of leading to patient errors-- see what we wrote here:
http://www.healthbeatblog.org/2008/03/newsflash-docto.html

And I think that as medical schools teach more courses on the "hand-off" patients can be safe when doctors end their shift on time.

Doctors deserve to have a family life, just like everyone else.

But I also think that, as part of their medical training, residents should be told that sometimes they will be needed in emergencies, and that's why they need to take their turn, covering an ER at night two or three times a month.

I think some element of voluntarism is part of feeling like a professional. I often work an hour or so past the time I'm supposed to go home in order to finish a post, or respond to readers' comments on a blog. No one asks me to do it--but I care about the work, and so I do it.

[bingo]

Maggie:

In the hope that you are still following this thread I have a couple of thoughts. I occasionally drop in to your blog and I have enjoyed your insights.

There has been a paradigm shift in the perception of my profession over the 30 years that I have been a physician. Part of this is due to runaway litigation, the generation of lawsuits in response to an adverse outcome regardless of cause. This has created an atmosphere of distrust on BOTH sides of the physician/patient relationship.

The second shift occurred in response to the Libby Zion case in NYC in the late 80's, resulting in work-hour restrictions during residencies. The "law of unintended consequences" came into play. Residents once left their training with an ingrained reflex to simply get up and treat each and every patient whenever and wherever they might be. We now churn out wonderfully trained young doctors who are accustomed to regular hours and schedules, trained to pass off responsibility at the end of the shift.

Lastly, the inexorable trends of declining reimbursement for each service and excalating expenses and buraucracy have combined with the above to cheapen, in the minds of many, many physicians, their sense that the sacrifices that a physician may make in their personal life are acknowledged and valued by patients personally and society in general. Leave a family gathering when you are not on call in order to provide complex, high-risk care for little or no re-imbursement, with the attendant increase in liability? Tough call. Put yourself in that position when you are on call when doing so will put additional downward pressure on your income, and do so without compensation? Another tough call.

I am a specialist, one whose services are difficult to obtain by ER's, and I DO cover our ER's. But I am sympathetic to the issues brought up by the docs involved, and have little sympathy for those who would simplify these issues in search of sound bites, etc.

My world is hard, Maggie, and not getting any easier. Medicine is what I DO, but being a doctor is only part of who I AM. The dialogue necessary to understand both sides is well nigh impossible on a blog.

[Maggie Mahar]

HC Berkowitz--

The great need for specialists covering the ER is not during the day, when they are in their office seeing patients, but at night, when they are home.

That's when it's hard to track down a specialist.

During the day, the patient can be sent to a doctor's office. For example, a few years ago, my husband cut his finger nearly in two--am ambulance took him to an ER, and then the ER directed him to the office of a hand surgeon a block away where the surgeon put his finger back together in the office. . .

But at 10 p.m. the doctor wouldn't have been in the office,and that's when someone needs to take call. Whether the hospital can afford to pay them or not depends on the hospital.

But certainly the $80,000 a year one doctor demanded for coming in for an hour or two twice month (if called)was excessive.

When you become a doctor, you know that sometimes you will have to leave a party, leave dinner, get up in the middle of the night--unless you pick a
specialty like cosmetic dermatology. . .

[Lisa Lindell]

Jenga, you're the one who started the finger pointing and "daring." If you don't need hospitals anymore, than don't use them. I was referring to you and others contributing an "effort" to improving the system for everybody, not just your zeal to be "in it to win it" so you get yours or paying dues. I'd love to hear about your efforts at reforming the healthcare system, I'm working with a research organization who would no doubt like to hear your input and feedback as well.

[jenga]

HC you hit the nail on the head. Years ago the ER was seen as a "practice builder". Obviously a way to get busy and be well compensated for the time with a higher population of insured as well as less of a demand for volume in the office. Now it is known as a "practice destroyer". What does it cost the physician for one uncompenstated case during the middle of the day that forces him to cancel 30-45 paying patients? Who knows. They are not only working for free they are losing money to take ER call. They don't have to be hit across the face with that skunk to realize, the hell with it, I ain't taking call.
Lisa- Good for you, but don't you dare question my effort I worked 5 years of 100+hour weeks for 25-29,000 a year. I've paid my dues and then some. I've worked 3 days straight before with no sleep, because imagine that people keep getting hurt. I done though, finished. They only way I walk into that ER now is if its worth my while, and warm fuzzies don't do it anymore. As far as "bartering" both parties have to bring something to the table to be successful. I can do 95% of my surgeries outpatient as well as 95% of my testing and other treatment, so why exactly do I "need" the hospital. I really don't. When a relationship is lopsided the other party has to bring something to the table to even things out and that now means compensation physicians for taking call.

[HCBerkowitz]

Maggie,

"I think the old system, which asked doctors to be "on call' a few day a month for the ER-- in exchange for being able to use the hospital's costly capital equipment, operating rooms, nursing staff, etc for free-- was fair. And back then, I'm quite sure that doctors themselves thought of it as fair."

OTOH, they thought of it as fair when they could earn a reasonable income without rushing a maximum number of patients through office visits. They thought of it as fair when they could build time to do hospital call on their hospitalized patients into their schedules.

They thought of it as fair when there wasn't a payor drive, and economic necessity, to turn care over to hospitalists, making them, I suppose, into "officeists". Certain specialties, of course, need to be hospital-based; I'd really wonder about a community that had a need for an anatomical pathologist or surgical anesthesiologist in solo practice.

[Lisa Lindell]

Oh yea, I forgot to mention in case I didn't make the point quite clearly enough. I was burning the candle at both ends for years, I would crawl under my desk at close my eyes in the afternoon from sheer exhaustion, after years of this crusade. One or the other had to go. In an effort to better balance my family with my committment to society, I walked away from my paycheck. I went for over a year with zero income, and worked on nothing but pt safety/medical errors/healthcare improvements...spending more money we don't have, volunteering ALL my time, selling almost everything we own. The threat of foreclosure forced me back into accounting. No I'm not a saint, I'm not suggesting others live their lives this way and quite frankly, I'm not proud of it, but you asked for it and you can just put that in your fahrfanugen and smoke it, Jenga.

[Lisa Lindell]

"They charge Medicare and Insurance companies for the use of said equipment" are you saying the physicians are performing procedures for free? They're not generating billable revenue to a third party as well? C'mon.
I never suggested I was a moral authority, but since you've decided you know me, now you will hear a rant:
"Don't suggest something you wouldn't have yourself or members of your family do." I'm not. First of all, I didn't suggest anything, Maggie rightfully pointed out volunteerism is part of professionalism. "Bartering" is not volunteerism. But since you brought it up...I don't talk any talk, I walk the walk. I have been a patient safety advocate for over five years now. My children have grown up and I missed it. My daughter moved away to live with her dad when she was 13, she's been gone over a year. It's like my right arm was cut off, but she doesn't want me to quit. In October 2006 I calculated just the financial costs my committment has cost my family, it topped $150k and I stopped counting. That's a lot of damn money for somebody who earns $45k a year. I bankrupted my family long ago. I spend almost every waking moment, and moments I should be sleeping, working on patient safety and healthcare improvements. I left my career (as an accountant) for over a year in an attempt to better balance this crusade with my family. I've sold my car, my husband has sold his tools, etc so I can travel across the country attending workshops. I've presented at same FOR FREE. I given away hundreds and hundreds of books, total cost to me is at least $25 a book, more if I'm shipping it overseas. Who cares? You think I'm interested in taking $20 bucks off Average Joe? Somebody thinks I'm "mad" at some doctor? Are you kidding me? This is my life, I live eat and breathe patient safety/medical errors, healthcare improvement, whatever you want to call it. On the rare events my husband is able to drag me to some event with the family, it's all I talk about, toss ideas around with everybody, it's constant and my entire family has sacrified for this crusade and thank goodness I have a very supportive family. Many do not. I vacillate weekly between quitting and digging my heels in further and it's people like you, Jenga, who make me wonder why I bother. If you devoted at least 1% of the effort that myself and many others like me have devoted, we might actually make some progress and we can all have a life someday. And it's a lot easier for somebody like you to improve the system than it is for me, because you're IN the system. No, I'm not martyring myself...you said don't suggest anything I wouldn't do myself and I'm just Throwing a big, fat TOUCHE right in your face.....I didn't suggest anything, I live it daily,.

[Lisa Lindell]

Jenga,
It is clear you're not bothering to actually read these posts in their entirety before submitting your thoughtful response. If you can't take the time, then why should I or anybody else? This is now the third time I will point out to you, NOBODY SAID DOCTORS SHOULD WORK FOR FREE and at least the second time I'm pointing out to you that nobody said other industries work every third night for free. Maggie said volunteerism is part of professionalism, which any professional would agree with, in ANY industry. Covering the ER in exchange for use of the hospital facilities and equipment is not working for free, have you ever heard of the word "barter?" Jenga, I think the only thing that will satisfy you is to open your own hospital where you can purchase everything yourself and charge whatever you want for your services, facilities and equipment, pay physicians however you see fit. Go for it.

[Lisa Lindell]

Jenga,
It is clear you're not bothering to actually read these posts in their entirety before submitting your thoughtful response. If you can't take the time, then why should I or anybody else? This is now the third time I will point out to you, NOBODY SAID DOCTORS SHOULD WORK FOR FREE and at least the second time I'm pointing out to you that nobody said other industries work every third night for free. Maggie said volunteerism is part of professionalism, which any professional would agree with, in ANY industry. Covering the ER in exchange for use of the hospital facilities and equipment is not working for free, have you ever heard of the word "barter?" Jenga, I think the only thing that will satisfy you is to open your own hospital where you can purchase everything yourself and charge whatever you want for your services, facilities and equipment, pay physicians however you see fit. Go for it.

[jenga]

Lisa-Are you saying all doctors should put their family second? What kind of moral authority do you have to suggest any sort of thing? Don't suggest something you wouldn't have yourself or members of your family do. What are these professions that get up every third night for free? I'm still waiting to hear what they are.

[jenga]

My point is this. It is a false arguement to say that hospitals are completely altruistic by "letting" physicians use their equipment and because of this physicians should take call and have a sense of community because of it. They charge Medicare and Insurance companies for the use of said equipment and if it was such a big burden on them, they would have no problem with physicians purchasing their own MRIs, PT departments, Labs and Surgery Centers so they didn't have to burden the hospital, but any hospital COO will have a BIG, BIG problem with that.

[maggie mahar]

Jeff C--

I basically agree that six hours is a very, very long time to wait with a small child and a broken arm.

I simply meant to contrast that with the cases where the medical problem could get much worse with a 6-hour wait. . .