Surviving the Medical Meltdown (4 page)

Ninety-five percent of doctors roll over and sign. Five percent refuse, and the government then, to make them examples, often adds criminal charges to the civil ones. In fact, recently, Dr. John Natale, a highly competent and respected vascular surgeon for many years, was released from federal prison. He was not charged with murder, rape, money laundering, drug trafficking, or securities fraud. No, he sat in federal prison because a government prosecutor claimed he essentially mis-dictated an operative note.
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At first, the Medicare squad tried to get him for overcharging the government. But he had the temerity to fight the charges in court, where it was shown he actually
undercharged
Medicare for his services. So having failed in easily squeezing his assets and having taken him to court, the Medicare squad created a new offense: they claimed he mis-dictated an operative report in an attempt to defraud the government. In the crazy world of Medicare, somehow having the wrong terms in an operative report (a fact disputed by several expert surgeons in this case) is enough to land you in jail. He spent ten months in federal penitentiary, and although I am not a lawyer, this seems to me to set a precedent not only in medicine but for nearly any business that does work for the government. Any form you fill out that is even remotely associated with billing can land you in jail for “fraud.” As you can imagine, this risk of prosecution does not inspire physicians to live and work in areas filled with retirees where the physicians
will be taking high volumes of Medicare and thus be subject to the whims of the Department of Justice.

Add to this the problems of central planning. As the Soviets discovered, central planning fails to anticipate market needs. The Central Committee could never predict how many tractors the farmers would need, so the Russian farmers either had too many (and not enough of some other machine) or too few, and the result was starvation. In modern medicine, ever since the 1970s the brainiacs in DC have used funding of medical education to regulate the number of doctors in the various specialties. I was in college in the late 1960s when students at liberal institutions of higher learning ran around sporting Mao jackets and waving the chairman’s “Little Red Book.” I suspect those are the very people in charge of deciding to cut the number of training slots for specialists, those holdovers from the sixties still being enamored of the concept of the “barefoot doctor.” They have been preaching for years that we have too many specialists and need more primary care doctors. As a result, today we have only five thousand oncologists in the nation to treat our cancer patients. We have not added training seats in orthopaedics for many years in spite of increasing demand for total joint and trauma care. Nationwide, there are thirty thousand general surgeons, and twenty-four thousand orthopaedic surgeons. In the last twenty-five years, the number of general surgeons has declined 26 percent when compared to the population they serve. One-third of all surgeons are over fifty-five years old, and 30 percent say they would like to retire within the next several years. Yet we train only about 650 each year.
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Ever tried to find a rheumatologist? Or a physiatrist (complex rehabilitation specialist)? They are rarer than hens’ teeth. These doctor shortages are completely a result of the central planning of the 1970s.

Let’s review what it takes to become a physician. Prior to 1960, many physicians became general practitioners (GPs). They had three to four years of college, four years of medical school, and a year of internship – seven to eight years in all. Today there are no GPs, and everyone does at least four years of college, four years of medical
school, a year of internship, and two years of residency. A general, neurologic, or orthopaedic surgeon does four to six years of training after residency, so the total time to produce one surgeon from the time of graduation from high school is fourteen to sixteen years. As in industry, the longer the pipeline, the longer bad production decisions ripple through the economy.

In a free market, such shortages don’t happen because the myriad observers and participants in the field make little day-to-day adaptations to increase or decrease production. But for years now, the hierarchy of graduate medical education has imposed Soviet-style central planning on the most precious commodity in medicine – the supply of physicians. Needless to say, predicting trends in populations as well as accounting for the rapidly changing science of medicine makes central planning of doctors impossible. But “central planners” keep trying. I have not found one specialty organization or one medical policy thinker who suggests letting demand for physicians determine the number of training positions available.

These shortages are about to get much worse: doctors are opting for early retirement or less productive shift work as hospital employees, and medical students are choosing specialties that have shorter training times and are not so damaging to their lifestyles. My son is a medical student at a private medical school. As he and his classmates discovered recently, they cannot pay back the cost of their medical education if they go into family practice or, in fact, anything but one of the top-paying specialties. And there are not enough training slots in the nation for everyone to do that.

I am an example of a highly trained physician being less productive than I would have been in a free market. I spent four years in college, four years in a private medical school, five years in orthopaedic residency, and a year of spine surgery fellowship. After all that, I worked for years in private practice. During those years, I worked eighty-plus-hour weeks, did six to twelve major spine cases a week, and took high-level orthopaedic trauma calls at a major regional medical center twice a week. I employed three full-time and four
part-time employees. But one day I recognized I was on a treadmill running faster and faster just to pay my overhead. Ten years after being fully established in practice, having a three-month waiting list for my clinic visits, filling and overfilling my operative time every week, I was making less and less money, had less and less time for myself or my family, and became generally dissatisfied. Today, after twenty years in private practice, I work as a private contractor for a small community hospital in rural America. I work twenty hours a week, do no major spine surgery, and have no employees, but I fill a need in an underserved area. I have lots of free time to enjoy my friends and family, and I do nearly as well financially as I did before.

A word needs to be said here about the impact of income taxes on physicians. I am always amused when some politician says he or she is going to save small businesses by lowering the corporate income tax. Besides the fact that the tax lowering is usually in the few-percentage range, small businesses do not generally pay corporate taxes. They pass their profits through to their owners, who pay
personal income tax
. So to help, government must lower personal taxes. The personal income tax is especially damaging to physicians. Let’s face it. Many other types of businesses are able to do some cash business or barter for goods and services – transactions that do not always make it to the 1040 report. On the other hand, doctors’ incomes are almost exclusively from companies or the government, who faithfully report that income to the federal and state governments. We may be able to maximize the tax laws, but it is virtually impossible for us to hide income (and note to the IRS, having learned from Leona Helmsley, I would
never
try to do so). But on the gray and black fringes of the American economy, hiding income from the tax collector makes the difference between profitability and failure for many self-employed businesspeople.

In real terms, I am in the top tax bracket of 39.6 percent federal taxation. I pay 9 percent to the state, 8.5 percent in sales tax, and thousands in property taxes and local bonds. It is not an unreasonable estimate that more than 50 percent of my income goes to the
government. Now, there are those who think doctors are rich and should belly up. Go ahead and keep thinking that, but at some point I am not going to work all night, standing in thirty-five pounds of lead, getting exposed to radiation and diseased blood and bone in order to give 50 percent of my labor to the government. I’d rather work less, have a life, and use my labor to my own ends – growing food, sewing clothing, building an add-on to my house, etc. And as more and more physicians have had the same epiphany, they, like me, have opted to work less. My podiatrist friend has an employed wife, also a professional. If she works more, he works less, since anything more would simply be taxed away. In Canada, a physician’s pay is capped. If you do orthopaedic surgery or obstetrics, for example, after you have earned a certain amount, you can continue to see patients, but you will not get paid a dime more. Those physicians can be found in November and December in Florida, lounging on the beaches. In Sweden, an oncologist is paid for only a certain number of patients a day – then goes home early to fish. In America, we tax professionals into not working.

The government has made those doctors who are still working woefully inefficient by forcing them to comply with ever-more-complicated regulations – most notably by demanding they use electronic medical records (EMRs). Many physicians say they are at 50 percent productivity because of the electronic medical record. I know I am. What I can dictate in five minutes takes me twenty to forty minutes on the computer and still results in an inferior note. When I dictated my notes, I could see twenty or more patients in the morning and have my dictations mostly done. Now, I see fewer patients and save all charting till after work, thus lengthening my day for no financial benefit and to the detriment of accurate patient history.

In sum, in the near future, as doctor retirements accelerate, there will be many underserved areas. Finding a doctor will be harder and harder, especially for the poor, the rural, and the elderly. In
chapter 14
, I discuss the strategies for finding a doctor who will be there when you need him or her, and for alternatives to the classic MD or DO.

Finally, the government has so overregulated medical education that the young doctors today are not trained to the former high standards. I know this firsthand having watched my son go through four years of medical school. When I went through medical school, I delivered thirty-four babies. He has delivered zero. When I trained I was always starting IVs and drawing blood. If he had not worked with me at my hospital, he would not know how to start an IV, and he is a senior medical student! Between fears of liability and the Medicare regulations, students today do not get their hands dirty, figuratively speaking, of course. Years ago Libby Zion was a patient at a teaching hospital in New York who died of cardiac arrest. Her lawyer father sued claiming it was due to poor judgment by the student residents because of their long shifts at the hospital. After that the government decided students and residents should be limited in the hours they can be in the hospital working. Now if residents are in the middle of a surgery case when their hours are up, they must scrub out and leave it to others – a luxury not afforded to surgeons in private practice. During my surgical residency we joked that the problem with being on call only every other night was that you missed 50 percent of the good cases. Today’s residents are taught a blue-collar shift work mentality, which has no place in the care of patients or the practice of medicine. And they are not getting trained. The advisor for my son’s surgical candidates has told them they should plan on doing another year of training after the five-year general surgery residency because those five years will not give them enough training to be competent! So when we look at physician man-hours in America, we must understand that a newly minted physician will be able to handle less than those trained in previous decades.

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WHY YOUR DOCTOR IS OUT OF DATE

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n 1976, during medical school, I listened while the lecturer in biochemistry explained why the optimum dose of aspirin to prevent clotting in heart vessels was 82 milligrams, or one baby aspirin a day, not the two-aspirin-a-day regimen used at that time. Yet in 1996, when I was first in practice in Arizona, I noticed that most patients were still taking two full aspirin for this purpose – a dose shown over twenty years before to actually work
against
the desired effect by turning off the anticlotting mechanism of the arterial wall.

I was shocked to think that doctors were practicing twenty-year-old medicine, employing a regimen that was in direct conflict with basic biochemistry. Subsequently I have learned this is not the exception but is the abysmal mode of practice in America. There are at least three major factors that have contributed to this sad state of affairs: state medical boards, clinical “groupthink,” and an ineffective approach to information gathering. (Additionally, some doctors are wrong in their approach – not necessarily out of date, but just flat-out wrong – due to drug company propaganda.)

In any aspect of life, there have always been the herd and those who break out of the herd with new ideas. Galileo broke from the
pack to change our view of the solar system; George Eastman threw out wet plates in favor of dry photo plates and overnight changed photography. Joseph Lister revolutionized surgery with carbolic acid antisepsis. These people became leaders by adopting different perspectives on old problems. But if Joseph Lister were alive today and proposed carbolic acid for asepsis, he would risk being sanctioned, even de-licensed, by his state medical board. Why? Because state medical boards use the concept of “standard of care” in determining if a physician is right or wrong in his or her treatment. If you are practicing the methods used by 90 percent of your peers, you are “correct,” but if your treatment falls within that other 10 percent, you are
wrong by definition
. Never mind that within that 10 percent are the new, improved ideas in any specialty. This concept of “standard of care” is an absolutely guaranteed formula for mediocrity that would ruin any other industry. Imagine if the electronic industry used this method for evaluating good engineering design. We would be using rotary phones and an abacus! Edison and Tesla would have been jailed in such a society. Yet we accept this worldview as normal in medicine. As I am writing this, the number one reason for being taken to task by a state medical board (punishment can range from a letter of reprimand to taking away a doctor’s medical license) is “overtreatment” of hypothyroidism. Unfortunately, medical boards are using outdated science to punish up-to-date physicians.