A John Galt Speech For Direct-Pay Practitioners

DrRich | September 12th, 2012 - 6:52 am

Very few of you will have read the final chapter of my new book (judging from the early sales figures, at least), and so most of you will not have read the John Galt speech I provided there for direct-pay practitioners.

Long time readers of this blog will know that I am a strong proponent of direct-pay practitioners, of doctors who “drop out” of the system to establish medical practices in which they are paid directly by their patients. This kind of arrangement is the only way today for physicians and patients to enjoy the classic doctor-patient relationship; you know, the relationship where the patient agrees to confide completely in the physician, and the physician agrees to work solely for the benefit of the patient.

In the modern healthcare system, especially under Obamacare, this classic form of the doctor-patient relationship is not only frowned upon, but is considered unethical. It is unethical because doctors have formally adopted a “new ethics” which obligates them to work for “social justice,” which is a pleasant-sounding euphemism for covert bedside healthcare rationing. The direct-pay model allows physicians to avoid this odious new responsibility.

The entire healthcare system today is disposed to hate the direct-pay model. The reason typically given is that this model of practice will establish unfair “two-tiered” healthcare, the new, undesired tier, of course, being the one in which patients would enjoy the benefits of a professional advocate who is looking out for their individual needs. Accused felons can still enjoy such a personal advocate as they face a complex legal system, but not so for patients facing a hostile and parsimonious healthcare system.  (If patients do not like this, well, they should have taken better care of themselves.)

Direct-pay physicians are being castigated all across the land for being greedy, elitist, selfish, lazy and unethical.  And if they cannot be shamed into returning to the medical gulag, they will soon be prosecuted into doing so.

When the attacks become serious, direct-pay doctors need to be prepared with a clear and compelling answer; an answer that does not offer any apologies; an answer that does not rely on the “goodies” that go along with having a direct-pay physician (things like same-day appointments, or access to the doctor’s cell phone number and e-mail address); an answer that instead boldly expresses in plain language that what they are doing does not destroy but salvages medical ethics, and indeed, it is the ONLY way that remains for doctors to practice their profession ethically.

What direct-pay doctors need is a John Galt speech.

And since I fear most of you have missed it, I reproduce my proposed John Galt speech here.

(I have liberally borrowed parts of the first three paragraphs from the actual John Galt speech in Atlas Shrugged. The blame for the rest of it falls solely upon your faithful author.)

A John Galt Speech For Direct-Pay Physicians

“You demand to know what has happened to us, the physicians you thought you controlled. You have cried that our sins are destroying the world and you have cursed us for our unwillingness to practice the virtues you demanded. Since virtue, to you, consists of sacrifice, you have demanded more sacrifices at every turn. You have sacrificed all those evils which you held as the cause of your plight. You have sacrificed justice to mercy. You have sacrificed independence to unity. You have sacrificed wealth to need. You have sacrificed self-esteem to self-denial. You have sacrificed happiness to duty.

“While you were dragging us to your sacrificial altars, we physicians who value justice, independence, reason, and self-esteem – we finally came to see the nature of the game you were playing, which we had previously been too innocently generous to grasp. And we have chosen to play no longer.

“All the physicians who have vanished from your system, the doctors you hated, yet dreaded to lose, we are gone from you. Do not cry that it is our duty to serve you. We do not recognize such duty. Do not cry that you need us. We do not consider your need a claim. Do not cry that you own us. You don’t. Do not beg us to return. We are making our own way, apart from you.

“In your cynical attempt to control the healthcare system, you have coerced us – with your threats to our livelihood, threats of massive fines, threats of jail – to abandon our sacred obligation to our patients. Society must come first, you say. The needs of the collective are paramount, you insist. We must do what the experts tell us to do, you demand. And in the process you have destroyed the doctor-patient relationship which is the backbone of our profession. You have reduced physicians to ciphers, to puppets. And you have reduced our patients – the living, loving, hoping, striving people who come to us, who place their trust in us and their lives in our hands – to interchangeable members of a vast herd. You have demanded that we guard society’s interests, and abandon our sick to their own devices in your cruel and parsimonious healthcare system.

“Your process is now firmly established. Your methods have been legislated by Congress, embodied in volumes of rules, regulations and “guidelines” (strictly and ruthlessly enforced), upheld by the courts, and finally (and most tellingly) sanctioned as being entirely “ethical” by your allies, the leadership of our own professional organizations. You have made the healthcare system untenable for doctors who value true medical ethics.

“You have placed us into a position where we must either resign ourselves to an unethical, demeaning, health-destroying style of practice, or get out. We have gotten out.

“We have gotten out. We have left your Program. We refuse to sacrifice ourselves for you any longer. We will not sacrifice our livelihoods, our morals, our independence, our minds, or our patients for your bastardized idea of virtue.

“We will practice medicine in the only manner that still permits us to behave ethically toward our patients, in the only way that we can honor the true doctor-patient relationship, in the only way we can legitimately regain the title of professional. We have chosen to be paid directly by the people to whom we provide our services, by the people to whom we dedicate ourselves as professionals. We have chosen to cut you out.

“To argue that direct-pay practices are unethical – to argue that any innovation that would somehow restore both our professional integrity and the patient’s rightful advocate is unethical – is completely upside down. This argument only reveals your own inner corruption. We are taking the only pathway that remains to us to restore the true foundation of medical ethics, to restore our profession – to always place the patient first.

“To argue that direct-pay practices threaten the general welfare completely ignores reality. We are doing the only thing we can do to begin restoring protections that people are supposed to have when they are sick and facing a healthcare system that is utterly bent on withholding their care whenever it can be gotten away with.

“To argue that direct-pay medicine will create a two-tiered healthcare system is absurd on its face. It provides a mechanism by which at least some of your intended victims can escape the deadly obstacles you have laid before them. Saying that it amounts to a two-tiered healthcare system is as absurd as arguing that slaveholders were wrong to free their slaves before Emancipation, because doing so would create an elite subpopulation of former slaves; that until all slaves are freed, no slaves should be freed. But when a few slaves were freed and walked the earth as free men, that action was not only ethical, but it also showed others what was possible. Over time, it created a widespread expectation for freedom that eventually could no longer be ignored, and that, at huge cost, was finally fulfilled.

“You wouldn’t understand this – you who already know everything, you whose experts already have all the answers – but any innovation that can potentially spare patients from some of the harm you have in store for them will necessarily be applicable to only a few patients at first. That is how disruptive processes work. In your proposed perfect system, of course, disruptive processes are anathema – because they disrupt. But in the real world disruptive processes are creative processes, processes of growth, processes of rejuvenation, processes that create opportunity. This is why you always try to suffocate disruptive processes, with your cries of “unfair!”

“Disruptive processes always begin as niche products or services, attractive only to a few high-end users; too expensive or too marginal for the vast majority; ignored, ridiculed or castigated by current providers. But if at their core they are offering something fundamentally useful, they will slowly demonstrate their worth – and eventually all the potential users will see the light, and demand for the product will become explosive. At this stage the means are invariably found to make the new product affordable and available to meet the demand, while preserving the core benefits. And when that happens, the traditional providers (who never saw it coming) are suddenly out of business.

” We are a disruptive process, and the process we are disrupting is yours.

“We are not playing your game any longer. We will no longer be victims; we will no longer subject ourselves to your attempts to make us guilty. We will no longer walk, heads bent down, to your altar of sacrifice.

“You no longer have any hold on us. We have done our time. We are getting out. If we decided to leave medicine and open a road-side fruit stand, or become lumberjacks, or just spend our time puttering around in the basement, you would have no objection to that. So by what right do you object if we hang out our shingles, and see a few patients who voluntarily come to us, using their own resources to do so? You can have no rightful objection to such a thing. So be quiet about it, or admit to your own corruption.”


Open Wide and Say Moo Now read the rest of the story!

DrRich explains it all in Open Wide and Say Moo! The Good Citizen’s Guide to Right Thoughts and Right Actions Under Obamacare

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10 Responses to “A John Galt Speech For Direct-Pay Practitioners”

  1. Laura says:

    As always, I greatly appreciate the information that you provide.

  2. james gaulte says:

    I am concerned that as the Maintenance of Certification movement gains momentum and clout that some of their requirements may well impact direct pay physicians to the point of doing away with their practice or making it so onerous that it will differ little from the current mess with various restrictions and obligations that swoop down from CMS and the other third party payers.I can envision a situation in which only docs employed by ACOs can jump through all of the MOC hoops which could even include mandatory treatment of a certain number of percentage of Medicaid patients. Then we would be talking about a real black market which so far seems to be the only typical outcome of price controls that has yet to happen in medical care.

    Lacking in optimism as always,


  3. james gaulte says:

    Whoops.While I am concerned with the MOC push (Maintenance of Certification) I confused the two in my previous reply. It is the MOL ( Maintenance of License ) that is the big threat that I thought I was writing about not MOC.Sorry.


  4. Kathleen says:

    Thank you, Dr. Rich, for sticking up for the traditional medical ethics. Patients need to “own” their own medical care, and their own health again, if they want real choices and personal attention. If someone else is paying, someone else is calling the shots.

  5. Dayna says:

    Absolutely, direct fee for service payment from Patient to Physician is the only way.
    …Consumerism had left medical care long ago. Patients haven’t a clue of the costs for meds, Office visits, labs, & other diagnostic modalities, and so on…
    It is time for the return.

  6. Becki says:

    But what happens to those of us over 70 who do not have the financial means to pay you? The “Board” will say we aren’t worth saving will deny the care we need, and we will die. This has got to be the absolutely most horrendous law ever passed. I was so hopeful… God help us all.

  7. Rob says:

    Dentists were smart and have adapted this system for decades. Few dabble in the government trough.

  8. CO says:

    I like the energy of this movement. It reminds me of the inspirational writings of Thoreau. Unless it can get some traction, the healthcare system is ruined. No intelligent person would ever choose to become a doctor now. Under Obamacare the game is lost. It is rapidly becoming everyone for him/herself, and the worst of socialism has yet to show its terrible face.

  9. Michael K MD FACS says:

    Becki, not all direct pay practices will be aimed at the high end. Right now there are older physicians who volunteer in community clinics. They are the logical providers for a lower end direct pay program. When I was a medical student a long time ago, hospitals had subsidized outpatient programs for low income seniors. Hospitals are part of the problem now but somebody will start to see the need and come through. The problem will be with hospital care and I don’t have a solution for that except to avoid them if possible.

  10. brilliant application of Galt’s speech

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