The Covert Rationing Blog

Another Reason To Let the Doctor-Nurses Take the Whole Thing

June 18th, 2008 by DrRich

According to NewScientist Magazine, David Fishbain, Professor of Psychiatry and Behavioral Sciences at the University of Miami, says that up to 1 in 20 patients would like to kill their primary care physicians.*

He learned this interesting tidbit in a survey he conducted among 800 patients undergoing physical rehabilitation or suffering significant pain. He presented his findings at the American Pain Society meetings in Tampa in May.

DrRich, who knows his readers, suspects that several who are physicians and who are unreasonably upbeat or excessively cynical (either personality trait will do) are at this moment thinking, “Sure they want to kill me. But as they’re disabled, their chances of success seem low.”

So chew on this. In a control group of patients not suffering from pain or disability, Fishbain reported that “only” 1 in 50 admitted to having murderous tendencies toward their doctors.

The math is not pretty: the typical primary care physician with a patient load of 3,000 souls can assume that at least 60 of these individuals (up to 150, if he/she treats a lot of patients with pain or disability) would not only like to see them dead, but would be pleased to be the instrument of their demise. (These statistics assume, of course, that everyone who wants to see their doctor lying lifeless in a pool of blood are comfortable admitting this fact to medical researchers doing written surveys.)

We have expended much space on this blog describing how physicians have been maneuvered into covertly rationing healthcare at the bedside, how they have allowed themselves to be limited to 7.5 minutes per patient encounter, and how they have acceded to spending those 7.5 minutes making little marks on a handed-down-from-on-high Pay For Performance checklist (thus leaving little or no time for whatever pressing issues may be on the patient’s own agenda). We have described how, to assuage guilt and to make such behaviors seem less than reprehensible, revered medical organizations have formally amended the code of medical ethics, thus officially wrecking the classic doctor-patient relationship - and committing professional suicide.

The fallout from these developments has landed disproportionately on the PCP, the gatekeeper for the bulk of expensive medical services, whose actions the healthcare system must control at any cost. The loss of PCPs’ professional integrity and their ability to act as autonomous advocates for their patients has done far more than the steady ratcheting down of their pay to make primary care medicine exquisitely unattractive, both to current practitioners and to potential future PCPs. (As per design, says DrRich.) Consequently, this carefully manufactured “PCP shortage” will soon become the medical crisis du jour.

When this crisis is finally ripe for unveiling, the healthcare system will be ready with a solution. Doctor-nurses (the healthcare system fervently hopes) will be more malleable than today’s PCPs, less encumbered by tradition, attitude, and delusions of autonomy, and more likely to follow whatever guidelines the “experts” choose to hand them.

But what about the risk to doctor-nurses from murderous patients?

If the healthcare system is wise enough to create enough of these doctor-nurses, they will be able to relax the 7.5 minute-limit-per-patient-encounter, thus decompressing some of the frustration patients now feel when they leave the doctor’s office, and preventing doctor-nurses from becoming as much a target for patients’ wrath as PCPs apparently are today. To receive that extra time however, doctor-nurses will need to use it wisely, unlike their physician forebears. They will need to spend it engaging in relationship-building and other feel-good activities, instead of (as physicians all too often are wont to do) uncovering new, potentially expensive medical issues that need to be explored.

Doctor-nurses are in the catbird seat, and as long as they follow the script and stick to the guidelines, they’ll be given enough time to keep their patients from hating them.

As for the soon-to-be-obsolete PCPs, DrRich has previously made them some friendly suggestions for salvaging their professional integrity, and he cannot understand why they are not adopting them. Are they waiting for the bullets to fly?

*Thanks to Laura Dolson, Guide to Lowcarb Diets at About.com, for pointing DrRich to this important study.

Posted in Primary Care in America

7 Responses to “Another Reason To Let the Doctor-Nurses Take the Whole Thing”

1. Adrienne Dellwo wrote on 06/18/08 at 2:05 pm :

   Perhaps the health-care system needs to speed up this transition - in my experience, nurses are far better at connecting with people, while too many doctors view us as a collection of symptoms. When I have a problem that needs medical attention right away, I’m quite happy to see a nurse practitioner in my PCP’s office or at urgent care. They take more time, ask more (and better!) questions, and give me a lot more information about my diagnosis (or possible diagnoses) and prognosis.

2. Dr. Val wrote on 06/18/08 at 2:54 pm :

   My doctor is following your suggestion, Rich. And it’s wonderful.

3. DrRich wrote on 06/18/08 at 3:20 pm :

   Adrienne,

   I am pleased that you merely say to PCPs, “Don’t let the door hit you in the a**.” This is far kinder than attempting to kill them. If some more humane option such as yours (i.e., telling doctors to “Get lost, I’ll go with the nurses”), had been available in Dr. Fishbain’s survey, it is frightening to think how high the tally might have been. As it is, PCPs might be taking inappropriate comfort in the apparently false notion that only 2 - 5% of their patients wish them ill.

   Rich

4. DrRich wrote on 06/18/08 at 3:21 pm :

   Val,

   So’s mine. Wouldn’t have it any other way.

   Rich

5. Jared wrote on 06/18/08 at 3:29 pm :

   Dr. Rich, if it makes you feel any better, I’m certain a higher proportion of medical students wish to kill their medical school administrators and instructors.

6. Dan wrote on 06/19/08 at 7:18 am :

   So, You Want To Be A Doctor…..

   Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason stated and speculated for this decline of this health care profession that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training.

   Yet considering the additional attention of shortages of students in some medical schools as well, one may ask the question as to whether or not people want to be any type of doctor in the first place in the United States. About one third of their lives are spent achieving the requirements of this profession. Reasons for not choosing to enter this profession are several and valid and include the following:

   There is the issue of long hours- with primary care in particular because of the apparent lack of doctors of this specialty. Such doctors may be over-worked without an expected pay reflecting the work they do. Furthermore, those doctors employed by health care systems are required to see a certain number of patients a day, and receive a monetary bonus if this expectation is exceeded. It seems that most doctors are members of such health care systems. So burnout never anticipated certainly may occur. And I consider such a requirement mandated by health care systems demeaning to this profession, and leave the doctor without the control that the doctor is entitled to due to their training and experience, and this competes with the other adversary of doctors, which is managed care. In fact, even government healthcare programs provide financial incentives in relation to the pay-for-performance system to improve the quality of care.

   However, the recent increase in hospitalists, who are those doctors that are usually Internal Medicine doctors who care for patients presently under hospital care, and they have lessened the load for all doctor specialties for the work they do that the admitting doctors would have to do without their presence. This in itself makes a doctor possibly more effective and efficient in their practice outside of the medical institution.
   All doctors, I presume, face a high degree of emotional and physical stress associated with their profession, as stated in the previous paragraph, for example. And this is not to mention the incredible stress associated with patient care in the first place, with some patient cases causing more stress than others. Patient care duty is a noble and great responsibility.

   Doctors, due to the changes that have occurred recently in the U.S. health care system, not only have the issue of money to deal with, but also a loss of autonomy regarding patient care combined with loss of respect that may be due in large part to the others previously mentioned who dictate how they practice medicine. Ironically and often, these others who direct these doctors are not as qualified as the doctor in the first place. This is complicated by the perception that the public, with some who view doctors as having the easy life with their pay and profession, which does not seem to be the case presently. Another frequent occurrence is the doctor’s patient directing their care with their doctor from either DTC ads or researching medical disorders on the internet themselves.

   There are also reasons of malpractice insurance, which is why doctors choose to join health care systems, it is believed, to pick up the tab for this necessity, along with eliminating the concerns of running a practice in a private manner, which historically has been the case, as their offices are owned by the health care system as well. Yet having another pay their malpractice premium does not eliminate their concern about being sued for error perceived by one of their patients. To protect against this, defensive medicine is implemented by doctors, which basically involves copious amounts of documentation and ancillary diagnostic testing regarding the doctor’s adherence to recommendations and guidelines.

   It has been said that up to 90 percent of malpractice cases against a doctor are baseless and without merit, so they are unsuccessful for the plaintiff, yet this still affects the rate the doctor or another system has to pay for malpractice insurance of a wrongfully accused doctor. This is combined with the amount the doctor has to spend to defend themselves in such cases, which separates them from their focus on the restoration of the health of their patients completely. Furthermore, malpractice lawsuits cost about 100,000 dollars over the course of about 4 years for such cases. A tort reform in Texas in 2004 resulted in annual malpractice premiums reduced by about a third of what they were. Soon afterwards, claims against doctors remarkably dropped by about 50 percent. Some specialties of doctors pay more premiums for malpractice than others. For example, OB/GYN doctors have been known to pay around 300 thousand dollars a year for this insurance. Certain types of surgeons experience a similar high rate of malpractice premiums. Malpractice flaws are catalysts for doctors to practice the inappropriate defensive medicine mentioned earlier to avoid potential litigation, which is a waste of health care resources with ordering unneeded patient methods or procedures to cover themselves against such lawsuits.

   Also, about a third of the U.S. is insured by Medicare, which progressively has lowered what they will reimburse a doctor for regarding the care doctors give a patient they treat. This fact is recognized by other insurance companies who will eventually follow the recommendations of Medicare, usually, regarding the reimbursement issue, so it seems. This will lead to a doctor having to see even more patients in order to make it financially with their profession, as this has resulted in the overall income of a doctor experiencing a decline of about 10 percent over the last decade or so.

   Further complicating the financial state of a primary care doctors is that doctors normally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed. About 20 years ago, that debt was only about a fifth of what it is today. Paying this debt off is typically about 2 thousand dollars a month that doctors on average is what the doctors choose to pay in order to eliminate this debt in a timely fashion.

   Conversely, there are some who believe that doctors in the U.S. are over-paid. This may be true, but they are not absent of financial concerns as with any other profession. And as mentioned earlier, clearly doctors accept more responsibility involved with human health than other vocations, so this should be kept in mind perhaps more by others.

   Most doctors do not recommend their profession to others for such reasons stated in this article so far presently, and perhaps other reasons not mentioned. This is somewhat understandable, yet extremely unfortunate for the health of the public in the future. There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state of mind that occurs as a doctor in today’s health care system, which is expressed by them at times in apathy, cynicism, and vexation regarding their limitations coerced by others.

   Conversely, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession. Personally, I believe that the intentions of most physicians are bonafide. Yet in time, due to the nature of the current health care system, doctors frequently and really do become cynical, demoralized and apathetic. This may be considered a significant concern to the well-being of those in need of restoration of their health, understandably.
   Not long ago, the medical profession that has been discussed had overt honor and a clear element of nobility. Such traits are not as visible or recognized anymore, which saddens many intimate with the profession and importance of public health that is needed by many.

   “In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero

   Dan Abshear

   Author’s note: What has been written has been based upon information and belief.

7. Theresa wrote on 06/19/08 at 8:42 am :

   I’ve had patients stand in the hallways of our clinic, threatening staff and yelling because we wouldn’t provide them with what they wanted.

   I wonder if DNPs will end up being held to the same P4Ps as physicians? That might put an end to the extra time they now have for patients.

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