Doctors on strike, raising banners at rallies, canceling appointments with patients to meet with politicians? Physicians in at least five states were so desperate about rising malpractice insurance rates and, in some cases, their inability to buy insurance at any price that they did just that in January and February. President Bush has taken their part, telling the American Medical Association recently that "if lawsuits are running up the cost of medicine [and] driving docs out of business, we've got to do something." But even if his bill to impose a cap on malpractice jury awards gets through the Senate -- the House approved it Thursday -- it will fall far short of fixing what really ails the medical profession.
I am a doctor, from a family of doctors, and the word "strike" is simply not a word we associate with what we do. For us to feel that a work stoppage is not just defensible but unavoidable is a sign of the profound unhappiness affecting American doctors -- and of concern for the future of our calling. The protests over crippling malpractice costs that shut down clinics and hospitals in New Jersey, West Virginia, Pennsylvania and several other states in the past few months address only a tiny part of the problem. Broader financial and regulatory pressures have become so onerous that I've seen many colleagues in the Washington area opt to retire early, and none of us feels much like encouraging young people to replace us when we know the impediments they will face.
I'm actually one of the luckier ones. I graduated from medical school in 1966 and over the years, I've built up a practice of my own. When I started out, doctors charged and patients paid -- or didn't if they couldn't afford it. Now doctors negotiate with insurance companies -- or don't, as I and a small number of my colleagues are in a position to refuse to do, though I have reluctantly chosen to continue to deal with the Medicare system. For the most part, I ask my patients to pay me directly, as lawyers and other professionals ask their clients to do, and then seek reimbursement from their insurance companies themselves. This approach gives me control of my practice and lets patients assess directly whether my services are worth what I charge. I am, of course, free to reduce my fees, and I often do. Against the tide, a handful of us thus work directly for our patients, rather than, in effect, for a third party.
My family's experiences, however, show that the prospects for young doctors to enjoy even this limited degree of independence are shrinking. At one end of the spectrum is my older children's paternal grandfather, a family doctor in Los Angeles who practiced into his early eighties, made house calls in the middle of the night and was often "paid" with cups of chicken soup. At the other end is my brother, a kidney specialist who works greatly extended hours because he still loves medicine. Then there's my sister-in-law, who spent most of her career as an emergency room physician but now heads a large employee health program, in part to reduce her exposure to the risk of lawsuits. My elder daughter and her husband, both cardiologists, have found less lucrative but more stress-free niches in which to work: He's an academic, and she has a salaried position with a private practice in Washington. But what do I tell my younger daughter, who, at 25, is thinking of going to medical school, which means at least 10 years of training and huge indebtedness before she will even begin to practice?
None of us went into medicine for money and none of us is fabulously wealthy, which is the way it ought to be. But we never expected to be harassed and "supervised" by government officials and insurance company clerks citing unreadable "treatment manuals," and we certainly didn't expect to be treated as fungible by the corporations that are increasingly likely to become our employers. What I worry about is the discouraging effect on young people of this growing encroachment on doctors' independence.
The face of American medicine -- or what is now called without irony the "health care industry" -- has changed almost beyond recognition within a very few generations, and the reasons for this are financial and organizational. First, there is Medicare -- and, to a lesser extent, Medicaid. The Mayo Foundation has estimated that the regulations and supporting documents that doctors and hospitals must comply with in treating Medicare patients total more than 110,000 pages; that's six times the size of the U.S. Tax Code. Yet Medicare arguably does as much harm as good. For one thing, it pays so poorly that fewer and fewer doctors accept Medicare patients even as larger proportions of patients qualify for it. Even worse, though, may be the damage it has done to the crucial relationship of trust between doctors and those they treat.
Several years ago, patients began to be encouraged to report their physicians to Medicare if they thought the latter were engaging in "waste, fraud and abuse." I don't doubt that there are doctors who run Medicare mills, but is there a need to paint with such a broad brush? I recently received a letter from the Medicare intermediary for my area alleging a modest overcharge -- less than $20, as I recall -- in the most abusive language and threatening me with dire reprisals if I failed to pay by a given date, which had already passed. (The letter was based on a computer-generated Medicare "coding" claim that would have cost more in staff time to investigate than the claim was worth.) Why was I being treated as an adversary? What other skilled professionals endure regular harassment simply to get their bills paid? And what are the long-term consequences of moving to a health care system so bristling with regulations that "providers" need computer programs and clerks equal to those of insurance companies and government agencies? Surely no one believes that the vast sums spent to wage such paper wars will lower the costs of health care or improve its delivery.
Then there is the issue of so-called malpractice -- a rapidly growing income-transfer system from doctors to lawyers that, quite apart from its toll on doctors, gives injured parties ever-diminishing shares of the proceeds. In some states, malpractice insurance premiums have reached six figures in certain specialties, particularly obstetrics and gynecology, threatening to put a number of doctors out of business and triggering this winter's strikes. Mistakes certainly occur in medicine, as they do in any profession, and it is right for badly injured parties to be compensated. But do we need to involve lawyers in the fact-finding or compensation process? Clearly, too, physician conduct needs to be evaluated, perhaps by a publicly chartered body of medical experts -- with appropriate compensation provided to people injured through negligence. And there must be a system for removing from practice those physicians who are guilty of multiple errors. (As I know from my service on the D.C. Medical Society's disciplinary committee, this is now, ironically, made exceedingly difficult by the threat of suit from those under scrutiny.)
Reforms of the fact-finding and disciplinary processes, combined with the current requirement for doctors to retake their board certification exams every 10 years to ensure that they are up-to-date in their areas of practice, would save us all the high costs of defensive medicine and the higher costs involved when physicians are pressed to think of patients as potential adversaries.
It would be a pleasure for me to be able to tell my daughters that they can look forward to careers as fulfilling as mine has been. Right now, all I can say is that they can probably count on making a living.