Physician Independence


Dr. Daniel Craviotto, an orthopedic surgeon in Santa Barbara, Calif., wrote this really nice op-ed piece for the WSJ.  I highly recommend you read it but since many of you cannot due to the WSJ’s subscription policy, here it is:

In my 23 years as a practicing physician, I’ve learned that the only thing that matters is the doctor-patient relationship. How we interact and treat our patients is the practice of medicine. I acknowledge that there is a problem with the rising cost of health care, but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it.

As a group, the nearly 880,000 licensed physicians in the U.S. are, for the most part, well-intentioned. We strive to do our best even while we sometimes contend with unrealistic expectations. The demands are great, and many of our families pay a huge price for our not being around. We do the things we do because it is right and our patients expect us to.

So when do we say damn the mandates and requirements from bureaucrats who are not in the healing profession? When do we stand up and say we are not going to take it any more?

The Centers for Medicare and Medicaid Services dictates that we must use an electronic health record (EHR) or be penalized with lower reimbursements in the future. There are “meaningful use” criteria whereby the Centers for Medicare and Medicaid Services tells us as physicians what we need to include in the electronic health record or we will not be subsidized the cost of converting to the electronic system and we will be penalized by lower reimbursements. Across the country, doctors waste precious time filling in unnecessary electronic-record fields just to satisfy a regulatory measure. I personally spend two hours a day dictating and documenting electronic health records just so I can be paid and not face a government audit. Is that the best use of time for a highly trained surgical specialist?

This is not a unique complaint. A study commissioned by the American Medical Association last year and conducted by the RAND Corp. found that “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction.”

In addition to the burden of mandated electronic-record entry, doctors also face board recertification in the various medical specialties that has become time-consuming, expensive, imposing and a convenient method for our specialty societies and boards to make money.

Meanwhile, our Medicare and Medicaid reimbursements have significantly declined, let alone kept up with inflation. In orthopedic surgery, for example, Medicare reimbursement for a total knee replacement decreased by about 68% between 1992 and 2010, based on the value of 1992 dollars. How can this be? Don’t doctors have control over what they charge for their services? For the most part, no. Our medical documentation is pored over and insurers and government then determine the appropriate level of reimbursement.

I don’t know about other physicians but I am tired—tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces. The legal profession would not. The labor unions would not. We as physicians continue to plod along and take care of our patients while those on the outside continue to intrude and interfere with the practice of medicine.

We could change the paradigm. We could as a group elect not to take any insurance, not to accept Medicare—many doctors are already taking these steps—and not to roll over time and time again. We have let nearly everyone trespass on the practice of medicine. Are we better for it? Has it improved quality? Do we have more of a voice at the table or less? Are we as physicians happier or more disgruntled then two years ago? Five years ago? Ten years ago?

At 58, I’ll likely be retired in 10 years along with most physicians of my generation. Once we’re gone, who will speak up for our profession and the individual physician in the trenches? The politicians? Our medical societies? Our hospital administrators? I think not. Now is the time for physicians to say enough is enough.

All great thoughts.  I couldn’t have said it better myself.  Wait a minute, I have been saying for years on this website?  The problem is that that we, as a group, are wimps.  Our organizations that represent us are neutered.  And we are just comfortable enough NOT to do anything. Remember, “comfort makes cowards of us all”.  We are all cowards.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  3 comments for “Physician Independence

  1. Stella Fitzgibbons MD
    May 7, 2014 at 12:26 pm

    I recently had a partner tell me that I needed to be less confrontational. This was after an administrator cancelled an order from a doctor without even the courtesy of a phone call, and another one objected to my refusing to discharge a patient whose previous facility couldn’t explain the injuries present on admission (because it would increase both “length of stay” and “avoidable days”). I am sad to say that I now work at a facility for the well-insured, because I no longer get the support from hospitals that is needed to take care of patients who lack funds or proactive families to ensure that they get the care they need.

  2. Pat
    May 4, 2014 at 12:16 pm

    I had a long conversation with friends last night explaining these very points. My conclusion was that the accelerating disconnect we see occurring between physicians and patients is a logical consequence of the external forces, mandates, threats, and loss of control which physicians now suffer. We are wimps, and cowards of comfort, and this was in great measure chosen by our patients who believe they have a right to our work, and by their politicians who have been happy to steal our efforts.

    The best we can do is a nationwide strike, which I favor. Absent that, we will continue to see the long, gradual strike of early retirement that too many of us cannot yet join.

  3. Steve Roberts
    May 4, 2014 at 9:42 am

    But when attrition takes care of the present supply of doctors and patients, who will be left to remember how things were? So who will care?
    In case you’re wondering, reread Orwell’s 1984. Which, by the way, was the year DRG’s were instituted.

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