Physician Bill of Rights by Sudha Prasad, MD

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The Physicians’ Bill of Rights

For quite some time now, I have been reading about the state of medicine from physicians in the trenches. Their attitude has gone from dismay to alarm and then to stirring entreaties to fight against the forces that control our time and the care that we deliver to our patients. The articles, stories, and blogs all seem to fall into a few categories:

  1. I’m really smart. No one told me that things wouldn’t work out the way I planned. It’s so unfair.
  2. I can’t believe that no one appreciates the intensely arduous road to become a doctor. I know a lot but no one really cares. Everyone, and I mean everyone, thinks they’re smarter than me.
  3. I am barely treading water, trying to love my job and take care of my patients but the tide is rising and I am going under any day now.
  4. It’s time to fight back against all of the forces against us. If we could unite- but not take a risk that our rebellion will cost us our livelihoods-that would be great.
  5. I can’t get along with anyone anymore. I resent all the people I work with- administrators, extenders, specialists and staff. I need to get out but I don’t know how.
  6. HELP! I am so overwhelmed and I’m being eaten alive- but I’m so busy being eaten alive that I can’t help myself.

I may have missed a few types but most of the articles can be distilled into one of these. The plaintive mewling has got to stop. It’s time to put our heads together and come up with a PLAN. I propose that as physicians we band together to create a Bill of Rights that we universally adopt.

A couple of decades ago, the medical establishment adopted a patients’ bill of rights but we neglected to come up with one for the individuals who turn the wheels of healthcare 24 hours a day, 7 days a week. We shoulder the burden, assume the risk, provide the accountability and struggle to keep our patients healthy.

Here is a diagram which shows major gaps in the control physicians have in their profession. It should serve as a springboard to generate a bill of rights that we can circulate. We must demand adherence to them from the organizations that pressure us to perform and that control our streams of revenue.

bill of rights graphic (1)

Our professional organizations have not served us well for the most part. As a pediatrician, I am happy that the AAP does a great deal to advocate for the global welfare of children’s health. However, I have yet to see that care and concern extended to its members. Five colleagues of mine can’t afford to work as doctors anymore. And even though the AAP is separate from the American Board of Pediatrics, the relationship does not appear to be as distinct as they claim. Most major ABMS organizations have faced backlash from their member physicians regarding MOC and numerous articles have helped to publicize some of the egregious financial shenanigans in which these boards have participated. See the series which begins with this article:

http://www.newsweek.com/2015/03/27/ugly-civil-war-american-medicine-312662.html

Meanwhile the professional associations support the ABMS with inane MOC activities. I’ve been reading the biography of Alexander Hamilton, and I’ve been struck by comparisons between the academic physicians who work with these organizations to create MOC requirements to the opportunistic Tories who supported the Crown.

The lesson I draw from these writings is that it’s time to stop seeing ourselves as members of a particular specialty but instead as physicians who need to rise up against the numerous forces that try to divide us and conquer our morale and our ability to control our profession. We have permitted the colonization of our profession by not taking the reins and by letting every carpet bagger who arrives in town parade yet a new senseless scheme that lines only their pockets, leaves us with less and less and aggravates the already inflamed relationship we have with our patients more and more. (EMR, anyone?)

There are many broad categories of rights to be addressed so it’s time to take action and stop complaining. The exquisite writings, complex statistical studies, exhaustive analyses, and searing soul searching articles about the unwelcome changes in healthcare and our lack of control over it, have unwittingly served as a form of “SOMA”, (the ideal “pleasure drug” from Aldous Huxley’s A Brave New World), to distract us and to prevent us from recognizing our unique leverage in the medical power balance. For the most part, we are an intelligent group and we don’t need to prove it repeatedly by yet another “attitude survey” or statistical frolic into self-evident information.

The Bill of Rights is a good start but it will not be accepted until every physician who has ever been frustrated by the byzantine tactics of the government, insurance companies, and our medical specialty boards, decides that they will sublimate their frustration and self-pity and instead, turn their energy towards protecting their chosen profession. This means pressuring every group that has influence over our revenue including our specialty organizations, our politicians in government, our employers, our insurance representatives, our vendors, and our malpractice organizations as well as many others.

Once a Bill of Rights has been properly promulgated, how will we as a profession protect them and keep them enforceable? Perhaps these are sweeping questions that assume that massive changes will materialize quickly. But a bold vision is necessary before the details can flesh out a working order.

In every century, physicians need to re-write their place in history and with the arrival of the new millennium, it’s time for us to stand up, join together, and claim our rightful place. If we continue our craven, piteous whining in the face of the battalions that appear much more powerful, then our profession will hold the place that it deserves.

“The limits of tyrants are prescribed by the endurance of those whom they oppress.”- Frederick Douglass

 

 

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] 

  22 comments for “Physician Bill of Rights by Sudha Prasad, MD

  1. Phil Lavine
    August 29, 2016 at 10:30 pm

    Thought a lot about this. tired of ranting about how bad things are. Defining rights seems more constructive. Here are a few I’ve come up with. I’m looking forward to seeing some more.

    1. MDs have the most significant training and experience of any participant in the medical world. As such, no decision made by an MD should be challenged by anyone other than an MD of comparable qualifications. (This would require most inscos to hire physicians to do prior auths, a major time killer for us today)

    2. MDs should expect and receive respect from others — including colleagues, staff, administrators, patients and families of patients.

    3. MDs have a right to make a decent living and should be paid appropriately for their time and skill.

    I’m gonna keep thinking….

    • Sudha Prasad
      August 29, 2016 at 11:58 pm

      so happy that you are working on it…the more you add, the more discussion we can have..

  2. Gerald A. Shubs, M.D.
    August 27, 2016 at 2:39 pm

    Despite all of the rationalizations, excuses and anxieties, the bottom line for physicians is the ability to say “NO, I refuse.” Nobody will respect us unless we do so. We, as agents for our patients and ourselves, must control what we provide and take responsibility for. Some form of true, organized medicine, created and controlled by us, refusing to provide care for selected patients and having options to provide input for the payment of medical care are our Rights. Nobody dictates what we do, unless we elect a fluid, competent group of physicians to set appropriate guidelines. We must get paid for what we do, without hassles. OUR rights are worth taking chances, the ones we finessed in the 1980s and 90s. We need some courage. We have the brains. As was said about the Golden Rule, the rest is “commentary.”

    • Sudha Prasad
      August 28, 2016 at 3:28 pm

      Thank you Dr. Shubbs. You have delineated some of the most important rights.
      When we get paid and knowing how much we will get paid are still very difficult questions to answer. I don’t think any other service providing profession wrestles daily with those questions.
      So number 1 bill of rights: We have the right to a speedy and timely payment.
      We have the right to know within 24 hours, how much we will be paid.
      We have the right to having designated navigators with insurance companies so that there is a speedy appeal process.
      Only doctors of our specialty should be involved in judging the appeals process for getting payments.
      Malpractice courts should be set up just as the ones that exist for tax liability and the department of labor.
      specialty organizations should have a say on drugs that are approved for an insurance company’s formulary.

      I encourage you and other readers to add to this list as a way to get started.
      Thanks so much for getting the ball rolling.

  3. Kurt
    August 24, 2016 at 9:37 pm

    I agree but I don’t see how anything short of “liquidation” of the inciting irritations would
    accomplish anything. That fell out of favor after WWII so I think you’re pretty limited.
    Massive lawsuits would get their attention along the lines of restraint of trade but that
    costs beaucoup dollars. I’m all ears on this one.

    • Sudha Prasad
      August 25, 2016 at 2:04 pm

      Dear Kurt, I am not sure what you are referring to when you speak of liquidation of inciting irritations and world war 2. Please explain.
      Lawsuits should be a last resort because it would funnel money from those who hold the financial purse strings straight through to the lawyers and would not accomplish much.
      I am speaking of an effort for each of us to pressure first our specialty organizations to come up with a bill of rights. Then these would have to be coalesced and presented in a political forum within the medical community. The key would be very good PR with the public. That is a major issue that doctors and doctors’ organizations are not good at-how to strategically sow the right stories among the public.
      I remember reading that earlier this year, in the UK, junior doctors were able to sway public opinion to the point that they got more pay…They are government employees and it seems that they had nothing to lose by the time they went on strike: see this article as an example: http://www.investors.com/politics/editorials/why-british-doctors-do-not-want-to-practice-in-own-country/
      This article lays out the dangers of doctors becoming government employees–I am wondering if many doctors who have become hospital employees will eventually face some of the conditions that are described here.
      I think that unionizing would lead to a whole other can of worms that would continue the disenfranchisement of individual doctors.

      Here is what I found re patient bill of rights :

      “Asserting that medical care “must be rendered under conditions that are acceptable to both patient and physician,” the Association of American Physicians and Surgeons adopted a list of patient freedoms in 1990, which was modified and adopted as a ‘patients’ bill of rights’ in 1995″

      If you read further, you see that passing the patient bill of rights as a law was ultimately defeated in 2001 in Congress due to “insurance industry resistance”. However, many institutions hand out bill of rights to patients to sign-
      so even thought it didn’t pass, its good PR to have these rights delineated to patients.
      This is the route that I am advocating. We need professional associations to promulgate the physician bill of rights and encourage their members to ask for them when signing contracts with hospitals and insurance companies-
      As you can see, it doesn’t necessarily have to be passed into law to be widely accepted.

  4. Robert Bosl, MD
    August 24, 2016 at 3:36 pm

    Why would you/did you use the Caduceus symbol at the top of the article rather than the more appropriate Staff of Aesculapius?? Aesculapius—god of healing vs. Hermes’ Caduceus

    • Doug Farrago
      August 24, 2016 at 3:40 pm

      The modern use of the caduceus as a symbol of medicine became established in the United States in the late 19th and early 20th century as a result of documented mistakes, misunderstandings and confusion. per Wikipedia

  5. Frank Rubino M D
    August 21, 2016 at 8:29 am

    Thank you. Well said!

    • Sudha Prasad
      August 21, 2016 at 2:15 pm

      Dear Frank Rubino, MD,
      Please pass it on. Not necessarily the article but the idea of a Bill of Rights.
      thanks,
      SP

  6. L. J. Sloss, M.D.
    August 20, 2016 at 7:14 pm

    I have spent well over an aggregate of two hours on the telephone to representatives of the AMA who would called me to inquire why I have not renewed my membership and are currently offering me a 50% discount. I told them quite plainly that while I found their publications high in quality and utility, I found their representation of their membership spineless and worthless. I suggested that if they had the spine to organize a nationwide physicians strike I would be more than happy to write the manifesto and lead the charge. Yes, in theory, the Sherman antitrust act prevents joint actions by purportedly independent entities, but one must remember that the antitrust laws were designed to prevent industrial behemoths and cartels from dominating and perverting the marketplace. In medicine, the only players that would be appropriate for antitrust action would be in the institutional realm of large hospital systems, Pharma and insurance companies, abetted by regulators, where de facto collusion, price-fixing, perverse incentives, and external market controls prevent any real alignment of price and value based on service input and patient satisfaction. The application of antitrust law as it might pertain to the current physician population is diametrically opposed to the primary intent of this law which is now in the case of the medical marketplace functioning in support of the sort of abuse it was originally designedto prevent. I would like to see the AMA or some other nation-wide entity poll America’s physicians on the issues of formation of a Physicians Union, rigid code-driven rates of payment and laws or contracts of adhesion disempowering physicians from pricing their own services, regulating remuneration of healthcare organization management and in particular in the nonprofit sphere. Perhaps armed with such a poll, the political process could be influenced to act on behalf of caregivers and their real constituency, the citizenry at large, to accord physicians the rights enjoyed by other well run service industries to realize fair market value for their efforts and in return receive a real voice and influence to ensure fair value for their healthcare dollar.

    • Sudha Prasad
      August 20, 2016 at 11:38 pm

      Dear LJ Sloss, MD,
      You make some great points about the utility of “anti-trust” rules in this situation. I am not sure that a Union is the way to go, however. From what I’ve seen of Unions, from members of my own family, its just a matter of jumping out of the frying pan and into the fire. There would be a new group of leaders to complain about, and worse, to distrust. (Think AMA on steroids) And this time, it would be our fault for joining the Union. So I disagree with you on that point.
      As for a poll that you suggest, again, there is no incentive for any national organization that currently exists to do it. We as doctors do have leverage if a majority of us speak up and write and submit petitions and pester our legislators. No medical organization, such as the AMA, which is in the business to fund itself and whose commitment to represent physicians is suspect, is motivated to conduct such a poll as you suggest that would make them unpopular with their real masters-big insurance companies and powerful politicians.
      Blogs such as these that can snowball into bigger forums and catch national attention are probably more under the control of physicians. As long as we can work on not doing the bidding of those who are currently in financial control of the medical marketplace-and chiefly that means not distrusting one another, not vilifying other specialties-in sum, not letting them sow divisiveness (a tactic all colonists employ to stay in charge)-we can move towards harnessing the power that doctors have in this situation. It is our refusal to see it and take it that is so endlessly satisfying to the financial interests involved.

  7. michael charles appleton
    August 20, 2016 at 1:44 pm

    There was nothing in my training that prepared me for actual practice. Just when I was able to adjust to one requirement, another “standard of practice” was presented. I practiced medicine for fifty years, the last 30 of which in a salaried status with rules and expectations defined by non-physicians. I enjoyed not living with my eye on the cash register but did not enjoy always having non -physicians looking over my shoulder and issuing orders. I retired at age 80 and my present experience with my “specialists” is dismal: rushed, impersonal, unsanitary ( they don’t wash their hands with soap and water)and disrespecting. I pity the physicians who are victims of the system they helped to create. I was told by a hematologist that pretty soon medicine will be practiced by robots. Will they be empathetic and rust if they cry?. Thank God I am out.

  8. William Braswell MD
    August 20, 2016 at 8:33 am

    There is only one definition of Physician: The Hippocratic Oath. All others are just providers. Hippocrates was a member of the Cult of the Temple of Asclepius. Therefore if one claims a member of the Temple of Asclepius one can also claim religious rights as an American. Exempt from what in reality is exploitation by ennumerate stockholders and overpopulated entitlement recipients. So what if we have to truly swear to uphold the Hippocratic Oath. An oath created 500BC and gloriously ratified 33AD by the Great Physician.

    • Pat
      August 20, 2016 at 11:20 am

      Great point! Adhering to the actual Oath would mean dispelling the nonsense that too many doctors, and all of the public believe: that we all took an oath that requires us to care for all patients. That is a poisonous falsehood that has been adopted by those who believe there is a “right” to care, and wielded by those who never took any oath.

      The only real power we have is the power NOT to work.

  9. Thomas Guastavino
    August 20, 2016 at 6:11 am

    Years ago I developed these rules to help me survive the rigors of a medical career. More pertinent today then ever

    Guastavino rules of medicine

    Efficacy, safety, and cost are of chief concern. If two treatments are of equal efficacy, choose the safer. If of equal efficacy and safety, choose the cheaper. Cost never trumps efficacy or safety.
    If you want the fastest, most efficient and cost effective care, go to the physician with the most experience in dealing with your problem
    Go to the physician who has been practice a long time and with the worst personality. That physician is surviving on their skills.
    Always start with the simplest treatment.
    Work with what the body wants to do, not against it.
    Before seeing a patient determine the real reason why they are there to see you.
    Always have an escape plan, especially in surgery.
    Never say “Never” or “Always”. No treatment or test is 100% predicable or accurate
    Unless the patient is terminal or very, very reliable, no narcotics for chronic pain
    Protocols work, until they don’t
    The patient/physician relationship is partnership. The partnership should be terminated if either party is dissatisfied.
    If your services are considered vital expect to chastised for wanting to get paid.
    Never take responsibility over that which you have no control.
    Never get into a fight over a shrinking pie.
    Never trust anyone whose job it is to find fault with you
    Of all the players involved in health care it is the physician who is least motivated by politics or greed and the only one actually licensed to practice medicine.
    Unless you are willing to put your name to what you say, what you say is worthless.
    There are five ways to treat: Rest and Protect, Observe, Drugs, Injections, Exercise and Surgery. Go to the physician who is familiar with as many as possible. (The medical version of the Hammer-Nail principle)
    Never ask a patient if they would like some Valium.
    If the reaction you get to providing free care is a demand for more free care you need to stop providing free care.
    Never criticize unless you have a viable alternative

    • Sudha Prasad
      August 20, 2016 at 11:40 pm

      Dear LJ Sloss, MD,
      You make some great points about the utility of “anti-trust” rules in this situation. I am not sure that a Union is the way to go, however. From what I’ve seen of Unions, from members of my own family, its just a matter of jumping out of the frying pan and into the fire. There would be a new group of leaders to complain about, and worse, to distrust. (Think AMA on steroids) And this time, it would be our fault for joining the Union. So I disagree with you on that point.
      As for a poll that you suggest, again, there is no incentive for any national organization that currently exists to do it. We as doctors do have leverage if a majority of us speak up and write and submit petitions and pester our legislators. No medical organization, such as the AMA, which is in the business to fund itself and whose commitment to represent physicians is suspect, is motivated to conduct such a poll as you suggest that would make them unpopular with their real masters-big insurance companies and powerful politicians.
      Blogs such as these that can snowball into bigger forums and catch national attention are probably more under the control of physicians. As long as we can work on not doing the bidding of those who are currently in financial control of the medical marketplace-and chiefly that means not distrusting one another, not vilifying other specialties-in sum, not letting them sow divisiveness (a tactic all colonists employ to stay in charge)-we can move towards harnessing the power that doctors have in this situation. It is our refusal to see it and take it that is so endlessly satisfying to the financial interests involved.

      • Thomas Guastavino
        August 21, 2016 at 7:28 am

        Agree that there is not the stomach yet for a full union. However, there are a growing number of physicians who have embraced the concept of a “micro-strike”. Early retirement, alternative practice models like direct pay, avoidance of the ER, super-specialization and avoidance of complex, difficult, high-risk or non-cooperative patients are all growing in number and it is getting closer to critical mass everyday.

    • Sudha Prasad
      August 20, 2016 at 11:44 pm

      Dear T Guastavino
      Love your rules. Especially, never get into a fight over a shrinking pie and
      If your services are considered vital expect to be chastised for wanting to get paid.
      sometimes, you may feel guilty yourself about it too.
      anyway, would love to hear whether you have ideas about generating a bill of rights…

      • Thomas Guastavino
        August 21, 2016 at 7:21 am

        Remember, the United States had to first collectively recognize an injustice, declare independence, then fight a war and win it before we were able to think about a Bill of Rights. With so many “physician loyalists” out there, especially in our own so-called leadership, we are not even at step one.
        Of course, many of us have learned how to fight our own individual war and if that number grows we may just have a chance.

        • Sudha Prasad
          August 21, 2016 at 2:20 pm

          The revolutionary war is a great example to draw from. I already labeled the Physician loyalists as the Tories, Then there are the physicians who compete unfairly, bad mouth their colleagues, seize upon any perceived weaknesses, run fraudulent scams against unsuspecting patients, etc whom I would label the Hessian Mercenaries.
          and finally, there is the government who lies in bed with the insurance companies and the hospitals whom I would label the Crown.
          So its all there for us to review and study and learn from, if we want.

    • August 28, 2016 at 8:28 am

      Great rules, I copied them so that I can reference them. Thanks

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