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Physician Killed by Ducks FREE TO VIEW

Kenneth R. Kellner, MD, PhD
Author and Funding Information

Affiliations: Gainesville, FL
 ,  Dr. Kellner is affiliated with the University of Florida College of Medicine, Department of Obstetrics & Gynecology.

Correspondence to: Kenneth R. Kellner, MD, PhD, Professor, University of Florida College of Medicine, Department of Obstetrics & Gynecology, Gainesville, FL 32610-0294; e-mail: kellnerk@obgyn.ufl.edu

Chest. 2005;127(3):695-696. doi:10.1378/chest.127.3.695
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One duck bite will not hurt you, but a thousand just might kill you. The medical profession is getting bitten, and the ducks are winning. Over the past decade, a remarkable number of laws, rules, regulations, and new ways of doing business have hit physicians. Each, when viewed alone, looks very reasonable, but, taken in aggregate, they are ruining the profession. The public, with the help of the media and our elected officials, is to blame and will, ultimately, reap the consequences.

People want the best medical care in the world but do not want to pay for it. How do we cut the cost of care? Just pay physicians less. Consider if you ran an auto repair shop and 90% of your business is fixing state cars. The state wants to cut its expenses, which is popular with the voters. So they tell you that instead of paying you 80 cents for each dollar you charge, they will now pay you only 40 cents. When you complain, you’re told to cut your expenses. You cannot move or pay less for electricity or water or taxes or supplies, so you cut the number of mechanics you have. But in order to pay your bills you have to fix more cars in the same number of hours with fewer people, which means you spend less time working on each car. Now you see why you spend more time on hold on the phone (fewer personnel answering them), wait longer for an appointment (more patients being seen), wait longer in the waiting room (fewer assistants to get you in), and spend less time with the physician (who has to see more patients per day) than ever before.

Another way to cut cost is to increase the requirements for the documentation of services by hospitals and physicians in order to be paid. This is what was done several years ago for Medicare payment. As the shop owner, in order to be paid, you must cosign every estimate, requisition, and completed task performed by every one of your mechanics. And before any repair is done, it must be preauthorized by the people trying to save money by not to paying you. You enjoy fixing cars, but now it seems you spend your day signing papers, filling out forms, and talking on the phone.

People want to be healthy, but do not want to take any individual responsibility for their own health. Despite overwhelming evidence that lifestyle (weight, exercise, smoking, and drinking) have the biggest impact on medical quality of life, people want a pill or a plan or an operation to make them healthy. And when those do not work, they look for someone to blame. Attorneys advertise on TV that they are eager to help you find fault, and who better to blame than your physician? Look at all the money physicians make from unnecessary procedures and all the insurance fraud, and they make all kinds of mistakes all the time, or so the media leads us to believe. As the repair shop owner, suppose that, despite how you fixed a person’s car, and knowing that most of the problem was how they drive it, you could be sued for millions of dollars if they did not like the way it drove after you fixed it? In court, the jury would be, not auto mechanics, but other drivers who would feel sorry for the customer for not having the exact driving experience they wanted.

People want to be safe, but the world is not safe and cannot be made 100% safe. No matter what anyone does, bad things are still going to happen that are not anyone’s fault. But the government and regulatory bodies, in efforts to win public approval, continue to initiate laws and regulations in the name of “safety.” Universal precautions were mandated to prevent the spread of HIV from health-care workers to patients. Something that has never, ever happened accidentally before or since the regulations, although numerous workers have been infected by patients. Who pays for the extra gloves, gowns, masks, safety syringes, and disposal systems? How do you feel when your physician approaches you as if you are an untouchable?

Sleepy people certainly must make more mistakes than rested providers, so it is now mandated that residents cannot work > 80 h per week or 24 h in a row. Who is going to see the patients? You cannot hire more residents because their numbers are regulated by the number of patients, which is unchanged, and there is no money for more nurse practitioners or physician assistants. So, you will see longer wait times and maybe more mistakes because there are fewer health-care providers rushing to see the same number of patients. And no one knows how seeing fewer patients and doing less surgery may decrease the competency of the residents once they are out in practice. The auto repair shop regulators have now told you that, in the interest of driver safety, your mechanics can work only 30 h per week at the same pay and you cannot hire any more, even if you could afford it.

People want privacy, but there is a cost. The new Health Insurance Portability and Accountability Act has very stringent and enforceable rules about the protection of health information, with fines and prison as possible sanctions. Confidentiality between patient and physician goes back to Hippocrates, but the problem is the nonphysicans who need access to the information that is now on computer databases. This need has grown explosively with managed care, government oversight, and malpractice. Now, as the auto shop owner, you need to keep your office and the repair area locked at all times so that anyone bringing in their car cannot happen to see any of the other cars in the shop or the paperwork on the counter. And when you discuss a repair with another shop owner, you cannot tell him the make or year of the car that you are working on. All your employees need computer passwords, and who is going to pay for the new data security system?

I do not equate repairing cars with repairing people, but the concepts are the same. These are just a few of the ducks that have appeared in the past decade, and I cannot recall a duck ever being captured once set loose. Each of these issues by itself seems like a good idea, but most are taken to unnecessary extremes and/or have had unanticipated consequences. All increase a physician’s expenses with no opportunity to increase income. Each is one duck bite, but some of the ducks are big and bite hard. The bites are starting to really hurt, and physicians are starting to be killed off.

Editor’s Note:

I am reprinting this piece, which first appeared in the Gainesville Sun, because it reflects my thinking exactly. I was about to prepare an editorial called “Death of 1,000 Cuts” that expresses the same sentiments. I realized that I would be plagiarizing this material, and I thought it would be best to reprint the original.

A. Jay Block, MD, Master FCCP Editor-in-Chief, CHEST




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