EXIT INTERVIEW: David C. Anderson, M.D.

General surgeon in private practice leaves for Arizona


Interview taped December 29, 1997
Transcribed from tape on December 30, 1997
Transcriber: Twila Brase, R.N.
Edited for clarity and length
Q: Why are you leaving Minnesota to practice in Arizona?
D.A.: If the practice of medicine had stayed the same, there's no question, I would've stayed. I enjoyed the practice environment here as it has been over the last 20 years, but the enjoyment factor of the practice has diminished as the business aspect of the practice has become the overwhelming driving force in medicine in Minnesota.
Certainly the reason to go to Arizona is not to make more money. My income will drop--maybe 30-40%. On the same hand the income factors in Minnesota are so driven by non-patient oriented mechanisms that my idealistic mind doesn't allow me to continue to practice that way.
Q: Can you talk about what those mechanisms are and how they affected your practice?
D.A.: As the control of patients went into the insurance or payment program, patient care was no longer driven toward the care of people with illnesses. Patient care is now driven by the people who control the reimbursement factors.
My training was to take care of the people who were really sick and really needed to be taken care of, and those people are finding more and more barriers in trying to get into the hands of the people who can really do something about their care. This has led to a tremendous waste of both fiscal resources and human resources.
Q: Can you site personal or profession examples?
D.A.: I can site a personal example first and then I can cite innumerable surgical examples. My wife has diabetes insipidus - a pituitary insufficiency. A year ago she developed a new onset of headaches and one of the things that diabetes insipidus is associated with is brain tumors. The acute onset of headaches in a woman in her mid-forties is highly suspicious of brain tumor.
When she called her primary care doctor--an endocrinologist--to have an appointment, she was told that the first time she could see him was in three months. Obviously the person who was making the appointments had no appreciation of the medical potential of that new symptom complex. That's just inappropriate. A three month hiatus for a patient like that is wrong. Somebody with those symptoms and history needs to be seen in the office in 2-3 days.
But the system is now set up to maintain strict office hours; to maintain the office being busy throughout the day. There's no time to work in people who have a medical illness--unless you run them into an emergency room or an urgent care. And as soon as you do that you're using medical funds at the absolute highest rate with the least amount of control over how things are ordered.
My wife told me and I pulled the strings. Most people out of the street would have no way of dealing with that problem other than just waiting the three months and if there is something bad, they wind up with a disastrous end result. That's not the way the system should work because the vast majority of people in the system are not in that kind of situation.
There should never be a time where you have to pull strings to get sick people into medical care, or demand that you go to emergent or urgent care where the cost is going to be way out of proportion to the benefit; where they'll spend tons of money on unnecessary work-up. The vast majority of those people would be much better treated in the office with a physician who knew them who could ascertain whether any workup needs to be done or not.
The last weekend I worked I had three patients that I had to take to surgery for acute appendicitis. All three, without any question--when you talked to them, when you examined them, when you had their white blood count--were appendicitis. There was no room for any question. They were straight forward, almost textbook cases of appendicitis.
All three of the patients were seen through the emergency room--on a weekend, that may be the only reasonable way they can be seen. All three of them needed to be seen by a surgeon to decide whether they needed surgery or not. Before I arrived, all three had a CT scan which is not necessary for someone with a clinical diagnosis of appendicitis. It's a waste of time, energy and money to do that. All three of the patients could have been seen and out of the operating room by the time they were initially seen by a surgeon, if they had just called somebody who could have done something about the problem when they were first seen.
Q: So they wanted to diagnose them technologically before they brought you in.
DA: Exactly. And that is the biggest problem that I perceive happening in Minnesota right now. Doctors, trained in business, can run people in and out of their office in very short order, can stick to their office plan, can make sure they see 10 or 12 patients an hour or whatever it is that they need to see, but in the process they have lost their skills to become quality clinical diagnosticians.
And if the primary care doctors lose their ability to become physical diagnosticians, they wind up spending their time and energy ordering expensive tests, tests that they don't even know for sure how to understand. They have no idea what to do and in a panic they either order more tests or inappropriate tests, or they put the patient into the hands of a specialist without any plan as to why they are going to see the specialist--except that they have a technological answer that says that something needs to be done.
A very classical example of this would be the fact that in the last 8-9 years we've developed the technology for much simpler surgical interventions. That has allowed primary doctors to do, almost ad lib, ultrasounds of the abdomen to look for gallbladder problems. Because of it, people with symptomatology totally unrelated to their biliary tree are getting operated on for gallstone disease just because they have gallstones. But because it wasn't the cause of the problem they came in for, there is very little hope that it's going to make any difference in how they are going to do. Many of those patients would probably live their lives out with gallstones and never have any problems.
Because the primary doctor is locked into seeing so many patients a hour, so many patients a day, the only way they can run the patients in and out of their office--rather than spending time finding out exactly what's going on in the patient's life, doing some reasonable history and physical examination that comes up with a reasonable working clinical diagnosis--is by ordering blood work and an ultrasound on patients with a bellyache. If the ultrasound comes back positive, they send the patient to a surgeon, and yet nobody ever sat down and talked with the patient to figure out why they came to the office in the first place.
And the truth of the matter is that once you have the positive diagnosis made, people lose focus of what brought them to the doctor. When I, as a surgeon, see these patients secondarily, after they've already had the diagnosis made, even though I may be convinced in my heart that it has nothing to do with their gallbladder, if I don't take the gallbladder out, they've got to go back to their primary doctor who will then send the patient to somebody else to take their gallbladder out.
This is going to change the doctor's referral pattern because he doesn't like to be one-upped. He will send the patient to somebody who will rubber stamp his diagnosis. This makes not only the primary care doctors poor diagnosticians, but it also makes specialty doctors poor diagnosticians.
As the reimbursements have gone down and when you're only reimbursed for what you do, not for the thought process, the only way you maintain an income is to do more and more procedures. We wind up giving diagnoses that don't need to be made, or at least don't need to be made at that time. And that's like an open siphon on the medical reimbursement pool.
And another problem occurs when you evaluate doctors, clinics, or health plans on how they're performing. The only evaluation that is accepted is something that will fit into binary - numerical - logic process. If it won't fit into a computer program where you make a system of binary choices then there's no hope of an honest evaluation. There's not even an attempt at making subjective evaluations in the process. It has to be a procedure or a lab test that generates a number.
A classical example is the evaluation of pain on a scale. When people come in for surgery, patients are coached on how to evaluate how much pain they have relative to a scale of 0 to 10. But, a person's pain at any given time is perceived in a vacuum as far as where the scale would be. And so the patient gives out a number and pain control is then based on that number. Concurrent with that, many patients are now giving themselves their own pain medication. If it's not adequate, the staff will ask them what their number is. We're probably allowing some people to abuse pain medications because we aren't paying nurses to sit at the bedside and spend some quality nursing time taking care of that patient and relieving their anxiety.
Oftentimes, if you can relieve somebody's anxiety, you get much better pain control with much less medication than just going in and asking somebody what their pain is. And many times, the person now asking what the pain on the pain scale is, has almost no medical background. They are somebody who has come in and been given 2-8 hours of training and then work as a nurse extender.
Q: Do they call them nurse extenders?
D.A. : They call them patient care technicians. They are the old nurse's aids but they aren't called nurse's aids anymore. They got a new name for them. I just became livid with that. I had a hard time living with the fact that the only calls I ever got at night was somebody asking whether a patient needed more for pain or not based on the pain scale. When I would ask the nurses what physical parameters indicated that this patient was having more pain, there was never any clinical evaluation of the patient. It was just a number.
The problem with that is, as I've explained to numerous nurses on the floor, the business people in the hospital love it. Because as it now sits, you don't need to be a nurse to ask somebody what the number is. So then we can have even fewer nurses.
Alot of this is based on the business premise that the customer is always right. That's why the business people in corporate offices running medicine today no longer talk about patients. They talk about customers. But in reality the customer is not the patient. The customer is the company who's going out and contracting with the plan. And the company's desire is to control costs. They'll say they want quality care but they want it for the cheapest cost.
The thing that will win out every time in the business world is the cheapest cost. And that's the driving force behind the people who are running the hospital and health care services. They want the cheapest cost and they realize that it will have to be real bad before it statistically makes a difference. And since business is controlling things in Minnesota, I can't go on like that.
And to top that off, they believe that if it's a technological thing--a CT scan, an MRI--the answer is always absolute. The interpretive factor of the equation never gets evaluated because they have no way of evaluating that. If they did, they'd have to admit that technology isn't the bottom line.
Q: Can you say something about what the hospital environment is like for surgeons and patients? I've heard about Patient-Centered Care.
D.A.: Patient-Focused Care. I could go on forever about that. From my perspective as a surgeon, this is a system that would fall apart completely, if it weren't for some incredible nurses just breaking their back to make a very obtuse system work.
It's removed R.N. or L.P.N. care from the patient despite the fact that there's just as many R.N.'s and L.P.N.s in the system, maybe more, but they have been given chores unrelated to direct patient care. Much of the task of primary care is given to these woefully undertrained individuals who are allowed to do what they do by programs, such as the pain scale or other things like that that are accepted as fact, although there's a tremendous amount of non-fact in what they're doing.
The mechanics of the physical environment in the situation at United is a disaster. Millions of dollars were poured into renovation of the system and physically, the plant is a disaster. It's accepted by the people there that it was poorly thought out. It's an architectural dilemma that is beyond the capabilities of being solved short of completely destroying the hospital and starting over from scratch and building up a new hospital, which would still be locked into the whole concept of how they are going to deliver care with paraprofessionals.
I think for the families of patients--there is a tremendous amount of appreciation for the new system. It allows them to stay at the side of the patient right up to when the patient goes to the operating room for pre-op.
Q: How did they redesign the whole hospital?
D.A.: On the floors, they've moved the old ward secretary, the person who ran the floor, to a centralized location away from where patient care is. Phone calls have been abysmal, disastrous. They finally went to having cellular phones for the nurses, but every system that they've tried has had major flaws.
Q: Where are the nurses?
D.A: It's a good question. You don't know.
Just an anecdotal story that raised alot of ire and drew alot of anger from the administration. When they first put this program in, I went in on a weekend on rounds, at 10:00 on a Saturday morning on a surgical PFC, with 54 rooms. I was out in the halls and I could not find anybody. There was nobody to be found. Since I needed to talk to somebody for some equipment, I paged overhead for any employee of surgical PFC. The vast majority of times, it's just per chance that you run into the patient's nurse because there's no centralized area that you can go to find them.
As they removed the centralized storage areas, they placed more minuscule storage areas outside every room or every other room. Oftentimes they're not stocked appropriately or if you need something that's less likely to be used frequently, they don't have it at all because they have a minimal amount that they can store on the floor. Or it may be something that you use every week, but because you aren't going to use it in every room once a week they just don't have that, or if it is available, it's hidden off someplace and nobody has any idea where it might be.
Q: Do you hear any complaints from the patients?
There are nurses in the halls frequently during the day, but when you ask patients, they say that there seems to be an inordinate amount of time, after they ring a buzzer, before somebody comes to answer. There seems to be an inordinate amount of time before somebody will respond when they need to be seen or ask for help.
When patients have complained it's generally been care-related. They perceive that they needed to get their bandage changed or they needed to get their bath. When patients compliment the system, they like the isolated room. They like the fact that their families can be in with them. They like the hotel features. And since the care features for most people don't make too much difference--it's only the occasional patient that's having medical problems--that statistically doesn't make the hospital want to change the parameter.
It's why they can drive people out of the hospital so fast because most of them are going to do OK.
Q: Why do you say "since care features don't make much of a difference"?
D.A.: Because the vast majority of people -- once you've gotten through your operation--are going to get well. So the the business type people say we can't spend alot of time babying these people. We've gotta just say we know we aren't going to get sued. We aren't going to lose a lawsuit because somebody perceived they weren't treated nice. We're going to get sued because they have an untoward result and the business people realize the untoward results are unlikely to happen.
Q: If this is the case, that the majority of people are going to get well, and that people like the hotel features, and that most people don't have an untoward event, then what's wrong with the system?
D.A.: You've spent at least $35 million, and if truth were known, probably $50 million, to design a system that, not only was money put into the building features, but it created a higher echelon of administrative type people who are making inordinately high salaries compared to the work load that they're doing. It's allowed them to pay the people really doing the hands on care at a lower rate by hiring these undertrained individuals to do the hands on care.
And it's driving out the career nurse. The old career nurse doesn't exist in the hospital anymore.
When I did my residency over at Miller, every station had a senior head nurse and that senior head nurse was a career nurse who had developed tremendous clinical acumen over the years which she passed on to all the younger nurses. All of a sudden we don't have those people around anymore because they are driven out of the system. They are driven into administration or they're driven into home nursing or they're driven into something that will pay them more and give them hands on, because most nurses still want to have some kind of hands on relationship to patients. That's why they became a nurse. By driving them away from the hospital and keeping a constant turnover of young nurses, who will go into any kind of system and work for awhile till they get frustrated and then they can move on, they wind up losing the very best thing that they had going for them before.
Q: So who really knows what's going on with the patient?
D.A.: Hopefully, you'll have a nurse that will have some degree of following along on the patient, who will be able to give you some idea. If I want to find out about a patient, I'm very much locked into trying to read the laboratory data that's off the chart. If it's not on the chart, it's almost impossible to find somebody who can find it for you now. Unless you can call the lab yourself, and that's almost a disaster because they want to put everything on the computer so that they don't want to even look up a number.
Clinically, nobody reads nurse's notes anymore. The reason for that is that they got away from narrative nurse's notes where nurses generally documented a long thorough note about the patients condition. A note which really told you how the patient was doing. Now they are suppose to 'chart by exception.' They are responsible for evaluating every organ system of every patient for every shift. There is a checkoff for "Within Normal Limits" of each system. What that actually means is that they didn't check the system, but that there were no problems or abnormalities noted during their shift.
This means reams of meaningless paper are generated every day. I didn't like the name of the new system. Calling it patient-focused care made it sound like the patient had not previously been the focus of care. In an open meeting, the CEO of United said, and this is a direct quote, "We had to give it a catchy name so that people would buy into it."
One of my nursing friends had an incident that she wanted to report to the state, but she was afraid that she might lose her job. The ER had to hold 3 acute MI [Myocardial Infarction (heart attack)] patients all day because there was no room in the hospital.
This is the position alot of older well-trained nurses are in. They know what good medicine is, but they're stuck.
Q: What do you think about research? According to a recent article in the New England Journal of Medicine, Mayo Clinic researchers want access to rich clinical data, but when you talk about the generation of reams of meaningless data, what will the impact be on research?
D.A.: I think rich clinical data is a figment of the imagination. There are some reasonable reasons to do clinical research. I think the clinical studies that have any significant meaning at all are the prospective studies. I realize that we have to have some retrospective studies just to give us an idea--a clue--as to what we should do, but my biggest concern is that there will be no research except what's funded by for-profit companies.
I'm sure that the HealthPartners, the Blues, the Allinas are going to want to publish research data that will support things that look good for their record. I can guarantee they will not be reporting anything that looks bad on their record, and I can guarantee that, just as with any human system, there will be bad results in any kind of system, but we'll never ever see that in a publication.
But the more frightening thing than that is what's happening with what I call the "businessization" of medicine. Research, pure clinical research, pure scientific research is going to be gone if it's not already gone now, because there is no one to fund it. No one is going to pay to do a project that doesn't give them the answer that they want to have at the end.
And, since drug companies, or instrument companies, or technology companies are going to want a given answer and are going to be willing to pay billions of dollars to get the answer that they want, there's going to be a tremendous desire to have skewed reporting, or reporting that's going to be based on who it is that's paying for the project. And it doesn't take alot of skill to design a project to give you a designed outcome.
Q: What do you think about the for-profit/not-for-profit debate?
It's sad to see that the University of Minnesota Hospital has been taken over by the Fairview System. I hate that they're called not-for-profit, because in reality, they're all for-profit. It's just whether they're tax-exempt.
And in fact, for the leaders of those tax-exempt corporations, there's a tremendous reward for making a huge profit. They probably have a higher likelihood of being able to bonus themselves out at the end than they would in a proprietary business because in a proprietary business, you'd have stockholders that would be interested in making sure that the upper echelon are not skimming off too much of the profit. Whereas when you have the good old boys system of appointing your friends to the board, and then giving them the information you want them to have, they're going to have no desire at all to look into this to make sure you're not ripping the system off.
Q: Unlike primary care, are surgeons able to have flexible schedules?
D.A.: Surgeons are fairly independent with their schedules. There's a real pressure from the Allina Medical Group (AMG) and everybody to contract out care. HealthEast is trying to contract out all their surgical care so that they will have control of it. Doing so would allow them to tell you when they want you in the clinic; how many patients they want you to see. They would make a contract that would allow them to bill for the patients that we saw. There would be an understanding that we would see most of the patients, but they would not write it in that we would see all the patients. I think there is some legalistic things that they find to be unsavory about that.
Q: They would do the billing?
D.A.: They would do the billing and then they would pay us back a percentage of what they billed out--or what they collected. We could bill the patients that we don't see in the clinic, if you have to see an emergency at night or somebody that comes in at a time other than the clinic.
Q: Let me clarify. They want you to see their patients only in their clinic?
D.A.: That's what they wanted to do. They wanted to drive us into their clinic. This is where I had my biggest argument with them. I said that's totally inefficient care. If a patient comes in with a surgical diagnosis on Monday morning at 8 o'clock and sees the primary doctor, is the doctor going to wait till the surgeon comes Tuesday afternoon? Even if it's a simple problem like a breast lump or a hernia, something that one or two days is not going to make a huge amount of difference, wouldn't it be much better if you were going to contract, for the proceduralist to say, 'Listen we'll keep somebody in the office. We'll open up time. We'll make a contract with you that if you send the majority of your patients to us, we'll guarantee that from the time they come in our front door, we'll have them seen by the surgeon within an hour'?
Q: And they didn't want that?
D.A.: No.
Q: Because it's easier to claim rights to the whole billing process with you in their clinic?
D.A.: I believe that is what they thought.
Q: And the billing process, how is that going to work? In the case of Medica, the Allina physician group, the AMG, would bill Allina's health plan, Medica, and then the AMG would charge you for the AMG's billing services for Medica patients? Would that decrease your overhead?
D.A.: I can't see that there was any realistic way that we were going to be able to cut our overhead at all. However, my concern--since they had control of the patients--was that alot of those patients on their own are probably not going to come in at a time different than when they were told by the office to come back to see the surgeon. The vast majority of them are going to wait until they can be seen by us again at their office.
Again, my concept of what specialty care should be would be that you have somebody seeing a specialist when it clinically is sound for them to go see a specialist, not to rule out that they might have coronary disease, but that you have a clinical diagnosis when you're done. That's what primary care ought to be. Primary care ought to be differentiating who's ill and who's not ill. And once you've ascertained that Joe Blow is ill, then Joe Blow gets in to see the appropriate person who can continue the work-up to more precisely define what the diagnosis is, and to start a more appropriate therapeutic action.
Q: About the billing. How much were they going to charge to bill their patients for you?
D.A.: Well, basically, it was going to be based off of our charge portfolio that we currently use. We were going to get roughly about 24% of what our charges were for a given procedure, whereas our average is 40% now across the board.
Q: You were going to get only 24% of the charge you billed? They were going to take off 15% for billing? (roughly the difference between 24% and 40%)
D.A.: Yes, plus they're establishing what the payments are going to be. They're establishing whether they're going to pay x or x minus 10. When it's Medica, Medica decides what they're going to pay. It has nothing to do with what we decide to charge.
Q: So, if you charge $100, and Medica decides to pay $45?
D.A.: They'd pay $45 to the Allina Medical Group (AMG) and then the AMG would pay us $25 or whatever it would be. It looked like it would be about 24% of what we were charging.
But the key thing, it's even more important than that, is that they're doing that because the AMG is paying the AMG primary care docs more than what they can generate out by reimbursements from Medica for their primary care. And that's a decision that Medica made. That's a decision within the Allina group. They said, we're going to ask you to work this hard, but we aren't going to be willing to reimburse you for it so we're going to take it away from the reimbursement from the other doctors and give it back to you, but in reality it's a shell game.
Q: So Allina said to the AMG that they were going to cut the payments to the AMG, but that they would increase the AMG payments by sending the surgeon's reimbursement to the AMG and allowing the AMG to subtract a billing charge from the reimbursement which then the AMG can keep?
D.A.: Actually, what they were going to do, with what was left over, 50% was going to go to the AMG and 50% was going to go to United.
Q: Of the $15? What was their rationale?
D.A.: The hospital thinks they're in trouble and needs money too.
Q: Tell me about your individual experience trying to give surgery to a person that really needed it.
D.A.: There were hurdles that had to be jumped to get certain people in. It was mostly in situations where there was some degree of clinical controversy in the diagnosis--diseases that there might be some differences of opinion as to what is the optimal kind of therapy; patients who do not fit the textbook definition for the given procedure. There was the simple fact of requiring second opinions for things like hernias or elective type of surgical procedures.
For a healthy person, particularly males, to drum up enough courage just to go into the doctor with the problem in the first place, like the hernia, it takes awhile. Once they come in, if you tell them they have to get a second opinion in order to have that taken care of, a lot of those guys just won't go out and get the second opinion. Alot of them will live a long time with a hernia without any problems. It's a great boon for the insurance companies.
There was always the disaster of retrospective denials. It was difficult to function when somebody could retrospectively say that what you did was not OK. You used your best clinical judgment to make a decision and you operated on someone and maybe found out something was different than what you thought. Then when you come out and tell them about it, you are told the procedure is not going to be paid for.
Q: But the only way you, or anybody, knows that is because you did it.
D.A.: Exactly.
Q: So how does that affect practice?
D.A.: It was a nuisance. It created additional paperwork, writing letters. It was certainly not a reason for me to think about abandoning ship.
It was not as big a problem to me as the philosophical problems of driving ourselves to doing procedures that probably weren't indicated. And not dealing with people from what was best for the patient clinically. It's so easy to do operations today. People are doing things because you can get by with it. There's very very low risk and somehow there's a perspective in the general public that you really were more sick if somebody did something to you and that you're going to be better if you do something as opposed to just talking.
Q: Why are doctors willing to not talk to their patients anymore; to take 10 patients an hour?
D.A.: There's tremendous pressure from the business organizations that own these primary care doctors. Primary care doctors in the Twin Cities are all owned by somebody now. These business people have told them they bought their clinics for any exorbitant fee--they bought them beyond what the clinic was ever worth--under the assumption that they were going to buy the patients. They really didn't buy the patients because the patients belonged to whoever they had their insurance carrier with. You can't buy Dr. Jone's office and then buy his patients because if the patients don't want to see Dr. Jones they're not going to see him except by their insurance plan, and then only if that is the only choice they have.
They bought sky.
And then they also, as part of buying that, contracted with these doctors at a salary that the purchasers realized the physicians were not going to be allowed to make. These doctors would have never signed an agreement to sell their practice if they would have been told that there was no way that they could make their salary, or that they were going to take a big hit in their salary. Therefore, all of these primary care offices are losing money because they're reimbursed on a scale set by the payer--a scale higher than the revenue coming into the office.
Let's just take the Allina Medical Group. The reimbursement wing of Allina is not willing to pay the AMG primaries for their clinical expertise. So the only way that these doctors can generate more income is to see more patients. And so if Dr. x only sees 4 patients an hour, then they will come in and say, 'Well Dr. x, here's the choice, you either take less income next year or you agree to see 10 patients an hour or whatever the number is.
I just happen to know one physician that I think that has gone from 4 to 10, because her style was to see 4 an hour and they said you can't do that anymore. There are very few of us willing to take a big hit in pay.
Q: Ten patients an hour? Do you realize how few minutes you can spend with a patient?
D.A.: Six. That's assuming you can "phase" yourself between patients. Any numbers that I've used here are taken with a grain of salt. They're for demonstration purposes. But what I'm telling you is the pressure is on these doctors to turn people in and out of their offices in short order.
And the truth of the matter is when somebody has a complex problem it's going to take time.
And when somebody comes in and they perceive that you're trying to push them out of the office, the only way you're going to get out of the room with that patient is to give them a prescription or order some kind of a test This creates a perception on the part of the patient that you really care.
It's a huge joke to me, because oftentimes they'll order these tests and then they'll tell the patient that they have to call back on Friday or two weeks from now to get the report. But the truth of the matter is that the report is instantaneously available. Within 2 hours of any procedure the report's done. And now with most offices, they're faxed back to the doctor's office. Patients buy into the concept that they can wait 2 weeks to get a report on something that's been sitting on the doctor's office for 2 weeks.
Q: Why does the doctor do that?
D.A.: To give him some kind of control. He no longer has control over his pay. He no longer has control over his schedule. The one thing he does have some control over is how he can report back to these patients so he doesn't get backlogged in making phone calls.
What business wants, is to control my finances and control my work schedule. And they're very effectively able to do that right now.
Q: So, do you think it's going to be better in Arizona?
D.A.: No.
Q: How would you classify the morale of your physician friends here in Minnesota?
D.A.: It's at an all-time low. The only physicians who might have some optimism are the ones who are primary care, because they've gotten more money in the last few years than ever before. They like it that they have more expendable income than they've ever had before. But most of those are very young doctors who've never seen it done any other way.
The primary care doctors who really took care of patients are realizing that the things they did that made patients love them, they can't do anymore. Because they're no money in that. And alot of the older ones are really disappointed. They're distraught even if they're making more money. They are made to practice in a way that is very, very distasteful to them.
Q: And why do you think they give up their Hippocratic Oath to practice this way? Why have physicians allowed it?
D.A.: Financial reasons. The rewards to physicians have probably always been greater than they should've been--at least since the Medicare Act. In a boom economy, to be made the goats of a system that we had really no control over, and to be made to pay a huge financial price, and still take the media perspective that you're the one that's responsible. And then, what's left? I think alot of doctors would like to do something different, but if you're 50 years old and you've been doing this all your life, and you really enjoy the direct one-on-one patient contact, it has become your life. You can't change it.
Q: The new physician won't know that or have it. The new physician will be an employee.
D.A.: Clock in. Clock out. And very unlikely to be talked into seeing somebody early just because they might have a brain tumor. I think it bodes bad for medicine as a whole in America for the next several years. It'll take a generation to rectify the problem. And the only way it will be rectified is the public realizing they have tremendous vested interest in this whole thing.
There's some rumblings that in California business has backed away from medicine because they no longer can generate the kind of dollars that they need, and business experts are getting into other fields where they can make a profit.
The American College of Surgeons has a practice accountant, a business advisor, who puts on business programs for surgeons. He says what's happened is these health plans in Southern California have lost their profitability. They are selling their clinics back to the physicians for 30¢ on the dollar. But, it was an artificial dollar when they were bought out and it's an artificial dollar when they're buying them back because in reality they aren't buying anything. They're buying equipment and office space, but they aren't buying the patients.
These doctors, who've maybe had 10-15 years in a controlled salary environment, are now having to run their own offices. They are going to have to practice like they did when they were 28 or 30 years old, except it's a very difficult thing to do. It's very difficult for a 55 year old physician to rebuild a practice like he did when he was younger. But I think that will happen.
And when it does happen, I think physicians will realize that they have to charge for professional work. They can't just let that slide. Our professional work is worth money. Our clinical diagnoses are worth money. And we have to charge. We have to make people pay for that.
At the same time I think we have to start rewarding people for more quality health parameters. Patients ought to have rewards in an indemnity type of environment for having an annual physical examination that they pay for out of their pocket. Maybe they pay $100 for a physical exam, or $250, but they get rewarded by an indemnity policy that charges at least that much less.
I still believe we should make health care taxable. If health care is a routine taxable expense, then it's not going to be to an advantage for 3M to buy health care. Then individuals will own their own policies, and they'll make more responsible decisions.
Q: Tell me about the new doctors; the young doctors.
D.A.: There's a huge difference. They're raised in an environment of outpatient care, making sure that everybody's seen and moved through the system quickly. They're customer, not patient, oriented, and their perception is to take care of the vast majority of people who are not ill in a way that gives them some kind of a sense of feeling better about themselves. Be it ordering of tests or ordering prescriptions, I believe there is a real lack of desire to understand clinical disease.
I think there's a real lack of concern about patients who are really ill. And I think there is a tremendous lack of desire to practice medicine beyond anything that they do. Medicine is just one of the activities that they want to have as a part of their overall lifestyle, and they don't really want that marriage to a very demanding partner.
Q: Is there anything wrong with that? Is it surprising that we've moved to a McMedicine mentality in our society?
D.A.: It's more than medicine. I think it's a cancer that's invaded the whole environment of our civilization of the United States. We're caught up in the profit end of the business. It really runs our government as well. But it will come to roost very quickly. We cannot maintain the exponential growth we have experienced. We can have one or the other: Desire of quality, employee satisfaction and limited profit, or we can have the cheapest work force, an adequate product line and suck off the biggest profit we can get.
Q: How about doctors who have become HMO executives?
D.A. They're the worst of the lot. They have turned from patient care as their driving function. They have managed to leverage themselves into a position without expending any resources of their own. Most feel it's a dog-eat-dog world, so it's OK.
Q: What about the Hippocratic Oath to put the patient first?
D.A.: Most likely it meant little to any of those people even when they took it. They are enamored by statistics which show that the death rates aren't going up. Without objective data they won't believe we have a system that's worse than before. And as I said before, it has to get really bad before it will even show up in statistics.
Q: Thank you for your time. Keep in touch.



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