Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, July 23, 2009

I Call Bullshit

Other bloggers have brought this to my attention, but I must join in as well.

Barack Obama, 7/22/09, 47 minutes into a nationally televised press conference (emphasis mine):
We wanted to make sure that doctors are making decisions based on evidence, based on what works. That's not how it's happening right now. Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out." Now that might be the right thing to do, but I'd rather have that doctor making those decisions based on whether you need your kids tonsils out or whether it might make more sense to change, uh, maybe they have allergies or something else that would make a difference. So part of what we want to do is free doctors, patients, hospitals to make decisions based on what's best for patient care.
I call bullshit, Mr. President. Bullshit, plain and simple.

How dare you claim that my medical decisions are based primarily on financial considerations? (In fact, when I do take finances into account, it's usually those of my patients without insurance or otherwise limited resources.) How dare you!! I work my ass off day in and day out making medical decisions based on the best scientific evidence available -- while earning only one tenth of what you do, I should add -- and you have the unmitigated gall to claim that I'm only in it for the money.

Where the hell did that come from? Please tell me you don't really believe that's how doctors make medical decisions? What were you thinking? You have a reputation for understanding complex and highly nuanced situations like the Middle East. I was under the impression that you understood that health care in America deserves similarly careful consideration. Please tell me your above remarks were off the cuff, that you spoke without thinking, and that they do not really reflect your opinion of American doctors.

Echoing Dr. Wes, you owe an apology to the doctors of America.

Edited to add this from the comments, courtesy of Rogue Medic:
Money is just one variable in a complex system. Suggesting that doctors are incapable of making decisions, without being forced by money, is disingenuous, sophomoric, and insulting. Insulting to everyone, not just insulting to doctors. For this blatant exibition of prejudice, President Obama owes an apology to all Americans and to doctors in particular.
(Read his whole comment.)


At Thu Jul 23, 05:50:00 PM, Blogger Nurse K said...

He's just an idiot w/o the teleprompter. A doctor who routinely sees patients for sore throats (ie pediatrician or a family practice doctor) isn't going to be the one benefiting from referring them for a tonsillectomy. That's like no-duhr 101.

At Thu Jul 23, 05:53:00 PM, Blogger DrWes said...


Your eloquence speaks volumes.

At Thu Jul 23, 06:07:00 PM, Anonymous Anonymous said...

Dr. Dino:

Pour yourself a nice cool glass of wine and relax!

I have a different spin on Obama's remarks.

Any physician presented with a choice between treating a patient via $30 office visit or via $2000 procedure HAS a conflict of interest (and yes, Nurse K, this could apply to to ENTS, to continue with this example). This is not because doctors are bad; it is because they are human beings.

I don't think it serves us well to assume that, by virtue of our training, we can can always and perfectly overcome this (think of McAllen, Texas). I think MDS are morally obligated to present the treatment options to the patient and to discuss any conflicts of interest also with the patient. To fail to do so is to fail the patient.

I think what Obama is getting at is that there is something very wrong with a system that values procedural time at a multiple of 30 or 40 over cognitive time (thank you, AMA!). He's blaming the system, not the MDS, and arguing that the physician who opts for office visits over procedures should be paid at a more equitable rate.

Or at least that's what I heard.

At Thu Jul 23, 06:09:00 PM, Blogger HMS said...

Ma'am -

Would you mind if i forward your grievance to him via email? It deserves a proper response/apology.

For whatever it's worth, i don't think he meant how it sounds.... There is no excuse for such carelessness, of course.

At Thu Jul 23, 07:04:00 PM, Blogger #1 Dinosaur said...

platens: please do! I wanted to email it to him myself, but haven't had a chance to check the addy. He should also see Dr. Wes' response, and all the other MedBloggers' calling him out on it.

At Thu Jul 23, 07:10:00 PM, Blogger Evan said...

Yes, I'm INCENSED at the idea that any physician would ever do anything wrong. The nerve of that Obama.

I'm sure there are no doctors out there who behave in this fashion.

But maybe there are a few rare cases.

But why take steps to curb this kind of abuse when it's so rare?

At Thu Jul 23, 08:10:00 PM, Blogger #1 Dinosaur said...

@Evan: Look at your examples: orthopedic surgeon, general surgeon, plastic surgeon. See a pattern emerging? Obama not only didn't specify; it sure sounded to me like he was talking about average joes like me, seeing average kids with sore throats and the like. I never said there wasn't a shitload of fraud out there. Hell, I've pointed it out.

What I resent is being lumped in with scum like that, both by Obama and by you.

At Thu Jul 23, 08:33:00 PM, Anonymous Anonymous said...

"Doctors are forced to make decisions based on a fee payment schedule that's out there."

Seems to me very clear that Obama is criticizing the payment system, not doctors.

Certainly, he could have been clearer, but as a primary care doc who is not forced to choose between OVs and procedures, I'm not ticked off by what he says.

As I said in an earlier post, it really sounds like he's urging the leveling of the playing field between "cognitionists" and "proceduralists."

At Thu Jul 23, 08:58:00 PM, Anonymous Chuck Brooks said...

How could anyone expct anything different from a professional politician that is trained as a lawyer, head of a faction that deliberately created this and other messes, with the ultimate gola of total control of the US economy. Nothing short of a reverting back to the Divine Right of Kings.
Chuck Brooks
FutureWare SCG

At Thu Jul 23, 09:22:00 PM, Blogger Evan said...


I'm a solo FP doing primary care every day like you are.

If I'm lumping you in with scum, I'm lumping myself in too.

I agree that proceduralists and partialists can have a greater temptation to do wrong than you and I do, simply because the value of over-operating, over-documenting and overcharging is greater to them, therefore the risk of being caught is a bit lower.

In fact, the example Obama gives is exactly an example where a large incentive (large reimbursement for surgery) can outweigh the best interests of the patient (small reimbursement for investigating allergic disease).

If you want him to apologize for not being specific enough, fine. But the fact that you yourself are pointing out examples of fraud that you suspect on the part of cognitive doctors solely to get more reimbursement suggests that Obama's critique was fairly accurate and that he owes no such apology.

I fail to see how aligning incentives to match the best outcome for the patient (what I see him proposing) is somehow a dis to doctors everywhere. I only wish he was more aggressive at applying those same principles to Wall Street fraud.

At Thu Jul 23, 09:27:00 PM, Anonymous Anonymous said...

What in the sweet holy name is he smoking? I'm an FP in primary care too, and I've never gotten a dime when somebody had a tonsillectomy. If profit or some "fee schedule out there" (WTF is that supposed to mean, anyway) would really make more sense for meto keep treating the stupid sore throats. And this guy is the leader of the free world?

At Thu Jul 23, 09:29:00 PM, Anonymous Anonymous said...

Geez, since when have we clinicians become so antagonistic and self-righteous/conscious?

At Thu Jul 23, 09:47:00 PM, Anonymous Anonymous said...

Starting with you, Nurse K

What's up with your "you idiot don't know jack [no-duhr 101] about real life healthcare - get out of my kitchen!" attitude?

Do you really think Obama was referring to Dx/Rx of sore throat?

We really should get over with our dog/cat-fights before Obama should even bother to deal with us.

At Fri Jul 24, 05:10:00 AM, Anonymous James said...

Anonymous has it right. You totally missed the boat on this one Dr. Dino. Doesn't affect primary care docs so much, but for the most part, current billing practices do incentivise doctors to do more. Ok, maybe you've never provided any extra service that wasn't absolutely medically necessary. But doctors do - the evidence is out there.

What we have to be concerned about with any public healthcare plan is rationing. A public plan may not cover as many services, you may not be able to see your patient's as often as you'd like, etc. Personally, I think this is the price we have to pay if we want to fix the system.

At Fri Jul 24, 07:58:00 AM, Anonymous Dano said...

If Obama was serious about health care reform he'd try to do something about all the frivolous lawsuits. That's the main problem.

There are no guaranties in health care. I go to a doctor because they are the best to make an educated guess at what is wrong and how to fix it. Might take a visit or two while we work out something that works, and over time things get easier because we both know how my body functions.

From what I've seen Obama wants to gut the best health care in the world... to the detriment of everyone in the world. At least it's a political correct hand basket we're riding in...

At Fri Jul 24, 11:05:00 AM, Anonymous Anonymous said...

I believe this president is all about controlling every aspect of our lives - how much we earn, how we live, and how we get medical treatment - and he'll tax us into oblivion to achieve his goals.

If we don't live it correctly, we won't be eligible for healthcare. If we're too old, we'll be denied treatment. If his program is so great, then why are all the federal employees exempt and can continue to get their private healthcare? Yep, I cry bullshit as well.

At Fri Jul 24, 11:12:00 AM, Anonymous Anonymous said...


just listen to yourself.

At Fri Jul 24, 11:44:00 AM, Blogger Nurse K said...

Do you really think Obama was referring to Dx/Rx of sore throat?

Yes, because, well...he did 'n stuff. Happy probably wrote that speech. "That's exactly what I said, but it's far from what I meant!"

At Fri Jul 24, 12:03:00 PM, Anonymous Anonymous said...

don't quit your day job, Nurse K.

At Fri Jul 24, 01:00:00 PM, Blogger jen said...

Read a fairly long article a few months ago where someone went searching for an explanation why the per capita Medicare spending was SO much higher in one specific town than in nearby towns and regions. Everyone he asked had an easy explanation, and in every case there was a reason why that explanation didn't apply.

The only reason they came up with for the difference that couldn't be shown to be wrong was that the doctors in this particular town were very investment-oriented. They owned parts of shopping malls, they owned medical facilities, etc. Most of their money actually came from something *other* than taking care of patients. And somehow they wound up performing significantly more tests and more procedures - maybe because they weren't as patient-oriented?

At Fri Jul 24, 02:22:00 PM, Anonymous Anonymous said...

A douche is a douche is a douche (with all apologies to Gertrude Stein).

Obama is a douche. My guess is he went off on a tangent without his teleprompter. Historically, unless the TOTUS is feeding him the correct words, he'll end up munching on his Florsheims.

Plus, he's a douche.

At Fri Jul 24, 02:35:00 PM, Anonymous Anonymous said...

you are either laxative or enema then.

At Fri Jul 24, 02:41:00 PM, Anonymous Anonymous said...

Better that -- the instrument/medication that causes the explosion -- versus the liquidy shit that is the Anonymous result.

At Fri Jul 24, 02:52:00 PM, Anonymous Anonymous said...

"explosion" -

in your pipe dream.

At Sat Jul 25, 02:31:00 PM, Blogger Rogue Medic said...

Anonymous #1,

Any physician presented with a choice between treating a patient via $30 office visit or via $2000 procedure HAS a conflict of interest

You make the same mistake that President Obama makes. You assume that money is always a conflict of interest and that other things are not conflicts of interest.

This is overly simplistic and demonstrates an inability to understand the complexity of the problem.

Here is what President Obama said:

Doctors are forced to make decisions based on a fee payment schedule that's out there.

Do doctors not possess free will?

Do doctors not have the ability to make informed decisions about what is good patient care?

Aren't there dozens of other things that affect the doctor's decision to use any particular treatment?

Why is it assumed that Evan giving three examples of misbehavior by doctors, justifies stereotyping all doctors by those egregious examples. President Obama is a lawyer and should be familiar with the phrase, bad cases make for bad laws. These are not even remotely the typical behavior, but they do get a something must be done response. Populists take advantage of this.

This black/white view of money as the only possible conflict of interest, and money as only an evil, is a childish oversimplification.

When demonizing someone based on their profession, or based on the presumed size of their paycheck, we are engaging in a form of discrimination that is just as pernicious as racial discrimination.

If we continue to view money as evil, how can we deny that the goal is, from each according to their abilities, to each according to their needs?

Is there any evidence that socialized systems, systems that try to eliminate financial influences, have any less corruption than any other?

When our prejudices against money, and the people who have money, guide our decisions, we harm everyone. We just allow ourselves to feel good about it.

Money is just one variable in a complex system. Suggesting that doctors are incapable of making decisions, without being forced by money, is disingenuous, sophomoric, and insulting. Insulting to everyone, not just insulting to doctors. For this blatant exibition of prejudice, President Obama owes an apology to all Americans and to doctors in particular.

At Sun Jul 26, 08:51:00 PM, Anonymous Anonymous said...

To the idiot here who believes that a surgeon gets $2000 for a tonsillectomy, let me give you the straight facts (as someone who actually does this operation). We get about $150 to $250 (depending on the insurer) for a tonsillectomy. Period. Oh, yeah, and that includes the pre-op office visit and the post-op office visit (what the insurance companies and Medicare/Medicaid calls the "global period"), for which we can't additionally bill the patient. Now, the patient may see a bill for $2000 (which includes the anesthesiologist, the nurse anesthetist, the scrub nurse, the circulating nurse, the recovery room personnel, the facility fee, all the disposable supplies, AND the surgeon's fee), but that's not what the doc gets. So: $200 for 30 minutes of O.R. time, the 15 minute pre-op visit and the 15 minute post-op visit...and ignore the fact that what we do takes decades of education, is a rare skill, carries great risk, and of course, if there's some complication, feel free to sue the surgeon for millions of dollars. Obama's an a$$hole. Maybe as a lawyer and a politician he weighs everything in terms of self-benefit, but most doctors, in contrast, actually try to look out for our patients despite the profit or loss.

At Sun Jul 26, 09:02:00 PM, Anonymous Anonymous said...

In reality, reimbursement for surgical procedures has actually gone down...waaay the last thirty years. So imagine if a procedure actually reimbursed well. And imagine that most surgeons and doctors were ethical people (and they are ethical, by and large, with the usual exceptions that occur in any population). If surgical procedures actually paid well, the ethical doctor could all the more easily decline operating on a patient who didn't strictly need it. Since he'd be making plenty with the well-justified procedures, the doctor wouldn't be having to jump on every case that came his way.

Thirty years ago you paid less for health insurance, you spent more time with your doctor, and the doctor himself actually made much more money. So what's happened? Docs are making less now. You're spending more now. You're getting less time and care. Where's the money in the middle? Hmmm... insurance company profits? Malpractice premiums? Greater overhead for coding, compliance, billing, etc.? This isn't as complicated as people think.

At Mon Jul 27, 07:02:00 PM, Anonymous tom said...

I don't cut him one inch of slack...he said what he believes..he wants to control healthcare and a good first step is to categorize physicians as not deserving the public trust.. needing to be controlled by the government to "assure that only the right and proper things are done" (gee I wonder what that CZAR will be called).

The only consistency I see in this guy is that he consistently does the opposite of what he says he believes in... he is an elitist, totally out of touch with the people he pandered to, to get elected.

He is acting more like an emperor than a president. "I have spoken therefore it is so"... now move along and be happy in your work at least while you still have a job

At Tue Jul 28, 11:00:00 PM, Blogger Rogue Medic said...

Thank you for highlighting my comment.

At Fri Jul 31, 03:50:00 PM, Anonymous Anonymous said...

Medicare pays $233-$268 for a tonsillectomy depending on age and whether adenoids are also taken. This is the payment for the surgery as well as all f/u. You could do tonsillectomies all day and barely pay a typical offices overhead, let alone actually earn a living.

At Mon Aug 03, 08:03:00 PM, Blogger Not the Doctor said...

Okay, sure. There are some practitioners that have a conflict of interest brewing when they diagnose. That's a fact. There's a bad apple n every barrel and medical professionals are far from exempt.

I'm more concerned that when I diagnose a condition I have to wonder if the patients insurance will cover the treatment I choose. How long will I have to treat with something the insurance company deems that I know won't work until they cough up authorization to use what I came up with in the first place? A month? Two? A year? Why will insurance pay for a lifetime supply of narcotics but not a month of physical therapy?

The issue of bringing up fraudulent doctors is a red herring. It's being used to redirect attention away from the real issue. Insurance companies have too much power over the diagnosing of medical conditions.

But, what the heck do I know. I'm one of those rogue NP's who everyone's convinced plays doctor without any training.

At Mon Aug 03, 08:32:00 PM, Anonymous Anonymous said...

That's why we need [progressive yet comprehensive] health care reform, desperately.

The "i do already have a insurance plan" argument is more or less a facade: "an estimated three-quarters of people who are pushed into personal bankruptcy by medical problems actually had insurance when they got sick or were injured."

At Mon Aug 03, 09:11:00 PM, Anonymous Anonymous said...

The question becomes: how can a politician conveys the grim reality of our current health care system without stepping on anyone's toes?

"What one considers 'waste' is most likely what another considers 'profit,'" one MD blogger once wrote.

It's almost a riddle with an impossible answer.

At Mon Aug 10, 02:10:00 AM, Blogger BrideOfPorkins said...

Oh doc, I've never met one like you.

I've been given antibiotics and no followup for frozen vocal cords, Tylenol for migraines, and was once asked to leave my "family" doctor's office with some excuse about overbooking. All two other patients in the waiting room had insurance. I didn't, and I'm still uninsured, and I still have health problems that are going ignored.

My mother had cellulitis and was told by the nearest emergency room to go to Chinatown to have her leg looked at because it was still another three months before her Medicare kicked in.

Maybe the doctors themselves would've acted different if we'd ever gotten near one. Who knows. I sure don't.

That said, I'm enjoying your blog!


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