Burned Out

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            Physician burnout is on the rise.  I’ve seen statistics that claim at least one symptom of burnout in 46-54 percent of doctors.  Critical care and emergency room doctors experience the most, according to one Continuing Medical Education report I read.  The symptoms of burnout include emotional exhaustion, depersonalization (the sense of not being completely present), and a sense of reduced personal accomplishment and quality. 


            And, the numbers are rising.  Only 13 percent of doctors reported burnout in 2013, but that number rose to 46% in 2015.  The most recent issue of Psychiatric News asserts that burnout has grown to 54 percent this year.  Obviously, it also affects patient safety.


            The primary reasons include excessive productivity quotas, limits on the time doctors in all specialties can spend with each patient, and documentary requirements.  The president of the American Psychiatric Association (APA), Anita Everett, MD, is inviting psychiatrists to provide feedback about burnout, so that causes can be addressed and perhaps ameliorated.


            Well, I have lots of feedback, but she probably doesn’t want it.  Let’s just say I retired because practicing psychiatry was ruining my health.  Seeing patients was the easiest and most enjoyable part.  My greatest stress came from the criminally abusive health scare/snare racket that grinds human beings up—patients, staff, and doctors—and serves them up to absentee bosses for unearned profit.


            Who are these absentee bosses?  In short, they are everyone except the patient in the room.  The patient in the room is at the mercy of the insurance companies, the pharmaceutical companies, the government, lawyers, and everyone who stands to benefit without risk from the doctor-patient interaction.  For a patient to see her own medical records, or her bill, requires formal written requests, and even then she must often wait or receive only partial information.


            As a “provider” I opted out of Medicare, because it didn’t allow patients to do their own billing.  For patients to do their own billing is an important therapeutic tool, as it empowers them to become involved in the decision-making process, to review and sign off on diagnoses, treatments, and to decide how much confidential information to share with people outside the room.  I did not make this up.  I learned in psychiatric residency that people tend to appreciate what they must pay—or at least work--for, and they tend to get more value for their treatment and their money.  No one seems to understand or remember that Medicare is not health care but health care insurance.  Medicare is a guaranteed insurance subsidy, primarily for Blue Cross.


            Obamacare, or the Affordable Care Act, expands the mandated insurance net to the entire population.  It is a case of Congress practicing medicine. 



            Congress is composed of about one-third lawyers.  The 115th Congress of 2017 has 15 MDs, three of whom are in the Senate.  It is considered medical malpractice for doctors to treat patients they have not personally seen.  What if the absentee treatment providers are not doctors but insurance company “utilization reviewers,” or members of Congress?  Could they be sued personally for medical malpractice, just as doctors are? 


            If we have human rights, certainly one of them is the ownership of our own bodies, at least since slavery was abolished.  The mandate for individuals to purchase pre-paid medical treatment of a specific kind—allopathic medicine is only one of many approaches—is a human rights violation of the most egregious kind.  So are drug laws, for the same reason, but the precedent for drug laws was set with the Whiskey Tax in 1791.  The US Constitution, which presumes all taxpayers are federal government property, makes no provision for health care, health insurance, or drug laws.


            The reason we have physician burnout, according to me, is that doctors are wimps.  While they presume to treat patients, they spend most of their time treating the system, the medical records, and the absentee bosses.  The patients suffer from the distractions, and they blame the doctors.  Confidentiality goes out the window when everyone who controls a piece of the check has access to the record.  Records are skewed to fit diagnosis codes, insurance codes, and payment codes.  The patient is skewed to fit the record.


            The “health care industry” was already changing rapidly when I graduated from psychiatry residency.  An onslaught of new, patented (read “expensive”) prescription medications was beginning to come down the pike, and they were being marketed directly to “consumers” over television and other media.  In the mental health field, psychotherapy was being shifted to the less expensive psychologists and social workers.  Psychiatrists became marginalized into “medication managers,” or prescription-writing machines, because of insurance requirements. 


            Did anyone go to bat for the patients who also had medical problems, whose psychiatric problems may be at least partially the result of those?  Did anyone think that the “brain-body connection” applies to everyone who has a neck, that the head is connected with every part of the body through the nervous system?  Did anyone point out that the doctor-patient relationship is a personal bond that in the past was maintained over years and generations?  What if your doctor is “out-of-network”?


            Does the AMA or APA speak for common sense and the dignity of patients and their doctors?  Well, the professional journals are dominated by advertising from the pharmaceutical industry, so the focus is on medications, with a bias hard to ignore.  The current trend is “integrative medicine” that involves everyone on staff in a professional gossip circle that passes for comprehensive care.  There’s also a push for “evidence-based medicine,” which in psychiatry depends in large part on questionnaires and subjective measurement tools.  “How many days were you depressed last week?”  How many days did you drink?”  “Do you ever feel life is not worth living?” 


            How many patients answer these questions honestly, knowing the answers will go into their records and may affect insurance re-imbursment or premium cost? 


            How courageous is the AMA or the APA in advocating for patients and doctors when it comes to the burdensome paperwork that consumes so much time, is generally irrelevant but demanded by the armies of absentee bosses?  Why are so many doctors leaving medicine?





George N Romey Added Jul 28, 2017 - 2:33pm
Great article Katharine.  The health insurance complex has expanded rapidly past actual health providers (doctors, nurses, aides).  Doctors are caught up in a system that demands ever higher profits while trying to treat patients.  So instead of what's the best course of medical actions they need to be more worried about the patient's ability to pay.
There are no great answers to healthcare.  Our population is aging and we are suffering from decades of bad habits. When you are 30 years old a daily habit of fast food, smoking, heavy booze and excessive drug use goes unnoticed.  Get to age 60 and years of body abuse are showing their wear and tear.
Of the not so great answers the best is public healthcare to at least get the never ending demand for a higher profit margin out of the industry.
Katharine Otto Added Jul 28, 2017 - 7:57pm
Thanks for your response.  I believe it's important to focus on a micro-health care concept, that is, starting with individuals and working upward.  I contend medical services are over-utilized because of insurance. Also, there's no balance to all the propaganda, extolling drugs in place of common sense.  
It's the same tactic--distancing people from their own bodies--that is used in finance, too.  I'm thinking bar codes instead of price tags, or the convenience of debit and credit cards.  It's so easy to lose track of what you're spending.  Same with health care.
You mention bad habits, and I agree.  Cardiovascular problems and cancer are the two leading causes of death.  I suspect stress is a huge contributor to the first, and environmental toxins (and maybe stress, too) contribute to the second.  Of course smoking, drinking, drugs, sedentary lifestyles, and fast/processed food probably contribute to both. Doctors are not trained in nutrition, and hospital cafeterias are dens of fast food outlets, so where will people learn nutrition if not at home in childhood?
We assume that age brings bad health, but it doesn't have to be that way.  I suspect many people live down to low expectations.
Stone-Eater Added Jul 28, 2017 - 8:10pm
Doctors are not trained in nutrition, and hospital cafeterias are dens of fast food outlets, so where will people learn nutrition if not at home in childhood?
Oh my. I guess one doesn't need to be a doctor to figure that fresh salad and veggies are healthier that McShit.....what the hell is going on over there ?
Does fast food lower IQ's to 50 ?
Jeff Michka Added Jul 28, 2017 - 8:43pm
Katherine Otto notes: Also, there's no balance to all the propaganda, extolling drugs in place of common sense. - Not only do media costs get passed along to patients by the pharma/industrial complex, diseases get "sold" to patients, or in the wors of pharma and tech, "users".  If they can sell a disease, that really has no standards of care, like "irritable bowel syndrome," where by people have intestinal pain, the runs, etc., they see a commercial for a prescription high-cost med, they'll tell their physician they "need" that.  MAYBE THEY COULD ALTER their diets of 4 Big Macs and two fries, and that would end symtoms, that's too much to ask, so popping a pill is much better.  We have badly educated consumers who fall easy prey to the pharma/ and medical industrial complexes ad campaigns.
Jeff Michka Added Jul 28, 2017 - 8:47pm
Katherine Otto repeats the current medical mantra at every Dr. visit: “How many days were you depressed last week?” - each time I've been asked that, Ive laughed and said "Everytime I've picked up a newspaper or turned the tv on."  “Do you ever feel life is not worth living?”- I'll laugh and give the first answer, then clarify that despite things, saying nothing is worth capping myself over.
John Minehan Added Jul 29, 2017 - 7:37am
"Only 13 percent of doctors reported burnout in 2013, but that number rose to 46% in 2015."
That seems odd.
That much of an increase in that short a period? 
Also, anecdotally, physician dissatisfaction has been increasing since at the least the rise of managed care in the late 1980s and 1990s.  
John Minehan Added Jul 29, 2017 - 7:53am
"Obamacare, or the Affordable Care Act, expands the mandated insurance net to the entire population.  It is a case of Congress practicing medicine."
The two are very different.
Everyone HAS to sign up for Medicare at age 65.  If you are still working and are covered by an employer-based plan (or your spouse is and you are covered under that plan) or if you are covered by a retiree health plan, then Medicare becomes a secondary payer.
PPACA ONLY becomes a factor if you AREN'T covered by something else.  Even if you are not covered by something else, you can still opt out and pay a penalty.
Medicare is several related programs (Part A-Hospital Benefits; Part B-Physician Services; Part-C Medicare Advantage; & Part D-Prescription Drug Benefits) all administered by CMS. 
PPACA is a number of different private insurance plans offered under state exchanges as well as expanded Medicaid (also administered by CMS, in cooperation with the states).      
John Minehan Added Jul 29, 2017 - 8:25am
"What if the absentee treatment providers are not doctors but insurance company “utilization reviewers,” or members of Congress?  Could they be sued personally for medical malpractice, just as doctors are?"
No, because they are not doctors.
Could they be sued, for example, for practicing medicine without a license?
In most cases, no.  Members of Congress are creating general rules and guidelines, most often with the assistance of physicians and other professionals.
UR people are following clinical guidelines and contract specifications that the treating physician agreed to as a condition of participation in the Plan.
On the other hand, physicians are the only ones involved who CAN practice medicine, which gives them (under the laws and rules promulgated by the members of Congress and state legislators) tremendous power . . . if they are willing to use it.
Most often when UR tells a doc they can't do this . . . and the doc says it would be malpractice not to do that as it is medically necessary (and can back that up under the standard of care), the physician should win . . . .
Dino Manalis Added Jul 29, 2017 - 9:17am
We need many more doctors; nurses; and pharmacists to take care of us!
John Minehan Added Jul 29, 2017 - 9:31am
Good article, despite my nitpicks. 
Kimberly Rose Added Jul 29, 2017 - 10:39am
So you actually believe Obamacare is the reason for physician burnout? I'd like to see the stats showing physicians quoting, as I find that assertion highly unlikely.
Billy Roper Added Jul 29, 2017 - 12:23pm
Too many people use Emergency Rooms like walk-in clinics. Too many illegal immigrants, especially, and taxpayers or medical care customers, or both, often get stuck with the bill. I'm sure that lends itself to physician burnout, as well.
Katharine Otto Added Jul 29, 2017 - 9:19pm
Thanks for all the comments, folks.  There are a few points I would like to clear up.
John M, I would claim Congress was practicing medicine in 1965, too, when Medicare was passed.  It did not give people the option of opting out of Medicare or the payroll taxes that pay for it.
The burnout stats do seem odd, but maybe more doctors were admitting to burnout.  Complying with Obamacare has created enormous costs and confusion in hospitals and among doctors.  That could be a factor.
When doctors have to argue with utilization reviewers to justify a treatment, that becomes a process of educating the UR people, and it is also a violation of confidentiality.  It takes time away from patients. Ultimately, the UR person has the last word.  And many insurance companies hire doctors for the express purpose of denying claims.  Also, treatments that aren't covered under Medicare, for instance, may never be mentioned to the patient.  Cochlear implants, for hearing problems, last time I checked, weren't covered.  So Medicare (and other insurance plans) subtly ration treatment by what they will pay for.  Hospitalization for acute renal failure is not considered "medically necessary," but hip replacements are.
You don't have to be a doctor with a license to perform as if you are doctor and commit malpractice. For Congress (or insurance companies) to presume they know what's best for everyone in the country is yet another symptom of the cancerous growth of government in the US.
Kimberly R., I can't speak for other doctors, but it is a primary reason I quit.  People don't realize how insurance coverage leads to drastic over-utilization of services, tests, procedures, doctor visits, and a general malaise that enables dependency on excessive medical care.  The body's natural state is health.  In the good old days, insurance was only used for major medical problems.  No more.  That's why ERs are crowded, doctors' schedules are over-booked, why there is so much medical error, why so many people are on too many prescription drugs, and on and on. Insurance raises cost at every level of the system, from hospital insurance to malpractice insurance, to liability, fire, etc., etc.  
Jeff M., They are coming up with new diagnoses on a regular basis.  "Social phobia," in psychiatry, comes to mind.  Lucky for the world, the FDA has approved Paxil for it, as any drug rep will tell you.  People forget that medical diagnosis is not an exact science, and most would argue with my belief that many problems are self-limiting without excessive intervention.  
Stone-Eater, People may know salads are better for you than Big Macs, but making salads is trouble. Fewer and fewer people know how to cook or don't want to take the time.  I'm a fan of good old fashioned soul food, myself, but cut back on the meat and fat.  Greens, beans, brown rice and potatoes. Simple concepts, like protein complementarity, (beans and grains for complete proteins) are unknown.
John Minehan Added Jul 29, 2017 - 9:34pm
"When doctors have to argue with utilization reviewers to justify a treatment, that becomes a process of educating the UR people, and it is also a violation of confidentiality."
But it is also a specific exception to the HIPAA Privacy Rule, the Payment, Treatment and Operations ("PTO") Exception.  You can build consent to this into your Notice of Privacy Practices ("NPP") that a new patient signs.  
Leroy Added Jul 29, 2017 - 9:48pm
Great article, Doc. 
It seems most professions today focus more on documentation than actual results.  Most teachers, I think, would agree.  Certainly, in my profession, documentation has become all important.  It contributes to burnout.
Katharine Otto Added Jul 29, 2017 - 10:14pm
John M,
HIPPA is a bureaucratic morass.  It may be legal but it's counterproductive and is another example of absentee bosses calling the shots.
Documentation is out of control in many professions.  I feel sorry for teachers who who are not trusted to do their jobs.  People who have less training than they do are setting the rules.
John G,
Something's wrong.  I'm agreeing with you more than before.  I do believe the health care racket is dedicated to making people sick (or to making them fear becoming sick) and profiting from it.  Look at the stock market to see how well pharmaceutical, insurance, biotech, and hospital stocks are doing.
Then we have McDonalds and the fast food industry making people sick.  And Big Food, like ConAgra and Archer Daniels Midland.
Then there are the war contractors, helping to kill and mutilate people for profit.  And the chemical companies profiting from herbicides, pesticides, and other agricultural chemicals.  And the plastics companies making all that packaging and filling up the oceans.  Just who isn't making people sick? Cosmetics companies?  Oil companies?  I could go on.  It's a sicko attitude across the board, of profiting from exploitation.
opher goodwin Added Jul 30, 2017 - 4:51am
It's the same over here with doctors, teachers, police, nurses and social workers. Here they are not funded properly. Their workload is ridiculous and stress levels go through the roof. They are grossly underpaid. They feel undervalued.
Eileen de Bruin Added Jul 30, 2017 - 6:22am
This is an enlightening post, Dr. Otto.  
It spells out more of the same in that the entire organisational entity of the US government (with the UK very tightly close by) is in the hands of the lobbyists. Pharma, Fast food, health care insurance and, yes, the fact that the health care insurers are investing in the fast food chains and on and on.  Recent documentaries highlight these very issues with "Fed Up" being the excellent recent American one.  The huge sugar intake in the US through such carbonated and sugary drinks as cokes etc. are rotting the teeth and destroying the liver and increasing the fat in the body cells. The evidence is all out there.
Let food by thy medicine and medicine be thy food..... is definitely not in the American Constitution then, and what a shame is that.
The question is:  what is the answer?  What and how is the way forward?  Does there have to be an American revolution or what?  The older, historical times had all of these things, but what about contemporary times?
Katharine Otto Added Jul 30, 2017 - 2:29pm
What is the answer?  I believe there are many interrelated answers, and they have to do with individuals' wising up and realizing nobody feels their pain, they are ultimately their own best doctors, and prevention is cheaper than medical care and can be fun, too.
First, I believe doctors---and medical care generally--are way over-rated.  I learned early doctors are becoming mere technicians, spouting their party lines. They don't even pretend to be "healers" anymore. They don't take time to educate their patients about healthy lifestyles in the office or as a group.  I've noticed no doctors (except those in Congress, like Rand Paul), going to bat either for or against the insurance game.  While they are in the best position to know and speak up about what the Affordable Care Act implies, how many are doing it?  Certainly they are affected as much as their patients, so why aren't they speaking out (either way)?  That's why I say they are wimps.
There's more to it, of course, but there will always be more.  This is a start.  Thanks for asking.
Katharine Otto Added Jul 30, 2017 - 3:08pm
John G,
I agree with you about the results, but not the causes. In "Wealth of Nations," Adam Smith asserted that the wealth of a nation boils down to the annual production of the land and its labor.  The entire book is about all the ways rulers tax their people, as he was trying to help the new UK pay off its debt from the 7-years war.  Smith said even the king probably couldn't get get by with passing an income tax, because people would resent the intrusion into their personal finances.  He said a government job is probably the best kind of job to have.  
His book was a huge success, as we know, and he was subsequently appointed as customs commissioner for Edinburgh.
My point is that Smith was all for squeezing labor as much as possible for maximum profits for middle men, like stockholders, and including government.  
While you believe government spending will solve the problems of unemployment, health care, and other social ills, I see government as the worst kind of enabler.  If you don't know, an enabler is the wife who covers for her hung-over husband when he misses work.  It is the parent who bails a teenage child out of a speeding ticket.  In other words, the enabler rewards illness and dysfunctionality, and basically cripples to control.  This is nowhere so apparent as in the US health scare/snare racket today.
Katharine Otto Added Jul 30, 2017 - 3:18pm
I've been hearing the UK system is breaking down, and suspect its a case of squeezing labor to fund the middle men, once again.  (See above.)  Salaried jobbers have a different mind-set from the self-employed, in all walks of life.  The salaried jobber has less incentive to excel, but for personal gratification, because the paycheck falls out of the sky every two weeks, even if the worker spends most of his work time in doctors' offices paid by their "benefits" plan.  This is most apparent with government (all levels) in the US today.  
The self-employed, on the other hand, can make more money by working hard, but he can also go out of business if he doesn't work hard enough, or if bad luck, bad judgment, or other circumstances interfere.  It's a lot riskier.  
Point is, the system is set up to squeeze the people who do the most work, so no wonder they feel exploited.  Their work feeds everyone in the chain, and all those people yanking their chains give them little room to breathe.
Stone-Eater Added Jul 30, 2017 - 4:10pm
Our way of life produces burnouts and "psychopaths". Nothing else, trust me.
Saint George Added Jul 30, 2017 - 6:25pm
Ain't neoliberalism great? Make people sick and then profit from treating them. 
Not as great as socialism, of course, which simply starves people to death.
We don't see many obese people in Venezuela or North Korea.
Stone-Eater Added Jul 30, 2017 - 6:37pm
We don't see many obese people in Venezuela or North Korea.
Of course not. They're not forced to eat junk food because fresh stuff is more expensive than that unhealthy crap. At least in cities.
Stone-Eater Added Jul 30, 2017 - 6:39pm
BTW: Obviously you don't know anything but simply blather. If you would you'd have understood by now that there was never a socialist country on that planet.
John Minehan Added Jul 30, 2017 - 7:13pm
"If you would you'd have understood by now that there was never a socialist country on that planet."
But if a socialist system is so hard to implement, is the idea even practical? 
Saint George Added Jul 30, 2017 - 8:34pm
They're not forced to eat junk food because fresh stuff is more expensive than that unhealthy crap. At least in cities.
You're disconnected from reality.
The reason there are no obese people in Venezuela and North Korea is that there's a severe shortage of food — processed and unprocessed — in both countries thanks to their government's socialist policies.
Saint George Added Jul 30, 2017 - 8:47pm
No one's interested in your crackpot conspiracy fantasies, John G. The famine now in Venezuela was predicted by many economists of many different methodologies years ago when Chavez implemented price controls on food. Price controls on any good = impending shortage of that good.
Katharine Otto Added Jul 30, 2017 - 9:57pm
John G,
I did read "Wealth of Nations," cover to cover, underlined, commented in margins, and took extensive notes.  Despite Smith's sing-song style, it is a very interesting social history.  So, you assumption is wrong. You're right that in Smith's time, real gold was the universal currency standard, but banks were beginning to understand the usefulness of fiat money.  
However, human behavior hasn't changed in that labor has been squeezed by every "ism" to come along. Government is always the biggest beneficiary, because government sets the rules and claims monopoly on the currency.  And the little guy--the worker--ends up subsidizing everyone else, by hook or crook.
In the health care "industry," the doctors are still just "labor," despite the glamorous trappings.
John Minehan Added Jul 30, 2017 - 10:39pm
"In the health care 'industry,' the doctors are still just "labor," despite the glamorous trappings."
Which gives doctors a LOT of power---IF they are willing to use it.  In my experience, they often don't think of doing so as against payers.  
John Minehan Added Jul 30, 2017 - 10:42pm
In a profession, the only ones who can 'labor' are those professionals. 
PPOs or HMOs without docs on the panel are SOL. 
Out of Network with a PPO, less leverage, BUT you still say what is and isn't medically necessary . . . .
Saint George Added Jul 30, 2017 - 11:40pm
John G has never read The Wealth of Nations. He's only read about the book by those hostile to individual freedom, division of labor, private property, saving, and capital accumulation.
Katharine Otto Added Jul 31, 2017 - 10:34am
John M,
My point, exactly.  But doctors are wimps who are not exercising their power and responsibility to set the standards for health care.  They have allowed the bureaucrats and politicians to take control, to everyone's detriment.  The AMA was all for Medicare, I believe, under the pretext that it would alleviate the stress of billing and allow more free time for patient care.  But he who controls billing and patient records controls the doctor, we've learned.  I know of cases where groups buy individual practices then fire the doctor.  Does the patient get a vote?  Haha.
That's why patients should own their own records, according to me, but nobody except me wants them to have that power.
Katharine Otto Added Jul 31, 2017 - 10:45am
John G.,
You have said a lot about gold, in other comments, on other posts.  My point is that Adam Smith lived in a time when gold was the standard.
Democracy has never been tried, but I've never suggested mob rule.  Socialism is a vehicle used to harness human capital under the self-appointed "elite" control freaks, and it uses tactics like guilt, fear, and hate to steal from the masses under the pretext of helping them.
You assume my views come from media, but you're wrong about that, too.  I've done my own research into social and economic history in order to find out for myself what went so wrong.  No one can speak for the "will of the people," but too many people presume to know.  I would say that a society which makes it as easy as possible to do the right thing would be worth a try.
John Minehan Added Jul 31, 2017 - 11:11am
"Democracy inevitably leads to socialism. That's why the very rich fund the think tanks and own the media and the political circus that misinforms and disinforms you."
But Socialism does not seem to lead to democracy, with some fairly rare exceptions (Tito's Yugoslavia, which was less autocratic than  the pre-war Royalist Government, comes to mind).
In fact, more representative government seems to come with economic liberalization (with the post -1979 PRC being the obvious exception).
Friedman's “Underlying most arguments against the free market is a lack of belief in freedom itself,” may go too far.  But, economic freedom is freedom and it does tend to create the surpluses that make more participatory political systems possible. 
John Minehan Added Jul 31, 2017 - 11:26am
"The AMA was all for Medicare, I believe, under the pretext that it would alleviate the stress of billing and allow more free time for patient care."
The AMA vigorously opposed Medicare in 1965.  The UCR payment system, in use until 1983, was adopted to appease the AMA. 
"I know of cases where groups buy individual practices then fire the doctor.  Does the patient get a vote?  Haha."
Actually, that is neither uncommon nor unreasonable. 
Many times a group will acquire a solo practice with the intent that they will install a member/partner or associate physician there after a transition. 
Many times the solo physician will sell the practice to the group on  an installment payment basis to finance retirement or transition.
In NYS, where are labor law tends to disfavor restrictive covenants, restrictive covenants against a selling business owner or someone with "unique or extraordinary qualities" (like a professional) are broadly enforceable.
Because of this, the patient is often denied her or his vote; one argument often asserted against enforcing restrictive covenants.  
Katharine Otto Added Jul 31, 2017 - 11:51am
John M.,
I stand corrected about the AMA and Medicare, as you do seem to know your stuff, and it's out of my area.  So the foot-in-the-door strategy worked to Blue Cross/Blue Shield benefit with the UCR system (which I'm not familiar with) for 18 years.  So what happened to AMA advocacy after that?  I'm not a member, obviously, as I've never felt it's worth the dues.
About selling practices and firing the doctors:  You are right that there are many scenarios.  It can also be political, in that the new owners are threatened by the doctor.  In any case, I tend to respect that a doctor who has built a practice over a career has built a personal bond with patients.  To sever that bond peremptorily is a tactic that is used too carelessly by the control-freaks who only care about the bottom line.  It seems the patient's records should go to the patient, but that's not what happens.   
John Minehan Added Jul 31, 2017 - 2:02pm
"It seems the patient's records should go to the patient, but that's not what happens."
Legally, it is what should happen (albeit with a modest charge for copying of up to $00.75/page in NYS under the PHL).
Practically, it almost never happens and when the insurance changes (as it tends to about every two years or so in small group plans) the record stays with the former PCP.
Possibly, EHR/EMRs and the HIPAA Common Data Set Rule will eventually change that, but I'm not holding my breath.    
John Minehan Added Jul 31, 2017 - 2:06pm
"UCR system (which I'm not familiar with) for 18 years."
Medicare, until 1983, didn't use a fee schedule of  CPTs in a Catchment area, they paid what was on the doc's chargemaster.  I'm not sure there was even a MFN clause where you have to promise to give Medicare your best discount on your Usual Customary and Reasonable charge. 
Eileen de Bruin Added Jul 31, 2017 - 4:48pm
So, here we are again, back at government types, drivers. Lobbyists rule. They are not rooting for the people; it's only for monetary gain for themselves and the entities which control. Their outcomes, dictated, justifies their means. It is not about the good of the people or the greater good or any kind of good.
Whatever happened to ideals?
Where do we go from here?
Well, said the Martian, wherever it is, you shouldn't start from there!
Jeff Michka Added Jul 31, 2017 - 6:39pm
Eileen de B sez: Whatever happened to ideals?-Went the way of the horse drawn cart and buggy whip, or gas lamp.  Ideals have little or no monetary value, so aren't something we need to think about, right? 
Bill Caciene Added Aug 1, 2017 - 8:30am
Expanding insurance to the entire population is no akin to Congress practicing medicine.  Healthcare insurance simply provides the means to pay for medical care. 
Eileen de Bruin Added Aug 1, 2017 - 1:44pm
Ideals are about living standards in this context.
Ideally, good, basic and unadulterated medical care should and could be made available to everyone. This would prevent social diseases and create a more equal and balanced society. Equal does not mean same. A balanced society doesn't have the two extremes as its model.
A physician does not, by degault, need to prescribe any drug at all, it could be any number of things including lifestyle advice and nutritional concepts.
This is an ideal.  But it doesn't fit the one size fits all and pile 'em high and sell them for as much as you can get model.
John Minehan Added Aug 1, 2017 - 1:51pm
"Socialism is where labour controls the means of production."
What are the "means of production" in a knowledge-based society?
For a programmer, that is a laptop and her mind; for a trader, it's her laptop and her instincts.
With something like Uber, who is "labour?" 
The driver or the programmer who wrote the ap or the founder and the VC who put the business model in practice?
"The new philosophy calls all in doubt; the element of fire is quite put out."---John Donne
Katharine Otto Added Aug 1, 2017 - 2:36pm
John M.,
Thanks for questioning the "means of production" term.  I've wondered what that is, too.  
Bill C.,
When Congress controls contingencies, even if it delegates those to insurance companies, it is by default practicing medicine.  Health care insurance does not provide the means.  Health care insurance competes for the dollars and the control of health treatment.
Public health departments traditionally have practiced prevention, such as screening for STDs, TB, and head lice in school children.  They monitor drinking water and make sure restaurant flatware doesn't have germ-harboring cracks.  They are locally based and accessible and accountable to all.  This hands on style is infinitely preferable and more cost effective than going through the middle men.
He who holds the money calls the shots.
John G.,
Labor does not control the means of production in socialism, unless you're talking about all the government employees.
Eileen de Bruin Added Aug 1, 2017 - 2:55pm
I like the John Donne quotation, John M. Indeed, the fire of ideals is put out under mind numbing controls.
Katherine, I wasn't thinking specifically or only about prevention, but an overall approach to the body heals itself.  Water is extremely important, yes. Drink water and green tea, and illness shall flee from thee!  (The people of Flint, Michigan, might have some concerns, though.)
Isn't this the point? clean water and unadulterated food lead the way. But that doesn't serve the main lobbyists and big company control, now does it?
How would you solve the problem, as you see it, Katherine?
Prof Claudewell Thomas Added Aug 1, 2017 - 7:48pm
Yes,the romance of Arrowsmith,is long gone,more time is spent with record keeping than with patient care.The model for psychiatric care,except for the very wealthy,is defined by psychotropic drug administration and minutes given to social workers,nurse practitioners,community workers,and rare assessment by " neuro" psychologists.The most relevant basic truths are not science based but social system based.How is care to be paid for?
That issue contributes mightily to what constitutes care.Many of us feel,excessively,However that reality is not going away.Many of us are simply going to be ground up in the mill of social change.What change? The old definitions are passé as well.Adam Smith warned that the free market would be perverted bybgreed
Katharine Otto Added Aug 2, 2017 - 9:55am
We share the same concerns.  Lead, for instance, is probably a much bigger problem than we know, because the "powers that be" don't want to see.  Yet, there is evidence from an Australian study that lead exposure in childhood can lead to long-term cognitive deficits.
Congress and lobbyists are guided by profit, ambition, and image, not by common sense.  As long as voters are willing to put up with that version of "leadership," they deserve to have poisoned water, air, and food.  My strategy is to embarrass them into behaving, but it requires a multi-pronged approach. First is to name the key players, for everyone to see, including--for instance, Archer Daniels Midland, which was apparently the main force behind the horrific ethanol mandate.  The GM corn manufacturers, like Montsanto and Dow, were of course behind it, too, as well as the farm "industry," if not individual farmers.
I'm working on a blog about the "opiod crisis" right now.  A previous blog on this subject is on my Wordpress blog.
Katharine Otto Added Aug 2, 2017 - 10:04am
Everyone has a different version of "reality," and it's important to remember that.  The "reality," is you don't fail until you give up, and maybe not even then.  You are only a victim if you believe that.
Even the very wealthy are subjected to the same paradigms as everyone else, which is driven by statistics based on questionable assumptions.  Psychiatry has lost its way, too, and has become big business, striving for relevance in a drug-happy culture.  Not just psychotropics, but drugs for everything except . . .what? There are even drugs for breathing.
Social change is a given, but it doesn't have to crush individuals.  If I have a message it is this.  Health, both psychological and otherwise, is a natural right.  The body and mind want to be healthy, yet "health care" as we understand it today, thrives on undermining people's faith in themselves and their bodies.
Katharine Otto Added Aug 2, 2017 - 10:06am
John G.,
I have decided you are not a real human being but a robot.  Your answers are predictable and insulting, I suppose designed to provoke, yet you add no insights of your own.
Prof Claudewell Thomas Added Aug 2, 2017 - 12:31pm
Well said.I like your assertion that health is a natural right.That we as a nation are at odds over whether health care is a right or a privilege indicates a divergence between what has evolved and what is needed.In that divergence enter globalism vs nationalism,ruralism vs urbanism,and all of the other opposable "isms". The circumstances determining who is expendable and when( the outcome of all this) belong to a"political"process.We need to revert to Bismarck's definition of politics as "the art of the possible"and hold our leaders to it.
John Minehan Added Aug 2, 2017 - 1:14pm
Health Care is not a right because someone has to provide it. 
At worst, if we assume Health Care is a right, to meet Person A's right to health care, I have to take away Physician/Nurse/OT/PT/ST/Pharmacist B's right not to treat that person (note: NOT Hospital B, so EMTALA does not apply and assume there is not an on-going treatment relationship, so Abandonment is not implicated).
Not quite the same as this, but related, is that Physician/Nurse/OT/PT/ST/Pharmacist B put a lot of time and effort into developing and sustaining their skills and have a right to be properly paid for them, as people are willing to pay for them.
On the other hand, public health is a concern of all societies.  That concern has tended to be placed upon governments.  Since the development of the Bismarck System in the FRG in the late 19th Century, that duty of governments has been seen as encompassing setting up a viable system of  providing and paying for medical services. 
That has included things like actual Bismarck Systems in places like the FRG, France and Japan; socialized delivery systems, as in Great Britain; socialized insurance, as in Canadian and Australian Medicare;, or mixed system like the US.  It also includes things like regulating the Profession of Medicine, as in the US after the Flexner Report.
If you consider providing a working Health Care System a  duty of a society, rather than a right of an individual, more viable options are available for meeting this duty, all of which are less likely to trample on the rights of providers.   
John Minehan Added Aug 2, 2017 - 1:31pm
"How is care to be paid for?
That issue contributes mightily to what constitutes care."
As a wise Healthcare System Administrator told me 20 years ago, "In Healthcare, form follows finance."
In my personal opinion, finance should follow epidemiology (morbidity and mortality, the M&Ms).
Where your epidemiological threat is acute infectious disease, a single payer system may be justified, as everyone can be a rugged individualist until the guy walking down the street in front of you, spitting on the sidewalk has multi-drug-resistant TB.
On the other hand, societies where acute infectious disease is prevalent tend not to have the resources to have a single payer system and might have a less robust system that might easily be overwhelmed by large numbers of infectious people presenting and spreading it to providers and everyone else.
With more affluent societies, the more cost effective way of meeting the duty of having good public health might be through keeping the public informed of health issues.
If a guy with multi-drug resistant TB is spitting on the sidewalk, both Rush Limbaugh and I have a vested interest in seeing him treated.  I don't have such a vested interest in Rush's treatment for cardiovascular disease or problems with addiction (save as a warning about these things).
Thus, a more affluent society is more able but less likely and less required to set up a single-payer system than a less affluent society that might benefit from such a system.           
John Minehan Added Aug 2, 2017 - 1:43pm
"Ideally, good, basic and unadulterated medical care should and could be made available to everyone. This would prevent social diseases and create a more equal and balanced society. Equal does not mean same. A balanced society doesn't have the two extremes as its model."
The basic question is "Who are the buyers" in the "Healthcare Model?"
In the US System, it is employers (through employment-based insurance) or the Government (through Medicare/Medicaid/the VA/FEHBP/Tri-Care/BIA)
However, I think non-employer-based groups might level the playing field by acting in the interest of the patient.  I also think keeping the focus on the patient favors physicians, institutional providers and allied health professionals' interests, not least by providing a less-distorted market.
Bismarck Systems, particularly that of the FRG, provide a model.
Prof Claudewell Thomas Added Aug 2, 2017 - 4:28pm
We're healthcare to be defined politically as a right then the responsibility of providing a working health care system would become public policy as would paying for it.Education and training would be in the context of the system so that certification and employment would be traceable.It would be possible to be tangential to the system( but not unrelated) with great wealth or great talent.Political change of heart would wreak havoc with such a system so that disavowal would be party suicide.
Such systems exist,tend to be single payer,relatively small,homogeneous populations with high taxation rates.Concierge type practices do exist for the very wealthy but modalities of treatment have to be approved by boards and/ or certifying bodies.Practice across national boundaries did not work well for the European Union.Brexit may be a remote reflection of that.
The U.SA. is large,heterogeneous,and has 50 states and a few territories with different certification procedures.There's miles to go and a lot of misery before Health Care as a right can make sense here.In the meantime technology will drive us to more coordination of records if not coordination of care.
Jeff Michka Added Aug 2, 2017 - 7:30pm
In article sez: at least one symptom of burnout in 46-54 percent of doctors. - IS "an easier go of things" a partial answer why our medical schools turn out fewer and fewer GPs, or is the "All specialists, all the time" simply a financial return deal?
Eileen de Bruin Added Aug 3, 2017 - 2:58am
"EPA and the Centers for Disease Control and Prevention (CDC) agree that there is no known safe level of lead in a child's blood. Lead is harmful to health, especially for children."
Katherine, above is the synopsis of you own US's government appreciation of the issue of lead in water; there is more detail in the website.
John M. This mantra that something has to be paid for is the one used comprehensively to explain away why the richest nations on earth deny basic human dignity and health to,its societies.  The very image of the purse not having endless amounts of money for everyone manages to keep the masses content, because they relate it, of course, to,their own household budget. Who is going to pay for it!?  Mrs May used the same mantra at the last election rallies.  The sure way of stopping the average voter in their tracks, when they have posed a very pertinent question. And the the rest of the audience can nod their heads in agreement.
So much heakth insurance and chronic disorder treatment wouldn't even be necessary John M, if the water and the food were pure and unprocessed. Huge farming production companies are not the way. Basic healthcare is not expensive at all and it provides the structure for civilised societies, without the word socialism in sight.
The truth is that the public is fed with bad food, bad media stories to develop narrow view points and a lobbying-driven government which has anything but the greater good in mind.
Administrative layers and insurance claims and forms provide work for some, and much misery to the degree of panic and fear for the many. Perhaps it requires a mass change of perspectives. The information is all out there, but what is spoon fed from the media is the usual narrowing laws of diminishing returns.
It does not serve the US well to have its people afflicted with social diseases and early deaths because basic healthcare is withheld on the grounds of who will pay for it.  We are all being made to pay for the ever narrowing positions of our very inward looking governments. The model is returned to mediaeval mode. The great and the serfs.
We all have birn out!
Eileen de Bruin Added Aug 3, 2017 - 8:44am
Sorr, I meant "burn out" of course (not birn).  
John G.  this is the whole issue.  monetary value is representative merely of that which the economy can produce. It is a paper, representative value of what the economy holds, its wealth.
Telos relates to the intrinsic value.  
That is, the lump of unmoulded clay.  Its worth.  The raw material.
Labour is applied.  It becomes a cup.
A cup from which to drink water.  
The labour cost plus the cost of the raw material gives the cost price.
The intrinsic value - the human function served - is something else. We do not put a monetary value on that and so it becomes forgotten or cast aside as an abstract.
A nation's wealth is not necessarily utilised for the good of the entire nation. The wealth of the US is not utilised to provide a good, basic, standard of living including education and healthcare, for everyone. 
This has nothing to do with socialism or communism or any other ism except common sense and a basic quality of life. Respect at all levels. These are the intrinsic values of such utilisation of a nation's wealth.
Katharine Otto Added Aug 3, 2017 - 9:22am
John M,
You misunderstood me.  I did not say that "health care" is a right.  I said "health is a right."  Maybe I should have said health is a "right, (and responsibility)" and no one else has the right to dictate what that means for anyone else.
This misunderstanding of "rights" forms the basis for my objection to the "health care industry" as a whole. The profiteers would have people believe health care is a right, but I agree with you.  Only health is a right. This puts the responsibility on the individual for maintaining health and doing what she considers necessary to deal with disease and infirmity.  The "health care industry" wants to burden others with that responsibility and have everyone pay up front for people who may never need outside "health care."
I agree with you that delegation means someone else has to pay for it.  Also, it unfairly obligates doctors and others to provide more for the individual than she provides for herself.  It has the effect of distancing people from their own bodies, and of caring for this most valuable asset.
Katharine Otto Added Aug 3, 2017 - 9:35am
I'm aware of the CDC's position that there is no safe lead level.  I also know there is enormous resistance to looking for lead in the environment.  
When it was outlawed from paints and gasoline, it didn't just go away.  It is an element.  Because it's a heavy metal, it probably found its way through runoff into the bottom of lakes and rivers, from which many municipalities take their drinking water.  The only way Flint, Michigan discovered it was somebody complained.  
No one suggested that the flowing river (which they used as an alternative source) probably stirred up lead that settled to the bottom in the calmer lake (which they had used before).  Instead, they are using bottled water (or were), which brings its own problems.  Bottled water in plastic throwaway containers is a newer, but underestimated, pox on the environment, much more dangerous to health than people recognize.
The buildup of toxins in the environment is to me a way more immediate threat to all life than global warming (and maybe an indirect contributor to it). Public health, in my opinion, would be much better served by paying attention to the poisons we are all ingesting while adding more every day.  This is an issue far beyond the basics of who pays for "health care."  We all pay dearly for ignoring this vital piece of the puzzle.
Katharine Otto Added Aug 3, 2017 - 9:47am
I like your recognition that human capital (the labor that makes the cup from the clay) is more valuable than money.  Both Ayn Rand and Milton Friedman claimed human capital is underestimated--and in my definition individual human capital is the basis of capitalism--but neither took the concept far enough.  
Labor--meaning people who do the useful things--does constitute the basis of any functioning society.  Society attributes "capitalism" to the imperialists who harnessed human capital for unearned profit.  
But not to get caught up in "ism's," I agree a universal change in attitude is needed.  For me, this means individuals have to wake up and realize their own health is directly related to society's health, and vice versa. Nobody feels your pain more than you do, but you can guarantee that if something is causing you pain, it is probably affecting others in a similar way. By taking steps to insure your own health, (such as boycotting processed food, or single-use packaging), you also help others.
Eileen de Bruin Added Aug 3, 2017 - 5:05pm
Yes, Katharine, the application of labour to the raw material can make the utilisable vessel. Without it, the raw material is form but no function. Lead in water and the plastic bottled water is, indeed, no answer. We were in Flint just over a year ago and were greeted with bottled water on our arrival in the hotel! Wandering around Flint, with its memorials to its stance against slavery and the wonderful statue of Gandhi, it is rather a shame that its principles achieved no kind of respect from its governments.
You must feel rather helpless. Knowledge and good will is not valued by lobbyists is it?
Eileen de Bruin Added Aug 3, 2017 - 5:13pm
Jeff Michka and your Eileen de B sez comment, sorry for the delay in responding! Ideals might well have gone the way of the horse and carriage etc.
Nostalgia seems to play a big part in American life though, so you would think that some ideals are worth fighting for. You need to get the masses away from the idea that it is monetary constraints that limit health care, though. And how might you do that I wonder?
Nostalgia plays a big part in UK life and it tends to function in the state pageantry of the seventeenth century guards, for show. Some less welcome Dickensian society ills like extreme poverty and deprivation alongside utter ignorance, are back; some kind of nostalgia is that!
John Minehan Added Aug 3, 2017 - 6:22pm
"Frauds like John Minehan would have you believe that money is a scarce resource. 
Whereas it is an accounting unit created from nothing that can move real resources around the economy."
Capital is hard, but feasible.  Something worth investing in is much rarer.  Good ideas are the key constraint, especially ideas that consider second order issues. 
Katharine Otto Added Aug 4, 2017 - 1:47pm
Thanks for your supportive comments.  I do feel helpless in the short term, but believe ideas need time to mature.  The idea of the dignity of human capital has never fully matured, and this may be the crux of our current dilemma.  Regular people are living down to low expectations about themselves and what they could accomplish in everyone's best interest, should they choose to see it that way.
I'd like to think that ideals have not been lost but buried.  There's a huge sense of betrayal going on, at every level of society, because it seems we've abandoned ideals, or they have abandoned us. Nostalgia may be stronger in the UK than the US, because of the longer history.  In the US, I suspect that what seemed to work in the past is no longer working, and we need different paradigms.  There is more to life than money and the blind pursuit of it. But when everything, like health, is reduced to financial terms, we can lose perspective.
Katharine Otto Added Aug 4, 2017 - 1:57pm
John M.,
Since responding to you about what constitutes a "right," I've thought more about it.  It seems the individual's most basic "right" is that of saying "no."  For me, that means saying no to a government-mandated prescription for its version of "health care."  Having worked in the system and also being a patient, I am increasingly horrified at what passes for health care in this country.  It has less to do with health than with keeping people on the hook for medical overkill.
Individual health care workers, like doctors, nurses, techs, and the like, seem personally pretty caring and compassionate, but that is subverted by all the demands on their time and attention.  They are perpetually frazzled, and I can understand why. Unfortunately, the patient suffers most under this scenario.  No amount of money can compensate for the beatings they take due to all the constraints on doing what they were trained to do.
Jeff Michka Added Aug 6, 2017 - 7:47pm
Katherine Otto says: welcome Dickensian society ills like extreme poverty and deprivation alongside utter ignorance,- The rightists further weaponize poverty and ignorance so people will die.  And that's okay to them since it rids their minimal consciences of any thoughts of "those people."  If they're all dead, they'll never have to see one again...what an exercise in free dumb washed down with liber-tea.  Outta sight outta mind. There's a clown on WB advocating healthcare for the poor be handed over to charity hospitals like St Jude, and hunger issues handed to foodbanks, because if they do, Americans will open their wallets and give money for tax breaks....

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