Thursday, June 18, 2009

What's up with Docs?

[Editorial note: my one professional critic would tell me "it's too long" (if she's still reading this). Yeah, sorry.
And it might be a little... over emotional. Yeah, sorry.
As these things often do, this ball of bile built up from a Facebook discussion on socialized medicine .... oops, I mean Universal Health Care. They're different. Really. No, really. Hey, look, a bird.]

Well, sure... we should totally regulate medicine. It's just a bunch of money grubbing, Porsche driving bastards that hold us hostage for our own health and close their office 2 days a week so we can pay them to play golf. Socialize the bastards...
...not so fast there, Bub. This seems to be the general consensus. But -- as someone that grew up in a doctor's house, if you feel this way, you might just be... wrong. And I don't mean a little wrong.
Let me give you a character sketch of the guy in the white coat. You probably see him one time for 15 minutes... and you're already crabby because the magazines in the lobby are 14 months old and are were not a subject matter that is in the least bit interesting. You're sitting there naked under a rustly paper smock and you aren't feeling good in the first place or you wouldn't be here. So let's meet Dr. Joe Average, shall we?
A doctor is the ultimate small businessman. He's like an electrician or a plumber -- except maybe not quite as wealthy.[1] He runs a very small business. In the old days it was just Dr. Average and one sidekick that played the role of receptionist, secretary, nurse and billing department. Now with the complexities of insurance, government rules, FDA, HIPAA, Medicare, Medicaid.... Now it's more likely that the small business has dedicated salaried positions for each of those roles. It's just more complicated.... Not the actual healing part, but the business of healing. And unfortunately that adds tremendously to the cost of health care. But I am sure some sort of Presidential edict or some nice Congressional reform will somehow regulate the business in a way that will allow those 4 positions to go away to reduce costs, right? Or maybe the reform is part of that "job creation" we are always hearing about and we'll get 4 more dedicated resources.
...But we're getting ahead of ourselves. If you want to know Dr. Average, you'll need to go back a ways. Like many of us, Dr. Average went to college. You know all those science courses you hated and bitched about? You remember changing your major just so you didn't have to take so many? Well, Dr. Average had to take lots of them. They were hard. Some so hard that he barely squeaked by... but he squeaked. Those that didn't were weeded out, which was the intent. Following that, he applied to medical school, which is damned hard to get into. He did 4 years there, working some on the side to try to cash flow the whole operation. Next was a year as an intern. He then applies for a residency program where he spends 3 years specializing in surgery. Note that each of these steps is a weed out... and not everyone makes it. People wash out at every step of the way.
During much of that training, he is technically a doctor, but not paid like one. He is paid $25 a month -- yes, per month.[2] For that paltry sum, he works 36 hours on and 12 hours off -- with most weeks being 100+ hour weeks.[3] He is a proud guy and totally against any such nonsense as government sponsored public housing.... Yet, unfortunately that's the only place he can afford to live. Gunshots outside were a regular occurrence. You learn the only way to safely dry clothes is to hang them up inside -- otherwise they'll just get stolen.
Once the hell of the training is over, real doctoring begins... and to be honest, the schedule is pretty similar. A normal week is probably 70 hours. A rough week is 80-100. There is no such thing as night and day. Things happen. The phone rings. He goes. Weekends... well he might get every other one off if he's lucky. But 7 day weeks are pretty normal. People will laugh and poke fun and talk about how his office is closed on Thursdays so he can play golf. But Dr. Average never corrects them. The office is closed so he can schedule surgeries starting at 6 am and lasting until well after his supper is cold.
And lets not forget Emergency Room on call rotation. This is in addition to his regular patients, who pretty much feel they can call him any time of the day or night and he will cheerfully help them. ER on call is another level of hell... another layer of hours that come at odd times and interrupt an already filled schedule. And while we're on the topic of ER on call, I'd like you to think back to all those child rearing memories... to all those family gathering times: Christmas, New Years, Thanksgiving, Easter, 4th of July. There will be none of those memories for Dr. Average. For the first 20 years of his career he will almost always find himself holding the on call pager during traditional holidays. In fact, this is the supreme sacrifice Dr. A faces. Many of these interruptions are normal everyday folks that are super grateful for his work, but they are just as likely to be drunks, prison inmates, wife beaters and drug addicts. But it doesn't really matter if they are a drug addict or the mayor -- they all trump the holiday.
Due to the life and death nature of his work, he never gets the time he wants with his wife and kids. And by the time he has enough seniority to pull a few strings and try to spend the time, the kids will invariably be sullen, snotty, difficult teenagers that don't appreciate him. And he'll just smile and swallow it. They'll be in their mid 20s before they realize what a heroic, hard working, honest man he really is.
On the odd night, he will finally get time away from his super stressful work. Most of us would vegetate in front of a television. But Dr. Average will go and sit in a big overstuffed yellow chair and worry and fret and contemplate on every patient he has in his little black book and when he's done with that he will beat himself up for every patient he couldn't help. Sure, he comes across as sort of quiet and stern, but when no one is looking he sheds tears for those losses, too.
Government sponsored Medicaid for the indigent? Dr. A. really doesn't need that. He gets lots of patients that can't pay at all or maybe just can't pay the full price. He just lets them pay what they can... or nothing at all. Some of them bring him produce or meat they grow themselves. And the bill is marked as paid because that's just the right thing to do. Making people better is a passion. He'd do it for free. Getting paid is just a nice benefit when it works out. This sort of stupid, silly, backwards way of thinking will eventually be impossible. Between tax laws and Medicare and Medicaid and various regulations too numerous to list, this sort of "Just fix them" attitude will become a thing of the past. In fact, at some point folks will start telling him exactly what he can charge for each and every procedure. His desire to fix folks that just can't afford it will prompt him to take trips to places with awful conditions in Africa and Central/South America. Here folks will walk an entire day for his treatment and pay him with nothing but a smile -- a payment he is more than willing to accept.
In fact, government regulation will turn that one man/one jack-of-all-trades secretary shop into a huge paperwork factory that requires 2 additional workers to handle. And the current over-litigious society we live in doesn't mean he possibly will be sued. It means he most probably will be sued some day. You see: people die. Some people die no matter what you do. There might be 5 right choices for treating someone... and all 5 might still not fix them. It's just how it is. We are mortal. And some folks just won't understand that. The real cost of this is that no hospital is going to let Dr. Average walk in their super secret doctors-only back door unless he is fully insured. And that insurance will cost him more than $100,000 a year. Don't you bitch and moan to me that you cannot afford $1000 a month for health insurance. That guy that's treating you is paying 100 times that amount of money just for the right to treat you.
Sure, you see some stereotypical doctor driving a red Ferrari and living in a 42 room villa. And you think "He's gotten rich off of my ills." But I really don't think so. You'd be awfully surprised at just how little he's making after expenses:
  • office space rent in probably one of the higher cost parts of town
  • salaries and benefits for all the office staff
  • equipment for the office
  • malpractice insurance and various and sundry legal fees
And while there are doctors that live that way -- more than likely they either shrewd businessmen with side business ventures or they are living well above their means.[4] Dr. Average has a nice house, but it's not off the scale or opulent. And he's lived there 45 years now that he can afford to live outside government housing. His "BMW" is a squeaky GMC truck that is over 20 years old. He's never played golf in his life. His retirement portfolio is adequate, but it's no more than Joe the retiring plumber or Mike the retiring electrician.
So now, there you sit in your crinkly paper gown, hating this rich son of a bitch for making money off your sickness. You want to regulate his life some more. You want to stick it to him and those awful insurance companies. And I'm here to tell you the saddest news of all: He'll let you. He'll let you because unlike you or I, he doesn't have a job. He has a passion. He can't NOT do what he does. Doctoring is what he is. It's his identity. It's the reason he wakes up in the morning. He'd do it for free and he'd do it for a loss.
This is the guy you want to enslave.

Footnotes

  1. Seriously. You should read The Millionaire Next Door. The author was interviewing the wealthiest folk in America. He expected a bunch of slick doctors, lawyers and investment bankers... and found out the average millionaire was an average Joe that lived within his means.
  2. Oh, sure, you'll say "but that was back then... there's been a whole lot of inflation." Okay, if you do the math then that's $200 a month or $0.50/hour in present dollars. You live on that!
  3. People will argue that this is lunacy. Why would we want them sleep deprived? Well, because they need to figure out that this is how they are going to live for the next 20 years. Sure you can say "just hire more doctors" but if you turn around and bitch about the cost of health care, I'll punch you in the crotch.
  4. If you live in a 3 million dollar house with 100% mortgage your net worth in this venture is still zero.

23 comments:

bigjohn756 said...

What a great post, Spork! Evocative, obviously from the heart.

All of the wealthy doctors I know aren't. Of course, they all make a lot more than I ever did and I think that that is what bothers a lot of people. What they forget, or do not know and don't want to know, is what these guys went through to get where they are now.

Many of the people who want to regulate medicine are the same ones who are eager to punish others who have worked hard and now earn a nice income for themselves. Is $250,000 really so much that one should be punished for making such an obscene amount?

Have I lost you? Oh, well, too many Salty Dogs.

Spork In the Eye said...

While I have never seen a tax return... I suspect $250K is a serious over estimate after expenses are paid.

Oh, and please PLEASE tell me you make salty dogs with gin like Jesus intended. I've seen too too much vodka salty dog insanity in my lifetime.

Kari said...

Great post, Sporky! You made me all teary. I think you will make Dr. Average proud with this.

El Gee said...

In between marriages back in NC about 20 years ago my roommate was a med student at Duke (he would have stayed at UNC where he graduated but they did not want him...). I clearly remember his 36 hour days. He would come home and collapse, sleeping as long as he could before he had to go out again. I also remember him having to do rotations at other hospitals out of the area where he lived in a generic apartment away from family for 30+ days at a time.

He took great pleasure in the simple things on his days off: Boys day out (movie, lunch, etc), watching ST:TNG on Fox, and anything we taped on the VCR for him that he liked.

It was a hard life for him and it was made harder when he married, had kids, then had his wife leave him. He almost didn't make it.

There are a *few* docs who live the champagne and cavier lifestyle, but those are specialists who have paid their dues 20 years ago.

Good post, Spork.

bigjohn756 said...

I wasn't talking about doctors when I mentioned the $250K. That's prolly about 2X what the average doc makes. The $250,000 is the level of income which Obama has apparently chosen as too much and which must be taxed extra as a punishment for success.

I have never had a salty dog made with gin. I thought they were supposed to be made with vodka. That's what I get for not having a recipe book. I will have to try one with gin.

Oh, and another thing, who's Jesus and where does he tend bar?

Becky said...

Okay, I'm at work and I have tears coming out of my eyes and rolling down my cheeks. Wow. What a wonderful tribute to our "Dr. Average." Hope you are going to give him a copy for Father's Day.

Og Make Blog said...

Huh.... I always thought Dr. Average was respected as being far more than average in the community... at least from what I always heard.

I still remember young Sporky's mini rants to those who would claim his family was rich just because ... yes, he was ranting way, way back.

As for Jesus, I met him recently. My mother has been trying to get me to meet Jesus for a couple of years and it finally happened a few days ago. He's a soft spoken, pleasant fellow, but he didn't give me any drink recipes. Now I find out he has a second job at night bartending and he didn't even hook me up! I suppose it is proper and fitting that he would tend bar in Tyler, though.... it seems such a lovely little way to jab at those Green Acres Baptists.

I'll have to ask my mother to find out which bar it is ... she talks with him about every week.

Spork In the Eye said...

I can only assume, with a name like "Jesus", that it is a Mexican food joint where he tends bar.

Ragtime Joe said...

Great tribute, thoughtfully written, to one who has earned it well.

Spork In the Eye said...

Just a note of clarification: While this may have similarities to persons living or dead... and it may be somewhat of a tribute... The intent here is that probably > 80% of all doctors (and probably >95% of all doctors over the age of say... 55) would read this and relate to it. Hence the name "Dr Average".

bigjohn756 said...

Tried a gin salty dog. I like vodka ones much better. And, so, once again, I reject Jesus.

Ragtime Joe said...

More on the gubment and Dr. Average, who, if he got his MD in the 50s or 60s, had 2 or more years confiscated out of his earning life for compulsive military service.
The politicians who run things now have much grander plans for him or her. They intend to control his entire career, sharing with him their considered judgment re what patients he should see and what procedures and treatments may, or may not be used when he sees them.
Their benevolent omniscience may soon bring us the following announcement:
"To all American citizens: You are now rescued from the clutches of the greedy, money-grubbing doctors. Your care is now in the hands of your loving gubment-XOXOXOXO --sleep well."

Spork In the Eye said...

Yeah, Joe, don't think that doesn't bother me too. As someone that's a bit skeptical over some parts of mainstream medicine I think are not good science (recommended diet, recommended statins, etc.) I am not entirely sure I am wanting a governmental panel deciding my fate -- particularly if they are going to impose some penalty. (I.e., "Oh, you're not following the high carb food pyramid we designed and subsidized, you don't get treatment.")

Donna said...

ohmygosh. What a great tribute to our dad in the yellow armchair who really, really does only care about medicine and the people he serves. But, it's also a great tribute to so many other docs in the profession who i have had the good fortune to know and work with....and who feel much the same way....I salute you for putting this down in words so well.

Chris said...

A good post about doctor's passion for what they do, but it is not necessarily certain that socialized medicine will change this. There is a lot of FUD going around about how bad social medicine is.

Here is a very good article detailing many of the problems with the US system and why it needs to change.

http://www.economist.com/displayStory.cfm?story_id=13899647

Spork In the Eye said...

Chris,
The point isn't whether socialized medicine would change a doctor's passion... you are right. It won't. The point is that government ownership of any person's means of survival is wrong -- and that passion just makes it more so.

It wouldn't matter if it somehow made society "better" or "more healthy" (which, I'd argue it doesn't). It is a repudiation of individual rights -- the absolute cornerstone of the USA's government.

Spork In the Eye said...

Comments on the article mentioned...

o statistics show Americans have poorer health outcomes than other countries. I'd point out here that correlation is not causation. If I had to theorize (again without proof of cause) I'd say this was our lifestyle, not our medical system. We also have a diet that is extremely high carb/low fat -- a diet that has been subsidized and pushed by the government. I'd theorize this has a lot to do with our health.

o 49 million without coverage - I like how this statistic is always bandied around ... and it includes a huge chunk of folks that would be covered by existing plans if they participated. Wanna see how those numbers break down? http://tinyurl.com/q2vyus

o high cost of USA medicine - the article misses one bit. One huge part of the cost is that existing government plans pay a little more than half of market value. The remainder is passed onto folks with coverage... giving the appearance of high cost, but caused by the very government plan that complains of high cost.

o doctor's pay: it aint as much as people think

o American's generous coverage leads to some overconsumption/high admin costs of insurance companies... true enough. I've made this argument myself. People need skin in the game. I suspect any proposal for universal coverage won't give this though... or folks would just go out and buy their own insurance.

Og Make Blog said...

BigJohn... don't reject Jesus just because he is a lousy bartender. He does some of the best yard work and he has the best prices in town! My mother can hook you up with the number. Her yard has never looked better.

Spork, et al..... just look at those countries with the national systems ... really look at the cost... it ain't cheap. Hell, the gov't. can't even run the post office. Do you want them running anything else? Those with any money will be paying through the nose in taxes to a newly anointed bureaucracy. I for one do not wish to be taxed on my 'benefits' as they call them now. Insurance companies and gov't. have been complicit in bloating costs ... just as universities... all running around 7% inflation over the past 20 something years. Also, look at the sheer number of hospitals in this country and the duplication of facilities.

Spork In the Eye said...

Just a little FYEye for you Og... don't assume Chris lives in the USofA... He isn't going to make me an advocate of any form of socialized meds, but he does have a little first hand knowledge on the topic. Just sayin....

Spork In the Eye said...

...as for number of hospitals and duplication of facilities... At one point they definitely WERE regulated (and they may still be.) Almost all hospitals get state/federal funding and that funding comes with lots of strings attached.

I can't imagine you're against them competing for bidness.

Og Make Blog said...

Good, then he can keep paying his high tax base whether he uses the system or not. Just don't force it upon me, thank you.

Compete at your own risk... but don't expect me or anyone else to pay for it at the point of a gun (or mandate).

LogoGirl said...

hmm, you must not be talking about the surgeons I was once related to via marriage. They had varied and inventive ways to spend their wealth. It was on a level i couldn't even imagine. My H's boss the lawyer is in the same stratosphere. The vacation houses, the multiple household staff, the drivers, the planes, the boats, the full time chefs. These people do actually exist.
DO i disagree with the good old boy "pay your dues" crap they do to the up and coming doctors? Yes i do. I also know that they have restricted the numbers of future doctors to the point that there will soon be a major shortage. There will soon be Nurse practitioners and possibly the influx of foreign DRs like we saw take down engineering.

Spork In the Eye said...

LG, without knowing them, I can't comment intelligently... But the docs I've known in that category either inherited the money... or lived above their means. It's very possible to have 5 million dollars worth of assets... and 5.2 million dollars worth of debt. And that is not the picture of a wealthy person. [ And as a side note, that is EXACTLY the picture that real research found when Thomas Stanley wrote The Millionaire Next Door. Seriously... If you've never read this, you should. It's purely statistics. It's not fluffy. But if you ever want to be wealthy, it is enlightening. It ain't about what you make. ]

As for "pay your dues" ... well, the reason for it is simply because that's how life is going to be for the next 20 years. If you can't handle it for 2 years during residency... well, it's better to quit now.