Nick And The Not So Happy Hospitalist

Posted by – August 5, 2009

I’ve inadvertently stirred up some shit controversy at one of the major medical blogs, Happy Hospitalist (a hospitalist is a relatively new term for a doctor specializing in the care of hospitalized patients).

Don’t get me wrong, this story is not black and white; there’s plenty of value in much of what “Happy” writes, I’ve gained a lot from his posts explaining the medical payment system and have learned about how government is skewing the incentives toward procedures and the many other failures of government health policy. So, I’ve found it informative,

THATS 15 UNCOMPENSATED MINUTES!

"THAT'S 15 UNCOMPENSATED MINUTES!"

and the frequent discussions useful, and stimulating me to think more and write more. But “Happy”‘s writings often seem the opposite of happy; he routinely complains about doctor’s pay, about being overtaxed by the government (when taxes on the rich are the lowest since the 1920s), about how he has to spend 15 minutes of uncompensated time with this patient and that patient. And how any uncompensated time is SLAVERY. After a paid evaluation is over, if the patient waylays him for 15 minutes asking questions, that’s SLAVERY! He rants about how people, heaven forbid, “feel entitled” to his time! I pretty much ignored that, until he juxtaposed all this with the ostentatious display of wealth in his hospital’s parking lot, revealing that doctors at his hospital ain’t struggling in the least. Then I blew up at him, and earned myself a new post from him focusing on what I’d said.

I may have been too strident in my initial response; I’m sorry for that. And you know what they say about fighting on the internet…. But my point was, you can’t expect me to buy into the “poor uncompensated doctor” shtick, nor can you expect the American people to support loan forgiveness or payment reform, right after showing “Drive Your Lexus To Work Day.” For most laymen, a lot full of Lexuses = doctors at that hospital are doing JUST FINE with the current system, and don’t need us increasing the fee schedule or other government help. Pleading poverty after that is going to go over like a lead balloon. If docs are really united in trying to convince the public to support their agenda, ostentatious six-Lexus-in-a-row displays should probably be avoided.

Not that some doctors shouldn’t complain; primary care physicians are grossly underpaid by our notoriously bad reimbursement system, to the extent it’s reached crisis levels. But primary care docs are mostly objecting to how they only have 10 minutes with patients, how the system harms patient care, how it hurts doctors and their patients; I don’t see many family doctors bitching about being “uncompensated” as they’re sauntering to their BMW and filing their nails. But “Happy”‘s no family practice doctor, and plenty of his posts give off that vibe.

Reading “Happy” complain is more akin to seeing the insurance companies claim poverty. I was accused of jealousy and hating the rich, but that was not my point. My point was that when (relative to most people) you’re swimming in a vault of gold, don’t whine about how unfortunate and enslaved you are! It’s too much, and sticks in my craw. And though there’s a lot I respect about the man (including how he’s built such a popular blog through sheer persistence to post 2-3 times a day) I couldn’t help but speak up on this one.

Nick

  • thanx for stopping my blog. I got your point. Happy’s mind must be like a meter ticking off when he enters a patient’s room. The irony of tthe cars and uncompensated time was certainly not lost on me. A lot of these docs seem disappointed they’re not hauling in the big money. I don’t think I’ve ever seen a doc go bankrupt.
    Glad I found your blog. You’re a remarkable person.

  • FisCon

    Cutting through the hyperbole on both sides of this debate, I think both sides are right–which can only happen in a flawed system. . .a collectivist system, that is: where everyone is a free rider of sorts, and everyone is also a victim of sorts.

    Unless and until doctors and patients must deal directly with each other, rather than appeal to a nebulous master who tries (but fails) to keep all of the plates spinning, you get everyone working harder to keep the same-sized slice of a shrinking pie, all the while more folks are invited to the table to get a 'free' slice.

    This problem will get worse, not better. You're both right, but we're ALL wrong!

  • AlisonHymes

    Um, he has time to post 2 to 3 times a day to a blog but complains about patients taking up his time? I'm sorry, I don't get it. And I'm really tired of this trope : “you hate the rich”, nobody hates the rich, the rich hate the poor and our society reflects that in every way. We could do with a little more actual hating the rich instead of falling for the trap of thinking some day we will be one of them as so many do and fight an inheritance tax they themselves would never ever pay. Good for you speaking up Nick.

  • I'm strongly in favor of giving patients skin in the game, through things like Cash & Counseling, but what can be done about the radical information asymmetry between doctors and patients? i.e. the doctor says you need a stent in your heart, but how do you know it can't be treated fine with medications alone but the doctor is recommending a stent procedure because the fee structure provides him/her an overwhelming financial incentive to do procedures?

  • AlisonHymes

    As a kidney patient the answer was always fellow kidney patients who have developed great listservs and bulletin boards and education programs full of information so one can be more informed when making such decisions. I still belong to a transplant listserv now and learn things all the time from it. Not sure if other health conditions have as many resources, since you are a kidney patient for life once you are a kidney patient there is more time for development of knowledge. There is the thought that uninformed dialysis patients don't live as long as uninformed ones but I don't know if there has been a study to prove it yet. Certainly the informed dialysis and transplant patients I have known have outlived expectations…….

  • AlisonHymes

    That should be uninformed don't live as long as informed….. 🙂

  • FisCon

    Nick–doctors have a lot of information asymetry between themselves and the truth. People used to get second and third opinions. When you could pick your own doctor, word of mouth allowed you to find doctors you could trust and switch at will.

    Information asymetry between doctors and patients isn't going to get better as the power of the force standing in between them gets stronger–it's going to have goals all of its own, and remove paths, but it certainly isn't going to bring much insight.

  • Third party payers (whether government or private insurance) now pretty much uniformly WILL NOT cover second opinions. So what do we do now?

  • FisCon

    Cutting through the hyperbole on both sides of this debate, I think both sides are right–which can only happen in a flawed system. . .a collectivist system, that is: where everyone is a free rider of sorts, and everyone is also a victim of sorts.

    Unless and until doctors and patients must deal directly with each other, rather than appeal to a nebulous master who tries (but fails) to keep all of the plates spinning, you get everyone working harder to keep the same-sized slice of a shrinking pie, all the while more folks are invited to the table to get a 'free' slice.

    This problem will get worse, not better. You're both right, but we're ALL wrong!

  • AlisonHymes

    Um, he has time to post 2 to 3 times a day to a blog but complains about patients taking up his time? I'm sorry, I don't get it. And I'm really tired of this trope : “you hate the rich”, nobody hates the rich, the rich hate the poor and our society reflects that in every way. We could do with a little more actual hating the rich instead of falling for the trap of thinking some day we will be one of them as so many do and fight an inheritance tax they themselves would never ever pay. Good for you speaking up Nick.

  • I'm strongly in favor of giving patients skin in the game, through things like Cash & Counseling, but what can be done about the radical information asymmetry between doctors and patients? i.e. the doctor says you need a stent in your heart, but how do you know it can't be treated fine with medications alone but the doctor is recommending a stent procedure because the fee structure provides him/her an overwhelming financial incentive to do procedures?

  • AlisonHymes

    As a kidney patient the answer was always fellow kidney patients who have developed great listservs and bulletin boards and education programs full of information so one can be more informed when making such decisions. I still belong to a transplant listserv now and learn things all the time from it. Not sure if other health conditions have as many resources, since you are a kidney patient for life once you are a kidney patient there is more time for development of knowledge. There is the thought that uninformed dialysis patients don't live as long as uninformed ones but I don't know if there has been a study to prove it yet. Certainly the informed dialysis and transplant patients I have known have outlived expectations…….

  • AlisonHymes

    That should be uninformed don't live as long as informed….. 🙂

  • FisCon

    Nick–doctors have a lot of information asymetry between themselves and the truth. People used to get second and third opinions. When you could pick your own doctor, word of mouth allowed you to find doctors you could trust and switch at will.

    Information asymetry between doctors and patients isn't going to get better as the power of the force standing in between them gets stronger–it's going to have goals all of its own, and remove paths, but it certainly isn't going to bring much insight.

  • Third party payers (whether government or private insurance) now pretty much uniformly WILL NOT cover second opinions. So what do we do now?

  • DiverDavePhotog

    Nick:

    This was an interesting read & I certainly consider your points valid, except for one thing: My fiancee is a family medicine physician in Gulf Shores. She drives an Toyota X-Terra and, most assuredly, does not file her nails in front of anyone but I.

  • family medicine is most definitely the lowest-paid specialty; it’s awful how underpaid they often are…