Physician Compensation

‘For the first time I found myself truly caught between my own needs and those of my patient.’

This is how a very interesting article (“P4P is changing me“) in Medical Economics begins. The essay won an award in the 2006 Doctors’ Writing Contest.

The author of the story is a physician who has been under much financial pressure of late; a divorce, med school loans, a mortgage, alimony and child support were all eating away at the author’s income. One day an 84-year old WWII vet walks into his office. He had a left renal mass, but did not want any further medical treatment for this problem. The author must contemplate how–or if–he should treat the patient.

There’s very little I could do to improve [the patient’s] life. I asked him once what I could do to help, and he requested merely that I talk with him. That’s what I’ve done, every three months, but I won’t get any extra pay for that. I could check his A1C, though—after all, he does have diabetes, and it has been more than a year since it’s been checked.

The patient had been very diligent in maintaining the correct levels of blood pressures, heart rates, and blood sugars. The author believed that an A1C test was clinically unnecessary. But…

We talked for 30 minutes (10 minutes over the scheduled 20-minute appointment); I was then behind. How would I wrap this up? Should I make one last plea that he open himself up to counseling and antidepressants, and not suicide? Or should I tell him that I need him to go to the lab and have his blood work checked? Well, I doubted I could do much to improve his life, but I did need the $50 . . .

Should I start statins on the drooling demented to lower their LDL? Should I preach to paranoid schizophrenics that they must quit smoking? Doing so might help ease my burdens—will it ease theirs? Without a financial incentive, I treated practice guidelines as guidelines, and I treated patients as patients. With financial incentives, will the guidelines become my goal? Will I lose patience for patients who are just a means to my means?