Why Doctors Hate Science

[blutoski]

Two small bussiness owners in Canada, Windsor ONT specifically said that they have income caps. Both ran resteraunts we ate in and they said that their income was limited to $250,000. Now that could have been an urban myth or how they interpreted tax law. I don't know.

Either way, I can't even concieve of an explanation other than just plain fabrication.

I am a part owner of many companies in Canada, - some in ON - and have never heard of such a thing, and it's ridiculous on the face. C'mon!

I was more marvelling that somebody could even think something as ridiculous as this was plausible, much less pass it on to a public skeptics forum without an attempt to verify.

UFOs: maybe; income caps: ridiculous.

 

[Dancing David]

While they may have been having one over on you (it is kinda a national pastime ), I suspect they were referring to being taxed at a different level or something like that.



More like astonishment. I find the stereotype of the clueless American kinda cute and funny myself.

Does it not occur to you to check on something like that before you starting spreading it around?

Linda

No, that is why I come here, to have my cherished beliefs trampled!

I think the man was sort of pining for a system more like the Us because he felt his income was limited. But you never know, he also told me the US dollar was trading 4 to the Canadian dollar.

I was just trying to poke at Ivor, that was just one tactic. And it turns out i was told wrong. maybe I should check out that gold mine I bought as well.

 

[Dancing David]

Either way, I can't even concieve of an explanation other than just plain fabrication.

I am a part owner of many companies in Canada, - some in ON - and have never heard of such a thing, and it's ridiculous on the face. C'mon!

I was more marvelling that somebody could even think something as ridiculous as this was plausible, much less pass it on to a public skeptics forum without an attempt to verify.

UFOs: maybe; income caps: ridiculous.

I don't know, I find it hard to believe the way the lawe is enforced here is the south, we still have stupid stuff like pharmacists refusing to fill certain medications and the like.

So i was duped, no suprise to me, I suppose he was complaining about progressive taxation or some such. he also said that manufacturers have production limits, another fabrication I suppose.

I was more disappointed that I got 'table syrup' on my pancakes. The same corn fructose as in the US, I was hoping for a Mountie to serve my pancakes with fresh sirop d'erable.

But i has a great time none the less, even the Leamington tomato festival was funny. It must be the only place that can grow tomatos , eh. If you start them in a greem house.

i was really impressed by the way people drove so politely.

ETA: I forgot stupid law outlawing pit bulls!

 

[T.A.M.]

What I'm being asked to provide is impossible to achieve in practice. There will always be sufficient wiggle room to claim any difference in cost and/or amount of treatment can be explained by other factors, even cases such as this one:



Fee for service provides an obvious temptation to exploit asymmetry of information.



In the UK it is required by law for the police to make audio recordings of interviews with suspects. Video recordings are currently optional.

Perhaps governments should try 'fee for arrests' remuneration for their police officers. What do you think might be the result of such a scheme?



I believe anyone is corruptible given the 'right' incentive(s).



Every group has a moral code. What makes doctors' moral code more robust than any other groups' moral code?



That does not mean what is being demanded is not being influenced by physicians.

I agree with you on almost every point actually. I think it is a matter of degree. How much, to what degree, does such tweaking of the system go on.

As for how the moral codes in "groups" might differ, you only have take the code of group A, and compare it with the CMA code of ethics to see.

TAM

 

[T.A.M.]

Do all treatments suggested by a physician result in the same remuneration to him/her?

If not then there is an incentive to recommend expensive treatments that are no better (as far as the patient is concerned) than cheaper alternatives.

An interesting fact is that as the number of GPs in an area increases, so does the demand for their services. E.g., figure 2 page 10.

Here in Canada, a physician, a GP, gets paid the same amount regardless of what he sees the patient for, and gets no positive financial incentive to send them to a specialist or for a procedure.

For any procedures I might do in clinic, the pay is actually so low, that I am better off referring them out for the procedure, as the time the procedure takes is not worth my effort. Despite that, I do them anyway, usually at the end of the day, so the time it takes does not interfere with my work day or my patient's wait time.

TAM

 

[paximperium]

Where I practice, the idea of Doctor Driven Demand is ridiculous, as there are not enough doctors to keep up with the demand as it already exists.

As someone who works at the County Hospital, we're the safety net of the community.

Business in booming. The ER's volume has doubled from over a year ago. We don't have have enough resources, the clinics are overfilled, the wait for a primary doctor is almost 2months long, the ORs are sometimes going through the night to clear the backlog in cases. It seems to be more a "patient driven demand".

I would be one of the first to criticize any physician in the community(and I do) who waste resources at this point, but I'm not seeing it. Most docs, even the private ones, are overwhelmed and have more than enough business at this point.

 

[Rolfe]

... the wait for a primary doctor is almost 2months long, the ORs are sometimes going through the night to clear the backlog in cases. ....

You're kidding! Americans keep telling us how they don't have waiting lists and we're in the dark ages because we might not get elective surgery the same week.

Here, we have to be able to see our GP within 48 hours, if necessary.

Sorry, I'm just really surprised because I thought that for all your system costs so much and excludes some people, when you were in nit it actually worked.

Rolfe.

 

[paximperium]

You're kidding! Americans keep telling us how they don't have waiting lists and we're in the dark ages because we might not get elective surgery the same week.

Here, we have to be able to see our GP within 48 hours, if necessary.

Sorry, I'm just really surprised because I thought that for all your system costs so much and excludes some people, when you were in nit it actually worked.

Rolfe.

This is for the uninsured which is what the County usually sees. If you have insurance it is different.

Oh, you can in and be seen within a week if you have a semi-emergent problem and you will definitely be treated for an emergency but elective stuff takes some time and to get a permanent Primary Doctor(not just who ever is available in the clinic) takes months.

 

[BillyJoe]

Do all treatments suggested by a physician result in the same remuneration to him/her?

As far as Australia is concerned, neither investigations nor treatments* suggested by a physician result in any remuneration to him. I can't imagine this happens anywhere unless the physician also owns the pharmacy or the pathology company.

*edit: I was thinking of drug treatments here, but this could also apply to physicians who remove skin lesions. This would, of course, result in remuneration to him. Off hand, I can't think of any other treatments that could be sensitive to the SID effect.

If not then there is an incentive to recommend expensive treatments that are no better (as far as the patient is concerned) than cheaper alternatives.

Hmmm....do you know any physicians who also own the pharmacy or the pathology company. I would hope that this is outlawed because of concerns about conflict of interest.

An interesting fact is that as the number of GPs in an area increases, so does the demand for their services.

If the area was undersupplied with GPs, then as new GPs came into the area, the number of services would increase. So, how do you know its not undersupply being satisfied rather than SID?

BJ


edit2: Here is an interesting quote from your last link:

...the existence of SID does not necessarily imply the need to regulate the medical market. If doctors are inducing services that are health promoting...it may be
judged unnecessary to regulate the sector...

Hmmm...I'm thinking that SID does not imply what you think it implies.
If SID includes services that are health promoting, we actually have no argument.

 

[BillyJoe]

Here, we have to be able to see our GP within 48 hours, if necessary.

Apparently capitation is coming to Australia.

Enrol with a GP and he has to attend to your every need at a price determined and paid by government.
I'm going to see if I can find a shonky one who'll split the proceeds, because the odds are excellent that I won't ever need to see him.

On the other hand, where do the chronics go?

BJ

 

[T.A.M.]

you can likely write off the "skin lesion" removal bit.

Here is Canada, to remove a skin lesion in your clinic, it takes about 20 minutes minimum. You walk in, talk briefly to patient. Get patient prepped, administer Xylocaine, wait 3-5 minutes for xylocaine to take, excise lesion, suture up lesion, dress it if needed, and discharge patient.

For your work you are paid about $15 more than a regular visit ($30.00). A grand total of $45. Now you take away 1/3rd for overhead (rental space, secretary, equipment, supplies), and another 1/3rd for taxes, and a GP takes home about $15 for the 20 minute procedure.

TAM

 

[T.A.M.]

Apparently capitation is coming to Australia.

Enrol with a GP and he has to attend to your every need at a price determined and paid by government.
I'm going to see if I can find a shonky one who'll split the proceeds, because the odds are excellent that I won't ever need to see him.

On the other hand, where do the chronics go?

BJ

They (the govt) have been trying to get this going here in Canada for years. Extremely opposed by most doctors for a variety of reasons.

1. Fixed salary just doesn't cut it for many.
2. Will lead to abuse, where first on the scene will select only the youngest, healthiest patients for their practice.
3. Where do the chronics, the elderly, the MMP (multiple medical problems) go?
4. Who sets your hours of work? Who sets the maximum # of patients before you close your practice? Can you be forced to do "on call"? Can you be forced to do house calls?

TAM

 

[BillyJoe]

They (the govt) have been trying to get this going here in Canada for years. Extremely opposed by most doctors for a variety of reasons.

Likewise the AMA over here.

1. Fixed salary just doesn't cut it for many.

Yeah, bummer hey, fixed salary but you're forced to do all the work no matter how much your patients demand of you.

2. Will lead to abuse, where first on the scene will select only the youngest, healthiest patients for their practice.

That was the point of my third sentence (well, I 'm not exactly young, but I'm healthy - 5 visits in half a life time aint bad!)

3. Where do the chronics, the elderly, the MMP (multiple medical problems) go?

Hey, you stole my last sentence.

4. Who sets your hours of work? Who sets the maximum # of patients before you close your practice? Can you be forced to do "on call"? Can you be forced to do house calls?

That, I believe, is the not so well hidden masterplan of our present Labor government. Well, you set your hours but you have to see all of the patients that are enrolled under your care. Close your practice? Are you kidding? The patients enrol with you. Yes, and meeting the needs of all the patients under your care obviously means doing all the on call and home visits.
Of course, the idea will be to introduce this in stages so there's not too much opposition all at once.

Want to migrate?

BJ

 

[BillyJoe]

Seriously, if I ever do need medical care, I don't want to be a patient of a doctor whose interest in his patients has been all but squeezed out of him by the overbearing actions of big brother government.

 

[Rolfe]

Could a British GP explain why these things don't seem to be a problem here? Or if they are, I never heard anyone talking about it.

Deetee, where are you?

Rolfe.

 

[T.A.M.]

Likewise the AMA over here.


Yeah, bummer hey, fixed salary but you're forced to do all the work no matter how much your patients demand of you.

It is a tough issue. Medicine, especially at the clinical level, is very much a mentor based system. As a result, we often admire greatly, and often imitate our mentors. This is good and bad. I have had great mentors, from a clinical/bedside manner pov, but they were also workhorses. The generation above mine and back further, saw medicine as a calling, something that took priority above EVERYTHING ELSE.

As a result, they buried themselves in their work at the sacrifice of their families, friends, and everything else.

That has changed with my generation. We now realize that medicine is a career, like any other in many ways. We now realize that Family and a life outside of medicine is just as important, if not more, then the career itself.

Why am I telling you all this? Because with this shift, comes a higher demand for MDs, simply because we are not willing to work the 90-100h weeks that our previous generation was. Of course there are still some who do, but they are few and far between.

Most in my generation are satisfied with a 50h work week. Most of us do not do house calls. The time it takes to get to a person's house, see them, etc... is just not worth it for most. Sounds selfish I know, but medicine is a business as much as a anything else.

For instance, in the time it takes me to do a housecall, and get paid the $80 it pays, I could see 6-8 patients at the clinic, paying $30 each. You do the math.

I am placing this long diatribe here, as it relates to the issue of patient demand and work load in Capitation versus Fee-For-Service (You run the show).

If it happens in the province I practice in, I will move...100%.

That was the point of my third sentence (well, I 'm not exactly young, but I'm healthy - 5 visits in half a life time aint bad!)


Hey, you stole my last sentence.

Patient selection will be the ultimate killer for Capitation. The argument is sound, and no one has provided a way to stop it, so I think it will be the nail that seals the Capitation Coffin.

As for your last sentence, Yes I stole it, it was good, Imitation is the most sincere form of flattery.

That, I believe, is the not so well hidden masterplan of our present Labor government. Well, you set your hours but you have to see all of the patients that are enrolled under your care. Close your practice? Are you kidding? The patients enrol with you. Yes, and meeting the needs of all the patients under your care obviously means doing all the on call and home visits.
Of course, the idea will be to introduce this in stages so there's not too much opposition all at once.

Want to migrate?

BJ

At present, nah, no plans to migrate. As for the masterplan, well I would say that the "Setting your own hours" thing is not as cut and dry. For instance, If I set my clinic to 9AM-4PM, and come 4PM there are 8 patients out in the waiting room, what do I do? Patients, and Govts know that Physicians are bound by their ethical code to not leave those patients unseen.

So ultimately, in that regard, you have no control over your hours. At least with Fee-For-Service there is the satisfaction of knowing that you are getting paid for those extra 8 patients. Now if their was some way to bill overtime for the hours you work, that might make some difference.

Seriously, if I ever do need medical care, I don't want to be a patient of a doctor whose interest in his patients has been all but squeezed out of him by the overbearing actions of big brother government.

That is the rub of it.

Capitation will leave some Docs (those who got into an area early and selected all of the young healthy patients for themselves) happy, and other docs VERY VERY BITTER.

TAM

 

[Ivor the Engineer]

As far as Australia is concerned, neither investigations nor treatments* suggested by a physician result in any remuneration to him. I can't imagine this happens anywhere unless the physician also owns the pharmacy or the pathology company.

*edit: I was thinking of drug treatments here, but this could also apply to physicians who remove skin lesions. This would, of course, result in remuneration to him. Off hand, I can't think of any other treatments that could be sensitive to the SID effect.

Page 26:

6 A Natural Experiment

Australia provides an interesting and unique laboratory for the examination of the relative importance of price and SID effects on patient demand. The perverse and idiosyncratic financing of health services results in a public sector in which hospital patients are treated without cost and a private sector in which, in return for the purchase of private health insurance, the patient is left with significant out of pocket expenses. In a simple market equilibrium public demand per capita would be expected to exceed private demand per capita. However, incentives facing doctors also differ. In the public hospital there is no financial benefit from the treatment of additional patients. In the private sector a full fee is earned. There is therefore no incentive for doctors to increase demand in the public sector and a strong incentive to increase it in the private sector.

In a recent study Richardson et al (1998) examined the treatment of patients after an emergency admission with a heart attack (acute myocardial infarction [AMI]). Various treatments are possible for AMI. The most expensive and recent of these include the diagnostic test, angiography, and the procedures collectively known as ‘revascularisation’, that is coronary artery bypass surgery, balloon angioplasty and stenting. Each of these four procedures attracts a significant fee. Differences in the rates of angiography and revascularisation for the Victorian population are shown in Table 5. In this, a percentage of patients receiving CARP (Coronary Artery Revascularisation Procedure) is shown in the first two columns and the likelihood of revascularisation in different hospital settings is shown in the subsequent columns in which the average likelihood of CARP for all AMI patients in Victoria is set equal to 100 in each year. Column entries show the likelihood of revascularisation in each setting after (indirect) age standardisation.12 Thus, in 1996 the likelihood of a private patient in a private hospital receiving CARP was 5.99 and 7.23 times greater for men and women admitted to private hospitals than the state average. The likelihood of public patients receiving revascularisation was 0.57 and 0.48 times the state average; that is, men and women were 10.5 and 15.1 times more likely to receive CARP as a private patient in a private hospital than as a public patient. It would require remarkably agile footwork to avoid the conclusion that these patterns were driven by physician judgement rather than patient preference.

Hmmm....do you know any physicians who also own the pharmacy or the pathology company. I would hope that this is outlawed because of concerns about conflict of interest.

Ever heard of private healthcare? Physician-owned hospitals?

If the area was undersupplied with GPs, then as new GPs came into the area, the number of services would increase. So, how do you know its not undersupply being satisfied rather than SID?

BJ

I don't.

Secondly, it is possible that GPs locate their practices in areas of high autonomous demand. It is for this reason that a serious statistical analysis of cross-sectional data must attempt to take account of reverse causation and endogenise the GP supply. The importance of reverse causation could, however, be overstated. Age/sex standardization does not reduce the variation in either the 1976 or 1996 data significantly. Price, income and socio-economic variation are also insufficient to explain a significant part of the variation.

edit2: Here is an interesting quote from your last link:

Hmmm...I'm thinking that SID does not imply what you think it implies.
If SID includes services that are health promoting, we actually have no argument.

That depends on the marginal cost and marginal utility of the service. E.g., using $1million worth of resources to extend a life 1 week would be a waste of resources (to give an absurd example).

 

[BillyJoe]

That has changed with my generation. We now realize that medicine is a career, like any other in many ways. We now realize that Family and a life outside of medicine is just as important, if not more, then the career itself.

Yes, it's obvious isn't it? But I wonder if patients see it that way. A political associate of my father (hey, it's actually embarrassing - look up the Australian DLP sometime ) had a son who was so devoted to medicine that he never married. He did morning, afternoon, and evening sessions during the week and Saturday and Sunday mornings as well as being on call around the clock, and he never went on holidays. His patients absolutely loved him.

Most of us do not do house calls. The time it takes to get to a person's house, see them, etc... is just not worth it for most. Sounds selfish I know, but medicine is a business as much as a anything else.

Yes and, taking the cue from your quote below, 6-8 other patients miss out on being seen that day. But what does a patient who is house-bound (eg elderly patient living alone, no car, or can't drive, or too sick) do when they are in need of medical care?

For instance, in the time it takes me to do a housecall, and get paid the $80 it pays, I could see 6-8 patients at the clinic, paying $30 each. You do the math.

Am I reading you right that you are not alowed to charge a private fee for house visits.

Patient selection will be the ultimate killer for Capitation. The argument is sound, and no one has provided a way to stop it, so I think it will be the nail that seals the Capitation Coffin.

How does it work in England then. But perhaps you're the wrong person to ask? Rolfe thinks Deetee might be able to inform us.

If I set my clinic to 9AM-4PM, and come 4PM there are 8 patients out in the waiting room, what do I do? Patients, and Govts know that Physicians are bound by their ethical code to not leave those patients unseen...So ultimately, in that regard, you have no control over your hours. At least with Fee-For-Service there is the satisfaction of knowing that you are getting paid for those extra 8 patients.

Well, you have some control. At least you don't still have 8 patients come 6PM or 8PM . But, yes, I certainly see the downside of capitation for docs, and hence ultimately for patients. In Australia it is intended to only to GPs who seem to earn no more than a good tradesman. (A Specialist's degree, on the other hand, seems to be a licence to print money. But that's another story for another time).

BillyJoe.

 

[BillyJoe]

Page 26:
Ever heard of private healthcare? Physician-owned hospitals?

Yes, that is a study done in Victoria, Australia where I just happen to live, so I was actually interested to read most of it, including the bit you link to above. One problem, however, is that it uses terminology that it does not even try to define let alone reference.

Perhaps you can define "autonomous demand", "reverse causation", and "endogenising the supply" for me in the context of the study?

I have a problem with Specialist as I have just indicated above. But there is a control in place: Unless the patient is referred by a GP, the patient must bear the full cost of specialist intervention. Also, in Victoria, how many hospitals are owned by physicians? As far as I can tell, private hospitals are owned by businessmen, or medicos turned businessmen who no longer actually practise medicine. Do you know any different?

As for that specific study of the difference in treatment of Heart attack patients in private and public hospital settings (15 fold difference). How do you know that the treatment in the private hospital setting is not "best practice"? Because the authors of the study find it hard to believe? That study was in 1998 and it would be interesting and informative to see if the public system has moved significantly towards the private system in terms of managing heart attack victims since 1998. If it has, this would suggest that the private system was doing "best practice" long before the public system caught up - cost restraints and budgets could have held up adoption of best practice until the evidence for it could no longer be avoided. Perhaps only the private system had the money and the resources to test the hypotheses implied by these treatments and, once these hypotheses were confirmed, the public system followed suit.

Perhaps I'll ask you. Would you rather have Medicare save money by allowing part of your heart muscle to die, or would you rather Medicare spend a bit extra (okay, a fair bit extra*) to preserve your heart muscle?
*Of course the cost may be offset by possible savings of avoiding a second heart attack, avoiding treatment and hospitalisation for heart failure, and maintaining fitness for gainful employment.

The article doesn't mention what is the evidence-based best practice for management of heart attack, so how can they conclude that it is just SID. On the other hand, as I pointed out before, the article includes this statement:
"...the existence of SID does not necessarily imply the need to regulate the medical market. If doctors are inducing services that are health promoting...it may be judged unnecessary to regulate the sector..."
so, if SID includes services that are health promoting, SID may be actually be no argument at all against the medical profession.

I don't [know its not undersupply being satisfied rather than SID].

Then, what exactly what is your argument

That depends on the marginal cost and marginal utility of the service. E.g., using $1million worth of resources to extend a life 1 week would be a waste of resources (to give an absurd example).

Of course. But that means that, unless you know the answer to the question of "best practice" taking into account cost-effectiveness and what people are willing to pay to derive a certain benefit, how can you make a call on SID?

BillyJoe

 

[Skeptic Ginger]

Do humans respond to incentives?

Are physicians human?

I don't believe any in the medical community here on the forum have claimed no health care providers are primarily motivated by financial reward. In fact, I'll go even further and say a few medical specialties are entered because they offer greater financial reward, not that everyone in those specialties is so inclined.

But what you seem to be missing is the fact most of us are motivated by professional rewards. That can be anything from being the top surgeon, a Nobel winner, a discoverer of cancer cures, to helping the poor around the world or teaching students. Being good at what you do is extremely rewarding, especially in the medical profession.