Last week I reported on the chilling story of Farid Fata, the Detroit oncologist (chemotherapy specialist) sentenced to 45 years in jail for fraud after stealing millions of dollars in medical fees because he administered inappropriate chemotherapy to hundreds of patients, many of whom did not have cancer at all. I mentioned that Fata’s crime and the way his survivors expressed their suffering reminded me of Robert Jay Lifton’s 1988 The Nazi Doctors, a horrifying book on the medical profession during the Third Reich.
Sadly, Fata’s case is merely a scraping of the iceberg tip. The recent sentencing of other physicians for performing unnecessary surgical procedures or for unnecessary (but insurance-billable) hospitalizations are crimes that have been committed for years.
Perfectly reasonable questions:
- What sets the stage for this malfeasance by allegedly respectable members of society?
- What I can do to prevent this from happening to me?
You also might wonder if this is unique to the US. The answer is probably yes, because no other country lavishes money on health care the way we do. No US industry generates profits and divides those profits like health care does. I mean, when you’re part of a team that’s divvying up 17% of the GNP of the world’s wealthiest nation, it’s baked into the cake that if you’re an administrator or a licensed professional (MD, RN, PT, RPh) financially you’re going to do well.
Becoming a doctor in the US
Every year, approximately 48,000 fourth-year college students submit an average of 14 applications each to the US’s 172 medical/osteopathic schools. (Yes, the schools do wade through about 650,000 applications.) About half the applicants are accepted. Were you to read the “personal statement” essay portion of their applications, the Why Do You Want To Be A Doctor? part, 100% profess wanting to help people, and 0% say they want “a steady job and a BMW just like my friend’s father who is a urologist.”
Many fail to mention they’ve been commanded by their parents to career choices of medicine or law. Let’s face it: if an applicant wanted to “help people,” like his essay says, he could join the Peace Corps, spend a life in the underpaid not-for-profits, or be a social worker.
Knowing he’ll earn the money back in ten years or so, the med student borrows a small fortune–almost $250,000–and plows ahead. But don’t worry about hosting a tag day to help young doctors. After four years of med school, there are specialty training residencies salaried between $45,000 and $55,000 per year. Once these are over, the specialists are kings. The top ten medical specialties all earn more than $375,000 a year (oncologists like Fata average $400K), orthopedists topping everyone at $464,000.
Lowest paid are physicians who actually see and talk to patients who aren’t under anesthesia–family doctors, internists, psychiatrists, and pediatricians. The lowest earners, geriatricians, have the dubious distinction of facing an income drop if they limit their practice to geriatrics because everybody’s on Medicare.
Competition for specialty residencies is fierce, just as tough as getting into medical school in the first place. As you might guess, many a young doc wants to be an orthopedic surgeon, plastic surgeon, ophthalmologist, oncologist, or radiation therapist, while family practice and internal medicine residencies go begging.
History tells us why
The basis for the disparity between surgical and nonsurgical specialties is this: the original health insurance companies were created decades ago to pay for hospitalization and surgical fees. Health insurance paying for a visit to your family doctor is really only a recent phenomenon. In a sort of fox-guarding-the-henhouse situation, the early insurance companies turned to surgeons to help determine who should be paid and how much.
You must be getting my drift here
Our healthcare system rewards doctors lavishly not for keeping us healthy and long-lived, but for doing things to our bodies with sharp knives, loading us up with toxic chemicals, and frying us with radiation. But for some doctors, Fata being a perfect example, the lavish pay isn’t enough. He wanted more and he crossed the line to get it.
In the 2009 book The Healing of America, author T.R. Reid went on a worldwide quest to learn about healthcare in other countries. He had a chronically painful shoulder and decided it might be interesting to ask doctors around the world what they would offer. Except for a single country, physicians recommended combinations of physical therapy, medications (including herbs), and sometimes acupuncture. In Colorado, an orthopedist wanted to schedule him for surgery the following day.
I don’t want to be unnecessarily alarmist. Most doctors play by the rules and do surgery only when necessary. However, you need to appreciate that a surgeon is trained to do surgery, not preventive medicine. The cliché “when your only tool’s a hammer, everything looks like a nail” generally holds true for surgeons. Surgeons repair bodies. If you go to an orthopedic surgeon with a sore shoulder, by training after some physical therapy and cortisone injections, she’ll likely recommend surgery.
I know this may sound catty, but most primary care physicians regard surgery as fairly tedious. Same old, same old, day in and day out. Three, four colonoscopies daily may make you $600,000 a year, but pondering what these docs do all day makes you appreciate why gastroenterologists frequently opt for early retirement.
During my residency, we had the greatest respect not for surgeons, but for the Dr. House– type diagnosticians earning relatively little money as salaried professors but whose knowledge of medicine was encyclopedic, their observational skills legendary. It was from a Dr. House kind of physician during residency that I learned that the British title surgeons as “Mr.” rather than “Dr.” to remind everyone that surgeons are essentially village barbers.
Confronted by a reimbursement system that rewards a doctor for performing as many surgical procedures as quickly as possible, there will always be some physicians tempted by the extraordinary profits that just a few iffy, probably unnecessary, surgeries can generate. In Fata’s case, think of supervising intravenous chemotherapy and radiation therapy as costing nearly the same as a minor surgical procedure. Somewhere along the way, Hippocrates’ memorable one-liner “First, do no harm” vanishes among epic rationalizations.
What you can do to protect yourself
Start by taking care of yourself, remaining healthy so you can avoid the healthcare system as much as possible. You can avoid a lot of surgeries by nutritious eating, regular exercise, and so on. Active, normal-weight people need fewer gallbladders removed or stents inserted into their coronaries. Nonsmokers virtually never need to have large chunks of their lungs removed. Instead of scheduling your podiatrist’s recommendation for hammertoe surgery, wear comfortable shoes.
But to seriously protect yourself from unnecessary surgery, get second or even third opinions. Good surgeons are never upset if you suggest this because they have confidence in their own judgment.
You can and should get second opinions not only for elective surgery, but also for cancer chemotherapy, colonoscopies, and even foot and dental work–in fact, just about every procedure available. Health insurance companies, always on the lookout to save money, encourage second opinions as well.
What, in theory, we could do to fix this
The principle problem in US health care is that it’s too profitable. If, in some magical way, we could convert the US healthcare system to one massive not-for-profit, as is the case in much of the world, many of our current problems would disappear. Yes, I know, new challenges would crop up. But just as legalizing marijuana in Colorado crushed the profitability of illegal sales, making medicine not-for-profit would end overutilization of services.
A couple years ago I wrote a Health Tip about a classmate of mine, Keith Lasko, MD, who in 1980 wrote the best-selling The Great Billion Dollar Medical Swindle. Although his book is now 35 years old, he devoted a lot of space to inappropriate overutilization within the system. He was on TV a lot, and very vocal. In response, the medical establishment moved against Lasko. His license to practice was revoked on what today seem like trumped-up charges.
Although much of his book is an extended (and entertaining) rant, Lasko suggested that the entire system could be converted to a government-run not-for-profit, placing all physicians on a salary that would be predicated on years of training, professional experience, and outcomes. Medical school would be completely free, thus opening its doors to those from all economic backgrounds. Since physicians would become public servants, albeit well-paid public servants, the personal statements of medical school applicants would reflect a genuine desire to help their fellow man.
With salaries fixed, of course, unnecessary surgical procedures and overutilization in general would become pointless.
For proposing this, Lasko lost his license.
Be well,
David Edelberg, MD