How money influences our decisions as doctors

When you ask young medical students why they want to be doctors, you will probably get all sorts of answers. Some may say they like people and want to interact with them and offer them help.  Some students will believe this is their calling. Others still may state they are intrigued by the scientific mysteries the human body is filled with. From my experience, not many medical students just starting out will say they are in it “for the money.” But I also believe a doctor wants to make money just like anybody else. And there is nothing wrong with that. At least not in my opinion. And I believe this is where a huge conflict of interests stems.

The modern practice of medicine is governed by various types of factors. First, there are the purely medical factors that I guess we all agree must always be on a doctor’s mind.  I am hopeful that these indeed take precedence in every patient-physician encounter. However there are also other factors that sometimes rise. And sometimes these are not negligible. Among these are both legal and financial incentives that have the potential to drive medical care in various directions. I claim these directions are not always parallel to a particular patient’s very best interests.

I would like to focus on the financial factors affecting medical care. I do not mean healthcare policy or medical insurance, both unarguably huge factors in everyday medical practice. I am referring to the chance that some doctors sometimes think about their own livelihood when taking care of patients. In this regard, I have written elsewhere about “rain making.” By the term “rain” one really means money. Making rain often means diverting a patient toward a procedure. This is because the way reimbursement is structured, you get paid more for performing a procedure than for withholding on one.  Now, here is where the hitch is. Various disease states can theoretically be treated with medicine and other non-invasive means or with a procedure.  Deciding when medicine is not enough and a procedure is needed is often part of the elusive “art” of medicine.  In other words there are occasions in which there is a subjective component to a treatment decision.

Here is an example from my everyday life in the vascular medicine office. A man comes to see me because he has been a long-time smoker and lately he has also developed elevated blood pressure and borderline diabetes. He is somewhat of a couch potato, or at least not the most active of people. He has been sent to me by his family doctor because every time he walks more than half a mile he develops cramping in his right calf. The truth is he rarely walks more than half a mile. But his doctor wants him to pick up walking so he can lose weight and perhaps get his diabetes and blood pressure under better control and that is why he is in my office. I also happen to have the results of his latest vascular testing. He certainly has blockages of some of his leg arteries.

What should I do? Should I disappoint his doctor by not offering the fix he was hoping for? Should I nag him about better diet, smoking cessation and gradual activity? Or should I suggest a procedure by one of my excellent colleagues? I am sure that will get me praise from all. Including from the patient.

In summary, the point I am trying to make is that modern medical care decision making can be clouded by all sorts of factors. Money is just one of them. And I am not sure we are always aware of the way money influences our decisions as doctors. But we should be.

-Ido Weinberg is founder of Angiologist.com.

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