An odd fight to pick

Recently I took some time to criticize Dr. Andrew Weil, about whom I continue to know very little. My beef was with his recommendation that direct-to-consumer pharmaceutical marketing be banned. However, as far as famous-doctors-who-probably-are-incredibly-rich-and-blog-at-HuffPo are concerned, he seemed relatively benign.

Well, it seems that Dr. Tuteur over at Skeptical OB begs to differ. She's taken after Dr. Weil a couple of times. I will let you check out her post on Dr. Weil's thoughts about preventive medicine yourself. However, I'm a bit perplexed by her more recent gripe.

In his post Fear, Greed and X-rays, Dr. Weil wrote:
Along with over-scanning, over-biopsying, over-blood-working and other diagnostic excesses, fear propels over-treatment. Anytime a physician diverges from standard U.S. treatment protocols, nearly all of which skew toward expensive drugs and surgery, lawsuit-fear looms. "Defensive treatment" strips physicians of clinical judgment, costs billions and leaves patients less healthy, but it's hard to blame physicians who practice it. As one wearily told me, "You never forget your first lawsuit."

Physicians like to discuss the fear side, because it shifts the blame to lawyers. The greed side, however, deserves just as much scrutiny and reform. Consider "The Cost Conundrum: What a Texas town can teach us about health care," a must-read New Yorker article by Atul Gawande, M.D. Gawande visited McAllen, Texas, to discover why per-capita health care expenditures there are the highest in the nation. He found that many physicians in high-medical-cost cities such as McAllen have a diversified "revenue stream," the result of what one hospital administrator termed "entrepreneurial spirit." This "spirit" often manifested in physicians owning their own medical testing equipment, which meant the more tests they ordered, the more money they made. A 2002 University of North Carolina study showed doctors who own imaging equipment sent patients for roughly two to eight times more imaging tests than those who don't own.


To quell the fear that drives physicians to over-test and over-treat, we need vigorous legal reform to cap malpractice payouts. Staunching the greed motive requires a more dramatic change. Since a single CT scanner can bring in $400,000 a year in profit, it's vital to sever the link between ordering tests and making money. Restricting ownership of testing equipment to nonprofit, government, or independent private entities is crucial.

As for popularizing less lucrative -- but often better -- low-tech treatments, putting physicians on salary can also help. Whether the paycheck comes from a nonprofit organization such as the Mayo Clinic or some variety of single-payer national health care, stabilized incomes would let physicians more readily focus on the health of their patients rather than on their own finances.

Dr. T responds:
Does greed play a role in healthcare? Unfortunately, in the case of unethical practitioners it does play a role. Should greed play a role? Of course not. So please tell us, Dr. Weil, why we should pay the least bit of attention to your faux outrage? None of the products that you hawk are essential and most do not even provide the health benefits that you claim for them. The only thing they do is line your own pocket.

You're right, Dr. Weil. Patients shouldn't trust doctors who recommend treatments that provide financial benefit for the doctor and little if any health benefit for the patient. In other words, Dr. Weil, by your own logic, patients shouldn't trust you.
Hmmmm. I'm giving this one to Dr. Weil.

First of all, over-testing because you fear a potential lawsuit is a real phenomenon. Ordering tests "just in case" motivates a lot of unnecessary blood tests and CT scans. I fully support capping malpractice claims, and creating a means of tort reform that alleviates the culture of fear that pervades contemporary medical practice.

But I think it is 100% appropriate to call for an end to the unethical, egregious practice of physicians owning the same testing equipment they refer patients to use. It defies any sense to pretend that such double-dipping does not create an incentive to order tests that aren't necessary to bulk up the "revenue stream." Further, I can attest that linking patient care to revenue creates an unhealthy dynamic in which patient care becomes a commodity. I fully support making physician pay salaried, and decoupling it from revenue generation.

Finally, there is a difference between buying some specialty tea or other product because you choose to spend your money that way, and getting a test or procedure because you trust your doctor that it is necessary. People view famous alternative medicine practitioners (who, for the record, I think are in the business of hooey) differently than they view their primary care physicians. If people with the cash to spend want to buy some kind of crack-pot olive oil, who am I to stop them? But it undermines the trust we as physicians rely upon if our colleagues are using that trust to order tests people don't need in order to line their pockets.


  1. How can you decouple salary from revenue generation? At company X, the salary of the employees depends upon how well Company X does revenue-wise. Revenues up, salary pool up, pay raises happen, everyone happy. Revenues down, salary pool down, pay cuts possible, no happiness. It is especially interesting when individuals can be measured in impact to the bottom line; sales is a great example. Sales employees have quotas to meet.

    OK, so, you are running the Maine physicians cooperative 134. How do you set salaries? Wouldn't the temptation be to look at the revenue generated by each physician? Surely there must be some link between money brought in and salary.

  2. "Greetings, Dr. X. We are delighted that you have decided to join one of the affiliated practices of the Mid-Maine Medical Co-operative and Lobster Pound. We pride ourselves on our delivery of competent, compassionate care, as well as the best lobster roll in northern New England.

    As per your contract, your starting salary is [xxx,xxx], which is commensurate with national and regional trends for members of your specialty. (Please see attached informational sheets.) We feel that this salary is competitive, and represents a reasonable approximation of what the local market can sustain. You will receive additional compensation for additional services provided (eg. attending high-risk deliveries, taking additional call, etc.) if you opt to participate in that provider pool. Further, should your practice hit certain quality benchmarks (eg. a threshold number of asthmatic patients receiving flu immunizations yearly), third-party quality care payments will be disbursed to you and your colleagues in the practice.

    Revenue data for your practice will be aggregated before being reported to Co-op administration. It is assumed that you and your colleagues will structure your schedule in keeping with your collective professional expectations. It is further assumed that any concerns about any individual provider pulling his or her own weight in the practice will first be addressed by your colleagues in conversation with that provider. Your medical director will arbitrate any long-standing grievances, and concerns will be communicated to Co-op administration only if these preliminary steps prove fruitless.

    Every five years, salaries are open for renegotiation. Cost of living and changes in national and regional benchmarks for your specialty will be taken into consideration, as well as provider seniority. We are confident that we will be able to keep your salary competitive.

    We look forward to a long and mutually beneficial professional relationship."

  3. Salary adjustments every 5 years? You certainly are not expecting the return of old Demon Inflation, despite President Scary-Smart's stunning deficits. I think you'll need a better contract to retain talent. I'm also not sure what the career progression is from reading your ideas.

    One more point. I would expect this to turn out much like Teacher's Unions, since there is a significant Federal aspect to the funding. Those omniscient Members will want to have their say about how the money is handed out!

    You'll need a professional grievance board to handle those "concerns" that will inevitably arise about the competency and work ethic of fellow physicians but fail to be resolved over coffee or by the medical director (who surely cannot fire physicians without a lengthy paper trail and due process). The seniority part is good, the Union will love that, as it will keep patients from bypassing the lazy old curmudgeon who fails to keep up with the times in favor of the bright young bundle of energy with the nice bedside touch.

    All in all, it is nice to see such idealism remaining in the medical profession.

  4. "You'll need a professional grievance board to handle those "concerns" that will inevitably arise about the competency and work ethic of fellow physicians but fail to be resolved over coffee or by the medical director (who surely cannot fire physicians without a lengthy paper trail and due process). The seniority part is good, the Union will love that, as it will keep patients from bypassing the lazy old curmudgeon who fails to keep up with the times in favor of the bright young bundle of energy with the nice bedside touch."

    Uhhhhh... John, I fail to see why it would be harder to fire me if I were salaried than it currently is when I am paid using a revenue-based model. Please explain to me what the difference would be.

    And, re: salary renegotiation every five years, pray tell how often you think my pay increases based upon the flux of how many patients I see.

    Finally, what is this "career progression" of which you speak? What kind of career progression do you think exists for physicians in hospital-owned practice? The area of medicine that offers the clearest path to a progressive career is in academia... which tends to be salaried.

  5. I'm saying that the Feds may well have a greater say in your employer's ability to fire you if the Feds start writing more of the checks. That's all. Remember the NEA.

    If/When we get back to 10% inflation per year, you might not be so happy with those 5 year deals.

    The Atlantic article I cited in another post asks a reasonable question: most ER physicians are salaried (all the ones I know are), and the buying power of the entire hospital is there to keep equipment and supply costs down, so why is ER care such an expensive thing?

  6. Ohhhhhhhhh. So, you're basing your comments on some imagined future reality of your creation. Gotcha.

    I'm still reading the Atlantic article. When I finish it, I'll probably post something.

  7. Thanks. I look forward to your observations and criticisms.