The Boston Tea party happened prior to the American Revolution due to a very small tax imposed by the British government on the tea that the colonists were buying. To show outrage over this tax, the colonists dumped tea into Boston harbor.
The major issue for the colonists was that the government imposed taxes on them without having fair representation for the colonies in that government. The reaction of the British government to the resistance in the colonies is what precipitated the Revolution. They felt that the colonists should be grateful for the benefits being part of the British Empire brought.
Yet the idea of people having the right of self-determination was so important to many in the colonies (that is why they left Europe in the first place) that they were willing to give up all of the benefits of being part of the empire for the sake of being their own boss. They felt that the individuals governed had the right to have a say in that governing. This is the foundation of the American mind-set.
In the light of this, I make the following statement: the majority of primary care physicians in our country are treated in an entirely un-American way.
Most internists, pediatricians, and family physicians work in small practices. A small practice is basically a small business with the commodity sold being care of the patient. A practice must be a successful business first for medical care to be possible. The best medical care, however, does not guarantee success as a business (in fact, the opposite is true, but that is not what this post is about). To be able to offer any medical care, there must be a enough revenue to offset expenses.
This makes it very unlikely that PCP's that work in a private practice setting can spend much time advocating for themselves. When I spend time away from my office, my business loses one of its main sources of income: me. My time off is always deducted from my salary; there is no such thing as paid time off.
This is true to a lesser degree for other private practice physicians, such as cardiologists and surgeons, but the margins are far smaller for primary care and the greatest dysfunction in our system lies in our offices, not those of the specialist (which is why so many medical students are becoming specialists, and not PCP's). They too lose money when the take time off, but it is not nearly as common for most specialists to run in the red as primary care physicians.
Instead of having private-practice physicians as representatives, we have either academic doctors or employed physicians - both of whom can more afford to take the time off. The problem is, few of these physicians really understand the reality of what it is to work in private practice during this very difficult time. They do not know what it is to have to lose staff because you can't afford to pay them as much as hospitals or specialists. They don't know the constant emotional burden it is to have to be the one running the business, when you weren't really trained to do so. They have not faced the conflicts of interest that we face on a daily basis:
- Do you spend less time with patients so you can make more money?
- Do you order more tests in your lab so you can increase revenue (despite the fact that it may not really be necessary)?
- Should you down-code so that you don't trigger an audit of your records?
- Do you drop Medicare and Medicaid because they don't pay you well enough, when doing so would be losing the opportunity to serve the elderly and poor?
- Do you do cosmetic procedures to subsidize the medicine you really enjoy practicing?
- Can you stay in business if Medicare cuts go through?
- Do you document more so you can bill more, or do you just document for the care you actually give?
No, the only ones who really understand what it is to be a primary care physician in private practice are others in the same situation. Yet the simple fact that the situation is so difficult makes it nearly impossible for us to have representatives that truly advocate for what we need. Instead, we have folks who think that the private docs are of poorer quality than the academic docs as our representatives. Decisions are made about our livelihoods and our practices without understanding of how it would really impact us. I don't think their intent is ill, I just don't think they offer us adequate representation.
Our medical societies are partly to blame for this. They collect dues from us but do not assure adequate representation. I was recently asked to be a co-chair for a national task-force on medical information privacy issues. The problem was that the government did not give any stipend for me to do this. I had to be gone for two days every other month to be on this committee, not to mention the phone conferences and e-mails. But I lose significant income when I am gone. My business doesn't really go on without me; it simply stops generating income for me when I am gone. I suggested to my professional society that there should be a fund to offset this loss set up by the society. Since that society, however, is made up mainly of academic doctors who don't understand, the idea wasn't felt to be worth it.
So what is our tea party? What can we do to start the move toward adequate representation? How can we rise up and make ourselves heard without costing us our businesses? Am I talking about revolution? No! Are the other doctors evil? No. The fact is simply that we are in the eye of the healthcare crisis and are possibly the key to fixing it - yet we don't really have a voice. This is not right.
Help me Dinosaur, Anonymous, Smak, Solo Doc, and any other private-practice primary care physicians out there (there aren't many who can afford the time off to blog)! What can we throw into Boston harbor to make our point? How can we fight the injustice of inadequate representation? If we don't raise our voices now, others will speak in our place. Those others are probably very content to keep us as colonies, rather than as independent powerful voices.