Category Archives: Motivation

Seven Days and a Pinch of Hope

As I write this evening, I am keenly aware of the seven legislative days Alabama has left in our regular session.  So much is left to decide, especially about the budget.  I hope you are also alert and continuing to make contact with our state senators, representatives and Governor.  It puts me in mind of watching a storm front approach and expecting a tornado watch—we hope it will dissipate into nothing much, leaving no paths of hurt and hardship across our beautiful state.  What will it be?  Seven days of creation—creation of new revenue and hope for our future?  Or seven days of destruction?


Searching for inspiration, I’ve started to read “The Impossible Will Take A Little While: a Citizen’s Guide to Hope in a Time of Fear” by Paul Loeb.  The title comes from a lyric in a Billie Holiday song.  I’m only at the beginning—I usually plow through a book in no time flat, but I plan to draw this one out.  In the opening, the author recounts how a group of women at a peace gathering in the rain were disappointed at the small turnout, only to learn later that Dr. Benjamin Spock had seen them and was inspired by their determination, their standing in the rain, to speak out himself against the Vietnam War.


Are you a bit weary of fighting or verging on despair at what’s happening in Montgomery?  If so, maybe we can take a moment to encourage each other, at the verge of this somewhat Biblical-feeling seven days.  If you have a small and hopeful story to share, please add it to the comments for this post.


Here’s mine.  Two days ago, my last patient of the afternoon had an eye injury.  It’s the Murphy’s Law of Friday in pediatrics—the child who needs the most urgent evaluation requiring more than just a history and physical always comes last, and we go into mad scramble mode trying to line things up.  I hate to send kids to the ER just because it’s Friday afternoon. 


I examined the child and found a significant looking injury to the central cornea—because of the mechanism, I was really concerned that eye drops and reassurance might not be enough.  I crossed my fingers and phoned the ophthalmologist on call.  Her nurse relayed Q &A back and forth between us—she wanted to know the age of the child, whether he could cooperate with an exam and whether he had any other injuries besides the eye.  Then the nurse said those blessed words every pediatrician longs for—“send him straight over to the office and we’ll take care of it.” I told the nurse to please give her boss a big hug from me and tell her we were grateful for her kindness.


It was only after I had given the mom instructions on how to get to the office and she had left that I realized there was one question the ophthalmologist hadn’t asked.  Do you know?  Try to think before you go down a paragraph, and don’t cheat.


The question she did not ask me was the question consultants ALWAYS ask me, occasionally even before deciding when/ where to see a patient:  “What insurance does he have?”


I asked our staff to fax the insurance referral so the consultant could get paid, and then I sat and smiled for a few minutes before typing his chart note.  She didn’t ask!  At that moment, late on a Friday afternoon when she probably was hoping to go home for dinner with her family, all she wanted to know was whether he could be still for an exam without ER sedation. 


And that is how it should be, isn’t it? No wallet or insurance card biopsy needed.  Just children, parents, and doctors, figuring out how to do the right thing.  


Filed under Alabama legislative session 2012, Children's Issues, Motivation

You Get What You Pay For

My Facebook friends keep me informed about every special event—last week it was National Angelfood Cake Day, and yesterday was National Coming Out Day.  For docs who see Medicare patients, it seems like every day has turned into Fix the SGR Day.  To the point that I want it fixed too, just so they will find something else to talk about!

The SGR (Sustainable Growth Rate) was intended to be a tool to keep Medicare payments to providers from escalating out of control.  It hasn’t worked, partly because it has never been used as anything other than a threat or bargaining tool.  Each year (or more often than that), Congress delays putting it into effect but lets the AMA foam at the mouth protesting.  Because payments have risen much faster than the SGR allows, invoking it would result in an ever-increasing cumulative pay cut.  I have been told face to face by more than one Congressman that it is too valuable as a bargaining tool for them to let go.  They like to stick non-related, harder to pass legislation onto it as a carrier.  Sometimes they let it take effect for a couple of months and then retroactively cancel it.  Look at all those cancellations and you will find, each time, another bit of less popular legislation included.

Last week, the Medicare Payment Advisory Commission (MedPAC) voted to ask Congress to scrub SGR completely instead of repeatedly overriding it.  They recommend freezing primary care physician payments from Medicare for the next 10 years and reducing specialist payments by about 17% over 3 years.

It wouldn’t directly affect pediatricians, at least initially, because our patients don’t have Medicare.  Most of my patients have Medicaid, which currently pays at about 2/3 the rate of Medicare for the same services.   I get sick of hearing the grownup docs whine about being paid 30% more than me.  Especially when it can take me twice as long to coax my patient’s mouth open to check her throat and risk my own hearing loss in the process!  The ACA, if it goes fully into effect, will bring Medicaid payment up to parity with Medicare in a few years.  I don’t know what my boss will do with that 30% bump, but I have a dream list of some cool things I’d like for the clinic—parenting classes for my families on site, the ability to text medication reminders to my teen patients, a spirometry machine to check the lungs of asthma patients, and more.  When I’m really dreaming, a child psychologist and nutritionist down the hall.

You might think docs would be thrilled to delete the SGR from their lives, but no.  Here’s an article describing their response.  I’m most struck by the urologist who said it might not be worth it anymore to him to see patients.  Really?  I hope he was misquoted or was just having a really bad day.  First of all, the average urologist salary is 294K a year.  A 17% cut would bring that only to 244K—knowing I’ll never even come remotely close to that decreased salary but am plenty happy, it is hard to believe he would suffer much.  The only time I wish I had more is when I can’t cover the medical needs of my family, and that could be solved without raising my pay. 

I’m more disturbed that he is measuring the worth of his work in strictly monetary terms.  What about his pleasure in being able to solve problems and help his patients feel better?  Isn’t that even a small factor?  Not enough to motivate him at 244K?  I know a few docs personally whom I believe to be motivated mainly by profit.  Unless I am just woefully deluded, most of us work with at least some measure of love for those we serve.

Maybe we need to start asking ourselves seriously what kind of doctors we want.  Do we want docs who can’t be happy with an ordinary salary, who dislike their work so much it takes a lot of money to persuade them to do it?  Do we want those who have to be paid extra, in the form of quality incentives and bonuses, to do that job correctly?  Do we want those who fight against easier access to healthcare because they see their work mainly as a commodity, not as a service profession? 

I would be just as happy to let those folks go their merry way.


Filed under Motivation, Physician pay, SGR fix

Fret a Little More: We Need Medicare for All

This post was inspired by my pastor Bob Hurst’s sermon last Sunday, built around the instruction not to fret over how some evil-doers never seem to get what they deserve.  As my mother put it, “life’s not fair” (subtext “quit whining and get over it”).  Bob did a lovely riff on this timely theme, including the pitfalls of punishments and rewards, and managed to work in Bernie Madoff to boot. No sermon on evildoers is complete without Madoff!

As a pediatrician and a parent, I realized years ago that the whole carrot and stick bit was pretty worthless when it came to teaching kids important things like honesty, respect, and courage.  The research literature backs that up at every turn—for both adults and children, punishments are one of the least effective tools at producing desired behaviors, and rewards twist them up terribly.   In any activity requiring higher order thinking, an external reward diverts attention from the good action itself.  The result is cutting corners to check off boxes (e.g., No Child Left Behind) and a loss of internal motivation.  Punishments create ripe soil for more sneakiness, among other problems.

Some writers take this so far as to imply human choices aren’t influenced very strongly by punishments and rewards, but that has always bothered me.  It seems obvious that behavioral modification works sometimes, and I’ve never seen a really good explanation why.  During my sermon-induced meditation on evildoers, I suddenly figured it out.  Rewards DO work—but only to stimulate wrong-doing.  Punishments DO work—but only to inhibit doing good.  Let me explain.

When drug companies reward doctors for listening to their false advertising, we get the wrong-doing of thoughtless prescriptions.  When we give so-called incentives for doctors to perform in certain ways, we get medicine distorted by box-checking and overshadow the best incentives—satisfaction at helping patients be healthier, and pride in good work.  When we pay subspecialists huge fees to do procedures, we get lots of unnecessary procedures.  If a person requires an external reward, separate from the good action itself, performance will ultimately deteriorate. I know someone is going to say doctors won’t work for free, so I’ll try to nip that in the bud.  Read Daniel Pink’s “Drive” for details.  As long as salaries are perceived by employees as subjectively reasonable, so that they do not feel disrespected or taken advantage of, more money doesn’t produce better work.

As for punishment, when corporate insurers issue forth their spin doctors to scare physicians and the public about universal healthcare, they are often successful in getting folks to oppose it or at least to just keep their mouths shut.  That explains why I hear, over and over, “well, I know Medicare for All sounds good, but. . . ”.  After the “but”, insert every variation of propaganda you can think of—this isn’t the time, it’s socialized medicine, government can’t do anything right, we need competition across state lines, etc.  Follow the money and you’ll find out where each sound bite came from.

The Bible passage about fretting encourages us to quit worrying about wrongdoers who seem to get a free pass. We are also advised not to think about whether we will get rewarded for doing good.  I agree.  But the consequences of doing ill or good have never fallen specifically on any one person’s head—the karma of justice is not that targeted.  Allowing private insurers to keep doing wrong is clearly hurting every one of us.

So I looked up “fret” in the dictionary and found another, older meaning of the word I’d forgotten—“to wear away” at something, as by constant rubbing.  When I get discouraged that advocacy for national health insurance is taking too long and I’m not seeing results, I remember that water, over time, can wear away the hardest rock.  We can never remove all the incentives in the world to do wrong—it will always require determination and courage to keep fear from deterring good work.  Let’s fret a little more and a little harder.  Medicare for All—everybody in, nobody out.


Filed under Healthcare reform, Motivation