Doctors are not poor but heavily dependent on their medical licenses in order to earn an income. More so than anyone else in another profession, our licenses mean everything to us. We spend over a decade to get to a place where we can see patients independently. This license is what’s used to inflict economic violence against doctors.
The term economic violence is rather harsh, I know. I’ll explain the context in more detail below. But it is nothing short of that. When the only way you can make a living is through clinical medicine, if that’s taken away from you, your income comes to a screeching halt.
Economic System of Medicine
Patients often believe that as physicians we have autonomy in billing and patient management. Far from it. Physicians cannot force an insurance company to pay for a procedure that’s not approved.
We don’t even have the autonomy to practice medicine the way we see fit. As a Family Medicine doctor I must abide by the guidelines of Family Medicine. We are bound by community standards of care and also by broader clinical guidelines.
And since the majority of us deal with some sort of an insurance system, our reimbursement is controlled by an economic powerhouse and not the patient. Lawyers and medical boards can use this to inflict financial harm on physicians.
As physicians we are among the highest earning employees. We are economic elites. Hence, nobody feels sorry for us.
Unfortunately, we see ourselves as economic elites as well. That’s why we have allowed ourselves to be so heavily regulated in our own profession. And that’s why others can manipulate us by controlling our income.
Even though we are the final decision makers for the patient, even though we are the ones performing the surgeries and prescribing the meds, we have no say in the medical system.
Credentialing, authorizations, investigations, and FDA approvals all happen without any input from us. We just do as we’re told because we make such a good income doing it.
The Physician Decision Makers
Some might say that there are plenty of doctors in politics and on state medical boards and on FDA and CDC committees.
Not only are these individuals the opposite of practicing physicians but they are a tiny minority compared to the number of licensed doctors out there.
They are often kiss-asses. They don’t care much about the profession or the ethics of it. Career advancement is their main goal. In a profession which already attracts quite a few megalomaniacs, they are among the elites.
Economic Violence Against Physicians
I didn’t go to medical school and residency to get a medical license. That was never the purpose or end-goal. And yet I feel that I’m held hostage by my medical license.
I realize that I’m a bit too much of an idealist. Maybe these are my excuses for trying to get out of medicine. Or perhaps it’s just bitterness from having dealt with 3 separate state medical boards for something that I feel was rather benign.
The whole system is so interconnected that any issue with my medical license limits my ability to see patients. Which limits my ability to earn an income.
The only string you need to pull on in order to control a physician is their ability to bill the insurance company. Whether BlueCross or CMS, if the doctor cannot bill, they cannot earn a living.
Economic violence happens when you limit the ability of a person to earn a living. As in, the intention to limit their income earning capacity as a form of punishment.
This term is often reserved for those who are destitute; think of a sweatshop worker who speaks out against poor working conditions. They’ll be blacklisted and won’t be able to find another job anywhere else in the garment industry.
Imagine you’re a physician who cannot get a job in your own field because of something on your professional record. There are quite a few such individuals who email me their story – often involving the medical boards.
Our society’s backbone is based on punishment and as a group we have decided that punitive actions are the best way to address clinical transgressors.
What about medical board investigations, a malpractice history, or a substance abuse history? What if your ability to earn an income was taken away forcefully for these reasons? Most doctors don’t have the capacity to find something else to do – we weren’t trained for anything else.
Substance abuse falls under mental health disorders. It’s a disease, no different from Diabetes or Cancer.
In our society we don’t view it that way. A narcissist, someone with anger management problems, or an alcoholic are all viewed as guilty individuals.
That’s how we can look upon the homeless population and dismiss them. Even though the majority are homeless because of some sort of mental health disorder, we can blame them for being lazy or fucked up in some way worth ignoring their human qualities.
So the medical board punishes a doctor for substance abuse issues. They terminate their license or suspend their medical license. That’s a form of economic violence; the purpose is to prevent that doctor from easily obtaining a job in the future.
In a medical malpractice case you are represented by an insurance lawyer. You will rarely hire your own lawyer since it’s financially prohibitive for many physicians.
The lawyer(s) will do what is economically best for the insurance company, not the doctor. They will settle or go to court hoping to minimize the payout and the legal costs.
This is something we as physicians will carry around with us for the rest of our careers. And just so that we don’t have to explain it to new employers we will often stay put, often risking burnout in a shitty job.
Medical Board Investigations
If you are suspended by your state medical board, placed on probation, or even have a letter of reprimand, all of these are enough to cripple your career.
Your ability to find a job will be limited. And if not that, you’ll have a hard time billing an insurance company.
And because of the economic structure of healthcare your ability to earn a fair income will be limited. This is the kind of economic violence I am referring to.
I don’t see any reason why a medical board investigation should financially cripple a doctor. From the cost of hiring your own lawyer to not being able to earn a decent income in medicine, it’s all economically punitive.
Consequences of Economic Violence Against Doctors
So let’s say the doctor is punished for one reason or another. They have something negative on their professional record which they’ll have to explain to every insurance group or employer, what now?
Most of the time such cases will lead to the termination of the physician. And once terminated it will be very difficult to find a new job. The employer reports the termination to the National Practitioner Data Bank.
Even if the doctor can find a job they may not be able to bill certain insurance groups or CMS (Medicare/Medicaid). Or perhaps the malpractice career will refuse to cover that physician.
BlueCross sanctioned me and I doubt that I’ll be able to bill under them in the future.
The Incentive to Practice Medicine
What’s my incentive to practice medicine? Is it the money I earn per patient? The health outcome of my patient? Meeting HEDIS measures?
Patient Care or Income?
Whatever is being taken away from you in form of a punishment is how our relationship is viewed in healthcare. When you’re being financially punished then the system assumes that the money is your incentive to practice medicine.
Let’s look at the medical system and the laws. I don’t have private access to the EHR and once I leave a certain medical system then I am no longer entitled to the clinical information regarding a patient. It’s all a business interaction – no continuity of care, no real patient-doctor relationship.
In fact, the best thing I can do as a doctor is to tuck a patient in as much as possible so that I can wash my hands of them as soon as they leave my office. Hence:
Patient advised of side effects. Returns precautions reviewed. Patient agrees with management. Told to discuss potential med side effects with pharmacist. Patient to call 911 or go to nearest hospital if any fevers or severe pain develop.
I am here in Los Angeles practicing at a Community Health Center because that’s the only option available to me. My prior incentive of patient care is now replaced with career preservation. How perverse.
Sure, if I was selling widgets on Amazon then it would make sense to make revenue my main incentive. But capitalism isn’t and shouldn’t be at the heart of medicine.
If you want to punish me, keep me from seeing patients for a few weeks/month. Crippling me financially has nothing to do with healthcare, it’s simply punitive. It harms the clinician and it harms the patients. Not like we have an abundance of doctors.