Just what do you think you're paying me for?

I get a lot of comments hostile to doctors, and I’m OK with that. Going to a doctor can be comforting, painful, humiliating, frightening, or all of the above. Doctors can be saints, assholes, and everything in between. But there are two phenomena I find puzzling. One is the act of “punishing” the doctor by not taking care of yourself, the other the idea that the doctor should take care of you for free.

We pay doctors for their professional expertise. We hope that they will behave as compassionate professionals, but as human beings, we often fail. I strive to be compassionate, and teach that to my residents and students, but we all have our bad days. 

Compassion does not mean doing whatever the patient asks. Being a doctor means telling people every day things they don’t want to hear. I frequently see patients who refuse to take medications, won’t follow a diet, or avoid vaccines because (they say) they are mad at their doctor. I have news for these people: doctor’s don’t lose a lot of sleep over patients who choose to go their own way. While I certainly prefer that you take good care of yourself, if you choose not to, there is a danger that my focus may shift to people who want to get better. 

Digging a bit deeper, when I hear, “I’m not taking that pill because the doctor’s an ass,” I think of two different things. One is an immature hostility that harms no one but the patient, but on another level, I hear someone who may be more frightened than they are letting on, and are in denial about their disease. If I am very lucky, I can reach this person. 

The other odd thing is people who think doctor’s should work for free.  I don’t just mean those who think we need a new health care system, or who expect us to magically diagnose them over the phone—I mean people who think that we should write prescriptions, administer vaccines, or give advice without charging a fee.  Folks, this is my livelihood.  This is how I feed my family.  My education wasn’t free.  My office isn’t free.  My supplies aren’t free.  My time and expertise aren’t free.  You pay me because you want my services (and out of simple respect).  I don’t come to your restaurant and expect a free bowl of soup, so don’t expect a free flu shot from me. Of course, unlike a restaurant owner, I’m unlikely to turn you away if you walk in my door holding a bloody appendage.  

Finally, a note on professionalism—no, not professional behavior, but the nature of professions.  Doctors have a special knowledge and skill that we pay for.  If we could all do it, that would be great, but we can’t.  It’s easy to deceive ourselves that googling “high blood pressure” makes us knowledgeable enough to take care of ourselves, but it doesn’t.  Every seemingly small decision we make every day is backed by years of study that inform us of the correct course to take, the risks, the benefits—-there are no simple decisions in medicine, or at least damned few.

Primary care docs may not get rich, but we are privileged to have a profession that allows us to study something fascinating and use that knowledge to help people.  Like anyone else, we hope people follow our advice, and we hope they pay their bills, but neither is certain.

45 thoughts on “Just what do you think you're paying me for?

  1. My former doctor is a GP who was in partnership with another GP, and they made a decent living. Then his partner dropped dead playing tennis. My friend struggled, tried to recruit another partner, but it didn’t really work. Debts mounted, and finally he closed his practice, and took a job at State Farm.

  2. I’m cutting corners where I can;
    It’s good to be so frugal!
    I’m cutting out my doctor, and
    Replacing him with Google!
    That mole that keeps on growing?
    I’m convinced it’s fungal rust!
    (If I can’t trust Wikipaedia,
    Who else, then, can I trust?
    My doctor says such fungi
    Are a problem… but for plants.
    He’s stuck in Western Medicine,
    Won’t give my view a chance!)
    My Neighbor swears by St. John’s Wort,
    My mom, by chicken soup–
    And eBay has a listing for
    Some pure organic goop–
    I’m going to cure that silly mole
    Through different ways of knowing;
    Ignore the fact that, as I act,
    The damned thing keeps on growing.
    It’s harder to ignore it now,
    And keep it out of sight;
    But god I hate that doctor, cos
    He’s so convinced he’s right!
    I’m going to try some reiki, and
    Some therapeutic touch;
    It’s just as good as doctors, and
    It doesn’t cost as much!
    Ok, it’s been a month or two–
    I guess it didn’t work.
    It’s time to suck it up and see
    The doctor (what a jerk!).
    I TOLD YOU SO! I did! I did!
    My fears have all come true!
    The doctor saw the mole and said
    There’s nothing he can do.
    (In truth, he added “at this point”,
    And placed the blame on me–
    Which shows that I was right, to hate
    The worthless S.O.B.)
    (dammit, I have work to do! This could go on all night–stop me now!)

  3. Remember Green Stamps? (Or, the rival company, Scotch Stamps?)
    This: “I’m not taking that pill because the doctor’s an ass,” is like collecting green stamps with the ultimate goal of saving up for a Darwin Award.

  4. My mum used to call the revenge that harms only yourself “cutting off your nose to spite your face,” which I guessed is a British saying.

  5. I gotta say I’m completely unfamiliar with a patient not following a doctor’s advice to punish the doctor… I would think that patient needs a referral to psychiatric care!
    While I have stopped taking medications because their side effects were more intolerable than the problem they were supposed to solve… punishment of the doctor never ever crossed my mind. Also, these medications were never for something life-threatening – ie, I’m not going to stop taking my blood pressure meds because I don’t like the side effects, but I will ask if there are alternatives.
    It strikes me as odd that one of the reasons I oppose current proposals for universal health care in the U.S. is that are based on cutting pay for doctors. While it personally limits my choice of physicians, I don’t blame any doctor for refusing to take Medicare and Tricare payments. They are ridiculously low in some (most?) instances.

  6. Some people treat their doctor like they do their relatives right down to the attempt at passive aggressive manipulation games over who is in control and dominate.

  7. Doctors are great when you need stitches, have a broken arm, etc. They are best for emergency medicine. Where people go wrong is by going to the doctor for preventive purposes. Doctors usually know little about nutrition and their idea of prevention is to take this pill to keep your BP down, take this pill to keep cholesterol down, take this pill to prevent your heartburn. Come on!!! All these are preventable through lifestyle change.

  8. Pardon the silly question, but if you think your doctor’s an idiot shouldn’t you get a new doctor? It’s not like there’s only the one out there.

  9. Are you sure the motivation “doctor’s an ass” is meant as a punishment for the doctor, and not as “I don’t trust the doctor”? I’ve had cases like that, where I felt the doctor hadn’t listened to me, or had not looked into things properly, or whatever. Ok, my reaction has been going to a different doctor to see what they said, but then I can afford it (thanks to free healthcare — if I have to pay for a second opinion, that’s ok). But I can see how someone might just ignore the doctor’s reccommendation instead.

  10. PalMD
    I was one of the people whose comment on a previous thread may have partly spawned this one. First: I agree that the thought of punishing your doctor by foregoing treatment is childish. I will point out, however, that there is a cost-benefit analysis that is applied when considering going to the doctor. (I have a LOT to say about this, but my original comment was well over 800 words and growing. But if you are curious, I’ll send it to you separately.)
    Basically, going to the doctor is always unpleasant, some more so than others. Due to some disagreements over billing and procedure codes, my relationship with my doctor’s office is probably poisoned beyond repair. Yet, this is where I go to get a flu shot? I’d rather go without.
    And the copay? It’s the same as if I go and actually see an actual doctor if I get sick. So far this month, my medical expenses are over $200 between copays and prescriptions. That’s WITH insurance. We’ve had to cut back on extras – like birthday presents. Christmas is going to be lean this year, primarily due to medical expenses.

  11. Yes, that’s a pretty lousy systems problem. It would be best if necessary vaccinations could be supported and administered by an efficient public health system, but our local health dept certainly can’t keep up.
    Once a doctor-patient relationship is broken, that’s pretty much it, and it’s time to try to find a new one, if at all possible.
    Copays are annoying, but of course under the current system, unavoidable. Health care isn’t free. We pay (a lot) for insurance, and some insurance has deductible, out of pockets, co-pays, etc. It’s the way the system (doesn’t?) works. You can’t hold doctors responsible for collecting the fees they need to keep their doors open.
    As to the idiot above who repeated the same brainless mantra about doctors and prevention, please, when you fill out your organ donor card make sure to remind them not to look to hard around the inside of your skull.

  12. Due to some disagreements over billing and procedure codes, my relationship with my doctor’s office is probably poisoned beyond repair. Yet, this is where I go to get a flu shot? I’d rather go without.
    TGAP dad: If the relationship is that bad why are you still seeing this doctor? I understand that sometimes there are reasons-s/he is the only doctor in the area (though you imply that your wife and children have a doctor or doctors you trust more so that seems less likely), insurance restrictions, need for a specialist, etc. Nonetheless, if at all possible you should consider changing. Possibly changing insurance as well, if you can’t get care that satisfies your needs with the current plan. The current situation is putting your health and life at risk: influenza-including the “normal” seasonal influenza-and secondary pneumonia kill people. Not getting a flu shot may seem like a trivial rejection of medical care but it could have consequences.

  13. I am sure I must have some brain imbalance, I am sure you could come up with some prescription for me. I am so sick of doctors diagnosing bullshit problems in the name of prevention so they can push more pills. I am sure you truly believe you are doing good but doctors arrogance (ignorance?) is harming a lot of people.

  14. The best thing my doctor’s office did to improve relationships with patients was to start accepting email through some kind of webbased system. Now my doctor is part of the very large primary care practice affliated with a university health system so economies of scale make it much easier to afford these kind of things.
    It’s reduced the telephone tag and the chance that things will get mangled by messages that are passed on. It’s made it much easier to deal things like perscription SNAFUs.
    The other thing my insurance company has done (to save themselves money) is their Ask A Nurse Line. They will give you an idea of whether or not you need to see a doctor. I found that very helpful.

  15. Doctors usually know little about nutrition and their idea of prevention is to take this pill to keep your BP down, take this pill to keep cholesterol down, take this pill to prevent your heartburn. Come on!!! All these are preventable through lifestyle change.

    You are factually wrong. Lifestyle is only one risk factor for these diseases. My father has a low BMI, eats healthy foods, and exercises every day. He still has high blood pressure and needs medicine for it. High cholesterol is also partially hereditary, and for some people, dietary changes just aren’t enough. It can also be a symptom of untreated or under-treated thyroid disease. Good nutrition and exercise are great for health, but they are not magic bullets that will cure or prevent every disease. There are certainly some bad doctors out there, but all the ones I’ve seen were knowledgeable about nutrition and encouraged it.

  16. My normal internal comment when dealing with these kinds of patients, “can’t fix stupid.”
    If you do not have the problem then it’s primary prevention so diet and exercise, quitting smoking and the like. If you have the problem — diabetes, hypertension, coronary artery disease, obesity, hyperlipidmeia / dyslipidemia — then it is secondary prevention. This is trying to prevent the second heart attack or having that first heart attack because of your diabetes. Lifestyle is improtant in secondary prevention but is seldom enough.

  17. I would agree that lifestyle change will not help in 100% of the cases but I have witnessed high blood pressure, high triglycerides, high cholesterol (true familial hypercholesterolemia is rare) all drop to normal range when you eat right (not package foods advertised as low fat), add exercise, and get proper sleep. I would argue that well over half of the people diagnosed with these conditions could normalize them with lifestyle change. I am not against prescriptions when necessary, but they must be used judiciously and the doctor should always work toward reducing/eliminating them if possible.

  18. but I have witnessed high blood pressure, high triglycerides, high cholesterol (true familial hypercholesterolemia is rare) all drop to normal range when you eat right

    Who have you witnessed this happening to? You anecdotes are not data. Plus, telling people to just not eat unhealthy foods is about as successful as telling teens to just not have sex. All the doctors I know encourage a healthy lifestyle, but they just can’t make someone follow it. Doctors have to make the best of a situation. If a doctor tells a patient to stop smoking or eat better, and the patient won’t or can’t do that, then the doctor can often help with medication. It’s not the doctor’s job to punish those people for the sin of eating by withholding treatment that will help them.

  19. keep it real — lifestyle changes are the first thing my doctors suggested in managing my conditions (mainly, asthma and gastro-esophageal reflux disease). Changing my diet helped a little bit with the GERD, for a while. But it didn’t cure it, and my esophagus became so scarred that I was having trouble swallowing. Had to have it stretched out during endoscopy. I took Nexium for six weeks while it healed, which was blissful. I’d never known what it was truly like to not have heartburn! I’d thought I was controlling my heartburn by being careful about what I ate and when, but really I was just reducing the pain. It was still bad enough to put me on the road towards esophageal cancer. (GERD greatly increases the risk of that.) Eventually, my doctor persuaded me to use Tums at the first sign of symptoms, rather than waiting until I couldn’t bear it anymore. And now that I’m done having my babies, I’m on Prilosec. And it is AWESOME!!! I cannot begin to express how good it feels.
    My aunt wasn’t so lucky. She stuck it out, partly due to a lack of funds for regular checkups. By the time she finally saw a doctor for her heartburn, she had Barrett’s Esophagus, a precancerous condition. Now she takes Nexium, the only drug known to keep it from getting worse. If she stops, she is at high risk of esophageal cancer.
    Too many people wait to get their conditions treated until they are out of control. If you get regular checkups, your doctor can detect conditions early enough that you can *avoid* major medical interventions, and that is a very good thing. It’s unfortunately true that some doctors are lazy, and will write you a prescription to get you to go away. But most PCPs (especially the family docs) prefer prevention to medication.

  20. I would not be rejoicing over taking prilosec or any other proton pump inhibitors. There have been studies published in JAMA that show these medications all increase the risk of pneumonia. It is ok to use them short term but it is not wise to depend on them indefinitely. Your stomach acid serves a very important purpose both for immunity and digestion and it is not something you want to suppress. Paradoxically, there is evidence that GERD can be cause by to little stomach acid, especially in older people. I am not advocating living in pain and ignoring doctors I am just saying a little investigation into the real cause is probably a good idea.

  21. “true familial hypercholesterolemia is rare”
    Keep it real, you’ve GOT to be kidding. Where did you get the evidence to support that extraordinary claim? Or is this the No True Scotsman fallacy at work?

  22. Your information on PPIs in incomplete, and I’ll also have to ask you to give citations for such claims if you want your comments up and unedited.
    PPIs such as prilosec are very safe, even long term, but are not without some problems. There is some evidence about risk of pneumonia in debilitated patients, where it is often used to prevent stress ulcers, and there is some concern regarding calcium absorption in women at risk for osteoporosis. Neither is a deal-breaker, however.
    JAMA. 2009 May 27;301(20):2120-8.
    CMAJ. 2008 Aug 12;179(4):319-26.

  23. JAMA. 2005;294:2989-2995 Use of Gastric Acid–Suppressive Agents and the Risk of Community-Acquired Clostridium difficile–Associated Disease
    JAMA. 2006;296:2947-2953 Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture
    JAMA. 2004;292:2012-2013 Acid Suppression and Pneumonia
    You may not think it is a deal breaker unless you are the one in the hospital with a broken hip…

  24. If that evidence is not enough and you need to remove my post I understand but I feel it is an egregious disservice to the patients to subscribe these without explaining there are potential serious problems from long term use.

  25. Thanks for the citations, although I already had you covered with that one.
    As with any powerful medicine, risks and benefits have to be balanced. My concern was that your tone seemed to imply that there is no place for therapy with these drugs, which is false. This is a very important class of medications, used for millions of person-years with very few adverse effects, but there are probably some populations that require extra care.

  26. I apologize if my tone implied there is no place for PPI, that was not my intent. I was simply saying that it is my opinion they should be used short term if possible and a person should try to find underlying cause of the GERD. I personally have been prescribed and used prilosec for a short time. I feel that most people have the impression they are absolutely safe to use because they are OTC now but they are not without risk.

  27. “true familial hypercholesterolemia is rare.”
    It’s not that rare. I’ve got it and there’s more than enough people running around that they can undertake randomised controlled trials for it. So not that rare, depending on what you think a rare condition is of course.
    Whilst it would be nice to treat the underlying cause of GERD in any patients what’s wrong with providing symptomatic relief in the meantime? Sleep apnea, is implicated in some patients, for instance. But sorting that out can take a bit of time.
    All drugs have side-effects. All drugs need to be evaluated for use in each patient with a carefull eye on the risk-benefit profile in that patient. What’s new?

  28. Calli Arcale, if your aunt intends to take Nexium forever to reduce her risk or her fear of cancer, you could save her big bucks by informing her that the active compound in Prilosec is IDENTICAL to that in Nexium. If Nexium is “the only drug known to keep [Barrett’s esophagus] from getting worse,” that just means that the company carefully refrained from testing Prilosec for that exact use, so that there would be new disease claims they could trot out only for the still-in-patent-so-far-more-expensive Nexium.

  29. What good would it do to punish a doctor? He/she doesn’t seem to care anyway. I can honestly say that I don’t trust doctors though. For the past two years I had a tingling all over my body that just kept getting worse, progressing to muscle cramps and twitches. My internist, who didn’t hesitate to prescribe statins and blood pressure medicine, said he couldn’t do anything about the numbness and tingling. I went to a few different doctors including my OBGYN. One doctor did an MRI of my lower spine and sent me to physical therapy for a bulging disc. He also did about 4 pages of blood tests that all came back normal. B6 and B12 tests were NOT on the list of tests even after I asked about them. I persisted and he sent me to a neurologist who did some physical tests on me and said that I was fine and had neurapathy which happens to older people (I’m 52, btw). All the doctors said I was fine and yet I was pretty much going out of my head. I stopped all medications, walked constantly, did a lot of yoga and was still in bad shape, even losing my concentration. I tried everything I could think of.
    Then somehow, I got the idea to discontinue taking my mega-vitamins. I had been taking them for about two years and they contained 300mg of B6. Within a week, I saw some improvement and 4 months later I am feeling much better.
    Duh? How much medical school does it take to figure out that too much B6 is bad for you? My supposition is that the doctors were so into their training that they didn’t even bother to consider something simple and obvious.
    And yes, btw, my blood pressure and cholesterol are down from changing my diet, which oddly enough, was prompted by this mysterious illness that scared me to death.

  30. Let me get this straight, Bridget…
    You were taking mega doses of some quack vitamin shit that the doctor never prescribed for you, and you’re blaming all the doctors (who never prescribed them) for not noticing you we’re being an idiot.
    How many kinds of fool are you, exactly?

  31. Errr, Bridget, did you tell your doctors that you were taking megadoses of vitamins? I find that patients often don’t mention vitamins (or other “supplements”) to their health care providers, because they’re “natural” or “just vitamins” and not “medication.”
    And what exactly did you expect your OB/GYN to do? I’d have referred you to a neurologist pronto.

  32. In discussing health care reform, I have acquaintances who would be happy to see doctors lose their livelihood…usually fellow technical professionals who make about as much money as the primary care physician national average, without the crushing debt or any realistic risk of legal defense costs on the job. I’m not sure why these folks feel we deserve a comfortable living and people who are serving their fellow human beings do not.

  33. PalMD- a lot of it has to do with the fact you can’t send the soup back to the kitchen. I actually think that’s one reason people get so damn litigation-happy. There’s often not a lot of recourse of a more moderate level.
    When I gave birth, they had to stitch me up afterward. I lost a lot of blood, and I’m incredibly grateful that there were modern knowledgeable doctors to help. That said, if I remember correctly (and, granted, I might not have been my usual self right after that experience), they had the resident stitch up a particularly nasty/unusual tear (this took *way* longer than active labor, and was more egregiously painful). I just went for my post-partum follow up. How would you feel about the amount charged by your doctor if you knew parts of your genitals would never be in one piece again unless you underwent another surgery?
    I understand the resident and doctors need to make a living. But well, there’s a fly in my soup, and no, everybody will *not* want one.

  34. They were hardly “quack vitamin shit”, but just a bottle of mega-vitamins that you buy at the grocery store. Nothing excessive or extreme. 300mg of B6 does not approach the suggested overdose limit of 500mg. Why didn’t the doctor just ask me what I was taking? Why didn’t he testing me for lack of B12 or too much B6?

  35. Bridget, the RDA (in the UK) for B6 is 2mg. You were taking *150 times* the recommended dose and you’re surprised this caused long-term side effects?! This isn’t really your fault, by the way, as the con-artists and messianic crazies who promote this sort of thing played you for a sucker, like they do to thousands every day.
    And the information I saw (Google!) on recommended maximum safe dose was 100mg for long-term daily use. I think most people here, and most doctors and properly-trained nutritionists, would agree that *any* vitamin overdosing without a damn good medical reason is “quack vitamin shit”. On the other hand, many doctors will have experienced patients getting very angry when asked about supplementation regimes (I know my doctors have always cringed pre-emptively when asking me that one).

  36. Let’s get this straight: you didn’t tell your doctors that you were taking supplements, and even if you had, you would have said that you were nowhere near an overdose. And you want your doctors to diagnose an overdose anyway? Real life isn’t an episode of House.

  37. Bridget, I think your question is fair. Why didn’t the doctor ask you if you were taking supplements/vitamins? Well, you have to realize that doctors find disease using a diagnostic method, that’s how they’re trained, kind of like a flowchart, if A is true go to B, if false go to C. False! Follow that next step and do the same…. of course this is an extreme simplification of that process, but it’s how they come up with a diagnosis. Sometimes simple stuff just doesn’t come up and they miss it or you forget to tell them about it. They are human and mistakes can happen. Though you will still get a bill in the mail because the office space isn’t free. This is why I think should all doctors should get a big house with a dog for free when they go into practice, because their education was so damn expensive and because life is tough some days when you are a doctor, and you can end up being an asshole, especially on the bad days, which are most days for many, because you have to see a lot of patients to make a lot of money in these hard economic times, and even in regular times. So you see, with human perspective, your doctor’s error was perfectly understandable. I’m just glad you figured it out before you needed another doctor, that’s the last thing you would have needed, right?

  38. Well, you have to realize that doctors find disease using a diagnostic method, that’s how they’re trained, kind of like a flowchart, if A is true go to B, if false go to C. False! Follow that next step and do the same…. of course this is an extreme simplification of that process, but it’s how they come up with a diagnosis.

    It is not an oversimplification—it is wrong.

  39. @ becca: the poor result may not have been the fault of the resident. I’ve seen bad things happen from similar sounding situations managed by everyone from consultant OB on down to medical students.
    Not YOUR fault, either, obviously. Some things do simply happen, like a fly in the soup. I hope you get a good result.

  40. Schwa, I would have told the doctors I was taking a multivitamin and they would have tested me for excess B6 or lack of B12. This would have been in addition to the myriad of expensive tests they did run.
    Bella hit upon my point, that people in the medical profession follow certain procedures and don’t like to deviate from them. Maybe it’s because these procedures have been adopted by the medical profession to provide the best success determined by scientific testing and lack of lawsuits, but that doesn’t mean that they are always the right solution.

  41. >>Copays are annoying, but of course under the current system, unavoidable. Health care isn’t free. We pay (a lot) for insurance, and some insurance has deductible, out of pockets, co-pays, etc. It’s the way the system (doesn’t?) works. You can’t hold doctors responsible for collecting the fees they need to keep their doors open.

  42. I’m not sure what your point about prevention is, but if you’re saying what I think you are, we are not “there” yet as far as genomics goes.

  43. ValSue said. Regarding prevention – if you carry the genetic markers, you will get the diseases.
    Apart from a small handfull of actual genetic diseases, like Huntington’s this is actually false. Genetic information, thusfar, explains almost none of the variability in human disease.

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