There’s an old joke about the doctor whose son graduates from medical school and joins his practice. After a while the son tells his father, “You know old Mrs. Jones? You’ve been treating her rash for years and she never got better. I prescribed a new steroid cream and her rash is gone!” The father responds, “You idiot! That rash put you through medical school.”
That’s a joke. It doesn’t reflect reality, but it reinforces a common misconception that doctors care more about their own income than about their patient’s outcome. That accusation is demonstrably untrue.
I’m sick and tired of all the doctor-bashing. They accuse us of being shills for Big Pharma. They say “Doctors are only out to make money.” Or “Doctors are greedy bastards only interested in the bottom line.” Or as one of our commenters recently put it: “First do no harm. Second ? Third, profit [sic]” Some have even made the ridiculous accusation that doctors have found the cure for cancer but have suppressed the information so as to keep people sick and increase their business. If profit were really their primary motivation, doctors would have to be astoundingly clueless, because they keep doing things that are guaranteed to reduce their profits.
Those who have already made up their minds that doctors are mercenary can always find plenty of examples to reinforce their belief: confirmation bias works really well to support preconceived beliefs. But if you want to ask whether a claim is true, the trick is to look not for confirming examples but for disconfirming ones. I don’t deny that there are bad apples in the medical barrel, but they are vastly outnumbered by the overwhelming weight of disconfirming examples.
In a recent post, Dr. Crislip describes medicine as “a calling” and explains that he is motivated by compassion. His criticisms of alternative medicine are clearly not based on any fear that CAM will cut into his bottom line, but by the distress he feels when a patient dies unnecessarily, as in the example he gives. Like the majority of doctors today, Dr. Crislip works for a fixed salary: his income does not depend on his decisions about treating patients. I practiced medicine in the Air Force, where nothing I did could have any impact on my paycheck. Even when doctors are in private practice, I think it would be hard to find one so cynical that he would do an unnecessary C-section just because his kid needs braces. And if he did many unnecessary surgeries, he would only expose himself to malpractice lawsuits and to chastisement by hospital management and/or medical boards.
Medicine is not a good way to get rich
People who go into medicine because they want to help people, not because they want to have a multimillion-dollar house, membership in a posh country club, and drive a Porsche. Medicine is not a good way to get rich. To repeat what I said in a previous post, medical education is long, grueling, and expensive. Most doctors incur substantial debts for their education and need many years to repay them. The nice houses and cars don’t come until long after graduation. The median net worth for physician households is $700,000 and their median income is going down. The ones who really get rich are those who market bogus remedies or spread misinformation (like Dr. Oz, Andrew Weil, Stanislaw Burzynski, Daniel Amen, Kevin Trudeau, and all the companies that sell diet supplements and miracle weight loss aids). For comparison, the average net worth of American families is $120,000, and the median net worth of the top half of one percent is $1.8 million. According to one financial analyst, “Membership in [the top half of a percent] is likely to come from being involved in some aspect of the financial services or banking industry, real estate development involved with those industries, or government contracting. Some hard working and clever physicians and attorneys can acquire as much as $15M-$20M before retirement but they are rare.”
Doctors consistently act against their own financial interests
Individual doctors may try to increase their income, but the medical profession as a whole is constantly doing things that tend to decrease provider income while improving patient outcomes. Doctors would surely make more money if they stopped vaccinating and could treat all those patients who would contract preventable diseases. They could charge for more office visits if they ignored the recommended vaccine schedule and delayed and spaced out the injections. They would undoubtedly make more by doing annual routine Pap smears on every woman and executive physicals with chest x-rays, EKGs, and treadmill tests than they can by following consensus recommendations.
If you’re old enough, you will have noticed that doctors no longer do many of the things they used to do when you were a kid, like routine annual urinalyses, TB tine tests, and chest x-rays. Why do you think they stopped? They could make more money if they still did those things and charged for them. Most doctors today do not automatically treat every ear infection with antibiotics, do not offer antibiotics for common colds, and they treat bladder infections with 3 days of antibiotics instead of longer courses. If you believe they are Big Pharma shills, you can only conclude that they are incredibly incompetent ones: shills ought to be maximizing the use of antibiotics and other prescription drugs, not cutting back.
Mainstream medicine has a long track record of re-evaluating its practices and discarding those that have not proven effective. In a recent post Dr. Gorski mentioned “Choosing Wisely,” an initiative of the American Board of Internal Medicine. Its goal is to help patients and doctors choose care that is supported by evidence, low risk, truly necessary, and doesn’t duplicate other tests or procedures. It asked national medical specialty organizations to identify five tests or procedures commonly used in their field whose necessity should be questioned and discussed. The resulting lists of specific, evidence-based recommendations were published in the Archives of Internal Medicine and are available online.
The American Academy of Dermatology list includes:
- Don’t prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection
- Don’t perform sentinel lymph node biopsy or other diagnostic tests for the evaluation of early, thin melanoma because they do not improve survival
- Don’t treat uncomplicated, non-melanoma skin cancer less than one centimeter in size on the trunk and extremities with Mohs micrographic surgery
- Don’t use oral antibiotics for treatment of atopic dermatitis unless there is clinical evidence of infection
- Don’t routinely use topical antibiotics on a surgical wound
The American College of Physicians list includes:
- Don’t do screening exercise EKG testing in patients who are asymptomatic and at low risk for coronary heart disease
- Don’t do imaging studies in patients with non-specific low back pain
- In the evaluation of simple syncope with a normal neurological examination, don’t do brain imaging (CT or MRI)
- In patients with low pre-test probability of venous thromboembolism, do a high-sensitive D-dimer test rather than imaging studies as the initial diagnostic test.
- Don’t do pre-op chest x-rays unless there are symptoms of heart or lung disease.
There are 46 of these lists. Each can be easily accessed by clicking on a link. They all make for interesting reading; but if you don’t want to bother, these two examples give you a good idea of what they are like. They address things that some doctors are still doing in the face of clear evidence that they shouldn’t. It always takes time for research findings to be translated into changing practices in the typical doctor’s office, and this is an effort to speed up the process. The goal is to improve patient care, not to boost physician income; in fact, almost everything on the lists is actually at odds with the financial interests of physicians.
The American Academy of Family Practice was not content to list only 5; they came up with this list of 15 items:
- Don’t do imaging for low back pain within the first six weeks, unless red flags are present
- Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement
- Don’t do DEXA screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors
- Don’t order annual EKGS or any other cardiac screening for low-risk patients without symptoms
- Don’t do Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease
- Don’t schedule elective inductions of labor or C-sections before 39 weeks gestation
- Avoid elective induction of labor between 39 and 41 weeks gestation unless the cervix is favorable
- Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients
- Don’t screen women older than 65 for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer
- Don’t screen women younger than 30 years of age for cervical cancer with HPV testing alone or in combination with cytology
- Don’t prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable
- Don’t do voiding cystourethrograms (VCUG) routinely for the first febrile urinary tract infection in children aged 2-24 months
- Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam
- Don’t screen adolescents for scoliosis
- Don’t require a pelvic exam or other physical exam to prescribe oral contraceptives
Please note that for almost every item on these lists, compliance will reduce the use of drugs, screening tests, and procedures. Think about it. What would you expect to see if doctors were really only out to make money? They could conceivably invoke the precautionary principle to justify continuing any of these practices. Why not put all kids with ear infections on long-term antibiotics to prevent recurrences? Why not give long courses of antibiotics for every bladder infection or put patients with recurrences on constant antibiotic therapy “just in case”? Why not do ever-more screening tests and physical exams at more frequent intervals? Why not do more procedures instead of fewer? Once doctors had adopted any kind of test or treatment, why would they ever want to stop doing them and give up the opportunity to get paid for them? C-sections are lucrative: obstetricians could make more money if they stopped doing vaginal deliveries altogether. Thank goodness we don’t see that kind of thing happening in mainstream medicine. We are not seeing promotion of unnecessary tests and treatments that would increase physician income; we are only seeing efforts to improve patient outcomes and rational use of resources.
A stark contrast with the situation in the world of CAM
Contrast science-based medicine’s consistent track record of re-assessment and improvement with the track record of any kind of alternative medicine. I have looked hard for any example of a diagnostic or therapeutic practice that has been tested, found not to work, and systematically rejected by organizations of acupuncturists, homeopaths, or chiropractors. BJ Palmer’s “nerve tracing” technique is no longer being used by chiropractors; but I don’t think there was ever any testing or any “official” rejection, and that’s the only example I’ve ever been able to find.
It would be refreshing to find recommendations by chiropractors for all chiropractors to stop treating infant colic with spinal manipulation, or by acupuncturists for all acupuncturists to stop needling a certain acupuncture point because it had been tested and shown not to correspond to the organ they once thought it did, or by homeopaths for all homeopaths to stop using “Oscillococcinum” because no such organism ever existed. I don’t expect to see any such developments any time soon. If there are any initiatives by a CAM board comparable to the “Choosing Wisely” initiative of the American Board of Internal Medicine and intended to stop diagnostic and treatment methods that have been found ineffective, I sure haven’t been able to find them.
If you want to see an example of blatant efforts to increase provider income without regard to scientific evidence or patient outcomes, there is no better place to look than the typical chiropractic practice-building websites. One website is heavy on advice to welcome patients, call them by name, pay compliments, thank them for referrals, add massage therapy as a new profit center, etc. Another offers these 6 steps for building a profitable practice:
- Define a niche market, like treating new mothers after the birthing process
- Market, market, market
- Run interoffice referral campaigns
- Never back down
- Be innovative
I’ve looked at a lot of chiropractic practice-building initiatives and I have yet to find any recommendation to improve patient care by stopping ineffective practices. Chiropractors can get CME credits for these science-free income-boosting programs.
The accusation that doctors are motivated solely by money is demonstrably untrue. Most doctors are committed to doing what is in the best interests of the patient regardless of the effect on their income. As new evidence becomes available, they are constantly changing their practices to eliminate the unnecessary and the ineffective. The contrast with CAM providers is striking.
This article was originally published in the Science- Based Medicine Blog.