The Ethics of a Dollar

  I will be the first one to admit that I have really taken a break from actively reading publications on a daily basis. This first year of practice has had me so involved with practice management, learning to run a business, developing staff and patient relationships that the last thing I wanted to do at the end of the day was read journal articles. This doesn’t mean that I turned my back on my patient care. I start my every morning with a review of the latest trends, discoveries, medications, and so on through various aggregated sites with the latest information. I keep up but I don’t actively chase down information unless pertinent to me at the time. This Is in sharp contrast to residency where we were constantly consuming information and building our knowledge bases so I am admittedly setting my bar high. 

 

  Being a doctor and running a business is a funny thing. Even being employed by a corporation is a perplexing idea in my mind. The exams I perform, the tests I run, the products I sell, and the advice I give all have monetary ramifications. Working for somebody else you are also expected to live up to a corporation’s expectations of you, proving your worth through profitability. Being able to truly leave your bottom line out of the thought process when creating a treatment plan is a difficult and tricky endeavor and a major concern when it comes for fee for service health care over outcome based reimbursement.

 

  I had the opportunity to spend about half of my 4thyear as an optometry student working in Indian Health Service hospitals. My residency was also spent practice rural medicine for a low income population. The drugs we had available were generally considered the gold standard of care and if we believed there was a better treatment available we were able to present our case and use these treatments on a patient by patient basis. Post residency I worked for a small group practice that paid me a base and gave me a bonus based on productivity and the amount I billed. This was my first experience with my treatment plans and follow-ups having any impact on my own personal finances. I stuck to my training, optimized treatment plans to include as few visits as possible while still providing high level care, and refused let my financial needs change my thinking. 

 

 I think it’s very easy to let looming rent, electric bills, vendor bills, etc. to negatively affect our thinking when it comes to treatments and follow-up. I reach the end of each month hoping whatever we as a team were able to accomplish will cover our monthly expenses. It’s also a business at the end of the day and we need to survive. Where do we draw the line? How do the choices we make effect our bottom line as well as our patient’s wallet?

 

  I was following an interesting topic online, and an admitted sore spot for me and my perception of patient care. A doctor was having trouble managing a patient who had confluent PEK, or stippling, similar to small abrasion and they were not seeing resolution. The patient was concurrently on a steroid (which delays healing) and artificial tears. When asking colleagues for advice many were quick to recommend an amniotic membrane, a harvested cornea from a donor that is inserted to speed up heeling. These membranes with insertion and removal fees are often hundreds of dollars. When questioned, all that was brought up was that its covered by insurance so why should we not do it? Well in my opinion, first off, with high deductible plans that cost is more than likely going to be passed straight on to your patient. Second, if you are putting something on the patient that actively slows healing – I would think that discontinuing this treatment would be your first step. This to me is a culmination of doctors chasing the newest latest and greatest treatment, preferring what it does to their bottom line, and forcing expensive treatments on to uneducated patients. I see this happening more and more in the optometric regardless of the disease, recommending costly unnecessary and sometimes even contraindicated treatments. We firmly believe that it’s important to discuss all treatment options, their physical cost, and risks v. benefits with each patient. Maybe it takes an extra few minutes but in medicine, education is power. It is our job to educate our patients to make them informed consumers and to aid them in taking the correct path. Medicine is half education, and we are the educators.