Professionals, not employees

When I read Roger Ladouceur’s editorial,¹ I felt a flush of resonance and strong emotion because he’s raised an issue that is dear to my heart and that has dogged my clinical life for 4 decades.

Since beginning practice, I have struggled with charging individuals fees for so-called uninsured services, and have undercharged, or not charged at all, on by far most occasions. I have never been able to look someone in the eye (or compelled my staff to do so) and tell them to pay a fixed sum for a service, knowing, for example, that their material life is dependent on a welfare cheque or other modest or even desperately meagre fixed income. Nor have I been able to charge a sum for a routine note that takes me 3 minutes to write, or a form for a student health clearance that requires only a signature, or any of myriad daily acts that occupy my professional time. I don’t ever charge for sending records to other physicians because—for heavens’ sake!—this is how continuity of care, that estimable prize of good clinical practice, is maintained.

In fact, when patients come in perplexed because they’ve received a bill for, say $30 to $50, from a physician they have seen 10 times and who has performed only perfunctory care for modest health issues, I encourage them to ignore it.

Subversive on my part?

I don’t think so. I think it’s realistic and honest. People in many jobs, especially on a fixed salary, do just as many routine tasks as we do, and the costs are folded into their overall wages. We physicians, handed fee-for-service earnings on a platter, have started to believe that every little thing we do is worth recompense.

Several commentators have said “medicine is a business,” suggesting Dr Ladouceur is naïve. One even went so far as to claim that not charging reinforces patriarchy² (quite a challenge for female practitioners, I suspect), as if absorbing the costs of uninsured services was somehow demeaning to patients. I would point out to her, and to many others, that charging extra for more and more things is a relatively new phenomenon, and more a reflection of a general corporatization of social mores (with a little help from Reaganomics and the World Bank’s infamous policy of structural adjustment, where privatization is a god) than it is a reflection of our work.

In making comments like these, I fear we forget several critical aspects of what we do.

First, our earnings, for the most part, come not from our patients, but from the public purse. Most practitioners get most of their cash simply by filling in a form or making a data entry, and behold, the cheques are deposited in our accounts without fuss. We are paid from taxes paid by all citizens.

That means what we do is not a business. It is a public service, delivered by us in this fashion because society has decided, in its collective (and increasingly eroded) wisdom, that what we do is essential enough to the well-being of others that we should receive automatic compensation for what we do. Lawyers don’t get paid like that. Scientists in discipline after discipline don’t get paid like that. Almost all of our patients don’t get paid in that automatic, secure way.

Calling what we do a business, under those circumstances, is illogical and truly naïve. If any practitioner feels otherwise, then read the business literature. It’s all about profit, loss, layoffs, downsizing, efficiency, “trimming” the work force (ie, firing or laying employees off) depending on market fluctuations, moving production overseas to cheaper and less regulated work environments, etc.

Physicians, almost across the board, are insulated from all those business realities. But there’s more. We can’t be downsized (a few operative specialists can be in some measure, but only in part). We can live where we want; we can practise as much or as little as we want; we can focus our work on areas that interest us; we can organize our practices in the way we find most convenient.

And by and large, compared with Canadians in just about any other occupation, we cannot be fired for anything besides indecent, immoral, or illegal behaviour. I would be the first to say that the colleges (the provincial ones that license) can be a bit starchy in the way they deal with clinical outliers, especially those who branch out into nonpharmaceutical remedies, but that’s another story.

Second, and derivative of the first point, we get these privileges because we call ourselves a self-regulated profession. Self-regulated.

That means that what we do as doctors is assessed and judged and regulated, for the greatest part, by other doctors—not by our patients, not by government regulators (they can control the fee schedule and infrastructure, but they don’t assess our clinical behaviour). We guard this privilege of self-regulation with great fervour, unwilling to let anyone tell us how to actually practise. That’s because we believe that the social contract that gives us this attribute is our right—but society acknowledges that right only if we exercise a parallel responsibility to act in the public good.

I have long contended that if we don’t take seriously our responsibilities—and a few modest sacrifices—to act consistently in the direction of achieving a public good, then society will be inclined to withdraw our self-governing status and turn what we do into just another job, with increasing restrictions, rules, and more of the standard employee vulnerabilities. Like other government employees, we will be told where to work, how to structure our clinical activities, what hours we can adopt, and if we will have to be let go because there are too many of us and our services are not valuable enough to be affordable.

Finally, we can all charge for services that are uninsured, but who we charge for them is critical. Charging large and profitable enterprises like insurance companies or legal and other third-party representatives whose fees are truly profit-oriented, or charging for a substantive effort (like a long letter in support of a patient’s personal needs, sent to a social service agency), is and always has been acceptable. I am not a billing nihilist.

So ...

Do I think we should charge for uninsured services? Yes, occasionally, and in concert with our fundamental principle of primum non nocere. Our actions in charging for services are not neutral or without effects. To see what we do as being part of a “business model” is, however, in my opinion, to negate the principles under which we work and, at worst, represents simple opportunism.

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