Imagine for a moment that you are a fly on the wall listening to the following exchange.  Take some deep breaths and try to take in the following conversation that actually happened last week. Before I reveal the conversation I further want you to imagine that you have just had surgery on your shoulder.  Your surgery didn’t go well.  You developed an infection.  Familiar with our website you are still confused about why your co-pay at the big hospital was more than the entire bill would have been at the Surgery Center of Oklahoma.  You still don’t understand why your family practice doctor sent you to the surgeon he did.  You told him you liked the surgeon you used before and sure liked the Surgery Center of Oklahoma.  Your family doctor didn’t seem phased by your comments.  Ok.  Here we go.

Setting:  a large hardware store    Actors:  A highly respected orthopedic surgeon practicing in Oklahoma City and a family medicine doctor who has been a hospital employee for about 2 years.

Surgeon:  Hey, how’s it going?  Haven’t seen you in a while.  Come to think of it, I haven’t seen any patients from you in a while either.  Are you doing ok?  Has my office staff been responsive when you have called?

Family Doc:  I’m doing ok.  You just don’t understand how things are and how they are going to be, that’s all.

Surgeon:  What are you talking about?

Family Doc:  You’ve refused to become a hospital employee and you’ve refused to play ball and now you’re going to see what that means.  I am not going to send you any more patients until you start doing surgeries at my employer’s new facility.

Surgeon:  Really?  Is the operating crew there experienced?  What do they have to offer the patients that the Surgery Center of Oklahoma isn’t providing?  Is their infection rate low?  Are the patients paying less out of pocket if they go there?

Family Doc:  That’s besides the point.  None of that matters.  If I send them to you, that’s where you have to go.  That’s just the way it is.

Surgeon:  Ok.  I understand.  You should expect to be the subject of a blog by my friend Dr. Smith.  Take care!

Now you are beginning to understand why, with your infected shoulder and having paid a fortune for your surgery, you wound up in the hands of a surgeon other than the one you already liked and  knew was good.  Your family doc was compromised.  What sort of leverage does the big hospital employer have?  How can they make him act this way, not in your best interest?  Your family doc has a performance graph.  The hospital employer has hired an army of accountants to make sure that he is earning his keep.  Your family doc gets “credit” for the charges he generates not only in his office but for the referrals he makes.  He also gets punished for the referrals he makes that don’t generate revenue for the hospital.  If, for instance, he sends a surgical referral to a surgeon who decides that the best place for the patient to have surgery is a facility other than the one employing your family doc, then it’s BIG POINTS OFF for your family doc.  Enough points off, not enough credits and his contract is subject to re-negotiation.  That means that the hospital is going to cut his pay.  A lot.  A 50% cut in pay is not unheard of.  Or, he could be let go entirely.  This wouldn’t be so bad if it weren’t for the fact that he is prohibited in the contract terms from seeing patients that are currently in his practice.  Or the clause that prohibits him from working within 50 miles of Oklahoma City.  Or the $50,000 “tail” provision on his malpractice insurance, payable upon termination of his contract.  Yes, I could go on.

In short, your family doc, if he is indeed an employee of a hospital, is incentivized to refer you to a surgeon that is not the best for you, but rather is the best for him.  Ouch.  Kind of pisses you off to read this when it’s put that way, huh?  Do I blame the family doc?  Yes, of course.  He is a collaborator.  Vichy.  He has sold out.  He has violated his oath.  Pathetic.  And you, the patient, are the victim.

Are there private practice physicians and surgeons who are abusive of patients and their wallets?  Sure. Referrals made to private practice abusers are usually made out of ignorance, though, and time and experience teaches primary care docs to avoid these guys.  But hospital employed family docs are forced to become mercenaries for their own self-preservation.  Nothing compares to the institutionalization of this mercenary approach to medicine.  Beware the physician working for a hospital.  He’s more than likely not working for you.

G. Keith Smith, M.D.