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Healthcare Reform & Voting With Your Feet As A Physician

How will physicians vote with their feet in response to the changes that have occurred?

When I was a kid-- I'm not exactly sure when-- I remember a teacher in school telling me that to get to the bottom of any current event, you simply need to watch and see how people vote with their feet.

For instance, whenever a dictator in some distant land would wax eloquent about the utopia he had created, the truth was easily found by watching how the citizens in his jurisdiction were "voting."  Were they risking their lives to flee this "paradise" to begin a new life elsewhere? If so, you could guarantee that all rhetoric aside, living under this dictator's rule was anything but pleasant.

How might this idea of "foot voting" apply to modern day American life?

Well, I recently read an article in the Washington Times written by a physician named Dr. Milton Wolf .  Dr. Wolf is a Radiologist who also happens to be a distant cousin of President Obama.  His article details a very interesting footnote to the whole healthcare reform debate and whether the changes made were for the better or worse.

In his article, Dr. Wolf notes that it appears that many friends of the President-- those who supported and pushed for the new healthcare reforms-- have received waivers protecting them from the obvious and dramatic increases in healthcare insurance costs that those who were against the reform package argued would occur if the measure passed.  In other words, recipients of the White House waivers-- over 700 thus far-- helped push a bill onto the American public that they themselves believe is too onerous to live under.  Their rhetoric says they love this new bill, but their feet are voting against it-- or at least voting against paying the price for it.

Another area where I've found individuals voting with their feet is within the realm of clinical medicine.  Physicians, especially primary-care physicians, are fed up with the ridiculousness of modern-day clinical medicine and are leaving it in droves.  The new healthcare regulations seem to add fuel to the fire, with one poll reporting that 40% of clinical physicians will leave clinical medicine or significantly reduce their practice hours over the next three years as the reform mandates are phased in.  This is in spite of the gleeful assurances from the American Medical Association that physicians in America were and are strongly behind these new initiatives.  It appears that the AMA is learning that controlling the behavior of America's physicians is a little more difficult than distorting their voice.

Which brings me to one last example of individuals voting with their feet.

In a recent article in Worth magazine, individuals of high net worth (ie- rich), were being given advice about the pros and cons of moving outside the United States and relinquishing American citizenship.  Here's an excerpt:

It used to be difficult for me to offer advice to people who emigrate from the United States about the tax rules that apply to them. As the son of an immigrant—my father came to this country by ship from Russia in the 1920s—I couldn’t understand why an American would relinquish his benefits and protections as a citizen of the country with the greatest liberty and highest standard of living the world has ever known.

Until recently, anyway. The sad truth is that the business environment in our country was in decline even before the recent economic crisis. Federal and state governments, through encroaching regulation and selective enforcement, appear hostile to both entrepreneurs and big business. Deficits will plague our country for decades, and without the political backbone to tackle entitlements, the only alternative is increasing taxes on the “wealthy.”

Regardless of where you stand politically, this sort of exodus is concerning.  Furthermore, until recently, it was simply unfathomable. 

The facts are very simple:  human beings are not automatons that can be easily controlled by distant bureaucratic rulers.  People respond to incentives, and when they no longer have an incentive to work hard or stay or be productive or take risks, they simply modify their behavior.  

I am reminded of a quote by a physician character in Ayn Rand's novel, Atlas Shrugged.  When asked why he stopped practicing medicine, this fictional physcian replied:

“I quit when medicine was placed under State control, some years ago,” said Dr. Hendricks. “Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I would not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun. I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward. I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything – except the desires of the doctors. Men considered only the ‘welfare’ of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter was regarded as irrelevant selfishness; his is not to choose, they said, only ‘to serve.’ That a man who’s willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards – never occurred to those who proposed to help the sick by making life impossible for the healthy. I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind – yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of a man who resents it – and still less safe, if he is the sort who doesn’t.”

The fuzzy-headed policy wonks in our federal government need to keep in mind a few simple realities as they attempt to micro-manage our lives and clinical practices in between sips of Starbucks expresso:

  • you cannot force someone to become a physician
  • you cannot force a physician to practice clinical medicine
  • you cannot force a healthcare system to function, when it destroys the healthcare providers necessary to support the system

While the talking heads continue their verbose debates on television and throughout the halls of Congress, my attention will be focused not on what's said over the next few years, but who's moved.  My prediction is that we will soon begin seeing some very obvious "foot voting" that will cut through much of the bluster and posturing.

Over the next few years I'll be watching to see how physicians, small businesses, and other mainstays of American society vote with their feet in response to the changes that have occurred.

I believe these votes will be dramatic and significant.

I'm already hearing footsteps...

Reader Comments (4)

Greg ~

In my last practice four female docs left mid-career to pursue teaching, homemaking, waitressing, and other more meaningful careers. I also dreamed of returning to my college waitressing job until I invited citizens to design their own clinic. Now I work for them. No upfront fees. Nobody turned away for lack of money. Innovative docs nationwide are doing the same. May we all inspire each other to recapture our dreams and renew our beloved profession.

Video clip:

Don't wait for politician-saviors. Patients and physicians must re-invent out health-care system together.

Thanks for the article. . .

Pamela Wible MD

Thanks for the comment, Pam, and good for you for not accepting the status quo.

It's distressing to me that so many physicians are thinking about leaving medicine or have already left. What's ironic is that when it is mentioned publically, many times the response from many non-physicians is, "quit your whining. you're a 'rich' doctor. my life is so much harder."

Hopefully, with Freelance MD and the Medical Fusion Conference we'll be able to salvage some careers and help encouage a rather frustrated group of individuals.

There is more than one way to vote with your feet. One does not even have to leave the country. Even within the United States, there has been a significant demographic shift that has been occurring for decades with people migrating from states with high taxes and high costs of living to states with lower taxes and lower costs of living. Businesses do the same.

Leaving clinical practice is obviously the other way to go. As the current system of reimbursement by the gov't and other third party payers has disrupted the classic model of supply and demand, more physicians will choose careers that engage in the classic system, be it concierge medicine or totally non-clinical venues.

Mar 7 | Unregistered CommenterAlan N.

Good points, Alan N.

You can read a couple of recent posts regarding Concierge Medicine here on Freelance MD that discuss that very issue.

I suspect we'll see more and more of this in the future as you suggest.

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