Curmudgeon Care

by John Loofbourow, MD

The mainstream of medicine has swollen to a devastating flood, drowning physician and patient alike in a torrent of punitive legislation, and crippling regulation. There is virtually no practice, "private" or otherwise, where third parties do not dictate the general terms of most medical decisions. Erosion of professional life for "providers" and of quality of care for "clients" requires no reiteration here, as these matters are already amply documented in the pages of Sacramento Medicine. Many of our colleagues, like gophers seeking to survive the floodwaters, have fled to some type of higher ground to be found in Rural America, in managed care administration, or in business. A recent Wall Street Journal article1 is devoted to a Denver physician who is quoted as calling his practice "a niche strategy"outside the main stream of medicine; he generally does executive physicals in the morning and alternative medicine in the afternoon. One reason that alternative medicine flourishes is that it usually operates in the free-market economy. In a telling if unintentional caricature of problems facing physicians today, there is in juxtaposition to that article an advertisement pitching a prescription medication directly to the patient-reader.2 "Ask your doctor…Proven to help prevent first heart attack". Note the carefully selected words "help" and "proven". As I return home after yet another day in an emergency department littered with human flotsam and jetsam, victims of the this managed care flood, I sometimes fantasize about how good it would be to drop out, and to seek refuge in what I will call Curmudgeon Care.

A curmudgodoc, an irascible, churlish person, would only accept the patient who pays for his own care, preferably with cash. Perhaps, as at the Fairmont Hotel, a charge card might be requested, to verify charge-worthiness, or, as at a United Airline check-in, a current photo I D, to confirm identity. He would be free to charge, or to charge not, to adjust or negotiate fees, or even to request a lab test that did not have governmental or third party sanction. The curmudgodoc might be poor, but would be free to practice humanely, something like the ‘50s; well, not quite. For one thing, docs were not then threatened with so many medical felony convictions. A modern curmudgeon doc would not be able to void the millions of pages of legislation and regulation that have been imposed on physicians since mid century. A billing error today can be just that, or it can be fraud. To allow a Medicare patient to pay for an uncovered service can now be a criminal act. Even though it is probably true that government employees, our fellow citizens, would be unlikely to use this huge armamentarium of regulatory power without good cause, any reading of human history justifies a curmudgeon’s concern about potential abuse of power, and the potential of power to lead to abuse. The true Curmudgeon can’t accept third party money.

The curmudgodoc should not hire employees, or should have very few, possibly only family members. In the first place, this minimizes overhead. More importantly, employees expose the practice to another regulatory inundation, which appears as a flood of acronyms, each defining a legal entity entitled to protect various members of society. Many psychologists and counselors seem to appreciate this curmudgodoc principal. The prospective patient calls for an appointment, leaving his request on an answering machine. The counselor calls back to arrange an appointment or session. At the first phone contact, fees are discussed, and the need for cash or check at each visit is emphasized. Arriving at the office, the patient encounters no one in the waiting area, but at the appointed time, a door opens and the counselor ushers the previous patient out, admitting the new patient into his office. That’s it: no answering service, no receptionist, no secretary, no billing clerk. Maybe a well-trained Doberman would be a comforting assistant in some areas. If the practice grows to the point that more help is needed, or if an assistant is required, sound Curmudgeon Care principles require these be secured from a contracting agency.

The Compleat Curmudgodoc should spend all his money as fast as it comes in (many of us already qualify), or should have no accessible assets. The result is no deep pocket, and no malpractice insurance. Getting divorced is a fast route to poverty for the curmudgeon who has assets and trusts his spouse. For obvious reasons, the curmudgeon will not be a member of any hospital staff, but should, of course, be a member of the medical society, and I expect a most welcome and interesting one at that. Under the circumstances, perhaps an honorary membership could be extended to anyone who meets the criteria for practicing full time Curmudgeon Care. No, Jerry,3 while somewhat curmudgeon-like, certainly interesting, and welcome, you lack the qualities of a Compleat Curmudgeon. Besides, didn’t you have something to do with that legislative flood? Nice try.

1 The Wall Street Journal, Jan.5, 1998
2 pravastatin sodium
3 Jerome Lackner, MD