KevinMD: Defending the physician, even when they are wrong

Recently I read a post on KevinMD titled: The blonde minority: Sexism is alive in medicine. on August 18, 2014, by Elizabeth Horn, a resident physician.

I look at the world very differently, I see patterns and connections that others don't see. Think Sherlock Holmes or House M.D. (Here is a little known fact: David Shore, the creator of House, based the character of House M.D. on Sherlock Holmes.)

As i read this article, I saw the proof of the theory (sexism is alive in medicine) presented supporting the opposite conclusion. What put me over the edge was Dr. Horn admonishing someone who was acting in a very respectful manner, in dealing with a confusing situation that healthcare created and refuses to address: the position of a person wearing scrubs.

I commented on how her story did not support the title and how she disrespected patients and their families. My comment was deleted. That pissed me off. So now I am going to hit back harder.

Here is my original comment that was deleted on Kevin MD:

There is a glaringly simple answer to the problem that you present and it is not sexism. (I hope you don't diagnose patients like you diagnose social issues).  

First I will address the "marry a plastic surgeon" thing. Plastic surgery is MOSTLY elective. They are usually not covered by insurances so they don't have to jump through hoops to get paid. They are happier with their profession, patients, etc.  

I don't know what your speciality is (you conveniently left that out) , but unless you are going into something where the pay scale is comparable with that of a plastic surgeon, then that person spoke the truth. I will acknowledge that it may have been inappropriate, but still the truth.  

Just as a physician says "we are professional and have seen it all" when a patient expresses apprehension about exposure of their body, thus making it about the physician's feelings and totally ignoring the patient's feelings: you are doing the same with this issue.
Perhaps the real issue is how you present yourself:  

"A natural blonde... my diminutive frame...my blonde mane...rather than a skirt suit... heels to a respectable 1.5” or less. I avoid using the word “like” too often...become disproportionately focused on the thoughts and opinions of male physicians and residents... Not that I mind a youthful complexion...a young, reasonably attractive blonde doctor... trust-fund boyfriend I had... the tortoise shell glasses, changed into my skinny jeans, a favorite sweater, suede heeled boots, put down my hair and applied a little mascara and blush." (Your words.) 

LIKE, oh my God, it's Elle-izabeth Woods of "Medically Blonde."   

Don't take not being called "doctor personally." In the 1970's you saw 3 people in hospitals: doctors, nurses, and orderlies. Each wore a specific uniform and were easily identifiable.  

As you stated, today there are "physician... ...nurse, physical or occupational therapist, student or housekeeper" and everybody wears scrubs. Let's not forget visiting surgical company reps (demonstrating equipment in the OR), janitors (sometimes), phlebotomists, lab techs, quality control specialists, EMT, and a host of others subject to the facility's infection control plan.  

Is it NOT just as disrespectful to you for someone to call a CNA doctor???? 

Calling you "miss" was sign of respect, respect that you are obviously LACKING for the person who called you that! Obviously they did not know your title, and used a respectful address for any unknown woman. 

Obviously with that paternalistic, arrogant, everything-about-you attitude, you are fitting quite well in the medical profession quite well.

While my comment may have been slightly inflammatory, the way she disrespected patients  and their families was more inflammatory. Everybody wears scrubs, there is no color coding to tell what position a person holds. People have been complaining of this for years. Calling her "miss" was polite and respectful!

Here is how she describes herself:

A natural blonde... my diminutive frame...my blonde mane...rather than a skirt suit... heels to a respectable 1.5” or less. I avoid using the word “like” too often...become disproportionately focused on the thoughts and opinions of male physicians and residents... Not that I mind a youthful complexion...a young, reasonably attractive blonde doctor... trust-fund boyfriend I had... the tortoise shell glasses, changed into my skinny jeans, a favorite sweater, suede heeled boots, put down my hair and applied a little mascara and blush.

If she is using sarcasm here, then I apologize for not catching that. I don't think that is the case though. I think that she presents herself (perhaps unconsciously) in such a manner then call it sexist when people don't take her seriously. I am not saying that this is right, and there may be some sexism involved.

There is nothing here about paying for college and med school, the burden of student loans, the years at a resident's salary trying to survive. If indeed she did have a trust-fund boyfriend then the only way you meet someone like that is if you are in those circles. Mentioning "residency at an ivy-league institution" is another giveaway, usually implying influence of the family she comes from. I suspect that she comes from a very wealthy family.

LIKE, OMG, it's Elle-izabeth Woods of "Medically Blonde." 

The frightening thing is how she deals with this issue and (more importantly) it would affect her interactions with patients  and their families:

 I have learned to speak up, to maintain eye contact and to assert myself if needed when rounds become disproportionately focused on the thoughts and opinions of male physicians and residents.

This is PATERNALISM! What if a patient doesn't agree with her decision of treatment?

It is troubling issue is that she aims this at ALL men. Has no man ever taken her seriously? This is stereotyping and REVERSE SEXISM. Then she makes the following comment where the man that she chose to marry is the only "good man" in the whole post, And the gender of the "trusted adviser" is conveniently undisclosed due to lack of pronouns:

During my internship, I went on a date with a good man and a couple of years later, he proposed. As I made plans for my career after residency, I met with a trusted adviser who after discussion of the several options I was considering, fellowship, research, physician positions, assured me not to worry too much. I was, after all, marrying a plastic surgeon.

I also comment on lack of disclosure of what her choice of speciality will be. All physicians are hurting financially, but general practitioners are hurting the most. The physicians that are thriving are the ones free of the bonds of medicare, medicaid, and insurance. Concierge physicians and plastic surgeons are two of these, and they are prospering. Dr. Horn fails mentioning her choice of speciality.

On July 28, 2014 KevinMD titled "Doctors today: Young, broke and human" by Aunna Pourang M.D. Indeed financial security is a major concern, even when both spouses are physicians. One being a plastic surgeon, alleviates much of the financial burden of that household.

Either I am missing sarcasm in this article, it is poorly written, or she is learning to be paternalistic. Looking at how the healthcare system operates, I go with the latter.

As a man I am offended by this post. As a patient, this post invokes fear in me of how Dr. Horn as a physician would respect my choices and my dignity.

I welcome a response from Dr. Elizabeth Horn or KevinMD.

--A. Banterings

Patient Dignity 15: The "Eye of the Beholder"

I was in a talking with someone today who made me thought of this analogy. Previously there was a discussion about our bad encounters with healthcare providers who were paternalistic, lacked empathy,  just didn't care about our dignity, or suffering stress from the healthcare system. It was suggested that we might be "the exception and not the norm."

Just because a physician is paternalistic, it does not mean he doesn't care about the patient. Think of paternalism as a pair of glasses that only let the physician see the physical body of the patient. The physician does not see the soul, spirit, or mind of the patient. He ignores the patient's wishes, especially for modesty.

He is running on the autopilot that was instilled in him over the many years of his training. This autopilot is good because he can react immediately to any situation. The downside is not seeing the patient's soul or wishes. He is the source of knowledge, of healing, and the treatment has to be his way.

Remember the Twilight Zone episode "The Private World Of Darkness" (originally titled and more commonly referred to as "Eye of the Beholder")? It originally aired on November 11, 1960 on CBS.

Fact: Many TZ fans mistakenly believe that the tile of this episode is "The Eye Of The Beholder," which would have been quite appropriate as the relative nature of beauty was discussed. Apparently, that was the original plan as creator Rod Serling referred to this episode with that title in a preview announcing it as the next week's episode, but somewhere along the line it was changed...

Janet Tyler has undergone her eleventh treatment (the maximum number legally allowed) in an attempt to look like everybody else. Tyler is first shown with her head completely bandaged so that her face cannot be seen. She is described as being "not normal" and her face a "pitiful twisted lump of flesh" by the nurses and doctor, whose own faces are always in shadows.

The twist in the tale is unveiled when the bandages are removed, and the reaction of the doctor and nurses is horror and disappointment. The procedure has failed, and her face has undergone "no change—no change at all". The camera pulls back to reveal a gorgeous blonde surrounded by grotesque doctors, nurses and hospital staffers.


Distraught by the failure of the procedure, Tyler runs through the hospital. Flat-screen television screens throughout the hospital project an image of the State's despotic leader giving a speech calling for greater conformity.


As she runs through the hospital until she encounters another "disfigured" human with the same "condition" as her. He arrives to take the crying, despondent Tyler into exile to a village of her "own kind", where her "ugliness" will not trouble the State. Before the two leave, the man comforts Tyler, saying that "beauty is in the eye of the beholder."

This made me think that the patient's dignity is mistreated by the healthcare system, and providers can't see it because of how the healthcare system enforces conformity...

Don't believe me? Read: "Death by a thousand cuts: how the machinery of academia enforces conformity." Academia is also involved in the teaching of the healing arts.

--Banterings

Patient Dignity 10: Paternalism and Pretending to Care

I recently read a very disturbing article on LevinMD.com titled, "Incorporate empathy in patient interactions."

It seems like a good idea one would think, until you read the article. The second sentence in the second paragraph states, "The greater the sense of trust, the more likely the patients will be compliant."


Empathy is used Machiavellianly to achieve patient compliance. That is paternalism at it's worst. That is no better than one person saying "I love you" to a partner just to get them to buy gifts. How could the empathy be genuine then?

This shows the worthlessness of the "patient's bill of rights" that all providers have. They are in fact worthless, they are NOT a binding contract. They just make the patient feel warm and fuzzy like they are actually participating in their own healthcare.

The "patient responsibilities" part, which always include "follow the physician's plan for treatment" are a direct contradiction to the "patient participation" part. The "patient responsibilities" only allow the physician to give the patient a "demerit" or justify firing them as a patient.

The beginning of the article only reenforces my point; do you think the insurance company is actually empathizing with people or just trying to get them to buy insurance?


If a physician reads this article and the next day tries to empathize with patients, don't you think they will see right through that. Physicians who actually care don't need to be told this. And there are many physicians who do actually care (and empathize) about their patients.

How would physicians feel about an article that tells patients to pretend to follow their physician's treatment plan, then return and say it is not working. Suggest a hybrid plan of the physician's plan and yours. The physician may suggest staying on the course of treatment or change it to something different. You may have to do this a couple times. Once he concedes to the hybrid plan, report that you feel better (but not enough), but you want to try altering the course of treatment.

Forgive me for saying this, but when is healthcare going to figure out that it is about the view of the patient?

--Banterings

Patient Dignity 07: A Broker Addressing Malpractice As Medicine Addresses Modesty

Let me start off by saying I am qualified to talk insurance premiums. For what I do, I decided to get all the insurance licenses my home state offered. It was a CYA move, so that I did not want risk being accused of being involved in insurance transactions without a license. At one point, I was a licensed broker in 20 states (for a specific project). I did not do health insurance, my specialty dealt with "work comp" insurances. 

 This is a cumulation of most of the complaints that patients have about the treatment of their dignity. This is satyrical and always, from the patient's point of view.  Most providers are just good people caught in a bad system. Changes that I advocate not only ensure patient dignity, but frees the physicians from the system to ensure the protection of patient dignity.

As more practices that were partnerships can't afford med mal/liability, they are selling to large healthcare corporations. Practitioners of the Healing Arts are becoming employees. I chose this narrative because you as a provider feel that you have been treated in this manner. You may have had some of the same, exact experiences and infractions committed against you.

I realize that some references may seem silly, but you are an intelligent, educated professional, and you will get the gist.



As a physician and a partner in a practice, would you find this aceptable???

An Insurance Broker Tells His Physician Practice Clients, in a Letter, What Really Happens

Dear Physician Practice Client,

Recently there has been posts on many internet blogs by physician practice groups bashing brokers and agencies. While most brokers and their support staff are honest, caring, professional, people, there are some (more than we like to admit, even more than we know), who give our profession a bad name.

We are just as guilty as them because we were brought up in a system that teaches us to ignore human emotions, we just look at the body of numbers. We attribute these infractions to the atmosphere we work in: big corporate agencies trying to run insurance like a fast food chain, insurance companies that keep negotiating lower and lower commissions, excessive workloads, the constant threat of Errors and Omissions lawsuits, continuing education credits, and so on.

I also do not see that many of these criticisms are valid, but I am looking from the inside out. Because I don't believe that they are valid, I don't try to see them either despite the overwhelming evidence staring me in the face.


We are accused needless ignorance or calloused disregard of the client's emotional well being going through a difficult process. We are not working in garage on automobiles here but with real live people who in all probability have never been through the initial application process and what happens is pretty distressing.

Renewals are easy, just sign and accept. You will definitely have to go through this process again if you get dropped. The "Big Insurance Association" recommends that even if you are getting renewed to go through the complete application process, annually to prevent future problems.

Many of my decisions on your coverage use to be influenced by commission rates, bonuses, MGA contracts, and contests with vacation prizes. Those days are pretty much gone. Being a carrier rep does not have the prestige that it use to.

I am sorry that  your malpractice/liability/work comp/EPLI/D&O/E&O insurance expires and is being non-renewed. I know that this is a scary situation that you may not be familiar with, but as your licensed insurance broker, I am charged to serve you, the partners, and the practice; my client,  first, in your best interest, professionally, and ethically.

You may feel humiliated being in front of me and my team with no insurance to cover you. That is only to be expected. You need to realize that we are working to save your practice, you need to stop being silly and put your feelings aside. We don't see the value of your feelings in this matter when you may lose your practice.

The first thing that I need to do is put together an application. I am going to have to ask you some very personal questions about the practice and the people working there. You may think that these questions are unrelated to your application, but as a professional, I need this information as part of the application process.

I will be asking you about education, finances, accreditations, employment practices, billing, accounting, criminal backgrounds, and so on of the partners, the practice, and the employees. This is necessary for me to look for any red flags that might pop up. We may have to run some tests on your employment policies. These may be unpleasant, but again all we are focusing on here is you not losing your practice.

I will also be examining some very intimate parts of the practice, like the finances of the practice and of the partners. I will try to remember to tell you everything that I do before I do it. At any time if you are uncomfortable, I will stop. I may not realize that you are uncomfortable about these issues, I may not be talking with you during this, just pushing foreword.

You may feel embarrassed about what I find, but don't worry, "I am a professional and I have seen it all before." I will try not to expose areas unless I have to. You need to realize that in order to do my job properly and serve you completely, I need to look at these areas even though other brokers might not and it might even not be necessary. Yes I can put together an application without them, but I do a complete forensic exam, my choice. If you are uncomfortable with that, perhaps you should seek out another broker.

I tell all my clients "I can tell a lot about your business by examining these intimate parts." We can get a healthy picture of the practice now, it will be easier to diagnose and prevent problems in the future. I may also request records from previous providers, like audited financials from your accountant. It is my choice how I conduct my application process.

I create a file about your practice with all my info, notes, application, and I may even come out to your practice to take pictures. We may identify certain rooms in your practice, but we do not take pictures of anything that identifies your practice. We may use the pictures and information we collect on your practice in scholarly studies to predict future risk, but you already agreed to all that in the "broker of record" form that you signed.

Very few people are comfortable having a complete stranger see their very private tax returns and other stuff, but I was taught the correct way to do this, so you have nothing to worry about. They are just numbers. I am not judging you based on this. I only look at one section at a time. I know that some people on the internet describe this as an anal probe and say it is too intrusive based on their financial modesty issues.

To make you feel better about your embarrassing situation of not being covered (by insurance), I may have this chap, alone, from my office with me when I have your folder open, looking at your stuff and doing the application procedure. This is for your protection and for mine. I don't want to be accused of "fudging your numbers" or "having my hand in your cookie jar." You might be more uncomfortable with this, but rest assure, I am not (it's NOT my stuff being looked at).

I keep this information in a manilla folder to protect your financial modesty. I know that manilla envelopes can open accidentally and expose your stuff, but as a "matter of efficiency," that is what we use. Yes, there are "interoffice clasp envelopes, but they are too inconvenient for us. Manilla envelopes cover enough up.

There are also going to be other members on your team here getting your submission together, you really don't need to meet everyone of them. They should introduce themselves when dealing with you, but they may not because they have too many clients heaped on them. Just so you know, they will be poking through your stuff. This also includes carrier reps who may be with me looking at your stuff showing me how to fill out a new insurance application.

We also have interns (trainees). These are people studying to get their insurance licenses. There is an obligation to train new brokers, so we have them working with us. They will be poking through your stuff too. Most brokers won't tell you they have trainees or who they are so that clients just assume they are brokers too. That saves us having some uncomfortable conversations with the clients. 

I know that you want to know about my finances and lifestyle, but that is my personal information, and it is not professional for me to share. Even though it would build enormous trust by me filling out an application, showing you my tax returns, putting my money where my mouth is, I wont because I don't have too. I have this plastic model of an application or a brochure that I can show you.

Negotiating our professional relationship, involving you in decision making, foregoing some painful parts of the process, giving you more control, and going through the process WITH you would build trust, alleviate your fears, and allow you to endure some of the painful and humiliating parts that you thought you would refuse.

But that means giving up control. I am a sales professional, a type A personality. I was taught that as soon as you get resistance from a client, get their information in a manilla folder and the humiliation and power imbalance will make them compliant. It also helps that I am in a suit, looking like a professional and you are in your pajamas (scrubs). In the good 'ole days, you would come in, show me your stuff, and I was in control from there.

I will also politely order you to do certain things, like "sign here." If you refuse, then I just repeat the order, in a stern, matter-of-fact voice until you comply. I am the authority figure, and I need to act as such.  Asking, although more respectful, gives you the opportunity to say "no." Then I need to explain myself, you are deluded in thinking that you can refuse. Again I was taught this too, but you will not find it in any book.

When I went to school, we never did applications on each other. Although it would have made us better brokers, given us a better understanding of what you go through, our paternalistic attitude prevented us from doing that. We did do superficial stuff, like figuring out the SIC codes of where we currently worked, but that is all.

Some teachers allowed us to process applications with their personal information. Mostly we had actors come in and we practiced on them . Other than that, you get experience as an intern. The broker who taught me would wait until the client was out (of the building), then me and four other interns would pull back his manilla folder and poke through his stuff.

At first I had a problem doing this, but my mentor said that since we were affiliated with a business school, this was a teaching agency. There was also informed consent, in the fine print in paragraph 49 in the "broker of record" agreement that the client signs.

You may feel depersonalized. We are taught to do this to solely make choices based on logic, fact, observation, science, and the numbers. You need coverage, and this is the coverage that you need. You don't want the deductible, but you won't get coverage without it.

We are all insurance professionals, but we are human first and foremost. That means we have curiosity, stresses, and make mistakes. Most of our administrative assistants are young, female, and immature. We will tell you they are professional. They will look through your stuff, will gossip about it, laugh about it, and may even post it on FaceBook.

If you are a middle aged man or older, or fat, you will be a source of entertainment for some of these young people, especially the women. If your manilla folder is bigger than most, they may be calling other admin assistants to look at it. They will present with a legitimate reason to look, and they are most likely entitled to look, so deal with it in the furtherance of education.

We  expect them to act as professionals. We can do more, but that takes time and money. Besides, we feel that we are doing enough to protect your privacy. I am not sure either exactly how often this happens, so it may not be a problem at all. The industry never studied this.

If you are a woman that is a partner in a practice, and especially if you are attractive, you may notice brokers coming over to talk to your broker. Your broker may even call a consult with other brokers if he feels that he needs to. This is normal. You should not feel uncomfortable, they are all professional.

The fact of the matter is that most of our brokers are men. Most of our admin assistants are female. We would like to hire male admins and female brokers, but their numbers are limited, therefore your choices and wishes are limited too.

In a busy office, people will see your stuff. That is just a fact of life. We could do more; private offices, clasp envelopes, better training, but we don't. That is because WE don't see a problem with your stuff being exposed. If you have a problem with it, then there must be something wrong with you.

If you come into my office, you consent to my entitlement to dig through your business. If you don't follow my directions, then you are noncompliant and I cant work with you. Here is the phonebook, good luck finding another broker, after being labelled a "bad risk."

I know that you want more, but I don't know what "more" is. That is because I never bothered to ask. I assumed that we are doing enough by saving your practice. To be honest, your emotions and financial modesty are just interfering with the process.

The Internet talks about making insurance consumer driven, but as an educated, licensed professional, and an arrogant SOB, I reject that. You are not a consumer, you are an "insurance client." Besides, I don't work for you, the insurance company pays me (commission).

You do have options. This is not extortion. There are many out there doing without vaccine insurance. There is speculation that this is due to backlash against the industry. Sorry, but if you don't have  vaccine insurance, I can't take you on as a new client or I will have to drop you if you are already a client.

I have seen predictions that a future trend will be many practices choosing the "Florida option," that is walking away from agencies because they are unhappy about the way they feel that they are being treated.

Welcome to our agency.