A Chat With An Internist

I was reviewing a case with an internal medicine physician who happens to be a good friend of mine. We were talking about a patient that needed a CT, and I said, almost without thinking, "At least you don't have a scanner in your office."

This started a discussion of the relative merits of in-office scanning and self-referral. My friend was unaware of the statistics that we all know so well: self-referring docs order from two to eight times as many scans as those who don't self-refer, and they generate $16 Billion in extra expenditures annually.

My friend is honest as the day is long, and quite non-judgemental. He had no harsh words for his colleagues who are dabbling in the scanning business. But he was very clear as to why he thought they were doing so. As an internist, he is very much aware of the impact of falling reimbursements. He notes that it is very difficult to keep his practice open at all these days. Thus, he sympathizes with those who are doing anything to stay afloat, including placing scanners in their offices. The temptation to order excess imaging is certainly there, but he expressed hope that this would not occur very often. Nothing was mentioned about convenience.

It has been said on numerous occasions that primary care physicians are underpaid, and that is the root cause for self-referral. I agree that our hardworking internists, pediatricians, and FP's do deserve a lot more than they receive, and the current situation is very sad and very difficult for them. However, a couple of points come to mind. First, two wrongs don't make a right. If I lose money in the stock-market, I'm not allowed to rob a bank to make up for my loss. Similarly, the lack of reimbursement for office visits and EKG's does not justify over-ordering of scans to produce additional technical revenue. Secondly, a significant pleurality, if not an actual majority, of self-referring physicians are not primary care docs, but rather are specialists, mainly cardiologists, oncologists, neurologists, orthopedic surgeons, and neurosurgeons, more or less in order of their abusive behavior as I see it. Maybe these guys have taken some hits as well, but their incomes have certainly not dropped as badly as the primaries.

It's hard to define what's "fair" in this setting. Certainly it isn't fair that my friend the internist works as hard as any physician I know, and isn't anywhere near as well-paid as he should be. But it also isn't fair for the self-referrers to exploit a loophole in the law and over-irradiate their patients in the name of some extra cash. But I guess life just isn't fair at all.