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04/25/2024 Allen M. Jacobs, DPM
The Future of Podiatry (Robert Kornfeld, DPM)
The commentary of Dr. Kornfeld with regard to the need for profitability in maintaining practice survival is appreciated. He has long represented a particular view on non-insurance based patient care which has been successful for himself and others. Medicine, including podiatry, differs from other "ordinary businesses". The practice of medicine is a calling, with a duty to care for patients as the foundation upon which all other business concerns emanate.
The practice of medicine is based upon the four cornerstones of medical ethics; beneficence, non- maleficience, autonomy, and justice. "For-profit first" thinking is the reason we are burdened with pre-authorizations, insurance payment reductions for services rendered, and denials for services. Money first thinking denies access to healthcare, treats healthcare as a commodity rather than a right, and creates a conflict between doctor and patient.
The American College of Physicians in a policy paper published September 7, 2021 noted that profit motive in medicine has contributed to a bloated, complex, and fragmented health care system. Personal enrichment should never represent the primary determinant of decision making in patient care. In my opinion, students and residents witness profit-first unethical behaviors which not only go unpunished, but are rewarded. They see that doctors are a generally autonomous group who self-discipline, meaning no discipline.
Students and residents therefore assume unethical behaviors as being acceptable and "normal", and profit-first thinking proliferates through the profession. This continues as post-graduate education allows industry driven unproven therapies to be presented at our CME programs, again a reaffirmation that profit-first behavior is the acceptable norm. Doctors are entitled to a fair reimbursement for their services. However, in conducting the business of podiatry patient well- being is always the priority.
In medicine, the golden rule, do unto others that which you would have done to yourself "prevails. Alternatively, the platinum rule; " do not do to others that which you would not do to yourself ". There is nothing immoral to making money in a legitimate manner. In many ways it is admirable to do so, when accomplished in an ethical manner. The people in medicine that I personally admire the most are those who have been dedicated educators, dedicated political leaders, and not those who simply accumulated wealth at any cost to patients, profession or society.
It is for these reasons that I believe legitimate business education be incorporated into the education of our students and residents.
Allen M. Jacobs, DPM, St. Louis, MO
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05/01/2024 Allen M. Jacobs, DPM
The Future of Podiatry (Robert Kornfeld, DPM)
"Profit first decision making" in medicine has nothing to do with direct pay medical practice. Many plastic surgeons, dentists, veterinarians, concierge practices are but a few examples of those who engage in direct pay medical practice. Dr. Kornfeld has presented reasonable and cogent arguments to endorse the direct pay model of practice. There is no more greed inherent to the direct pay model than exist in the traditional billing of third parties for medical care rendered. Your misinterpretation of the commentary which I made on this subject is the suggestion of a need for you to reexamination your own motivation for the practice of podiatry. The concept of avarice appeared in your mind, not mine. Dr. Kornfeld's thoughts and philosophy on direct pay are well taken and acknowledged as such.
Regardless of the payment model, ethical behavior and unethical behavior are what they are. Unnecessary surgery, the irrational use of expensive wound care products, the choice of non- generic medications with no proven advantage to generic medications, the suggestion that all postural complaints require functional orthotics, are a small representation of profit first thinking.
Direct pay or not, medical decision making should be founded upon what is needed and what is in the best interest of a patient. How much and in what manner a patient is asked to pay for such consideration is a different manner. Direct pay or not, any medical decision should be such to attempt to limit potential harm to a patient. These are two of the basic tenets of medical ethics. Direct pay medical practice and ethical medical practice are not mutually exclusive. Conversely, traditional medical care billing has clearly served as the terrain in which fraud and abuse have proliferated.
To repeat the words of Sir William Osler: "you have entered this profession to make a living. But in doing so this must be a secondary consideration". When I make rounds with the residents, I point out to them that they are likely young and healthy. It is not until they are ill, lying in a hospital bed, and dependent upon others for limb or life-saving decision making, that they can fully appreciate the power and position they hold as a healthcare provider. That patient desires and deserves a first consideration of the best care indicated for their health, not the most profitable to the health care provider. I suggest that until you are on the receiving end of serious medical care, this concept of your ethical responsibility is not fully appreciated.
Allen M. Jacobs, DPM, St. Louis, MO
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