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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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