I am a newly minted surgical specialist, less than one year into practice. Residency was no walk in the park, but the clinical experience, along with hours of studying, reading papers, and reviewing practice guidelines, undoubtedly gave me the tools to practice modern, evidence-based medicine. As residency came to a close and the light at the end of the tunnel grew bigger and brighter, my excitement to move on to the next stage of my career was building.

I decided that I would go into private practice, and I had a choice to make between two positions at large single-specialty groups. I provided professional references to both. A few weeks later, my attending, a former resident who then served as my residency mentor, waved me over to his office after clinic.

“So, I got a couple of calls from the practices you interviewed at.”

“Oh yeah? And …?”

“Well, one of them asked me what kind of person you are and how capable you are in the operating room.”

He paused for a moment.

“But, when I talked to the other one, the first thing they asked me was if you can do [insert lucrative in-office procedure here]. I tried to tell them how you were a good resident, how you can do a wide variety of challenging surgical cases, and how you were well-liked by your colleagues. They weren’t really interested.” He scoffed and shrugged.

I was not naive. I knew that the financial side of medicine was not mutually exclusive from patient care decisions. We are, after all, in a fee-for-service system, and such a system naturally encourages surgeons to have higher volume practices and perform the procedures that are most lucrative. Private, physician-owned groups are frequently structured with a so-called “eat what you kill” approach, an inherently predatory phrase that describes a system in which physicians are paid for what they do. The more you do, the more you make. It’s as simple as that. But still, to see it on display so plainly when interviewing for a job was a bit of an eye-opener.

Eventually, I was offered both positions. I had a better feeling about one, but the decision was cemented after talking to a physician from the practice I was leaning toward. In response to my inquires about the difference between the two groups, he responded with a thinly veiled but telling critique of his competitor. “You know, at the end of the day, the patients should always come first. And when you put your head down on your pillow at night, you have to decide whether you are doing something just.” He looked down for a moment and then looked back up at me and added: “I’m confident that you’ll make the right choice.” Soon after, I took a lower salary and joined the group that I felt to be more in line with my values. I was going to do my best not to let financial pressures dictate my practice.

It has now been one year since I finished residency, and as time goes on, I’m getting more of a sense of the scope of this problem. We’ve heard in the media for years about doctors performing “unnecessary procedures.” Some are so egregious that they make the evening news. A surgeon implanting pacemakers that patients don’t need. An oncologist diagnosing and treating patients with chemotherapy who don’t have cancer. But, what I don’t see in the news are those smaller, more subtle, and, I believe, far more common violations of patient trust. My colleagues and I often see patients for second opinions who come from other surgeons in the large, metropolitan city in which I practice. The story is frequently the same. “I went to ‘Doctor So and So,’ and they offered me an in-office procedure.” No history. No physical exam. No medical management. No discussion of the treatment options and risks. Just a lucrative surgical procedure, and not even the one that would actually help the patient. A shorter, easier, minimally invasive, nearly painless procedure, all for the low, low price of three, five, ten, or twenty thousand dollars. You can almost smell the leather on that new Range Rover. My colleagues and I whisper about this deplorable behavior behind closed doors but do not disclose our true feelings to the patient. They remain in the dark.

Is it a few bad apples or is it a systemic problem? It’s hard to say. All I know is that this behavior is probably more prevalent than we care to admit. Perhaps even examining our own actions may show us the unfortunate truth that we who see ourselves as righteous are guilty of putting too much weight on finances at times. The longer this goes unchecked, the more patients are going to be harmed (physically or financially), or at the very least, not helped in the way they need. Don’t get me wrong. We worked our tails off for years to get here, and I want to be compensated for my efforts just as much as the next physician, but not at the expense of the trust that the patients put in us to operate in their best interests. We took an oath, and violations of that oath, whether our own or our colleagues, reflect negatively on all of us and lead to distrust.

Like many large scale problems, the solution is not simple. Should board recertification or medical license renewal be contingent upon a peer review of our medical decision making and surgical cases? Should the entire fee for service system be scrapped? Are we morally obligated to be whistleblowers against offending colleagues within our community? Some of us would shudder at the thought of these suggestions, or perhaps even fiercely oppose them. I don’t have the answer. But I, like you, took an oath, and thus I feel compelled to, at the very least, speak up.

The author is an anonymous physician.

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