Last week, I had the delight of being a good doctor – one of those events that peppers my activities and keeps me going.

As part of conscientious diligence, I was following up on some low-risk pulmonary nodules, I got a CT after six months.  The nodules were stable, but the CT showed history of a PE.

To make a long story short, I detected a tiny renal cell cyst – likely the early makings of a clear cell carcinoma.

Also importantly, I kept the patient informed so that this call was not out of the blue, but something that was discussed along the way.

THAT is what the practice of medicine is.  I then turned away for my obligatory two-hour daily sifting through the alarm fatigue that is error messaging and alerts.  I sifted through the pages of “ABNORMAL A1C” flags.

The Taylorist fear of leaving people alone with their thoughts, to have spare time, is showing up like gangbusters in Medicine.  I may have saved the System $100K in catching a cancer before it became advanced and incurable; but that only pays off to my own self.

The alerts on A1C are tied into the factory QA reports, and if they are not checked off within three days, the quality office is alerted, and provides feedback.  This also goes for weekends, so Monday is chock-full of weekend warnings.

In evolutionary biology, you get what you select for.  The Medical System selects for invisible mediocrity.  It draws attention to what is obvious, and makes one too busy for the subtle and hidden.  That would not be so bad, if it were a widget factory – it is not.  The biggest cost drives are the subtle things that could be remedied.

I lost a patient several months ago to hepatocellular carcinoma.  Not only was he curable – the net cost to cure would have been a fraction of his treatment cost.  In other words, had the System saved his life, it could have made a profit.  If the System returned (some) of the profits to those who made the call and saved a life, it would be better – not whether the doctors and nurses “deserve” to make the money, or what they will spend it on.  It is a big deal to get a reward FOR saving a life.  That’s the system stating that saving a life is valuable.  What we have today says that saving a life is not worth anything.

I do make great calls and catch things, and I DO get an ego boost from that.  What would morality say about my getting financially incentivized for saving lives, as well?  Why is that a matter different from the bonuses for executives?  Aren’t they “supposed to” do what they do, as well?

When does it stop being fairness, and just become ingratitude?  If one likes one’s patients, and strives to help them – what makes it a shady deal to reward that?

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