It’s always nice to get something for nothing. There’s usually a catch, however, or at least a trade-off, a quid pro quo. So, it’s not really free. It’s a transaction with both sides realizing something of value. Perhaps not equal value, but value. It’s a situation where no one feels taken advantage of, or used. Because if they do end up feeling used, that might be the last transaction. It wouldn’t encourage an ongoing relationship. 

If you’re in a business where there needs to be repeat customers, you might want to be careful not to push your customer/partner too far. They might leave, despite any perceived leverage or higher obligation that exists, which would likely be bad for both of you. 

This entire line of thought came up as I struggled yet again, and on an almost daily basis, with the challenges of providing consulting services to our medical center affiliate. They expect almost instantaneous response to all requests—from patient consults, trauma and the ER to emergent surgery. They pay for nothing. No retainer, no click fees, no on-call payments. We can bill the patient for the services but in an inner-city location the percent of patients paying nothing is significant. We’re certainly not covering the costs to provide 24/7 response across all subspecialties. They assume we will have or will engage the clinical staff to respond to their needs, even when those needs grow with no consideration or consultation with us. 

When I’ve asked about funding to help support the necessary resources, I’m told we have to do this because we are on the medical staff, and it’s an obligation. Historically, that’s the way it worked. You needed to be on the hospital staff to practice medicine even if you didn’t use their facilities. The insurance companies demanded it. And, the ability to be part of a larger medical staff led to relationships that resulted in referrals that kept your practice alive. 

If this is starting to sound like a page out of the history books, it’s because it is. Medical care has moved largely outside of the medical center and into offices and surgicenters, all encouraged by patients and insurers.

So out we went, to fend for ourselves in many ways. What benefit remained by staying affiliated? The ‘prestige’ of belonging to a famous hospital? No one believes that anymore. It’s the remnant of an obligation most of us felt when we became doctors. We wanted to help those in need, no matter their circumstances. The Hippocratic oath. Everyone chipping in together. Conceptually we still believe that, but others in the health-care system take advantage of it. 

Individual physicians have taken a huge beating in reimbursement over the years. The ‘gravy’ is gone, and every minute we spend doing something unpaid is more painful. The ability to be gracious about our time and resources has been stripped away. Still, someone needs to attend to those in need of care. But who? And with what monies? 

To be fair, health systems are also very strained. Many have gone out of business, merged, been bought, sold and/or have been traded like a commodity. They’re on the brink as well. And this has led to a more predatory attitude from larger players. Anyone not fully inside their walled garden is a resource to be used, not supported. Not that those inside are protected either. It’s harsh either way. 

So we’re back to trying to find a relationship that is equitable enough that no one walks away, that no one is fatally hurt. It’s not really a negotiation these days. It’s a game of chicken. Or rather a contest between David and Goliath. Goliath expects something for nothing, and David is out of ammunition. 

Dr. Blecher is an attending surgeon at Wills Eye Hospital.