Two surgeons were talking in a London hospital over a cafetaria lunch.
Dr. Rob was staring intently at his soup bowl as if he hoped to find Nessie in it. “I hate this new performance based bonus system” he said.
“You mean NHS’s idea of giving us a bonus for every patient who doesn’t die on the operating table?? What’s not to like about it?”? Dr. Nife asked.? “Why, is your success rate low or something?”
Dr. Rob smiled.? “Not at all, these days practically nobody dies on my operating table.”
“What, not even the complicated cases?” asked Dave. “Your surgical skills must have improved, then!”
“Oh no, I don’t even operate on any of the complicated cases!? I just refer them to other hospitals!”
“Wouldn’t it look a little..” Dr. Nife paused, “awkward if you only operated on easy cases?? Plus, I think the bonuses are better if the surgery is complicated.”
“But the surgery is always complicated” Dr. Rob grinned.? “I have mastered the technique of making routine cases seem like really complicated ones.? Like, I can look at a scan and see suspicious lesions that no one else can. ”
Dr. Nife wished he had thought of all these things.? He was suddenly rather jealous of Dr. Rob.
“Seems to me you are doing quite well then”, he said.? “Why do you hate the new bonus system then?”
Dr. Rob suddenly looked very haggard.? “I met my nemesis yesterday.? The system hit back at me”, he said.
“Why, what happened?” asked Dr. Nife, sounding very concerned.? Secretly, though, he was a little pleased.
“Normally, I look at a patient and put them in three categories,” Dr. Rob said.? “High-bonus, medium bonus and low bonus.? The low bonus patients I refer to others.”
“But this patient who came in yesterday”, he continued, “was high bonus.? Middle aged but fit woman, the case itself seemed complicated but I knew it wasn’t, and I knew this patient’s history really well so it was an easy surgery.”
“Then, what was the problem?”, Dr. Nife asked, puzzled.
“Well, she was my ex-wife’s mother “, Dr. Rob said. “We don’t, you know, get along that well.”? He paused. “Oh, who am I kidding? I dislike her intensely. She made my marriage fall apart.”
Dr. Nife thought about this.? He was a fair man.? He was a surgeon and he also had a mother in law.? “You did say it was a complicated case”, he said.? “Nobody will blame you if the surgery didn’t go well.? Of course you will lose the bonus, but what’s a little sacrifice?”
Dr. Rob laughed bitterly into his soup. “That’s what I told myself”, he said, “all the way to the operating theater. But do you remember that boat I always wanted?? The bonus from this surgery would get me to the down payment.”
“So… you saved her?” Dr. Nife couldn’t believe it.? “You had her on the operating table…and then, you saved her.”
Dr. Rob nodded to his soup bowl. “I saved her,” he said gloomily.? He looked almost pleadingly at Dr. Nife, “I wanted that boat! I need a vacation.? I have been working so hard now, seeing hundreds more patients because of this new bonus system.”
Dr. Nife could empathize. He, too, badly needed a vacation.
“And today”, Dr. Rob said, now again talking to his soup, “the ex-wife called. She wanted to meet me.”
“She wants to thank you?”
“She does, but I’ve been behind on the alimony payments, and you can be sure she’ll bring that up.” Dr. Rob laughed bitterly.? “There is no gratitude left in this world.? Let’s hope she doesn’t find out about the boat, at least.”
Dr. Nife looked into his soup now.? “At length I realize, he said, the bitterness of life.” he quoted.? “Lewis Carroll wrote that.”
Dr. Rob nodded vigorously.? “Was he a surgeon?”
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Ha! Well done, this.
Performance-based incentives for doctors is a great idea. I mean, if a little money doesn’t motivate the MD to save a few lives, what will?
loves it!
I’m guessing the life-saving rate is pretty low in the old blighty. Imagine something similar in India, would create an agitation!
Don’t even get me started on some nefarious doctors.
They’re everywhere beating the sytem.
Good one.
Good one !!
Nice one. But I really think that if the doctors need money as a motivation to save lives, then there is some serious problem with this world.
Let me get this straight. Doctors now need a monetary incentive to save lives? Like what about the Hippocratic Oath? Or should we now call it the hypocrite’s oath?
This was truly eye-opening. I’ve a friend who’s a small town MD and he was complaining about paperwork and restrictions and rules that don’t allow him to do what he’s skilled at. Looks like the medical profession is as screwed up as the legal system. Oy!
Deb Gallardo
Ok here is the deal.
Everywhere else in the world, the patient pays the doctor in the hope that he (the patient) can walk away alive after a surgery. Are you complaining about the UK government instead paying them huge wads of cash?
??!, La Vida Loca, Kavi : Thanks
km: I wonder why doctors had any motivation to save lives at all, before this. What was in it for them anyway?
maxdavinci: Two agitations actually – one from doctors in corporate hospitals – for a similar bonus. The other, from government doctors saying the bonus was too low. Arguments like “Is this all you value a life saved? Shouldn’t urban doctors get higher bonuses because people in urban areas have higher earning power ?
rads: I guess medicine, like everything else, has become a business
Amit: I agree, I share your sense of outrage.
Deb Gallardo: My thoughts exactly! I can understand doctors’ frustration with paperwork, arcane rules, with bureaucracy and insurance companies.
But why should one give them performance bonuses for saving lives? This creates a moral hazard issue. The NHS is making doctors think of patients as a number – a percentage of their success rate, or as a bonus number.
The Hippocratic Oath seems to be well and truly dead
Shefaly: Think about it, doctors will no longer try to save every patient – they will look for low hanging fruit, i.e. easy cases. Younger doctors entering the profession will not specialize in fields where the success rate is low. Hospitals will refuse to take in complicated cases.
And finally, what is the value of saving a patient? Are all patients valued equally? Or will the bonus be higher in some cases (based on complications, age, whatever)?
I would rather that patients pay their doctors, I don’t want the government deciding how much that patient’s life is worth
Nicely written but I hope reality is no where close to the story – i hope…
Lekhni
Alas, the NHS does treat all patients equally and all patients have to be treated – the good and the bad ones. So the doctor really has no choice to say no, esp if he/ she is a specialist and has had a referral… As for people not picking tougher specialisations, well, the more difficult fields are the best paid in the UK, as in the US and in India, so more fool them.
And in case of disputes, where patients are paying but die anyway, the courts put a value on the life of the dead person, a negotiated settlement which is as arbitrary as if somewhat higher than the value government may put on it.
Sorry did not mean to take away from the humorous tone of the post :-/
a very very well written interesting piece:)
keep posting
so now they can proudly say they’re in the business of saving lives.. good one
Lekhni
This new measure will also interest you.
http://news.bbc.co.uk/2/hi/health/7520705.stm
There is no such thing as easy money or a free lunch (except at one’s parents’ house!).
Lekhni
I am testing that new Gravatar advice from you. Please delete this message. Thanks.
Wow, this is brilliant, Lekhni. Chilling and funny at the same time. Hope the ex-wife kills the rest of his day!
Kamini.
prasoon: Human nature being what it is, what do you think ?
Shefaly: I agree that doctors have to treat everyone, in theory. There are ways that they can refer patients to others – for suspected other issues, for instance. For instance, lots of things, trust me, can be blamed on a suspected dental infection
Courts putting values on dead people is what I mean – courts are part of the govt. too
And hey, your gravatar seems to be working fine in my Dashboard, so I guess it will start appearing in future comments. Why it doesn’t show up already in the comments section is a mystery.
manuscrypts: Oh yes, the operating word being “business” of saving lives
Like in every business, they follow the money 
nefariousoutlook: Welcome, new commenter! Thanks for the compliments. Keep visiting:)
Kamini: The ex-wife does appear to be someone not easily swayed by emotion
She knows our doctor well!
Lekhni:
“..courts are part of the govt. too”.
No, no, they are not.
The independence of the judiciary is one of the key cornerstones of the UK and the Indian ways of structuring constitutional governance. That politicians – not government, not parliament – try to influence them in India is very sad; that the judiciary gets influenced is sadder still. But courts are meant to be and in the UK, are independent of the government.
If the government disagrees with a court judgement, e.g in case of the BAE and Serious Fraud Office case in the UK, they can apply to appeal and if they are allowed, they can appeal the decision in a higher court.
The higher court can also reject the government’s appeal as happened here:
http://www.guardian.co.uk/world/2005/dec/21/iraq.iraq
So the courts are very much _not_ the government, I am afraid..
PS: Let’s see if the Gravatar appears now. Thanks for your patience with my experimenting and thanks for the advice.
Shefaly: Come on Shefaly, surely you know what I am referring to – there are 3 branches of government, and the judiciary is just one of them
Maybe you should give it time 
Also see if the same thing happens in other blogs too..
Your gravatar still appears in my dashboard, but not in the comments section
Lekhni
Sorry for making the pedantic point. The executive branch values life (say, in case of an Amtrak accident or a National Rail accident) so I used ‘government’ as synonymous to ‘executive’ branch hence the distinction.
Of course, technically those two and the legislative comprise the government but we were discussing that specific thing hence… Sorry.
The last line was superb !.
or better go to a surgeon with good perks and bonus.
Now we might have to think twice before lying on the surgery table