"Judging by your extraordinary fee it doesn't look like you are interested in doing much about it." - Mrs C

“Part of the problem with the mental health system is the lack of availability to people of limited means. Judging by your extraordinary fee it doesn't look like you are interested in doing much about it." - Mrs C

Dear Mrs C,

I can understand why you may feel this way and I appreciate your openly expressing your views with me. In some cases I do slide my fee, when I believe there is a good fit between the patient and myself, and when I believe that the patient needs the service I offer, even though they cannot afford my full fee. But I do not bargain with people or offer them a lower fee just to get them to come in for the sake of filling my clinic, because to do so would not be congruent with my values. Some people do not want to pay out of pocket for health care and certainly everyone has the right to choose what they can afford based on what is available. 
I too feel your frustration with the current health care system, which is why I have “abandoned ship” and will not participate in a degrading and dehumanizing corporate machine that puts profit over people. To understand why I charge as much as I do, it may help to take a look at the context of the service I offer and why I feel my fees are within range of what is fair and appropriate, and in keeping with the community standard.

When you or anyone decides to make a purchase of any good, service or item, whether it be a set of tires, an article of clothing, or a trip to the movies, you make a conscious or unconscious cost benefit analysis. “What is this worth to me?” and “How easily could I find the same product/ service/ experience for a better price with the same level of quality/ utility/ enjoyment?”.  “How badly do I need this, can I do without it, and what other things do I need to buy with the money I have?”

These are all very personal decisions and what may be worth a lot to one person may be worth nothing at all to someone else. A bald man does not invest in a curling iron for example. Your concerns have merit, and I respectfully agree with some but not all what you said.  No one I know, whether patient, doctor, or hospital administrator thinks the health care system we are in is working as it should. Our current system has nothing to do with “health” or “care” and is so disorganized it can hardly be called a “system”.

The only people who truly benefit from the current “system” in place as we know it are large for-profit corporate entities, the people at the very top of those corporate ladders, and their shareholders.  There are many myths about doctors and greed and the motivation of doctors in general. I have met many an arrogant, embittered, and insensitive doctor who did not appear to give a rats ass about his or her patients. It is easy to loose sight of what brought us into medicine in the first place, and many of us now feel so beaten down by our jobs that we hate our lives and our original decision to go to medical school seems in retrospect to be a sort of farce.

I have made a personal commitment to myself to not allow myself to become an embittered doctor and in order to serve patients with joy, I find I need to create a balanced life for myself that involves having enough time to spend with my family, to be able to relax outdoors, and to be able to afford nutritious food to help me think and feel my best. To do it, I decided to live a more modest lifestyle, to purchase fewer new items for myself and my family, to be contented with a more plain and simple material existence because doing so affords me to work at a relaxed pace and get more joy from personal interactions from each patient I care for as a unique and valuable human being.

I may eventually pay off my student loan debt or I may not. Whether I die as an old lady who paid off her student loans or as one who did not, in either case I will have known the joy of making a difference in the lives I have touched.

To understand why I have decided to charge what I do, it may help you if I explain that my family and I live in a house that isn't fancy, that the cars my husband and I drive are both over 12 years old, that our daughter was raised often with used or recycled clothing and that we do not take expensive vacations or lead an expensive lifestyle. Together my husband and I currently owe over $300,000.00 in student loan debt and this may or may not get paid off before we are both dead.

On average, my work week as a medical student, resident and employed doctor required on average 60 to 80 hours of work per week, sometimes more. This included being on call throughout the night, multiple nights per week, to respond to medical crises and patient needs. During these years of training, I missed approximately half of all weekends and holidays with my family, because I was required to work. It was not a choice, it was a requirement of my training and I gladly made these sacrifices because this brought me closer to my goals of being able to serve patients upon graduation.

I only ask that you consider your statement in the context of the situation as it really is. I feel comfortable charging the fees that I do because the the level of skill I offer and the amount of effort and personal sacrifice I have made and my family has made in order to be able to offer the expertise that I bring to my work with patients. I have invested 18 years and over $300,000 and I continue to struggle with crushing student loans which is the norm for doctors rather than the exception.

I also missed many of my growing child’s events and milestones due to the demands of my training. While other young adults were earning money and spending time with their families, I was in the medical student library or working at all hours in the hospitals, caring for sick patients.  I did not do these things because I wanted to get rich.

I did these things in order to be able to better serve my patients, to not miss a diagnosis or go home before doing everything possible to care for the vulnerable individuals in my care. I spent more than 16 years altogether as an undergraduate college student, in graduate school,  medical school, and in psychiatry residency.  If I wanted merely to make money, there are many easier, quicker, and simpler ways to do it.

By contrast, an attorney who easily charges what I do or more, who never accepts insurance and who has had less than half the number of years of training that I have had would not think twice when charging the same rate. People pay for what is important to them, for what they think they need and for what they believe is worth the money they pay.

If the shoe were on the other foot, if I were for example to tell you (which I am sure is not the case) that you are paid far more than what you are worth, how then, Mrs C, would you be likely to feel? I personally feel hurt by your comment but I am trying to understand the context of why you say this and I’m sure your meaning is largely based on a perception that is true in some aspects but not true in others.

I am sorry that you do not feel that my skills are worth the fees that I charge, and to you, I am sure, these most certainly would not be a worthwhile exchange. And yet I feel safe and confident that what I have to offer is worth every bit of the fees that I charge to those people who choose to make use of my services. The patients who do come to see me have all been what you might call people of fairly average means, certainly none of them are wealthy, and yet all of them have expressed authentic gratitude to me and appear to feel very happy with the work that we do together when they are in my office.

I feel extraordinarily lucky to have found the profession that I have, which allows me to experience the precious intimacy that develops in a relationship of profound trust and mutual respect between two human beings who happen to be in a doctor patient relationship with one another. I honestly feel that I was called to my profession by something bigger and wiser than myself, and I perceive that this bigger and wiser someone presents to me the patients who most need my help so that I can have the honor of caring for these precious human souls, who are, after all, the children of the very Being who first breathed life into us and who will eventually carry each one of us safely home.

That being said, I do respect your right as a consumer to make choices that are rational for you and your own needs.  I thank you again for having the courage to come to me directly with your concerns and I appreciate your time in letting me address these matters with you. I wish you luck in your search for appropriate care that meets your needs and your budget. Have a good week and thank you for sharing your thoughts with me. 


Lisa E Goldman MD