It was the best of times, it was the worst of times, it was the age where arrogance and duplicity made you rich and selflessness and honesty made you poor.

His name is Rick. He didn’t pretend or care to be a good student and with barely a B average in college he didn't bother applying to any American medical schools. But with the aid of his parents, and a nice donation to a foreign medical school, he was granted admission to and graduated, nearly at the bottom of his class. Three years later he finished his medical residency at a small community hospital, that was happy to have any intern or resident program ( bodies to help care for doctor’s patients), and after a few tries at the medical boards became a Board Certified General Practitioner.

What he didn't know about the theory or practice of medicine was shortly made up for by his astute business know how; this guy knew how to swim with the sharks! He joined every insurance plan, every HMO, placed ads in the Yellow Pages and even in those coupon savers we all get in the mail. He proclaimed himself an expert in heart and endocrine diseases and within two years built himself a sizeable practice. He purchased a small building and built himself an office, and, for those who wanted his consults (and there was an abundance of them) he rented small rooms for more dollars/square foot than was offered on the Ginza or Fifth Avenue. From just his rental fees alone he earned well over $100,000 per year. He allowed drug reps to see him at his office and even used many of their prescription drugs, as long as they made him a paid speaker for the company, brought lunch for him and his staff, and paid him handsomely for attending the dinners they gave. Just because he hardly knew much medicine did not matter; after all, he had all those renters that he promised to call on anyway and so if you came to his office with a cough you were sent to the lung doctor, with a stomach ache, to the gastroenterologist, a zit meant you would see the dermatologist and so on.

Although he hardly examined his patients he allowed them to see any consultant they wished to see (whether they really needed to or not), he disabled anyone who asked to be disabled, and by means of his charm, most of his working class clients found him endearing. Besides, he accepted their insurance and except for a small co-pay patients really had little out-of-pocket expense.

After two years he became a very affluent and influential physician. He bought himself a new Porche, Italian suits, and put a down payment on a two million dollar home. It was truly the best of times for Rick.

His name is Steve. He graduated Summa Cum Laude from a highly competitive college and was admitted to a private, highly ranked, and very costly medical school. He graduated from medical school with many honors and $300,000 dollars in debt. He had always dreamed of being a general doctor in a practice in which patients became almost an extended member of his family. And so, after finishing his residency in a top-notch university he opened his office in an urban community. Steve worked very hard building a practice and did so by word of mouth, by taking on patients who had been recommended to him by other satisfied patients. He saw patients in his office almost every day and consulted at the local hospital where he had trained and where he now volunteered to teach other residents.

After two years he built a nice sized practice, and an excellent reputation, but he was unable to save much money; his fees were as little as $30 dollars an office visit; his school loan payments over $3,000 per month; and his malpractice and other fees meant he had barely enough money to run his practice and to care for his family. He drove the same ten year old Honda he had driven to med school and lived in a small apartment.

Steve ordered tests and consults on patients only when necessary and made sure that his patients saw only the best doctors. While he probably saved the insurers millions of dollars – compared to the doctors like Rick- his reward, like all doctors, was a 5% cut in his payments the next year. People like Rick just ordered more tests, found more to rent office space from him in cozy deals, and so at the end of the day Rick profited even more while Steve wondered how he would survive..

Steve loved caring for his patients but began to wonder about his job, which involved dealing with the insurance companies, working for peanuts, and watching some of the worst doctors rape the healthcare system that he both idealized and wished to make better. Rick loved the money, the respect he received from local hospitals who preferred doctors like Rick, who could fill their beds, than Steve who had a smaller practice and didn’t admit patients that he could easily care for in his office.

The biggest loser, the lowest form of scum, the snake oil salesman is profiting from our healthcare system. The caring and intelligent physician is being profited by our healthcare system.

About the author: Evan S. Levine, MD FACC, is Director of the Cardiovascular Center at Saint Joseph’s Hospital and a Clinical Assistant Professor of Medicine at Montefiore Medical Center – Albert Einstein College of Medicine. He is also the author of the book “What Your Doctor Won’t (or can’t) Tell You.” He lives in Connecticut with his wife and children.