You are defensive because I am certainly not talking about every specialist, or for God’s sake, you in particular.

Examples: I know certain cardiologists that will cath anything: A 90 year old with dementia in the ICU, Or the patients that get cath after cath after cath.

Or vascular surgery: Everyone knows the leg really needs to be cut off. Let’s try a fem-pop. Still gotta chop the toe, bypass the tibia. Didn’t work, lets chop the ankle and try and de-clot the popliteal. BKA next. I have seen a patient with 19 vascular surgery procedures.

Now I am not picking on these speciaties in particular. If you are a hammer, everything looks like a nail and you do what you are trained to do. I think questionable things could be found in every specialty, things that haven’t been put to test in rigorous outcome trials. Medicolegal defense certainly plays a role as well

I didn’t use the work “greedy”, you did. But would you deny that greed doesn’t exist in every case????

If you are a proceduralist enjoy things while reimbursement balance is in your favor. If you spent extra fellowship years becoming an endocrinologist or pediatric neurologist then I hope you enjoy what you do.

“It is not implausible for a specialist to make nearly a million a year performing procedures of marginal benefit and indication in factory like fashion.”

Am *I* the one who implied that specialists are greedy?? And likely dishonest?? How ELSE is one to take your comment? Please dont’ try to cover up your shoddy argument by accusing me of being defensive.

You want to talk about how to divvy up the finite pie? Fine. That’s what the thread is about and ALL of us are willing to participate in that exchange of ideas. Leave your prejudices at home unless you’re willing to stand by your assertions and back them up with facts.

And the poor providers are being starved or “killed” by the costs of doing business.

Here in the US, its common for a specialist to make 3-4 times more money than a PCP. In CAnada, that ratio is much smaller, specialists make maybe 70% more than PMDs at MOST.

Canada’s ratio is much better IMHO. Yes, specialists spend longer in training and should get paid more, but not 5 times more than a primary care doc.

I worked in an interventional radiology lab where the fellows were getting starting offers greater tahn 700k.

You are actually quite distressed and defensive. I never said specialists were dishonest. You implied it.

I never said it was easy to make a million dollars. Again, you put words in my mouth. However it is possible in several specialties with a lot of hard work and high volume procedures.

The truth is 3rd party payment is skewed towards tertiary care rather than primary care. We could argue about where the balance should be all day.

Medicare pay ZERO for a physical and hundreds for an NST. That needs to change.

Killing the golden geese of colonoscopy, EGD, NST, cath and stent would go a LONG way toward improving preventive medicine.

I AM a specialist. I don’t make a million dollars. No, I am not envious of those who do. But I make over twice what my spouse does in primary care with less hours. My spouses primary specialty was 4 years. Mine was 6. Should that extra two years be worth the millions extra over a career. I don’t think so. You think yourself way too important

As long as primary care physicians keep playing the politics of envy, you’ll get nowhere.

I’m not naive in the least about the costs. But even at defensive medicine’s most generous estimates (since there is no way to accurately determine it), it still amounts to less than 10% of all spending. And, given that most physicians appear to have little understanding of what their actual risk is, a little education could go a long way to removing that cost.

Other than that, we agree. So how does it become legislation?

I understand the power of the AARP. I am trying to make the same point you are. No one has the political will or power to place any kind of attack or limits on entitlements. It is a statement of “why” and not “how” to fix it. Until the country is completely bankrupt we won’t have the guts.

Of course you still remain naive about malpractice and costs. I spend easily 7 figures a year with the stroke of a pen to “rule out” that extra 1% that I can’t do on clinical judgement alone. Multiply that by every doctor and you are talking about a lot of savings to be had.

There is plenty of money spent on healthcare. A little redistribution could save primary care. It is not implausible for a specialist to make nearly a million a year performing procedures of marginal benefit and indication in factory like fashion. The same doc of similar skill, talent, brains that went to the same school but chose primary care is really struggling to make 100k. That is fine if people want to pay the specialist out of their own pocket for their services but it is not right for government payers to create this chasm.