Kevin, M.D. - Medical Weblog

Powerless? Hardly. Look at the after-expense compensation figures again. As long as the providers remain at the top and as long as the CME colludes with the states to control supply, the providers will still be in power. Now, if Hillary gets elected and breaks the back of the AMA, then the appearance of being powerless will become an actuality.
 

Kevin, I've definitely been hearing about this disillusionment from more than a few corners in all specialties. (One of the most intense rants of frustration I've heard in recent weeks was from a dermatologist-- yes, you read that right-- who'd seen her own malpractice fees go skyward with compensation dropping accordingly.)

Even weirder-- at least from my own perspective-- a good number of my ex-colleagues in the healthcare field (docs as well as nurses and technicians) are getting all kinds of language tapes in I guess French, Dutch and German and emigrating to European countries on the Continent. (They're definitely *not* going to the UK or to Australia, which are as bad or worse than the USA in all these departments, from what I've heard.)

I always thought this was off the table due to the more socialized medicine they had there on the Continent, but apparently the reimbursement system is more complex than we've led to believe-- at least in some Euro countries-- with decent incentivization and salary rewards for accomplished physicians in certain fields in particular.

And in the main Euro countries at least-- especially France, Germany and Spain, among others-- you don't have any of this ridiculous medical malpractice stupidity that's bankrupting our system with CYA costs and ruining the careers of excellent physicians due to unavoidable bad outcomes rather than actual malpractice at all.

Apparently on the European Continent, patients with adverse outcomes receive some kind of financial compensation-- a decent amount AFAIK-- regardless of whether it was actual malpractice or just one of those outcomes that was too tough to avoid. (Makes sense from a cost perspective-- how dumb is the system used in the USA/UK/Australia, where a bunch of jurors from off the street, w/o specialized training, is asked to make incredibly detailed judgments on ultra-complicated medical cases that even docs with a decade of training have trouble figuring out?)

Where malpractice has clearly occurred, those countries' medical boards use it as an opportunity for more intensive training and education, not the punitive nonsense we have in the USA. But the key is that the patient and the doctor aren't adversaries as they are here in the States.

So in the Continental European countries, the docs and the patients-- to my surprise-- seem to have a much less costly, much more efficient, much friendlier (for *both* sides) and in general much less punitive system that emphasizes cooperation and rapid incorporation of medical advances better than we do in the States. And, at least in places like France, Germany, Spain, apparently also Italy, Austria and other countries with somewhat mixed systems, also provides payment incentives to docs especially in much-needed specialties.

Again, places like Britain and Australia categorically seem to be non-options since they've regrettably taken the lead of the USA in these departments. (The United Kingdom seems to have the worst of both worlds-- the med mal nonsense of the USA combined with the worst of socialized medicine.)

Thus, there seems to be a little cottage industry brewing in language-learning software and CD's for languages like French, German, Spanish, Italian, Portuguese and Dutch especially.

Even the retraining and licensure aren't as tough as I'd thought they'd be-- especially if you have an MD from the United States, they practically crave you over there and will get you up and running within a couple years (with paid "transitional residency" years as needed-- much easier residency than in the USA), provided that you can demonstrate language proficiency and pass a basic licensing exam there.

There's also the added draw of earning a salary in Euros (huge benefit vs. dollars), plus being able to send your kids to high-quality schools *and* universities *and* professional schools essentially free of charge. As opposed to the USA, where you'll go bankrupt sending your kids to school.

Go figure-- never thought I'd read an article on US-trained professionals being driven overseas like this. But I guess, when enough crap hits the fan at once, people tend to vote with their feet.
 

I sure somethng just like this was written 32 years ago--it certainly could have. But we all putter along. For every doctor who leaves the US, there will be at least 100 more wanting in to take his place.


The AMA was broken more than 32 years ago. The loss of the Medicare fight followed by the antitrust ruling was then end. It didn't need to be, but it was.

All that is said in the original post is true, but it ignores some other important truths:

1. While organized medicine is nearly powerless, individual physicians are not. We still have the freedom to accept or reject participation in the various insurance programs, including the government ones.

2. A great many physicians do indeed overcharge without compunction. A colleage recently went to a urologist for an office consult of less than 10 minutes. The fee was $275. No procedure. The many suffer for the sins of the few. Can you blame people for trying to empower someone to protect them from that kind of greed?

3. While the tort system is fouled up, there actually is indeed a great deal of medical malpractice. There is a remarkable amount of really sloppy sloppy care going on. The physicians providing it are usually members in good standing of their specialty societies. This is one area where organized medicine is not powerless, but has simply choosen to not act--effective and agressive self-regulation of quality of care.

4. The NP's and PA's are presumably working under a physicians supervision. it is physicians who cooperate with turning this into a farcical charade in many cases. What are we doing about that ourselves?
 

I don't think I've ever felt powerless as an individual physician. As part of organized medicine, yes, to some degree, but living and practicing in Texas has made that easier to accept as the combination of higher reimbursements, lower malpractice, and a low cost of living have made the annoyances of organized medicine's failing more an issue of the cost of doing business for me.

I see plenty of folks who have it worse anyway (like airline employees who have seen their labor unions practically broken in the last several years). One one level I do agree what was posted but on another level I just don't feel it. And I've never felt myself to be any sort of polyanna type who see's medicine with the wide-eyes of a groupie.

Ten years practicing medicine has dealt me quite a few annoyances and hassles and I'd be lying if I said I never felt burnt out.

But something still gets me up in the morning to go to work and tackle runny noses, people with stressed out lives, and diabetes among other things. After ten years I think that the power of medicine lies not with organizations like the AMA or even the state medical boards, IPAs or hospital networks- it exists in every exam room when a physician is able to make a connection with a patient to form a therapeutic team. Okay, sure some patients bring more to the table and are more willing to better themselves (which naturally makes our jobs easier), but there's something that I have often felt is transcendent in the patient-doctor relationship that has always (or hopefully will stay) independent of outside hassles like HMOs, malpractices, and the antics of Big Pharma.

The battle is striking the balance between appreciating what it is we do for folks while maintaining an awareness of the external factors that can affect out jobs, even peripherally.
 

Maybe the Urologist gave good advice to his patient, saved him an unneeded surgery, or allowed him to sleep through the night, or ordered the correct test to figure out a vexing problem? Maybe $275 was a bargain for the value to the patient's life?
 

undoubtedly the urologist was reimbursed by the patient's insurance, probably about half of what he "billed".

many doctors DON'T EVEN KNOW what their fee schedule is - it is set by an outside billing agency that makes a particular fee high enough to catch every insurer's "maximum allowable contracted fee".

so the $275 number is irrelevant, and such a comment shows why medicine is a frustating field with lots of third parties, misconceptions from clueless patients about wealth, and physicians left holding the bag when patients are pissed, when in fact we have no control over our own fees.

imagine if you invested $300,000, took a hundred exams (& aced them) over 12 years, all to open a grocery store - then the government sets your prices below your cost of doing business!

as medical care becomes even more fragmented with the death of primary care, patients & insurers won't have physicians to blame for the crisis as much, as physicians will become scarce.
 

I personally can't wait for the medical meltdown. It can't come fast enough as it is the ONLY way our problems, along with patient access to quality care, will be recognized and actually fixed. Only then, as a group, union if you wish, will we be able to negotiate from a position of power.
 

Never having been a member of the AMA, I've never had any positive expectations of them.
Personally, I prefer an attitude of constant, unremitting pessimism.

I used to wonder how I would decide to quit practicing medicine, since all in all it was so much fun. Now, I can clearly foresee the day when I will retire, even though it's not any time soon (at least I don't think so).

I also expect that there will some day be some kind of meltdown/shakeout/crisis, but it's not likely to be fun for anyone, nor do I anticipate that it will lead to something better.
 

Memo to All:

Whine, whine, whine. Where is it written that life is easy? Personally, I relish a good fight when I am in the right.

Get off your knees and fight with all your might against the ultra-greedy crooked John Edwards trial lawyer wing of the democrats, Bush style bipartisan or Hillary "solutions" to health care, and the Enron-type insurer monopolies.
 

Don't you think you ought to have a good solution ready before you get too deep into your good fight? Because you'll lose the war even if you win the battle.
 

To Happyman, About my anon 7:55am comment re: the urology charge I postulated was appropriate. I am a physician and I read the comment as a cash price. Apologies for any confusion. I agree we work at a mysterious discount that most do not appreciate.
BTW, keep up the thoughtful comments but are you really happy? You must be retired. An EYEMD
 

How much should medicine cost? How much are doctors allowed to make? Which doctors should make more than others?

Anon 12:23 says doctors are whining because of our "after expense compensation". If CEO's make millions or billions, and a doctor works as hard or harder, at what point should we be allowed to whine? Can we only whine once we are losing money? Is 100K the magic number for you? Should doctors just be grateful to see patients at all and expect to do it for free?

Get a hold of your life. You can't ask some of the most intelligent members of society to take a job and then dictate we make as much as a typist or “life coach” (check out http://www.msnbc.msn.com/id/14247570/ if you dont believe me)
 

Yet, again, I am reminded why I quit clinical practice. From neurosurgery, at age 37. I went into full time research, and my life is infinitely better.

The battle for phyisicans rights and respect has been lost. The lawyers, politicians and insurance companies have won. You just might not realize it- yet.

My solemn advice for any physician under the age of 45: get out now while you can still build a new career. For those over 45: sink every penny into your retirement plan.

Many of the friends I trained with are either already out or are looking for their ticket. Unfortunately it will probably be another ten years before the extent of this disaster is fully realized.
 

To anonymous from the previous posting who has left clinical medicine and is now happier in research.. I need some pearls of wisdom from you...please contact me at npando@pandoassociates.com
 

"Meanwhile, organized medicine appears powerless, sitting on the sidelines."

It's not so much that organized medicine is "powerless" as it has decided not to exercise its power in ways that might avert the coming meltdown (which is pretty much already here).

The AMA and state medical societies will pay and pay dearly for failing to truly represent "the little guys" in medicine (which is most of us in primary care).

At some point people get tired of paying the expensive dues only to get a whole lot of nothing. I know I did.
 

"I went into full time research, and my life is infinitely better"

If you're paid by industry, I'm sure your life is much better. However, if you do academic-style research in a University and are dependent for your salary on "soft money" from the NIH, your life msy be easy now, but when you can't get a grant, and the mortgage is due, you'll be crying in your beer.

One of the best things about medicine, is the "hard money"!
 

EYEMD-

I am not yet retired (perhaps 20 years away) but am actively pursuing other avenues of income. If any are fruitful, I will have little regret in leaving medicine.

And i AM happy generally in life, just overall not with what has become of medicine. This however, does not impact the treatment I provide my patients, and theirs & colleagues' opinions of me personally & professionally are good, I think.
 

Koko,

I am paid by industry, so I don't need to worry about NIH grants. On the contrary, there is tons of private and public money looking to invest in biotechnology. To be honest, I did take a slight pay cut whent I left clinical practice, but I still make a very good living: for me it was worth it.

Besides, the sheer joy of not carrying a pager is worth $$$ to me and my family.
 

"many doctors DON'T EVEN KNOW what their fee schedule is - it is set by an outside billing agency that makes a particular fee high enough to catch every insurer's "maximum allowable contracted fee"."

They are responsible for knowing and for setting it at an appropriate level. It is this very attittude and practice that digs the hole deeper. The uninsured patient or patient with traditional indemnity then finds that the only way to get a reasonable charge is to get in a restrictive insurance plan. So the doc then gripes about the problem he created.

BTW, the person in question is unisured and is unisurable because of a chronic preexisting condition. Working and producing income and able and willing to pay fair fees for care, but now another recruit for the political forces arrayed against what is left of physician independence because of a piggy $1650/hour professional fee.
 

Calling all doctors...

Hello All,

I am co-producing a documentary with a colleague of mine, Dr. Ryan Flesher, board certified in emergency medicine. I am a licensed Social Worker from the healthcare industry who never fully understood, until recently, the impact and impossible demands made upon our doctors.

I now straddle two worlds: a view from the patient’s side and a view from the doctor’s side. It has been both an enlightening and disheartening experience. After all that I have learned from my research for this film - clearly, it is time that we elicit compassion for our physicians.

The physicians’ view is rarely talked about. If I had not researched, interviewed or discovered what doctors are experiencing, I would never have known. The film’s producer, Dr. Flesher is discouraged by the business and politice, not the art, of medicine for a myriad of reasons, all of which we will be highlighting in our documentary. He could quietly walk away from medicine, leave it all behind. But he is not doing that. Instead, he is doing something purposeful with his experience by creating a film that will give voice to physicians on what needs to be said. This film is a first of its kind.

We have traveled extensively across the United States filming physician wellness seminars, career counselors for doctors, physicians who love medicine, others who feel beaten down by it. We have met eager med students, medical school professors, healthcare gurus, mental health experts, MD’s in their retirement and otherwise.

The common misconception is that doctors choose medicine for monetary reasons. And, yet, our research shows, and experts concur, that on a fundamental level, doctors choose medicine for altruistic reasons of wanting to help people, heal them.

Our data indicates that 60% of physicians are suffering from low morale and that medicine is a fragmented brotherhood. Where is it written that doctors must take a vow of silence when treated unfairly? Medicine is fraught with regulations and bureaucracy all in the name of achieving perfection and, yet, by virtue of the fact that we are human, how can perfection possibly be achieved? Furthermore, medicine is not black and white, but an inexact science. Perhaps most disturbing of all, why are capable, caring healthcare professionals the only ones who are handcuffed to the threat of malpractice every patient of every day?

Dr. Flesher and I have put our careers on the line for the sake of this documentary. Why? Because taking care of those whom we depend upon to take care of us is that critical. It is an aspect of the healthcare crisis that has yet to be addressed. What we know about change is that it doesn’t happen by silently wishing and wanting. Change takes action, courage.

We have a number of people participating in this documentary. As filmmakers, however, we do not rule out that maybe your story is the one that needs to be heard.

We look forward to talking with you.

Sincerely,
Nancy Pando, LICSW, Producer
Crash Cart Productions
npando@pandoassociates.com
www.crashcartproductions.com
781.828.8955
 

"Perhaps most disturbing of all, why are capable, caring healthcare professionals the only ones who are handcuffed to the threat of malpractice every patient of every day?"

They're not.
 

Well, I'm not so sure about the medical profession but in some other very high-techie wonkie propeller head-ish professions there has been some voting with the feet.

It's been all kind of feet-voting- mostly from one state to another I'd imagine, but there have been some North American tech pros who are, I guess, following in their ancestors' footsteps just, er, in the opposite direction to European countries.

Europe seems like a mixed bag to me to say the least- no system's perfect- but at least in a few places there seems to be somewhat less BShite compared to our own exalted Continent. Surprising, I always thought the bureaucracy in Euroland made Hell seem like a Caribbean vacation, but I guess this just shows how far down the road of hellholedom the USA has become.

The United States is rapidly becoming an extremely unwelcome place for at least some professionals- I'd imagine docs might top the list, but not the only ones. All the red tape, hyperlegal crap, higher taxes- USA has higher corporate taxes than Socialist Norway, go figure- increasingly expensive schools with lower pay and less time to start businesses, yeah it's there.

I'd personally be afraid of the frying-pan-into-fire effect, but most of the eggheads who've embarked on that harrowing crossing from, uh, LaGuardia to Salzburg or so seem to be doing fine.

I guess it depends on where you wind up, but if you can snap up a gig in a medium-ish Euro city you've probably got it made- not too expensive, still hip enough to have a decent urban existence, easy rail access to other cities, and you can save up income that's paid in Euros so that you can snap up that yacht you've always wanted in the Virgin Islands.

Or I guess that's the cover story at least.

But the nouveau Euro-warriors seriously seem to be doing OK, and I'd agree that the Euro has a lot to do with it. That seems to be the new int'l currency measured by the fact that among other things I guess, international drug cartels demand payments in Euros more than dollars. Or something alone those lines. Having your savings in that currency is probably a nice little boost, and if you can use that dough to get more rupees and pesos and, uh, dollars when you travel, that combined with the low-cost tuition and other goodies probably attracts a goodly number of eggheads looking for the same.

At the very least, if you folks are right about the no-fault malpractice thing in Europe, that's damn smart- eliminates the idiotic waste and pseudo-debate we have in the USA in a sec. This was that whole vaccine fund analogy people were proposing a while ago.
 

If doctors were less concerned with turf wars and more concerned about the overall direction of medicine I might agree with this post.

But over all doctors seem happy to have their little petty fiefdoms and wait for someone else to do "something."

I thought doctors were supposed to be smart?