Comments on: Primary care is dying, may already be dead http://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html Tue, 14 Feb 2012 22:28:00 +0000 hourly 1 By: Anonymoushttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-83193 Anonymous Thu, 31 Jan 2008 04:36:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-83193 I'm a surgeon, and a specialist (trauma). All I have to say is that WE (doctors) have to stick together. I have enormous respect for a talented general internist... and a talented "specialist" They are underpaid, and so am I. We are not the enemy. It saddens me to see us throwing darts at one another. Please don't quibble about board scores or anything else. Your level of commitment to your patients and the profession is what really matters. (and yes I was AOA, in the top of my class, good board scores etc), but what I take the most pride in (and what really matters) is being a GOOD DOCTOR and it has so little to do with all of that other crap. I’m a surgeon, and a specialist (trauma). All I have to say is that WE (doctors) have to stick together. I have enormous respect for a talented general internist… and a talented “specialist” They are underpaid, and so am I. We are not the enemy. It saddens me to see us throwing darts at one another. Please don’t quibble about board scores or anything else. Your level of commitment to your patients and the profession is what really matters. (and yes I was AOA, in the top of my class, good board scores etc), but what I take the most pride in (and what really matters) is being a GOOD DOCTOR and it has so little to do with all of that other crap.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-79313 Anonymous Tue, 21 Aug 2007 02:18:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-79313 One specialist looking for a good internist here. <br/><br/>You can argue about specialist being paid more that generalist because they are worth more all you want. The fact is, you can't really know that because the market place is distorted by centralized price fixing. The fixers obviously fix payments for most specialists at an adequate level because I can get one tonight if I need it. They obviously fix the price too low for generalist because they are hard to find.<br/><br/>The solution is not to try to correct the erroneously fixed prices by doubling the rate for primary care. The solution is to stop fixing prices centrally. Let medicare decide what it will pay but let all providers balance bill at whatever level the market will bear. The market will then decide whether primary care services are worth the public paying a rate that good medical students will be glad to work for.<br/><br/>My own opinion is that in an actual free market, general internists would do just fine. If they did, some specialists would find themselves hurting because much of what many specialists occupy themselves doing would be be done by generalists were reimbursement not a barrier to their availability and to them doing their best work when they are. One specialist looking for a good internist here.

You can argue about specialist being paid more that generalist because they are worth more all you want. The fact is, you can’t really know that because the market place is distorted by centralized price fixing. The fixers obviously fix payments for most specialists at an adequate level because I can get one tonight if I need it. They obviously fix the price too low for generalist because they are hard to find.

The solution is not to try to correct the erroneously fixed prices by doubling the rate for primary care. The solution is to stop fixing prices centrally. Let medicare decide what it will pay but let all providers balance bill at whatever level the market will bear. The market will then decide whether primary care services are worth the public paying a rate that good medical students will be glad to work for.

My own opinion is that in an actual free market, general internists would do just fine. If they did, some specialists would find themselves hurting because much of what many specialists occupy themselves doing would be be done by generalists were reimbursement not a barrier to their availability and to them doing their best work when they are.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-79312 Anonymous Tue, 21 Aug 2007 02:11:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-79312 When I was finishing 20 (or so) years ago, the residency spots for the higher paying specialties were more competetive and I think got higher GPA's on average--but there were people from every sector of the class going into every field. There were a number of people who scrambled for a medicine spot after not matching in surgery, and I think primary care/psychiatry got a lower GPA overall. <br/><br/>Having said that, the top 10% of the class sent a disproportionate number of students to general internal medicine and psychiatry. So basically the generalizations are simultaneously valid and also bullshit insofar as people make too much of them. For one thing, if you know you want to go into orthopedics, you are going to gun for grades in med school, whereas most (in my class) really didn't worry about grades much. When I was finishing 20 (or so) years ago, the residency spots for the higher paying specialties were more competetive and I think got higher GPA’s on average–but there were people from every sector of the class going into every field. There were a number of people who scrambled for a medicine spot after not matching in surgery, and I think primary care/psychiatry got a lower GPA overall.

Having said that, the top 10% of the class sent a disproportionate number of students to general internal medicine and psychiatry. So basically the generalizations are simultaneously valid and also bullshit insofar as people make too much of them. For one thing, if you know you want to go into orthopedics, you are going to gun for grades in med school, whereas most (in my class) really didn’t worry about grades much.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-79219 Anonymous Sun, 19 Aug 2007 01:09:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-79219 "Oh, and I am in the real world and that is why I save my rants for anonymous message boards... :)"<br/><br/>Actually you are a second month intern, not exactly the real world. But good luck to you, you will be soon enough. “Oh, and I am in the real world and that is why I save my rants for anonymous message boards… :) ”

Actually you are a second month intern, not exactly the real world. But good luck to you, you will be soon enough.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-79210 Anonymous Sat, 18 Aug 2007 21:51:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-79210 I'm a resident who just went through match. I know what I'm talking about. <br/><br/>Trust me I know what a good internist is worth since that is what I am doing my residnecy in currently and I am not a good one yet. <br/><br/>My only point is that currently family practice does not have its pick amongst the top students in school. HOw this translates into the real world I do not know yet. But, school grades and test scores are used as an indicator for gaining better/higher paying jobs in every other area such as law school and MBA programs. So why not medical school too. <br/><br/>My only point was that family care docs should not expect to be paid on the same level as specialists due to these many factors. BUT, I sure as hell think that they ought to AT LEAST be breaking 200K average. <br/><br/>That is my only point. Oh, and I am in the real world and that is why I save my rants for anonymous message boards... :) I’m a resident who just went through match. I know what I’m talking about.

Trust me I know what a good internist is worth since that is what I am doing my residnecy in currently and I am not a good one yet.

My only point is that currently family practice does not have its pick amongst the top students in school. HOw this translates into the real world I do not know yet. But, school grades and test scores are used as an indicator for gaining better/higher paying jobs in every other area such as law school and MBA programs. So why not medical school too.

My only point was that family care docs should not expect to be paid on the same level as specialists due to these many factors. BUT, I sure as hell think that they ought to AT LEAST be breaking 200K average.

That is my only point. Oh, and I am in the real world and that is why I save my rants for anonymous message boards… :)

]]> By: Anonymoushttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-79206 Anonymous Sat, 18 Aug 2007 21:16:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-79206 So anon are you a med student? resident? I am saying this from experience (I used to be an internist before subspecializing and going back into practice). Medicine ain't a board exam or a med school exam. A competent well-trained internist/FP is worth their weight in gold (and other subspecialist's will tell you that). Their knowledge base is much broader than any specialist and denigrating them will get your ass-chewed off when you get in the real world. Additionally, when I worked as a internist/hospitalist, I worked a hell of alot harder than I am now (I still work hard). I am saying this from real life experience not text book/internet research. If we (society) don't fix primary care to the point where people aren't running away screaming then we are all fu*&ked. Mid levels have their place, but I can't tell you how many c/s I get from midlevels that I could answer as an internist. It may be easy money, but is it in the patient's/society's best interest? So anon are you a med student? resident? I am saying this from experience (I used to be an internist before subspecializing and going back into practice). Medicine ain’t a board exam or a med school exam. A competent well-trained internist/FP is worth their weight in gold (and other subspecialist’s will tell you that). Their knowledge base is much broader than any specialist and denigrating them will get your ass-chewed off when you get in the real world. Additionally, when I worked as a internist/hospitalist, I worked a hell of alot harder than I am now (I still work hard). I am saying this from real life experience not text book/internet research. If we (society) don’t fix primary care to the point where people aren’t running away screaming then we are all fu*&ked. Mid levels have their place, but I can’t tell you how many c/s I get from midlevels that I could answer as an internist. It may be easy money, but is it in the patient’s/society’s best interest?

]]> By: Anonymoushttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-79199 Anonymous Sat, 18 Aug 2007 17:12:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-79199 Just because you know a person who slept with someone to get a cardiology spot doesn't mean that specialists aren't smarter/harder workers in school. <br/><br/>They have higher board scores and higher grades as shown by the amount of people who are AOA going into these specialities. <br/><br/>I know what I'm talking about. So spare me the crap of giving your anecdotes of how someone slept with someone to get a spot. In primary care they just want you to have a pulse to get a spot, you don't even have to sleep with anyone. Just because you know a person who slept with someone to get a cardiology spot doesn’t mean that specialists aren’t smarter/harder workers in school.

They have higher board scores and higher grades as shown by the amount of people who are AOA going into these specialities.

I know what I’m talking about. So spare me the crap of giving your anecdotes of how someone slept with someone to get a spot. In primary care they just want you to have a pulse to get a spot, you don’t even have to sleep with anyone.

]]> By: Mikehttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-79184 Mike Sat, 18 Aug 2007 02:21:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-79184 Some of the dumbest people I know ended up specializing. One woman got a Cardiology spot because she slept with the director.<br/><br/>So spare me how much "smarter" the speiclaists are. The smarts come from doing something 1000 times. Some of the dumbest people I know ended up specializing. One woman got a Cardiology spot because she slept with the director.

So spare me how much “smarter” the speiclaists are. The smarts come from doing something 1000 times.

]]> By: another anonhttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-79154 another anon Fri, 17 Aug 2007 06:45:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-79154 Primary care is dead because the reim bursement is shitty, the paperwork is tedious, it is considered 2nd class (see the first post from Anon here if you doubt that!) and the workload is enormous. The amount of knowledge and responsibility that is required to be an excellent general internist far exceeds most micro focused specialists. Young doctors get it! Primary care is dead because the reim bursement is shitty, the paperwork is tedious, it is considered 2nd class (see the first post from Anon here if you doubt that!) and the workload is enormous. The amount of knowledge and responsibility that is required to be an excellent general internist far exceeds most micro focused specialists. Young doctors get it!

]]> By: Greg Phttp://www.kevinmd.com/blog/2007/08/primary-care-is-dying-may-already-be.html#comment-79143 Greg P Fri, 17 Aug 2007 01:30:00 +0000 http://clients.emmense.com/kevinmd/2007/08/primary-care-is-dying-may-already-be-dead.html#comment-79143 The primary goal of E/M coding was to save money, and it does this in a rather brutal fashion, then once instituted, payments get reduced, and it gets harder to justify higher levels of coding.<br/>Basically they were flawed to begin with, since there is nothing about them that had much to do with what a patient would consider to be quality medicine. It was alleged that it wasn't just about time, but it's all about time, and in essence not paying for time spent with a patient to help them understand what was going on, explain things, answer their questions. There was some sense that you could quantify the brain power or the difficulty of the medical decision-making in a given situation, but we all ended up like accountants filling cells of a spreadsheet. Then every patient gets all the cells filled in, so they had to reduce reimbursements, because as I said, it's all about saving money, not about health care delivery. The primary goal of E/M coding was to save money, and it does this in a rather brutal fashion, then once instituted, payments get reduced, and it gets harder to justify higher levels of coding.
Basically they were flawed to begin with, since there is nothing about them that had much to do with what a patient would consider to be quality medicine. It was alleged that it wasn’t just about time, but it’s all about time, and in essence not paying for time spent with a patient to help them understand what was going on, explain things, answer their questions. There was some sense that you could quantify the brain power or the difficulty of the medical decision-making in a given situation, but we all ended up like accountants filling cells of a spreadsheet. Then every patient gets all the cells filled in, so they had to reduce reimbursements, because as I said, it’s all about saving money, not about health care delivery.

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