Comments on: My take: Dwindling primary care, spinal care, ratting out patients http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html medical blog Sun, 22 Nov 2009 19:59:44 -0500 http://wordpress.org/?v=2.8.4 hourly 1 By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83627 Anonymous Fri, 15 Feb 2008 17:55:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83627 jb,<br/><br/>Sounds like we agree on most things. <br/><br/>I don't know of any family docs who feel we should make as much per hour as the longer trained specialties, but I whine plenty when 70-80 hour work weeks are needed to stay afloat financially and the hourly income works out to less than most plumbers and nurses earn.<br/><br/>family doc jb,

Sounds like we agree on most things.

I don’t know of any family docs who feel we should make as much per hour as the longer trained specialties, but I whine plenty when 70-80 hour work weeks are needed to stay afloat financially and the hourly income works out to less than most plumbers and nurses earn.

family doc

]]> By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83609 Anonymous Fri, 15 Feb 2008 00:53:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83609 As a fp for 18 years I take great issue with the comments by jb and the cardiology ex. I chose FP because you really won't get bored with work and AT THE TIME I GOT OUT OF RESIDENCY THE PAY WAS MUCH BETTER compared to my specialist colleagues. This disparity is what many primary care drs. are "whining about". In my community the disparity goes beyond pay but also to resources our health system devotes to health care. We are on our third construction project for orthopods, we subsidize anesthesia to an average of over 300,000 a year, but we must be "whining" to jb if we try to get the system to give 25000 for loan forgiveness for an fp.<br/> That being said any "generalist" i.e. FP, IM, PEDS, GEN SURG,and even to some extent OB/GYN are the providers that are suffering. I've spent 10 years in med staff leadership and these practices have been squeezed the most. My FP group still bucks the trend and do inpt with its call etc. All those specialties id'd perform a great deal of scut that "consulting" staff doesn't do, do a lot of highly compensated but clinically dubious procedures, then sign off. A consult from a specialist shows no thought any longer except to trot out a great deal of expensive work. We in these "general fields" need to get to work at our grass root institutions and force our boards to recognize that we need to address the cost of our care to be able to assert any real political control.<br/> I may get irritated at the comments jb left, but I am irritated that at my hospital an appy may pay him @ 1000, whereas a crna/ or anesthesia gets 1500!!!! for passing the gas . Unless the workhorse specialties are paid better to attract more/better talent, this country is going no where in health reform. As a fp for 18 years I take great issue with the comments by jb and the cardiology ex. I chose FP because you really won’t get bored with work and AT THE TIME I GOT OUT OF RESIDENCY THE PAY WAS MUCH BETTER compared to my specialist colleagues. This disparity is what many primary care drs. are “whining about”. In my community the disparity goes beyond pay but also to resources our health system devotes to health care. We are on our third construction project for orthopods, we subsidize anesthesia to an average of over 300,000 a year, but we must be “whining” to jb if we try to get the system to give 25000 for loan forgiveness for an fp.
That being said any “generalist” i.e. FP, IM, PEDS, GEN SURG,and even to some extent OB/GYN are the providers that are suffering. I’ve spent 10 years in med staff leadership and these practices have been squeezed the most. My FP group still bucks the trend and do inpt with its call etc. All those specialties id’d perform a great deal of scut that “consulting” staff doesn’t do, do a lot of highly compensated but clinically dubious procedures, then sign off. A consult from a specialist shows no thought any longer except to trot out a great deal of expensive work. We in these “general fields” need to get to work at our grass root institutions and force our boards to recognize that we need to address the cost of our care to be able to assert any real political control.
I may get irritated at the comments jb left, but I am irritated that at my hospital an appy may pay him @ 1000, whereas a crna/ or anesthesia gets 1500!!!! for passing the gas . Unless the workhorse specialties are paid better to attract more/better talent, this country is going no where in health reform.

]]> By: jb http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83605 jb Thu, 14 Feb 2008 21:16:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83605 Family Doc-<br/>I'm not a troll, I'm a real live general surgeon. I agree that it's a problem that so many docs are getting out of clinical medicine, but that was not my point. My point was that MDs who make an informed choice to enter a relatively low paying specialty have no standing to then whine about what a low paying specialty they are in.<br/><br/>My fervent wish is that MDs of every specialty, but especially the low paid ones, will open cash based practices in which the doc will get to keep 70-80% of the fee instead of the current ~30%. She will earn a much better income, be able to give much better care, and everyone will be better off except the insurance companies. That model appears to be quite practical in primary care, where encounters can be <$100 per if the doc does not have to have an army of insurance clerks and a significant investment in computer hardware and software to keep the insurance people at bay. That's certainly the way I would do it if I were in FP or IM. It's not too practical for a surgery practice where the encounters generally start at $500 and go way up from there- that is truly what insurance is for- infrequent, high cost, and unpredictable events.<br/><br/>I will need you to stay in business. You will not be able to stay in business under the current scheme, no matter how much whining you do. Family Doc-
I’m not a troll, I’m a real live general surgeon. I agree that it’s a problem that so many docs are getting out of clinical medicine, but that was not my point. My point was that MDs who make an informed choice to enter a relatively low paying specialty have no standing to then whine about what a low paying specialty they are in.

My fervent wish is that MDs of every specialty, but especially the low paid ones, will open cash based practices in which the doc will get to keep 70-80% of the fee instead of the current ~30%. She will earn a much better income, be able to give much better care, and everyone will be better off except the insurance companies. That model appears to be quite practical in primary care, where encounters can be < $100 per if the doc does not have to have an army of insurance clerks and a significant investment in computer hardware and software to keep the insurance people at bay. That's certainly the way I would do it if I were in FP or IM. It's not too practical for a surgery practice where the encounters generally start at $500 and go way up from there- that is truly what insurance is for- infrequent, high cost, and unpredictable events.

I will need you to stay in business. You will not be able to stay in business under the current scheme, no matter how much whining you do.

]]> By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83604 Anonymous Thu, 14 Feb 2008 20:58:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83604 ""unless they're dumb enough to enter family medicine which rules out future fellowships"<br/><br/>It doesn't rule out a sleep medicine fellowship<br/><br/>10:39 AM"<br/><br/>It doesn't rule out Sports Medicine either. I'm sure there are a few others. “”unless they’re dumb enough to enter family medicine which rules out future fellowships”

It doesn’t rule out a sleep medicine fellowship

10:39 AM”

It doesn’t rule out Sports Medicine either. I’m sure there are a few others.

]]> By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83601 Anonymous Thu, 14 Feb 2008 17:40:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83601 family doc,<br/><br/>...and you'll wait 12 hours to see a real live doctor in the ER because everyone else is in the same boat. <br/><br/>But don't fret, you may be able see a "physician extender" somewhere, somehow, once all the doctors have decided it isn't worth it anymore. 1/2 the training at 2/3 the cost. What a deal. <br/><br/>Now when they tell you your problems are "too complex" and you need a specialist, back to square one. family doc,

…and you’ll wait 12 hours to see a real live doctor in the ER because everyone else is in the same boat.

But don’t fret, you may be able see a “physician extender” somewhere, somehow, once all the doctors have decided it isn’t worth it anymore. 1/2 the training at 2/3 the cost. What a deal.

Now when they tell you your problems are “too complex” and you need a specialist, back to square one.

]]> By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83598 Anonymous Thu, 14 Feb 2008 15:43:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83598 jb,<br/><br/>I suspect you're just a troll but I'll take the bait. The problem isn't us whining, that just clogs up blog comments, big deal. <br/><br/>The problem is that we're retiring, quitting, or reducing our scope of care (no more 1 AM runs to the ER as above) because we can't stay in business. Remember that when you or your parents are in the golden years and can't get in to see a doc for weeks unless you go to the ER.<br/><br/>A Family Doc jb,

I suspect you’re just a troll but I’ll take the bait. The problem isn’t us whining, that just clogs up blog comments, big deal.

The problem is that we’re retiring, quitting, or reducing our scope of care (no more 1 AM runs to the ER as above) because we can’t stay in business. Remember that when you or your parents are in the golden years and can’t get in to see a doc for weeks unless you go to the ER.

A Family Doc

]]> By: Michael Rack, MD http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83597 Michael Rack, MD Thu, 14 Feb 2008 15:39:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83597 "unless they're dumb enough to enter family medicine which rules out future fellowships"<br/><br/>It doesn't rule out a sleep medicine fellowship “unless they’re dumb enough to enter family medicine which rules out future fellowships”

It doesn’t rule out a sleep medicine fellowship

]]> By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83596 Anonymous Thu, 14 Feb 2008 15:31:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83596 In response to jb:<br/><br/>Thanks for your constructive feedback.<br/>It is nice to know you are so happy in your career choice. Quite frankly, the most unhappy physicians I have ever known are the general surgeons.<br/><br/>As far as my career choice, it is true for me, as well as you, that money was not a deciding factor. However, in 13 years of practice, things have gone from ok to bad to worse to pathetic, while the specialists have stood by and said nothing.<br/><br/>But your advice is well taken, if I could change I would. But with med school loan and other debt, I feel somewhat trapped. It is very disconcerting to be losing money in medicine.<br/><br/>Underpaid in New York In response to jb:

Thanks for your constructive feedback.
It is nice to know you are so happy in your career choice. Quite frankly, the most unhappy physicians I have ever known are the general surgeons.

As far as my career choice, it is true for me, as well as you, that money was not a deciding factor. However, in 13 years of practice, things have gone from ok to bad to worse to pathetic, while the specialists have stood by and said nothing.

But your advice is well taken, if I could change I would. But with med school loan and other debt, I feel somewhat trapped. It is very disconcerting to be losing money in medicine.

Underpaid in New York

]]> By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83595 Anonymous Thu, 14 Feb 2008 14:34:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83595 how much does a 1 am cath pay?<br/>the reimbursement differences need to account for the call frequency and intensity, and also account for risks of practice, including radiation exposure, and liability. <br/><br/>another point to consider is the opportunity cost of the lost compound interest of 401k's over 35 years and savings for those 3-4 years for the 35 years and add the compound interest of the loans accruing for an additional 3-4 years paid over the 30 year repayment schedule.<br/>there are a lot of ways to massage the numbers to prove whichever point you believe in.<br/><br/>i also believe that many small primary care practices lack the time and resources to be reduce overhead and run business as efficiently as larger groups. it is just that small subspecialty groups can afford to do it and don't get as much attention. how much does a 1 am cath pay?
the reimbursement differences need to account for the call frequency and intensity, and also account for risks of practice, including radiation exposure, and liability.

another point to consider is the opportunity cost of the lost compound interest of 401k’s over 35 years and savings for those 3-4 years for the 35 years and add the compound interest of the loans accruing for an additional 3-4 years paid over the 30 year repayment schedule.
there are a lot of ways to massage the numbers to prove whichever point you believe in.

i also believe that many small primary care practices lack the time and resources to be reduce overhead and run business as efficiently as larger groups. it is just that small subspecialty groups can afford to do it and don’t get as much attention.

]]> By: jb http://www.kevinmd.com/blog/2008/02/my-take-dwindling-primary-care-spinal.html/comment-page-1#comment-83594 jb Thu, 14 Feb 2008 14:20:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-dwindling-primary-care-spinal-care-ratting-out-patients.html#comment-83594 Oh, come off it, Dr. Whiney Underpaid. When you were in med school, you had a choice. Go for primary care, surgery, rads, or whatever. If you did not know then that there were large discrepancies in the paychecks of the various specialties, you may have been the only high school graduate in the USA that was ignorant of this. You spent several weeks on a clinical rotation with the surgery residents, who worked their asses off but somehow seemed to be having a good time, and decided, I can not/do not want to do this for 5 years, and then for a career. I made the same decision regarding my specialty (general surgery). The relative increase in income is nice, but not the deciding factor. Yes, the anesthesiologist does do much less work, for more money than I make, but what a boring way to earn a living. If you go into a specialty because of money, you will have money and misery To me, sitting in a darkened room mumbling into a dictaphone (i.e., radiology) would be a form of torment, despite their lofty incomes.<br/><br/>No one in this economy is underpaid. You get up every morning and voluntarily go to your place of employment for whatever paycheck you draw. Unless someone is holding a gun to your head, you are trading your time and expertise for money on a voluntary basis. It's up to you to make yourself more valuable to someone, anyone, so you will not be "underpaid." Until then, shut up and get to work. Oh, come off it, Dr. Whiney Underpaid. When you were in med school, you had a choice. Go for primary care, surgery, rads, or whatever. If you did not know then that there were large discrepancies in the paychecks of the various specialties, you may have been the only high school graduate in the USA that was ignorant of this. You spent several weeks on a clinical rotation with the surgery residents, who worked their asses off but somehow seemed to be having a good time, and decided, I can not/do not want to do this for 5 years, and then for a career. I made the same decision regarding my specialty (general surgery). The relative increase in income is nice, but not the deciding factor. Yes, the anesthesiologist does do much less work, for more money than I make, but what a boring way to earn a living. If you go into a specialty because of money, you will have money and misery To me, sitting in a darkened room mumbling into a dictaphone (i.e., radiology) would be a form of torment, despite their lofty incomes.

No one in this economy is underpaid. You get up every morning and voluntarily go to your place of employment for whatever paycheck you draw. Unless someone is holding a gun to your head, you are trading your time and expertise for money on a voluntary basis. It’s up to you to make yourself more valuable to someone, anyone, so you will not be “underpaid.” Until then, shut up and get to work.

]]>