Kevin, M.D. - Medical Weblog

I really don't think it should be the patient's "right" to demand a plastic surgeon perform a repair unless they are willing to pay for the services themselves. If the ED doctor is willing to do the closure, that alone is sufficient service under EMTALA, especially if the patient is otherwise unable to pay for the plastic surgeon. It should be solely the ER doctor's right to decide whether a plastic surgeon is necessary and if so, the patient should have to pay for that extra service.
 

Problem is, if its on the face, and the appearence is affected, then it sounds like lawsuit city.
 

Ummm, excuse me, but why on earth would a board certified EM phyician call in a plastic surgeon to repair a "minor lacreation" (his own words) anyway??
 

This has come up a lot in South Florida lately. The Palm Beach Post and South Florida Sun Sentinel have run articles about the critical shortage of specialists willing to cover the ER, especially hand surgeons. South Florida is lawsuit city, so I can't say I blame them. Unfortunately, rendering free care does not mean that they are free of liability.
 

He bitches about Orthopods then never mentions them in his rant. If he doesn't want to hear them complain. Simple DON'T CALL THEM. Take care of it yourself.
 

Enough.
You are all missing the point.
Like the rest of America, medicine exists of the haves and the have-nots. Plastic surgeons, orthopods, radiology, anesthesiology, dermatology (and others)are the spoiled rich children of medicine.

I'm sure the above comment will inspire the anger of the privileged few.

How much public money goes in to train these specialists? Residency education is largely funded, albeit dysfunctionally, by medicaid and medicare. Despite liability and payment issues, all of us have a moral imperative to return this investement by providing some form of public service, whether it be ER call or clinic service, etc. I think that doctors who do not provide services such as these should have to pay back the public money that went to train them. Certainly the upper class of physicians can afford such a tax.

Recently, in my community, the local orthopedists extorted a rather handsome fee from our hospital for service call due to a local shortage. Shame! The rich get richer.

Please don't respond with platitudes about family practice, and how I knew what I was getting into. I never expected to make as much as these specialists, I just did not expect to be crapped on by them so much either.

Underpaid in New York
 

Ummm, Underpaid: please answer my query about why a board certified EM physician would even bother to call a Plastic Aurgeon to repair "a minor laceration."

So everyone who's had their education "subsidized" in whatever dysfuncitonal manner should be required to work for free??

The taxes I paid to support the local Vo-Tec which trained a plumber entitles me to call him in the middle of the night to come to my house to fix a leak for free??
 

Yes, I think the prima donna specialist posters are actually reinforcing the whole point.
 

Still waiting for an answer as to why a board certified EM physician would bother to call in a Plastic Surgeon to repair a "minor laceration."

Does that make me a prima dona specialist??
 

To 11:16 am:

In response to your query, an ER doc can call a service physician whenever he or she feels it is indicated.

In response to your second point, I do feel strongly that doctors should strive to do some form of public service; our reluctance to do so as a profession belittles our stature in the eyes of the public, who thinks we spend all our time driving BMW's to the country club.

I am upset by certain specialists who drop community service as quickly as it is expedient, despite having had their education subsidized by the government.

Your last point about the plumber from Vo-tech is just plain silly; if you do not see the difference between a high school public education and residency funding for plastic surgeons, I am not sure how I can convince you otherwise.

Underpaid in New York
 

To answer the question of "why does a board certified EM doc have to call a plastic surgeon in to do a simple lac": HE DOESN'T. We can easily fix them - and do so all the time. We call them in for the simple ones when people ask for it - and I tell patients that if they have weak or no insurance they may be charged for such services. About 99% of these elective PS repairs are for insured or wealthy patients anyway. The point of my post was about the follow up for cases that I have nicely taken care of in the ED by myself but need a specialist to refer them to. The PS I was arguing with also moaned and groaned that he WANTED to see the minor and the insured patients (in fact he really just wanted the "option") in the ER so he could either get full out of network ER pay (which he would not get in his office) or so he could keep his office hours free of nonpaying follow-ups and book more botox! That is sad that he basically says he just does it all for the money. I made ZERO money on that illegal whose finger I fixed for an hour. Finally, about Ortho - I mentioned them just so as not to just pick on plastic surgeons. We have had ortho guys (certainly not all of them - just some bad eggs) behave similarly with tantrums when they take hand call.
 

So your specialty consultants, who take call at significant inconvenience and definite risk to their careers due to liability, are there for the patient's preference??? If they don't come in for real, true emergency case, you would have reason to complain. When they don't come in to satisfy a patient's preference, that's another thing entirely. When I'm on call to the ER, it's time that "civilians" spend on personal pursuits- family, relaxing, reading- that is in addition to the hours I spend taking care of patients during the regular 10-12 hour workdays. It's a little much for you to demand that we come in just because you or the patient prefer it that way. The way it really works in the ER is that we come in and do the work, take full responsibility for it, and maybe, if we're lucky, get some fraction of our fee from the patient or insurance company, if we do the paperwork right, if the insurance is still valid, a couple of months later. Maybe the insurance is valid, but they don't want to pay because the injury is workers' comp. We wait several months for our money while they fight that issue out.

The concept of docs doing "Community Service" went out with EMTALA. Now that we are told where to go, how long we have to get there, and what we have to do when we get there, our motivation for "Community Service" (isn't that what minor felons do instead of hard time?) is no longer present. Same principle as having to carry malpractice insurance to work in a free clinic. It takes all the fun out of it.

Once again, more whining form "underpaid" docs who knew full well what they were getting into, but chose to pursue easy to get into, 3 year post-grad training instead of the more challenging surgical fields that ultimately pay more but require more sacrifice initially.

And yes, what is the difference between a plumber trained at public expense and an orthopedist? At what point does publicly funded education result in loss of freedom? If I really need (or want) to know something in the middle of the night, am I entitled to drag someone who earned a Ph.D. from State U. out of bed to instruct me?
 

As I have said, I call plastics in for patient preference only after it is apparent they have insurance OR I tell them that this is an elective plastics consult and that they will likely receive a bill. Most of the time this is fine since I would say plastics is called in 1-2 times per day for a medical indication and 1-2 times for an insured patient preference. Again, I am not suggesting that there are not pitfalls with taking ER call and dealing with EMTALA (don't worry I get sued just as much as you do)however, it is a necessary evil these days. You have to get some business when you are just starting out and I still think it is part of your ethical duty to do some work for the needy. But please don't throw a tantrum because I referred someone to follow up in your office when you were on call. I could have called you in by saying "I can't handle it" - which I know some lazy ER docs do.
 

This is funny that ER docs are giving specialists a hard time when the primary reason lots of people choose ER is that it is shift work that doesn't require you to be on call. You would think they would be a little more understand considering this is one of the top 3 reasons why my friends say they want to do a residency in ER.
 

Response to jb:

I'll assume jb is a plastic surgeon or similar specialist.

I didn't call them the spoiled rich children of medicine for nothing. Notice his obvious contempt for primary care physicians.

This guy thinks he has the monopoly on having difficulty getting paid. He also thinks he's the only one who gets called in the middle of the night.

To fellow primary care doctors:
pay attention to jb's tone; this is how specialists really feel about us. Remember that the next time you refer a "good" patient.

jb's lack of understanding regarding public financing of residency education also speaks volumes; if he does not think he owes the public anything, then he is welcome to pay it back (which is what I initially suggested).

Underpaid in New York
 

JB more than likely has already paid back his "debt" and then some. Speaking for myself, I owe absolutely nothing.
Student years:
Let's see I paid back 200 grand in loans.
Residency Years:
The government paid a pittance to me for 5 years in a university setting that if they were paying any other physicians for the same work it would be 4 to 5 times as expensive. Twenty Nine grand a year for a physician to work 100 hour weeks is an absolute steal for the government and hospital. I once spent 4 days in the hospital taking care of patients without leaving. Consider how much that would cost. We figured our hourly rate all of the time and it was less than minimum wage. The government got back what they paid for and then some.
Public Financing may be a big deal if you are doing a cush residency. It's completely irrelevent in a surgical setting, or correct me if I'm wrong but the 80 hour work week implemented because of the extremely harsh shift work of the ER.
Go ahead and take care of your "good" patients yourself, I don't need your charity.
 

The generalization of "us and them" thing is so stupid. It is all about working relationships. Some primary care docs AND specialists just lack tact and skills. A specialist who doesn't want to be interrupted should not take call. Period. On the other hand, one that does take call I will try to give as many good referalls as possible for every bad case he has to eat.

In a way ER doctors have become victims of our own success in that we can handle lots of things. Now ist seems that many specialists want me to do what even they do not do routinely.
 

Underpaid in NY:

Lets be clear about something: having taken a residency funded by HCFA/MMS does not create an obligation or levy a debt to be repaid, no matter what you might want to believe. Consider that the government is getting someone with a doctorate and fresh training to work between one-and-a-half to two full-time equivalent jobs by hours worked in a single year for the wages of a public schoolteacher, and the balance is clearly in their favor. Neither you nor the public have a right to collect on any debt or demand of anyone but yourself alone the service of the "needy." If you think that you do, then you really are nothing more than a thief, demanding to take from others what you cannot or will not give yourself. Dressing up those demands as "ethics" is nothing but the cynical rationale of the robber who pretends virtue because he only steals from those he thinks have too much.

I don't know what JB thinks, but I don't think I "owe" the public anything and I certainly don't owe any payback for having done a residency. I did plenty of free care then and have done plenty since, and not because I owed anyone.

Maybe you need to adjust your own understanding, Dr. Underpaid (or is that Comrade Underpaid?) Just because someone does work that isn't paid doesn't mean it is done because it is "owed". Doctors who see patients in EDs ahead of getting payment are behaving generously and ethically, placing a sense of mission and trust before their fears of liability--real fears, mind you--and their own need to be paid for work.

Your own moniker reveals your apparent resentment of those who work hard and earn well. Why is that?
 

If I get called to the ER and its a BS consult for a simple lac, I usually tell the ER doc that its fine to go ahead and sew that up and leave. I've met any possible EMTALA problem and can go home. The last ER doc I had balk at that I just sent in a med student running around the ER to sew it up. He was more than happy to take care of it.
 

Some bitch and state there are critical access issues because there are not enough specialists taking call and another states if they don't want to be interrupted don't take call. Make up your mind, I'm sure they will be more than happy to take people up on their offer and stop taking call and take all of their cases to a surgical hospital or surgicenter if they haven't planned to already.
 

I think alot of it is presentation and how the specialists are treated. I have one ER doc that is always ready when I call gives a great description of the Xray. If I come in to reduce anything, IV in, respiratory is ready and he's almost waiting at the door with Diprovan. Heck, even the casting material is right there. Everytime he calls I trust what he says as almost gospel and I would help him out for anything, soft admits whatever. It makes an huge difference because if anyone else is on it becomes the entire turf war, bs consult battles we all know and love. I come into the ER with the other guys half of the time proper xrays aren't even taken, you are lucky if there's an IV, hardly anyone even knows where the patient is. It nearly takes divine intervention for help putting on a splint or cast and conscious sedation. HA! thats anesthesia not me. So guess what they will get the Xray beatdowns, no social admits, I'm not comfortable find someone else chats again and again that we all love. He gives me special treatment and I return the favor, by coming in at the drop of a hat if he says so.
 

“Underpaid-”
I’ve told you this before. You are not underpaid. Whoever is signing your paycheck is paying you enough, and possibly more than enough, to get you to show up for work. He or she would be a fool to pay you more than that, unless you threatened to leave and it would cost more to replace you than to keep you. You’re not underpaid, you’re undermotivated. You’re too lazy to do whatever it takes to earn what you think you’re worth (a concept that your employer does not share), so you complain a lot.

And no, thanks for the compliment, but I’m not Plastic. I’m a general surgeon, one of the blue collar specialties. I’m very proud of what I do and my work ethic. In over 2 decades of covering ERs, I have never (Never) declined to come in when requested by an ER colleague (my career began way before EMTALA), and I have never (as in never, ever) asked about insurance coverage when called from the ER. I am very proud of the close respectful relationship that I have cultivated with ER and primary care colleagues. The ER physicians that I work with have too much respect for me to call me for abusive crap like what you pester your consultants with. My contempt for people like you has nothing to do with your choice of a primary care specialty. It has everything to do with your choice of primary care combined with your endless whining about its perceived disadvantages, coupled with your unsuppressed jealousy of those MDs who chose a different path, succeeded, and left you in the dust, professionally, financially, or personally. I never said that I’m the only one who has trouble getting paid or gets called in at night. It’s a routine occurrence for all of us who serve as ER consultants. You know that, yet you insist on calling consultants in not for medical necessity, but for the patient’s preference, and you criticize them for being unenthusiastic. Your viewing of me and others whose training was subsidized by taxes as public utilities for the remainder of our careers is an expression of contempt as well.

And no, I do not recognize any debt due to my training, any more than any other State U. grad owes a debt because of his or her training. Back when the profession was allowed to govern itself, we felt a responsibility to make sure that people did not die in the streets due to lack of medical care. Now that we are governed by tens of thousands of pages of federal regulations, price controls, and oligopolistic insurance companies, and the threat of liability suits if our efforts in a free clinic go bad, I have a hard time conjuring up any feeling of need to repay any debt to society. Most of the time, I have to actively try to protect my self from those I try to help/
 

Underpaid in New York is one of the whiniest and most divisive non-team players on this blog. His or her glass is not half-empty, it is empty-empty. When I start hearing someone talk about "moral imperatives" I think about Fidel Castro or Hugo Chavez. Highly judgmental and jealous individuals who would restrain other people's freedom in an atmosphere of misery and mutual deprivation have no place at my table.

Any public "debt" related to residency training in dollars is more than made up for by the value rendered by underpaid residents/fellows working perpetual overtime while interest accumulates on their loans and opportunity cost exponentially escalates compared to other career choices. Hospital ED's have been getting a free ride from private practitioners for too long. And for the non-emergency medicine docs out there who might be swayed by the ER docs taking care of the underinsured, be aware that hospital subsidies often make up for this "charity care".
 

Well, I had a hard time deciding whether to let these issues go or have "one more round"; I opted for the latter so here goes:


To jb:

Although you deny contempt for primary care, your assumption that I am "lazy" betrays a prejudice that you lack the insight to admit you have. I don't know you, you don't know me; I can assume you're a "typical" surgeon but I believe in giving people the benefit of the doubt. What conjured my ire was your comments that primary care was "easy to get into" and that other fields are "more challenging", further manifesting your prejudice against primary care physicians. These are your words, you can retract or modify them but you cannot deny them.

You also assume I am an employee, which is incorrect; I own my own practice.

As for anonymous 2:52pm:

The argument that I am not a team player is interesting. Whenever primary care complains about being treated badly by consultants, we are told we are not good team players. Whenever we complain about disproportionately low reimbursement, we are told that we are all in this together.

The irony is that this whole debate began when an er doctor wrote about being treated badly by plastic surgeons regarding follow up visits; whose not the team player in that picture?

As I originally stated, there are two classes of physicians, and an ever-expanding divide between them. I actually believe primary care as provided by physicians will die, replaced by cheaper mid-level providers. That's basic economics and demographics; I wish I could say quality would suffer but I kind of don't think it will.

However, once we primary care physicians become extinct they're going to come for you next.

Signed,
underpaid, overworked and underappreciated family practitioner in upstate New York
 

That last post makes me want to buy you a plate of Dinosaur Barbeque. "Upstate" New York, now there's an oxymoron.
 

The article seems to imply that the plastic surgeons are being asked to provide the very occasional charity care. Then I see one person post "plastics is called in 1-2 times per day for a medical indication and 1-2 times for an insured patient preference."

That does not sound like occasional work, that's four ER calls a day, on average. Unless that particular hospital has an extraordinary number of plastic surgeons on staff.

I'm not a specialist, I'm your basic FP. Can't say I blame the consultants, though. Even if the plastic surgeon wins, I'd say the publicity of litigation would put a damper on someone trying to build an elective cosmetics practice.

The public wants to be able to sue doctors, they shouldn't whine when they can't find doctors. If I were a plastic surgeon, I'd save the charity work for well-defined overseas missions.