The physicians of today have given up their unique soul

I had a conversation with a family practice physician today, a man who is far closer to the end of his career than the beginning. He is part of a private practice group that recently was sold to one of the larger hospital groups in the area, which put him on a salary, but also allowed him to work only three days per week. He stated that the decrease in earnings was more than compensated by the better lifestyle and benefits he receives while being an employed physician.

He also commented on how their group practice has changed. There are several physician’s assistants and nurse practitioners within their group. They handle the acute problems: sore throats, URI’s, etc. He spends his time caring for his long term chronic patients, most of which are on multiple medications with multiple co-exisiting medical conditions. “They take more time,” he said, as a statement of fact, not a complaint.

“Managing such patients requires a knowledge of disease interaction that our physician’s assistants and nurse practitioners don’t understand.” His words, not mine.

I thought about this for a while and thought even more about my general surgery practice and the way medicine is practiced in all the hospitals I attend.

Look at the typical scenario: a patient comes to the ER, sent by a primary care physician who doesn’t admit to the hospital. The ER triage nurse sees the patient and orders a battery of tests, lab work and imaging studies and then reports to the ER physician, who looks at all the tests, may go to see the patient briefly and then decides on that patient’s disposition.

A very ill patient will be admitted to the ICU, with hospitalist as attending, consultation with an intensivist and any other appropriate specialists and the patient is cared for by committee. Renal monitors the kidneys, GI does the inevitable endoscopies, surgeons go by and palpate the belly and order abdominal CT Scans, infectious disease changes the antibiotics and orders lines changed and, in the middle of all this is a very ill patient and family trying to get some idea of what is going on. The answers come in dribs and drabs.

“The abdomen seems OK,” I’ll tell them, “The primary problem is pneumonia.”

“I think it’s a UTI,” pulmonary states, “there may be s a touch of pneumonia, but I don’t think it is the primary source.”

“Kidneys are improving, BUN and Creatinine are lower,” renal reports.

All the while the family sees Grandpa on a ventilator, multiple IV’s, five different continuous infusions blinking on and off, intermittent piggybacks and numbers flashing on monitors which may or may not represent good news. The family wonders: “Does anyone really know what’s going on?”

I wonder myself sometimes. But, through all this the patients usually get better, because of or in spite of the multitude of specialists. It is different for my patients that undergo surgery or have a specific condition that falls within my scope of practice. I usually know every detail about such patients, every lab and imaging result, the latest vital signs, urine output and overall physical condition. These ICU patients are usually seen twice a day and I always call in the evening to check on them. That’s just my paranoia and belief that surgical patients need the care of someone who truly understands their particular surgical disease.

This brings me back to the topic of this article. The inexorable rise of mediocrity in health care.

I have read several articles recently about the changes that are occurring in medical education.

“There’s too much medical science to learn; no individual can know everything.”

“We need to emphasize compassion and ethics in medical education, learning the science of medicine should be de-emphasized.”

“If a patient asks me a question, I usually excuse myself from the room, then look up the current literature on ‘UptoDate’ and then give them the ‘evidence based’ answer.”

If this is the way medicine is being practiced then why do we even have four year medical schools, or residencies? Just give a few basic courses in smart phone utilization and turn the student loose to diagnose and treat based on the latest evidence based practice.

There is an assumption in the practice of medicine, commonly made by insurance companies, government officials, hospital administrators and, probably, many practicing physicians. This  assumption is that one doctor is as good as another. One GI doctor is the same as any other, all general surgeons are equal, or that every interventional radiologist is the as good as the next. Of course, being flawed human beings, this can’t be true. Those of us who care for the sickest patients know it isn’t true.

How do we know? The fruits of the labor give the answer. Infection rates, lengths of surgery, recovery times, complications all are indicators of an individual’s quality of care. From the choice of patients, to the timing and type of intervention, to the post operative management, each step requires thoughtful decisions and judgment. Our government strives to eliminate such judgment, reasoning that standardization of care, protocols and appropriate monitoring will lead to improved outcomes. If only humans were automobiles.

Years ago I cared for a mounted policeman, not mounted on a horse, his mode of transportation was a bicycle. I first saw him with rectal bleeding. He was hospitalized and an extensive workup revealed internal and external hemorrhoids which did not appear to be bleeding and had no manifestation of recent bleeding. Colonoscopy revealed nothing else.  His bleeding stopped and he was discharged. About two months later he came to my office with a referral requesting a hemorrhoidectomy. He had experienced two more episodes of bleeding, had another colonoscopy and the only finding was hemorrhoids. He did have enlarged, symptomatic hemorrhoids so the surgery was performed. He recovered uneventfully and two months later had bleeding again. He came to see me and I referred him to a different GI specialist. Another colonoscopy revealed an AV malformation in the right colon which was cauterized and was the end of his recurrent LGI bleeding. Presumably, this abnormality had been missed on the previous colonoscopies.

Two vascular surgeons may operate on similar patients. Why does one have infections after almost every procedure while the other’s patients heal without any negative sequelae? How can one surgeon perform complicated surgery in 2 ½ hours and send the patient home in 4-5 days, while a second surgeon requires 8 hours for the same procedure and then sees their patient linger in the hospital for weeks?

Judgment, experience, innate talent all combine to create physicians who may be a cut above their peers. What is disturbing is that today’s training programs appear to be ignoring the fact that some physicians are not cut out to be surgeons, or interventional radiologists or cardiologists. They pass them through and send them into the world to flounder or worse. Surgeons such as these may struggle, rationalizing that it was a difficult patient and try to cover up bad results, but in the end it is the patient who suffers.

It is obvious to me that there is inherent variability between individuals, be they doctors, baseball players, musicians or ditch diggers. Most professions reward the skilled and talented individual. Top athletes, entertainers, even lawyers are rewarded. Yet the trend in the health care world is to establish strict guidelines and protocols that stifle the thoughtful, skilled practitioner while rewarding the individual who best “fits the mold.”

The truly sad thing is that such a physician has no incentive to tackle cases that may be complicated or time consuming or “interesting.”

“I’ll stick with gallbladders and hernias.  And I don’t want to take ER call, those patients may be too ill and might mess up my profile. I’ll send the complicated cases to the Med Center, the gastric cases to the ‘foregut surgeon’, the colon cases to the ‘colo-rectal surgeon’ and don’t even begin to talk to me about trauma.”

Common words among general surgeons.

Today I received a note from Sheila reporting that she was free of disease on her recent PET scan and thanking me for taking care of her. Sheila had come to me eight months ago with painless jaundice. She underwent a Whipple procedure, which is removal of the head of the pancreas, duodenum, portion of the bile duct and sometimes a part of the stomach,for pancreatic cancer and recovered uneventfully. She had traveled two hours to see me, because she had been unable to find anyone on her insurance plan that performed a Whipple’s. She had, literally, picked my name out of her book. Admittedly, the Whipple procedure should be done by those with some experience.

Have we reached the point in surgery where surgeons are not trained to do complex cases or are taught to refer such cases to tertiary care centers? But, what if the tertiary care center refuses? Such was the case recently. A patient was admitted to one of the hospitals where I work with painless jaundice and a mass in the pancreas, presumably cancer of the pancreas. She had been told by her Primary Care doctor to travel six hours to the world famous cancer center, which is just down the road from me. She, however, did not have insurance. She was turned away and showed up in the ER at my hospital and was admitted.  She underwent a Whipple procedure and  is recovering uneventfully at this moment.

I have similar experiences on regular basis, sometimes for conditions as simple as inguinal hernia or cholecystitis in patients who may have some sort of complicating condition. Maybe I’m setting myself up for a lawsuit. These patients, however, are often desperate and suffering after experiencing nothing but the run around from physicians and hospitals who don’t want to be bothered.

Where are all these ramblings leading? The physicians of today have given up their unique soul. To be a doctor use to mean to live a life of dedication to the medical arts and to the care of patients. The medical school selection process was highly competitive, the curriculum was intense and rigorous and those that were not up to certain standards fell away, sometimes in medical school, often in residency. The residency programs believed it was their duty to produce doctors of the highest quality, skilled, knowledgeable, ethical, and dedicated. Is this still true?

David Gelber is a general and vascular surgeon who blogs at Heard in the OR and author of Behind the Mask.

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  • Suzi Q 38

    Your article is so insightfully true.
    I sometimes wonder if I am on the receiving end of the physician “hot potato” game. No, this isn’t my problem….

  • Jen S

    Couldn’t agree more with the concerns expressed in this article, as well as Suzi Q’s.

    Nowadays all doctors have become not just sub-specialized in their respective field, but sub-sub-specialized. It’s not just about seeing an hip orthopaedic surgeon, but seeing one who specializes in a specific procedure (or two) your ailment may call for. It’s not just about seeing a neurosurgeon who specializes in the spine, but one who specializes in the specific area of the spine you are having issues with.

    If you don’t have an issue they “treat” per se, you are bounced around like a hot potato.

    Our medical system has allowed this to happen. Doctors, and more specifically surgeons, are pretty much able to do what ever they want; and to not do whatever they do not want to do.

    For the past 2 years I’ve had a very specific pain whenever I lay down that involves the iliac crest and anterolateral hip area. It has worsened and is now bothersome during the day. It is enlarged with an area hardened. 2 years, over 40 doctor visits, not 1 doctor has actually examined it. 2 have felt the hardened and since nothing showed up on a hip MRI shrugged their shoulders.

    One doctor recommended exploratory surgery. I spent WEEKS calling almost every general surgeon, and several orthos, in NYC (where I live) and not one would take me because it wasn’t precise enough for them. The one guy my PCP recommended had a rap sheet of complaints and settlements with the state and is no longer board certified…not about to let him touch me with a scalpel. Finally, I just gave up.

    The hip orthos I’ve seen are only concerned with the hip joint. God forbid you have issues that do not involve your hip joint, they don’t examine it or even acknowledge it.

    And that is with “the best” doctors, Cornell, HSS and Columbia.

    Since I have spine issues the orthos shrug their shoulders and say it must be spine. Yet spine surgeons are not too sure, and there are very few spine surgeons who have any expertise in the Thoracic spine.

    So, here I am 2 years later, more pain, and seeing a physiatrist, ame exact place as last year just more in debt, more frustration, and more pain. This is the 3rd physiatrist I’ve seen. After being led by a string like a dog around a pole by a neurosurg who had recommended surgery, I was told 4 days before the surgery that he wouldn’t do it, telling me to see a physiatrist.

    He wouldn’t even hear that I had and that for over year, including several injections, over 4 months of PT, etc.

    That is today’s medical care. We have created this mess and Obamacare will not take care of these type of issues as we have enabled GENERATIONS of doctors to become this way. It will take at least twice as many generations to undo it. That is, if it ever is. Hospital administration only makes it worse.

    • azmd

      That is a horrible story. Have you considered seeing someone in Boston? My experience (with living and training in NYC) is that the medical care there is surprisingly mediocre. I think Boston is a better bet. Just a suggestion.

      • Jen S

        Thanks. I’ve thought about that or Hopkins but, at this point, am not able to invest the time or resources for that to happen. I’ve been running around, taking far too much time off of work, the past 2 years. And I have to work, or else I won’t have insurance, yet alone a place to live.

        Not to mention the back pain prevents me from travelling for up to, yet alone over, an hour.

        It’s even more frustrating because in the midst of all the spine hip appointments and scanning, a tumor came up on my liver. Since it was a rare tumor, had no problem finding a surgeon for that…1 of the 3 I had seen kept trying to persuade me to go to him even though I had already made my decision to go elsewhere. Had that removed at MSK over Christmas without issue.

        • http://www.facebook.com/janet.gysi Janet Gysi

          You are really going through hell… I hope you find answers.
          I have congenital hip dysplasia and, predictably, developed severe arthritis as I hit my 50s. What surprises me is that, like you, visits to orthopedic physicians did not result in any kind of actual examination. An xray, “yep, you have arthritis” and “let us know when you are ready for surgery” was the extent of the visit. The ONLY provider who actually touched me and put my joints through range of motion, etc was the nurse practitioner at my ortho’s office. For the surgeon, it was all about the joint. For the NP, it was about how the joint was affecting the rest of my anatomy and my function. I ended up referred to tertiary care at the University. Same thing… not one of the physicians (attending, fellows, residents) actually put their hands on me for an examination. Guess that was why they were surprised I wasn’t walking with a cane at 6 weeks. My hip stabilizer muscles were so weak that I couldn’t stand without a walker. PLEASE, healthcare providers of all types, remember that patients are a whole… not just the part you specialize in.

          • Demdrybones

            I agree, it is flat out wrong, and it embarrasses me that we as physicians (and my sub-specialty in particular) have devolved to the point where a patient is viewed as a CPT code. There is no excuse for not examining a patient.
            Unfortunately, there is also no reward for spending time with patients. This is not an excuse, but just an explanation for why this happens. Declining reimbursement has forced doctors to cram more patients into already overbooked clinics which leads to less time spent per patient, glossed over histories and exams, and an overall feeling of dissatisfaction on the part of the patient. Meanwhile, surgical indications become broader which increases usage of services and potential complications.
            If you have been in practice 10, 15, 20 years and have become accustomed to a certain lifestyle, you aren’t simply going to sit back and accept a lower salary. You’re going to compensate for reduced reimbursement by stepping up your production. You’re going to seek out alternate methods of income (PT, MRI, surgery centers). The cost of a medical education isn’t going down either.
            I’d love to think that INCREASING reimbursement rates significantly might reverse this trend by allowing doctors to reduce the number of patients they need to see per clinic (thereby spending more time and delivering better care) and reduce the number of surgeries that are done (thereby reducing use of services, complications, and narrowing surgical indications where they should be). However, now that we know we can find a way to get through 40 patients in a morning or do 8 surgeries in a day, why not just make more money instead of slowing down?

    • karen3

      I sure understand Jen. There comes a point where the endless rounds of “not my problem” and highly touted “experts” who clearly haven’t so much as read the “up to date” it really becomes a decision about wasting what little energy and money on a pointless quest versus spending your time and money enjoying what little you have. Azmd, this is pretty much par for the course unless you have something so incredibly obvious and easy to treat that, well, you don’t need a doctor…

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Doctor Gelber and I use the word Doctor with the utmost respect, you have hit the nail on the head. Mediocrity and dumbing down medicine at the expense of the patient is the norm. That doesn’t mean that this policy is what today’s young students want. It is just the policy that the Robert Wachter’s, Bruce Berensons, E Emanuel, C Cassel and Arnold Relman’s of the academic political world have created in response to the desires of insurers, pharmaceutical houses and employers looking for the most bang for the buck. Throw in a failure to institute sane medical malpractice reform and you have American health care today. No one has a doctor. No patient has an advocate.

    • Suzi Q 38

      I agree with this.
      i have a doctor that had no influence when I had to get a specialist or two. He would submit the referral to the teaching hospital, but I would have to write it for him first. I would sent my draft to his receptionist, who would fax it over to the teaching hospital.

      Now, after being with the same familiar doctor, I am now feeling quite alone. The teaching hospital looks huge and intimidating to me, and I am not intimidated normally. It is my health, and so I am more concerned.

      I am confused as to what is the difference between a regular radiologist and my neuro radiologist. A fellow and a resident,
      a spine orthopedic surgeon and a neuro surgeon that specializes in spines and my suspected OPLL.

      At the last hospital, my concern was cancer. Once that got taken care of the neuro problems started. In the end, it was all so mixed up. My cousin fron another state suggested that I get a nurse navigator to help me. Thank goodness I did. I was out of ideas, and she helped me sort everything out.

      I don’t blame the physicians, I just blame the system.
      Why not give us patients a nurse navigator as soon as things get somewhat complicated. The doctors never got in a room to discuss my problems or to think about solutions for me.

      I went it a circle for about a year and a half, praying that they would figure it out for me…after all, they were experts with impressive credentials. They tried, and I am appreciative, but I had to move on
      to a teaching hospital that had a neuro department and several neuro surgeons and various neurologists and a neuro radiologist.

      After talking with other patients, I am lucky that I was able to find out
      what the problem was under 3- 5 years.

      It was only with persistence on my part, as an internal medicine doctor at the first teaching hospital would have been invaluable.

      • margo

        I also had an unusual problem that was a space occupying lesion in sacral foramina ppt unbearable pain. Went to multiple neurosuregeons and specialties of all kinds and no one wanted to own the problem. I would be seen once and that was it. No referral usually. They were done. Wasn’t their problem to figure out and PCP basically behaved same just believing what the consultant said and minimizing my problem. Years of my life were passing..I am lucky to have searched out myself and eventually found a wonderful neurosurgeon who recognized this as an emergency and operated successfully. If I were not an MD myself –struggling to find the diagnosis I would probably be paralyzed by now–unfortunately I am not being overly dramatic. I saw this as a sign of medical system being broken. The wait to get into specialty clinics were 6- weeks to 3 months. Then if you are sent to the pain clinic –you are lost and so is your diagnosis. More months to get an appt or injections there–which in my case were unnecessary. No one collaborated or cared to be curious. No one spent the time or maybe had the time to be curious about the diagnosis. NOT the procedure–the diagnosis!!

  • http://www.facebook.com/david.gelber David Gelber

    I remember academic physicians during medical school and residency who could quote the literature in great detail. During residency, as Chief Resident, we had to know the literature to justify any decisions we made. In contrast, I recently had an encounter with a Vascular Surgeon, just out of residency who had no idea what the dose of Protamine is to reverse Heparin. I would consider this basic knowledge, particularly for a Vascular Surgeon. It made me wonder about the quality of training today

    • Suzi Q 38

      Sometimes, I agree.
      When I had my problem, the doctor said, “My surgery didn’t cause this….” I acknowledged that the cause doesn’t matter to me….if not what is it??? Let’s figure it out so that I can go back to my life before the hysterectomy. It could be purely coincidental. Why let it continue to persist and get worse without treatment? Ignoring it will not make it go away. Help, me. doc. Cut me a break. I came in for a hysterectomy, and now I am having difficulty walking….

    • karen3

      I can’t tell you how many ‘fellows” I have had to walk through basic reference ranges, what tests were for, etc. If you want me to train your doctors, pay me. By the same token, I once spoke to a well published “guru” with my primary condition. Guru had published the primary study establishing a certain test as dispositive for my condition. Had the termerity to have read the study and noted that the findings were really to separate one condition from another. Asked the doc what “normal” was for the test. Guru HAD NO IDEA. This had been published in the premier journal for this specialty, was quoted everywhere, Was part of the clinical practice guidelines. And for all people knew from the literature, the “diagnostic” level was absolutely a normal result. So much for peer review. The peers were clearly blinded by who the employer was of the author and wasted not a moment actually thinking,

  • Demdrybones

    With all due respect, I am a young orthopaedic surgeon and am growing tired of hearing from the older generation how poorly trained, mediocre, lesser-skilled, and undedicated my generation is. There seems to be this pervasive attitude amongst senior surgeons that the egregious dues they feel they have paid in their day gives them the right to constantly denounce the next wave of physicians.

    In fact, the older generation has contributed greatly to a broken medical system and has left my generation to deal with the consequences. Declining reimbursement, increasing regulation and government intrusion, increasingly distrustful patients, overall declining respect for physicians in the community. I can no longer accept a pen from an industry representative without fear of reprisal from the DOJ due to the abject greed of those that came before me and accepted kick-backs, “consultant” fees, and other such perks. Pardon me if I don’t feel like being lectured about medical ethics from the baby boomer generation of doctors.

    Sub-specialty training has gained traction in my field not because of fear or refusal to do “interesting” cases but rather due to increasing patient demand for the “latest and greatest.” My generation would rather excel in a few areas than be a jack of all trades and master of none. The paternalistic model of patient care has been replaced by the consumer model, and it started long before I added MD after my name. Sure, I could muddle through a shoulder scope, take twice as long and do an inferior job, or I could refer the patient to my partner who spent a year refining his technique and could do a better job in half the time. In the same manner, he could do a sub-par knee replacement or send the patient to me for superior care. The older generation attitude of “do enough until you (may) get good at it” doesn’t register with my generation. Personally, I don’t think it’s fair (or ethical) to make the first 10, 50, 100, 200 patients suffer through my learning curve because of my own ego or greed.

    I also scoff at the notion that the younger generation is afraid or unwilling to take on the more challenging cases. I can assure you, my senior partners have no hesitation in sending me the cases they have no interest in tackling (the morbidly obese, medically ill, under-insured, narcotics abusers, those with failed surgeries). One of the most senior surgeons in my group operates with impunity and expects me to take his complications off his hands. The straightforward cases are cherry-picked and the more complicated ones filter their way down. And good luck getting an experienced surgeon to help you with the complicated cases. They can’t be bothered. What kind of backwards system expects the least experienced surgeon to tackle the most complicated problems?
    In my experience, the physicians most recently out of training are generally more up to date on the literature and evidence-based medicine. It is the senior surgeons who cling to the “my way is the right way” approach. Perhaps it is different in the academic setting than it is in private practice.
    Sorry, I have heard one too many times how sub-standard my generation is, and I’m not buying it. We are dealing with a radically different and rapidly changing medical environment, and most would agree it’s not changing for the better from a physician’s standpoint. I will see more patients, do more procedures, and make less money than those that came before me. I will deal with ever increasing government interference, regulation, and pointless policies disguised as improvements in patient care and safety but really designed to strip doctors of autonomy. Meanwhile, I can’t watch the evening news without constant lawyer adds for bad drugs, recalled implants, etc. Those that came before us have helped to drive the system into the ground. More physicians of my generation feel compelled to seek hospital or health system employed positions because of fear. And let’s not forget older physicians all to willing to sell their practices to hospitals for one last cash grab before they bow out and leave their younger partners in the lurch when the 2 year honeymoon period of guaranteed salary and autonomy evaporates.
    My generation is proud. We have a strong sense of ethics and want to do what is right for patients. We covet a better work-life balance, but that doesn’t make us any less dedicated to our craft or patients, only more dedicated to our family life (if I had a dime for every story I’ve heard about which of my senior partners had an affair with this person or that person…). We know we will get paid less, and we are generally OK with that because we will still live pretty comfortably and get to do something truly amazing. I suggest that the baby boomer generation take a good hard look in the mirror before decrying the state of medicine and the mediocrity of today’s young doctors. We see your hypocrisy but are too respectful to call you out on it.

    • http://www.facebook.com/david.gelber David Gelber

      It is difficult to generalize and I shouldn’t have done it. As in anything there is variability in talent and dedication. I did not mean to denigrate younger physicians. I agree with much of what you say. I have observed a lot of surgery and seen many different surgeons operate. What I’ve concluded is that a good surgeon will be good whether he or she limits the scope of their practice or decides to practice a wide range of procedures. And, a poor surgeon will be poor no matter what they do. It is the responsibility of our education system to separate one form the other.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      You are a product of what you were trained to do. It has taken years of priming you based on public policy implemented in your medical school training and through out residency to put you in a position that you currently are. It appears you are well meaning, well trained and able and willing to handle a narrow scope of orthopedic problems which you handle very well. As my local orthopedists have insisted they are all consultants. When a 40 year old world class athlete with no medical problems slips in a shopping mall on a wet spot and ends up in the ER with a fractured hip that patient gets admitted by the medical service not the orthopedic service. That despite the fact that the patient has few if any medical issues, allergies, medications or risk factors for complication of the procedure. Its a great system for the hospital and institution with an over worked system employed hospitalist called in to do a history and physical and pre op evaluation, a surgical nurse explaining the pros and cons of surgery and getting the informed consent signed ( even though the responsibility rests with the surgeon) and the surgeon performing the procedure and leaving the post op care to his nurse practitioner or physician’s assistant and not seeing the patient again until several weeks later. This system was created by insurers, employers looking for less expensive but ill defined higher quality care, and academic teaching faculty who when asked to actually care for the patients on their ward teams when they did their teaching rotation, did not want to or remember how to care for problems outside their limited specialty area.

      Yes the baby boomer medical generation has seen many negative trends in medicine which now impact younger physicians. We have seen the implementation of the confusing and frightening Stark laws which limit income generating opportunities for doctors in areas they actually rely on for patient care. This I might add is a product of the same academic types who didnt want to take responsiblity for care of the patients on their teaching services. We have seen the insurers working with employers kidnap patients and sell them back to the physicians at a 25-30% discount per encounter or procedure. We have seen the trial lawyers prevail in the tort battles at the legislative level outmanuevering the American Medical Association which was pre occupied with generating sustaining income through the coding of medical visits and diagnoses and less interested in hand to hand combat with the plaintiffs attorneys and politicians over defensive medicine. All through this period baby boomer doctors showed up for work, saw more patients day to day for less reimbursement, continued their teaching and research activities and provided pro bono and charitable care when able to. While they were busy providing more care for less money the hospital systems changed the bylaws in bloodless coups and non medical administrators and attorneys re designed the medical care model to comply with what insurers were demanding.

      I think few of us question the altruism and hopes and wishes of todays young clinicians. Few of us question your work ethic and most respect your desire to have a more balanced life than our generation of practitioners has had. We recognize however that your training has been far less well rounded and far more specialty driven than previous generations. It has created an environment where most physicians have less knowledge of the complexities of other areas of medicine outside their own and that plus a failure to communicate adequately in transitional situations and overlap care areas lead to far more fragmented care than patient’s deserve.

      • http://www.facebook.com/david.gelber David Gelber

        The practice of medicine has been stolen by politicians, administrators and insurers. I was a resident when the first managed care companies moved in. It sounded great to the attending staff: “Just agree to take 70% of your usual fee and we’ll funnel all our patients to you.” Thus began the downward spiral to today. Now we have SCIP and core measures and case managers calling every day to find out if the patient two days post colon resection for perforation with generalized peritonitis and sepsis is ready to go to LTAC. Sadly, I’ve seen too many such patients shipped out of acute care to SNF or LTAC, only to return one or two days later, sicker or worse.

        • Demdrybones

          Welcome to the new game. If you keep them too long, we won’t pay. If you send them out to soon and they bounce back, we won’t pay then either.

          • margo

            The medical system to a large degree ignores complicated medical problems and does not reward excellent work. in a way thank god there are docs like you who invest themselves with these difficult pts. In a way you are the heroes in all of this.

            I am an MD–not old not young. Have seen this coming for a long time and no one paid attention. MD’s /AMA could have tried more to deal with mangled care when it first arrived. However, the american public is responsible as well. There is more investment in paying a $10 copay. The same people will spend large amounts on entertainment and sports but not on health. I guess the phrase you get what you pay for applies here.0

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          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            The reason that some are more willing to pay large amounts on entertainment and sports is because the cost of some of those things are still cheaper than the price of healthcare. No, I am not saying that this makes it ok because it’s not. Unfortunately, even a good number with health insurance are having to forego necessary tests, procedures, etc because the copays, coinsurance, and deductibles are too costly. Then the ones that don’t pay large amounts on entertainment and sports but are still in a situation where they can’t afford to pay for healthcare so must forego necessary tests, procedures, etc because they may not be able to afford the copays, coinsurance, and deductibles because they are too costly due to the fact that now they must decide whether they are going to be able to eat, pay the mortgage, and the electric bill. Again this does not make it ok but this is where a lot of people find themselves these days. And these type of decisions are not fair to have to make but must be made for fear of the electricity being cut off, or risk having their house foreclosed on because they can’t make the payment. And there are yet others that are so financially tight that even these latter things are a struggle to pay just by themselves, so how are they going to be able to afford getting necessary health care services?

            Yes, there are programs out there to help those that are financially not able to pay for healthcare services. And that’s great but those are for those that are either not insured at all, or don’t have enough coverage if they qualify. But if someone has health insurance people get the idea that if you can afford the premiums of your health insurance that you can also afford everything else that goes with it. That is not always the case. I have numerous friends that are in this situation. So what are they supposed to do? So that means not being able to qualify for these kind of programs which could possibly help them.

            This in part goes back to the discussion of why it is felt that a Primary Care Physician is necessary because they help care for the patient’s needs, and while doing so helps reduce the costs of health care. But many of these ones can’t get access to a Primary Care Physician because they can’t afford it.
            I wish it were as simple as saying, “ok, we need to cut back more on how much entertainment we make use of”, or “we need to cut out…..”, but unfortunately it’s not because not everyone falls in to this category.

            And trying to fix the problem on all levels is going to be quite a challenge over the next number of years to come.

      • Demdrybones

        Not sure that I agree that my training has been more specialty driven. It’s still 4 years of med school and then 3-5 years of residency and possibly a fellowship after that. The complexity and volume of information to learn has increased to be sure.
        Primary care doctors should be the glue that holds the system together. I agree, everyone involved in the patient’s care has to see the patient as a whole and not a body part. PCPs have relinquished their dominant role in the process by becoming glorified triage nurses. Abnormal EKG? Refer to cardiologist (who almost certainly will order an echo/stress test). Knee pain? MRI and referral to ortho (I could probably diagnose knee OA on physical exam alone in 90% of cases and on x-ray in 9% of the others – MRI is the most overused and abused test out there). Diabetic? Let an endocrinologist manage your blood sugar. My brother-in-law was referred to heme/onc by his PCP for a PT that was 0.1 above normal. The heme/onc laughed in his face, but everyone in his insurance plan paid for that pointless referral.
        I understand that primary care doctors have been hardest hit in terms of being overworked, underpaid, and fearful of medical malpractice. However, many of them refuse to get admitting privileges or follow their own patients in the hospital. It doesn’t make sense economically. Just another factor in a broken system.

        • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

          If PCPs have become glorified triage nurses its because the system and their colleagues have legislated that. Well trained internists and family practitioners coming out of a good residency program could do everything from performing punch biopsies on skin lesions, to performing simple office based surgery, to working ventilators in the ICU, reading EKG’s . They were economically credentialled out of it at the hospital executive committee levels and later by organizations like JCAHO and insurers. Having taken and passed the geratrics boards in 1992 I felt comfortable evaluating and treating seniors with cognitive impairment. Nonetheless it is a rare patient who isnt sent to the neurologist by their children or grandchildren. Evaluating and treating cardiac risk factors is a staple of training and yet i have hypertensive and hyperlipidemic patients with no evidence of valvular or ischemic coronary artery disease who see a cardiologist to manage their hypertension and lipids based on friends and relatives insistence. I have no problem referring patients for opinions and to ask and answer complicated questions or sincere concerns of the patients and their families for a second opinion. Those patients often never return even though the treatment and evaluation as per the consultant are right on the mark. There was a time that uncomplicated patient was seen and referred back to the referring doctor with suggestions and parameters for another visit. Today that patient gets a followup appt in a few months and regardless of the control of the problem or simplicity of caring for it, is rarely turned back to the referring doc for longitudinal care.

          • margo

            Wow!! That’s somewhere between ridiculous and unfair!! Are you saying for routine matters of say Htn, the PCP is not the one following up on this? What is left then–new triages??

          • http://www.facebook.com/david.gelber David Gelber

            When I started in practice, twenty two years ago, PCP’s routinely followed their patients in the hospital, some even came to the OR to assist on their patients surgery. Gradually, the number of PCP’t that followed their hospitalized patients diminished to zero. Primary care docs don’t get paid to see hospital patients; they have told me that they are better off economically and from a liability standpoint if they stay in their office. A good patient for them is, and I quote a Family Practice friend, “A sore throat; takes five minutes and treatment is straightforward.”

          • Suzi Q 38

            My PCP was concerned about this.
            After getting treated by my endocrinologist for post hysterectomy hormonal symptoms, I went back to my PCP.
            Why? It turned out that I had no hormones, and nothing was wrong with my thyroid.
            I told her that I was going back to my PCP, since not much was wrong that she could fix.

    • Dave Mittman, PA, DFAAPA

      WOW. Great post. Totally agree and will post feelings on my own about the PA mediocre slight.

  • buzzkiller

    You really have to keep your posts shorter and more focused, doc. You’re all over the map here.

  • http://twitter.com/ThirdCoastPA Matthew Edwards

    “Where are all these ramblings leading?”

    Goshed durned kids these days with their smartphones and EMR and midlevels and lady doctors! By golly, I walked 20 miles to medical school in the snow and I paid my professor with acorns I collected on the way! Those were the days when doctors had real respect, I tell ya! None of this insurance company gobbledy gook! That was real medicine!

    • http://www.facebook.com/david.gelber David Gelber

      It was also uphill both ways.

    • Suzi Q 38

      Even though I don’t agree with you, you are very funny.
      Maybe take the humor to The Comedy Store….you could do a routine about older doctors and what you think of them, and what makes them fun to hang out with….
      I thought that doctors didn’t have much of a sense of humor because they had to study way too much and kept seeing “sick people.”
      Kind of like a line in a movie about 10 years back when the little boy looks at his adult friend and says: “I see dead people…” too real for a pathologist…..

    • karen3

      Um, as a well experienced patient, I will tell you that I absolutely cringe when I see the doctor is a fresh green one. Absolutely no ability to do a history, no critical thinking skills. The old guys are out of date (“I learned everything I ever needed to know at HAHVAHD thirty years ago”) but sometimes you can at least have an intelligent, albeit not particularly well informed, conversation.

  • http://twitter.com/RHR_Chat RHR_Chat

    As a patient advocate, what I see is territory fights between specialties. The oncologist or ED doc may request the patient be admitted for a particular purpose (ie. elderly cancer patient with infected cellulitis needs IV antibiotics). But once the patient reaches the floor, the concerns of the oncologist or ED doc are irrelevant.

    Especially in the elderly community, hospital generalists (even in teaching hospitals) triage the patient, stabilize the patient and get the patient out of the hospital. On more than one occasion, I’ve witnessed this precise set of facts and the hospital generalist (read, hospitalist) refused to treat for cellulitis. The patient was stabilized, received no abx and was discharged with infection and pain. The elderly patient was readmitted within a few days with pneumonia. That second course of hospitalization lasted weeks.

    My point is that once the patient is admitted into the hospital, the oncologist (a pcp for cancer patients) and/or ED doc’s concerns were ignored. No one in the hospital consulted with the oncologist or ED doc. The patient care became a turf war.

    I have even had orthopedic surgeons refuse to speak with the oncologist or infectious disease before operating on a fallen arch. The orthopedic surgeon decides surgery should be performed – period. But chemotherapy or infectious disease obviously impacts the bone healing. Bone doesn’t heal, more infection ensues, patient dies. It all could have been prevented if the physicians spoke with one another.

    The patient as a whole has become a collection of parts. No one physician specialty is caring for the patient. I guess that would be old fashioned.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      Once upon a time the patient had a doctor. That doctor admitted his or her patient to the hospital and cared for them. When that patient was ready for transfer or discharge they transferred them to their care in another setting. If they needed specialty assistance they asked for it and colleagues were willing to give an opinion. That original admitting doctor has been replaced by the hospitalist. The hospitalist is there because the hospital system wanted an employed physician they could influence in a subtle manner. In the teaching hospitals the faculty for the most part wanted to teach but did not actually wish to be responsible for the care of the patients their interns and residents were caring for. The insurers were told the hospitalist would ” move patients along quickly and cut hospital days” so they and the employers loved them. As hospital employees working shifts the hospital based doctors rarely argued with the case managers when they decided the time was right to move the patient elsewhere.The outpatient primary care doc who normally would come to the hospital was told that if you take time away from the office routinely to care for hospitalized patients , based on your overhead and our reduced payment you will need to see more patients per day to pay the bills so stay in the office and be more productive. The only one who suffered is the patient who is in fact the reason we all go into medicine in the first place

      • Suzi Q 38

        Amen.
        I remember delivering our first child and the doctor walking up to me after 24 hours and asking me to get my stuff, call my husband, as I was going home.
        I looked at him and said…”No way.”

        He was rather surprised, and said, well, you can’t stay here too long.”
        “I know, doc, but I think I feel a fever of unknown origin coming on…” I will definitely be feeling better and ready to face my daughter solo tomorrow.”

        Same thing happened with my son for a C-section…
        Hysterectomy, da vinci style, the doctor wanted me out in less than 24 hours. He found out that DD was an E. R. nurse.

        What the heck??? I barely knew my name in less than 24 hours, let alone the doctor’s, as I had requested Morphine as my drug of choice for my anesthesia.

        Anyway, I knew that it was probably pressure from the insurance company, or the fact that he wanted to show administration that the daVinci saved patient hospital days.

        Unfortunately, I didn’t care and was somewhat guarded and careful about staying 2 days.

        • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

          You are very welcome

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Speaking from the patient side of things, when I first heard about hospitalists around 10 years ago or so I cringed. I still cringe because I don’t like the idea of someone other than my own doctor caring for me if I ever need to be hospitalized.

      • Texas Doctor

        “hospitalist would move patients along quickly and cut hospital days”- part of it is not because the hospitalist is all business minded, but because they can focus on the admitted patient without having to worry about clinic patients waiting in office-as would be with a traditional PCP. Generalization is unfair, no matter what the context is. There are sincere, patient centered hospitalists who love to practice medicine. I am a hospitalist, and when I contact PCP and ask why the patient is on a particular medication, most of the time I see that they have no idea!! They often say-”oh are they on this medication! let me add it to their list”. Some do not even bother to talk to me and never return a call. Some say- if you are planning to consider hospice, call facilty X, because that’s what I use. Still I notice how deeply patients are connected to them and take their words as final. I have absolutely no problem with that but I just want patients to reconsider what would be their criteria of a dependable or otherwise “good doctor with a soul”. Basically this is all a psychological game.

        My opinion is that when you see a patient with diagnoses of ESRD, DM, PVD s/p B/L AKA, HTN, CVA, pressure ulcers with severe dementia admitted to hospital for septic shock by a PCP from a Nursing home, that speaks something. If you are a good PCP, this patient would not have come to hospital in the first place, but would have had a death in dignity. If you do not want to deal with such a patient and their family with surreal expectations, why criticize someone else (hospitalist) who sees this patient and calls appropriate consults while priming the family to get a grasp on reality?

        Speaking about case managers, it’s annoying when they tell you what to do. We all know why they act that way. Let everyone do their job, but do not yield to pressure. Be welcoming, but do not move from what you think is right for the patient. Sometimes we can prevent a re-admission by making the “length of stay” a little longer. As long as you have the knack to do that, you will be ok.

      • karen3

        Hospitalists are a scourge to both patients and the practice of medicine. Other professions consider it unethical for said profession to report to a person not a member of that profession, to have a non-professional profit from the professional’s work, to have any say over said professional’s work, to have a non-compete or to have an “exclusive’ referral arrangement,. Never saw one who could diagnose his or her way out of a rest room,

  • margo

    In a way I think we’re all talking about the same thing. And it’s enraging that the medical system has been allowed to break. But I’m not sure it’s all MD’s fault. I wish the MD’s had fought mangled care when it first came out. I’m not sure how much they could have done but I never saw effort on the AMA’s part which was profoundly disappointing. I’m not sure how much MD’s could do alone on this. THe American public has accountability too in letting this happen. They are focused on letting their employers pay or insurance pay and are frankly cheap. They only are willing to pay a small copay. And the phrase you get what you pay for comes to mind. Yet the same people are happy to pay larger sums for entertainment, sports–you name it.
    I feel for new residents feeling left alone and angry to deal with this. Clearly each individual resident MD may want to be curious and invest themselves in helping the more complicated pts–but how sad to be left alone in it!! the medical model of being curious –finding interest and pride in medicine as far as diagnosing problems of difficult pts does not seem there anymore. I am in the middle—not old not young– but have seen this happening for a long time. Until more recently the american public has not seemed to care or pay attention to the failing healthcare system–unless they themselves get sick—

  • margo

    I think both Demdrybones and Gelber in a way are dealing with the same kind of problem. The medical system to a large degree ignores complicated medical problems and does not reward excellent work. in a way thank god there are docs like you who invest themselves with these difficult pts. In a way you are the heroes in all of this.

    I am an MD–not old not young. Have seen this coming for a long time and no one paid attention. MD’s /AMA could have tried more to deal with mangled care when it first arrived. However, the american public is responsible as well. There is more investment in paying a $10 copay. The same people will spend large amounts on entertainment and sports but not on health. I guess the phrase you get what you pay for applies here.

    • Suzi Q 38

      I remember telling the nurse navigator that “Dr. D was my hero. He told me to tell my doctors where the problem was. Here he was the gastro, and he told me where it was when the neuro had no clue.”
      I tried to get him to call the doctors himself. I thought that they wouldn’t believe me. When I told him my concerns, Dr. D said:
      “No YOU tell them what I said. Your problem is in you upper spine…you need an MRI of the upper spine. Do not go to the surgeon first. Go the the neuro.”
      When I told the neuro what he said, he jumped and came alive.
      He finally ordered the very tests that I had been asking for in prior visits. (I had wanted a full MRI of entire spine and nerve tests on my legs, feet, and hands).

      I was not expecting a doctor, mush less the gastroenterologist to “go to bat” for me like this. If he hadn’t, I don’t know where I would be.

      Part of the reason is that he has worked at the hospital for over 20 years. He had been chief of staff at one point, so he was confident enough to correct a couple of doctors.

      He sure sent them “scrambling.”

      His actions restored my faith in doctors.
      Thank goodness there are those that truly care.
      He cared more about me and my health problem than he did about any potential embarrassment it would cause the other two doctors.

      The other two thought that I was making it all up to cause trouble.

      I am going to gracefully leave their care at some point, because my trust in them is compromised.

  • Dave Mittman, PA, DFAAPA

    Again with all due respect, I would like to provide on the “NPs and PAs who need more insight” to diagnose the more chronic cases comment.
    I can’t tell you how many times I or my PA (and NP) friends have diagnosed patients with multiple illness that were missed. Or treated something no one else wanted to treat, or bailed someone out who did not have PA after their name. All of us do it. Many of us PAs are good and are managing very complex patients. Maybe this FP group hires people right out of school? Or burns people out? Or pays poorly. Or expects you to see too many people and be a turf machine? Or does not have time to mentor and teach so the only people who stay are the ones that are OK with seeing retail health like patients 24/7. Many of us would not be happy at all.
    Many of us have gone through real apprenticeships or residencies which were very good. As good as doing one in surgery at Harvard, maybe not, but good enough to launch a person into the world of medicine who can think and who has the skills to get better.
    If you want excellent co-workers you have to look for them, be they physician, NP or PA. You also have to want to work as a team that demands the best from everyone on the team. Hire a PA who served in the Army in Afghanistan and tell me they have problems treating complex problems.
    I’m sorry, I did not see why that dig was necessary.
    Dave
    Dave

    • http://www.facebook.com/david.gelber David Gelber

      The comments about Pa’s and NP’s were from the Family Practice Doc, not me. I don’t know any details about his PA’s adn I did not mean it as a dig. AS with most things there is great variability in quality between individuals, which is one of the points of my ramblings.

      • Dave Mittman, PA, DFAAPA

        No offense taken. Could not help but feel that we were being pointed out as part of the problem. We are not.
        Many of us care as much as you do and about very much the same things. We too have a stake in the future of medicine as clinicians and (I am getting old) consumers.
        Dave

  • karen3

    This is probably the best essay i have seen from a doctor in a long time.

    First, it is not mere mediocrity, it is incompetence. If I were a recent graduate of a medical program, I would be furious as to how little is actually learned. A reasonably motivated and computer literate patient can out ‘doctor” all but the very best doctor. My experience is that doctor Google, plus some labs, is actually better than 90% of the docs out there. The insanely simplistic “standards of care’ will come to a cheaper and better result that 90% of doctors. If compensation for doctors is going down, this is why. If you are competing with Google as to “what facts you know” you will be cheap indeed.

    What is valuable to me is not the warm and fuzzies (I have friends and they do that for free — used to have a mother who joined in as well, but incompetent doctors killed her) but having the experience that lets a doctor know what google and a passel of patient groups cant tell me. And if I doctor wants to have that — something that is of real value — he or she is going to have critical thinking skills, will be a good listener, and will have taken on the hard cases.

    Maybe the better thing would be to have a base percentage multiplier for the various codes — a multiplier depending on how difficult your case load is and how well you do with those complicated patients. That would address the green, untrained, fool right out of med school getting the same reimbursement as the 20 year, 750 successful surgeries, veteran.

    I have respect for the idea of subspecialization, but for goodness sakes, there needs to be some way of informing patients EXACTLY what you do (ie don’t say you do abdominal surgery generally if you only operate on a particular two inches of the small intestine and that is it) and insurance panels need to reflect that specialization, so I am not expected to have a spine surgeon operate on a tumor wrapped around my auditory nerve. And there needs to be accurate tools for internists to help patients navigate this increasing complex maze. A bit more transparency on success rates, number of each type of surgeries performed each year (minus padding), would do the system wonders.

    And if someone has gone through three jobs in two years since residency, there needs to be some questions on licensing.