(I confess, what with the feasting, shopping, caroling, and wassailing of the holidays I cannot collect my thoughts to write anything coherent longer than a couple of paragraphs. My apologies. -PB)
Taking Leave of our Common Sense
In a previous article I mentioned that politically, health care reform was not a big issue for me and I was instead more concerned about national defense and killing terrorists. I reiterate that from a purely utilitarian point of view, building, equipping, and manning a Carrier Battle Group is a better way to spend our national treasure than attempting to guarantee free health care for all. I know that as physicians we’re supposed to believe in medical care like foxes believe in chickens but there are more important things in life most of the time, for most people, most of whom don’t need that much medical care except on infrequent occasions. It is more the fear of not getting medical care that is driving the current electoral panic rather than any real risk that anbody is going to be left outside the door of the hospital for lack of insurance. While it is true that there is a small subset of the population who have no medical insurance, this doesn’t mean that the majority of them have no access. We act as if access can only be had if somebody else pays the bill but large numbers of the uninsured could afford major medical insurance and their own primary care (which is not expensive) except that they have other priorities. There is nothing preventing their access to medical care except their reluctance to divert money from other, more important discretionary spending.
That and a lack of primary care physicians but that’s not a problem that can be solved by giving everybody free health care. Even the insured have difficulty finding a doctor and waving a magic wand, declaring that the unwashed now have access, and even throwing a bunch of money at the problem is not going to materialize a couple hundred thousand primary care physicians out of nowhere.
The real question is whether somebody who doesn’t care about their health should get free health care courtesy of the public treasury. A pack of cigarettes costs around five bucks in my neck of the woods. That’s 150 bucks a month, to which we can add another couple hundred for booze and other irregular pleasures. With this kind of money changing hands even among the Holy Underserved, it is inexplicable why you or I should be asked to finance their routine health care except through some sort of quasi-extortion where the usual suspects pushing We-Swear-It’s-Not-Socialized-Medicine hold a gun to the patient’s head and threaten us with higher costs down the road if we don’t cough up some money now. Or look at it like a mugging where, to avoid getting hurt, we’re supposed to hand over our wallet without making any trouble.
The key concept is that primary care is not expensive and, under the care of a physician who has the time to think about a patient, it can be extremely effective in keeping chronic conditions stable or at least delaying the inevitable expensive interventions significantly. But only if the patients give a crap about their health which no amount of free health care will do a thing to encourage. In other words, a good predictor of how much or little expensive medical care you will eventually need during your life is the amount you care about your own health. If you care, you will pay for the occasional doctor visit even if you have no insurance and both take your medications (which are hopefully inexpensive generics) as well as take steps to modify your lifestyle. If you don’t care then you will ignore your doctor, decide that personal watercraft are more important than your blood pressure medication, and despite getting all the free primary care in the world you will still end up dying the death of a thousand interventions as you decompose slowly in the medical triangle trade. (Nursing home to Emergency Department to Intensive Care Unit.)
To smoke a pack a day in the face of severe emphysema or to choose booze over your antibiotics is to demonstrate that you don’t give a rat’s ass about your health. If you don’t, why should anybody else except because of the previously mentioned blackmail mentality?
Throwing Money Away
Primary care is dying in this country, largely because the the government which sets both the amount that doctors are reimbursed for their time as well as pattern by which private insurance reimburses, has decided that cognitive skills are less valuable than throwing a lot of procedures at the patient. Most of this is a lack of trust by parsimonious bureaucrats who reflect the general American character trait of preferring action to deliberation. A typical patient, if he gets a large bill from an internist who did nothing but ask a lot of questions, poke him a little bit, and then lean back in his chair staring at the ceiling while he thought about the case, feels as if he’s been cheated. After all, he spent an hour with the guy and he didn’t do a thing but change his medications a little and give him some advice.
The motherfucker didn’t even order any tests.
On the other hand if he presents to the Emergency Department and is loaded to the gills with intravenous contrast dye and then assaulted with every possible test and invasive procedure imaginable, the typical patient or his family will settle complacently into their happy zone convinced that now, finally, they are getting their money’s worth. Doesn’t matter that much of what is done is unnecessary or at least could have been replaced with a little bit of sound clinical judgement, nobody’s happy until they see some action.
This is not to say that people don’t want to spend a lot of time with their doctor, just that they don’t feel they should have to pay more than a couple of bucks for the privilege. Thinking is easy, after all. It’s not like the doctor had to do anything. The government has picked up on this philosophy and has subsequently come up with the perfect formula to save money which, as is typical when people who are qualified for nothing else but government come up with a plan, has resulted in large amounts of money being thrown away.
Consider the typical internist or family physician trying to keep the lights on in his practice. The amount that Medicare or Medicaid (and private insurance as they typically take their reimbursement guidance from the government) pays the doctor for his cognitive skills; the traditional history, physical exam, and clinical judgment, is so small in relation to both his expenses and his completely reasonable desire to make as least as much as a decent auto mechanic that he is forced to run a high volume practice. Of course, not every patient requires a long visit and certainly a more complicated patient can be given a little more time but when you are seeing thirty patients a day, you can see that it is impossible to give the truly sick and the multiply co-morbid the time that they need.
The typical elderly patient who needs anything more than a routine physical exam cannot have her problems addressed in a fifteen minute visit, much of which is taken up by compliance and admininistrative tasks. Consequently, there is a disturbing tendency to consult specialists for every medical problem that will take more than fifteen minutes to address (a tendency that is completely separate from the legal imperative to fend off the predatory plaintiff’s attorneys). The result of this is that you have three or four doctors doing the work that one could do with all of the lost time and inefficiency that this entails. Additionally, under the theory that to the man with a hammer everything is a nail, when you send a patient to a specialist they are going to use their signature procedures to the full extent allowed by reimbursment and ethics. In other words, the default position of a gastroenterologist is to perform the colonoscopy because short of this, he may be adding nothing of value to the patient’s care. Now, I’m not saying that there is no use for specialists, just that sending a patient to a specialist to confirm something you already know or to implement a treatment plan that you would start yourself is a waste of money…except that the economic realities of primary care make it impossible not to use them like this.
Many specialists are used as nothing more than physician extenders, kind of like mid-level providers if you think about it, for busy primary care physicians who know what to do but don’t have the time.
The Ticking Time Bomb
Having patients followed on a routine basis by a cadre of specialists is not only wasteful but dangerous. Under the team-based health care delivery philosophy, physicians are supposed to communicate with each other but, as talking to other doctors is generally non-reimbursable time, communication suffers for the same reason every other poorly-reimbursed activity suffers. The danger is that patients who are being followed by a disorganized squad of specialists will receive dangerous interventions and studies seemingly willy-nilly and, most importantly, are placed on long lists of medications, the interactions of which cannot possibly be fathomed except that someone has the time to sit down and spend an expensive half hour doing it. I regularly see patients with one-page medication lists taking three or four medications of the same class as well as medications that seemingly act at cross-purposes, not to mention having the potential for dangerous interactions.
I know perfectly well that many patients require this kind of complexity but after you see enough unexplainable altered mental status, coumadin levels (INR, I mean) through the roof, as well as the effects of everybody’s favorite loaded gun, digoxin, you sometimes wonder if anybody has ever taken the time to verify that yer’ demented granny really needs to be on 20 different pills.
Now, and I’m just thinking out loud here, what cardioprotective effects are we getting by keeping an 89-year-old woman on a beta-blocker, a statin, and an ACE inhibitor that are not completely offset by the possibility of side-effects and dangerous interactions with her other medications? It is this and other questions that need to be addressed and decisively answered by one doctor who has the time, via adequate reimbursement, to do it. The alternative is highly fragmented and slipshod care.
And no, it is not enough to expect the patient to keep track of these things. Some can of course, but it is very common for the multiply comorbid patient to know nothing more about his medications than their colors and shapes or that one is a water pill and another is for his “gouch.” In an ideal world, the only variable would be the compliance of the patient, not the confusion that results from trying to coordinate the care of various specialists.
Happy New Year
Another one has come and gone. One day, as the memory of medical school and residency fades and I have to devote most of my free time to moonlighting at Taco Bell to make ends meet under whatever silly health care reform comes out of the trailer parks, ghettos, universities, and other islands of provinciality and entitlement in America, I may grow tired of this blog. As I am, however, still going strong, I appreciate your taking the time to spend your time reading and I hope I can continue to provide you with a good reason for doing it. As always I appreciate all comments even the ones I have to delete.
Hey, we have rules on this blog. I had to go to a moderated comment format because of a few people with bad manners and I hope this hasn’t been too much of a burden. Not to mention that my spam filter catches about a thousand spam comments a day which leads me to this question: What on earth has Britney Spears done to deserve this kind of attention? Fully half of all the spam comments I receive promise to link me to naked pictures of her in all kinds of situations. I’m just not that interested. In fact, my interest in Paris Hilton, Anna Nichole Smith, and Anglina Jolie, the other members of the internet Gang of Four, is about a 0.001 on the ten-point pain scale.
An apt comparison considering the famous panty-less getting-out-of-vehicle pic of Britney was, in fact, painful.
Love the “qualified for nothing else but gub’mint…” comment.
Will be a sad day if/when you decide to discontinue your blog; in the meantime, I always look forward to seeing entries from pandabearmd via RSS.
Panda, your views on primary care are perfectly reasonable. I am wondering what your thoughts are on expensive treatments (such as for cancer). Chemotherapy is expensive, and if you don’t have insurance, and often times even when you do (and are denied for some reason such as pre-existing conditions), you simply cannot afford care. What, if anything, should be done about expensive treatment such as those for cancer, AIDS, etc? You’re correct that Primary Care would likely be relatively affordable, but what about everything else? Do we leave these people out without treatment? We could, but we are not sure if we should.
You have said that people do not have an inalienable right to your labor. Why shouldn’t they? We have the right to the labor of government employees such as police officers or fire fighters, so why not hospital staff? I would think the best solution would be something like the British system (with NHS) where all doctors are employed by the government.
They make a decent salary (about $180k for GP, which is more than most FP docs make in the US). Instead of it being a volume business, you make a flat rate with incentives for primary care. Obviously, as you mentioned before, we’ll have to ration care like they do in Europe and perhaps we will have to put that 89 year old granny down. But I think that’s a fair compromise. If you’re 50 and need chemo, you’ll get what you need but, but if you’re 97 and on your sixth heart attack, you won’t be followed around twenty four hours a day by a cadre of heart specialists.
Now, I could very well be blowing sunshine from my ass, so I’d love to hear why you don’t think this would work or is a good idea.
Anyway, keep up the great blog – I’m completely jealous of your writing ability.
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(I have no solution to the problems you mention except a few suggestions that will appear in my next article as well as the general observation that there is no solution to the problem, at least no finely tinkered wonkery or well-crafted legislation that will do anyting but result in either exploding health care costs or the severe kind of rationing you mention. I will say that on a general, non-medical level what we need is a low tax economy where the disincentives to productivity are removed and the incentives to be a free-loader are made more stringent. The alternative is to evolve into just another creaking welfare state like much of Western Europe (including the UK) where stagnant economies lead to too many stagnant people living at the expense of productive people. This kind of thing is unsustainable as it is nothing but a ponzi scheme. The best, but not a perfect solution as none exists, is to have a dynamic economy with steady growth and the opportunity for every citizen to work and provide for himself as much as possible.
Why the Freeloader Model as practiced in Europe has become the ideal is beyond me particularly as these systems are as weak and liable to collapse as our own system of realtively limited (for now) entitlements. -PB)
your thoughts on money and primary care are absolultely spot on. I don’t know how else to say it.
Every administrator and bean counter trying to “fix the system” should read this post before every meeting
keep up the outstanding work.
Did you see Michael Moore’s ‘Sicko’ documentary? I found it curious that even the physicians quality of life (in terms of hours and benefits) seemed superior in Europe compared to the U.S.
(American doctors generally make much more money and have a higher standard of living than their European cousins although we do work many more hours. Michael Moore knows as much about health care as I know about making movies, that is, nothing. -PB)
Happy New Year, Panda,
I’ve been enjoying your blog for a few months and wish I’d found it a long time ago; I’ve recently “retired” after 9 years as an ER doctor at a very small semi-rural hospital, which can be intensely isolating. Your posts are audacious, hilarious and so refreshing – what a relief! I feel like I’ve found a compatriot. Thanks!
Olivia
PB:
I couldn’t have written it better my self.
What if hospital based docs were moved from a reimbursement-based income to a flat salary? The PCP would be able to spend as much time with his patients as he sees fit, without worrying about having his water shut off.
(Where’s the money going to come from and why would a hospital pay a doctor more money than he generates in revenue? Now, there are probably some cases where a hospital would pay somebody more than the revenue they ostensibly generate but this would only be because the the doctor has some other quantifiable value or the hospital is a money-loser anyways and the need to stay open supersedes economics (as in a charity hospital) but generally, everybody need to pull his weight and in the medical world, this means volume.
There are relatively few doctors who are hospital employees. Most work for independent groups that contract to the hospital, even in hospital-based specialties like Emergency Medicine. Being a hospital employee generally means that you sacrifice some income for not having to deal with the hassels of self-employment.Â
I guarantee that if you were a PCP and worked as an employee for a big firm like KaiserPermanente you wouldn’t last long if you spent as much time as you saw fit with each of your patients.
By the way, a European-style model where physicians are essentially government-payed civil servants would make the problem of access worse. Suppose you decide to accept a relatively low salary (like physicans in Germany, for example, where surgeons make around $60,000 per year) in exchange for job security and freedom from the hassels of independence. How hard do you suppose you are going to work if your salary is not dependent on your production? In other words, where on one hand the baby-boomers getting ready to flood the system need you to work 60 hours a week, you are only going to feel like working forty…and even then at a leisurely pace because the incentive to work faster is not there. I suppose there are a few zealots out there but very few government employees work anything but nine-to-five with mandated lunch hours, breaks, and every holiday possible.-PB)
Panda,
What about Great Britain? They work less hours, but they are still required to meet minimum standards. And they do get paid decent money ($180-$250k).
(For your reading pleasure if you think that everything is Hunky-Dory in the UK.
http://www.drrant.net/
A typical GP in the UK earns about $110K per year (60K Pounds) -PB)
I may remind the reader that $110K in England is lke earning $80K in NYC.
London is the second most expensive city in the world to live in with a cost comparison to NYC of about 25% higher.
Try getting someone to train in this country for 11 years of school, miss their entire decade of life just to earn $23 an hour after taxes (based on only $40 hours a week)
I could make way more putting auto parts together in a unionized job.
And nobody is gonna sue me for you crashing your car.
By the way, as a hospitalist who works only in the hostpital, your insinuation that being employed by the hospital is somehow a good thing is not explainable.
If you want to see how employeed federal government health care workers function, go visit a VA anywhere in this country and you will see how the culture of laziness, not my problem, beaurocratic delays, turfing, do as little as you can attitude.
My experience as a resident in a VA for 3 years made me feel sad for veterans everywhere that they have to put up with this bullshit beaurocracy just to get basic health care.
I have patients every day who decline to use their VA benefits and be transferred to our local VA hospital, who will instead use their Medicare benefits just because they themselves cannot stand the way the VA operates.
Government run health care with employed salaried doctors and nurses would turn our health care into: well, imagine what life was like without cell phones and you get my drift.
Interesting. Thanks for the link. I never thought anything was hunky dory in the UK – I was simply wondering if it might be a better system than the one we have now.
Love the blog, dude. Read your posts way back on SDN but never thought your site would go this big. Can see why it did though and now I’ve got you in my bloglines.
Starting up my own blog now, but I shall forever hold PB as the Big Daddy of medical blogs.
Thanks for the props to primary care.
Great post again!
PB, what are your opinions on high-deductible universal healthcare, say $1000 per pt per year (excluding meds….that would be a seperate deductible)? Do you think that would provide “coverage” to those who need it and make people a “wiser” consumer? People would think twice about going the ER, or God forbid their actual primary care doc, for every sniffle and hang nail that they have. What if ALL citizens were covered under a national policy? Wouldn’t that lower/minimize corporate spending on healthcare from it’s own profits? Of course, there will still be free care for those that need it (Medicaid).
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(I favor, if anything, exactly what you speak of except that this would be paid for by individuals with the government only serving as a guarantor or an enforcer of the risk pool. For this to work, of course, EMTALA would have to be repealed or at least clarified so Emergency Departments could turn away people trying to avoid paying for their major medical policy by using the ED. The poor could have their major medical care paid as for them and it could include a low deductible which at no times allows anyone get any routine health care completely for free.
But generally the solution is not really medical at all but to privatize social security and medicare (which currently steal 15 percent of most people’s income for their entire working life) to allow them to have a nest egg at the end of their life from which they may pay for major medical expenses, to structure tax policy to encourage productivity, and to get a handle on the legal profession which is currently out of control in every aspect of American life, not just medicine. -PB)
Dead on, as usual. The great unwashed believe that health care = procedures and/or tests. It’s not health care unless you do stuff. Also, it should be high tech looking. And I’d like some pill, too.
Then I know I’m getting my money’s worth.
“A typical patient, if he gets a large bill from an internist who did nothing but ask a lot of questions, poke him a little bit, and then lean back in his chair staring at the ceiling while he thought about the case, feels as if he’s been cheated. After all, he spent an hour with the guy and he didn’t do a thing but change his medications a little and give him some advice.”
Nonsense. The public is used to paying for time with a professional. It’s physicians who have allowed their time to lose its values, signing reimbursement contracts that don’t reward that time, but reward volume. This necessarily encourages the physician to push the diagnosis off to the lab, and creating the expectation that the only way to diagnose is via testing.
The public, if you actually spend the time with them to explain what you are doing, will pay for your time. Will some still grumble? Sure, but that’s people.
Don’t blame the patient because you signed on to a crappy payment model.
Wait one second there, Dr. Panda. You’re not leaving us, are ya’?
“(which currently steal 15 percent of most people’s income for their entire working life)”
For them to steal it would mean they don’t get it back, wouldn’t it? Yet the vast majority of people do get that money back in the form of either cash or services paid for by medicare. Perhaps your case would be better made with less rhetoric.
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(Bull. The real rate of return for Social Security (where fifteen percent of most people’s income goes every year for their entire working life) is so low as to amount to theft considering that even in conservative investements, most Americans would do far better if they could invest their own money how they see fit.   Medicare is only about 1.5 percent of the total 15 percent (6 percent from the individual, matched by the employer with money that could have been payed to the employee) and is not capped.
Most people are not sick, even the elderly which is something we tend to forget as doctors because we only see the sick elderly, and could afford their own inevitable major medical expenses towards the end of their life if they could invest 14 percent of their income for their whole life.  The difference is that it is their money and if they don’t get sick, it is still their money.
Here, read this: http://thehappyhospitalist.blogspot.com/2007/12/eight-wonder-of-world.html -PB)
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Whoa, whoa, whoa there Matt… the “public” is far from being “used to paying for time with a professional.” The great majority of the “public” spends time with a professional (lawyer, accountant, etc) about once in their lifetime.
BTW, what gave you the idea that Medicrap allows physicians to negotiate their reimbursements? No siree Bob! The government tells you exactly how much their number-crunching nerds have decided your time is worth and in some cases doesn’t even let you choose whether you want to work at that rate (EMTALA). Medicare/caid are essentially the base from where all reimbursements are negotiated and they started the piece-work model as opposed to a market-based money-follows-preference model that I would prefer
I’m sure that if it was a (relatively) free market (maybe some monopoly-busting but I’m not too picky) Panda would be happy to let REAL negotiations provide the highest quality care at the lowest efficient price to allocate resources effectively.
“Most people are not sick, even the elderly which is something we tend to forget as doctors because we only see the sick elderly, and could afford their own inevitable major medical expenses towards the end of their life if they could invest 14 percent of their income for their whole life. ”
You assume they would do that, and they would do it intelligently. If they didn’t, however, are we going to let them die in the streets? Or are you just putting it on the taxpayern when they get sick? I highly doubt it will be the former, and if it won’t be, I’d rather it be their money, not mine, paying for their care.
“The great majority of the “public†spends time with a professional (lawyer, accountant, etc) about once in their lifetime.”
Accountant once a lifetime? No. And hey, hourly isn’t the only model of payment. But the public knows when they come in to see these people, they will pay either an hourly rate or a flat fee for the privilege. To pay it to a physician would not be so crazy they’d be shocked and appalled.
“BTW, what gave you the idea that Medicrap allows physicians to negotiate their reimbursements?”
Never said it did. I said why sign up to take Medicare patients if you aren’t getting paid in a manner you like.
“I’m sure that if it was a (relatively) free market (maybe some monopoly-busting but I’m not too picky) Panda would be happy to let REAL negotiations provide the highest quality care at the lowest efficient price to allocate resources effectively. ”
He can do that now. Nothing stopping him but himself. Of course, the current system pays physicians pretty well so it may not be worth the risk.
(No, it pays Emergency Physicians well, not other generalists. I will probably make, just starting out, almost twice what a family physician or internist makes because anything done in the ED, even low-level stuff, pays much, much more even through Medicare and Medicaid. “The System” does not pay generalists well which is why “concierge medical practices” are going to become the norm, not the exception unless the government legislates against them. -PB)
Matt said:
“Nonsense. The public is used to paying for time with a professional. It’s physicians who have allowed their time to lose its values, signing reimbursement contracts that don’t reward that time, but reward volume.”
I’m afraid that the public doesn’t see physicians as professionals, at least in the sense as somebody who provides a service in exchange for compensation. The current election cycle highlights one fact that Panda extolls on his blog more than anything else- Americans think healthcare is an entitlement that should be provided (or ensured) by the government. I should be able to pay a flat fee (deductible) and consume as much as I want.
It’s a damn tragedy (of the commons)
The system has an average salary of $150K. That’s $50K higher than any other profession. If family physicians aren’t getting paid well, or at least what they think they’re worth, drop out of Medicare/Medicaid and go to private pay or do something else in medicine. If the public thinnks they are valuable, then they’ll be willing to pay more to make it attractive. If not, then that’s the market at work.
Again, the only people physicians have to blame is themselves if they don’t like their payment models or reimbursement amounts.
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(I believe we actually agree that bad contracts with insurance companies and the government are the root of the problem. But I guarantee you that if (when) primary care doctors start quitting the racket and restructuring themselves as “cash only,” retainer-type practices along the same business model used by most dentists the government and insurance carriers are going to have the proverbial cow and the full-court press will be on to demonize doctors that opt out of the system to take care of patients on their own terms.
I repeat, if I were in primary care, on finishing residency I would work urgent care to pay the bills while I got a retainer practice started. All you would have to do is pick a fair-sized town, rent an office, amortize some basic equipment, compile a list of specialists who will take referrals, contract out to a lab for any but simple blood tests that you can do with basic equipment, and refuse to take any insurance. I guarantee that in even in my hometown in rural Lousiana, perhaps the poorest state in the Union, once you got going and established a good reputation, you would have more patients than you could handle (if you wanted that many patients). Your overhead would be low compared to collections. Amortizing twenty thousand bucks worth of equipment would run you what, five or six hundered a month? Rent? A thousand a month? Salary and benefits for a tech or a nurse if you didn’t want to draw your own blood or clean your own exam room? Depends on what you want or think you need. Malpractice if you want it? $15,000 in my state. 200 patients paying you a retainer of $500 per year? That’s most of your overhead and then some not even counting what you charge for a visit. Ten patients a day with an average bill of fifty bucks for 250 days a year? $125,000 a year in collections which is what FPs make but without the hassle, the paperwork, the bureacracy, and the need to see forty patients a day.Â
Not to mention that you would be giving high quality medical care and your patients, who could have access to you unfiltered through HIPPA and the byzantine rules that govern the “system.” Imagine the satisfaction of documenting for medical purposes and not to appease your suited masters in the government as well as having the time to think about your patients and optimize their treatments.
Not to mention the write-offs and tax advantages of owning a business. Consult with an accountant for optimal business structure. Collect up front for new patients, avoid the need for collections.
My sources tell me that you need a panel of about 1000 patients to see 10 per day.   Might take you a while to get this number which is why you’d have to work urgent care or for somebody else while you got it going. But remember that your patients are paying you a retainer so after overhead, the rest is profit. Hell, you could (and should) probably work in some free care for the truly needy…but on your own terms, not the nanny-states. -PB)
The average debt load for an medical education more than explains the salary difference you describe.
Also, the average work load, and residency. Do other professionals work for less than twice minimum wage for 3-7 years AFTER getting their degrees?
Go work out the opportunity cost of a 7 year neurosurgery residency. Dont forget interest compounding.
“Accountant once a lifetime? No. And hey, hourly isn’t the only model of payment. But the public knows when they come in to see these people, they will pay either an hourly rate or a flat fee for the privilege. To pay it to a physician would not be so crazy they’d be shocked and appalled.”
Must be nice in that ivory tower. People that frequent accountants more than once in a lifetime other than to get their taxes done (who in themselves are already a definite subset of the population) probably aren’t the ones who’d pitch a fit if physicians decided to re-evaluate the value of their time and really aren’t the issue. If everyone from CEO to janitor had their own financial planner who they had semiannual meetings with to discuss their future with it probably wouldn’t be a big shock for physicians to change things up, but if that’s your assumption of the Average Joe that’s some fairly rarified air you’re breathing there.
” and the full-court press will be on to demonize doctors that opt out of the system to take care of patients on their own terms.”
No one said running a business or having a wholesale change would be easy. And if the insurance companies put the full court press on you, frankly, I’m not that sympathetic. You guys hopped in bed with your liability carriers to do the same thing to lawyers, so why should you get treated with kid gloves by the health insurers?
(Whoa, Matt. Inurance companies can pound sand but governments can legislate to prohibit physicians from working outside of whatever crappy reimbursement scheme comes out of single-payer health care. -PB)
“Must be nice in that ivory tower. People that frequent accountants more than once in a lifetime other than to get their taxes done (who in themselves are already a definite subset of the population) probably aren’t the ones who’d pitch a fit if physicians decided to re-evaluate the value of their time and really aren’t the issue.”
I represent some very poor people, but they still need legal services. I work out payment plans, I give them discounts for prompt payment, etc. But all of them come in expecting to pay, and most do pay. I work in a small town in a very poor state, and my county’s average income is probably around $19,000 per year. So tell me about that ivory tower again?
“Whoa, Matt. Inurance companies can pound sand but governments can legislate to prohibit physicians from working outside of whatever crappy reimbursement scheme comes out of single-payer health care”
Then I guess you better start offering them legislative alternatives beyond just “lawyers are bad.” Because all your bitching about healthcare has led the politicians to believe you want something done. And if you don’t tell them, they’re going to do the easy thing that appeals to the most voters.
PB says “In a previous article I mentioned that politically, health care reform was not a big issue for me…”
Oh yea, that couldn’t be b/c medicine is the dominant health profession in America effectively pulling ALL the political strings already could it?
(The next 2 paragraphs are paraphrased from an unrelated article and author)
American medicine through its political entity the AMA and its many tentacles has a long record of stifling competition by supporting laborious and expensive accreditation for new competition, labeling everything and everyone they don’t control quackery and fraud, preventing willing M.D.’s and instituions from participating in treatment with non M.D.’s and even going so far as to threaten to de-license M.D’s/institutions willing to teach chiropractors or in chiropractic institutions.
IMO, the problem with American medicine is that it’s lazy, complacent and uncompetitive. It has been able to drive out the possibility of any vigorous challenge to its prominence of health care in America.
How can political medicine legitimately and PB ethically criticize the lack of hands on experience with the vast variety of patient conditions seen by medicine of CAM practitioners that is the result of denying CAM and chiropractic practitioners to medical educational rotations?
Is that not two faced?
Its not for the lack of trying on the part of Chiropractic, its solely b/c political medicine has frozen CAM out!
Political medicine is plain ugly when exposed to the sunlight of truth of its own acts over DECADES.
That is why I have known that medicine does not put patient welfare first and hasn’t for a very long time. For everybody else just read what the m.d.’s here write to determine who this group puts first.
Chiropractors and all CAM practitioners I have meet put patient welfare first and foremost and are happy to work together with M.D.’s for their patient’s benefit and health outcome.
Why don’t m.d.’s, at least the ones like PB and many who post on his blog?
BTW, the AMA did not have this prohibition prior to WWII only after, so it is possible to reverse the policy when a younger and open minded set of M.D.’s control their profession.
At least that is my hope.
‘By their acts you shall know them.’
Panda Bear opines on “Throwing Money Away and other Medical Topics”
Hey, Panda Bear if you have been keeping up with the medical news you should be aware that it is the patients that have been ‘throwing money away’ on worthless medicines.
Todays news from the NEJM says certain antidepressants are over prescribed and mostly worthless (like I’ve known all along).
And Big Pharma is hiding studies that show how ineffective their medicines are.
That ought to make you worry about every prescription you have ever written.
And every patient you disparaged b/c they failed to get better on those meds so you assumed they were flakes, fakes or chronic complainers.
Nope it turns out YOU were the flake, fake and failure.
I hope you learn something from these episodes and become more empathetic with your patients especially the ones that don’t respond to your ministrations.
And to make matters worse two big Pharm giants in the Statin business have had their drugs shown to do more harm than good (zetia/vytorin) and another and this despite that fact that they objectively lower LDL and raise HDL.
Now that is particularly spooky b/c that calls into question the vary foundation of the cholesterol myth and means lots more needs to be known before saying just lowering LDL any old way is good for us.
So many questions so little time.
I do not come here tonight to berate you or medicine though medicine may desires it, but to praise medicine for having men and women of the kind of character who put their patients and the truth ahead of profits and myth.
I am very proud of those professionals and your profession b/c of it
Those are GIANTS in your profession.
I respect your profession b/c of them.
(Like I said, shortcomings of the medical profession, mistakes we make, or gaps in our knowledge do not justify quakery and snake oil. Did you miss my point in all of those articles I wrote?  I mean, seriously, it’s like you’re not even reading. Am I not the one who says that we are ridiculously over-doctored and that a lot of our therapies are worthless? But that’s just life in the world of real medicine. Worthless things are tried and if they don’t work, despite inertia from entrenced interests are discarded. The same cannot be said about CAM. No amount of evidence to the contrary will ever get you to admit that your treatment modality as a chiropractor is worthless.
Jeez, buddy. Sort out what you want to say because in this you are preaching to the choir. I do not, by the way, prescribe many medications. Mostly pain meds. Most of the drugs we use do actually work…like narcan for example. Dramatic results.-PB)
PB states the obvious: “Like I said, shortcomings of the medical profession, mistakes we make, or gaps in our knowledge do not justify quakery and snake oil.”
Yea buddy, and you can start by looking in mirror followed by at your colleagues and institutions.
That is where “quakery {sic} and snake oil” ABOUNDS in the US Health Care system today.
By your OWN estimates UPWARDS of 50% of what you and your colleagues do is worthless and excessive.
Get angry about that.
“Did you miss my point in all of those articles I wrote? I mean, seriously, it’s like you’re not even reading.”
The issue as I see it is that you haven’t a clue about that which you rant when you stray from the traditional medicine.
You are an M.D., therefore judge your own and stop pretending you can judge others.
It’s that arrogance that sickens me.
“Am I not the one who says that we are ridiculously over-doctored and that a lot of our therapies are worthless? But that’s just life in the world of real medicine. Worthless things are tried and if they don’t work, despite inertia from entrenced interests are discarded.”
My oh my, reading your justification for sweeping the American medical profession’s widespread, deadly, diffuse, and endemic dirty laundry under the carpet is akin to reading a science fiction novel.
And a scary one.
Your argument is simpleminded “Do as I say not as I do.”
No wonder your profession deserves the blame being heaped upon it today from all directions for the past 6 decades of ever increasing corruption, today’s venally debased health care system, inducement based prescriptions, therapies, tests and surgery recommendations as well as for the for-profit bottom line driven options for medical decisions in networks.
Just b/c YOU believe that your profession is moral and righteous does NOT make it so.
I find–and so do millions of our fellow citizens–that your profession can be and at times is both immoral and unrighteous b/c of the failure to put the patient’s welfare first.
And if you followed recent news about Big Pharma you would know many of the most prescribed medications are over-prescribed per diagnosis, worthless compared to placebo per diagnosis and dangerous.
Do you really believe that writing such prescriptions earns you a pat on the back?
“The same cannot be said about CAM. No amount of evidence to the contrary will ever get you to admit that your treatment modality as a chiropractor is worthless.”
Ah, dude, that’s b/c its not.
All valid and reliable scientific evidence to date shows chiropractic to be highly efficacious, less dangerous and cheaper than comparable medical treatments for certain conditions.
That you refuse to admit that speaks volumes about YOUR objectivity, education and understanding of the issues.
Chiropractic is not ER medicine or any other medical specialty. We may treat the same patient but different conditions with the same complaints and symptoms.
I realize some chiropractors stray and go outside of the paradigm. So do some m.d.’s, it’s something both professions must deal with.
That the majority of the patients we treat get well faster and rate our care superior to medicine for what we treat you will just have to come to grips with.
I readily admit that the placebo effect and self-limiting nature of many conditions we see in our offices contributes to our success.
I await your admission of that same truth in medicine as well.
I think you fool yourself b/c you relate only to what you see and not to the universe of health issues that actually exist in the community.
That is you mostly see ER cases when people are ‘broken’ or overwhelmed healthwise.
Someone has to break it to you, most health care is NOT based on emergency medicine.
You have a micro view of a macro world.
“Jeez, buddy. Sort out what you want to say because in this you are preaching to the choir.”
Have I been opaque or have I said from the beginning you are unqualified to disparage CAM and should instead focus on your own profession?
I have provided links to legitimate research on CAM.
Talk about someone who doesn’t seem to read, time for you to look in the mirror and wipe the egg off your face.
“I do not, by the way, prescribe many medications. Mostly pain meds. Most of the drugs we use do actually work…like narcan for example.”
I’m personally very glad you have them to prescribe since my family and I have been beneficiaries, as I have posted previously.
That’s not an issue for me.
I have never said you should not practice medicine for the benefit of mankind b/c of the questionable issues in medicine.
It is you who asserts my colleagues and I should not practice b/c of the issues we have in ours.
Try to get who-says-what straight for a change.
Just b/c medicine is not holy and therefore unpure and imperfect does not mean it should be removed, erased and restricted from helping mankind.
Logically, rationally and reasonably the same principle applies to my profession and CAM in general.
Why is it you can’t get that? Not getting enough sleep?
Panda Bear, read ask yourself why this was necessary.
Then ask yourself why it was the employees and not the m.d.’s that demanded the change.
From today’s USAToday:
“Health system sweeps drug trinkets from clinics”
MINNEAPOLIS (AP) — When a Duluth-based operator of hospitals and clinics purged the pens, notepads, coffee mugs and other promotional trinkets drug companies had given its doctors over the years, it took 20 shopping carts to haul the loot away.
The operator, SMDC Health System, intends to ship the 18,718 items to the west African nation of Cameroon.
The purge underscored SMDC’s decision to join the growing movement to ban gifts to doctors from drug companies.
…”We just decided for a lot of reasons we didn’t want to do that any longer,” Dr. Kenneth Irons, chief of community clinics for SMDC, said Friday.
“So SMDC put together a comprehensive conflict-of-interest policy that, among other things, limits access to its clinics by drug company representatives.
##############Employees suggested the “Clean Sweep” trinket roundup, Irons said.”#############
Reconstruct the link:
http:
//www.
usatoday.
com/news/health/
2008-01-19-drug-trinket-roundup_N
.htm
I greatly admire this doctor, his health network and its people for taking this bold and unusual action. Bravo.