paradigm shift

[fuegorama]

Since I certainly can't discuss my potentially stupid idea with PD-types in person, I would like to hear the input from my future colleagues on a semi-anonymous forum.

I will never be "wealthy" as an EP. My partner has demonstrated to me the ease with which serious coin can be garnered in other professions. Emergency Medicine is the thing I want to do with my life and I would do it for near nothin' if I could. However, I have a crazy amount of debt and I do enjoy travel, decent cheese and very expensive bicycles.

Payor-mix is the gold stone we all tag when job searching. It is also the great vulnerability in the EM world. As fewer private employers offer insurance and as premiums increase for everybody else, the reimbursement struggle is getting harder and harder.
Combine this with the inordinate amount of resources groups like ACEP put forth in an effort to hold-the-line on medicare funding and future incomes really begin to look like a house of cards.

No matter your political leaning, I think we can collectively acknowledge that the GOP has failed to maintain power. The coming democratic presidency is largely predicated on some form of universal healthcare. The public has voted and is sick of not being able to afford getting sick. 50% of the bankruptcies filed have medical bills as a primary source of debt. Our countrymen want coverage. What will this look like? What will it mean for the doc in the trench? Is there anyone who thinks that today's income will continue for the next decade? What should we do?

While it is a hated piece of legislation, EMTALA is a major pull for me and many of my more altruistic leaning applicant colleagues. The 'take all comers' role of the EP is an aspect of EM of which I am very proud. We are the profession with a federal mandate to provide care. This has never been funded. We have settled for the paradigm of bridging the self-payers and un-reimbursed. This has worked well for the past twenty years. It is grinding to a stop.

Idea (not new, but I think worth discussing)
What if EM became the first group of federally employed physicians on a national scale? (cue panda, FF, and flighterdoc)
One route to success for this shift would entail negotiation started by us. Making demands now for a wage along the median incomes of today's EPs with an ironclad cost-of-living annual raise would be a start. Add loan forgiveness, insurance and retirement and this could look pretty good for the majority of current clinicians.
Overnight we would see the dissolution of med-mal reform. It's a little harder to sue a government entity. The push back against medicare would die. Our political dollars could go toward actual patient care initiatives including a national EMS system and fluid EMR.

Down sides-decrease in productivity, loss of our already flagging autonomy, getting screwed on the next fiscal cycle a la Canada's docs in the 80s etc. etc.

So, is this ridiculous fantasy? Could we be arbiters of our own fiscal health? Or, will I spend the majority of my career hoping the gov't agrees to pay me enough to pay back their loans while working for a public that can't/won't pay me for my legally required service? Whew!

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[fuegorama]

53 views and no discussion. Hmmm. Lame thread indeed. Sorry.

 

[Soup]

Down sides-decrease in productivity, loss of our already flagging autonomy, getting screwed on the next fiscal cycle a la Canada's docs in the 80s etc. etc.

I think that this answers your question.

 

[deleted87716]

If you really want to work for the government, you can always get a job in the VA system.

 

[EctopicFetus]

Yep. BTW your political leanings are quite evident in your post. Bottom line is that while some people believe health care is a "right" others dont think it is.

As such as Kent stated you are always welcome to join the military to work for the govt or simply work in the VA System. Other options are to work for large county hospitals like cook county.

 

[EctopicFetus]

It's a little harder to sue a government entity. The push back against medicare would die. Our political dollars could go toward actual patient care initiatives including a national EMS system and fluid EMR.

This is only partially true. People sue the government and win all the time. Dont think that this would somehow make med mal go bye bye. Also keep in mind that if the govt decides to cut your salary by 50% your recourse is limited. It is sad that the government alreayd pays 50 cents of every dollar in health care costs.

I know you wrote about the demands we would make of the govt but you surely wouldnt get all of them and even the ones you got would only last for 10 yrs or less and then you would have to start from scratch.

 

[iatrosB]

I know you wrote about the demands we would make of the govt but you surely wouldnt get all of them and even the ones you got would only last for 10 yrs or less and then you would have to start from scratch.

That's an important point. You know the gov would sign up initially and possibly agree to our "terms" knowing full well that they could screw us over after a period of time once we are "trapped" by the system.

 

[EctopicFetus]

That's an important point. You know the gov would sign up initially and possibly agree to our "terms" knowing full well that they could screw us over after a period of time once we are "trapped" by the system.

Iatros, the OPs original post is just idealism and thats fine esp if it never comes to fruition!

I understand the position of "we want all people to have healthcare" but knowing that the government doesnt do anything efficiently or particularly well would you want to put them in charge of your healthcare?

 

[hornste]

I understand the position of "we want all people to have healthcare" but knowing that the government doesnt do anything efficiently or particularly well would you want to put them in charge of your healthcare?

I'd like to challenge this notion that the government is incapable of doing anything particularly well. Let's consider 2 government sponsored endeavors that have benefited the nation.

First, the national highway system. It's an indispensible part of interstate commerce and works relatively well. I think its a good example of when the government should step in, when the private sector is unwilling or unable to provide an essential public service. Granted, they probably could have mechanized things when they first built it, but they did keep people in work longer during the great depression.

How about another example. Lets look at NASA and landing on the moon. Yet another example of government leading the way when the private sector is unwilling or unable. It might not have been essential, but I think we're all proud the government decided to undertake the challenge.

Do government-run organizations have problems? of course. especially since they're vulnerable to the whims of the political climate. There are plenty of things wrong with the NHTSA and NASA, but can any private sector company take their place?

I find this argument that healthcare should not be run by the government because it is either inefficient or incompetent to be repugnant. These arguments are based on fear, some real, most imagined.

 

[GeneralVeers]

You really want to work for the government? Just ask Canadian doctors how well that works out. In the 1960's Canadian doctors had the same fears as you, decreasing reimbursement, and changing payor mix. They subsequently agreed to all work for the government and were promised a stable salary and guarantees that their billing level would be the same. They also gave up their rights to practice privately, and it's now illegal in most of Canada to work for anyone but the government.

The result? The government constantly decreases the amount of reimbursement, the doctors have almost no autonomy over their practice, and many are faced with salary caps.

The salary for most Canadian doctors is 1/3 to 1/2 their U.S. counterparts, primary care gets approximately 2/3.

Anyone who event thinks that we should nationalize healthcare, please look closely at Canada.

BTW, I don't believe healthcare is a "right". It's not defined anywhere in the constitution as such.

 

[EctopicFetus]

I'd like to challenge this notion that the government is incapable of doing anything particularly well. Let's consider 2 government sponsored endeavors that have benefited the nation.

First, the national highway system. It's an indispensible part of interstate commerce and works relatively well. I think its a good example of when the government should step in, when the private sector is unwilling or unable to provide an essential public service. Granted, they probably could have mechanized things when they first built it, but they did keep people in work longer during the great depression.

How about another example. Lets look at NASA and landing on the moon. Yet another example of government leading the way when the private sector is unwilling or unable. It might not have been essential, but I think we're all proud the government decided to undertake the challenge.

Do government-run organizations have problems? of course. especially since they're vulnerable to the whims of the political climate. There are plenty of things wrong with the NHTSA and NASA, but can any private sector company take their place?

I find this argument that healthcare should not be run by the government because it is either inefficient or incompetent to be repugnant. These arguments are based on fear, some real, most imagined.

R u kidding? i can provide 30 examples for each one of yours showing waste, inefficiency, and downright ineffectiveness. NASA? are u kidding me? there is/has been talk of scrapping this whole thing. Less govt is better imo. u can have yours.

 

[GeneralVeers]

R u kidding? i can provide 30 examples for each one of yours showing waste, inefficiency, and downright ineffectiveness. NASA? are u kidding me? there is/has been talk of scrapping this whole thing. Less govt is better imo. u can have yours.

To quote Thomas Jefferson: "The Government that governs best governs least"

 

[EctopicFetus]

To quote Thomas Jefferson: "The Government that governs best governs least"

agreed 100%

 

[hornste]

Anyone who event thinks that we should nationalize healthcare, please look closely at Canada.

I don't think Canada is a fair comparison. Ideologically, they are far more to the left and are culturally willing to accept a socialist state. We are not.

A more adequate comparison would be Taiwan, a market driven, democratically run capitalist society who implemented a national healthcare system 10 years ago. Popular approval for the system runs at about 70%, there has been cost containment rather than a cost explosion, and providers are still on a fee-for-service plan. It's a system that works, and by all accounts, works well. Healthcare is affordable, but most importantly, its accessible and equitable to all.

http://www.hsph.harvard.edu/phcf/Pa...h insurance make health care unaffordable.pdf

BTW, I don't believe healthcare is a "right". It's not defined anywhere in the constitution as such.

I believe the argument goes that Healthcare is a basic human right. No one argues that it is a constitutional right, at least not yet.

 

[EctopicFetus]

I believe the argument goes that Healthcare is a basic human right. No one argues that it is a constitutional right, at least not yet.

Keep in mind it is an argument and not everyone agrees that it is a "basic" human right. I dont know much about Taiwan and how things work there but ill stick to the idea that less government is better.

 

[docB]

53 views and no discussion. Hmmm. Lame thread indeed. Sorry.

Not a lame thread. Like many points on this board it's only of interest to senior residents and attendings so the response takes a while.

I hate socialism. That said I'm so burnt on worring about getting sued and dealing with the short comings of the current system that I'd accept a socialist system if I was immune from malpractice under it. My concern about the looming Democrat Congress is that they are totally beholden to the trial lawyers and some are med mal lawyers. If they socialize they'll leave the med mal jeapordy intact so that there's no way to get patients the care they need but you're still liable for the bad outcomes. It would be another unfunded mandate like EMTALA. They love unfunded mandates because it provides entitlement without the political burden of raising taxes.

The idea of trying to bargain for concessions early in the process is fine but I don't think you'll get anywhere because they can inflict whatever they want on us and don't need to make any concessions.

 

[DogFaceMedic]

The worst thing about military medicine is some hospitals are union-protected government bureaucracies, managed by a conspiracy of medicority. (Being deployed is not the worst, because when I signed up I kind of knew about that and I want to fight terrorism.) Let's not spread something already in need of reform.

A powerful example happened in France in the late 80s where the RN's went on strike because of such low wages. So, the gov't brought out riot police and water cannons to disperse those wild-eyed, revolutionary little old ladies. The French pliticians know how to fight unarmed women.

Further, Canada is a mess - unless you are healthy. In one province, when a new party took control of the legislature, they needed to cut back health care costs. So, they closed healthcare clinics in political districts that voted for the other party. I don't want that.

Still, our system such that it is, does need its own reform, or voters will just demand that it be free, and then ruin it. No easy solution or silver bullet to this.

 

[docB]

I'd like to challenge this notion that the government is incapable of doing anything particularly well. Let's consider 2 government sponsored endeavors that have benefited the nation.

First, the national highway system. It's an indispensible part of interstate commerce and works relatively well. I think its a good example of when the government should step in, when the private sector is unwilling or unable to provide an essential public service. Granted, they probably could have mechanized things when they first built it, but they did keep people in work longer during the great depression.

How about another example. Lets look at NASA and landing on the moon. Yet another example of government leading the way when the private sector is unwilling or unable. It might not have been essential, but I think we're all proud the government decided to undertake the challenge.

Do government-run organizations have problems? of course. especially since they're vulnerable to the whims of the political climate. There are plenty of things wrong with the NHTSA and NASA, but can any private sector company take their place?

I find this argument that healthcare should not be run by the government because it is either inefficient or incompetent to be repugnant. These arguments are based on fear, some real, most imagined.

I agree that these are excellent examples of the government in action and we can extrapolate these into how healthcare might function.

The highway system does function but is frequently overburdened and undermaintained. The funding is done in a very inefficient way by federal tax money being redistributed to the states after overhead, loss, graft, etc. has been removed. There is a lot of variation from region to region on the quality of the service. I know that when I was stuck in traffic on the way to work today I was wishing that the people who put I15 together were telling me how to run my ED.

As for NASA it has done extrordinary things. It has done this with a massive budget. It has a high failure rate. It has tragically lost 2 manned spacecraft in flight, one on the ground and come close with another. It has lost many unmanned vehicles. We accept this because of the nature of the missions but can we fund healthcare like NASA? Would the people accept that type of failure rate if we were pushing the high tech envelope? There are many groups trying to privatize spaceflight now.

There are some things that govt has to do because only govt can do them. If healthcare becomes one of those things I don't anticipate it working anywhere near as well as NASA or the highways even with all of their problems.

 

[GeneralVeers]

Not a lame thread. Like many points on this board it's only of interest to senior residents and attendings so the response takes a while.

I hate socialism. That said I'm so burnt on worring about getting sued and dealing with the short comings of the current system that I'd accept a socialist system if I was immune from malpractice under it. My concern about the looming Democrat Congress is that they are totally beholden to the trial lawyers and some are med mal lawyers. If they socialize they'll leave the med mal jeapordy intact so that there's no way to get patients the care they need but you're still liable for the bad outcomes. It would be another unfunded mandate like EMTALA. They love unfunded mandates because it provides entitlement without the political burden of raising taxes.

The idea of trying to bargain for concessions early in the process is fine but I don't think you'll get anywhere because they can inflict whatever they want on us and don't need to make any concessions.

You summarized the problem perfectly. If we went to a socialized system, with a single source of reimbursement (the government), we would only be adding problems. The government will always want to cut costs, and the easiest way to do that is cut doctors salaries. It's publicly popular to do this, as many people have the image of the "greedy doctor" and think we make too much anyway.

Additionally, the malpractice environment wouldn't change. The lawyers (who make all of our laws concerning healthcare) are not going to enact any meaningful tort reform nationally, as they make too much suing us.

Doctors and the AMA have been too apathetic, and too weak to protect our interests, so probably would get steamrolled when trying to negotiate with the government.

To the "human rights" argument, I argue that there's no such thing as a "human right". If you went to 100 different countries and asked for a list of basic human rights, you'd probably get 100 different answers. I rather think of rights as "privileges" granted by a society. Our society is fully capable of revoking any and all of those privileges, rights, or whatever you want to call them.

 

[BKN]

Given that:
1. the feds buy more than 50% of healthcare services,
2. they set the amount that they are willing to pay by law,
3. we are unable to turn folks away without a screening exam, and
4. said screening exam must be thoruough to avoid missing a disaster,
we already are de facto federal employees. Why would the feds negotiate with us, since they've already got what they need?

Finally, is the situation really that bad? I believe EM incomes have gone up by 50% over the last ten years, while salaries have been flat.

And if med mal makes you crazy move to Texas. for the moment at least we've got it controlled with caps and gross negligence requirements.

Honestly, for EPs the future's so bright you gotta wear shades.

 

[hornste]

The highway system does function but is frequently overburdened and undermaintained. The funding is done in a very inefficient way by federal tax money being redistributed to the states after overhead, loss, graft, etc. has been removed. There is a lot of variation from region to region on the quality of the service. I know that when I was stuck in traffic on the way to work today I was wishing that the people who put I15 together were telling me how to run my ED.

Agreed, the redistribution of funding does produce unnecessary overhead. However, this is precisely what happens now with medicare/medicaid dollars trickling down through the states. A single payor system would not worsen the existing overhead. In fact, a single payor system would encourage a unified national health infrastructure, complete with electronic payment/billing which would drive down the overhead associated with multiple payors.

In regards to the government telling you how to run your ED... I think it is important to make a distinction between a single-payor system, and a nationally run healthcare system. I don't believe they necessarily need to be one in the same. Despite the power of the purse, I believe it is imperative that ED's retain their autonomy so that they can remain dynamic and adapt to their specific practice environment. This is exactly what happens in Taiwan (single payor system) with much less government oversight than the US (JCAHO, CMS, etc.)

The overburdening of the highway system is a very good point. It represents a monumental shift in the culture of Americans towards personal transport. No one would have envisioned the amount of cars on the roads today when the highways were originally conceived. I think its a good parallel to the shift we see in healthcare; specifically, the aging of the population and shift towards more acute patients, and consequently, increasing utilization of healthcare. The traffic system (government), much like healthcare (private enterprise), has done poorly to address this unexpected surge of usage.

Someone mentioned healthcare unions. They should be disbanded. They breed mediocrity and complacency. I'm tired of nurses tell me they're on break

 

[hornste]

To the "human rights" argument, I argue that there's no such thing as a "human right". If you went to 100 different countries and asked for a list of basic human rights, you'd probably get 100 different answers. I rather think of rights as "privileges" granted by a society. Our society is fully capable of revoking any and all of those privileges, rights, or whatever you want to call them.

I argue that there are some basic human rights that most cultures would agree on.

"All human beings are born free and equal in dignity and rights."
"Everyone has the right to life, liberty and security of person."
"No one shall be held in slavery or servitude"
From UN Declaration of Human Rights http://www.un.org/Overview/rights.html

I believe these three rights are irrevocable, regardless of circumstance. Doing otherwise would treat humans as a means to an end (A Kantian argument, I know).

Max Weber would say human rights are by definition granted by a society. You give up certain rights (freedom to kill your neighbors, steal cars, etc), in exchange for societal rights (security that your neighbor won't kill you, they won't steal your car.) and societal benefits.

BKN: EMTALA. correct me if I'm wrong but EMTALA doesn't actually provide compensation for uninsured EMTALA care. Compensation, (consideration), is necessary for employment, de facto or otherwise. You are not a federal employee, rather an obligate volunteer.

 

[GeneralVeers]

I believe these three rights are irrevocable, regardless of circumstance. Doing otherwise would treat humans as a means to an end (A Kantian argument, I know).

They are hardly irrevocable. The government can imprison you, take your property, and even take your life if they deem it necessary. If there is a war and a draft is enacted, the government takes your liberty, person, and safety.

If core "rights" like these are not absolute in our society, then something more nebulous like healthcare is certainly not a right.

 

[hornste]

They are hardly irrevocable. The government can imprison you, take your property, and even take your life if they deem it necessary. If there is a war and a draft is enacted, the government takes your liberty, person, and safety.

If core "rights" like these are not absolute in our society, then something more nebulous like healthcare is certainly not a right.

The government does on occasion suspend these rights, but it does not mean they are justified in doing so. That the US government violates human rights does not mean that these rights do not still exist.

For example, look at the Japanese internment camps during WWII. American citizens were stripped of their human rights in the name of the greater good. Even though they were revoked, history would show that the government was not justified and violated their human rights. I think the same will be said of the military camps in Guantanamo Bay.

The draft is a tricky one. Conscription does take away liberty, person, safety, as a means, but also as an ends to ones own liberty, person, safety. So, you forgo your immediate rights to secure those same rights for the future. Without doing so, you forgo those rights for all of society.

Healthcare, as a human right, derives directly from these core human rights. Access to adequate health care necessary for the development and maintenance of life and for the ability of human beings to realize the fullness of their dignity. Reworded, without healthcare, you won't have any of these things.

 

[DropkickMurphy]

Lets look at NASA and landing on the moon.

Two words: Columbia. Challenger.

 

[DropkickMurphy]

If there is a war and a draft is enacted, the government takes your liberty, person, and safety

No, because I'm out of here if that happens. Oh wait....I'm medically ineligible to be back in the service.....although I might still leave just to be on the safe side.

 

[EctopicFetus]

I argue that there are some basic human rights that most cultures would agree on.

"All human beings are born free and equal in dignity and rights."
"Everyone has the right to life, liberty and security of person."
"No one shall be held in slavery or servitude"
From UN Declaration of Human Rights http://www.un.org/Overview/rights.html

I believe these three rights are irrevocable, regardless of circumstance. Doing otherwise would treat humans as a means to an end (A Kantian argument, I know).

Max Weber would say human rights are by definition granted by a society. You give up certain rights (freedom to kill your neighbors, steal cars, etc), in exchange for societal rights (security that your neighbor won't kill you, they won't steal your car.) and societal benefits.

BKN: EMTALA. correct me if I'm wrong but EMTALA doesn't actually provide compensation for uninsured EMTALA care. Compensation, (consideration), is necessary for employment, de facto or otherwise. You are not a federal employee, rather an obligate volunteer.

The government does on occasion suspend these rights, but it does not mean they are justified in doing so. That the US government violates human rights does not mean that these rights do not still exist.

For example, look at the Japanese internment camps during WWII. American citizens were stripped of their human rights in the name of the greater good. Even though they were revoked, history would show that the government was not justified and violated their human rights. I think the same will be said of the military camps in Guantanamo Bay.

The draft is a tricky one. Conscription does take away liberty, person, safety, as a means, but also as an ends to ones own liberty, person, safety. So, you forgo your immediate rights to secure those same rights for the future. Without doing so, you forgo those rights for all of society.

Healthcare, as a human right, derives directly from these core human rights. Access to adequate health care necessary for the development and maintenance of life and for the ability of human beings to realize the fullness of their dignity. Reworded, without healthcare, you won't have any of these things.

So while some people think the UN is the end all be all that is not necessarily the case and while you might interpret their "rights" having something to do with healthcare it is nothing but your opinion of what it says if you follow the letter of the law there is nothing about this "right".

Access to adequate health care necessary for the development and maintenance of life and for the ability of human beings to realize the fullness of their dignity.

nice try but this is not true and again is nothing but YOUR opinion. I would argue that in order for me to have dignity I need an Aston Martin perhaps once that gets taken care of with tax payer money then we can deal with the other stuff. I mean Dr Fetus without an Aston Martin is not only absurd but also injurious to my "dignity".

 

[BKN]

I argue that there are some basic human rights that most cultures would agree on.

"BKN: EMTALA. correct me if I'm wrong but EMTALA doesn't actually provide compensation for uninsured EMTALA care. Compensation, (consideration), is necessary for employment, de facto or otherwise. You are not a federal employee, rather an obligate volunteer.

That was my point. The feds set the compensation levels, oblige you to see the patients and provide more than 50% of your income from medicaid, medicare and tricare. "obligate volunteer" is an amusing oxymoron but to differentiate it from "de facto employee" is a distinction without a difference.

 

[EctopicFetus]

That was my point. The feds set the compensation levels, oblige you to see the patients and provide more than 50% of your income from medicaid, medicare and tricare. "obligate volunteer" is an amusing oxymoron but to differentiate it from "de facto employee" is a distinction without a difference.

 

[EctopicFetus]

It is important to understand that for a politician an unfunded mandate where the individual providing the service cant say no is as good as it gets.

The politician can state that they did something "good" for society without raising taxes. People would love that cause they dont see the people providing the service getting screwed in the end.

 

[The White Coat Investor]

Since I will never be "wealthy" as an EP.... !

I'm not sure I understand why you'll never be wealthy with a salary of over $200,000. Even if you only save 1/4 of your salary, and earn 9% on it over the next 30 years you'll retire with $6.8 Million. How exactly do you define wealthy?

 

[fuegorama]

I'm not sure I understand why you'll never be wealthy with a salary of over $200,000. Even if you only save 1/4 of your salary, and earn 9% on it over the next 30 years you'll retire with $6.8 Million. How exactly do you define wealthy?

Given my life choice to begin a practice in my mid 40s + having an insane amount of tuition debt from my chosen school, there is no way I can bank that coin. But, thanks for the suggestion.


My curent lifestyle feels fairly lavish in my world view. Having just spent a pretty great weekend with someone I love in a warm house with representation of 6 different local microbrews, I feel stinkin' rich. Then again, I have walked down some of the poorest alleys in the world and know what a bowl of rice means.

Contrast this with the plastic surgeon I have recently rotated with who travels cross-country to have his bimonthly haircut, and then quick stops at his favorite Manhattan hotel and restaurant because "froie gras just isn't the same anywhere else".

Wealth defined by a sage and pathetically depressed relative of mine is ~15% more than you are making right now.

It was in quotes for a reason.

 

[fuegorama]

Yep. BTW your political leanings are quite evident in your post. .

Really? Please tell me what they are because I frankly don't know anymore. I am ashamed of the Dems and loathe the GOP. Am I a socially leftist libertarian maybe? Or a church-like conservative who believes in smaller gov't, docs on payroll, pro-choice, adherence to Christ's teaching while supporting gay marriage. Oh Fetus!! Please help me.

Bottom line is that while some people believe health care is a "right" others dont think it is.

.

How did health care is a right get extrapolated from my post? I mentioned EMTALA. That's a law. It guarantees an exam and stabilization. while this is the great, lively argument of our profession, it does not implicitly guarantee definitive care.

Health care is not a right. In its present form, health care in the US is frequently delivered as a public good. Care requires input of resources, time, labor and energy from individuals. If this is truly a "right" then these individuals are compelled to deliver. This doesn't sit well with me for a variety of reasons some distance outside the topic at hand.

 

[fuegorama]

.

 

[fuegorama]

Given that:
1. the feds buy more than 50% of healthcare services,
2. they set the amount that they are willing to pay by law,
3. we are unable to turn folks away without a screening exam, and
4. said screening exam must be thoruough to avoid missing a disaster,
we already are de facto federal employees. Why would the feds negotiate with us, since they've already got what they need?
Finally, is the situation really that bad? I believe EM incomes have gone up by 50% over the last ten years, while salaries have been flat.

And if med mal makes you crazy move to Texas. for the moment at least we've got it controlled with caps and gross negligence requirements.

Honestly, for EPs the future's so bright you gotta wear shades.

How did you make all my points in 4 bullets?
Thanks.

The bolded bit has me sweating. As medicare etc. continues to get squeezed, how long before the gov't no longer feels the need to hold the line on cuts. As your point #1 becomes 55% then 75%, then???... how will incomes be sustained?
Wouldn't it be prudent now to start the inevitable begging. From my admittedly alarmist vantage, it seems only a matter of time before the government will dictate my salary. I'd like to have that argument while my reresentative PACs still have a voice.
Your last line is so great......for the present.
I am a solid 4 years away from all this lucre. I'm not at all sure it will last. While income stats overall have risen, this is a transient and geographically defined increase. There are tremendous disparities in reimbursement for EM. Would anyone like to be in a TN. ED w/>60% medicaid users over the past year when TennCare went mammaries skyward?

(anecdote alert!)
One of my mentors when paycheckless for 2 months last year as his private group could not collect enough to cover their med mal plus a retiree buy out. His loans and mortgage didn't go away. Only his coin.

Can you wisened attending-types give me something for this constant hand wringing? My wrists are killing me.

 

[EctopicFetus]

Fuego is you want to give your wrists a break....

From BKN's previous post

Finally, is the situation really that bad? I believe EM incomes have gone up by 50% over the last ten years, while salaries have been flat.
And if med mal makes you crazy move to Texas. for the moment at least we've got it controlled with caps and gross negligence requirements.

Honestly, for EPs the future's so bright you gotta wear shades.

You are freaking out a bit much and while things might "tighten up" keep in mind ED visits are up. Some states are better than others and if you want the options are there where you could be a govt employee. Bottom line dont freak out and if you are in your 40s youll be retired by the time the poop really hits the fan.

 

[EctopicFetus]

One of my mentors when paycheckless for 2 months last year as his private group could not collect enough to cover their med mal plus a retiree buy out. His loans and mortgage didn't go away. Only his coin.

Anectdote alert... there are EPs making 500-600K and there are the ones who own planes and probably fly cross country for foie gras these are the "stories" that lie at the fringes. Recently in ACEP news avg ED income was at about 250K.. I can live with that but ill pass on the cross country flights for haircuts and goose liver!

 

[EctopicFetus]

Combine this with the inordinate amount of resources groups like ACEP put forth in an effort to hold-the-line on medicare funding and future incomes really begin to look like a house of cards.

They put forth this effort to stop the government from cutting reimbursement by 5%.

No matter your political leaning, I think we can collectively acknowledge that the GOP has failed to maintain power. The coming democratic presidency is largely predicated on some form of universal healthcare.

Hmm your political leanings arent evident here? Anyways most people would tell you the GOP failed because they approved a *****ic drug plan and the war in Iraq was the # 1 issue.

The public has voted and is sick of not being able to afford getting sick.

This is not at all what they voted on. It was a minor issue, very minor.

50% of the bankruptcies filed have medical bills as a primary source of debt. Our countrymen want coverage. What will this look like? What will it mean for the doc in the trench? Is there anyone who thinks that today's income will continue for the next decade? What should we do?

While it is true that 1/2 of the bankruptcies were due to health care more than three-quarters were insured at the start of the bankrupting illness.

http://www.consumeraffairs.com/news04/2005/bankruptcy_study.html

Making demands now for a wage along the median incomes of today's EPs with an ironclad cost-of-living annual raise would be a start. Add loan forgiveness, insurance and retirement and this could look pretty good for the majority of current clinicians.

Sure if the government wants to give me 250K a yr 50K in loans reimbursement per yr and COLA along with med mal what more could we want.... wait how about when that expires? We will be royally screwed!

Overnight we would see the dissolution of med-mal reform. It's a little harder to sue a government entity. The push back against medicare would die. Our political dollars could go toward actual patient care initiatives including a national EMS system and fluid EMR.

Down sides-decrease in productivity, loss of our already flagging autonomy, getting screwed on the next fiscal cycle a la Canada's docs in the 80s etc. etc.

So, is this ridiculous fantasy? Could we be arbiters of our own fiscal health? Or, will I spend the majority of my career hoping the gov't agrees to pay me enough to pay back their loans while working for a public that can't/won't pay me for my legally required service? Whew!

Pipe dream but why not. IMO I have no desire to work for the Feds. If this happened and if nurses happened to join this as well nothing would happen. Government is inefficient I could never be fired and I would have no incentive to see a decent number of patients. Oh and if I work for the feds I want 1 hour paid lunch even when I am on single coverage! All other Feds do it!

 

[fuegorama]

Man! I hadn't even thought about the lunch breaks.

But my cafeteria better look like the capitol's caf. Veggie club's for everyone.

Thanks for the reassurance. If the incomes stay where they are, I will be much more than satisfied.
I hope you are right.
F

 

[EctopicFetus]

you know lunch/dinner/breakfast breaks are key when you work for the feds. How else can the ladies file for diability when they cant walk anymore cause their BMI is 50?

BTW you also have to figure out when the overnight person gets their lunch break. As a resident I havent figured this out. But maybe the government can fund a $200 million study to provide the answer for us?

 

[hornste]

BTW you also have to figure out when the overnight person gets their lunch break. As a resident I havent figured this out. But maybe the government can fund a $200 million study to provide the answer for us?

well, the on-call radiologists in India take their lunch around midnight. It would only make sense that you get lunch at 12am and dinner at 6am.

 

[EctopicFetus]

well, the on-call radiologists in India take their lunch around midnight. It would only make sense that you get lunch at 12am and dinner at 6am.

I work midnite to 9am.. our rads guys are in house. Perhaps we really need to fund that study. Of course in 6 months that will change.. Ill start my overnights at 11pm.. so at midnight that would be breakfast right? Ohh my 2 neurons are hurting.

 

[hornste]

I work midnite to 9am.. our rads guys are in house. Perhaps we really need to fund that study. Of course in 6 months that will change.. Ill start my overnights at 11pm.. so at midnight that would be breakfast right? Ohh my 2 neurons are hurting.

I think you're better off doing a study to figure out when you should take your siesta, also known as nap-time. You could even get librium or lunesta to sponsor your study.

One of the best lectures I attended was one on sleep hygiene and patient safety during morning report. A good 3/4 of the housestaff took it to heart and fell asleep during the lecture.

 

[EctopicFetus]

Funny. I was just reading one of the magazines related to EM and they did a study showing a 40 min nap during an overnight shift makes docs work "better" (I forgot the criteria for "Better"). This study clearly was not sponsored by the sleepy meds cause you have to get 8 hours for those meds.

Also they recommended doing all your overnights in one month as that is better for your health.

Anyways im looking into the lunch issue as this is not studied yet and the whole sleep thing is well documented. Im looking for original work!

 

[Miami_med]

I will not stake my future on a government contract. I'm really liking the EP thing, but socialization of the emergency medical system would be enough to drive me away. It is only in the era of EMTALA that crowding has really become a problem in the first place. I shudder at the idea of the government running the whole system.

You see, the problem with your idea is that it railroads everyone who doesn't buy into your political philosophy. I don't want to work for the government. I don't want a union. I hate the involvement that already exists in the system on the part of the government. Your idea forces me into a working condition I do not like at my own expense.

 

[deleted109597]

well, the on-call radiologists in India take their lunch around midnight. It would only make sense that you get lunch at 12am and dinner at 6am.

I thought that in India midnight here is around noon there. That's why they send them overseas, because of the time change.

 

[beyond all hope]

I agree with most of the posters in that I wouldn't want to work for the government. However, I do think that radical thinking is required in order to fix the current situation of steady decline of our health care system. And fixing the medmal crisis is at the heart of it.

I have often maintained that I'd take a 50% cut in salary to work without threat of malpractice and in a system where everyone had access to primary care. I'm pretty sure I'm in the minority.

Don't be afraid to think outside of the box. In a conservative society like the house of medicine, you will likely be ridiculed, taunted and put down. (I certainly have, and my ideas are a lot less radical than yours)

It's a lot easier to shoot down other people's ideas rather than come up with your own. That doesn't mean you should stop trying to make things better.

 

[fuegorama]

.

 

[fuegorama]

It is only in the era of EMTALA that crowding has really become a problem in the first place.

A little history please.
Q:When did the 'EMTALA era' begin?
A:2005? 1995? Nope let's go back to Life's Rich Pageant and Iran Contra
Q:Who signed the omnibus bill of 1986 into law?
A:the Gip

Say this three times in front of your mirror and watch what happens.

You see, the problem with your idea is that it railroads everyone who doesn't buy into your political philosophy.

What is my political philosophy again? I believe the spirit of EMTALA is moral and piece of legislation worthy of a country w/a decent heart.

That said, its implementation is the perfect example of bad government gone worse. Its abuse is the evidence that there are entitled and irresponsible aspects of our populace.

 

[hornste]

I believe the spirit of EMTALA is moral and piece of legislation worthy of a country w/a decent heart.

That said, its implementation is the perfect example of bad government gone worse. Its abuse is the evidence that there are entitled and irresponsible aspects of our populace.

hahaha. I pretty much said the same exact thing during my last residency interviews. For some reason, it just never seems to come out right I learned to keep my big mouth shut.