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Where is emergency medicine going?

Discussion in 'Emergency Medicine' started by TrumpetDoc, Sep 25, 2011.

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  1. TrumpetDoc

    TrumpetDoc

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    SDN Members don't see this ad. (About Ads)
    Meant to be purposefully vague.
    Invite any and all personal opinions of the course our specialty is headed.

    I see Press Ganey sinking it's blood sucking fangs further into our practice so that our pay is not simply "bonused" but "based" on it.
    Govnt will increase it's hand in telling us what we can and cannot order-by way of reimbursement- for what "they" deem not necessary.
    As other specialties are hit with the ACA pushback is going to get even worse. Yea, I really hope this us all way off base. This was stemmed from a discussion i was having with a couple of friends (EPs) and I thought it enlightening.
    I went through training with blinders on to this, focussed on just getting smart, being a good resident, etc. And I feel like a schmuck for not opening my eyes earlier. It's my fault for that. Now, can we as a specialty direct our own future? I sure hope so.


    Perhaps a played out topic...if so I apologize as I cannot search on tapatalk on my phone for some reason and I only use this program for my forum subscriptions.
  2. Jack is Back

    Jack is Back

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    I think other fields in medicine have just as much trouble.

    Anesthesia has a huge midlevel problem rising up. Radiology has had reimbursements cut recently. For the amount of risk and work that goes into general surgery, they have been cut pretty bad and also have to deal with post operative care for well after procedures.

    Basically, all of medicine is being squeezed. I don't think emergency medicine is more of a target than any other specialty. Some of the more lucrative specialities, like orthopedics, may take some hits too in the future. Lots of media targeting physician pay as a driver of health care costs, even though it is very small percentage (10% or so? I forgot the article I read on it).
  3. TrumpetDoc

    TrumpetDoc

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    No doubt. Suppose I could have generalized this to medicine in general.
    Anyone up for an LSAT study group :)

    Was not meaning this to be a strictly compensation rant...more quality of work-life issues.
    Afraid if oh so more Govt telling me how I need to practice and PGs and so on. This too, probably affecting everyone out there, but doesn't make it ok.
    Alas...


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    Last edited: Sep 26, 2011
  4. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    It could get interesting. There's been talk of "salary caps" (which by itself speaks to the fact that few outside of medicine understand how we get paid). If those went through there'd be no incentive to work hard. You'd just work your minimum hours and check out. Money would go down but lifestyle might improve, time off anyway.

    It'd be like when the OBs would limit themselves to 200 births a year to avoid the big malpractice costs. They'd hit their number and hang it up until January.
  5. WilcoWorld

    WilcoWorld Senior Member

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    Here's one possible indicator:

    I know of a private ED in town that has a new program where the docs are expected to do an MSE on patients and then send them away with a PMD appointment if they're non-emergent. So far, that sounds fine to me, but I was bothered when I heard that they now have a quota, and will get a talking to if they aren't turning away 25% of the patients that present during their shift!
  6. WilcoWorld

    WilcoWorld Senior Member

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    However...

    While I see medicine getting tougher and compensation getting leaner, I think that EM is one of the specialties most ready to face the impending changes. Additionally, I'm darn near certain that, in spite of what happens I'll have job security until I retire and that I'll never have to worry about having food on the table, living in a comfortable home or even sending my kids to college.

    So, it may not be as good as it was "in the old days", but EM is still a pretty good gig, financially speaking.

    I guess I could summarize my views as follows: Administrators are encroaching on our specialty from every direction, and they're using threats of decreasing compensation to get us to acquiesce. To me, job satisfaction is more important than pay, so I think we need to stand up to the admins when they're wrong. "Fine, doc my bonus pay, but if 80% of the people who show up need to be seen, I'm not going to send 25% of the people away."
    Last edited: Sep 26, 2011
  7. GeneralVeers

    GeneralVeers Globus Hystericus

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    We will always be affected more by the changes due to the nature of our specialty. EMTALA in particular requires us to provide care to everyone regardless of insurance. I can't think of any other specialty with that obligation. What it means for us is that we can't pick and choose the insurances or patient population we see. If Medicare reimbursement is cut, the primary docs and specialists can always opt out and not see them if they so choose.

    I don't anticipate a single payer system like Canada, though I suspect we will inevitably move towards a two-tier system more like Australia than in Britain. This may be relatively neutral towards us, depending on how malpractice liability is handled. If malpractice claims are not limited I can see Emergency Medicine dying an agonizing death if we have universal government-run healthcare.

    The talk of "salary caps" and "buffet rule" taxes on the rich are frightening, and I can envision a world where I work at EM for 6 months of the year and go part time or travel for the other 6 months. If government is taking 50% of everything you earn over $250K why bother?
  8. WilcoWorld

    WilcoWorld Senior Member

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    This was a main motivating factor in my decision to practice EM, which is why I'm not so afraid of the future.
  9. GeneralVeers

    GeneralVeers Globus Hystericus

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    You picked EM because of EMTALA? I'm confused....
  10. WilcoWorld

    WilcoWorld Senior Member

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    I picked EM because I think that everyone deserves access to quality care, and by working in an ED both me and my employer are obligated to uphold this principle.
  11. GeneralVeers

    GeneralVeers Globus Hystericus

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    That's fine, as long as you're okay with indentured servitude to the government, and being forced to provide free care. Oh and there is no protection from getting sued, so while you're helping people with "access" and giving out charity, those same people can sue you for the slightest mistake or bad outcome.

    Just so you understand up front.
  12. Arcan57

    Arcan57 Junior Member

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    A little outside of your world view, but it does help knowing if someone comes in with an emergency I can help them. In a world without EMTALA, you'd have consultants refusing charity cases and you'd be stuck with pathology that you couldn't deal with but also couldn't transfer. Functionally, EMTALA has a much larger effect on our consultants than it does on us. I'd never feel like it was the right thing to tell someone to crawl off into a corner and die (on someone that was not clearly futile care), and thanks to EMTALA I never have to say that.

    I'm well aware that such "do-gooder" tendencies can lead to fiscally unsustainable scenarios, but I don't believe they are the main driver in health care costs. As EM physicians we are already wholly owned subsidiaries of the government, as nobody is working at a shop that can afford to be cut off from Medicare reimbursement. At least EMTALA forces our colleagues into the same boat.
  13. TrumpetDoc

    TrumpetDoc

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    Seeing as it has been expanded from an antidumping law to forced pro-Bono care, some legal protections would be nice. Figure if you are mandated to see people you should have at least some protection from suit...yes I know this will never happen. Just sayin'


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  14. Birdstrike

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    I know a tremendous amount about this subject. Stick with my wordy response and I'll answer your question.

    First, you know exactly where the specialty is headed, otherwise you wouldn't be asking the question.

    Don't be fooled: the "pay for 'performance'" you refer to ("Press Ganey...not simply "bonused" but "based" on it") is NO SUCH THING. Is this a way to "reward" you for scoring well on your Press Ganey survey and increase the overall amount of money the hospital, or government, allocates to your group? No. It's a way to cut costs. It is a pay-CUT, for LACK, of performance. In other words, if you score in the 99th percentile on your patient satisfaction survey, you are granted the privilege of continuing to make the same. If you score poorly, you're docked some percentage of you're pay. It's really unfortunate, but true.

    You will be treated how you expect and demand to be treated. Read that again:

    You will be treated how you expect and demand to be treated. As long as you think it's okay to be paid for saving a life (intubation) one tenth of what a plastic surgeon demands and expects to be paid for a breast augmentation, things will never change. The typical ER doc fashions himself as a sort of hero, and feels guilty and ashamed to ask to be truly rewarded for what he's given to a patient or society. It weakens his "hero cred". A plastic surgeon, has no such delusion. He expects what his patients (customers) will pay. He has no such "treat all comers, pay what you can afford" policy. Yet, for some reason, if an ER doctor expects to be rewarded for saving the life of, or providing critical care to, one of his "customers" (and that's exactly what administrators have told us patients should be treated as), as much as a plastic surgeon does for a breast augmentation, somehow the ER physician is greedy and cruel. The plastic surgeon, however, is helping his patients feel better about themselves, and "that's okay" (which it is). I don't resent or intend to insult plastic surgeons or any other high paid specialty. In fact its the opposite. It think EM physicians have a lot to learn from them.

    Would it be acceptable to radio to a pilot to pressure him to fly through a severe storm, rather than fly the longer route around it, so that he can arrive faster to keep the customers happy and profit more? No. Why is it okay for a hospital CEO to apply severe pressure to the ER physician to go faster, see (or "greet") everyone, including non-emergencies in 30 minutes when he has critically ill and injured patients?

    Also, the typical ER doc I've interacted with sells himself tragically short on his worth and abilities. Having left the specialty for one that very well could pay me twice the salary, for 1/10 of the stress, with a schedule that puts little if any stress on my family life, I now know this to be true because I've lived it. Emergency Medicine is the hardest specialty in medicine. Taking care of multiple critical care patients from every specialty in existence (trauma patients, cardiac patients, surgical patients), at breakneck speed, with less than a 30 minute wait, with a zero percent miss rate with a stellar Press Ganey rating, at all hours of the night, for a patient population that >50% of the time won't pay you yet exercises the right to sue you, at times when your body hasn't adapted to circadian rythm changes when you'd really rather be home with your family, off when they're off, awake when they're awake is difficult. It's very, very, difficult. When I first started telling my colleagues I was leaving EM, routinely the reaction I got, from people practicing much higher paying fields was this, "Oh, man, good for you. I don't know how you guys do it! It's brutal down there. Good for you." Here I am thinking, "Wait. All these years, over and over again I hear how important, and difficult and superior this specialty, or that specialty is, and now the exact people who were telling me this all these years are finally telling me that they have huge respect for me and could NEVER do what I do, yet they make twice as much doing a job they're now admitting is much less demanding".

    Now don't get me wrong, I'm immensely, immensely proud of the work I did in the ED. I'm equally as proud of the (mandatory and mostly unrecognized) charity care I provided in the ED. However, there has to be an end to the policy of, "Let's just keep crapping on the good guys because they'll take it." Did I get "burned out"? Maybe. Do I see this as a personal failing or a sign of weakness in the slightest? No. I consider it smart. And I'm a much happier, more content, better rested, better father and husband for it.

    So, until the ER physician first, recognizes his own worth, and expects and demands to be rewarded for it, the powers that be will continue to take advantage of the "self-less soldier" that is the ER physician.

    So what is my point? To be negative and trash the specialty? No. To answer your question "can we as a specialty direct our own future?"-Yes. But that's not even the question. The question is, "Will you?".

    Here's how to make the specialty much better, more rewarding, less taxing, and better compensated and less a target for misguided administrative experimentation.

    1. Give yourself the credit for how difficult and immensely valuable it is that which you do.
    2. Refuse to feel guilty about being rewarded for it.
    3. Demand respect and autonomy from administrators.

    It doesn't have to be this way, but what I suspect will happen is that by-and-large, the typical ER physician will continue to play the part of the unsung hero, and soldier on thanklessly, head into the wind, creating a little bit of order out of chaos one patient at a time. For that, you will at the very least, have my undying respect and admiration for what you do. I know how difficult, amazing and valuable it is what you do. Don't ever let anyone else tell you otherwise.
  15. Jack is Back

    Jack is Back

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    Always interested to know the new specialty choice.
  16. TrumpetDoc

    TrumpetDoc

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    Love it...thanks for the post that was awesome.

    Suppose a very hard part is that bigger corporate groups will pander to the hospitals every effin whim jut to get a contract...essentially screwing our bargaining power as a specialty, particularly dangerous for smaller pvt groups...make a stir, then screw off we will bring in "insert bigger corporate group here"



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  17. Jack is Back

    Jack is Back

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    I'm always excited about a career in EM, but then I read Birdstrike's posts...
  18. Birdstrike

    Birdstrike

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    Loves my post :love:


    Hates my post :mad:
  19. EctopicFetus

    EctopicFetus Keeping it funky enough

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    Birdstrike.. what do you do now? Curious..
  20. Jarabacoa

    Jarabacoa non carborundum ilegitemi

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    I think this really is the future of EM.

    Increasing unfunded government mandates leads to an increase in hospital bureaucracy to deal with the government mandates. Bureaucracy deals best with bureaucracy. Independent groups of ER docs are too powerful and unwilling to bow to stupidity. The modern group of graduating residents are not willing to risk financial ruin in putting up their (nonexistent) capital to form staffing corporations. I personally know of 5 different contracts that have gone from independent physician groups to giant megacorporations, with a subsequent mass exodus of well-respected, seasoned ER physicians. Why? The hospital wouldn't cave to their demands as an ER group.

    One of the major principles of the Studor philosophy which has cancerously infiltrated every part of medicine is that you need to cut dead meat. My old boss told our group that we were going to get Press-Gainey scores up at all costs, even if it meant 99% turn-over in nurses and physicians. I sat in the rah-rah "inspirational" type meeting where he learned this concept and decided to implement it. Since I left my old ER, the nurses got a new nurse manager who was basically just a little mini-me of administration and started inacting all kinds of weird policies and @#!*% the nurses off. The most seasoned, compassionate ER nurse there took exception and started inciting rebellion. Their response was to kick her out of the ER and put her in charge of education. Imagine! A rural hospital who has a huge chronic problem with staffing their ER with quality experienced ER nurses takes their best nurse out of the ER.

    In summary, get used to big brother/ big sister looking over your shoulder and telling you it is their way or the high-way.

    Anybody else see a trend toward huge ER staffing corporations obtaining more contracts? Or is my experience unique?
  21. la gringa

    la gringa Senior Member

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    i know of a hospital in a very desirable area w/ a very desirable payor mix... that kicked out a longstanding democratic EM group b/c the hospital wanted to institute some automated workup that was meant to maximize billing based on chief complaint.

    they brought in one of the big national groups maybe 14 mo ago, and is now looking to replace them b/c metrics aren't what they want. they had great metrics w/ the old group. really sad... group had to let a lot of really good docs go, and obviously the partners took a hit.

    my next job will likely be for the money. i'm pretty much a bleeding heart, but have my own medical issues (musculoskeletal not really "medical" - almost worse!) and have a big hole to dig out of. i'm fluent in Spanish, thinking TX may be a good fit...
  22. Jack is Back

    Jack is Back

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    My guesses on Birdstrike, after reading some of his posts, are:

    • Some type of PMR / Pain
    • Anesthesia / Critical Care

    I know this is "just a job" and not a calling, but I feel like EM is very interesting and broad, making it one of the cooler specialties around. I also understand that people have a tendency to check out what the other guy (specialty) is getting, thinking the grass is always greener.

    I'll say this, I'm looking between general surgery and emergency, and honestly, EM doesn't seem like they have it as bad as GS. There is no perfect specialty. So while it may not be the best lifestyle/pay, it certainly isn't the worst. From my perspective, it is one of the more interesting and unpredictable (variety-filled) specialties.
  23. Jarabacoa

    Jarabacoa non carborundum ilegitemi

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    Texas, a good fit for a bleeding heart?

    Yeah, Texas is where the money is. The economy in Texas has grown, while the rest of the country has stagnated. What is different about Texas I wonder?
  24. la gringa

    la gringa Senior Member

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    i meant for the "bleeding heart" and "spanish/tx" to be sort of separate comments - i feel the way WilcoWorld does about EM and being able to care for everyone... it was in my personal statement for residency, then i did my residency at a county hospital, and still feel that way after 4 years there and 2 as a community attending.
  25. la gringa

    la gringa Senior Member

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    forgot to say - TX has at least some degree of malpractice reform - i imagine that's at least part of it. i'm in the SE now so will have to look where i am (NC) and out that way... am a single gal so not really wanting to go rural. hoping i'll be more able to commute after my back is fixed...
  26. TrumpetDoc

    TrumpetDoc

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    Sad but to be quite honest, my compassion and thoughts for patients have taken a huge nose dive.
    I get an almost adversarial feel now a days. I really don't want to feel that way.
    I feel actually nothing for people on codes etc. Not just the I have seen a lot, hardened feel, but an absolute void of emotion in what should be emotional situations.
    This is really not like me and sometime I find personally disturbing. I am trying to rationalize it, change it, but really not getting anywhere.
    I guess what I'm trying to get at is I "used" to be a bleeding heart type,
    But now I could give a -:;;(@
  27. Birdstrike

    Birdstrike

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    Something that has required me to undergo some more training (but not another entire residency), allows me to have normal hours, and a normal life and still practice medicine. I still plan on maintaining my EM boards.
  28. EctopicFetus

    EctopicFetus Keeping it funky enough

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    Anesthesia? just let us know.. inquiring minds want to know~!:laugh:
  29. EctopicFetus

    EctopicFetus Keeping it funky enough

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    The job is hard no doubt. I kind of get what TrumpetDoc is saying but personally, I still connect with a patient or 2 on most shifts. For the most part I still enjoy what I do (year 3 post residency). The factors that lead to my satisfaction are realistic financial expectations and working in a functioning system.

    I save my emotions for my family. The group I chose is private after moonlighting at 2 EmCare sites. I just dont see how early in my career I could be happy at a place where I am helpless. The sad downtrodden state of the docs at those places confirmed my decision to not work for those places. Now I get paid better, have influence in decisions and my daily job while hard isnt terrible.
  30. Jack is Back

    Jack is Back

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    Has to be anesthesia or pain.
  31. inspirationmd

    inspirationmd

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    Occupational Medicine is my guess

    Edit: Could also be Toxicology with the right job
    Last edited: Oct 1, 2011
  32. Birdstrike

    Birdstrike

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    Expect the Unrealistic

    Is your experience unique. No. The problem is physician thinking. Yes physician thinking. We need to change our attitudes and start standing up for ourselves, especially EM physicians.

    If such hospitals as you described, literally, couldn't staff their ER, at all because ER physicians and nurses flat out refused to subject themselves to it anymore, things would change.

    1) ER Physicians should flat-out refuse to take jobs as hospital employees and mega-staffing-corporations and insist upon working for independent physician groups (in my opinion).

    If ER physicians refused to work for contract groups because such groups turn around and take other ER doctors jobs at lower cost, applying downward pressure on ER physician salary and essentially cutting your pay, then such groups would go bankrupt. But what happens, you guys keep taking jobs with them. Why? Either, they haven't done your homework, they're not aware that such groups cannibalize their own and work against them (not directed at you Jarabacoa, because you seem to get it) or, they just don't care because in the short term it works for them. Or they haven't prepared financially with 6 months cash savings in their bank account so that they can financially survive losing their contract without being forced to be re-hired at a pay cut by the contract group that threw their group out.

    Factory workers mobilized in unions and amassed so much power and were so successful accumulating so many benefits they actually crushed GM, the largest corporation in the world at one time. What do docs do? We whine moan and complain and get pushed around and deal with it because we are afraid to be called "rich greedy doctor". (You're also essentially banned from unionizing by the Federal government, see below).

    Is the crush of government, contract-group, hospital administration unique to EM? No but it's much, much, much greater. Why? Because (some) patients in the ED or so sick, so injured, so desperate, so in need that for you to do anything but selflessly take care of them without any concern for your own job satisfaction, well being, family life, career or shift-work sleep disorder is considered selfish or cruel. The altruistic nature of (most) physicians, especially EM physician is taken advantage of by the government and hospital administration.

    So, what's the point of all this ranting? It is time to focus the negativity towards positive solutions.

    Since, EM physicians are de facto government (EMTALA) and/or hospital employees (either outright or treated as such through hospital admin) without any of the benefits it's time to start having some unrealistic expectations...

    ON UNFUNDED GOVERNMENT MANDATES:

    2) No care of EMTALA patients without payment at FAIR MARKET RATES. Yes, FAIR MARKET RATES. Not Medicaid rates, or 2 cents on the dollar. FAIR MARKET VALUE. No excuses, no explanations, no exceptions. Find the money. If you require us by law to treat them, their should be a law requiring you to pay us, and our malpractice. Period. No exceptions . Find the money somewhere or change the law. It's against the law for you, specifically only you as an Emergency Physician, to pick and choose what insurance you accept. The law essentially states you can be paid $100, $1, 1 cent or nothing for a life saved. It's not up to you. It's decided for you. Fortunately, and thank God for it, other physician specialties can choose whether or not to participate in any given insurance plan, Medicaid, Medicare or private. Thank God. If the government takes that away from all physicians. Game over. The profession is dead. Let me be clear, I am NOT suggesting anyone violate EMTALA or any other law. I am suggesting the law be changed to require that ER physicians and hospitals receive payment for such government required care. Whether ObamaCare will result in 1) all patients being insured and, 2) ER physicians getting fair market payments for this care is, to say the least, greatly in doubt, in my opinion.

    3). NO, absolutely no, "medical screening exams" where the physician is expected to "screen" the patient, deem the patient a "non-emergency", turn them away without getting paid (to save the hospital money). At first it seems logical to defer non-emergencies to their PCP. However, there is a critical shortage of PCP, and largely this will never happen. The patients either, won't get care, or they'll just go to a hospital ED without such a policy. What you're doing, for one, is totally angering the patient, and then accepting all of the liability if something goes wrong, without fair market payment or malpractice converage, for no other purpose than to save the hospital money, not help patient. If your hospital or group tells you they do pay you for these patients, ask them where the money comes from. It should NOT be taken out of funds previously allocated to physician payment (taken out of your right pocket to pay you in your left pocket) but new funds, taken from somewhere else, the CEOs bonus, whatever. No more, no exceptions, no excuses. There's no way, NO WAY, you should be able to be sued for 1 dollar let alone $20,000 or $200,000 or more, for a patient you're required by law to evaluate and prevented by policy or law, to bill. It's coercion by force! It's equivalent to sticking a gun to your head. If you don't think so, what do you think would happen if you refused to do such exams under EMTALA, and got a $50,000 EMTALA fine and refused to pay it? You'd be arrested and dragged into some court at some point. And if you refused to go? You're arrested. If you resist arrest....guns are drawn. This is Federal Law and you don't dare violate it, and shouldn't, but you should be compensated and protected for the great, GREAT benefit you provide to society under the most stressful, difficult and short staffed circumstances.

    4) No laws preventing physician collective bargaining. None. Wipe the books clean. Why do union workers push huge corporations around and doctors do what they're told and say, "Yes, sir, whatever you say. Okay sir, yes sir" and complain, complain, complain until they're blue in the face with nothing ever changing? Because, amongst other reasons, laws prevent you from joining forces and negotiating as a union. It's against the law for you to do what any other American worker takes for granted as his God given right. Yes, illegal. Why? So they can tell you what to do without you having a choice. Read this below, written by a lawyer, not even a physician:
    "Current antitrust enforcement policy unduly restricts physician collaboration, especially among small physician practices…there is a profound imbalance in the marketplace between the health insurers who collect premiums to pay for medical care and the physicians who provide medical care. Such an imbalance has resulted in an increasingly unfair and inefficient healthcare delivery system" from Physician Collective Bargaining, by Anthony Hunter Schiff, JD, MPH. Clin Orthop Relat Res. 2009 November; 467(11): 3017–3028.

    5) And finally, why, why, why haven't we eliminated or drastically weakened, Certificate of Need Requirements? They've failed MISERABLY in accomplishing what they were intended to accomplish - reduce health care costs. That's laughable. They've done nothing to reduce health care costs. Nothing has reduced health care costs. Why do we still have a policy requiring hospitals to beg and plead and wait years for approval for hospital beds from government officials who know nothing about health care? Many times, once the permission is granted for a hospital to add bed, and the beds are built, so much time has passed, they already need more! THIS IS INSANE. Read this article from LA TIMES where county officials "gave permission" to L.A. County/USC Medical Center to increase their ED beds from 96 to 137 but forced them to REDUCE the number of inpatient beds from 824 to 600. Now they've got head bleeds boarding in the ED for 34 hours, at times. This is not an isolated mishap. This is happening in lots of places. This is a real crisis, created by the same government officials who claim to protect us and patients. Talk about an EPIC FAIL. Why can't L.A. County/USC Medical Center add more beds right now? Although I have no such inside knowledge of their situation, I guarantee you they'd have to ask for a certificate of need from the same board that denied them the beds in the first place. Why are we so afraid to add TOO MANY hospital beds? Could someone please give me an example of where TOO MANY hospital beds caused any problem, let alone anywhere near the crisis certificate of need policies have created by limiting beds? Please. Why aren't we questioning this insanity?

    6) More Physicians should run for public office. The reasons are obvious. We only have a handful of physicians in Congress nationally and it's not enough. We're subjected to whatever misguided policies politicians can craft to rule our domain and have virtually no hand in shaping the process. The results have been devastating already.

    REGARDING PRESS-GAINEY SCORES:

    7) Mandatory 30 min meal break per 8 hours worked. Once you're done laughing, and get over how unrealistic it sounds, follow my logic. I know what you're thinking, this guy is lazy and probably only saw 8 patients per shift when he was in the ED. Wrong, wrong and wrong. I busted my tail when I was in the ED. And I'm not talking about leaving the bedside of a critical patient and punching out. I'm talking about working in a scheduled, mandatory break at some point during a shift, every shift, except in extreme circumstances. Follow me:

    Why a mandatory break? Again, if you are a de facto government/hospital employee, which you are, you should get the benefits. Period. End of discussion. If you're expected to kill yourself seeing 30, 40 or more patients per 12 hour shift, and stop to order your patients a meal tray to keep your Press Ganey stellar, you should get a meal too, without being interrupted unless it's an emergency. A real emergency, not a hangnail patient with insurance that's been waiting over the allotted 30 min time goal. It's one thing if every patient is critical, but when you're expected to kill yourself to "greet or treat" every patient within some ridiculously low and arbitrary time window, when the vast majority are not sick, there should be some time scheduled for a mandatory break. Nurses in the ED do it. All other government and hospital employees do it. The hospital CEO and ED director do it. You'll be able to treat your patients better, and provide "better customer satisfaction"; if you're rested and fed. Again, the point isn't "Are you tough enough?", because everyone knows you are. But your residency and 30 hour shifts without a break are (should be) over, and if you're going to have to be burdened by the requirements and regulations of a de facto government/hospital employee, you should get the benefits. Don't let the hospital or you're group tell you "We're too busy". Lie #1. It's a complete lie. They staff the ED precisely the way they want it, based on how much $ they want to allocate to the ED, within a decimal of patients per physician per hour. They have the place exactly the way they want it. Your ED director knows it. There's a reason he's cut back his shifts. It's no accident you're getting killed each shift. It's not to help people and save lives (even though you are, this is essentially irrelevant). These policies are created to ram as many patients through the cash machine to make money for the hospital period. To them, the more overwhelmed you are with insured patients with non-emergencies, the better. Skip lunch, hold your bladder, move the meat. They take advantage of the legendary physician work ethic and perpetuate the myth that if you just work a little harder...you'll get caught up. Ever been in an ED that's caught up? I bet not. I have. You know the first thing they did? They cut coverage! They could have double the coverage if they want. Increase the amount you pay the docs and nurses to work until they sign up for more shifts. It's very simple.

    They'll tell you, "there's an ER physician shortage, that's why we're overwhelmed." Lie #2. There are plenty of ER physicians to take care of the EMERGENCIES in the United States. However, when you raise the bar to say ALL COMERS, the vast majority of whom do not have life or life threatening "emergencies", no matter how inappropriate, or un-sick, or non-emergent, and say they must be seen within 30 minutes (or some other arbitrary time frame) you just manufactured a false "CRISIS" that can be used to motivate. All of a sudden you're overwhelmed, everyone is waiting too long, you're pushed to work harder, faster at all hours of the night with no excuses to deal with the never ending crush of patients all to be seen within 30 min no matter how many come in. Now you have a "shortage" and you're expected to fix it every shift.

    Ask one of your (non-emergency patients) if he gets a mandatory lunch at work. I bet you he does. Ask him if he gets time and a half for overtime, nights, weekends and holidays. Again, the point isn't "am I tough enough to do it?"; It's not about laziness or being a slacker. You're able to crank through 40 patients in a 12 hour shift with a few critical patients and a boat load of non-emergencies without taking a lunch break, or bathroom break. The point is that they've made you a de facto government/hospital employee and burdened you with requirements but have not given you the benefits. And in one of the busiest most stressful specialties in one of the most stressful professions of the planet, you deserve it. You deserve it. Why is expecting a lunch break such radical thinking?

    8) Mandatory time and a half per any hour worked greater than 8 in a shift, or 40 in a week, for nights and holidays.
    Why? Again, all other hospital, government, and corporate employees get it. Why shouldn't you? If you work for a group and you don't think you're a hospital employee, just start changing the rules in your ED, try to fire an incompetent employee, change the on-call policy, the triage policy, the staffing ratios without the hospitals and/or governments permission. You'll find out you're essentially the highest paid hourly worker on the hospital payroll. Nothing more. Until you start demanding it and expecting these things, you're right, it'll never happen.

    9) Workers Compensation for Shift Work Sleep Disorder caused by your job.
    If your job causes you to have legitimately have a disease listed in the DSM-IV (Circadian Rhythm Sleep Disorder - Shift Work Type) or any other textbook, you should be compensated for it. Period. Don't suck it up, because you can, or you're tough or superhuman or whatever. No other segment of society would let their job cause them a legitimate disease or disorder and not expect to be compensated for it, or have rules and regulations enacted to protect them.


    Radical change requires radical thinking. I don't expect anyone to snap their fingers and these things will become reality tomorrow. But until you think and know you deserve better nothing can change. ER doctors deserve better. Patients deserve better.

    Think Big.

    Expect the Unrealistic.
    Last edited: Oct 2, 2011
  33. Birdstrike

    Birdstrike

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    EM really is a "calling", actually. It absolutely has to be. Once you lose that "call" to do it, it's "game over", say hello to "burnout city". If you think EM is "interesting, broad and one of the cooler specialties around", then go into EM. It's that simple. Why listen to my rants?

    As far a the "grass always being greener on the other side". You're right. It's not always greener. Some might say it's brown everywhere. But sometimes it is greener. And you'll never find out unless you check it out for yourself. Life's a journey. No one said it was easy. The vast majority of people make many, many career changes is a life time, but physicians for some reason are supposed to make the perfect career decision in their mid 20s and live happily with that decision through out an entire life time, for a 30 or 40 year career and never make a change, or its a sign of weakness, personal failing or the D-R-E-A-D-E-D....BURNOUT! It doesn't make sense.

    I've noticed that the people who seem to appreciate my post the most are those who've been knee deep in the trenches of some busy Emergency Department for several years and they "get it". Those that tend to be disturbed by my posts are those that are early on in their careers who think I'm presenting an overly negative view compared to their view of things. I wouldn't have liked to read the stuff I've recently posted 15 years ago. I would've dismissed me as well. You really shouldn't make too much of one internet strangers opinion, anyway.

    I find it quite interesting that the reaction to most of the stuff I've posted from the experienced attendings on here tends to be along the lines of "spot on" or "I can't disagree". I always try to focus the negativity towards how to make things better, because it can be better. ER physicians, and physicians in general, have tremendous power to improve their situation. But they don't. Physicians generally act as "lone wolves" doing what's best in the short term for their specific situation, selling out themselves, their specialty and their profession in the long run. Working for contract groups, as hospital employees, supporting government-run health care and insurance are perfect examples. Some are smart though. They figure it out, and make a new fork in the road. They pull the rabbit out of the hat, and everyone else is left staring, jaws dropped open.

    I don't have it all figured out. I'm still learning myself. When you've got it all figured out, please post it here.


  34. Birdstrike

    Birdstrike

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    You don't have to leave the specialty to make a difference. Leaving a state with a terrible malpractice environment for one that supports physicians (Texas) is a PERFECT example.

    Physicians tend to whine, complain, and moan amongst each other. This accomplishes nothing! Actions speak, and only actions speak.

    Remember when neurosurgeons and OB-Gyns faced insane malpractice premiums pretty much everywhere (still is the case many states)? What did these physicians do? The OBs left entire states in droves, or dropped their OB privileges and practiced only Gyn. What did neurosurgeons do? Did they sit back and take it, and bend over the barrel again? No. They left states where the lawyers preyed on them like sharks or they dropped their "brain" privileges (which involved 90% the liability and only 10% of the reimbursement) and kept spine only. What happened? Certain states were left with critical OB and Neurosurgery shortages and........then.....things started to change. Certain states like Texas, South Carolina, and other started enacting meaningful malpractice reform. It's unfortunate that it had to come to this, but unfortunately in the past, boneheaded and insane policies forced these physicians to make these choices to protect themselves from abuse from frivolous lawsuits.

    Moral of the story? Don't practice in a state where you are med-mal lawyer fodder. Just don't do it. And if you're in such a state, look for every reason to move to another state with better, malpractice, better weather for your spouse, lower income tax, closer to your family, farther from your family. Whatever. Get out.

    The same goes for reimbursement. If you're in a state where the powers-that-be are attacking certain specialties with punitive reimbursement cuts. Get out. Just get out. Staying is saying, "OK, cut my pay. I'll continue to work harder for less. You decide how much I make".
  35. Jack is Back

    Jack is Back

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    Well, as an inexperienced medical student, I'm sure your views are "spot on" whether negative or not.

    My problem is, I'm trying to find a career that I love and I understand now that all these fields, be it: EM, Anesthesia, Surgery, etc. , they all have challenges and uncertainties. They all feel like $ will go down and lifestyle is getting worse. Not that I care that much, I just want to be able to provide for family, have time for family and a few other things while doing something really interesting (not for $).

    Like you said, it is difficult to make a decision on WHAT to do for the next 20-30 years as a medical student.

    And I agree with you on the idea that physicians are "lone wolves". I can already see that and it is unfortunate we can't form unions to get decent working conditions. I was very excited when I began medical school but the excitement is waning now that I'm trying to find a place to put my passion and everyone is all jaded in their fields.

    Thanks for the replies.
  36. Birdstrike

    Birdstrike

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    It is very difficult to make such a big decision. When I made mine, SDN didn't exist. That fact that you have it now is a huge advantage. Keep in mind, such forums are falsely skewed towards the negative. People are more apt to voice a complaint than when they're content.

    Also, not everyone is jaded. I'm sure when it's all said and done you'll be happy you choose medicine. Try lots of specialties, make an informed decision and go for it. Don't make too much of the rantings of the old-timers on here, myself included. Don't totally ignore them either. Take what info you can and use it to make your situation better.

    I do think the future of medicine is bright, though not perfect. No profession is. There are huge differences in each specialty, though. None of them are perfect. They each have their cross to bear, some much heavier than others. Docs are very smart, though, and I'm confident we ultimately will make things better for ourselves and our patients.
  37. TrumpetDoc

    TrumpetDoc

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    Well I am an attending and while not a seasoned veteran, your points hit home realy hard.
    In fact, I had my wife read this thread and she swore your posts were mine...I vent the same things to her constantly, some were freakishly verbatim:)

    I don't have a very optimistic l
    View of medicine in general. Seemed like a good choice at the time, but with a lag from career choice to actual career of like a freaking decade who could have seen this blitz coming?
    Definitely agree, when you Loose that "calling", or in my case perhaps never had it and convinced yourself you liked it because it was super fun as a msIII, the burnout sets in and FAST.



    ---
    I am here: http://maps.google.com/maps?ll=36.024042,-115.062992
  38. NinerNiner999

    NinerNiner999 Senior Member

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    Birdstrike is right on - and I'm speaking as one of those "directors" he mentions in his post. In general, amongst most physicians, there is a general feeling of apathy, and a reliance upon "the people who choose to be administrators" to enact change.

    Sadly, behind the scenes, there isn't a physician "administrator" who is able to make the right change for their physicians without placing their physician's contracts at risk. For this reason, physicians are working harder, and doing so often to earn the same wages. Hospitalists are a great example, and another area of medicine to begin to watch, as regulations begin to impact their line of service as well. The types of change suggested by 'Strike are appropriate, and there is definitely validity to many of his/her claims. Sadly, it takes the right type of hospital, with the right type of administrators, and the right group of physician leaders to make these changes a reality, and even if they could be started, I don't see them surviving the tidal wave of government regulation and economic downturn headed our way. Again - this is in general to all physicians, not just EM.

    Now, for EM in specific, and where I see OUR field going...

    1) Visits are going to continue to increase, and hospital volume will increase as well. Payor mix will likely stay the same, or potentially increase in the short (5-10 year) term. As people continue to lose their employment (and their insurance), and as the uninsured become insured (via the ACA), we will again reach a steady state in our payor mix.

    2) We will see a higher percentage of low-acuity/non-critical patients while the number of actual "emergencies" stays the same. For those of you practicing in the ED now, how many more back pain / narcotic withdrawal / URI types of complaints do you see now compared to just 5 years ago?

    3) As our volume increases and true "emergency" visits stay the same, this will reflect on our specialty as a "decrease" in the number of emergencies our specialty cares for. Hopefully the analysts at CMS or HHS won't interpret this as our specialty "doing it's job," "healing the community," or "stomping out disease." If they do, it will likely reflect in a reduction of the number of funded "emergency departments" based on need - yes, I said REDUCTION, which will mean our "offices" in which we practice will become even fewer. This will be the easiest way for the "shortage" of emergency physicians to be fixed, and the first step toward decreased EM specialty reimbursement across the board.

    4) As the baby boomers continue to age, the effects of this age will present with more emergency conditions, requiring more resources and hospital space. This might buffer item "3" above. If it does, however, these patients will likely be covered by medicare, which means the sick patients with the most time-consuming work for us to perform will likely be the ones who reimburse us the least. This is already happening, and the non-emergent patients, if seen in the same numbers as the high-acuity medicare-only patients are actually reimbursing more in some markets. Of course, as private insurers catch on, this too will drop.

    5) Hospitals who are not cutting their emergency departments will begin to expand their emergency departments (renovations, new construction, etc) in the short term to capture a higher volume of all-comers, placing additional burden on the ED staff and physicians. To fill that burden, there will be an increase in recruitment of Emergency Physicians. Enter the large contract management groups, who by economy of scale, will be the only "private groups" that have the capital and economy of scale to retain physicians without everyone taking a major loss. This is already happening in several locations nationwide, and physicians in communities who used to be covered by individual EM practices are now joining together under the umbrella of Teamealth/EmCare/etc. This is also another key reason NEVER to sign a non-compete in your contract.

    6) Sub specialty reimbursement is going to be cut by 1/3. Period. This is unavoidable and independent of any CMS or ACA cut. As new tax laws become enacted and as the global economy continues its downward spiral, anyone earning above $250,000 per year will be taxed at a much higher rate. Those subspecialists making more will be taxed at a greater level, especially those earning greater than $1M per year. Then, when you factor in the global reimbursement cut expected by the SGR, even more loss of revenue will be felt. These specialists will either retire or significantly begin to cut back their coverage, leaving more patients untreated and requiring transfer to locations who have coverage. This means the return of ED boarding and greater expectations on ED staff to do even more with less.

    7) New EM graduates from residency entering medicine will expect less work hours, more pay, and no overhead for their practice. This is already being noted in salary surveys and new-hire surveys nationwide. As this occurs, there will be more employee status physicians who choose to clock-in, clock-out, and not be bothered by anyone or anything else. The age of the 9-5 mentality for Emergency Medicine is upon us, and the harsh reality of practice as employees will set in quickly. Income taxes will increase, and benefits will become more expensive. There will be an ironic dichotomy that presents itself in emergency medicine - the practice of our field for lifestyle will become the cause for the decreased quality of the same lifestyle one expects to achieve. Of course, those who can be hired by large groups as independent contractors will have more flexibility in this regard. The choices made now by new residency graduates will shape the future of our specialty in all aspects. It's funny how the new grads who expect this type of practice have only been exposed to one type of practice in their training - paid for as employees of Medicare, i.e. residency. Maybe it isn't too funny afterall...

    8) In the end, nothing will change, except for our reimbursement. Yes - you read that correctly. Our patient population may change, people may get sicker, volumes may go up, or they may go down. Regardless of what else happens, hospitals will expect more from us, and we will be given less to do it. Those groups who are successful in being efficient and earning bonus pools will quickly see that the hospitals who renew their contracts will take note of their success. Hospitals will expect a share of the group's profits on an annual basis - 1%, 3%, 5%, etc. This will be the deciding factor for contract renewal. As more contracts owned by the large corporations fall victim to this strategy, it will only be a matter of time before individual physician contracts become revised, and our salary becomes diminished to cover the corporate cost of paying individual hospitals. See Item 7 for those who still want to work as employees out of residency.

    9) Hospitals will begin to look towards our physicians as more than a necessity to staff their federally-mandated department, but as a vehicle for income. They will charge a de-facto "lease" to use their department through the strategy mentioned in "8" above. Eventually, when the events of "3" and "5" above become reality, there will be fewer ED's nationwide, and competition for those contracts will become more intense. Group A will offer 10% each year to the Hospital and BAM - Group B is out. Everybody loses, except for the hospital.

    This is not meant to sprinkle the thread with gloom or doom, just another perspective on where I think we are headed, and why there is little any of us can do to change things. Look around - this is already happening everywhere. Other specialties continue to get hit harder than us, but because we are so dependent on other specialties for our practice, we will have the misfortune of being victims of the financial and legal impacts of these changes, while being forced to manage and assume liability for sick patients who require specialty care that will be in even shorter supply.

    Then again, it will soon be 2012, and if the Mayans have their way, none of this will matter by next December...
  39. Birdstrike

    Birdstrike

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    Great post. Extremely dismal, but extremely well thought out and very interesting from a directors point of view. I really can't disagree with much if anything here. I still think we, as physicians, have vastly more power to change things than we realize or are willing to wield. Whether we'll ever get fed up enough to ever use it, that remains to be seen. Buckle up.
  40. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I am terrified of this very real possibility.
  41. Jack is Back

    Jack is Back

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  42. Jack is Back

    Jack is Back

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    I wonder what it says about my future that my favorite specialty so far in medicine has a dismal outlook. Oh well...

    Back to studying hard! lol.
  43. inspirationmd

    inspirationmd

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    Wow...this is depressing. What are your thoughts for those of us who are thinking of doing critical care fellowships after residency and practicing both in the ED and the unit? Do you think Intensivist work will be safer from an economic standpoint if all this comes to pass?
  44. Birdstrike

    Birdstrike

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    You never can predict what will be safer, down the road. There are a lot of factors to weigh and arguments can be made on either side (short-term financial, and time sacrifice), but in general, specializing through a fellowship, additional skills/training, and becoming double-boarded will help, and give you more options down the road when the pendulum swings back and forth, in favor of one specialty, or one practice environment, or the other. In fact, the more unique your niche is, the better off you'll be. :thumbup:
  45. Birdstrike

    Birdstrike

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    Where is this place? Could you private message me the info? Are they hiring? Do they pay a night diff? I think I would do well here.



    :laugh:
  46. Arcan57

    Arcan57 Junior Member

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    Pro's:
    Few/no drug seekers
    Constant darkness from ash clouds make night/day transitions easier
    No Press-Ganey
    Appreciative patients

    Con's:
    Poor payor mix/Majority of patients self-pay
    Minimal specialty coverage
    Being eaten by irradiated giant insects

    Looks like six of one, half-a-dozen of the other.
  47. la gringa

    la gringa Senior Member

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    ya'll hit the nail on the head, niner and birdstrike. due to my ongoing injury (that i should have fixed soon, i've had to think long and hard about what i want to do for the next 20 yrs. i didn't work for 6 mo and when i came back... i really missed it. i tried to convince myself i could do one of a variety of fellowships, but as long as my upcoming surgery is successful - i'll be back. i really do enjoy taking care of people, it's part of my makeup no matter how hard i fight it.

    i've come up w/ my own policies for most crazy/annoying patient types, and when i feel like i can't take it anymore, i remember somethings that were ground into me in residency - that the only thing important at a given moment is that patient to whom you are paying attention. that there are only some problems you can fix.... and to stick up for people who really need it.

    so hopefully i'll be back in practice by late winter... in a state w/ good malpractice laws. interestingly enough birdstrike, i just left an "independent" group that totally raped anyone who wasn't partner. they continually make the requirements for partner more and more exclusive and expensive. the surrounding area has one of the highest COL and worst traffic jams in the country. let any group get too big, and that's what happens.
  48. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    So Texas is great and all, but it is dominated by the corporate groups. Comically that probably had more to do with MLR than anything.
  49. la gringa

    la gringa Senior Member

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  50. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    I think he means "malpractice reform", or something that means that (i.e., "malpractice law reform").

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