CA wants to increase midlevel's scope of practice

[The kitchen sink]

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If an MD's product to a patient is a 5 minute rushed conversation, ordering an UA and writing a prescription to treat a UTI, who would blame a patient for preferring that same experience with a PA/NP for half the price or less.

If however, the MD spends an hour exploring the underlying reasons for this patient's frequent recurrent UTI's especially as how it related to his/her quality of life and other health issues so that the patient walks away feeling very well-cared for, then (some) patients would be willing to pay what it is worth to them. Those who value it would compensate the doctor accordingly. Those who don't value it will stick with the NP/PA's that their managed care plans give to them for free.

I cite this story as a general example. It is not meant to be an exact scenario, but you get the point.

I agree with this. This is the sort of business savvy I support; what i mean is not in the sense of billing efficiently, which is always great but using your interpersonal skills to create a reputation that will put your services in demand thus generating business for yourself or your group in a positive manner.

In order words, physicians should know how to run a business so it sells itself for lack of better words aka 'business savvy'.

I may have repeated what you said in different words but only to further the sentiment.

 

[ivfmd]

Yeah, demand, scarcity, and a more unique product would give you the necessary leverage. I would extend your ideas, though, to say it isn't that feasible in some field and almost a requirement on the extreme end in your case. I mean, are there any public service REI outfits. It's not reimbursed by any of the public payors right?

Yes, you said the same thing that I said. In some fields it's less feasible. In some fields it's more feasible.

As for infertility treatment, there is quite a bit of public service. In fact, there is a lot more pro-bono or deeply discounted sliding-scale work being done that you would probably think. I can speak for myself and because I'm the head of our county's local REI society, I have somewhat of a pulse on my colleagues and I can tell you that many of them do a significant amount of pro-bono type work as well.

As a caveat, in case you don't fully believe me, I would put this question out there in case we differ on the exact definition of pro-bono care.

If a patient comes to see an RE and it turns out that she has a diagnosis (blocked tubes) where IVF is the only option. She can't easily afford the procedure. The doctor decides to accept 20%, giving her an 80%. By the way, it's wrong to think that the doctor is still making out because he gets that 20%. That's arguably not enough to cover the lab supplies, let alone the doctor's own labor.

So this patient is ecstatic about her baby and an end to the heartbreak of her longstanding childlessness. She is very vocal about praising the kind act of the RE to her circle of friends. Over the next five years, this brings many patients to the RE who otherwise may not have heard of him.

So to you, is this altruism or self-serving marketing? Or does it only meet the definition if I do the charity, force the patient to sign a promise never to tell anybody and to never refer anybody. I know this may sound contrived, but I totally feel that when we, as human beings do altruistic things, the fact that we gain benefit from it does not detract from the altruism. Isn't that true in life? If a person spends his whole life being a nice guy, there are so many indirect benefits, karma so to speak. Doing good, while a reward in itself, can also result in abundant unexpected rewards.

 

[JourneyAgent]

Yes, you said the same thing that I said. In some fields it's less feasible. In some fields it's more feasible.

As for infertility treatment, there is quite a bit of public service. In fact, there is a lot more pro-bono or deeply discounted sliding-scale work being done that you would probably think. I can speak for myself and because I'm the head of our county's local REI society, I have somewhat of a pulse on my colleagues and I can tell you that many of them do a significant amount of pro-bono type work as well.

As a caveat, in case you don't fully believe me, I would put this question out there in case we differ on the exact definition of pro-bono care.

If a patient comes to see an RE and it turns out that she has a diagnosis (blocked tubes) where IVF is the only option. She can't easily afford the procedure. The doctor decides to accept 20%, giving her an 80%. By the way, it's wrong to think that the doctor is still making out because he gets that 20%. That's arguably not enough to cover the lab supplies, let alone the doctor's own labor.

So this patient is ecstatic about her baby and an end to the heartbreak of her longstanding childlessness. She is very vocal about praising the kind act of the RE to her circle of friends. Over the next five years, this brings many patients to the RE who otherwise may not have heard of him.

So to you, is this altruism or self-serving marketing? Or does it only meet the definition if I do the charity, force the patient to sign a promise never to tell anybody and to never refer anybody. I know this may sound contrived, but I totally feel that when we, as human beings do altruistic things, the fact that we gain benefit from it does not detract from the altruism. Isn't that true in life? If a person spends his whole life being a nice guy, there are so many indirect benefits, karma so to speak. Doing good, while a reward in itself, can also result in abundant unexpected rewards.

Well I didn't really mean to broach the ethics of fee-for-service private practice. I was just thinking of opportunities for entrepreneurial activity in different fields. And that it's not just about business saavy. Or if it is it starts as a medical student being able to envision the distant practice possibilities from looking at a small, distorted view from clerkships and the like.

But since you mention it, it had occurred to me to ponder what I felt about that. For instance I'm interested in Psychiatry--increasingly in light of these discussions in some specialized niche within it. I was wondering how I would approach my career with how to balance my desire to be independent of bureaucracy while still helping people who might not be able to afford me. I was thinking of a split type of career. Public day job with PP on the side with little pro-bono, and then increasingly as I built my practice or business, less or no day job and more pro-bono.

I don't have any opinions on the extent of pro-bono. Covering the costs of you supplies seems like a perfectly reasonable thing to expect of someone who can organize their life around the conscious decision to have a child.

If you get something out of it that for your practice that's a win win for everybody.

I'll liken this to Bill Burr's commentary on the Lance Armstrong fiasco: Who cares if he's an @sshole. A psycho going up and down hills on a bike is better than a psycho running a major bank. Something along those line. What does our collective morality plays on him have to do with the fact that he raised money for cancer. The person who can arrange for positive impact is the person doing things. The idea of act as separate from the purity of it is some kind New Testament stuff I don't trouble myself with.

 

[ivfmd]

Since I'm greatly learning from this forum, I'll put another idea out there. With regards to psychiatry as it exists today, how much is helping somebody that wants to be helped and how much of it is putting labels on another human (especially a child) so as to have an excuse to do things to him/her against his/her will and force him/her to take drugs that profit the pharma industry or to restrict him/her for the safety (convenience?) of others?

🙂
I have to wear my conspiracy theory tin foil hat on this one because I could have easily been diagnosed as a child with borderline DSM-IV criteria for OPPOSITIONAL DEFIANT DISORDER.

That was a conversation that I was involved in the other day and it opened my eyes to a lot of things. For what it's worth, my sister is a psychiatrist.

Good luck in your future career. I hope you help a lot of people feel healthier mentally.

 

[JourneyAgent]

Since I'm greatly learning from this forum, I'll put another idea out there. With regards to psychiatry as it exists today, how much is helping somebody that wants to be helped and how much of it is putting labels on another human (especially a child) so as to have an excuse to do things to him/her against his/her will and force him/her to take drugs that profit the pharma industry or to restrict him/her for the safety (convenience?) of others?

🙂
I have to wear my conspiracy theory tin foil hat on this one because I could have easily been diagnosed as a child with borderline DSM-IV criteria for OPPOSITIONAL DEFIANT DISORDER.

That was a conversation that I was involved in the other day and it opened my eyes to a lot of things. For what it's worth, my sister is a psychiatrist.

Good luck in your future career. I hope you help a lot of people feel healthier mentally.

I'll take your question but keep in mind I'm an M3 who has just been around the field as an interested student:

Psychiatry attracts a lot of criticism. Some of it fair, some of it not. Firstly, if there is someone else who wants to treat psychiatric patients in the medical model please stand up.....oh...ok. Secondly, if there is someone else among those who wants to treat children who are having such problems with normal functioning expectations of their age group that they are headed for disaster and the juvenile justice system if a team of people doesn't help them to get to life's 1st base of adult society...please, please stand up.....oh....ok.

So what you have is exhausted, cornered parents...if the patients are lucky that is...and nowhere for them to turn for at least a plan for mitigating some of the problems. Enter the Child psychiatrists with drugs, many of which are untested in child populations, trying to do something. And for doing this they are vilified by the Jenny McCarthy types. Armed with loads of BS and some very damaging, very culpable information.

ADHD remains a skeptical diagnosis for many of us who have been watching the rise of dubious pharmaceutical use. School systems are saddle with the ridiculous task of keeping overcrowded rooms of same age kids from sinking into chaos and mutiny. All the pressures are there for systemic abuse of those diagnoses and their treatments. Most of them having nothing to do with the psychiatrist. Some of them quite damagingly having a lot to do with how psychiatry is being practiced and who is practicing it.

These last points are cause for my strong impulse to enter independent practice, where if my spidey sense serves me, might be the appropriate venue to work with alternative conceptions of psychiatric diagnoses and a resistance to over prescription.

 

[ivfmd]

These last points are cause for my strong impulse to enter independent practice, where if my spidey sense serves me, might be the appropriate venue to work with alternative conceptions of psychiatric diagnoses and a resistance to over prescription.

I will be rooting for you, my friend. Your heart is in the right place. I hope you get a chance to learn from currently practicing psychiatrists and see if the reality of what the field is like today is compatible with your views.

So much of the art of medicine exists outside of drugs and surgery. Even in my field where our primary tool is IVF (drugs and surgery), a lot of the success or failure of a cycle hinges on the doctor's ability to be a life coach (quit smoking, lose weight, reduce stress), a teacher (follow recommendations and take complex protocols of medications compliantly) and sometimes, even a marriage counselor.