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After reading the hatred thread and following a lecture this week by a guru surgeon, I started thinking about this kidney stone of an education Im trying to pass and what it will cost me.
You guys should read the hatred thread and make your own judgements.
http://forums.studentdoctor.net/showthread.php?t=185661
The lecture I sat in this week was with a great doctor who was droning about the diagnostic issues surrounding Ischemic Bowel disease. Mid- hour he drops this line, as physicians you will be the administrator of your patients finances. Really?!! I thought I was being trained to make the best recommendation regarding my patients health and her potential pathology.
How did we become responsible for peoples financial issues? Why do we keep doing it? How can responsibility be transferred back to the patient where it belongs?
We are being taught a science and an art that has trust as its foundation. Right now that trust flows in one direction, and it isnt toward docs.
Some observations:
1. Physicians are no longer the controllers of medicine. There are administrators that demand production which is interpreted as minimal testing + maximum patients seen = risk assigned to docs. Lawyers equipped with low-tech retrospectometers have made every diagnostic decision a risk. Patients are web-educated experts that are convinced they have at least as much knowledge about the appropriate interventions they need.
2. We have created a system where the physician assumes all risk and responsibility. You may not be able to pay for that full body CT to rule-out the horribloma, but your doctor better not miss it.
3. Patients demand to have more say in their care.
We are witnessing a collision of ethical, financial, and resource distribution issues.
A suggestion-
In a possible future, everyone will have some form of health-care account. A percentage of this will be government funded. I can hear the teeth gnashing, but get over it. This will happen. The good news is that this account will be finite. Lets say everyone is given $4,000 to start. If thats all thats in your account, no other investment or insurance, when its gone its gone.
On presentation a patient is given a copy of their financial situation. Here is your account. Here is what it will pay. Here is the dollar amount for which you are responsible. You can now see your doctor. Your visit will minimally cost $x to cover the physicians fee. This has already been deducted.
The physician takes an H&P, performs her exam and steps out to mull over the diff. On returning to the patient, the conversation will be significantly different than the current heres your diagnosis, lets hope Im right.
Rather, it will sound something like, Your s/s are likely due to a new onset of migraine headache. However, we must also consider that this could be due to meningitis, sinusitis, a stroke, an arteritis, any autoimmune disorder, a tumor of primary or metastatic nature etc. This differential will appear on a prepared sheet with percentages assigned to the probability of each diagnosis. The diagnostics required to r/o each of the alternatives will be listed along with their price and potential harm. E.G. Tumor-contrast CT head- ~$950, radiation exposure risk of anaphylaxis. The doc and patient discuss the probabilities and the patient decides the diagnostic pathway. She signs the sheet and leaves with the glow of owning her own healthcare.
The lawyer? What stinking lawyer? The patient has sought expert advice, has received said advice and has made her decision. Will she be suing herself?
Lets take another example only with an emergent presentation. If EMTALA is still a reality in this future, then EM docs should have a form of credit whereby they can apply diagnostics. This would not differ from today except care given under the EMTALA rules will be required to be funded!
(all numbers and tx. are fictional examples from an MSII perspective)
So a gentleman presents with his nasty anterior MI. The doc paints the big picture and gives the family and patient some alternatives. This is where familiarity with a Chinese menu comes in handy.
A. The full court. NTG drip. Some wondrous anti-platelet potion, a date with a cath cowboy. Two days in the CCU. 30-day mortality without complications =<12%. Cost= $12,000
B. The special. NTG SL, MSO4, ASA, IV Heparin, IV beta blockers, a cheap thrombolytic (when youre looking at $4,000 as real money, then the difference in $1200 for tPA vs. $2000 for Tenectaplase makes a difference). A day in the CCU. A day on the tele floor. 30-day mortality without complications =<20% Cost=$5500.
C. Lunch menu. NTG SL, MSO4, ASA, LMWH, IV beta blockers. Tele admission for two days. 30-day mortality without complications =<40%. Cost $2500
D. The free mint. NTG SL x 3, ASA. A consultation with clergy of choice is complementary. 30-day mortality without complications =<80%. Cost $200
This suggestion eradicates the need for administration. The production is based on patient decisions. The dollar is not the physicians to spend.
The risk is shared.
The patient is given the say in their care they so vocally demand.
Thoughts? Flames?
You guys should read the hatred thread and make your own judgements.
http://forums.studentdoctor.net/showthread.php?t=185661
The lecture I sat in this week was with a great doctor who was droning about the diagnostic issues surrounding Ischemic Bowel disease. Mid- hour he drops this line, as physicians you will be the administrator of your patients finances. Really?!! I thought I was being trained to make the best recommendation regarding my patients health and her potential pathology.
How did we become responsible for peoples financial issues? Why do we keep doing it? How can responsibility be transferred back to the patient where it belongs?
We are being taught a science and an art that has trust as its foundation. Right now that trust flows in one direction, and it isnt toward docs.
Some observations:
1. Physicians are no longer the controllers of medicine. There are administrators that demand production which is interpreted as minimal testing + maximum patients seen = risk assigned to docs. Lawyers equipped with low-tech retrospectometers have made every diagnostic decision a risk. Patients are web-educated experts that are convinced they have at least as much knowledge about the appropriate interventions they need.
2. We have created a system where the physician assumes all risk and responsibility. You may not be able to pay for that full body CT to rule-out the horribloma, but your doctor better not miss it.
3. Patients demand to have more say in their care.
We are witnessing a collision of ethical, financial, and resource distribution issues.
A suggestion-
In a possible future, everyone will have some form of health-care account. A percentage of this will be government funded. I can hear the teeth gnashing, but get over it. This will happen. The good news is that this account will be finite. Lets say everyone is given $4,000 to start. If thats all thats in your account, no other investment or insurance, when its gone its gone.
On presentation a patient is given a copy of their financial situation. Here is your account. Here is what it will pay. Here is the dollar amount for which you are responsible. You can now see your doctor. Your visit will minimally cost $x to cover the physicians fee. This has already been deducted.
The physician takes an H&P, performs her exam and steps out to mull over the diff. On returning to the patient, the conversation will be significantly different than the current heres your diagnosis, lets hope Im right.
Rather, it will sound something like, Your s/s are likely due to a new onset of migraine headache. However, we must also consider that this could be due to meningitis, sinusitis, a stroke, an arteritis, any autoimmune disorder, a tumor of primary or metastatic nature etc. This differential will appear on a prepared sheet with percentages assigned to the probability of each diagnosis. The diagnostics required to r/o each of the alternatives will be listed along with their price and potential harm. E.G. Tumor-contrast CT head- ~$950, radiation exposure risk of anaphylaxis. The doc and patient discuss the probabilities and the patient decides the diagnostic pathway. She signs the sheet and leaves with the glow of owning her own healthcare.
The lawyer? What stinking lawyer? The patient has sought expert advice, has received said advice and has made her decision. Will she be suing herself?
Lets take another example only with an emergent presentation. If EMTALA is still a reality in this future, then EM docs should have a form of credit whereby they can apply diagnostics. This would not differ from today except care given under the EMTALA rules will be required to be funded!
(all numbers and tx. are fictional examples from an MSII perspective)
So a gentleman presents with his nasty anterior MI. The doc paints the big picture and gives the family and patient some alternatives. This is where familiarity with a Chinese menu comes in handy.
A. The full court. NTG drip. Some wondrous anti-platelet potion, a date with a cath cowboy. Two days in the CCU. 30-day mortality without complications =<12%. Cost= $12,000
B. The special. NTG SL, MSO4, ASA, IV Heparin, IV beta blockers, a cheap thrombolytic (when youre looking at $4,000 as real money, then the difference in $1200 for tPA vs. $2000 for Tenectaplase makes a difference). A day in the CCU. A day on the tele floor. 30-day mortality without complications =<20% Cost=$5500.
C. Lunch menu. NTG SL, MSO4, ASA, LMWH, IV beta blockers. Tele admission for two days. 30-day mortality without complications =<40%. Cost $2500
D. The free mint. NTG SL x 3, ASA. A consultation with clergy of choice is complementary. 30-day mortality without complications =<80%. Cost $200
This suggestion eradicates the need for administration. The production is based on patient decisions. The dollar is not the physicians to spend.
The risk is shared.
The patient is given the say in their care they so vocally demand.
Thoughts? Flames?