how do you start up a practice after internship?

[PostCall]

Except that numerous things happen in the military that are exceptions to the rules. Or rather they have their own rules, that very clearly don't apply to civilian life. So actually different game, with different rules..

riiiiiight. "numerous things" that are "exceptions to the rules". whatever that vague, ambiguous non-response means.

---

Members don't see this ad.

 

[PostCall]

whatever, this is just going in circles. you guys painted yourselves in a corner when you claim anybody who hasn't finished residency is "unqualified" to practice independently...but then you let them do exactly that when it's convenient for you. anybody who has done a single night of call knows that even if you're unwilling to admit it because it would contradict your "they're unqualified" premise. but when called out on it you then backtrack by saying the attending is a phone call away or he "reviews" the resident's actions the next day. so can he also travel back in time the next day and undue the decisions the resident made and carried out independently the night before? as i said you want it both ways and talk out of both sides of your mouth to justify it.

 

[Sneezing]

Um no, the "solution" to this issue isn't sending out an army of lesser qualified GPs. That's like trying to fix the Titanic by drilling lots of holes in the bottom to let the water out. The way you fix this, is the same way folks in the legal profession fixed it. If your ship is in danger of sinking you start firing torpedos at all the potential attackers. You run to court and sink them. Show judges and congressmen why the practice of medicine should be left to folks with adequate training and education. Sue people for unauthorized practice of medicine. There have to be tons of dead babies and other outrageous mishaps you can parade out to show the travesty of having unqualified folks rendering medical services. What you cannot do (and which the profession seems bent on doing) is assume that the administration and politicians and the insurance lobby, etc are going to come to the right conclusion on their own. They aren't. In their push for healthcare for underserved, they are basically willing to destroy the medical profession to give every person someone in a white coat to take care of them, regardless of qualifications. If doctors don't stand up and say "no, that NP at the minute clinic in your local CVS isn't providing equivalent care as a physician", the public is more than happy to blindly let the politicians push them in this direction. Someone has to show that there are risks to providing medical care without adequate training. If instead you say, the answer is to pump out our own untrained people, then you aren't solving the problem, you are compounding it. I really am astounded that you see this as a viable solution. Arm the torpedos and full speed ahead if you want to fix this. Don't go down and start drilling holes instead.

We have several things going against us.
1) people don't believe legal advice is a right
2) the people who make our laws are most often lawyers, as such they will protect their kind
3) The tides are shifting towards believing healthcare is a right and politicians are responding by feeding that right - they don't care about quality - its the government afterall.

Recognizing this, how can we win the battle in the long run? Anesthesiologists are some of the most conservative politically active members, and they, as canaries in the mine, are still losing ground to politicians and CRNAs.

That is why I advocate the oldest solution in the book...

The solution to polution is dilution. Bring on the GPs!

Hence, Anesthesiologists are pushing the Anesthesiology Assistant degree. In the short run we should be pushing PAs over (D)NPs until, we get more GPs.

 

[Arcan57]

One last time... taking one night of call does not make you qualified to practice medicine independently. The truth of that statement is self-evident. Keeping someone alive for a night and practicing medicine as an unsupervised, independent practitioner are not equivalent.

Clinical judgment varies by level of training and individual, and how much leeway I give a resident to practice under MY license is an individual call. The procedure I'm comfortable letting the med student watch is the same one I'm comfortable letting the intern do with me in the room. Which is the same one I'm comfortable with being in the same area as the senior resident in case they need me. On occasion, I'm ok with an experienced senior resident teaching an intern on low risk procedures. But considering how often I've had to keep interns from killing patients, I'm not going to say that they are qualified to practice medicine independently.

So if you want to continue saying that the system of graded responsibility (which is a fantastic method of training) with an attending as the final responsble party is the same as unsupervised solo practice go ahead. But know that you are wrong. If you decide to order 400meq KCL pushes on all of your patients overnight (and if the nurses carry out the order), then I'M responsible. If you drop a lung and don't look at the post-procedure film and you never tell me about it... I'M responsible. Your actions can have massive consequences for me both professionally and personally. Your "negligence" is my "inadequate supervision".

 

[Law2Doc]

...Recognizing this, how can we win the battle in the long run? ...The solution to polution is dilution. Bring on the GPs!
....

That's like burning down the village so there's nothing to attract marauders. It's a losers gambit. You destroy the profession so nobody else can destroy it first. With ideas like this it's pretty clear why medicine is suffering the way it is. In fact, this is still salvagable, but it's going to take a lot of effort, money and personal inconvenience, none of which doctors seem willing to stomach. Lobbyists and lawsuits can do wonders in this situation, you just have to pony up the cash, pull the trigger and be prepared to make a lot of noise. Sitting in the corner whining about poluting the profession with untrained physicians doesn't help the cause. It actually vindicates those who suggest that you don't need a "real" trained doctor to provide healthcare to the masses. Medicine needs to stand up and say either you have some quality control that comes with advanced training or don't do this at all.

The answer is simple -- there are only so many medical travesties at the hands of untrained non-physicians you have to show the public before they get the picture. A full on blitz of suing, lobbying and plastering the media with the horror stories of providing medicine without a license and this battle is over. None of this dilution suicide mission garbage -- you either fight it like a war or you capitulate.

 

[Buzz Me]

In the end, if you're looking for a relatively easy job that doesn't have a lot of liability (read: sick patients) yet comes with a great salary and few pre-requisities (being board-certified/board-eligible, having your medical license, etc.)...well, unfortunately, you're not going to find one.

 

[tncekm]

In the end, if you're looking for a relatively easy job that doesn't have a lot of liability (read: sick patients) yet comes with a great salary and few pre-requisities (being board-certified/board-eligible, having your medical license, etc.)...well, unfortunately, you're not going to find one.

Congress, senate, etc. All you need to do is sell your soul to the establishment, and you're in!

 

[Sneezing]

That's like burning down the village so there's nothing to attract marauders. It's a losers gambit. You destroy the profession so nobody else can destroy it first. With ideas like this it's pretty clear why medicine is suffering the way it is. In fact, this is still salvagable, but it's going to take a lot of effort, money and personal inconvenience, none of which doctors seem willing to stomach. Lobbyists and lawsuits can do wonders in this situation, you just have to pony up the cash, pull the trigger and be prepared to make a lot of noise. Sitting in the corner whining about poluting the profession with untrained physicians doesn't help the cause. It actually vindicates those who suggest that you don't need a "real" trained doctor to provide healthcare to the masses. Medicine needs to stand up and say either you have some quality control that comes with advanced training or don't do this at all.

The answer is simple -- there are only so many medical travesties at the hands of untrained non-physicians you have to show the public before they get the picture. A full on blitz of suing, lobbying and plastering the media with the horror stories of providing medicine without a license and this battle is over. None of this dilution suicide mission garbage -- you either fight it like a war or you capitulate.

Okay, we agree on fighting the war. Check!
We disagree on how. Check!

You just stated yourself, in bold above, that doctors aren't willing to fight using legal. So how do you propose we change our views to want to fight with legal?

Until I hear a good proposal of how to rally the legal brigade, I advocate pollution dilution.

 

[Arcan57]

Right now a residency trained MD is the gold standard for medical care. We are more expensive (and sometimes less convenient) than our competitors in the patient care market. We have two things going for us: brand recognition and superior training. They are interrelated. Toyota was the gold standard for reliability among mid-size cars. They reduced quality in order to increase production capacity. Their name is now associated with high-speed, uncontrollable crashes. Now they are losing market-share to competitors they had crushed just a couple of years earlier. The closer MD and NP outcomes become, the less likely people are to pay the premium to see an MD. And while you can make a general argument regarding the overall intelligence (as measured by aptitude on standardized exams) differential between MDs and NPs, it's really the training that makes an MD worth a damn as a clinician.

 

[PostCall]

In the end, if you're looking for a relatively easy job that doesn't have a lot of liability (read: sick patients) yet comes with a great salary and few pre-requisities (being board-certified/board-eligible, having your medical license, etc.)...well, unfortunately, you're not going to find one.

when i did my IM rotation we had to do an attachment out in the community. i got sent to some building to work in an outpatient IM office. in another part of this building was a slick office that was a "medical spa". its waiting room looked like the lobby of 5-star hotel. i later learned the doctor for the medical spa had either quit or been dismissed after her internship year and never finish a residency. all she did all day was botox for women and sell them beauty products. apparently it costs a few hundred per botox treatment and it takes 10 minutes or so to do. cash up front, son. she herself looked like a supermodel and drove a new McLaren SLR. oh and the office hours posted on the door of her spa? mon-thurs 10 a.m.-4 p.m.
just sayin'

 

[Law2Doc]

Okay, we agree on fighting the war. Check!
We disagree on how. Check!

You just stated yourself, in bold above, that doctors aren't willing to fight using legal. So how do you propose we change our views to want to fight with legal?

Until I hear a good proposal of how to rally the legal brigade, I advocate pollution dilution.

The point of engaging in a war is to win. If you advocate fighting by having the profession as it exists now committing a massive suicide attach, then who's left when you win the war? -- Nobody who represents the current profession, just some poorly trained GP who doesn't know his arse from his elbow (but is happy to splint either for a competitive fee). So no, destroying the profession to make sure the non-physicians don't win isn't the goal. That's the same mentality as nuking the planet so the communists don't get it. ie *****ic.

The ONLY way you are going to achieve the goal, which is to have trained physicians providing medical care and these other fields providing ancillary, but not autonomous medical care, is to hold them in check via the legal process. And it's really easy to do. The lawyers created a perfect roadmap because the already fought the identical battles against paralegals, realtors and accountants, and prevailed in all 3 cases. What it is going to involve is physicians getting active, directly or through organizations. And it will involve ponying up money -- thousands of dollars per practice or well off physician. That's what the lawyers did, and it paid massive dividends to them -- decades later they still have a very broad scope of practice with no competition. This is something that can be started at the grassroots level, so no whining about it being something we have no control over. You do have control. This can be fixed. And it's easy to fix. But the hard part is getting some momentum to act within the profession.

Throwing up your hands and suggesting "lets all be poorly trained" so that way the NPs can't beat us on pricing for an inferior product (that we will now be offering as well) is not well thought out, sorry. At the end of the day, you still want the profession to be intact or you have lost the war, albeit by your own gun.

 

[Sneezing]

Well, you have convinced me against a policy wide endorsement of GPs. Although, I will always cringe as I write the check that puts food on the table for a lawyer.

I still think we shouldn't hate so much on a GP. I believe there is still a niche and room for the few who give it a try for whatever reason.

 

[Law2Doc]

...Although, I will always cringe as I write the check that puts food on the table for a lawyer. ....

A lawyer is basically a loaded weapon. You aren't happy when it's sites are on you, but it's often worth it to pay to have one in your arsenal.

 

[Buzz Me]

when i did my IM rotation we had to do an attachment out in the community. i got sent to some building to work in an outpatient IM office. in another part of this building was a slick office that was a "medical spa". its waiting room looked like the lobby of 5-star hotel. i later learned the doctor for the medical spa had either quit or been dismissed after her internship year and never finish a residency. all she did all day was botox for women and sell them beauty products. apparently it costs a few hundred per botox treatment and it takes 10 minutes or so to do. cash up front, son. she herself looked like a supermodel and drove a new McLaren SLR. oh and the office hours posted on the door of her spa? mon-thurs 10 a.m.-4 p.m.
just sayin'

Sure, there are always exceptions. But planning your future on setting up one of these practices (without a realistic backup plan)? Career suicide, IMHO.

It's like the IMGs who get misled because they know of a friend of a friend who got into a great residency spot (and who is now the program director at some academic program) despite multiple failures on the Steps and weak USCE. Sure those things occasionally happen, but while you're shooting for that pipe dream, bust your butt to improve your app.

 

[Taurus]

The answer is simple -- there are only so many medical travesties at the hands of untrained non-physicians you have to show the public before they get the picture. A full on blitz of suing, lobbying and plastering the media with the horror stories of providing medicine without a license and this battle is over. None of this dilution suicide mission garbage -- you either fight it like a war or you capitulate.

This is why I don't support tort reform unless the scope of non-physicians are clearly defined and will not change, which is unlikely. Do not underestimate the deterrent effect that the threat of litigation has over people.

 

[turquoiseblue]

If we take care of our own kind (MDs and DOs).and don't throw people out of residency or make them scared enough to resign..turning them into GPs, we wouldn't be having this problem of NP's taking over their future doctor jobs who most likely have it much easier than a medical doctor resident. That way a nurse can act as a GP and an MD can get to be a resident and subsequently a board certified physician. We're ruining our own 'species" so another species will flourish using whatever we have discarded. I'm saying this in reference to the fact that NP's are now allowed into derm residencies, and the 15,000 residency slots bill is most likely not passed, so there goes all our spots to NP's to fill the physician shortage void.

 

[Speculatrix]

If we take care of our own kind (MDs and DOs).and don't throw people out of residency or make them scared enough to resign..turning them into GPs, we wouldn't be having this problem of NP's taking over their future doctor jobs who most likely have it much easier than a medical doctor resident. That way a nurse can act as a GP and an MD can get to be a resident and subsequently a board certified physician. We're ruining our own 'species" so another species will flourish using whatever we have discarded. I'm saying this in reference to the fact that NP's are now allowed into derm residencies, and the 15,000 residency slots bill is most likely not passed, so there goes all our spots to NP's to fill the physician shortage void.

Anyone who confuses a nurse practitioner for a physician merits the results of natural selection.

 

[DrJosephKim]

States are becoming more strict about medical licensure requirements. In the past, you could do quite a bit as a GP. Now, you probably won't find any payors or hospitals that will be willing to credential you if you're not board-eligible. So, that leaves the option of opening a cash practice or working for someone who has a cash (or concierge) model.

 

[Winged Scapula]

States are becoming more strict about medical licensure requirements. In the past, you could do quite a bit as a GP. Now, you probably won't find any payors or hospitals that will be willing to credential you if you're not board-eligible. So, that leaves the option of opening a cash practice or working for someone who has a cash (or concierge) model.

It can be even worse than that.

Many of the hospitals I have privileges at require Board CERTIFICATION to be on staff.

 

[sima2113]

Hey,
I saw your post about medi spa from 2010 about when you were on your IM rotation, you saw a doctor that did botox injections and sold beauty products because she didn't finish residency. That actually sounds like something i'd love to do. Where was this at? Do you have any more information?
Thanks,
Sima

 

[Socrates25]

Yes, I know this thread is 2 years old.

But I wanted to let you guys know.

Massachusetts became the first state in the country to allow a doctor to supervise UNLIMITED number of PAs.

I'm going to move up there and set up a chain of 100 urgent care clinics staffed only by PAs. I get to bill for "supervising" all of them and I'll be rich!

 

[docu]

Yes, I know this thread is 2 years old.

But I wanted to let you guys know.

Massachusetts became the first state in the country to allow a doctor to supervise UNLIMITED number of PAs.

I'm going to move up there and set up a chain of 100 urgent care clinics staffed only by PAs. I get to bill for "supervising" all of them and I'll be rich!

how do you bill for supervision? what's the billing code?
what's the number to be supervised before the bill was passed?

 

[Law2Doc]

Yes, I know this thread is 2 years old.

But I wanted to let you guys know.

Massachusetts became the first state in the country to allow a doctor to supervise UNLIMITED number of PAs.

I'm going to move up there and set up a chain of 100 urgent care clinics staffed only by PAs. I get to bill for "supervising" all of them and I'll be rich!

You do realize that as supervisor you are on the hook for medical malpractice for every mistake made, right? It's dangerous to supervise many because you aren't able to keep a watchful eye on everything. For liability reasons, having more than 1-3 assistants is probably a big mistake. Te only way this works is if if you supervise 100 physicians who each supervise 1-2 PA helpers. But that cuts into the net profits.

 

[badasshairday]

how do you bill for supervision? what's the billing code?
what's the number to be supervised before the bill was passed?

Yeah what is the billing code? Do you actually get paid extra to supervise? Most PA's I know have a supervising doc but the PA does their own billing.