interesting article

[8744]

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My original post stated that healthcare does not operate in a free market economy. You said a lot of things in your reply, but nothing was really germain to what I originally wrote. The free market is defined as "business governed by the laws of supply and demand, not restrained by government interference, regulation or subsidy." With rare exceptions (e.g., a doctor who only accepts cash), medicine in the U.S. operates almost exclusively under the umbrella of regulation. The free market law of supply and demand is not a factor.

There is not a single business that is not regulated to one extent or another by the government. I was in the manufacturing sector for many years and we were beset by all kinds of OSHA and environmental regulations.

The medical industry is probably the most regulated of any but it's just a question of degree. If the criteria is that only unfettered capitalism results in free markets then I guess there is no such thing as free market.

As long as you are able to choose how you will work and what you will charge for your services, the market is free. The "freeness" of the market has nothing to do with whether your offered price is accepted. You can practice a cash only business. You can also require your patients to file their own insurance claims but nobody wants to do this because the consumer expects a low price and no responsibilty to pay for thier health care except that they pay part of their premium.

I repeat, if the government or an insurance company could set the price for your services and you had no choice but to accept this price, they would set the price at zero minimizing their cost in the process.

The price they have arrived it is high enough to entice doctors to accept it. Your confusion results from not correctly identifying the health care consumer. Since most Americans have either private or governement health insurance, the health care customer is the insurance company, not the patient, and it is this relationship that responds to market forces.

People do make money accepting medicare, medicaid, and private insurance. Like most industries the low bid price is offset by increased volume which is why family medicince doctors only spend a measley five or ten minutes with most patients.

 

[8744]

Private insurers set their fee schedules according to Medicare. Medicare rates are determined using a formula based on the gross national product (GNP), not the actual costs of providing healthcare. Again, not a free market.

The insurance industry itself operates in something more akin to a free market (which is why it's such a profitable industry), with insurers negotiating rates with employers based on market forces in their particular geographic area. However, these rates have little bearing on the fee schedules that are offered to physicians. With rare exceptions, physicians have little leverage when negotiating fee schedules with payers. The "negotiations" typically amount to little more than "Here's what we pay, take it or leave it." In many locales, one or two carriers now insure the majority of covered lives. If you don't accept those plans, you lose access to a significant chunk of your patient population. Again, not a free market from the physicians' standpoint.

You are confused. How the buyer determines what he is willing to pay is irrelevant to the operation of the market. The only important thing is whether his offer is accepted. It doesn't matter if the price was calculated using a GDP-based formula or astrology.

Obviously the government's bid is high enough or nobody would accept it. You continuously point out the princely sums to be made by Family Medicince physicians so in your sector, at least, the market is working. The fact that it is not working to your satisfaction because you are making less than you think you are worth is immaterial.

My worry about FP is actually that the government's bid price will continue to decrease as less expensive options, NPs for example, move into your market to undersell you.

Every free market has automatic downward pressure to reduce the bid price to the lowest possible level at which the "economic profit" is zero. Once again, below this price only the zealots will work as every other rational person will look for a job where he does not lose money.

I repeat. Nobody will work for free or if they are taking a loss.

"Take it or leave it" is valid free market concept. We do this all the time in real life. I shop at Wal Mart, for example, because I will not "take" Food Lion's asking price for a can of corn which is 40 cents higher than I am willing to pay.

Does Food Lion decry the lack of a free market from their point of view? Of course not. Setting the price high or low is just a function of what the market will bear.

"The actual cost of providing health care" is a meaningless concept. What you mean here is that you'd like to be paid more for your part of providing health care.

 

[8744]

..but actually ive never seen an ed doc complete an entire code in isolation...

Captain Obvious strikes again. Nothing at a major academic medical institution happens in isolation. On my last MICU rotation the MICU resident was part of the code team and his only job was to put in the central line. (which was usually a femoral line and not really a central line if you want to get technical) People came form all over the hospital and Upper-level floor resident on the ward that called the code was in charge.

It's kind of embarrassing having "Family Medicine" on my ID badge in a code because the assumption was that I couldn't put in the line.

When a patient "codes" in the ED, they do not call a hospital-wide code. The EM residents run the code with the usual cast of characters. Like most things if you are timid somebody else is going to take charge and if this is the trauma chief who happens to be seeing a patient in your ED than he is going to do it.

 

[deleted87716]

"The actual cost of providing health care" is a meaningless concept.

I think we'll just have to agree to disagree. Have a nice day.

 

[8744]

Don't they teach anything other than Marxist economics at universities any more?

 

[8744]

I think we'll just have to agree to disagree. Have a nice day.

Well, this thread is kind of confusing to me too. On one hand the premise is that Family Medicine salaries are going up responding to the increased demand from a normally functioning market. On the other hand family medicine salaries blow because the eee-vil gubmint' and the insurance companies have colluded to keep your salaries down to fast-food levels.

Is the salary picture good or bad?

Then you all tell me that EM blows because it has a high burnout rate secondary to treating all of those critically ill and seriously injured patients only to tell me several posts later that EM physicians don't actually treat any seriously ill patients but immedietely pass them on to real doctors.

 

[sophiejane]

Captain Obvious strikes again. Nothing at a major academic medical institution happens in isolation. On my last MICU rotation the MICU resident was part of the code team and his only job was to put in the central line. (which was usually a femoral line and not really a central line if you want to get technical) People came form all over the hospital and Upper-level floor resident on the ward that called the code was in charge.

It's kind of embarrassing having "Family Medicine" on my ID badge in a code because the assumption was that I couldn't put in the line.

When a patient "codes" in the ED, they do not call a hospital-wide code. The EM residents run the code with the usual cast of characters. Like most things if you are timid somebody else is going to take charge and if this is the trauma chief who happens to be seeing a patient in your ED than he is going to do it.

This is exactly why no one should train at an opposed residency for family medicine, "prestigious" or not. It's just not worth it, and the kinds of docs these programs turn out are the kind that people too often associate with FPs: fine for the clinic but incompetent at everything else.

The complete opposite is often true of FPs from solid unopposed programs like Ventura and JPS.

As for the NP debate...let's just sit back and watch. I doubt the doomsdayists are going to be proven correct on this one.

 

[8744]

This is exactly why no one should train at an opposed residency for family medicine, "prestigious" or not. It's just not worth it, and the kinds of docs these programs turn out are the kind that people too often associate with FPs: fine for the clinic but incompetent at everything else.

The complete opposite is often true of FPs from solid unopposed programs like Ventura and JPS.

As for the NP debate...let's just sit back and watch. I doubt the doomsdayists are going to be proven correct on this one.

You are so right. I would have gotten better training at the E.A. Conway program in little old Monroe, Louisiana than I am getting here at Duke (for Family Medicine, I mean).

It is just too easy to punt everything to a specialist. Not to mention that since our clinic is somewhat "volume driven" being a money-making practice the teaching suffers.

 

[lateness]

Well, this thread is kind of confusing to me too. On one hand the premise is that Family Medicine salaries are going up responding to the increased demand from a normally functioning market. On the other hand family medicine salaries blow because the eee-vil gubmint' and the insurance companies have colluded to keep your salaries down to fast-food levels.

Is the salary picture good or bad?

Then you all tell me that EM blows because it has a high burnout rate secondary to treating all of those critically ill and seriously injured patients only to tell me several posts later that EM physicians don't actually treat any seriously ill patients but immedietely pass them on to real doctors.

i dont agree with that about EM. i think you do treat and manage well critically injured patients, and pass on when its nec. but their is alot of stress and burnout, but thats in evfery field.

 

[mmmmdonuts]

On my last MICU rotation the MICU resident was part of the code team and his only job was to put in the central line.

and yet the point is that someone who was a member of the micu team did everything. obviously in a code one person is the leader and everyone else has designated tasks but that is not to say that the team as a whole is not acting independently and in isolation. it is quite different in the ed because they may initiate a code but most certainly one of their initial steps is to notify someone else to come to aid them. obviously captain obvious was not obvious enough for you.

 

[zippy81]

and yet the point is that someone who was a member of the micu team did everything. obviously in a code one person is the leader and everyone else has designated tasks but that is not to say that the team as a whole is not acting independently and in isolation. it is quite different in the ed because they may initiate a code but most certainly one of their initial steps is to notify someone else to come to aid them. obviously captain obvious was not obvious enough for you.

In community/private hospitals if someone codes the ER docs are the ones called to the floor to run it right?

 

[8744]

In community/private hospitals if someone codes the ER docs are the ones called to the floor to run it right?

Right. And let me reiterate that they do not call a "hospital wide code" if a patient codes in the ED. Presumably the assumption is that the EM physicians with their staff in the ED can handle it.

 

[8744]

and yet the point is that someone who was a member of the micu team did everything. obviously in a code one person is the leader and everyone else has designated tasks but that is not to say that the team as a whole is not acting independently and in isolation. it is quite different in the ed because they may initiate a code but most certainly one of their initial steps is to notify someone else to come to aid them. obviously captain obvious was not obvious enough for you.

No. The MICU resident was the "line" person and did just that. The ward resident who called the code ran the code.

But at other hospitals the MICU staff is also part of the code team but they do not respond to codes in the ED.

 

[RuralMedicine]

actually it is since you have to demonstrate/prove that you have the facilities and services to qualify for a designation as a level x trauma center. you dont just say 'i am one', which means you are being accredited either by the acs or the state.

just how many major traumas do you know of that are being handled by ed docs?



i didnt say people administered them without caution and for good reason. but how many people requiring thrombolytics are being treated by ed docs without consultation to cardiology? at duke or anywhere else?

Perhaps things are different because I practice at a rural institution (but I believe Panda made the point that the majority of care occurs at non academic centers so perhaps this is relevant). Traumas are handled by our EM physicians (unfortunately some of them are not EM trained and this is a problem--ideally we would have an 100% EM trained/boarded ED we're working on it) with Peds traumas managed by Peds & EM. We stabilize and ship (fly if the weather permits which is a little less than 50% of the time on average) but sometimes it's the things that are done in the first hour that make the difference.

As far as thrombolytics in ACS the standard of care with STEMI is cath lab in <2 hours or thrombolytics (providing no contraindications) and ship. We do not have cardiology at our institution so the thrombolytics decisions are made by either EM or medicine on call. I feel that part of being EM competent requires comfort with thrombolytic therapy the indications and contraindications. For the most part the EM trained cadre of our providers have this competency some of our non EM trained are not competent in this arena and the case diverts to the medicine on call. [But in these cases I feel that this is a deficiency in our ED physician. I'm not saying its something I'm not comfortable/competent with or shouldn't be, because it is and I am. However, I think that it delays care if the decision is turfed to me, but you have to do the right thing for the patient so I will see and stabilize and ship these patients. In these cases we usually ship ED to ED and I basically function as if I was an EM provider (and when we get an 100% EM trained ED I'll be glad to opt out)]

 

[mmmmdonuts]

In community/private hospitals if someone codes the ER docs are the ones called to the floor to run it right?

you gotta be kidding me.

 

[mmmmdonuts]

No. The MICU resident was the "line" person and did just that. The ward resident who called the code ran the code.

again as i said in any code there is by definition according to acls protocols a team leader and other people with designated jobs. doing a job as part of the code team is different from having the code team take over.

 

[RuralMedicine]

In community/private hospitals if someone codes the ER docs are the ones called to the floor to run it right?

you gotta be kidding me.

Right. And let me reiterate that they do not call a "hospital wide code" if a patient codes in the ED. Presumably the assumption is that the EM physicians with their staff in the ED can handle it.

Ideally at community hospitals the physicians do a better job of checking their egos and attitudes at the door than you three seem to have today. That said, in our community rural hospital if there is a code on the floor and it is the middle of the night our ED physician may be the only physician in house. They will run the code until the attending on call arrives in house. I admit that this made me uncomfortable at first as I was used to residency where there were multiple physicians in house and the idea of driving in from home for a code seemed quite honestly frightening. You adapt to your practice to the resources you have to practice with and the situation and I make it a point to make rounds before heading out the door and the nurses are trained to call sooner rather than later knowing that we can be 10 minutes away. So far in my short tenure I haven't had the experience of truly coming in for a code. I have come in for near codes and was fortunate to still be in my office the night that one of my colleagues patients got sent to the floor with saturations in the 70s on 50% venti mask by one of our less competent EM providers (don't slam EM he isn't EM trained perhaps that is part of the problem) the RT got him on 100% with marginal saturations (low 90s) and the nurses called me and I came over and intubated. My patient who self extubated at 3AM was considerate enough to do it on the morning of one of my worst weekend calls and I was still on the medical floor completing my final H&P so I could just cruise back over to the ICU and reintubate. (Had I not been in house depending on patient condition the ED physician might have been asked to attempt reintubation---some of our ED physicians would be challenged by that request another reason we need EM trained providers).

As far as ED codes as we are a single staffed department with some non EM trained providers our ED codes do "go overhead". I have been the airway or access physician while the ED physician ran the code or vice versa. We try to work together to do what is right for the patient. With pediatric alerts the ED nurses often contact the pediatrician on call even before letting the ED physician know (partly because we may not be in house).

 

[mmmmdonuts]

They will run the code until the attending on call arrives in house.

nobody ever said ed docs cant code people. i said and you just reiterated that ed docs are strictly temporizing agents at best. certainly at academic centers even this is debatable as it is barely disputable that they are essentially triage nurses. but ok if you want to focus on small isolated community centers that does not change things.

 

[RuralMedicine]

Well good riddance! Hope you enjoy the absolute #1 burn out specialty. Thought I read somewhere the average job span of an ER doc was 10 yrs. Enjoy all the lawsuits, drug seekers, absolute scum of the earth patients none of us would touch. Then come back and post about how wonderful your new specialty is.

This is a very troubling attitude from anyone, but especially an attending. You are a physician, not God, I challenge you to take a deep breath and meet your patients where they are and attempt to move forward. I hate to break it to you but addiction, mental illness, and lack of responsibility or compassion are not exclusive to patients presenting to the ED. Unfortunately you have demonstrated some of those qualities in your response now.

 

[RuralMedicine]

nobody ever said ed docs cant code people. i said and you just reiterated that ed docs are strictly temporizing agents at best. certainly at academic centers even this is debatable as it is barely disputable that they are essentially triage nurses. but ok if you want to focus on small isolated community centers that does not change things.

Well if I'm five minutes away to be honest the die is likely well cast (based largely on the care provided by the ED physician) by the time I arrive. Sure I can attempt to swoop in and save the day but it may not be possible at that point. You seem to have a real hang up with EM providers, please do your patients a favor and get over it.

 

[mmmmdonuts]

You seem to have a real hang up with EM providers, please do your patients a favor and get over it.

you seem to be full of pap. youre one of those people who think that as long as you put 'do your patients a favor' or 'this will benefit your patients' in front of a statement that makes it unassailable despite the fact that the two thoughts are completely disconnected. in other words you have been trained well to be a sheep. and before you get mad at what i say, put your patients first.

 

[RuralMedicine]

you seem to be full of pap. youre one of those people who think that as long as you put 'do your patients a favor' or 'this will benefit your patients' in front of a statement that makes it unassailable despite the fact that the two thoughts are completely disconnected. in other words you have been trained well to be a sheep. and before you get mad at what i say, put your patients first.

When you are unable to have a professional working relationship with your colleagues in another specialty patient care suffers. Hence growing up and putting patient care before trashing someone else (which seems to be the jist of the majority of your posts) would be beneficial. Perhaps how you conduct yourself in real life is vastly disparate from your conduct on the message board. If that is the case then good for you (and is life really so boring that you feel the need to flame and troll on a message board?). Otherwise please grow up. I've been told that you are no longer allowed to be actively involved in the practice of medicine and are disgruntled as a result of the situations and actions that led to that. If this is indeed the case then my sympathies and I wish you the best of luck in addressing your own issues in due time.

 

[mmmmdonuts]

When you are unable to have a professional working relationship with your colleagues in another specialty patient care suffers ...please grow up.

that hardly sounds professional. does that mean your working relationship with collegaues is suffering? or do you only give out advice and solliliquisms without following them? see the thing is that people like you like to talk like youre these very mature and compassionate people who are adults. but then you pick and choose when that needs to occur. in the middle of lecturing me about understanding and getting along you started trying to do some shots in the dark that are frankly fairly low blows hoping to yank my chain. but that contradicts your own message. and if i say that then you get all angry and start blustering some more because you dont like faceing the facts.

the fact that you couched your words in a backhanded pretense of sympathy doesnt make them more mature. if i said to you 'i apologzie that you are so ignorant and hope youre able to improve yourself as you grow in life' would you find that to be an acceptable message since it is the same way you speak?

 

[zippy81]

you gotta be kidding me.

I believe the Physician who works in a small hospital pretty much backed up my statement that ER docs run the codes on the floor. In the middle of the night who else is gonna run it, the janitor? I know for a fact even in large private hospitals ER is responsible for ALL floor codes. So I guess no, I'm not kidding you...

 

[mmmmdonuts]

I know for a fact even in large private hospitals ER is responsible for ALL floor codes. So I guess no, I'm not kidding you...

for about two minutes. so yes you are kidding me.

 

[sophiejane]

I believe the Physician who works in a small hospital pretty much backed up my statement that ER docs run the codes on the floor. In the middle of the night who else is gonna run it, the janitor? I know for a fact even in large private hospitals ER is responsible for ALL floor codes. So I guess no, I'm not kidding you...

Right, and guess who is running the ER (and thus the codes) in those small hospitals? Your friendly neighborhood jack or jill of all trades family doc. 🙂

 

[zippy81]

for about two minutes. so yes you are kidding me.

You think the attending is gonna make it out of bed and to the hospital in two minutes? Are you even in medical school?

 

[8744]

Right, and guess who is running the ER (and thus the codes) in those small hospitals? Your friendly neighborhood jack or jill of all trades family doc. 🙂

So let me get this straight. A Family Physician who spends his day dealing with chronic health care issues and treating other non-acute complaints can run a code but an EM physician whose job description includes stabilzing horrifically injured or seriously ill patinets cannot?

I wil grant you that every physician is ACLS certified but isn't it possible that an EM physician might have a little more practical experience than an FP?

 

[Newdoc2002]

You can't cast such a wide net on the hospitals, EM's or FM docs. It will be different in almost every hospital you go to. If I'm in house, I'll run the code. But at 2 am I'm in bed and the ED doc runs the code if no other doc is in the hospital. They'll call me if the patient is coming out of it and I will stabilize the patient after I haul A@@ to the hospital.

You can argue all you want about who is right and wrong. Chances are you all are both right and wrong.


PS This thread is worthless at this point.

 

[sacrament]

PS This thread is worthless at this point.

It is still serving the very important purpose of entertaining me.

 

[RuralMedicine]

So let me get this straight. A Family Physician who spends his day dealing with chronic health care issues and treating other non-acute complaints can run a code but an EM physician whose job description includes stabilzing horrifically injured or seriously ill patinets cannot?

I wil grant you that every physician is ACLS certified but isn't it possible that an EM physician might have a little more practical experience than an FP?

ACLS is basically the epitome of cookbook medicine (but this isn't bad because the cookbook is grounded in evidence and updated in a timely fashion) so yes I think FP can run codes, IM can run codes, Med-Peds can run codes, EM can run codes. Sadly being comfortable comes from doing it frequently. Procedural prowess with intubations and central access plays into your success somewhat as well (but this goes back to experience the more you do the better you are within reason). Experience varies by institution, I know where I trained FP residents never carried code pagers and the IM code team coded their patients for them. (I think this did them an educational disservice but that is another topic). They did not have unit privileges so they did not do lines or intubate. Other residency programs at other institutions may have similar problems.

In our institution as a pediatrician I'm more comfortable with pediatric acute care than all but one of our ED physicians (but again we don't have 100% EM trained providers in our ED 🙁 ) and I have had our ED physicians step back and let me (and even ask me to please) run the code in the ED with adults. The point is that we all have our strengths and weaknesses and you must adapt to practice within the resources of the health care system you find yourself in. The goal should be having EM trained providers in rural EDs (but if that isn't reality then it is even more critical that your IM, FP, and Peds doctors be comfortable with critical care).

 

[8744]

ACLS is basically the epitome of cookbook medicine (but this isn't bad because the cookbook is grounded in evidence and updated in a timely fashion) so yes I think FP can run codes, IM can run codes, Med-Peds can run codes, EM can run codes. Sadly being comfortable comes from doing it frequently. Procedural prowess with intubations and central access plays into your success somewhat as well (but this goes back to experience the more you do the better you are within reason). Experience varies by institution, I know where I trained FP residents never carried code pagers and the IM code team coded their patients for them. (I think this did them an educational disservice but that is another topic). They did not have unit privileges so they did not do lines or intubate. Other residency programs at other institutions may have similar problems.

In our institution as a pediatrician I'm more comfortable with pediatric acute care than all but one of our ED physicians (but again we don't have 100% EM trained providers in our ED 🙁 ) and I have had our ED physicians step back and let me (and even ask me to please) run the code in the ED with adults. The point is that we all have our strengths and weaknesses and you must adapt to practice within the resources of the health care system you find yourself in. The goal should be having EM trained providers in rural EDs (but if that isn't reality then it is even more critical that your IM, FP, and Peds doctors be comfortable with critical care).

Well said.

I matched into EM, by the way.

 

[RuralMedicine]

Well said.

I matched into EM, by the way.

👍 Congratulations! [And if you have any interest in relocating to a rural ED in 3 years let me know 😉]