SBAR: How hard should a pain doc work to make $1 million/yr?

[drusso]

S: "I have a concern that this employed-HOPD pain doctor is being compensated over fair market value."

B: My friend who is a CMO at a community hospital calls and asks for advice regarding pain MD compensation. Hospital has employed the pain doctor for 4 years and the doctor is on track to make $1 million this year. S/he is doing a ton of kypho, vertilfex, pumps, and stim. Sees 40 patients per day in the clinic with NP. I ask the CMO, "What's the doctor's enterprise value to the hospital?" Without even taking a breath he says, "It's on track to be over $11 million this year." Note: When negotiating with Admin they will always act sketchy and naive if you ask about projected physician enterprise value. Some Admin claims to "not track it." That's pure, unadulterated BS. It would be tantamount to business malpractice for any CFO, Department Chair, etc to not know the "top-line revenue" of their employed MD's. Moreover, any competent hospital governing board EXPECTS to see 2, 3, and 5-year projections based upon enterprise values. Despite this, physicians routinely fail to consider enterprise value when negotiating compensation arrangements.

A: I say, "You're telling me s/he brings in $11 million per year and you're paying out $1 million. His compensation is certainly greater than 90%tile of MGMA benchmarks, but this doctor seems justifiably exceptional in his/her productivity. The only question the C-suite and Board need to answer is whether or not they think the ROI is satisfactory and meeting expectations.

R: Pay him. While I'm not certain I could stomach such a lopsided split on my proceeds, I also can't imagine the hospital doing much better for itself in this scenario. And, at this current pace, the doctor is likely to burn out. But, so what? When that happens, just get another one and lather, rinse, repeat.

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[Ligament]

that is amazing compensation. Also amazing insight into how much a hospital profits from specialists like us. Why should not this physian get compensated $5M? $3M? who decides the physician should only be compensated 10% of collections?

40 patients per day is a ridiculous patient load, that is 5 mins per patient or something silly.

 

[BobBarker]

The PE ($11M) includes lots of things that are inappropriate to be compensated for such as hospital PT and referrals to ortho. There are also major costs for the devices that it doesn’t account for.

 

[Ligament]

The PE ($11M) includes lots of things that are inappropriate to be compensated for such as hospital PT and referrals to ortho. There are also major costs for the devices that it doesn’t account for.

Very true on the devices.

But why NOT get compensated for those things? This pain doc is making a TON of money for the hospital and the administrative team that does nothing, and takes no personal legal risks, and needs no extended education or student debt.

 

[drusso]

The PE ($11M) includes lots of things that are inappropriate to be compensated for such as hospital PT and referrals to ortho. There are also major costs for the devices that it doesn’t account for.

PEV, as typically computed, doesn't include specialty referrals and downstream system income from those referrals. It does include facility fees, labs, PT, imaging, DME, and pharmacy directly ordered by MD and attributed to the MD. If you include the other downstream system income from specialty referrals, then the value is even higher.

It's really mind-boggling how much money is on the table. Owning doctors is still a growth industry.

 

[BobBarker]

It probably becomes hard to calculate. Who do you give the revenue to: the orthopedist or the referrer. Just simpler to fully allocate it to the orthopedist.

I would think the anesthesia fees are pretty significant. 400 surgical cases for the employed CRNA’s is probably a large amount of money. Someone who still does anesthesia might be able to give us a good estimate. @algosdoc

 

[deleted993114]

S: "I have a concern that this employed-HOPD pain doctor is being compensated over fair market value."

B: My friend who is a CMO at a community hospital calls and asks for advice regarding pain MD compensation. Hospital has employed the pain doctor for 4 years and the doctor is on track to make $1 million this year. S/he is doing a ton of kypho, vertilfex, pumps, and stim. Sees 40 patients per day in the clinic with NP. I ask the CMO, "What's the doctor's enterprise value to the hospital?" Without even taking a breath he says, "It's on track to be over $11 million this year." Note: When negotiating with Admin they will always act sketchy and naive if you ask about projected physician enterprise value. Some Admin claims to "not track it." That's pure, unadulterated BS. It would be tantamount to business malpractice for any CFO, Department Chair, etc to not know the "top-line revenue" of their employed MD's. Moreover, any competent hospital governing board EXPECTS to see 2, 3, and 5-year projections based upon enterprise values. Despite this, physicians routinely fail to consider enterprise value when negotiating compensation arrangements.

A: I say, "You're telling me s/he brings in $11 million per year and you're paying out $1 million. His compensation is certainly greater than 90%tile of MGMA benchmarks, but this doctor seems justifiably exceptional in his/her productivity. The only question the C-suite and Board need to answer is whether or not they think the ROI is satisfactory and meeting expectations.

R: Pay him. While I'm not certain I could stomach such a lopsided split on my proceeds, I also can't imagine the hospital doing much better for itself in this scenario. And, at this current pace, the doctor is likely to burn out. But, so what? When that happens, just get another one and lather, rinse, repeat.

Why is the hospital concerned about the guy's salary if he is making them that much cash?

Employing physicians can be profitable, but in MANY instances (particularly primary care) the hospital lose money on such practices.

I had set up a clinic in East TN for an internal medicine practice. The reimbursement there was AWFUL (lots of medicaid and medicare). Yet there was a hospital employed pain guy in town (nice guy-not a crook) who made $1.2 million per year, as he generated a ton of money for the hospital, given the high procedure fees and the spin off revenue. He really was not busting his butt, but was certainly putting in full days.

 

[SSdoc33]

Why is the hospital concerned about the guy's salary if he is making them that much cash?

Employing physicians can be profitable, but in MANY instances (particularly primary care) the hospital lose money on such practices.

I had set up a clinic in East TN for an internal medicine practice. The reimbursement there was AWFUL (lots of medicaid and medicare). Yet there was a hospital employed pain guy in town (nice guy-not a crook) who made $1.2 million per year, as he generated a ton of money for the hospital, given the high procedure fees and the spin off revenue. He really was not busting his butt, but was certainly putting in full days.

when you talk about not counting other people's money, you should direct your comments at drusso. he seethes in bed at night and invents scenarios like the above so he can get reassurances from others that the system isnt "fair". this is a very poor coping mechanism, drusso. it is not healthy.

 

[deleted993114]

when you talk about not counting other people's money, you should direct your comments at drusso. he seethes in bed at night and invents scenarios like the above so he can get reassurances from others that the system isnt "fair". this is a very poor coping mechanism, drusso. it is not healthy.

I guess I have not seen him expressing such notions.

Guys should only be concerned about their practice, doing the right thing, and seeking adequate compensation for themselves. That is the only thing you can control.

Where I work now, there are two guys in town that make well over a million per year. Such practices are certainly available around the US, but I guess I really prefer an easier schedule and less money. It makes me feel more like a doctor than a factory worker. Keep in mind that the high salaries come with high taxes, so it is not as much money as it appears.

High salaries come at a personal cost and one has to ask themselves whether such sacrifices are worth it. In some situations, you are forced to bust your butt by circumstances. In others, we get a choice about level of work vs reimbursement. I don't think many pain docs will be on food stamps at retirement time, and will be just fine financially.

 

[SSdoc33]

Agreed. Nobody is making 1 million without working hard -- employed or private

 

[lobelsteve]

Adequate compensation is in the eye of the beholder. $250k is a lot of money. I’m happy with current deal. Would be richer but not necessarily happier with 1.2m salary.

 

[deleted993114]

Agreed. Nobody is making 1 million without working hard -- employed or private

Indeed. I am not making that much anymore and am much, much happier with work. When you work that fast, it is more akin to being a factory worker. I do see waste and inefficiency everywhere in my current gig (I am an efficiency freak), but I have learned to just let it go and let someone else be concerned about such things and get old dealing with those issues.

Life is too short to be unhappy at work. I think we all minimize the negative consequences that such a work environment can have on your overall health and well being.

Medicine is a pretty fun and interesting gig that can keep one engaged for a long period of time. The trick is minimizing the economic and political aspects of a practice and just focus on regular old medicine. I think we all worry too much about the political and economic issues, which for the most part, are ones we can't really alter that much anyway.

Don't be envious of those guys making over $1 million- pity them. I know that sounds trite, but it is the truth; they will probably realize this as well in retrospect. Also, would you really want to be one of those guys who has sold their soul to a particular company to get big bucks from them? We all know who they are, but would you want to do what they do?

You have lobelsteve guy here who takes the time to educate and teach others at ISIS meetings, which is pretty cool (but probably not worth it from a financial standpoint, or the time committment). That helps advance the field and is probably very satisfying, much like an academic post. That is far, far different than the guys getting millions from the equipment companies to promote their gear and put out stuff which may or may not be true for cash.

 

[drusso]

when you talk about not counting other people's money, you should direct your comments at drusso. he seethes in bed at night and invents scenarios like the above so he can get reassurances from others that the system isnt "fair". this is a very poor coping mechanism, drusso. it is not healthy.

What are you talking about? I'm posting a real-life SBAR as an illustration of how new grads and fellows can get cognitively anchored to a false "price is right" distributive bargaining model of compensation and not see the fuller value proposition on the table.

There are only two ways to compensate doctors: You can pay them for what they do or what they don't do. Ever wonder why hospitals propose splits on "shared-savings" based upon what doctors DON'T do (don't order MRI's, don't prescribe opioids, don't do procedures), but don't propose similar splits based upon physician enterprise value/ top-line revenue---ie what they "do"?

You ever hear the refrain, "As we shift from volume to value..." in compensation discussion? Who will be at the table to operationalize "value?"

 

[SommeRiver]

I just don't see how it is humanly possible to generate 11 million dollars considering that is more than every surgeon in my group doing spine and joints, and together with their PAs (most have 2) are doing high volume.

None hit that mark. I don't get it.

 

[SSdoc33]

What are you talking about? I'm posting a real-life SBAR as an illustration of how new grads and fellows can get cognitively anchored to a false "price is right" distributive bargaining model of compensation and not see the fuller value proposition on the table.

There are only two ways to compensate doctors: You can pay them for what they do or what they don't do. Ever wonder why hospitals propose splits on "shared-savings" based upon what doctors DON'T do (don't order MRI's, don't prescribe opioids, don't do procedures), but don't propose similar splits based upon physician enterprise value/ top-line revenue---ie what they "do"?

You ever hear the refrain, "As we shift from volume to value..." in compensation discussion? Who will be at the table to operationalize "value?"

do you have a reference for this "real-life SBAR"?

 

[Ducttape]

have you thought, drusso, that maybe that CMO friend of yours is having a crisis of ethics and maybe, just maybe, started wondering whether employing a needle jockey is not in the patients or communities best interest?

after all,
"and what happened then?
Well, in Whoville they say - the Grinch's small heart grew 3 sizes that day!
And then - the true meaning of Christmas came through, and the Grinch found the strength of ten grinches, plus two!"

 

[drusso]

do you have a reference for this "real-life SBAR"?

It's a sentinel event/anecdote not a published research finding.

 

[drusso]

have you thought, drusso, that maybe that CMO friend of yours is having a crisis of ethics and maybe, just maybe, started wondering whether employing a needle jockey is not in the patients or communities best interest?

after all,
"and what happened then?
Well, in Whoville they say - the Grinch's small heart grew 3 sizes that day!
And then - the true meaning of Christmas came through, and the Grinch found the strength of ten grinches, plus two!"

No one expressed any ethical concerns about the situation except me--ie the ratio of the split on PEV.

 

[Ferrismonk]

I probably get paid fairly for what I do (Private practice, employee), and while the $250K mentioned earlier is a "high income" relative to most Americans, every time I look at my $500K student loan burden a part of me says be a needle jockey and play stick-a-stim.

 

[SSdoc33]

It's a sentinel event/anecdote not a published research finding.

so... its bullsh$t.

this is a hypothetical scenario that supports your agenda.

you are essentially a conspiracy theorist at this point.

give me something real and we can have a legitimate discussion. i dont trust your numbers, narrative, embellishments, etc....

 

[drusso]

so... its bullsh$t.

this is a hypothetical scenario that supports your agenda.

you are essentially a conspiracy theorist at this point.

give me something real and we can have a legitimate discussion. i dont trust your numbers, narrative, embellishments, etc....

You're talking nonsense and sound like a conspiracy theorist yourself. One of my side gigs is health policy and consulting. I have these kinds of conversations all the time.

Your response to the situation is typical denialistic defense mechanism/rhetoric: If you can't argue the theory; argue the facts. If you can't argue the facts; argue the theory. If you can't argue either the theory or the facts; attack the person.

 

[deleted993114]

I just don't see how it is humanly possible to generate 11 million dollars considering that is more than every surgeon in my group doing spine and joints, and together with their PAs (most have 2) are doing high volume.

None hit that mark. I don't get it.

so... its bullsh$t.

this is a hypothetical scenario that supports your agenda.

you are essentially a conspiracy theorist at this point.

give me something real and we can have a legitimate discussion. i dont trust your numbers, narrative, embellishments, etc....

I don't know what an "SBR" is, but I can tell you there are plenty of guys out there making over $1 million per year. I would say that is in the top 2% of pain clinic physicians (according to my old accountant), so it is by no means a reflection of the average situation. One thing I CAN tell you is that they are not training the fellows anymore to be fast. So among the majority of pain providers, they are just not fast enough to generate that kind of revenue. But is faster really better?

Who cares if someone is making big bucks? Let them do so if that is what they want to do. One should only be concerned about your own practice and your life.

I really do not understand why one would want to work that hard, unless the circumstances dictate it and you have little choice. If you do have a choice, isn't it more fun to take some time and practice like a real doctor, not a factory worker?

 

[SommeRiver]

I don't know what an "SBR" is, but I can tell you there are plenty of guys out there making over $1 million per year. I would say that is in the top 2% of pain clinic physicians (according to my old accountant), so it is by no means a reflection of the average situation.

Who cares? Let them do so if that is what they want to do. One should only be concerned about your own practice and your life.

I really do not understand why one would want to work that hard, unless the circumstances dictate it and you have little choice. If you do have a choice, isn't it more fun to take some time and practice like a real doctor, not a factory worker?

I'm talking about an 11 million dollar valuation of that physician's practice. I don't see how it could be so high.

 

[drusso]

I'm talking about an 11 million dollar valuation of that physician's practice. I don't see how it could be so high.

It's not a valuation of the MD's practice. It's the amount of "top-line" revenue that the MD is making for the hospital:

A new formula to track the ROI of your employed physicians - Becker's Hospital Review | Healthcare News & Analysis

When thinking about the financial performance of the employed physician enterprise for your health system, is your first instinct to focus on the operating loss of the medical group as a standalone business? While this is certainly an important part of the equation, it's by no means the whole story.

www.beckershospitalreview.com

 

[drusso]

I don't know what an "SBR" is, but I can tell you there are plenty of guys out there making over $1 million per year. I would say that is in the top 2% of pain clinic physicians (according to my old accountant), so it is by no means a reflection of the average situation. One thing I CAN tell you is that they are not training the fellows anymore to be fast. So among the majority of pain providers, they are just not fast enough to generate that kind of revenue. But is faster really better?

Who cares if someone is making big bucks? Let them do so if that is what they want to do. One should only be concerned about your own practice and your life.

I really do not understand why one would want to work that hard, unless the circumstances dictate it and you have little choice. If you do have a choice, isn't it more fun to take some time and practice like a real doctor, not a factory worker?

SBAR is a form of structured communication used to communicate effectively in an emergency. It drives rapid decision making:

SBAR - Wikipedia

en.wikipedia.org

 

[SSdoc33]

I'm talking about an 11 million dollar valuation of that physician's practice. I don't see how it could be so high.

its not that high. drusso just made up a bunch of numbers, and now we are discussing it.

 

[drusso]

its not that high. drusso just made up a bunch of numbers, and now we are discussing it.

You don't think that a busy, employed, HOPD-based pain MD can generate $11 million per year for her employer?

 

[SommeRiver]

What a confusing number. This is why I can't work for a hospital...I'd rather get raped by a bunch of physician partners than a hospital system.

 

[SSdoc33]

You're talking nonsense and sound like a conspiracy theorist yourself. One of my side gigs is health policy and consulting. I have these kinds of conversations all the time.

Your response to the situation is typical denialistic defense mechanism/rhetoric: If you can't argue the theory; argue the facts. If you can't argue the facts; argue the theory. If you can't argue either the theory or the facts; attack the person.

we live in a gray world, where you only see black and white.

if you came across a case report in your "side gigs" or your masters of health care economics yada yada yada that is published, then post it.

otherwise, this is a meaningless discussion based on data provided by a single (biased) source

 

[SSdoc33]

You don't think that a busy, employed, HOPD-based pain MD can generate $11 million per year for her employer?

i think it could be theoretically possible.

i think you came up with a somewhat similar scenario, and manipulated the numbers and data to get your point across.

 

[drusso]

i think it could be theoretically possible.

i think you came up with a somewhat similar scenario, and manipulated the numbers and data to get your point across.

Well, it's absolutely possible because it's really happening. I don't understand why you're attacking me. I came down on the side of paying the MD. I said that it is well over 90%tile MGMA, but pay them anyway. This person is killing it and bringing $10 million worth of activity to his institution. I could understand you attacking me if I advised that they cap the RVU's or something, but I said PAY IT!

 

[SSdoc33]

Well, it's absolutely possible because it's really happening. I don't understand why you're attacking me. I came down on the side of paying the MD. I said that it is well over 90%tile MGMA, but pay them anyway. This person is killing it and bringing $10 million worth of activity to his institution. I could understand you attacking me if I advised that they cap the RVU's or something, but I said PAY IT!

i thought it was a woman. thats weird. maybe just an oversight......

and we both know that your point was not that the MD "deserved" to be paid

 

[drusso]

i thought it was a woman. thats weird. maybe just an oversight......

and we both know that your point was not that the MD "deserved" to be paid

The doctor is a person...I'm keeping it vague to protect identities. The hospital felt the MD was overpaid.

 

[deleted993114]

SBAR is a form of structured communication used to communicate effectively in an emergency. It drives rapid decision making:

SBAR - Wikipedia

en.wikipedia.org

Thanks! Learned something new today. I see it is distinct and a separate entity than "FUBAR" (also a military acronym).

 

[lobelsteve]

Well, it's absolutely possible because it's really happening. I don't understand why you're attacking me. I came down on the side of paying the MD. I said that it is well over 90%tile MGMA, but pay them anyway. This person is killing it and bringing $10 million worth of activity to his institution. I could understand you attacking me if I advised that they cap the RVU's or something, but I said PAY IT!

Ouchie. At least my dog is not a humper at the park.

 

[drusso]

Ouchie. At least my dog is not a humper at the park.

He can't help it.

 

[ateria radicularis magna]

we live in a gray world, where you only see black and white.

if you came across a case report in your "side gigs" or your masters of health care economics yada yada yada that is published, then post it.

otherwise, this is a meaningless discussion based on data provided by a single (biased) source

You sound insane or over caffeinated.

 

[hyperalgesia]

I really do not understand why one would want to work that hard, unless the circumstances dictate it and you have little choice. If you do have a choice, isn't it more fun to take some time and practice like a real doctor, not a factory worker?

You're so right about this. Time is irreplaceable.

 

[Dr. Ice]

that is amazing compensation. Also amazing insight into how much a hospital profits from specialists like us. Why should not this physian get compensated $5M? $3M? who decides the physician should only be compensated 10% of collections?

40 patients per day is a ridiculous patient load, that is 5 mins per patient or something silly.

So if you can’t see 40 patients a day how do you expect to survive in a Medicare for all world? Are you gonna totally change your lifestyle?

I see that many patients now. I do notes in the early mornings or at lunch or weekends. I have no pa or np and I still probably spend more time with my patients than anyone else I know. Am I burnt out? Absolutely..but I’m preparing myself for a huge shift in payment once trump gets impeached and removed and the country goes totally progressive..

 

[SSdoc33]

So if you can’t see 40 patients a day how do you expect to survive in a Medicare for all world? Are you gonna totally change your lifestyle?

I see that many patients now. I do notes in the early mornings or at lunch or weekends. I have no pa or np and I still probably spend more time with my patients than anyone else I know. Am I burnt out? Absolutely..but I’m preparing myself for a huge shift in payment once trump gets impeached and removed and the country goes totally progressive..

I've been going hard for the last few years based on this assumption as well. But, it seems like its pretty hard to change the status quo. I think it will be more like death by a thousand cuts, rather than dropping off a cliff

 

[drusso]

So if you can’t see 40 patients a day how do you expect to survive in a Medicare for all world? Are you gonna totally change your lifestyle?

I see that many patients now. I do notes in the early mornings or at lunch or weekends. I have no pa or np and I still probably spend more time with my patients than anyone else I know. Am I burnt out? Absolutely..but I’m preparing myself for a huge shift in payment once trump gets impeached and removed and the country goes totally progressive..

How worried are you about hospital price transparency and site-neutral payment?

 

[hyperalgesia]

How worried are you about hospital price transparency and site-neutral payment?

Does anyone know why insurance companies haven't broken with Medicare to favor the most cost effective care (in the office)?

This seems like such low hanging fruit for them. Why don't they offer cheaper plans to patients willing to accept office based vs hospital care?

 

[Ducttape]

consider Pete Buttigieg...

 

[SommeRiver]

consider Pete Buttigieg...

I consider that he sux...

 

[deleted993114]

Does anyone know why insurance companies haven't broken with Medicare to favor the most cost effective care (in the office)?

This seems like such low hanging fruit for them. Why don't they offer cheaper plans to patients willing to accept office based vs hospital care?

They do- that is what we call plans with higher co-pays.

I don't think I would trust a democrat to do anything that would involve a further entitlement, as the chances are good that I would be paying several fold what I would normally. Due to pre-existing conditions, I can't buy a health insurance policy (no-Obamacare did not rectify that problem, unless you are nearly broke), so I am forced to work as an employ in a larger group/system. I don't blame them- I wouldn't insure me either, as they would lose money.

I would not mind a single payer system, if:

1. the cost was spread around
2. payments to providers and facilities did not bankrupt them
3. "red tape" and pre-auths were reduced

Any such system designed by the dems would be another tool to "punish the rich" to satisfy an angry political base, rather than a means to satisfy healthcare needs for everyone.

 

[deleted993114]

So if you can’t see 40 patients a day how do you expect to survive in a Medicare for all world? Are you gonna totally change your lifestyle?

I see that many patients now. I do notes in the early mornings or at lunch or weekends. I have no pa or np and I still probably spend more time with my patients than anyone else I know. Am I burnt out? Absolutely..but I’m preparing myself for a huge shift in payment once trump gets impeached and removed and the country goes totally progressive..

You are going to be waiting a long time for a liberal fantasy that will never come to fruition. The dems won't even pass impeachment in the Congress, as it will involve dragging Biden and Hillary into the mess. Even if they did, an impeachment wont pass the Senate. It is a similar charade to when Clinton was impeached. It was never going to pass, yet they went through the exercise anyway for perceived political gains. This impeachment process is just as dumb as the Clinton impeachment.

You have the ability to change- there are plenty of jobs out there where you can make north of $500K and see 25 patients per day. You just have to look for them. EVERY job has its negative aspects; generally the higher paying jobs are in "less desirable" locations. You always have to serve some master, it is just a different one in different situations. Did you think about academics or the VA? The VA is cool, as you get a pension when you are done and Blue Cross Federal for life. Academics can be appealing to the right person as well. Life is too short to not like your job; it takes courage to change, as we accept less than pleasant jobs for fear of the unknown when we change.

There is no way in hell that I would see 40 patients per day and I am extremely fast. I dictate and my notes are done one minute after I walk out of the patient's room. EMR has the ability to use dictation. Also, GET MID LEVELS- there is no way that you can be efficient without NPs. I have always had 2-3 NPs myself. They pay for themselves (you can actually make some money off them if you choose to do so- I always let them have whatever they made with no overhead costs) and make your life more pleasant.

If you want the nation to "go progressive", speak to people who lived in Eastern Europe, the USSR, China, Cuba, or Venezuala first. Talk to a Vietnamese refugee- look before you leap. I am always shocked by people who pine for such systems and think they will be better off. Keep in mind that Orwell was a Marxist before being a volunteer for the communists in the Spanish Civil War- a chance inaccurate sniper bullet spared his life; then he woke up and wrote "1984" and "Animal Farm" (must reads for any progressive). Churchill read "1984" five times and was an admirer of Orwell. The modern progressive movement in the US was born out the Frankfurt School, which was a Marxist think tank started by Stalin to make the west more susceptible to Marxism. Those that were not killed by Hitler fled to the US (NYU specifically) and continued their mission here in the US. Their targets? The church, the middle class, and the family. Read some history.

 

[SSdoc33]

You are going to be waiting a long time for a liberal fantasy that will never come to fruition. The dems won't even pass impeachment in the Congress, as it will involve dragging Biden and Hillary into the mess. Even if they did, an impeachment wont pass the Senate. It is a similar charade to when Clinton was impeached. It was never going to pass, yet they went through the exercise anyway for perceived political gains. This impeachment process is just as dumb as the Clinton impeachment.

You have the ability to change- there are plenty of jobs out there where you can make north of $500K and see 25 patients per day. You just have to look for them. EVERY job has its negative aspects; generally the higher paying jobs are in "less desirable" locations. You always have to serve some master, it is just a different one in different situations. Did you think about academics or the VA? The VA is cool, as you get a pension when you are done and Blue Cross Federal for life. Academics can be appealing to the right person as well. Life is too short to not like your job; it takes courage to change, as we accept less than pleasant jobs for fear of the unknown when we change.

There is no way in hell that I would see 40 patients per day and I am extremely fast. I dictate and my notes are done one minute after I walk out of the patient's room. EMR has the ability to use dictation. Also, GET MID LEVELS- there is no way that you can be efficient without NPs. I have always had 2-3 NPs myself. They pay for themselves (you can actually make some money off them if you choose to do so- I always let them have whatever they made with no overhead costs) and make your life more pleasant.

If you want the nation to "go progressive", speak to people who lived in Eastern Europe, the USSR, China, Cuba, or Venezuala first. Talk to a Vietnamese refugee- look before you leap. I am always shocked by people who pine for such systems and think they will be better off. Keep in mind that Orwell was a Marxist before being a volunteer for the communists in the Spanish Civil War- a chance inaccurate sniper bullet spared his life; then he woke up and wrote "1984" and "Animal Farm" (must reads for any progressive). Churchill read "1984" five times and was an admirer of Orwell. The modern progressive movement in the US was born out the Frankfurt School, which was a Marxist think tank started by Stalin to make the west more susceptible to Marxism. Those that were not killed by Hitler fled to the US (NYU specifically) and continued their mission here in the US. Their targets? The church, the middle class, and the family. Read some history.

face..... palm.

i suspect that dr. ice doesnt want to uproot his family and move to nebraska.

i also suspect that his employer would exactly jump at the chance to hire "2-3" mid levels. mid-levels do nothing but provide worse care, but to each his own. also, they are a financial risk unless you have a ton of patients rolling in with a good payer mix.

i am not ignorant of history, but your political ramblings are not based in reality. this is the point in the conversation when ducttape typically embarrasses people, but ill leave that up to him.

 

[Dr. Ice]

Here’s the thing. I’m not a liberal. But I’m not naive to think that after this impeachment debacle that there is gonna be another republican in the White House next term. We are gonna be stuck with a dem..and I’m hoping that the country doesn’t swing the pendulum all the way progressive but who knows. I know that in a Medicare for all world, the 40 patients/day will likely amount to half my take home pay now.

 

[lobelsteve]

Here’s the thing. I’m not a liberal. But I’m not naive to think that after this impeachment debacle that there is gonna be another republican in the White House next term. We are gonna be stuck with a dem..and I’m hoping that the country doesn’t swing the pendulum all the way progressive but who knows. I know that in a Medicare for all world, the 40 patients/day will likely amount to half my take home pay now.

I think the longer the impeachment hearings go on, the stronger it makes Trump. I think this is his plan. Nothing burger. Shiff = joke.
Bloomberg is best bet unless Starbucks guy comes back or another name jumps in that is a viable candidate. Current dems are all horrible.

 

[deleted993114]

Here’s the thing. I’m not a liberal. But I’m not naive to think that after this impeachment debacle that there is gonna be another republican in the White House next term. We are gonna be stuck with a dem..and I’m hoping that the country doesn’t swing the pendulum all the way progressive but who knows. I know that in a Medicare for all world, the 40 patients/day will likely amount to half my take home pay now.

No man can predict the future. I don't think anyone can say for sure who the next president will be.

face..... palm.

i suspect that dr. ice doesnt want to uproot his family and move to nebraska.

i also suspect that his employer would exactly jump at the chance to hire "2-3" mid levels. mid-levels do nothing but provide worse care, but to each his own. also, they are a financial risk unless you have a ton of patients rolling in with a good payer mix.

i am not ignorant of history, but your political ramblings are not based in reality. this is the point in the conversation when ducttape typically embarrasses people, but ill leave that up to him.

What's wrong with Nebraska? Omaha is a good town that has a very good insurance mix. It is cold as hell there, that is for sure. However, I would assume that the practices are decent. One person's home may be considered a dump to others (Im not from Nebraska).

The best incomes are in the Midwest and southeast; some people like living there, others do not. That is the part of the trade off in desirability of an area vs income.

Mid levels are great for medicine management and follow ups. I don't know of any efficient practice that does not use them in some capacity; NPs have become a reality for most providers. My NPs always made money, even in one area in which the payer mix was not great.

Perhaps you should read a little more history- it is not always what we have presumed it to be. Heroes of the past are sometimes not that heroic in reality and the origins of what we believe can be rather shocking. Perhaps a little reading on the Frankfurt School could be enlightening, as it is an interesting topic. It is very interesting to find that many Hollywood liberals were very pro-Nazi (including Sean Penn's father) right up to the time they invaded the Soviet Union. Papa Joe Kennedy was pro-Nazi and JFK was having an affair with a Danish Nazi spy; when discovered, the "deal" between Hoover and Joe Kennedy was to ship him off to the Pacific, where he became a war hero. PT-109 is a great read; I actually like JFK, despite him having a very shady social history, although that was common at the time. The only guy in that period who could keep his pants on was Truman. Even Ike, Patton, FDR, and MacArthur were lechers. Lord Mountbatton was a pervert who not only had many affairs, but apparently diddled young boys.