Shed The Old View, And Accept Modern Medicine For What It Is

[Birdstrike]

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[docB]

Wow. I have to agree.

I'd also add that the inability for anyone to comply with #9 will make them unemployable. I have trouble with this and it causes me lots of grief.

 

[Birdstrike]

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[Birdstrike]

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[Birdstrike]

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[GeneralVeers]

I disagree that we will be spending $1,000,000,000,000 more on medicine. I think we will spend more (that is inevitable) but the amount per patient is going to go down as more people become "insured" (I used the quotations because it is not insurance in the old-fashioned sense). That means someone is going to take a hit. Hospitals, radiologists, nurses, administrators, shareholders, hospitalists.....or us.

Additionally the money to fund that $1,000,000,000,000 has to come from somewhere. It will come from us in the form of higher taxes. If we see ANY increase (doubtful) in our bottom line, it will simply be the case of the government taking money out of our left-hand pocket to put in the right.

 

[Birdstrike]

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[GeneralVeers]

Veers, you're not listening to me. It's a new normal. The old rules don't apply. You're thinking "the old way." The opportunities are there, and they're big. Think big. Think positive and retrain your brain. The old way is dead. Evolve or end up in a museum with T. Rex.

Not sure what you mean. I completely understand that the Marcus Welby way of doing medicine is dead. Fine with me, as I was never into the touchy-feely claptrap anyway.

The "New Way" involves lower (but still high) salary for us, higher taxes on us, and more regulation and oversight.

I'm not disagreeing with you about whether the change will happen, I just don't see it as a positive in any way. Unless my math is wrong, I can't figure out a way that we make the same or more money seeing patients who are paying less per person on average.

 

[Birdstrike]

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[Arcan57]

There is a culture of victimhood amongst doctors that I refuse to be a part of any longer.

I normally find your posts skewing more bitter than what I feel, but I have to agree with almost everything that you've said on this thread. Clinical medicine as a road to long-term wealth died in the 80s for most specialties and will be dead in the next 10 years for all but the superstars of the cash-only subspecialties. We'll still be paid way better than the majority of the population, but the wins in the (temporarily) increased spending on healthcare are going to be the people and groups that figure out how to provide good outcomes for less money. The group that figures out how to reliably control HgbA1c levels across diverse patient populations is going to make BILLIONS, the consultant that can show hospitals how to have consistent sub 60 min. care complete to admit times is going to be making their clinical salary without ever seeing the inside of a hospital on nights or weekends. The problem for us as physicians is that we're useful for our clinical knowledge, but have no real advantage over the social scientists and statisticians in terms of providing population based health. Our education no longer puts as at the top of the hierarchy, because we've been taught the wrong things to be the leaders of the next model of medical care.

We'll still be valuable commodities, but for the most part that's all we'll be. And while it's going to chafe, the actions (and inactions) of our predecessors are directly responsible for leading us here. As a profession we made money hand over fist charging for interventions, many of them of questionable efficacy. We did this because we could, and that's what reimbursed well. That gate closed for most of the profession, and so we tried the evolutionary step of working harder and doing more procedures of questionable efficacy. That gate is closing as well. We're running out of ways to optimize the current system to our benefit (there are only so many hours in the day and pay per procedure isn't going to go up) and unless we lead a revolutionary approach we'll be left watching the riches go to those that do.

 

[Birdstrike]

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[WilcoWorld]

It's somewhat paradoxical. I don't think I could've endured the path to becoming a doctor if I hadn't viewed it as a calling. But now that I've arrived, the only way for me to find happiness in it is to stop thinking of medicine as a calling and to start thinking of it as a job.

It can still be a good job if you make it one. Getting to know the new rules is a crucial step.

 

[Birdstrike]

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[bravotwozero]

What makes you so sure that the rolling medicare cuts wont be approved? Since when did congress care about protecting doctors salaries?

 

[Birdstrike]

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[dotopmr]

Love Birdstrike posts --his wisdom, insight and dark humour 🙂
Birdstrike for surgeon general lol or head of AMA.

My perspective you know -- goverment (or corporations) decided to replace physicians long time ago with midlevels and they will continue to do this.

Best solution --- unite or unionized--- for revolution which is highly unlikely, since most physicians think they are independent gods.
Worst solution --everyone for themself ---- most of us will be eaten by much bigger fish, but minority will do very well

Just my 2cents

 

[EctopicFetus]

It's somewhat paradoxical. I don't think I could've endured the path to becoming a doctor if I hadn't viewed it as a calling. But now that I've arrived, the only way for me to find happiness in it is to stop thinking of medicine as a calling and to start thinking of it as a job.

It can still be a good job if you make it one. Getting to know the new rules is a crucial step.

👍 Could not have said it better myself. I love my job.. I do.. I worry I wont in 10-15 years. My career will last at least that long. At that point I will need much less to be happy as far as work goes.

 

[EctopicFetus]

The SGR fix has passed every time it's come up.

Failure to pass this would lead to a even worsening paucity of PCPs willing to care for these patients.

 

[la gringa]

👍 Could not have said it better myself. I love my job.. I do.. I worry I wont in 10-15 years.

me too... fortunately life hit me square between the eyes relatively early in my career and i'm trying my best to live well under my means.

 

[Siggy]

Failure to pass this would lead to a even worsening paucity of PCPs willing to care for these patients.

On the other hand there's the Atlas Shrugged, 'Let it burn and we'll rebuild it better" route.

 

[Siggy]

Best solution --- unite or unionized--- for revolution which is highly unlikely, since most physicians think they are independent gods.

Enjoy the potentially criminal antitrust case.

Of course the alternative argument is, to quote Benjamin Franklin, "We must, indeed, all hang together, or most assuredly we shall all hang separately."

 

[EctopicFetus]

On the other hand there's the Atlas Shrugged, 'Let it burn and we'll rebuild it better" route.

Thats true.. by the time it is rebuilt I would be way retired. If the system blows up the old docs will all quit.. the shortage would greatly worsen. About 30% of practicing docs are 55+.. Thats not a small number.

 

[Arcan57]

Thats true.. by the time it is rebuilt I would be way retired. If the system blows up the old docs will all quit.. the shortage would greatly worsen. About 30% of practicing docs are 55+.. Thats not a small number.

I can't remember the last office based primary care doctor I saw that was under 40. The market crashing was probably a good thing for medicine because it delayed the retirement of a bunch of docs in their late 50's who watched their nest egg get cut in half or quartered.

Other fun things to consider: the nurses had this figured out long before we did. The DNP that's going to be required for new grads? The one that makes no sense from a clinical perspective? I pulled up a curriculum and it's 90 required credits, half of which are leadership and translationing research to best practice. The other 45 hrs for Advanced Practice still includes "...the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy.

While we've been busy being scornful of their clinical skills and the inferiority of their training compared to residency, they're already preparing for the new world order.

Fighting over clinical skills is a useless game, the real battle is going to be who has betters outcomes. The individual MD led model doesn't do a good job of addressing the main drivers of disease at a population level (HTN, type II DM, obesity, sedentary lifestyle). If you never picked up a pheo or renal artery stenosis, but on average your patients' BP was in the 120/70 range your outcomes would be far better than what we're seeing now. We learned all the meds to control BP and what comorbidities get which meds, but they didn't actually teach us how to keep BP under control in med school. I remember getting 2 lectures on diet modification, which was basically a review of the literature on the DASH diet. A diet that bears no resemblance to the eating habits of the majority of our patients. There were no talks on how to get patients to buy into completely changing their lifestyle, especially when their families and friends are not changing theirs.

A significant amount of the healthcare we provide doesn't change outcomes, and the group that figures out how to make less care palatable to the patient is going to be very rich.

 

[EctopicFetus]

I dont know where you guys are but in Phoenix anything short of an MD gets snickers from patients.

While DOs are numerous here and the ones I work with are excellent one of my colleagues had a patient say to them "I didnt think this hospital had DOs".

I dont think the lines to see the DNPs will be long. It will be full of Medicaid patients who also tend to be the ones who care for themselves the worst. I dont think this will be a problem in the short to medium future.

 

[NinerNiner999]

If DNP's have to share any of the malpractice pain we do, good luck getting insured to cover our limits with that training. Then again, they'll probably be part of Obama's healthcare army, and immune from the pitfalls of "real" practice.

I mostly agree with many of Birdstrike's quotes, and the sad fact is that in today's world, all patients see is an office, a bunch of chairs, a wait, some tests and painful needles, a piece of paper, a trip to a pharmacy, and a repeat visit they have to take time out of their lives and spend money to attend. We are more of a nuisance to their lives than a service to be respected - even though we are diagnosing cancer. And if we become too much of a nuisance, they will find a reason to get back at us for their perceived inconvenience, and sue us for radiation exposure from that MRI that was non-diagnostic (negative) and therefore "unnecessary."

Then again, they can go to their nearest ED (also known as urgent care center on steroids) so they can maybe avoid that repeat visit and MRI and get 4-5 months worth of workup done in 3 hours and, if they are smart enough, complain about the service and bill enough to have it all for free (or even better do nothing if they are covered by Obamacare). To hell with the people who have the real emergencies, and to hell with us for considering those sicker people first.

This is the cold, hard truth for those of you in residency, and take heed: Your training is enough to get you a job and help the hospital that markets your ER generate money you will never see in the form of satisfaction, quality, and throughput metrics. Every year, there will be more people who do your job graduate residency, and every year, you will face replacement. We have EMTALA, and have had it for years. Now we have Obamacare mandating everyone has free insurance, and that they can be seen under another mandate that says we have to see them. Great. Where's the free popcorn?