There are some aspects of the "business" of medicine and the "politics" of medicine that you probably won't realize until you start doing clinical things. When you are writing on a chart, for instance, you actually have to be thinking about things like reimbursement because if you don't document things right, you wont get paid for it. If you order a test without documenting the problem well enough-- and to the insurance company's standards-- you don't get paid for it. When you have a patient in the hospital and you dictate the discharge summary, for instance, you can cost the hospital a lot of money by not doing it right. I'm fortunate in that I'm working with a group of hospitalists who know coding like the back of their hand. They know what you have to do to get reimbursed well. They typically pull in 40% more for their patients than any other group because they know how the system works. Their patients also leave the hospital a half day earlier than everyone elses's, freeing up the beds for other patients. The hospital absolutely loves them because they lose money on many other patients. In return, when they ask the hospital for something, they typically get it. They asked the hospital to fund a years subcription for Uptodate (BTW, you need to use this a lot for PBL) and the hospital never balked at the money.
That's part of the money game, and a big part of the political game that you have to learn to deal with. The bottom line is what's best for your patient, though. Sometimes you have to find a reason to keep a patient one more night because Medicare won't pay for rehab unless the patient is in for three nights, for example. There's so much more to medicine than just "medicine," and most new docs aren't prepared for it. If you really want to survive, you have to learn how things work and, sometimes, how to manipulate them to yours or your patient's advantage. It's shame sometimes....but that's the way it is.
