Why don't doctors unite?

[Argephontes]

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I'm still a pre-med but I come from a family of doctors and have seen and heard how medicine has changed from generation to generation. I've also done a fair amount of research on the current medical system.

What I want to know is why doctors don't unite into a more cohesive and powerful unit that uses its hold over patient care more politically. Let me give a couple of examples. In the first place, there is the huge problem with physician compensation going down, while patients simultaneously pay higher premious to insurance companies (which make astronomical profits). At the same time, physicians work longer hours (because there frankly aren't enough of them). Why don't physicians unite (by specialty, perhaps) to hold some salaries constant or even raise them, and at the same time demand smaller premiums for patients? Is this really that revolutionary of an idea? If doctors have to play in a market health system, shouldn't they play the cards they are dealt and have some control over the service they provide? I realize that doctors need to avoid being painted as bad guys, but it seems to me that if doctors paint their desire for more compensation in the light that they also want better conditions and premiums for patients, they could turn this situation on its head.

Another example is this whole issue with DNP liscensing. There's a lot of outrage among doctors (especially younger ones) but few people are really doing anything to get this situation handled. Are doctors really just going to sit back and allow their practice and their patients to be abused?

I know there are organizations like the AMA that "lobby" on behalf of doctors, but from what I understand, they haven't ultimatley curbed the overall negative trends medicine is experiencing. I am entering medicine because, like many others, I love what doctors do. But that doesn't mean doctors can't also, in an ethical manner, improve their working conditions by exercising their service, does it?

-Argephontes

 

[Blade28]

Are you asking, why don't physicians unionize?

 

[Coastie]

[YOUTUBE]http://www.youtube.com/watch?v=Pk7yqlTMvp8[/YOUTUBE]Herding cats is easier..

 

[AwesomO]

Starting in pre-med it's screw you all every man for himself. Did you expect 11-13 years of hostility and one ups man ship to disappear and for everyone to unite like a Disney movie?

 

[Pinkertinkle]

A lot of priv practice docs are incorporated as businesses. They can't unionize because it would be business collusion and run afoul of antitrust laws. However, I think doctors who are employees of a hospital may be able to unionize, but this would give only a little leverage over their employer hospital.

 

[docB]

What I want to know is why doctors don't unite into a more cohesive and powerful unit that uses its hold over patient care more politically. Let me give a couple of examples. In the first place, there is the huge problem with physician compensation going down, while patients simultaneously pay higher premious to insurance companies (which make astronomical profits).

We are prohibited in many instances from uniting due to antitrust laws. Ultimately there are politically powerful interests aligned against us such as the insurance industry, trial lawyers and the government itself in the form of CMS so that's not going to change.

At the same time, physicians work longer hours (because there frankly aren't enough of them).

Do physicians work more because there aren't enough of them or because that's what it takes to maintain your income in the face of cuts in reimbursement.

Why don't physicians unite (by specialty, perhaps) to hold some salaries constant or even raise them, and at the same time demand smaller premiums for patients? Is this really that revolutionary of an idea? If doctors have to play in a market health system, shouldn't they play the cards they are dealt and have some control over the service they provide? I realize that doctors need to avoid being painted as bad guys, but it seems to me that if doctors paint their desire for more compensation in the light that they also want better conditions and premiums for patients, they could turn this situation on its head.

The specialties are unlikely to unite. Instead we spend our time and resources trying to swipe reimbursement from the other guy. For example in EM we're continually fighting to get ourselves exempted from the annual CMS cuts. We've been pretty successful at it which is why we haven't been cut as much as primary care. Is that good for us? Yes. Is it good for the medical system? Probably not.

I don't even know how or why we would argue for lower premiums. It seems like it would be easily recognized as an attempt obscure our real issue which is reimbursement. And you can't cut premiums and at the same time increase reimbursement. I know you think that insurance company profits are bad but and that's debatable but the alternative is an outright socialized system. There might be one or two threads on the merits and pitfalls of socialized healthcare on SDN if you look hard enough.

Another example is this whole issue with DNP liscensing. There's a lot of outrage among doctors (especially younger ones) but few people are really doing anything to get this situation handled. Are doctors really just going to sit back and allow their practice and their patients to be abused?

They will win this battle. They're cheaper. Patients won't know the difference. CMS and/or insurance will pay less and patients will still think they're getting a "doctor" so everyone but us will be happy about it.

I know there are organizations like the AMA that "lobby" on behalf of doctors, but from what I understand, they haven't ultimatley curbed the overall negative trends medicine is experiencing. I am entering medicine because, like many others, I love what doctors do. But that doesn't mean doctors can't also, in an ethical manner, improve their working conditions by exercising their service, does it?

-Argephontes

The AMA is largely ineffective. They are too divided, mainly on the issue of socialized healthcare. Maybe under socialism we will unionize. I'm sure then any action we undertake will be at least as effective as when the air traffic controllers had their strike back in the 80s.
http://en.wikipedia.org/wiki/Professional_Air_Traffic_Controllers_Organization_(1968)

 

[Argephontes]

Thanks for all the feedback. I realize I am very naive regarding this issue which is why I posted here for feedback 🙂.

I have a couple of responses.

1st off, when I said "unite by specialty" I meant *within* a given specialty. Foe example, why don't radiologists unite?

As far as striking is concerned, in the 80s a bunch of neurologists and neurosurgeons (one of my uncles included) in my area refused to perform certain operations and tasks until their compensation for those operations was increased. It was successful.

In terms of DNPs, I don't think it would be hard for a united physicians' base to win the battle against these guys. The care they provide is frankly inferior to that of IM docs and there is significant evidence to support this. All it would do is take some basic campaigning that "informs" patients, pointing out that they have a much larger chance of dying or having a silly error in judgment made with a DNP as their sole provider. After all, physicians don't go through thousands of hours of residency just for kicks. The idea that people won't know the difference: I have not been around the hospital as much as you so I'm not going to disagree here, but I think patients will know the difference, especially if doctors make it clear that "A DNP is NOT a physician who went to medical school." Patients want the BEST care 100% of the time, and doctors could definitely take advantage of this. Am I wrong?

I think my overall point is: Physicians provide services that no one else is really able to provide. If they really united (and I mean *really*) and said, "no, we won't do such and such for this compensation," there ultimately isn't anything the government or insurance companies can do. There's little way for the government to break a strike of this kind since physicians would still be doing the majority of the work asked of them. Is it ethical? That's for physicians to decide, but if in the end it somehow brings better conditions for doctors and patients in the long run I think it's the right idea.

Any other feedback is greatly appreciated.

 

[Winged Scapula]

In terms of DNPs, I don't think it would be hard for a united physicians' base to win the battle against these guys. The care they provide is frankly inferior to that of IM docs and there is significant evidence to support this.

Are you sure about that? That vast majority of healthcare provider-patient interaction is low level care which does not require a physician. I'm not sure the care they provide is "frankly inferior" in the vast majority of cases. What is missing is the ability to recognize a problem or potential problem in some encounters.

All it would do is take some basic campaigning that "informs" patients, pointing out that they have a much larger chance of dying or having a silly error in judgment made with a DNP as their sole provider.

Won't work. Physicians are not a sympathetic group. "Oh boo hoo...look at those filty rich doctors trying to get more money and get rid of our beloved nurses!" Patients *love* their NPs and PAs who spend a lot of time with them and are so much more empathic than we are. 🙄

After all, physicians don't go through thousands of hours of residency just for kicks. The idea that people won't know the difference: I have not been around the hospital as much as you so I'm not going to disagree here, but I think patients will know the difference, especially if doctors make it clear that "A DNP is NOT a physician who went to medical school." Patients want the BEST care 100% of the time, and doctors could definitely take advantage of this. Am I wrong?

Yes. I agree with docB...most patients don't know the difference, won't remember the difference even if you told them and probably don't care. Are there patients out there that want nothing more than a BC physician who is on the cover of the 'Top 100 Local Docs" issue? Sure...but with few exceptions, this is not your average patient. I correct my patients all the time when they tell me "Dr Hoover" referred them. Since I was new to town, it took me awhile to realize "Dr" was a PA. Didn't matter to them. The lay public thinks medical school is what anyone who works in a hospital goes to...nurses go there, PAs go there, etc. Besides, doctors have such a bad reputation that I think you'll get arguments over your last statement as many people don't trust us and are not sure we offer the best care, at least not anything close to 100% of the time.

I think my overall point is: Physicians provide services that no one else is really able to provide.

Do we? Not always. I don't need a physician to do well woman checks, prescribe some chronic meds, give me my annual flu shot, order my mammograms, etc.

If they really united (and I mean *really*) and said, "no, we won't do such and such for this compensation," there ultimately isn't anything the government or insurance companies can do. There's little way for the government to break a strike of this kind since physicians would still be doing the majority of the work asked of them. Is it ethical? That's for physicians to decide, but if in the end it somehow brings better conditions for doctors and patients in the long run I think it's the right idea.

Any other feedback is greatly appreciated.

Sounds good except you will never get such a large group of diverse individuals to agree to do something. Someone, some group will break and that ruins the strike. Besides, because of antitrust laws and ethical concerns, they can make us go back to work.

I can tell poor paying insurance companies I won't see their patients anymore because of the crappy reimbursement I get because there is some other surgeon in town to whom they can send their patient. There will always be another option - and it will be a colleague of yours or an allied health provider.

Doctors on strike? "Mrs. Jones, go to your nearest Wal-Mart and Dr. DNP will be glad to see you right away, no appointment necessary. And you can pick up a People magazine, a Snapple and a nice gift for your grandson while you are there. Tell 'em BC/BS sent ya."

 

[sirus_virus]

I'm still a pre-med but I come from a family of doctors and have seen and heard how medicine has changed from generation to generation. I've also done a fair amount of research on the current medical system.

What I want to know is why doctors don't unite into a more cohesive and powerful unit that uses its hold over patient care more politically. Let me give a couple of examples. In the first place, there is the huge problem with physician compensation going down, while patients simultaneously pay higher premious to insurance companies (which make astronomical profits). At the same time, physicians work longer hours (because there frankly aren't enough of them). Why don't physicians unite (by specialty, perhaps) to hold some salaries constant or even raise them, and at the same time demand smaller premiums for patients? Is this really that revolutionary of an idea? If doctors have to play in a market health system, shouldn't they play the cards they are dealt and have some control over the service they provide? I realize that doctors need to avoid being painted as bad guys, but it seems to me that if doctors paint their desire for more compensation in the light that they also want better conditions and premiums for patients, they could turn this situation on its head.

Another example is this whole issue with DNP liscensing. There's a lot of outrage among doctors (especially younger ones) but few people are really doing anything to get this situation handled. Are doctors really just going to sit back and allow their practice and their patients to be abused?

I know there are organizations like the AMA that "lobby" on behalf of doctors, but from what I understand, they haven't ultimatley curbed the overall negative trends medicine is experiencing. I am entering medicine because, like many others, I love what doctors do. But that doesn't mean doctors can't also, in an ethical manner, improve their working conditions by exercising their service, does it?

-Argephontes

Don't let them fool you. Antitrust prevents physicians from collective bargaining for pay. It does not....I repeat DOES NOT prevent physicians from unionizing and protecting their turf in many other ways. In fact there is no law on planet earth that prevents residents from forming a union as we speak.

Physicians cant unionize because they don't know how to. 11 years of training on how to kiss ass and comply with any crap(work hours, pay, abuse ..etc) will typically produce cowards, and as you can see, there is a saturation of cowards in the physician workforce. The only time physicians know how to make noise is when they stand in front of their subordinates.

Now that physicians are well on their way to becoming the laughing stock of all workers in America, I wonder if they still feel like unionizing is something the "common folks" do.

 

[docB]

Don't let them fool you. Antitrust prevents physicians from collective bargaining for pay. It does not....I repeat DOES NOT prevent physicians from unionizing and protecting their turf in many other ways. In fact there is no law on planet earth that prevents residents from forming a union as we speak.

Are you talking about residents or attendings? And if you can't collectively bargain what's the point of having a union?

 

[TaiShan]

The competitiveness to become a physician has made us look for our own interest since... high school. We rarely look after each other. I mean, a surgery chief was fired due to taking an inapproraite picture in OR. Yes, he needed to be punished but his career and 10+ years hard work should not be ruined just because of a single episode. What about his family/wife who has sacrificed just as much to get to the point. We got rid of him like a bad apple and none raised any issue with that.

Make Physicians unite is like herding cats.

 

[sirus_virus]

Are you talking about residents or attendings? And if you can't collectively bargain what's the point of having a union?

Residents can form a union and go on strike as it stands today. No law preventing that. Attendings can unionize and fight stuff like midlevel encroachment, and if they went on strike based on that, no one is going to get arrested. That translates to money in the long run. How about the legal environment, that is also costing physicians big time. The only people exempt are physicians in supervisory roles, and there is a staff size requirement for that too.

BTW, while physicians cannot negotiate money, the law does not prevent them from going on strike to protest laws that hinder such negotiations. There is always a fight to be fought for those ready and capable of fighting. Labor unions have always had laws hindering negotiations, but they fought and they won for the most part. Using antitrust as an excuse to surrender the entire profession to the forces of natural selection is not going to favor physicians. The cat is out the bag, and they know physicians are the weakest link in the community, I don't see this resolving favorably for physicians without a fight.

 

[docB]

Residents can form a union and go on strike as it stands today. No law preventing that. Attendings can unionize and fight stuff like midlevel encroachment, and if they went on strike based on that, no one is going to get arrested. That translates to money in the long run. How about the legal environment, that is also costing physicians big time. The only people exempt are physicians in supervisory roles, and there is a staff size requirement for that too.

BTW, while physicians cannot negotiate money, the law does not prevent them from going on strike to protest laws that hinder such negotiations. There is always a fight to be fought for those ready and capable of fighting. Labor unions have always had laws hindering negotiations, but they fought and they won for the most part. Using antitrust as an excuse to surrender the entire profession to the forces of natural selection is not going to favor physicians. The cat is out the bag, and they know physicians are the weakest link in the community, I don't see this resolving favorably for physicians without a fight.

So this all boils down to physicians can unionize and threaten to strike. Physician strikes are a very tricky proposition. When the UAW strikes agains GM the public are spectators. When doctors strike we are leaving that same public without medical care. Striking just isn't the way to go. Now I would be completely on board with attempts to change the laws that prevent us from bargaining collectively. That would be where the real opportunities for change would be if we could get everyone to agree on a few things. Ultimately the government would crush us outright but it would be our best chance at reforming some of the minor things.

BTW the fact that residents can strike doesn't mean it will do them any good. And we're clouding the discussion by flipping back and forth about residents and attendings as they are totally different situations. I'm not belittling residents but when residents talk of striking and unionizing they're discussing residency specific issues that don't readily apply to the rest of medicine as a profession.

 

[Flopotomist]

. When doctors strike we are leaving that same public without medical care. Striking just isn't the way to go. Now I would be completely on board with attempts to change the laws that prevent us from bargaining collectively. That would be where the real opportunities for change would be if we could get everyone to agree on a few things.

How is it that nurses are able to strike without the same fear of "leaving the public without care?"

Before medical school, I witnessed two nurses strikes and here is what happened:

1. The hospital was still staffed during the strike, but by "travellers" who cost triple what the staff nurses cost.

2. The nurses eventually won massive concessions in wages and working conditions.

3. Patient's generally supported the nurses who were striking.

 

[Dr.Millisevert]

So this all boils down to physicians can unionize and threaten to strike. Physician strikes are a very tricky proposition.

All the residents in New Zealand were able to successfully strike last month demanding better pay. On average residents in Australia make slightly more and Aus and NZ residencies are all accredited by the same regulation bodies. So, many of the residents are leaving for training positions in Australia. They feel at the end of the day.. striking for 2-3 days once and getting competitive pay is better for the public than having a large percentage of their medical graduates leaving for Australia every year. 🙄

 

[docB]

All the residents in New Zealand were able to successfully strike last month demanding better pay. On average residents in Australia make slightly more and Aus and NZ residencies are all accredited by the same regulation bodies. So, many of the residents are leaving for training positions in Australia. They feel at the end of the day.. striking for 2-3 days once and getting competitive pay is better for the public than having a large percentage of their medical graduates leaving for Australia every year. 🙄

resident/attending = apples/oranges

And we're clouding the discussion by flipping back and forth about residents and attendings as they are totally different situations. I'm not belittling residents but when residents talk of striking and unionizing they're discussing residency specific issues that don't readily apply to the rest of medicine as a profession.

 

[docB]

How is it that nurses are able to strike without the same fear of "leaving the public without care?"

Before medical school, I witnessed two nurses strikes and here is what happened:

1. The hospital was still staffed during the strike, but by "travellers" who cost triple what the staff nurses cost.

2. The nurses eventually won massive concessions in wages and working conditions.

3. Patient's generally supported the nurses who were striking.

People don't think nurses are rich prima donnas who deserve to be taken down. That is what they think about docs.

 

[sirus_virus]

resident/attending = apples/oranges

You are missing the point. Everyone needs to learn the concept of fighting to protect the profession. Residents/attending != apples/oranges, because an apple is not destined to become an orange, while most residents are destined to become attendings. If they learn the concept of turf protection in training, it will not be a foreign and confusing subject as an attending. Not to mention that residents unions in some countries will openly fight for things that are directly beneficial to attendings but indirectly beneficial to them, since they are on their way to becoming attending themselves. The main point here is that there are lots of opportunities to fight on different levels, and complacency is going to hurt, if not bury the physician workforce.

 

[Dr.Millisevert]

resident/attending = apples/oranges

I understand where you're coming from. However, do you not think that if residents were successful with a strike to increase their GME funding and benefits that it might also have the possibility to indirectly increase attending salary and benefits packages as well?

I was just informing the forum that the idea of residents striking (they are basically government employees) is not such a farfetched idea and has been successfully done before. 👍

 

[Dr.Millisevert]

Everyone needs to learn the concept of fighting to protect the profession. Residents/attending != apples/oranges, because an apple is not destined to become an orange, while most residents are destined to become attendings. If they learn the concept of turf protection in training, it will not be a foreign and confusing subject as an attending.

Not to mention that residents unions in some countries will openly fight for things that are directly beneficial to attendings but indirectly beneficial to them, since they are on their way to becoming attending themselves. The main point here is that there are lots of opportunities to fight on different levels, and complacency is going to hurt, if not bury the physician workforce.

agreed.

 

[Blade28]

I was just informing the forum that the idea of residents striking (they are basically government employees) is not such a farfetched idea and has been successfully done before. 👍

Don't the residents over at Michigan have a union?

 

[Geri_Gal]

Another impediment to organizing for change -- especially for young resident physicians -- is fatigue. Even with an "80-hr work week", it is difficult to maintain a personal life & relationships let alone organize outside of work to advocate as a group.

As a profession, though, we have lost a lot of respect from the public and are in a bit of a public relations crisis. Traditionally, physicians were seen as the top of the medical hierarchy and in a position of great power. Some of this was historically abused and undeserving but now we have been virtually castrated by insurance companies, big pharma, and CMS. The public, however, still sees us as having authority and control and many of my patients look at me with disbelief when faced with the inequities of our health care system -- such as when I told my 51 yr-old patient (whose anterior heart wall was saved with 2 bare metal stents) who had just started a new job and had no health insurance that he would have to take Plavix for one month and that there was not a generic substitute for it. And I had no answer when he asked about how he would pay for his hospital bill.

I think that the public would begin to respect us more if we were to work together to advocate for THEM and to help reshape the health care system. And reform it not just to improve our compensation or protect our turf -- by focusing on these narrow pursuits, we will only continue to harm and degrade our profession.

 

[Argephontes]

Thanks again for all your responses. I have a few last comments to make.

I couldn't agree with Geri-gal more.

I think it’s a load of bull that doctors can’t win a fight against insurance companies, DNPs, excessive malpractice claims, etc. I’ve already had a lot of people here and elsewhere tell me why these fights “will not go anywhere.” Yet, no one has given me any real evidence supporting these claims. In fact, in the few cases where doctors have stepped out of their complacent bubble and made an effort to better their situation and the situation of their patients, they have mostly been successful, both here and in other countries.

Doctors are portrayed as "evil" because, frankly, they've let themselves, and continue to let themselves, get put in bad situations where it’s easy to be portrayed that way. Part of the problem here is that doctors are so strung out. There is way too large of a patient base, and because doctors' compensation has diminished so much it's nearly impossible for them to work less without seriously dropping their income. Part of why they aren't getting paid as much is due to technology and, as a consequence, the fact that physicians do not have as much of an elite stranglehold on what they're doing. Physicians will never make what they made fifty years ago; it’s not possible given the amount of money that healthcare has to spend on MRI machines and arthroscopically guided surgeries etc. But part of it is the fact that insurance companies lower their wages simply to make profit. I don’t believe people when they tell me that it’s not possible for physicians to fight against this state of affairs. In fact, I think that if anything is going to change the current system, it is going to be physicians making an effort to fight against it, not the government, and certainly not the patient base. Physicians are the only ones who have a good enough grasp of what’s going on and a deep enough love for their patients to make any serious ameliorations. If physicians repaint the picture, if they come out with a new PR campaign and say, “We’re on the patients side against the insurance companies and malpractice etc.” I think they could make some serious public in roads. Part of what they need to do is explain their situation to the public, instead of letting insurance companies, nurses, lawyers, and unreasonable patients make doctors out how they will. Geri-gal said it well: physicians must look out for themselves, but just as importantly, their patients. This broader frame of the situation could get an increasingly powerful patient base on the side of the physicians, rather than against them.

Malpractice suits, as some people have noted, have become an insane problem as well. However, there have been several doctors strikes and- in the case of West Virginia- doctors leaving the state- that have ameliorated this problem as well.

Yesterday, my sister was telling me about how she loved the NP she went to much more than the doctor she met a certain clinic. However, when I asked her who she had more respect for, she said, without question, the physician, and noted that she knew the physician to be far more competent, although she noted that “it didn’t feel that way.” There’s something to this, and again, I really doubt patients would pick DNPs over IM docs if docs made an effort to point out the difference. Then again, gathering from some of the responses here, some people have given up all hope without a fight.

The real question is when physician are going to end this pathetic culture of complacency and self-pity and address the problems facing patients and their own problems instead of assuming they’re screwed, which seems to be approach to things right now.

Argephontes

 

[dl2dp2]

once you get into med school you'll know better what you are talking about.

Physicians aren't seen as "evil". And there's no reason why they'd have to "fight" anything.

Radiologists are getting paid 250k to start, and 350k 5 years in. How many 27 y os in the USA do you think make 250k?


The only doctors who are screwed are the primary care docs. But they are populated by FMGs anyway. I think AAMC/AMA etc. have been extremely savvy in the past 50 years. The best jobs go to US-grads, with lower standards.

Doctor's don't need to unionize. We are capitalists.

Thanks again for all your responses. I have a few last comments to make.

I couldn't agree with Geri-gal more.

I think it’s a load of bull that doctors can’t win a fight against insurance companies, DNPs, excessive malpractice claims, etc. I’ve already had a lot of people here and elsewhere tell me why these fights “will not go anywhere.” Yet, no one has given me any real evidence supporting these claims. In fact, in the few cases where doctors have stepped out of their complacent bubble and made an effort to better their situation and the situation of their patients, they have mostly been successful, both here and in other countries.

Doctors are portrayed as "evil" because, frankly, they've let themselves, and continue to let themselves, get put in bad situations where it’s easy to be portrayed that way. Part of the problem here is that doctors are so strung out. There is way too large of a patient base, and because doctors' compensation has diminished so much it's nearly impossible for them to work less without seriously dropping their income. Part of why they aren't getting paid as much is due to technology and, as a consequence, the fact that physicians do not have as much of an elite stranglehold on what they're doing. Physicians will never make what they made fifty years ago; it’s not possible given the amount of money that healthcare has to spend on MRI machines and arthroscopically guided surgeries etc. But part of it is the fact that insurance companies lower their wages simply to make profit. I don’t believe people when they tell me that it’s not possible for physicians to fight against this state of affairs. In fact, I think that if anything is going to change the current system, it is going to be physicians making an effort to fight against it, not the government, and certainly not the patient base. Physicians are the only ones who have a good enough grasp of what’s going on and a deep enough love for their patients to make any serious ameliorations. If physicians repaint the picture, if they come out with a new PR campaign and say, “We’re on the patients side against the insurance companies and malpractice etc.” I think they could make some serious public in roads. Part of what they need to do is explain their situation to the public, instead of letting insurance companies, nurses, lawyers, and unreasonable patients make doctors out how they will. Geri-gal said it well: physicians must look out for themselves, but just as importantly, their patients. This broader frame of the situation could get an increasingly powerful patient base on the side of the physicians, rather than against them.

Malpractice suits, as some people have noted, have become an insane problem as well. However, there have been several doctors strikes and- in the case of West Virginia- doctors leaving the state- that have ameliorated this problem as well.

Yesterday, my sister was telling me about how she loved the NP she went to much more than the doctor she met a certain clinic. However, when I asked her who she had more respect for, she said, without question, the physician, and noted that she knew the physician to be far more competent, although she noted that “it didn’t feel that way.” There’s something to this, and again, I really doubt patients would pick DNPs over IM docs if docs made an effort to point out the difference. Then again, gathering from some of the responses here, some people have given up all hope without a fight.

The real question is when physician are going to end this pathetic culture of complacency and self-pity and address the problems facing patients and their own problems instead of assuming they’re screwed, which seems to be approach to things right now.

Argephontes

 

[shag]

So cynical, so young...

The medical field is built on tradition. Traditionally, we base our practice on the care of patients. When physicians try to "get tough", the powers that be call our bluff by threatening the quality of care that our patients receive, and we back down.

As reinbursement is tightening, docs are forced to think like capitalists if their medical business (practice) is expected to succeed.

An example: Traditionally, surgeons take ER call for free, and only get paid if they see a patient or operate... The "Eat what you kill" model. As things stand now, ER patients are more likely to be uninsured and are more likely to sue. Some surgeons, especially subspecialists, are refusing to take call unless they get paid (go figure)... This is giving the old guys in the field CVA's or MI's depending on the distribution of their atherosclerosis...

The field is changing, and not necessarily for the better. Studies have shown that volunteerism has decreased as reimbursement has declined, which can be presumed to be due to docs having to work more hours to keep their practice afloat.

I don't see docs striking... wouldn't that be treated in a similar fashion to police or firefighter striking? Could lead to government intervention to force work. Rather than striking, I see docs cutting areas of their practice that lose money. Uncle Sam can force you not to strike, but can't keep you from "quitting". For example, general surgeons may "quit" trauma by not renewing certification, thereby avoiding a largly uninsured population that is likely to sue. Many OB/GYN's have dropped the OB part of their practice.

Bottom Line: Forget med school; go into hospital administration.

 

[Geri_Gal]

Argephontes -- keep the faith.

This thread isn't about capitalism vs. socialism or even about physicians striking. It is about working together and advocating to improve the system of health care for our patients, which will only improve our profession. This isn't a zero-sum game.

 

[Taurus]

For the sake of protecting the public, physicians need to unite over the issue of DNP. It's obvious what Mundinger et al are planning with the DNP. Once they are firmly established in primary care, they will then argue that why DNP's shouldn't be allowed into the specialties? Just because you're not going into primary care, don't get complacent on this issue. For too long, the medical groups have given the NP's a pass when it comes to scrutiny. While the ACGME spent more enormous amounts of time determining the length of a particular residency, the NP's lobbied successfully to gain autonomy both in practice and scripts in many states through political means and not through well-designed studies. Make no mistake, the nursing groups want to control both nursing and medicine. Through the DNP, the nursing groups have put out someone with very low qualifications (1000 clinical training hours vs. over 12000 for a PCP, can be done completely online, etc) to practice independent medicine and the AMA and all of the medical groups need to scrutinize their competencies to demonstrate to the lawmakers that they are a danger to the public.

AMA resolution 303

ANA Response to AMA Resolution 303
Re:American Medical Association House of Delegates Resolution 303 (A-08)
Protection of the Titles "Doctor," "Resident" and "Residency"

AMA resolution 214

ANA Response to AMA Resolution 214
Re: American Medical Association House of Delegates Resolution 214 (A-08)
"Doctor of Nursing Practice"

 

[DeLaughterDO]

Ummm... because the federal government, in their conspiracy with the insurance agencies to control the practice of medicine and hand it all over to the "doctor" nurses, dreamed up and passed the Sherman Antitrust law, thus prohibiting physicians from bargaining collectively.

So, basically, we have to accept what they give us, because we have no power to bargain as a group and fight back.

We are forced to see patients (EMTALA) regardless of whether they can pay, and even if they can, we have to take the pittance they (the insurance companies and the gov't) have decided "we are worth."

 

[Geri_Gal]

?? Not sure how the Sherman Antitrust Law would prevent physicians from advocating/lobbying together. We can't join together and fix our prices.

When the DNPs are in full competition with physicians, we will no longer have a "monopoly" on the service we provide.

 

[Taurus]

When the DNPs are in full competition with physicians, we will no longer have a "monopoly" on the service we provide.

I believe in the free market as anyone. If patients feel more comfortable going to a NP over a PCP, fine. If a woman wants to go to a CNM over a ob/gyn, fine.

However, what I and many people oppose is fraud and false marketing. What does saying that the DNP has the "knowledge of a physician" and yet the skills of a nurse imply? The nurses are trying to dupe the public into thinking that if they go to see a DNP that they will have someone who is even more knowledgeable and skilled than a physician! That's blatantly fraudulent. DNP's have 1000 clinical training hours and many programs offer it online vs. over 12000 hours for a physician in 3 year residency. Furthermore, the DNP's are pushing for the right to introduce themselves as "doctor" and have even paid the NBME for a test.

The DNP's are clearly making every effort to defraud the public into thinking that they are equivalent or better than physicians.

If physicians allow that to happen, not only does this put the public in danger it also puts physicians at a huge disadvantage. A physician has to go to minimum of 7 years of training, take on huge amount of debt, pass innumerable tests, demonstrate tons of competencies in both knowledge and skill -- for what? So that the physician can have the same scope as a DNP who did the degree online and has only 1000 clinical hours?

Just because you may not be going into primary care, it's dangerous to get complacent. Primary care is just a way for them to get a foothold. Their true goal will be the specialties like derm, GI, cards, etc because that's where the lifestyle and income are. If DNP's can do primary care, why can't they do the specialties? If they can't get into the residencies, then they will create their own sham versions. For example, CRNA's in Louisiana tried to argue that they were qualified to do pain medicine after two weekend courses. Pain medicine is a fellowship after anesthesiology, PM&R, etc residency.

This is why physicians need to unite on this issue. Many things can be done.

1) Demand true studies on NP outcomes. If they can do studies on residents, why can't they do them on NP's? There is a lot of anecdotal evidence of NP's not knowing very basic medical knowledge. Such studies can quantify the competencies of NP's in relation to physicians. Recommendations can be made once the results are available.

2) NP's are practicing medicine, yet they hide behind the boards of nursing because these boards have a conflict of interest. They are not so interested in regulating and disciplining NP's; they're more interested in expanding the scope of nursing to include even medicine. We need to petition the medical groups to challenge in court if we have to that NP's should be regulated by boards of medicine and not nursing.

3) Until those things happen, I've committed to never hire a DNP or CRNA. I will hire only PA's and AA's.

 

[DeLaughterDO]

When the DNPs are in full competition with physicians, we will no longer have a "monopoly" on the service we provide.

Problem with this is, DNPs, being nurses, DO have the right to strike and walk off to increase their pay, we, as physicians, do not...

And once they have independent practice and a good foothold in primary care, do you think they will be happy making 85-90K/year? Think again!

 

[DeLaughterDO]

However, what I and many people oppose is fraud and false marketing. What does saying that the DNP has the "knowledge of a physician" and yet the skills of a nurse imply? The nurses are trying to dupe the public into thinking that if they go to see a DNP that they will have someone who is even more knowledgeable and skilled than a physician! That's blatantly fraudulent. DNP's have 1000 clinical training hours and many programs offer it online vs. over 12000 hours for a physician in 3 year residency. Furthermore, the DNP's are pushing for the right to introduce themselves as "doctor" and have even paid the NBME for a test.

The DNP's are clearly making every effort to defraud the public into thinking that they are equivalent or better than physicians.

Agree completely.

I also, am a doctor nurse. My undergrad degree is in nursing, but I got my a$$ in gear and went to medical school. So, I guess I can make these claims to be better then regular physicians?

In fact, I am a DO, so I'm even better than better than physicians, since I am a fully trained nurse, physician, and also have Osteopathic manipulative medicine to offer my patients. Let's see some "doctor" nurse top that!!!

Don't get me started on the NBME bit... talk about steaming!

2) NP's are practicing medicine, yet they hide behind the boards of nursing because these boards have a conflict of interest. They are not so interested in regulating and disciplining NP's; they're more interested in expanding the scope of nursing to include even medicine. We need to petition the medical groups to challenge in court if we have to that NP's should be regulated by boards of medicine and not nursing.

I've never understood how they can say what 'advanced practice' nurses are doing is still considered nursing practice... does anyone know if there have been lawsuits against NPs or CRNAs for practicing medicine without a license? Might be something interesting to look into... Of course, since the BONs are run completely by nurses, they can make their scopes of practice anything they want and pretty much get away with it, since there is very little-to-no oversight of the whole process.

 

[Dr.Millisevert]

Problem with this is, DNPs, being nurses, DO have the right to strike and walk off to increase their pay, we, as physicians, do not...

maybe.. but I beleive MD/DO residents can strike. They are still gov employees (GME funded) and are not yet attending/staff doctors.

Problem is.. I don't think the AMA or AMSA are really on board yet. 🙂

 

[EM_Rebuilder]

I have no idea if doctors can or cannot legally strike, but you can imagine typical joe blows reaction to doctors striking to say they dont make enough money? There was a march by farmers on the white house many years back about not having enough money; all the farmers drove their 100K+ tractors to the whitehouse. When reporters questions enough money and $100K+tractors and $30K+ trucks, suddenly it did not seem effective anymore.

I am not saying we make enough money, but when you are the 'general public' and see the cars and homes that most doctors are in.... not enough money becomes a mute point. I can see the doctors showing up in $3K+ suits, Porsches, MB, BMWs...and the media going through towns and filming the physicians home fronts with the tax apprisals flashing on the screen....

Unfortunately the general public cannot grasp the complexity of our training and how difficult and stressful our day to day lives are. I am a first year EM resident doing Trauma this month. I have had many months of calls already in my short time as a 'doctor', but my family and friends still simply cannot fathom the fact I go to work one day at 5AM and get back the next afternoon at 1 or 2 without any sleep....and this week, with 3 calls including the weekend, I'll be pushing 100+ hours. No other profession does that...nor can anyone else relate.

I think the people that really have big issues with reimbursement are the 'generations of doctors' as they have seen the heyday of medicine and dont understand why it has changed. When people who come from a very average family enter medicine, they wonder why the heck is everyone hollaring? I dont think anyone in my entire extended family has seen the inside of a country club...i've been to 4 thus far. Most of my family, including extended, live in a home 1200-1800 sq feet in size. My immediate family was a bit more fortunate with having our own business, but still our home was around 2400 sq feet. I have been to doctors homes approaching 10K... and dont forget their lake houses. Many families are lucky to drive a car not over a few years old... an EM attending at my medical school let me take his new porsche boxster s to get us midnight snacks multiple times. IMHO, its those images that will be difficult, if not impossible, to break through if we ever think we will get 'more money' one day......

Sure, insurance companies make 'big money' but it does not encompass society like the 'doctors' do. You can still go to any smaller town, and most likely the largest estates will be the physician, lawyer, or old oil money....still, the lawyers tend to be better at hiding their wealth than the doctors.

 

[frantic983]

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[frantic983]

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[Dr.Millisevert]

I can see the doctors showing up in $3K+ suits, Porsches, MB, BMWs...and the media going through towns and filming the physicians home fronts with the tax apprisals flashing on the screen....

Unfortunately the general public cannot grasp the complexity of our training and how difficult and stressful our day to day lives are.

Which is why it would be better and more successful if medical students (and residents who are effictivly goverment employees via GME funds) striked. Driving their beat up hyundais and toyotas to capital hill and explained how they have 300k in educational debt and make 6.50/hr. 👍

Isn't this one of the nice things that goes along with adopting a public health system. Everyone is a gov employee and has the right to B!t@h and complain about their hours and pay. 🙂

 

[badasshairday]

Which is why it would be better and more successful if medical students (and residents who are effictivly goverment employees via GME funds) striked. Driving their beat up hyundais and toyotas to capital hill and explained how the have 300k in educational debt and make 6.50/hr. 👍

Isn't this one of the nice things that goes along with adopting a public health system. Everyone is a gov employee and has the right to B!t@h and complain about their hours and pay. 🙂

I would be so down with that. 👍

 

[Dr.Millisevert]

If the US health care system goes public. We had better also damn well see the other things that also usually accompany all public gov health care systems.

Changes that will also be required are as follows:

1. Medical school tuition no more than 5-10k/year across the nation.
2. Immediate loan forgiveness or at least very generous repayment programs from the government with nil interest.. for those currently graduating from medical school or in residency in the US who do have 100-400k/debt.
3. All malpractice costs reduced to 1/20th their current rates. --> (Something that will never happen if career malpractice attorney Mr. John Edwards, ESQ has his hand in the picture anywhere)
4. Residents should earn a salary not a stipend. This should be at least 30% higher than current stipends.. and hours should be better structured.

US medical students, residents, and physicians need to make Obama (and Hilary since Obama wants her to be in charge of healthcare) fully understand that these aspects are also part and parcel of the type of public heath systems they wish to create for the US... and that we demand these benefits also be included in their public health care plan. 👍

 

[Dr.Millisevert]

I worked in a union environment, on the management side actually, before starting med school. And if there was a situation that seems to beg for a union it is medicine.

A fast search produced the following:

http://www.physiciansnews.com/discussion/weinmann.html

looks like this is actually in progress.

Its a start.

In fact there is no law on planet earth that prevents residents from forming a union as we speak.

Agreed. I think this is much more likely to be successful if the effort were directed by medical students and residents.

 

[NotAProgDirector]

There's many comments about unions and strikes here. Physicians can certainly unionize and strike. Although I'm not a lawyer, here's what (I think) the facts are:

• Physicians who are employees of a hospital or health care plan/HMO can unionize and strike against their employer. This is similar to what happens when nurses strike.
• Some physicians who work for hospitals form a separate corporation which then contracts with the hospital for services. This is usually done because the hospital is not-for-profit, and having a for-profit physician group practice affords benefit options not available in a not-for-profit environment, and allows the practice to shield actual physician salaries. In this case, the group practice is already a "union" -- they could simply refuse to provide services unless the terms were adequate.
• Residents can certainly unionize against their hospital and demand better pay / working conditions. What makes this difficult is that residents have a short "working lifetime". There are several programs that have a union, and as far as I can tell their salaries are not necessarily better.
• As a private physician, you are welcome to decline to contract with any insurance company whose payments you find objectionable. (Note: EMTALA applies to Emergency rooms and some hospitals, which makes this not true. EMTALA does not apply to private offices, I believe)
• Physicians (in general, from different practices) are not allowed to get together, decide that they are not going to accept some insurance program. You can't call your "competition" (the practice across the street) and agree to only take a contract paying a certain amount. That's illegal, like ExxonMobil calling Chevron and agreeing that gas is going to be $4 a gallon. Oh wait....
• In the same way, all residents can't get together and decide that they are not going to work unless they get paid more. Residents at any one program are welcome to do so, but all residents together can't. This is no different from any other business -- the airline pilots at American can have a union and argue with their employer, but all airline pilots from all companies can't negotiate together / go on strike together.
• A single union structure could try to win representation at every residency program in the US, and would need to do so one program at a time. They then would need to negotiate with each program independently.
• Strikes can be very effective at getting salary / concessions / work conditions changed.
• Some "work actions" have not gone well -- the classic is the Air traffic controller strike in the 80's. The bad things that can come of a strike are: businesses closing, hiring replacement workers, solidarity of the union collapsing, negative response from the public, etc.

Whether a union will improve resident work conditions is unclear. Some programs have unions, and it is not clear that they are any "better" than other programs. Perhaps if there were widespread unions, then things could change. Then again, widespread union pressure might push some hospitals out of the GME business altogether.

Physician unionization in general is difficult because specialties won't agree (i.e. as a PCP, I think PCP's should get paid more, and specialists get paid less. I doubt my specialist colleagues would agree. Simply paying everyone more won't work, with healthcare going bankrupt), and because it won't be popular with the public.

The only work action that would be popular with the public would be one that stressed health, and not money. If physicians went "on strike" for "health care coverage for everyone" or for "free prescription medications" or "viagra over-the-counter", the public would eat it up. Ask for more money, and we look as bad as the professional sport players and Hollywood types on strike.

 

[badasshairday]

The only work action that would be popular with the public would be one that stressed health, and not money. If physicians went "on strike" for "health care coverage for everyone" or for "free prescription medications" or "viagra over-the-counter", the public would eat it up. Ask for more money, and we look as bad as the professional sport players and Hollywood types on strike.

Yeah, but those people strike and get what they want. For example, 1994 MLB players strike. 2005 NHL strike? Hollywood writers strike just last year. The public wasn't mad, they just wanted the writers to get what they wanted so they could stop watching reruns. lol.

 

[frantic983]

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[U4iA]

Don't let them fool you. Antitrust prevents physicians from collective bargaining for pay. It does not....I repeat DOES NOT prevent physicians from unionizing and protecting their turf in many other ways. In fact there is no law on planet earth that prevents residents from forming a union as we speak.

Physicians cant unionize because they don't know how to. 11 years of training on how to kiss ass and comply with any crap(work hours, pay, abuse ..etc) will typically produce cowards, and as you can see, there is a saturation of cowards in the physician workforce. The only time physicians know how to make noise is when they stand in front of their subordinates.

Now that physicians are well on their way to becoming the laughing stock of all workers in America, I wonder if they still feel like unionizing is something the "common folks" do.

you totally hit the money.
entering medicine from the business world.. having done the MBA thing.
it truly is amazing how such a hard working group of people can be so lazy when it comes to their own futures.
the business world is ONLY concerned about their own futures - maximizing shareholder wealth is the ultimate goal of business.
unchecked doctors are bound to get completely screwed... especially if we don't do something about our collective ignorance/cowardice.

 

[docB]

unchecked doctors are bound to get completely screwed... especially if we don't do something about our collective ignorance/cowardice.

The calls to do "something" are deafening. So what should we do?

 

[Taurus]

The calls to do "something" are deafening. So what should we do?

Pressure the medical groups to:

1) Do true NP outcome studies

Except Mundinger's pathetic study, there are no really solid studies evaluating NP competency. Why is this? The anecdotal evidence would suggest that there are signficant deficits in knowledge and skill of many NP's. We need to quantify and document that.

Malpractice suits against advanced practice nurses are rising in number and increasing in severity, according to malpractice insurers.​

2) Bring DNP's under sole BOM or joint BOM/BON regulation

BON's have an inherent conflict of interest. They want to expand the scope of nursing. Therefore, they don't regulate and discipline NP's like how BOM's discipline physicians.

Sadly, state boards of nursing may be underreporting unprofessional behavior and incompetence to the National Practitioner Data Bank, according to one government representative who spoke at the meeting. APNs who've had a lot of claims against them and have settled out of court can often work in different states without fear of retribution because of confidentiality agreements.​

What can you do individually? Until these reforms are put in place, you can preferentially hire PA's and AA's.

 

[elwademd]

The calls to do "something" are deafening. So what should we do?

Pressure the medical groups to:

1) Do true NP outcome studies

Except Mundinger's pathetic study, there are no really solid studies evaluating NP competency. Why is this? The anecdotal evidence would suggest that there are signficant deficits in knowledge and skill of many NP's. We need to quantify and document that.

Malpractice suits against advanced practice nurses are rising in number and increasing in severity, according to malpractice insurers.​

2) Bring DNP's under sole BOM or joint BOM/BON regulation

BON's have an inherent conflict of interest. They want to expand the scope of nursing. Therefore, they don't regulate and discipline NP's like how BOM's discipline physicians.

Sadly, state boards of nursing may be underreporting unprofessional behavior and incompetence to the National Practitioner Data Bank, according to one government representative who spoke at the meeting. APNs who’ve had a lot of claims against them and have settled out of court can often work in different states without fear of retribution because of confidentiality agreements.​

What can you do individually? Until these reforms are put in place, you can preferentially hire PA's and AA's.

when you say medical groups, i think you mean medical associations and medical boards.

having read one state's (nevada's) laws governing the practice of physicians/pa's/np's/rt's, its not clear that "something" actually needs to be done. pa's and np's have to work under the auspices/supervision of a physician, and may only step out of this "role" in emergency situations.

where do dnp's fall? it would seem currently, under np's, and thus the same rules would apply.

while mundinger and others may want dnp's to practice solo, current state laws (in nevada and california, since those are the states i know) do not allow for independent practice.

while studying for my boards (abim) this week, a respiratory therapist started asking me questions about step 3, and the clincal case vignettes. turns out he was a physician "back home", and wanted to try and do it here. i ran through a tension pneumothorax case a few times with him, showing him how the system worked. when i mentioned a patient on the real test may have something like dka, he stated that would be too hard to manage. i hope i didn't scare him from taking the test!

but i bring up that story and wonder if one true "test" for dnp's would be to simply have them take and pass step 3 (or a test similar in scope and breadth). we know there are, unfortunately, plenty of physicians who do not pass step 3. it's rather broad, general, and has a component of managing patients from the simple/routine, to a little more complex.

 

[docB]

The DNP issue in particular and the the midlevel issue in general are not the only fights we have. There are lots of issues that medicine as a profession needs to attack. We are, as many have pointed out, dismal failures at finding consensus and then battling as a unified front for our profession's interests.

I'm not talking about midlevels, reimbursment, malpractice, resident issues are any of the other individual problems we face. I'm asking how we as a profession, made up of various specialties, saddled with some arcane legal hurdles, could ever unite enough to fight for what we know is right.

 

[DrDre311]

where do dnp's fall? it would seem currently, under np's, and thus the same rules would apply.

while mundinger and others may want dnp's to practice solo, current state laws (in nevada and california, since those are the states i know) do not allow for independent practice.

There are 23 states that currently allow solo NP practice. The list is available on the AANP website.

Probably the most realistic intervention being proposed on these boards to regulate NP's/DNP's is to bring them under the auspices of their state BOM's.

 

[U4iA]

The calls to do "something" are deafening. So what should we do?

our biggest challenge is a lack of knowledge in this realm for most medical students and MDs. the second biggest challenge is a lack of organization.

so the simple answer to your question: organize & educate.

here's a possible roadmap.

1. start an organization geared toward educating medical students and docs about issues pertaining to trends in healthcare delivery, issues pertaining to the business of medicine and how the status quo is deteriorating the doctor-patient relationship and physician autonomy. the end goal is to cultivate more physician leaders who are concerned enough about the future of the field to take action.
the first few steps in starting this organization:
- get the mission hammered out
- use SDN to get a student rep from every medical school to help start up a chapter.
- prioritize the work that needs to be done and come up with 3 projects to execute in the next 6 months.

2. have a similar approach focusing on MDs. (on the backburner because students tend to have more flexibility and interest in being a part of the creative process - if only for CV boosting reasons.)

3. start a website, have people who are interested sign on to the listserv, get articles submitted from students/docs for a quarterly publication.

this would be a great start. i know it's thin on details because these would need to be discussed and agreed upon by the team...

sounds like a decent start and definitely sustainable.

ps: PM me if you think that something along these lines would be worth your energy.