7.28.2007

Kids don't need health insurance as long as we have open ERs


No need for health insurance....everyone has access to healthcare....just go to the emergency room.


President Bush suggests uninsured children go to hospital emergency rooms for their care.


"People have access to health care in America," he told an audience in Cleveland. "After all, you just go to an emergency room."


What a fucking idiot!!


And where are they going to go for definitive care for their chronic asthma, leukemia, autism, seizure disorder, juvenile diabetes, eczema, obesity, hypertension...


...when would they ever see a pediatrician?


Where's ACEP (american college of emergency physicians)? Where's the AMA? AAP (american academy of pediatrics)??

One good thing about an idiot president is...
....it forces people to become more politically involved.

Unfortunately, many folks cannot, just cannot, give a damn about humankind, fairness, corrupt leadership, human rights, and really "do as Jesus did"...until they find themselves wondering what the hell happened? How they end up with no job, no safe food, no healthcare, no pension, no basic freedoms and no respect as a human.


Hopefully there are many more folks....who are more forward thinking than our idiot, dumbass president....


Hopefully the future is brighter, for medicine, for our country, for our (very small) world.

7.23.2007

Choosing a Specialty - Being Gay, a General Surgeon, and a Woman...tell us more.

Surgeons are so cool...aren't they?

What's your specialty, and how did you get there? And did being gay cause any difficulty during the process?
I've completed my surgical residency, which took 6 years. Following graduation, I worked at a hospital as a staff general surgeon for 2 years while I contemplated my next move. I took and passed my surgical boards during this time. Additionally, I had my first son. I then completed a vascular surgery fellowship, and now work as a vascular surgeon.

Being a lesbian in medicine makes you the brunt of lots of jokes and off-color remarks. Moreso in surgery, I think, because it is so macho male dominated. The culture has been so testosterone driven that, it's almost *acceptable* to say inappropriate things. And you feel stuck. What can you do....who can you tell? In the end, most gay medical students and residents feel it's just easier to deal with the abuse...than to fight the fight when you're completely at the mercy of the establishment.


How did you obtain a spot at a top medical school and subsequent residency program?
I basically put my life on hold from high school graduation until the completion of residency. I believed that (as young ladies are told) "you can have fun later...study hard and don't get distracted (i.e. pregnant)." So in high school, although I had a fully developed social life, I felt tremendous pressure to perform well so I'd 'get into a good college'. While in my 'good college' I had to work my ass off...more so than if I'd have went to simply an 'okay college.' But, you need to have a degree from a 'good college' to earn serious consideration for entry into a 'good medical school.' So, in college, I studied....volunteered...and basically had no social life. I kinda regret that now, in retrospect. I don't have a strong network of college contacts as my law school friends do. If I had that to do over, I'd probably choose a college a bit closer to home, less expensive, and would allow me to excel academically while having a social life.

Once in medical school, I worked harder than I'd ever worked before. Even the most dedicated and diligent study regimen only yielded mediocre scores. But, since I wanted 'the very best residency' spot, in the 'most prestigious surgical program' in the area....I worked even harder, sacrificing everything else, basically. I didn't eat Thanksgiving dinner with my family because that "vacation" was prime study time before the winter mid-terms. During winter and summer breaks (and vacation) I did research. That's a necessity to publish a paper...and publishing is mandatory for a top echelon residency spot. I kissed a lot of ass, and ate lots of crow. I did the song and dance every arrogant surgery attending enjoys in a surgery department. I tolerated the character defamation, humiliation, sexism, and picked up the surgical instruments from the OR after the surgical attending threw his weekly temper tantrum (because the bed wasn't 'tilted enough to the right'...or some other equally stupid powertrip gone wrong). In the end, I ended up co-authoring 2 papers as a medical student...and earned AOA recognition in my clinical years.

In exchange, I had no meaningful relationships outside of my family. And I wasn't available, mentally nor physically, when my grandmother (whom I adored) fell ill. I was so consumed doing this insane thing as a doctor in training, I actually missed spending time with her...and she died too soon. I missed weddings, and birthday parties. To the point where I was no longer even invited. My friends found new friends who had time to return a phone call...and I was very isolated.

How did you stay sane during training?
I didn't, actually. I just worked all the time. I gained 25 pounds, and developed varicose veins and plantar faciitis so painful, I took analgesics constantly. My blood pressure went up, and despite my best efforts, I could not eat healthy as a resident. I developed prediabetes, and basically ignored my physical needs altogether. It is a show of weakness to express the need for the requirement of basic human needs as a surgical resident. Going to the bathroom was a big deal, actually. My only saving grace was the fact that I was only in my mid/late 20s, and my body tolerated the abuse...abuse that would be difficult (perhaps impossible) to physically recover from for someone a bit older.

I had no hobbies, nor could I engage in any meaningful discussion with other people (outside of medicine), since I had no time to engage in the world activities and issues. I became very one dimensional, and my entire identity became "me, the surgeon."

What about the residency work hours?
We didn't have them when I was training. I do advocate for them, however. As the environment of medicine changes in this country, we need the physicians to participate on every level. To participate meaningfully, they need to have more dimensions to their persona.


Also, to tolerate years and years of abuse, at the expense of your relationships with family, being present for ill loved-ones, and at the expense of your very own health...isn't worth maintaining the status quo.

What was practicing general surgery like?
Horrible!! Absolutely horrible. The ER would call with "this old lady has non-specific belly pain...I'd like you to come lay hands on her?" As if my hands are magical. As if I can really tell what the hell's going on. The ER doc is just trying to cover his ass (which is necessary in a society where patients see a 'normal, expected complication' as an opportunity to get rich), so it makes my workload that much heavier. So, I got lots of these CYA calls.

Also, I was oncall every 4th night. And sometimes that would increase if a member of our group was ill, or otherwise absent. The money was pathetic, especially for the amount of time you're available. It even got so bad that the hospital wanted to stop paying us, unless we actually operated!! As if my time, just making myself available...taking time away from my life....isn't worth payment. I couldn't even have a glass of wine with dinner, for fear I may be called in. I wouldn't make promises to attend events, or meet other obligations (that may be more meaningful to my life and well-being), just in case I got called in...or happened to run late on a case. This is a big imposition on your life, and to not be compensated for your time is crazy.


Then, it got to the point where we were actually covering 2 different hospitals, miles apart. Not on the same night, thankfully. But the drawback of that is, where do you live? Getting to and from work is a hassle if you're covering 2 or 3 hospitals that are far apart.
You spend your entire life (all of your waking hours) sleepy and fatigued. You try to have a normal wake-sleep cycle so you can at least see your children. But you're freshest, sharpest hours are spent in the hospital. The rest of your life gets the "scrub time". The days are a blur. Sleeping becomes your favorite thing to do (instead of other hobbies, or spending time with loved ones). Life moves very fast...and you miss it. Your vacations are very planned well in advance...and only come once a year. Think about it, would you exchange a 2 week vacation to Europe for one 3 day weekend a month, every month, do hang out locally and bond with those closest to you...and then spend a week in Europe and later that same year a week domestically, like Florida? What I'm saying is, you'll get to do once a year big things. But it's the frequent, smaller things that I prefer.

Basically, your life is unbalanced. You miss tons of things that are important to you. You go thru life sleepy and tired...chronically. Your health isn't optimal...and it's all for what? To be called 'a surgeon.' That will get old as your children begin acting out in school....or choose grandpa over you for comfort and snuggles. When they seem to not like you very much...and you feel excluded from their lives. When you have a mild, dull headache from lack of sleep (or some other vital ingredient to a healthy body), on that 1 day off you may have in 10. And, low and behold, if you get 2 consecutive days off....you try to make-up for lost time. Guess what? You *cannot* make up for lost time. So, do you really want to spend your life doing this? And if not, why torture yourself for a decade, give up your 20s/30s, when you could be building something more sustainable....mentally, and physically?

The variety of work was non-existent. Appys and choles. The occasional exploratory lap. And sometimes you'd get to do a minor surgical procedure when the ER calls for help. But, overall, it's the same cases. The best (most interesting) cases go to the 'appropriate' subspecialist covering that part of the body. So, a cool upper bowel case will go to the foregut guys. Or a complicated heart or lung case would go to the cardiothoracic guys. The exciting trauma cases...the trauma guys. We, general surgeons, pretty much got the parts of the body that aren't 'interesting enough' to have their own subspecialty.

What about malpractice?
That's an issue, but is covered by the group/hospital.

How much did you make?
Not enough. About $200,000 year. Sounds like a lot...but let's break it down.


200K was about a $10,000/mo bring home. But, that's for a tremendous work load. And my loans are in excess of a quarter million dollars. I couldn't even afford to purchase a decent house, and simultaneously pay back the loan at $1500/mo. House note of about $6000 /mo (for a 3 bd 2 ba 15oo sq/ft house in the city-center). Insurances at $1000/mo. That leaves $1500 left. Currently I have children, so I know that childcare in this city exceeds $1000/mo for the hours I need them. At the end of the day, you can clearly see that $500 left is hardly enough to live on. There's utilities, car note, and miscellaneous. There's no money for incidentals, so they're charged. There's no savings, no investment money, and no emergency fund. I pay the minimum on my credit cards (which I have 2). The only saving grace was, during this period in my life, I had a working spouse and only one child.


Also, keep in mind that the ancillary staff I work with were making, hour for hour, just as much (and some of the RNs even more) than I made. This fact takes a toll on your morale as well. You feel that society expects you to be very altruistic, to the point of self-detriment. In a place, like France, where you are debt-free as a doctor, and you have a pension waiting for you when you retire, and where you're not sued for things gone wrong when you're not at fault...you can get away with making less money. Afterall, society has decided that doctors are worth this effort. In America, if I can't pay for food....I starve. There is no "village" looking out for me, vested in my well-being....making it difficult for me to justify self-sacrifice for society.

Why not just buy a cheaper house?
Where? Even a shit house in Compton is over $300K. Our home is a modest $800K. It's no multi-million dollar mansion. Nor do I drive a benz. My lifestyle was below where I'd like it to be. Well below where it needed to be for the services I provide. It was below the "break-even" point in the equation of time vested vs. income. I had to do a different thing. My parents are getting older, and my dad may soon need to come live with me. The people who've been supporting me throughout this process deserve a bit of my time and resources. I couldn't take care of them. I needed to make a change.

So, what did you do?
Well, I took 6 months off to regroup, and worked in an outpatient ambulatory surgery center. This was a much better environment, but kinda boring. During this time I was pregnant with my second son, so it was ideal. Later, I decided I'd go back and do a vascular surgery fellowship to decrease my burden of in-house call, make more money, and spend more time with my thriving family.

How did this work out for you?
It was a great decision for me. I always thought I'd want to be a general surgeon. To have the ability to do various procedures, and not be stuck doing one type of procedure on one part of the body. I was never interested in ophthalmology or cardiothoracic surgery for this reason (very popular choices among those who are able to hack it gradewise). Vascular surgery offers me a variety of projects, since vessels are everywhere. Granted, I don't operate on vessels in the brain, nor on a few other body parts that have others who'll likely do a better job (like hands/feet). But, I don't get called at home often. My scheduled cases are routine enough for me to feel comfortable doing it. Routine enough for me to find it easy. Routine enough for me to master it. But exciting and different enough where I'm not bored. Exciting enough to keep it interesting. And exciting enough to make my training, and the sacrifice worthwhile for me. Especially since I make over $300K now...which is plenty to cover my bills/debt, and care for my children and parents. I have a savings now, and feel more secure.


Any advise for gay medical students and residents -specifically?
Medicine needs you. Medicine needs more diversity, period. More women, more color, more spice....
I think it's safe (depending on the part of the Country in which you live) to allow the fact that you're gay to be exposed. If you live in Podunk Mississippi, perhaps you shouldn't. Eventually you'll have to allow yourself to thrive and live the life that best represents your essence. This probably means that you'd be better off choosing a training location where people are better educated. Eventhough you may be willing to fight the fight....you have to consider what type of environment you'd like to raise your family in. Where will your partner be comfortable? Medicine is labor intensive, and time consuming...and you'll likely not have the time, or energy, at the end of the day to deal with closed-minded, dumbass Podunkians.

Any advise for those who may be trying to decide on a specialty? Shouldn't students pursue something they'll enjoy rather than a choose based on lifestyle? I agree that you should do a medical specialty that you (think you'll) enjoy. But, how long will you enjoy a miserable lifestyle? Is the practice of 'that specialty which brings you joy' going to be *enough joy* to off-set the absence of life outside of work? Like seeing your kids play little league. Being there at your daughter's dance recital. Taking your kids to a puppet show in the middle of the week at the local library. Sleeping in late on Sunday morning, then going out to brunch, spur-of-the-moment with your wonderful family. Drinking until you're tipsy, and then having great sex with your spouse. Just having time for creative flow of energy, and silence to obtain inner peace!! These things may not be possible if you only get one day off a week...and you have a ton of basic life stuff to attend to. For the rest of your life...imagine 'not having enough time.'

Who runs your household? Grandma or mother-in-law? That may be better than a nanny, but it's still not ideal. A mom who's in her 30s - 40s is a lot more attentive, active, and better able to deal with toddlers/tweens than a grandma. Besides, Grandma has raised her kids...and now it's time for her to be a *Grandma.* It's one thing for Grandparents to be intricately involved, and to hire a nanny for supplemental support as needed. But, if they're raising your kids instead of you...you'll have to consider the consequences of that (for both you, your family, and your children).

Would you rather pay someone to be the Mommy while you're the doctor...or would you rather be home doing the mommy (or daddy) thing yourself? Would you rather have other kid's fathers who have time to coach flag-football on Saturday mornings teach your son how to throw a football, or otherwise be present as the male figure in your son's life....while you're at work being the 'greatest surgeon ever?' It's no wonder that so many old men end up saying "Rosebud" as they lay dying, alone, on their deathbed.

You'll need to nurture your marriage, or it won't last. People (including spouses) will only tolerate so much. Even if you think your wife is "happy staying at home"...no one gets married to be alone.

You need to be present while your kids are kids. In 12-15 years, they won't need so much of your time...and a large part of your influence over them (your parental guidance) is over.
Are surgeons so cool? Yes and no. The work is like no other. It's exhilarating when you can cut someone open, and fix the problem. It's easy to get an ego...which is almost a requirement if you want to survive the process of training. If you're to compete, and not become an emotional wreck....you shield yourself from criticism with an enormous ego. This translates to the rest of your life....and your personal relationships will become antagonistic. At times, the only thing in your life going as planned is...surgery. So you hold on to that. Surgeons are as diverse as the population. I'm sure there are some who get off on being a surgeon because everyone says "ooohhhh." But, most people are just as impressed when you say "I'm a doctor." Nothing special (or even distinctive) about being a surgeon to much of the population. So, who are you really trying to impress? Other doctors? Your partner? Yourself? And that ego, that desire for respect and accolades, keeps 'em coming to surgery....even if it's not the right career choice for them. That thought of 'surgeons are so cool.'


Criteria used to decide:
I say, decide *overall* what's important to you...and find a way to make those things fit together. This may mean choosing "your second favorite medical/surgical specialty" instead of your dream specialty...if you want a *dream life* overall!!

Work doesn't define you...and neither should being a doctor. You'll be disappointed if you don't understand, and clarify, this distinction. Balance doesn't just happen...you have to make informed decisions in order to achieve it.


*written with the input from a vascular surgeon.

7.21.2007

Harry Potter everywhere - Wanna know what happened?*


Are you a Harry Potter fan, but like me, you just can't seem to find time to sit uninterrupted and read the last book? As a (temporary) anesthesia resident, I had lots of time to relax and read behind the blue curtain in the OR. I gobbled down 3 or 4 Harry Potter books with great enthusiasm during those 4 hour appys (performed by new surgical interns in the middle of the night, as they literally fell asleep mid-operation, dropping their tools, and falling face first onto the sterile field...but I digress). However, as an EM resident...needless to say, there was standing room only in the ED at the Kingdom. Sooo, I fell behind.

I'm a cliff note version type of person...
...if you wanna know what happened because you actually care about Harry, but aren't interested enough don't have enough time to read the book, keep reading. Actually, knowing the spoilers makes me want to go get the book...and read it!!
***


Harry Potter spoiler!!


Who lives?
Hagrid lives.
Professor McGonagall survives.
George Weasley lives - he's wounded, but lives.
Draco Malfoy lives.
Harry Potter lives.

So who dies?
Snape is killed by Voldemort, well actually by the big snake, and as he dies, he passed on his 'memories' as a silver liquid to Harry...which would allow him (Harry) to finally 'see' what happened with his mom many years prior.
Professor Charity Burbage dies - professor of muggle studies at Hogwarts.
Hedwig the owl, Harry's own, dies.
Fred, Rons's brother dies.
Scrimgeour, the Minister of Magic is killed.
Gregorovitch, the wandmaker, and Grindelwald, the dark wizard.
Dobby, Harry's protector creature dies.
Some students die.
Crabbe, Malfoy's sidekick, was killed by the Fiendfyre he created to kill Harry.
Dumbledore does something stupid with a ring, and begins a slow, sure death.
Oh, and Voldemort dies...actually he sorta inadvertantly commits suicide...dying nonetheless.

Of interest: Turns out his mom was a wizard, and her sister, Petunia was a muggle.
Petunia was very jealous of her sister. Wasn't Petunia the Aunt that Harry lived with? The family that locked him in his room in the early books? I guess that's the reason they hated him, because the Aunt was hateful, and jealous of his mother.

Snape and Lily were childhood companions.

What's with Snape?
When Voldemort goes after Lily's son, he begs him to spare Lily (because he loves her, and had for a long time. But since he was an 'Evil doer' they couldn't be together). When Voldemort shows no mercy, and kills Lily. Together with Dumbledore, he secretly protects Harry as a tribute (in a way) to Lily.

The Horcruxes are the objects which house the pieces of voldermort soul when he split it into pieces to increase the likelihood that he'd live forever, since all the souls would have to die in order for him to die.
The pieces of his soul (thus the horcruxes) were in:
Tom Riddle's Diary
Gaunt Ring
RAB locket
Hufflepuff's Cup
Rowena Ravenclaw's Lost Diadem
Nagini the big snake
The Sword of Gryffindor
And (get this) in Harry Potter.
When Voldemort went to kill Lily, she used some sort of spell that 'reflected' the Voldemort's curse, causing a piece of his soul (unbeknowst to him) to break off into Harry - this is why Harry can talk 'snake language' and seems to 'be connected' to voldemort in thought sometimes.

In the end, it seems like Dumbledore "just kept Harry alive so Voldemort can kill him at the right moment....raising him like a pig for slaughter."

In short, Dumbledore betrays Harry...and Snape. (This is revealed via Snapes aforementioned 'silver memory liquid.')


What are the Deathly Hallows? They are the objects of 3 brothers who cheated death. The third brother, Ignotus Peverell, was a common ancestor of both Harry Potter, and Voldemort. The items - the first was The Elder Wand, and the second was The Resurrection stone located inside the Snitch, and the third was the Invisibility Cloak that Dumbledore had the night Harry's parents died. "Three objects, or Hallows, which, if united, will make the possessor master of Death....Master....Conqueror...Vanquisher...". So it's good vs. bad. Hallows vs. Horcruxes.

Interestingly, Voldermort was raised in a Muggle orphanage.

And they live happily ever after...
On page 753 begins the epilogue, 19 years later. Harry and Ginny have a daughter named Lily, James and Albus. Ron marries Hermione and they have a daughter, Rose and Hugo. Draco Malfoy is married and has a son named Scorpius. They happen to meet up in the infamous train station as they send their respective, age-appropriate children to Hogwarts on the magical train.
And finally, his forehead scar pains him no longer.


**I apologize now if this information turns out to be complete bullshit completely inaccurate. This is what happens when you rely on random websites for information.

7.13.2007

Choosing a specialty -What about Primary Care?*


Q: Primary care is extremely challenging. "Is it also like this in other areas of medicine?"

A: No. I don't think so. The two main issues that concern all doctors, regardless of their specialty are 1) income, and 2) lifestyle.

Income means how much you make for your time and energy (Do you spend an hour talking to your patient and get $50, versus, you spend an hour doing a high-tech procedure and make $3000). Just really try to visualize this scenario to appreciate its meaning: $50 vs $3000, in your hands. Which one do you pick. See the difference?

Lifestyle means whether you will be able to care for yourself, your loved ones, and your other interests throughout your life. Are you able to go to sleep at night, without thinking, "I might need to go into the hospital at 3am, to deliver a baby," or "I might be woken up to see a patient in the ER in respiratory distress." Do you want to sleep with a pager next to you, like a time bomb that might go off at anytime, at which point you have to leave your cozy bed and your lovely family, to drive to the hospital to care for the patient? Many of us have hobbies. Are you able to knit, work out, read, garden, plus care for your family, on top of having a career? If you have to do calls for 30 years, every 6th night, until you are an old woman, it gets pretty old. One rule of thumb, which is a general concept, is that your lifestyle has to do with what kind of disease processes you are treating. If you go into a specialty where the disease needs to be addressed on a moment's notice (a baby and mommy in labor, or a ruptured brain aneurysm), you are going to have deal with the call and the lifestyle issue, because you and your colleagues in the same specialty will have to share calls to deal with emergency no matter what time of the day it is.

If you go into a specialty where the disease can wait (allergy, a cancer-looking mole, a deck of slides of non-emergent pathology specimen) until the next business day, you are going to have a better life style. If the disease can wait, you can have banker's hours, and live a normal life. Another way to have predictable hours is to work in a specialty where one doctor is just as good as another doctor--i.e. no continuity of care. For example, you can work shifts as radiologist, or ER physicians. You work your ass off for 8 hours, and you go home. This type of lifestyle may be more amenable to flexibility of your life. You can work as many or as little shifts as you like (if you can negotiate it in your contract). You can work in California this month, take 3 weeks off, and then go work in Oregon next month.

Q: "My question is: WHAT area of medicine DO YOU SUGGEST? For sanity, for family, for salary?"

A: Since I am a primary care doc, I can only comment on what I think are better specialties, and I welcome doctors from these specialties to shed some insight if they disagree.

For lifestyle:
Dermatology
Allergy & Immunology
Pathology
Occupational Medicine
Physical and rehabilitation medicine
Ophthomology
Radiology
Plastic cosmetic surgery

But if all you care about is the actual amount of dollars that you make regardless of any other factors:
Neurosurgery
Invasic Cardiology
Interventional Radiology
Orthopedics
Gastroenterology
Urology
ENT
many of the surgical subspecialties

Neither (bad lifestyle, bad pay):
primary care - internal medicine, family practice, pediatrics
Obstetrics & Gynecology

A bit of both (depending on your practice)
Emergency medicine
Ophthalmology
Anesthesia pain management
some of the surgical subspeciaties
some of the medical subspecialties.

And, special mention, anything that is minimally invasive yet procedurally oriented is going to be HUGE. Example, the art of open vascular surgery is now slowly being by encroached by radiologists who can thread a wire up on someone's blood vessel and repair the damage by using stents, making a tiny incision through the groin, versus an open procedure. So, another general, basic concept is that how well-compensated you will be, depends on how much you "cut" people. The more cutting and fixing you do with needles, catheters, scalpels, the more money you will make--especially if you can fix something permanently by operating on it: like a hip replacement. Even better than that is if you can do a procedure that most people want but do not need: like lasik surgery, or cosmetic procedures. You can crank out many of these, and get paid by patient's out of pocket CASH.

So a good basic rule of thumb to remember is the following. The more you talk to people in medicine, the less income you'll make. The more you cut people in medicine, the more income you'll make. The smaller the cut you can make to achieve the same result, the more income you'll make. The less you have to depend on insurance payment, the more income you'll make.

A note about general surgery: they have complained to me that they are the "primary care" of all surgery specialties, and some of them are struggling. ER dumps on them all the time. They get called day and night to evaluate vague problems, like tender abdomens. I think general surgeons have it pretty hard. They have longer residency years, but they really don't make significantly more money for the time and effort.

OBGYNs have it pretty hard too. All the malpractice threats, and the terrible hours. Perhaps someone else can comment on these specialties.

Q: "What area is not completely scrutinized by this frankly jacked up system?"

A: None.
Every area is scrutinized by the system. In order to understand why this is the case, you have to understand how the doctor's work is paid. The concept of the third party payer must be addressed. In America, the doctor usually receives a payment for his/her work, not from the customer, the patient herself. The payment is received through the insurance company which is tied up with corporations, and the government. Because money is actually disbursed by the insurance companies such as Blue Cross/Blue Shield, or the US government in terms of Medicare and Medicaid, these third parties (the first and second party being the patient and the doctor) control how much doctor gets paid.

So the one who hands out the money controls the system.

The purse-holder decides how much the doctor is to get paid, how fast the doctor is to be reimbursed, what type of paperwork the doctor has to fill out in order to get paid, what kind of fee negotiation the doctor can have with the insurance company, what procedures are considered acceptable, what kind of patients the doctor can afford to see, which drugs are approved, etc. All of this is regulated. The final translation is that it impacts how you practice medicine. This is what we mean by "loss of autonomy." Essentially, because someone other than the patient pays your work, the third party that pays you tells you how to do your job. So every doctor who is paid by the third party is affected by regulation and scrutiny. I need you to understand this concept.

Again: whoever pays you, is who manages you, and who controls how you doctor your patients.

How does this happen? -prepare for a rant- The person who pays you, decides how much they will pay you, which affects your income, which affects how you treat your patient, which in turn affects your lifestyle, which ultimately affects your life, period. The doctor, say the plastic surgeon who does cosmetic surgery, who is paid directly by the patient out of pocket (i.e. not through insurance), is less under the scrutiny of the system, because the surgeon is not being reimbursed by the third party. But even doctors who do not accept insurance, are affected by the system--because the system sets up an industry "standard." For example, if the third party is saying that your UCR (usual, customary, reasonable) fee for a an angioplasty is $1000 (a factitious number), you will have a hard time to say that you are going to charge $2000 for doing the same procedure as Dr X down the street.

So in that way, as long as the system of regulation exists, every doctor is affected just more or less in degree. I cannot stress this concept enough. Who pays you, controls how you practice your craft. This is what we mean by "losing our autonomy." We no longer decide for ourselves and our patients. Other people tell us what to do, how to do it, where to do it, how much to do it, in our own profession! And yet when something goes wrong with the patient, it is our fault. The individual doctor is first to blame--not the system, not the insurance company, not the lawyers, not the government, not the patients. We pay out of our own malpractice insurance to compensate the patient. So there you've got a deadly combination. We have very little power in controlling our working environment, yet we are held liable for mistakes or errors in the system.

The loss of autonomy, in the setting of the constant threat of malpractice is very suffocating and demeaning, not to mention chronically stressful. This is why in a recent survey of doctors (I forgot whether the survey was for all docs or just primary care docs), 66% of them said they would not advice their children to go into medicine. Sounds benign? Well, think of this analogy. Say you go to an internet site to decide on a hotel choice. If 66% of the guests at a particular hotel say that they would not recommend staying in this hotel, would you want to go ahead and book a room in this hotel (if you had other choices)? Probably NOT! Unless you were stupid!

Well, you may be saying by now, "don't patients control how you practice?" Not really. Patients are not the ones disbursing the money either. So they have no power. Moreover, they are clueless about how to navigate within the healthcare system. They can't force the insurance company, for example, to pay more to the good doctors, than the bad ones. Patients are the sacrificed lambs in the system as well. And I am sympathetic toward patients. They pay their monthly premium, month after month. But they have no control over how the money is spent. They have no control over the Medicare Fee Schedule, either. The current health care system is so opaque that patients and doctors really have no idea how our money, 1.7 trillion dollars a year, is spent. That is trillion, not million or even billion. Trillion.

Example 1. Patients will take out a credit card loan to pay for a $6000 dollar breast augmentation job, but they will not want to pay one more cent than when they have to for a life-saving bypass surgery. Patients feel that healthcare is a given right, not a want. They expect top-dollar service, but would rather not pay for it. Is it their fault? Maybe yes, maybe no. But I can see their point. I see that ordinary citizens are already paying lots of money into their health care premium. In fact, many people choose a job because it offers health care coverage. These working class folks pay, month after month into their health insurance premium. No wonder they don't want to pay anymore.

I think it's not so much that money is not there, but that money is poorly managed. Many people who have no real contribution to the healthcare delivery are benefiting from healthcare spending, e.g. million dollar salaries given to insurance company CEOs. If you thought a plastic surgeon making close to a million dollar a year is a lot, wait until you see that the CEO of United Health last year got over 80 million dollars in salary and stocks. But, we live in a capitalistic society, and CEOs are paid based on how much money they can make for the company so the stockholders can all benefit. The CEO's job is not to promote health. His job is to milk as much money of this quarterly earning income as possible. So there you have a conflict of interest at hand.

Example 2. Counseling patients about obesity can avoid costly health problems down the road. Yet, the insurance industry will pay more for the doctor to perform angioplasty (a couple thousand dollars ) for heart disease as a result of obesity, rather than for obesity counseling (two hundred dollars tops) to prevent the disease itself. Why is that? Well, you do want to make sure that you attract the brightest people to do these invasive procedures. You can't just not compensate the doc who is doing angioplasty handsomely. Do you want to make angioplasty so cheap so that any joe off the street will want to do it? Don't you want the best and the brightest to do invasive procedures? But who is to say that counseling about obesity to prevent heart disease in the first place is not equally important. So what do you do? Do you pay the angioplasty guy as much as the counseling guy? Ummm. Tough choice.

Remember how we just talked about this: whoever holds the purse, tells you how to do your work. Well, then you have to ask yourself, "what is the motive of the purseholder?" If the purseholder was the patient, he would want the best medical care possible for his money. But remember I said that in this country, although the money comes from patients, it is the insurance company that holds the purse? Well, being for-profit insurance companies, their motive is not to promote health. The CEO of the insurance's only motive is to stay competitive as a business, to be cost-effective, to cut cost as much as possible. His goal is not long term health of those insured. His goal is to make the company as profitable for his company during his tenure there. It is a very short sighted goal. The two goals: profit and healthcare are mutually exclusive. Health care costs money.

You may say that, "wouldn't the insurance company want to keep its insured healthy so that they don't have to get expensive procedures down the line?" In order to understand what is at stake for the insurance company, we must look at the way insurance works in our country. One of the biggest problems is that we do not have universal health care system, where the risk of cost is truly, and justly distributed amongst ourselves as a nation. The original concept of insurance is so that risks are equally distributed across a group of people who pool together their resources to deal with catastrophic costs.

But the way our nation's insurance system is set up is really screwed up. If you don't work, you are not insured. If you don't continue the insurance, you are not insured in 5 years. You may be insured with company y today, but be insured with company x the next year. Insurance companies cherry pick the most desirable of insured people, and try to drop them as soon as they become "expensive," with "pre-existing conditions," or when they become old, defeating the very purpose that the insurance was put in place in the first place. Because we do not have a universal health care system where patients' risks are distributed longitudinally over the life-time where diseases often take decades to develop, what kind of incentive does the insurance company have in providing counseling for now, for benefits that may not happen until 50 years down the line when the patient is no longer on the panel of the insurance company, but now at the age of 65, becomes a problem that the government has to worry about. Everyone over the age of 65 has Medicare, a problem that the government has to deal with? How many of us have the same insurance policy for 50 years in length, for the insurance company to make it worth their while to provide counseling?

Example 3. Can you imagine the political battle that has to be won in order for the insurance companies/government to reimburse top dollar for preventive counseling? There are multibillion dollar industries (drugs, devices, catherization labs, cardiologists, hospitals, even fellowship training programs) that are built based on the results of obesity. These are powerful forces that would be impossible to dismantle. If there were less obese people in this country, and less heart attacks, do you think the advertisement of Coreg (a drug used in treating heart disease) would be a cash cow for GlaxoSmithKlein, a pharmaceutical giant who brings in the profit by the millions for its profit holders? I hope these examples will open your eyes to see the reality of healthcare, the complexity of it. -end of rant-

Q: "Does pediatrics fall in this same category of PCP - and does the caution "do not pursue this field" apply?

A: Peds, geriatrics, internal medicine, adolescent medicine, family practice, and according some people, psychiatry--all fall under primary care.

Q: And the puzzling thing: if most physicians are so underpaid, how come over 75% of the parking spots in the physicians parking garage at the hospital I work for are fancy luxury cars??

A: Ah, this is my favorite question. What about those fancy cars in the physicians' parking lot. Specialists are still making high income. It is not uncommon, for example, to find interventional radiologists to making over $300,000 a year, GI, path and dermatology docs making $200,000, or neurosurgeons and cardiothoracic surgeons making upwards of $400,000. When you make a million every 2-3 years, these super-specialists can afford to buy mansions and luxury cars. Plastic-cosmetic surgeons can make over $600,000 a year, partly because patients pay out of pocket. Since hospitals are now housing only acutely ill patients who need procedures, fewer primary care physicians are parked in the physician parking lot all day, as compared to the disproportionate number of surgeons/proceduralist who are over-represented in the parking spaces, because they are doing procedures in the OR/cath/radiology suites all day.

Primary care doctors make about $150,000 (pediatrics even less), and the figure is not keeping up with inflation. If you look at the math, the so-called debt repayment programs or even military sponsored programs do not come close to what super-specialists make. How much you make may depend on how long you have been in practice. Many of these fancy car drivers are over 45 years old. It may mean that they have worked like a dog for the last 15 years of their lives, making that income to buy extravagant things. Many cardiothoracic and neurosurgeons work 60 hours a week. Men work longer hours then women. The question you want to ask yourself is, do you want to work like a dog for 15 years neglecting your children and your loved ones?

Of course, the type of practice you are in also determines how much income you make within any given specialty. Are you in an inefficient practice, where overheads (rent, hiring of personal, equipment, billing short come) steal money away from your pocket, or are you in a good practice where everything is working like a well-oiled machine. Are you the owner of the practice, who gets to pocket all the extra profit as generated by your employee physicians, or are you the employee physician who is working for the owner physician. Your patient profile (also called payer-mix) makes a difference as well. Are most of your patients well-to-do, and well insured? Or are most of your patients old, uninsured, immigrants, and poor? You may have idealism to go into medicine to help the latter group, but when you realize that you are working like a dog, or you are doomed to shop at K-mart for the next decades, you’ll think twice. Especially when you see your colleagues drive away in the wind in those sports cars, carrying expensive bags, their debts completely paid off. Are you a investor-owner of a medical facility, or even a hospital? Do you own the real-estate of where healthcare takes place?

Lastly, it depends on what kind of medicine you practice within your specialty. You can run an assembly line practice where you are churning out 40 patients a day, seeing each patient only 15 minutes per visit, generating in more income from your “productivity,” vs. being someone who chooses to spend time with patients. If you were a surgeon, you can operate on twice many cases, for example, to double your income, than someone who takes more time to care for patients before and after the operation.

So your income level depends on these 5 factors:
1) What specialty you are in
2) How long you have been working
3) What kind of practice you are in
4) How hard you want to work
5) How much corner you are willing to cut

Q: So what are we suppose to do? Are you telling us not going into primary care?

A: You've got two options.
Go into primary care but only after you are fully informed, and are willing to take the risks and make the sacrifices. Do it because you feel passionate about the specialty regardless of its difficulties. Do it because you feel it's the right thing to do. Do it because you believe in it. Do it with joy and pride even if it means that you are going to be in debt longer and will have to drive a beat up car, when your colleagues are driving Mercedes. Do it even if your higher earning colleagues think that you are the loser and the sucker at the end of the barrel. But better yet, design a primary care practice that minimizes the non-sense. But believe you me, this very labor-intensive and time consuming...to the point it may not be worth the tremendous personal sacrifice.

The second option is don't do primary care.



more insight to 'choosing a specialty' in future posts
*This was written from input of other doctors. Thanks doctorhope.

7.02.2007

The Rodriguez Medical Examiners Report

They've made Ms. Edith Isabel Rodriguez's autopsy available on the internet.

The medical examiner reports that...it was an accident. That her abdominal pain, and ultimate bowel perforation, was partially secondary to her chronic drug abuse. It seems like the medical evaluation and treatment involved multiple radiologic examinations, hospital admission, evaluation by specialists...the whole deal.

It's difficult to determine if a drug abuser is 'for real this time' . And I do have sympathy for the medical staff as this was a very complicated, and difficult case. It seems as if this woman did, in fact, receive great, comprehensive (expensive) medical care. Actually, it's the fact that she died in the waiting room that makes the case newsworthy...not the fact that she died.

I've read lots of comments on various message boards ranging from:

"She deserves a Darwin Award...she was an illegal immigrant, criminal, homeless, drug-addicted prostitute..who cried wolf one too many times."

to "the entire medical staff should be brought up on premeditated murder."

Both are outrageous, and completely inappropriate points of view. But, in the middle lies the answer.

Edith wasn't an innocent victim absolved of any responsibility, and her family doesn't deserve millions just because she happened to die in the waiting room rather than the ED hallway/chair/floor. She apparently had lots of things going on (diabetes, HTN, cholelithiasis, obesity, drug addiction with sequelae, social issues, and was a frequent flier with inappropriate follow-up). What she died from possibly developed after her hospital evaluation and discharge earlier that same day. It's an unusual diagnosis in a woman her age. And, it sounds like she was appropriately worked up.

But, how horrible is it to see someone die in the ER, begging for help? Perhaps if she would have been reevaluated by an MD, she would have received IV fluids, antibiotics, pressors, and possibly even a surgical evaluation revealing an acute abdomen. This intervention *may* have saved her life if it were possible to clinically recognize the emergency (but it seems like this was no easy task).

Like most of you, my sole source of information regarding this case is via internet, and news media. I am well aware that I don't have enough information to make an informed decision one way or another. It's unfortunate that many of the people who are talking out of their asses don't have this same realization.

The truth, whatever it is, will probably not be revealed in the local paper. And without knowing the truth, thoughts/opinions are a product of media persuasion...

...I'd like to think of myself as an independent, critical thinker.