9.21.2007

Medicine the man-whore

Like many young doctors, I get asked a couple of the same questions over and over and over again.

Would you do it again? Any advice to premeds? Would you encourage your children to become doctors? Or some other variation of "Are you happy doing what you do?"

The short answer is 'yes.' I love being a doctor. I love being called 'doctor.' I am proud to tell people I am a doctor. It makes me feel 'satisfied' to know my parents are proud of me...that I have accomplished (in their mind) the epitome of accomplishments. I love it when patients say "your mother (it's always only 'mother') must be so proud of you!!" Yes she is. It really feels good to hear your loved ones brag about you...simply being a doctor is a big deal to most people.

Becoming a doctor doesn't require one to be a genius. You just have to be focused...and do your homework. In high school - go to class and do your homework. In college - ace your exams and do your homework. Medical school certainly isn't about being 'smart' but rather 'organized' and methodical. Studying smart, concentrating on only the most relevant, high yield material. Doing research, and kissing lots of ass. If you study hard, do research, and get good letters of rec, you'll likely get into the field of your choice (especially if you're willing to move anywhere in the country). Once there...you work your ass off. All of this doesn't require you to be smart, per se, just dedicated, passionate, organized, persistent, etc.

I recommend a student go straight thru the process, and not take breaks. If you finish up residency at 26, you still feel like your young adulthood is yours to experience. As a resident, you can have a life (depending on the specialty, of course). You can still go out with friends, date, and hang out. I even endured 2 pregnancies as a resident (afterall, when are you supposed to have those babies?). Residency isn't about studying and learning....it's about working. If you work, you'll finish. You can always study for a test (boards) later. I found residency less stressful than medical school because...in my mind, I'd 'made it' already. I was a doctor. Simply being a medical student makes you....nothing. No pass = No MD. The fact that I'd accomplished a major achievement by simply graduating from medical school, relieved lots of stress for me.

If you go straight thru, you may graduate residency at 29 years old. That's still plenty young. The sacrifices are much less. Afterall, you don't feel as though you've sacrificed 'your entire young adulthood' to medicine if by 30, you're making 6 figures...like many of your professional friends. (Granted they may not have the debt you have).

If you put off medical school, and do a long residency, by the time you're finished...you may feel you've given too much of yourself, of your life. If you decide to put off relationships, marriage, having kids...you may find yourself in a situation where you *can't* have kids, or the family you always dreamed of. You may miss end of life activities with grandparents/parents. You may miss other significant life events of other family members/friends. And, you'll gradually lose your close friends as they have families, and hang out with other people in similar social situations. You may realize that you're the oldest guy/girl at the club. And, it may become increasingly difficult to find a suitable match as a life partner. Young adulthood is the time to lay the foundation, both professionally, and personally, for the rest of your life. If you are a medical student/resident thru this process, you may find yourself, your life, unbalanced. As you pursue this (arguably) awesome career, you lose the opportunity to experience these other aspects...that are much more important in the grand scheme of things.

Being happy in medicine happens as a result of going into it with accurate information, eyes wide open. Forget about the fuzzy 'feel good' I wanna help people bullshit. Forget about the 'privilege' or 'calling' that some try to say is medicine. Realize it is just a job. It is just one aspect of your being. It, in itself, will not make you happy. Realize that patients are no substitute for family. If you can see yourself doing something else, and being happy doing it...you should strongly consider that option. Medicine is like a sexy man-whore. Attractive, alluring, exciting, and seems to have 'everything you'll ever need'. But, the reality is, he will betray you. He will beat you. He will not keep his word. He will not appreciate your greatness. He is selfish. And basically, not what he appeared to be. Likewise, medicine will not be what you thought it'd be. The patients will sue you. The 'purse-holders' will not appreciate you or value your work. You will see plumbers make more per hour than you do. Medicine will not provide the life you thought it would...and you'll feel betrayed.

You'll be happier if you realize that medicine isn't 'everything.' You will not make even the modest money you thought you'd make. Realize that student loans *are* a big deal, and will not be easy to pay off "on a doctor's salary." Realize that you don't have control, and are at the mercy of the powers that be...and the pig-headiness of some arrogant peers who see no value in unionization and advocating for 'physician rights'. Do not put off things in life that you really want to do, like get married, or have children. Develop outside interests, and don't let medicine become your identity - do this and you'll have a strong defense against burn-out and disenchantment (this is why it's so important for residency to be humane. Medicine isn't what it once was. There is no pot-o-gold at the end of the rainbow if you suck it up and sacrifice your young adulthood like back in the day when docs were respected, and paid handsomely for their services.) If you view medicine as a stable job that pays a decent wage....you'll be happier. Do not try to make the man-whore a loving husband. See him as he is, and either accept it, or move on.

Also important is, finding a specialty that fits your personality. If you want to be an involved parent, surgery isn't for you. If you want to have a comfortable lifestyle, you might wanna rethink primary care. If you like to interact with people, radiology/pathology may not bring you satisfaction.

Don't overwork yourself. Even if you enjoy speeding around the ED running codes and trauma, do it too much/often, and at the expense of personal health, relationships, or other recreational activities....I promise it will cease to be fun quite quickly. The check is nice...but your life is suffering. In the end, many docs decide it isn't worth it....

...all because they haven't achieved balance.

So, in review - to increase the likelihood that you'll be happy in medicine:

-get the training over with while you're young; don't take breaks (or alternatively, wait until you're a bit older)

-keep it in perspective. You are not a saint because you are a doctor (don't be arrogant and think more highly of yourself than you should). It is not a calling. See it as a stable, respectable, secure, job. Your work is valuable, but not more valuable than yourself, or your family.

-know the drawbacks, and balance those with the benefits of becoming a doctor today.

-the money *does* matter (both the student loans, and the eventual salary).

-don't sacrifice having children, visiting aging parents, or other significant life events in lieu of becoming a doctor. It will not be worth that sacrifice.

-Choose your specialty with care. Chose based on your personality...not based on what is most prestigious, what other people want you to do. Your specialty will determine your potential work environments, your pay, your lifestyle, and the number of years you spend 'training.'

-Finally, don't work too many hours. If you do, you'll be more tired, less healthy, and more likely to experience dissatisfaction and fatigue.

9.13.2007

What is it like working for Kaiser as a Pediatrician?


*again, what follows is just opinion from a couple of Kaiser pediatricians.

What do you do for Kaiser?
I'm a pediatrician. I've been working part-time/intermittently for about 20 years.

Do you work other places?
Absolutely.

What are the positive aspects of Kaiser?
For children, Kaiser is a great place. Most kids are healthy, and seeing children for health maintenance is Kaiser's forte. They have same day peds clinic appointments, after hours urgent care that actually stays open long enough for working parents to utilize the service. They have caring physicians, caring nurses, and a wide range of pediatric subspecialists concentrated in a couple of 'pediatric centers'.

You make it a point to mention that Kaiser is good for healthy kids, what about sick kids?
Kaiser is good at preventive care and health maintenance. They have some great docs/departments that treat common diseases very well, like diabetes and asthma/allergy. They're making great strides in treating obesity, childhood HTN, and really promoting health education and healthy lifestyles with their 'thrive campaign.'

However, if a child has a not-so-common disease, children's hospital is always better. If a child has a disease that has lots of research dollars (therefore lots of new research, treatments, etc) Kaiser will be behind the times. Kaiser is slow to change its approved drugs/management plans, so the latest/greatest treatments may not be available to a Kaiser patient that fall into these categories (for instance, cancers, autism, cystic fibrosis, genetic/congenital diseases, etc). Sometimes this makes little difference...but sometimes this can be life altering.

Do patients seem happy with Kaiser?
Absolutely. Those who have Kaiser, seem to really like Kaiser. Kaiser is easy, you know? The patient know exactly where to go for services, how much they are going to pay, what's covered under their plan, etc. Other insurance companies have very hard-to-understand 'networks' and such, with percentage co-pays, and it's not always clear which hospitals are covered, which services in the hospital are covered, etc. I've heard many frustrated Blue Shield patients who are constantly receiving bills from the hospital for the birth of their baby. Anesthesia bill. Pediatrician bill. Bill for supplies. Hospital room bill. OB bill. Some services that are covered, haven't been....and they keep receiving bills, threatening their credit score if not paid...but supposedly covered under their plan. Very frustrating for these people.

Kaiser makes it easy. There is one bill. Everything is on that bill. The bill is expected. It's a set dollar amount and not a percentage of an unknown dollar amount. It's clear.

How's the ancillary staff?
I think they're mostly a great group. Pediatrics tends to bring out more positive than negative, you know. Kids have way of brightening a day....if you truly enjoy them.

What don't you like about Kaiser?
I agree with the EM attending...the lack of self-determination. When I started here I had big ideas. As I spent more time here, I realized that the doctors were starting to lose their fire. Their life-force so to speak. The job became 'just a job.' Everyone clocked out on time...and only did enough to not get fired. Typical employee mentality. I never wanted to be an employee...especially if it meant keeping a timecard. I know docs who used to go on health related missions to other countries, volunteering overseas and such. Young, energetic, and full of life. After being at Kaiser for a few years...they demonstrated less enthusiasm, and just kind of settled into...submission. It's like watching your friends walk into a soul transformer...coming out with no spirit.

Why do you think that happens?
I think it's because they do silence you. It's quite clear to anyone who's been at Kaiser that it's not okay to be....yourself. To have ideas and such. In order to 'be okay with being silenced' many just shut down, never expecting to get satisfaction from the job. Perhaps they seek it elsewhere. EM attending is right, it is an extremely political environment...and doctors don't always do well. If you're on the 'right side of politics' you'll likely be more accepting of it.

I hear Kaiser lacks diversity among the physicians, is this your observation?
That has been my observation. Usually there is more diversity among the primary care physicians than specialists. There is a tremendous amount of diversity among nursing, and other staff. But, among physicians...not much.

It's interesting that Kaiser brags about being such a diverse corporation, but the physician staff is not.
I agree it's misleading. When Kaiser states they are diverse, I guess they are counting the janitors and secretaries, giving the illusion that people of color are actually in high places, and in more 'professional roles' such as doctors. That does bother me since most of our patients are people of color, and I think Kaiser should do a better job of recruiting/retaining a workforce of physicians that more accurately reflects the patient population it serves. There are a multitude of reasons this would be beneficial...both to patient, and physician. Many people seek physicians who they connect with. Ethnicity and gender are major 'factors of connection.' Language, cultural understanding, and simply a demonstration of positive role models in a community is very important for children/families. Kaiser does a very poor job in this area, but 'hide' it by bragging on diversity that primarily exists only among low-level staff.

What's the money like?
The money at Kaiser for a pediatrician is actually very good. Easily equal to (likely better than) colleagues on the outside. Peds is a very low-paying specialty, so Kaiser's salary is good. This is why I continue to work per diem at Kaiser, because the compensation is very good for a pediatrician.

Lifestyle?
Good. We have hospitalist pediatricians, so call is non-existent. You do work 40 hrs/wk for 10/10, and you do go over hours at times. But, because Kaiser doesn't want to pay staff/nursing to stay late (overtime and such), there's a big push to get everyone (else) out on time...which means you get done at a reasonable time. There's mounds of paperwork to do, uncompensated time. And email/messages to respond to from patients (also uncompensated). But, overall, you get your weekends off...nights off....and one half day a week for education/CME. You are scheduled for a lunch hour, but you usually work right thru it. And, there are times where you have (very welcomed) holes in your schedule...

What about having to see a patient every 15 minutes?
I actually can do it without much ado. I'm a very 'to the point' type of guy...and really don't relish in the chit-chat of nervous parents. So, 15 minutes for me, is all I need. And actually its less than 15 minutes...

...but I will say I have a colleague who has great patient satisfaction scores (among the very best), and enjoys spending more time with her patients. Kaiser delayed her ability to fully participate as a partner until she 'sped up' the visits. I say this to share that not everyone enjoys speeding thru patient encounters. Especially, when they aren't making more money to see more patients!!

Why have you only worked part-time for so many years, and never signed on full time?
I still have my fire...even after 30 years post residency. I've accomplished so much more than I would have had I 'settled' for Kaiser. I have a business. I've worked in various cities. I volunteer where ever I want, when ever I want. I teach interns and residents, and am therefore on staff at nearby academic institutions. I make enough money thru other mechanisms to really travel and enjoy life.

Would you recommend Kaiser to a pediatric resident/fellow?
I would want them to know the facts first. To talk to me, and other docs who know, and see if Kaiser can offer what they want. For a pediatrician, Kaiser has a nice mix of money and lifestyle when compared to the outside. The pension is certainly a perk, and there is the opportunity to decrease your work hours to 8/10 or 6/10 time (with comparable drop in pay as a result, of course). It is possible to avoid much of the politics depending on the clinic, and the staff are supportive of each other. The patients are wonderful, and the atmosphere is pleasant.

However, if you have aspirations to do 'something else' with your MD other than practice medicine forever....you might want to think twice. Also, if you want to work at an academic center, maybe mix up your practice a bit between ER, urgent care, clinic, hospital...you may not find satisfaction at Kaiser.

Overall, I'd recommend it for most of the pediatric residents I see graduating today.

9.09.2007

What is it like working for Kaiser? Let's start in the emergency department.

I have a few friends who work for Kaiser (Permanente Medical Groups), and I often wonder if they are happy working for an HMO. Here are their (collective) responses to some very common questions. (I'll break up the responses in various posts...to keep it bite-sized). These are just their opinions, observations, or experiences...not necessarily facts, truths, or gospel.

The Players:
Emergency Medicine Physician
Medicine hospitalist
OB/Gyn attending
Peds
Surgery

Let's start in the ER!!
The Emergency Attending


So, what's the ER like at Kaiser?
It's a nice facility, and of course there are constant upgrades (which is both good and bad). The patients are working class folks, which is nice. They are more-or-less compliant with follow-up, and outpatient visits are very easy to arrange.

Upgrades bad?
Sometimes stability is nice. Consistency. Satisfaction. "Upgrades" to the computer programs lead to delay in processing. Upgrades sometimes are not needed...and certainly shouldn't be encouraged to be trendy. When something is working...just leave it alone.

Do you see many non-kaiser patients?
Not really. I'd say that I see maybe 80-90% Kaiser patients. Kaiser patients are nice, and a good group to work with. They are reliable, working-class, mostly speak English (thereby helping expedite flow thru the ED), and have PMDs. They are not usually drug-seeking, and would rather be home than in the ED.

I hear that Kaiser doesn't give the docs much autonomy. Do you find your practice is stifled?
A bit, I guess. But, keep in mind that protocols are more your friend than your foe. If you have a patient, and they fit within 'the protocol' things are on 'autopilot.' The nurses, techs, PAs, CNP, everyone is on the same page from the very first record of the patient's chief complaint. This means things get done without you actually having to be there to do/order them. This is usually a very good thing. Likewise, when it comes time to disposition a patient....there are protocols. This alleviates arguing with consultants, or faltering on borderline cases. You feel comfortable discharging patients that you may otherwise worry about because 1) you're following a protocol, 2) you know that your colleagues are doing the same thing 3) and the patients have good follow-up. Kaiser has clinics for everything. If you believe a patient needs admission for something, you may be surprised to learn that there may be a clinic that can supply all the patients inpatient needs.

Are you worried about malpractice issues since Kaiser, in a sense, is telling you how to practice medicine?
Yes and no. I try to do the best I can, realizing that mistakes will be made. I do worry about bad outcomes, for multiple reasons, not just litigation. But, I feel (relatively) protected since risk management cases go to arbitration, instead of a jury trial. However, Kaiser will settle a case...which seems to make everything better. But I've seen colleagues get screwed if the settlement exceeds the amount reportable to the medical board (and that amount is very low, like 30 thousand dollars). Then, you're suddenly dealing with the medical board for your license because Kaiser decided to settle. Suddenly you realize that (like all organizations) Kaiser is about protecting Kaiser. So, they may settle a case that you'd actually prefer fight...but practically, you don't really have a choice. Many physicians have to employ their own attorneys despite having 'Kaiser attorneys' to be sure that it is their own interests (and not those of Kaiser) are at the forefront. So, you're not as protected against litigation as one might think.

How's the money?
I probably make about 30% less than colleagues on the outside. And I work more. Full time for Kaiser is 40 hours a week. That's an obscene amount of hours for ER work, rotating shifts and all. Not to mention the hours you stay past your shift tying loose ends and such. If I worked even half the number of shifts at another place, I'd easily make the same money.

But don't the benefits make up for what lost in income?
I don't think so....unless you retire in your early 60s and live well into your late 80s. Maybe, at some point in your life...it'll balance. But, staying at a place for 20-30 years of your life (all of your adult life), with the hope of a golden retirement....is actually costing you lots of money. Especially if you consider all that's lost in doing so. Additionally, some of the docs actually have insurance policies to protect their pensions. Ask them why and they'll say they've seen docs screwed out of their pension in one way or another.

You seem to pooh-pooh on the pension, which is seemingly the greatest aspect?
Among Kaiser docs, the pension is known as the golden handcuffs. The doctors feel an obligation to stay their entire career or lose most of their pension.

Put it this way...Kaiser pays you, let's say 30% less than you'd make elsewhere. But that 30% "lost" is actually going toward your pension, benefits (sick leave, disability, vacation, etc). Good stuff.

But, let's say you work somewhere not Kaiser. You take that 30% and create your own 'rainy day' account (for your 'sick leave', FMLA, maternity leave, vacations, etc.). You have disability insurance on your own. And health benefits are usually offered by the EM groups and partnerships...you just have to buy-in (so you do have to pay for that too). You invest a portion of your earning into a diverse financial portfolio including domestic and international property, stocks/bonds/mutual funds/etc. That total competes with (and very possibly exceeds) Kaiser's salary.

You can't actually believe that Kaiser's 'giving' you something. Why would they pay you more than market? You can't believe that the benefits are *costing* Kaiser money. That wouldn't be good business. It's like deducting my allowance for food costs, then advertising that I get to eat "for free." If they deduct your salary to pay for the benefits...they are not 'gifts.' Sometimes I hear people refer to Kaiser's "great benefits" as 'gifts' of some sort. Gifts they are not.

So...to make things easy, and not nit pick, let's say the total package is comparable*.

But there are other factors to consider...like your tax liability (i.e. how much the government is going to take from you), and how much (and how hard) you have to work to get the money.

So, what about these other factors?
Well, as an employee, you cannot write off...much of anything. You pay lots of taxes, and you can only write off a few things. As a partner, or IC, you can write off much more. In the end, since you end up spending quite a bit of money doing business, your tax liability may be lessened.

At Kaiser, you have to work 40 hours a week for 10/10 time (full time with the comparable* salary), as mentioned. On the outside, you work maybe 32 hours week. So, even if we agree that the pay is comparable*, you're working a bunch of extra time for that same pay. By the same token, if you actually worked 40 hr/wk on the outside, you'd make a considerable amount more, even after accounting for the benefit package.

But, you don't see major trauma at Kaiser...so it seems like the work is easier.
Perhaps in some ways. With the protocols, easy dispositions, and lessened risk of lawsuits...there may be less stress. However, non-kaiser patients can still sue you. As mentioned, there are the settlements that may adversely affect you. But overall, I guess the stress is less.

Keep in mind, major trauma isn't seen (regularly) at many community EDs, so that's not very unique. The Kaiser ED is very busy, and rarely quiet. Since I'm always moving, and frequently have no opportunity to eat, urinate, or check my email...I'm not sure I'd classify it as a 'tea party.' We do not sleep on a night shift. And the patients can be very demanding...which is draining in a different way. Overall, eventhough you see less patients, they are not necessarily not-as-sick, and you actually spin your wheels much of your shift, making you inefficient, giving the illusion that you're surfing the net the entire shift only seeing 1.75 patients per hour. The reality is you're running...most of the shift. Doing scut work, and non-physician tasks. Besides, I'd rather bust my ass, see more patients, do more doctor stuff when I'm at work...while making more money, working less shifts, allowing me to enjoy more time off.

What's the most difficult part of working in the ED for Kaiser?
At Kaiser, there are lots of 'rules.' Guidelines, protocols, and constant hoops to jump thru in order to keep step with the latest regulatory entities. It's very overwhelming. Many of us feel that the Corporation is much more concerned about the paperwork, and how things look in retrospect (to surveyors, auditors, lawyers, etc), than really making the environment better for patient care. As a Corporation, they attempt to adhere to regulations to the point of skittishness. No real physician advocacy in my experience, therefore no real patient advocacy. But, on paper, to outsiders, things look good.

The computer systems!! They are very cumbersome, and inefficient. They slow you down (and I'm a relatively computer literate person, I type fast, and love electronic charting). The ED doesn't flow well. Things aren't set up to maximize the physician. Much of our time is spent putting pieces of paper in the chart. For instance, we are to print our H&Ps. Sounds simple enough. But what that actually means is, apart from actually doing it....load paper into the printer....attempt to print....trouble shoot the computer....troubleshoot the printer....attempt to print (again)....walk over to printer....if all pages didn't print (or are not clear) you may have to reprint....sign the paper....find the chart (and this can take upwards of 10 minutes)....put the paper with the chart. And this is only the H&P. Repeat for the medication requisition, the aftercare instructions, the prescription...per patient!! This process can easily take 20-30 minutes per patient. Just printing paper!! And, it's still required (by joint commissions I guess) that the original paper H&P (the one we used to write on before the computers) still must contain information. So you have to write times, a brief history/diagnosis, and sign it. After all this, the computer crap still isn't enough. This can be fixed...but there isn't enough interest as of yet. And, when patients are waiting for the physicians for an hour or five...our satisfaction scores (thus our profit sharing) diminish. You are punished for systemic failure.

Speaking of satisfaction scores...
Not unique to Kaiser, but still a pain in the ass. It's very deflating to be 'graded' by patients who are given this *one* opportunity to express their frustrations with the *entire* ED experience...and the results are linked to the physician. So, if they cannot find parking, or the security guard wouldn't let them into the back....or if the nurse was rude, the coffee cold, the room too hot...whatever...they will use this 'survey' as a mechanism to express their frustration (which they should). The problem occurs when the physician is either rewarded, or reprimanded, based on these survey scores. Much of which they played no part.

Finally, the politics are superincumbent. I've been told that per diem docs work for Kaiser years and years, and never 'get picked' for full participation. Like in other political work environments, it's expected that one kiss major ass, and the right ass, to gain recognition. Meaning, being 'available' to work the undesirable shifts, fill-in at the last minute, and basically play the intern role all over again. Silent and content while getting screwed. Even partners are not immune to the effects of top-heavy, unilateral decision-making by non-clinical administration. Being made to come in early for 'time-outs' pre-op, but not get compensated for working 'overtime.' Staying late after a shift to care for a critical patient, sometimes for hours...uncompensated. Being made to travel to far away places in order to get the hours you need for full-time. Being made to work longer shifts (11 - 12 hours) to save money for the organization...on a whim, or at the recommendation of outside consultants. Lack of control and ability to self determine...

Are there good things about working for Kaiser that hasn't been mentioned?
The nurses do their jobs well, for the most part. Since Kaiser agreed to many of CNAs terms, including major pay raises and the agreement to not make their managers, 'managers' (i.e. exempt from the union), the nursing jobs are pretty well paying. However, despite the money, the nurses don't seem any more pleasant or happy to be there. Actually, it seems like since they make good money...they actually aren't catered to. They aren't made to feel special. I guess if the job is a 'good job' there's always someone in line to replace you. So, as a unit, the nurses are strong. But talking with an individual nurse, they seem....frustrated and unappreciated. These feelings aren't well concealed.

Other good things: Since most of the patients have insurance (i.e. Kaiser) their payer mix is excellent. (So you'd expect that the physicians should actually be paid much, much more than they are). Again there are very few dispo problems, follow-up problems, liability isn't constantly on your mind, and most of the staff are excellent. It's a "good job" for the ancillary personnel...so you have good people. Consultants are available. You may have to transfer people for various things, but most facilities will take a Kaiser patient (because they will get paid). This makes transfers, when they are necessary, much smoother.

As mentioned, follow-up is great. I can usually successfully get a patient into a specialty clinic the very next day...or within 2 days for sure.

Would you recommend an ER doc work for Kaiser?
It depends on what you want, where you are in your career, and your personality. Most ER docs today are very lifestyle oriented, outspoken, and expecting to be paid well. In my experience, Kaiser doesn't encourage (actually they discourage) being outspoken. If you want to be at Kaiser a long time you mustn't criticize 'administration' too vehemently. Actually, you mustn't criticize at all. It is what it is, period. You cannot influence the style, attitude, or practice with good suggestions and constructive criticism. You will piss them off...and they may conspire against you. 40 hours of rotating shift work is not conducive to a good lifestyle, actually, it inhibits your ability to balance medicine with personal time. And, the money, as discussed, is not quite equal to the outside when all things are considered (like your time).

But, if you're a quiet, go-with-the-flow-no-matter-how-asinine-things-are, kind of person. One who likes protocols, and is seeking the illusion of 'security' (while the pension is not guaranteed, and they can kick you out, just with more difficulty, as a partner so don't be fooled)...perhaps Kaiser is for you. There's still quite a bit of running around...so by no means is it a sleepy ED. If you don't mind being at the hospital or sleeping 80-90% of the time that the rest of your family is off. If you feel more comfortable with the possibility of having a pension waiting for you (like all the workers at Enron, Delta, etc), and are willing to allow the Corporation to invest/control your retirement/investment capital on your behalf (for good or bad). If you have health issues...and can work 10 years and become vested into their lifetime health benefit program (albeit the Kaiser Health program...which may or may not be good for your particular illness). You may be a good match for Kaiser as an ER doctor.

Sounds like it's not a great match for you, what would you say is the single biggest problem with Kaiser for you?
Lack of self-determination with respect to career, working environment, and ability to make money make Kaiser suboptimal for me long-term.

The ability to work elsewhere, have your own business, or the freedom to be more in control of your destiny in non-existent. There are no branch-points. You will always make (close to) the same (inadequate) money your entire career...and once you retire, you'll get 60% of that (inadequate) salary. There is no entrepreneur opportunity...no place for creativity or control of the workplace. You'll never be financially as free as you think you should be...free to travel, invest, live comfortably. As an employee, your work doesn't extrapolate to more money or respect. As Kaiser makes record profits and builds new hospitals all around the state....the doctors are seeing way too many patients, and aren't getting a piece of the pie...even as patients choose (or are given) Kaiser for the sole purpose of having the ability to see a doctor.

Additionally, it seems to me that many decisions are made behind the closed doors of top executives (despite the declaration of democratic partnership) - and the effects of those decisions are often acutely felt by the frontline physicians and the patients they treat. This happens without their input, or consideration for their impact on the ability to render appropriate patient care. Outside consulting firms are hired, and their recommendations/opinions, supersede many (free) suggestions from their very own docs. Actually, suggestions are not appreciated, and many once enthusiastic 'Kaiserized' doctors are just 'putting in their time' and 'counting down the days to retirement.' Many I talk to feel completely and utterly stuck...have too much vested to just walk away (with their pensions, and home loan programs), but feel powerless to improve (or participate in) their work environment. As orders are handed down to them...they are silenced...underpaid...and unable to even venture out into the world and start a business or work elsewhere part-time. In many ways, it feels like a trap - just like cheese under a box...

Overall?
I find it a great transition...but have no desire to pay my $30-50K dollars, or whatever it may be (via additional payroll deduction) to become a 'partner'. I enjoy my time...and have too many ideas, hopes, dreams, aspirations...to be happy with Kaiser as it is today. There is certainly the foundation for a great HMO, and I understand the necessity of hierarchy, but the doctors have to feel as if they are truly apart of an organization that has their best interests in mind. And today's Kaiser has not accomplished this. The illusion of security is attractive in our insecure world, and to sacrifice your freedom may seem like a fair trade...at first. But, I have yet to meet an old Kaiser doc who doesn't seem bitter...and is crossing off days on a calender to retirement.

Caveats...
There are multiple Permanente Groups, and a great many facilities - of course I'm sure are happy Kaiser docs, and I'm sure there are places where things are completely different from the experience described. We welcome other points of view....and please be reminded that this is just the opinion of the ER docs I spoke with...


*comparable - maybe, maybe not. but let's just agree that it is.