Thirty years ago, most newly minted doctors, fresh out of their long dark marathon of medical school/internship/residency/fellowship hung out a shingle, hired a secretary, rented office space and opened practice as a shop owner, often with partners, often without. Close to 90% of physicians did that. Today, in the 21st century, new doctors want a W-2 form, a job, a salary and 90% work for a corporation, a large group and they are no longer independent shop owners: They are employees.
Physicians, like me, voted with their feet, away from the entrepreneurial mode of medical practice as the burdens of running a business beat them down.
"Just let me practice medicine," we said."Put me on salary. You take care of the money."
Surgeons, who have always been different from physicians, have not been as eager to make that leap and while they often have contracts with corporations, they still run their own shops, and often many other shops--as partners in surgical centers, owners of buildings in which medical practices are located, but physicians, your internist, pediatrician, specialists in neurology, rheumatology, endocrinology, pulmonary have opted out of the business end--leave that to the folks with the MBA's.
Radiologists, pathologists, anesthesiologists for the past 50 years typically were not shop owners--they worked for big groups that had contracts with hospitals, or they were employed by hospitals or by universities.
So there are many different cases, but the big numbers, most doctors and surely most of the doctors the average citizen sees have gone down a very different road. For many of them, they have found the "be careful what you wish for," thing kicking in.
Today, I spoke with an assistant Chief Medical Officer of a hospital system looking to hire me to take care of the hospitalized patients who are current running an average blood sugar of 300 during their stays in hospital.
"Well, who are these patients?" I asked.
"Oh, you know old guys with pneumonia, post operative patients, broken arms in diabetics on insulin."
"So, how long are these patients actually staying in the hospital with their blood sugars of 300?"
"Average stay is 3 days."
"So," I asked, "What difference does it make to the patient to have a blood sugar of 300 for 3 days? You know I could make a lot of non diabetics get up that high by just admitting them to a hospital, or more surely, to an ICU. But 3 days later, they are home, past their crisis, eating normally, up and about again, taking their usual doses of insulin rather than the brew the hospitalists gave them and they are running sugars in the low 100's again."
"But our hospital's metrics are worse than comparable hospitals."
"So what? The patients have suffered no harm."
"Oh, of course, I know that! Everybody knows THAT. But we are paid by insurance companies based on quality assessment ratings of the hospitals and that's one of the big metrics."
Profit driven medicine, in a nutshell. Doesn't make the patient any better. Doesn't do anyone any good, but we have our metrics and we must meet them. And this hospital practices "patient centered medicine" it advertises.
As if.
One of my younger colleagues asked me about a patient I had just seen for diabetes and found him to be in atrial fibrillation, phoned his cardiologist, and shipped him over the hospital.
"How did you know he was in AF?"
"I listened to his heart."
"Why would you do that? He was in for diabetes."
"Well, I have them take off their shirts in case there's a melanoma lurking about. And I listen to everyone's heart, in case they are in AF, which is common. Had to borrow an EKG machine from oncology. We don't have one? Did you know that? No EKG machine in our clinic!"
"Yeah. Why would you want an EKG machine?"
"Well, sometimes listening is not enough to be sure they are in AF. Sending him across the street to the ER based on just listening? That's a lot of time and worry for the patient, if you're wrong."
"But then you have to interpret the EKG."
"Well, we all did internships. I think I can recognize AF when I see it. I bet you can too."
"Yet, but then you're responsible."
And so it went.
This particular doctor is a wonderful endocrinologist. He taught me how to see thyroid glands with sonograms and he is a master at fine needle aspirations of thyroid nodules. Most endocrinologist produce unusable specimens from FNA's of thyroid nodules about 12% of the time. His rate was 1%.
So he is very good.
But he quickly calculated that if he sees a new patient for a thyroid nodule (consultation $540) does a sonogram of the thyroid ($85) and uses that sonogram to biopsy the nodule ($350) that patient visit is $975 in billing. All that takes 60 minutes. If he sees two returning patients at 30 minutes each, he can bill $115, or total $330.
So he makes sure his secretary makes the new patient/thyroid nodule a priority.
When I arrived at this clinic there were no gowns for patients to wear when they took off their shirts. Nobody every examined their hearts.
The nurses were perturbed when I insisted all diabetic patients take off their shoes and socks so I could examine their feet. The patients complained about the cold floors. They had to get towels for the bare feet. Patients asked why they could not take off just one shoe.
"Well, fine," I told the nurses. "Just tell them to take off the shoe on the one foot they want to save."
Older doctors are retiring fast.
Electronic medical records, being told what to do by thirty something managers reading spread sheets about "productivity." Elimination of anything which does not add to profit, insistence on efforts which are medically worthless but which enhance profits are just too much to bear.
If they are lucky, these old docs have salted away enough to retire.
But, you know, it's not them we ought to worry about.
Physicians, like me, voted with their feet, away from the entrepreneurial mode of medical practice as the burdens of running a business beat them down.
"Just let me practice medicine," we said."Put me on salary. You take care of the money."
Surgeons, who have always been different from physicians, have not been as eager to make that leap and while they often have contracts with corporations, they still run their own shops, and often many other shops--as partners in surgical centers, owners of buildings in which medical practices are located, but physicians, your internist, pediatrician, specialists in neurology, rheumatology, endocrinology, pulmonary have opted out of the business end--leave that to the folks with the MBA's.
Radiologists, pathologists, anesthesiologists for the past 50 years typically were not shop owners--they worked for big groups that had contracts with hospitals, or they were employed by hospitals or by universities.
So there are many different cases, but the big numbers, most doctors and surely most of the doctors the average citizen sees have gone down a very different road. For many of them, they have found the "be careful what you wish for," thing kicking in.
Today, I spoke with an assistant Chief Medical Officer of a hospital system looking to hire me to take care of the hospitalized patients who are current running an average blood sugar of 300 during their stays in hospital.
"Well, who are these patients?" I asked.
"Oh, you know old guys with pneumonia, post operative patients, broken arms in diabetics on insulin."
"So, how long are these patients actually staying in the hospital with their blood sugars of 300?"
"Average stay is 3 days."
"So," I asked, "What difference does it make to the patient to have a blood sugar of 300 for 3 days? You know I could make a lot of non diabetics get up that high by just admitting them to a hospital, or more surely, to an ICU. But 3 days later, they are home, past their crisis, eating normally, up and about again, taking their usual doses of insulin rather than the brew the hospitalists gave them and they are running sugars in the low 100's again."
"But our hospital's metrics are worse than comparable hospitals."
"So what? The patients have suffered no harm."
"Oh, of course, I know that! Everybody knows THAT. But we are paid by insurance companies based on quality assessment ratings of the hospitals and that's one of the big metrics."
Profit driven medicine, in a nutshell. Doesn't make the patient any better. Doesn't do anyone any good, but we have our metrics and we must meet them. And this hospital practices "patient centered medicine" it advertises.
As if.
One of my younger colleagues asked me about a patient I had just seen for diabetes and found him to be in atrial fibrillation, phoned his cardiologist, and shipped him over the hospital.
"How did you know he was in AF?"
"I listened to his heart."
"Why would you do that? He was in for diabetes."
"Well, I have them take off their shirts in case there's a melanoma lurking about. And I listen to everyone's heart, in case they are in AF, which is common. Had to borrow an EKG machine from oncology. We don't have one? Did you know that? No EKG machine in our clinic!"
"Yeah. Why would you want an EKG machine?"
"Well, sometimes listening is not enough to be sure they are in AF. Sending him across the street to the ER based on just listening? That's a lot of time and worry for the patient, if you're wrong."
"But then you have to interpret the EKG."
"Well, we all did internships. I think I can recognize AF when I see it. I bet you can too."
"Yet, but then you're responsible."
And so it went.
This particular doctor is a wonderful endocrinologist. He taught me how to see thyroid glands with sonograms and he is a master at fine needle aspirations of thyroid nodules. Most endocrinologist produce unusable specimens from FNA's of thyroid nodules about 12% of the time. His rate was 1%.
So he is very good.
But he quickly calculated that if he sees a new patient for a thyroid nodule (consultation $540) does a sonogram of the thyroid ($85) and uses that sonogram to biopsy the nodule ($350) that patient visit is $975 in billing. All that takes 60 minutes. If he sees two returning patients at 30 minutes each, he can bill $115, or total $330.
So he makes sure his secretary makes the new patient/thyroid nodule a priority.
When I arrived at this clinic there were no gowns for patients to wear when they took off their shirts. Nobody every examined their hearts.
The nurses were perturbed when I insisted all diabetic patients take off their shoes and socks so I could examine their feet. The patients complained about the cold floors. They had to get towels for the bare feet. Patients asked why they could not take off just one shoe.
"Well, fine," I told the nurses. "Just tell them to take off the shoe on the one foot they want to save."
Older doctors are retiring fast.
Electronic medical records, being told what to do by thirty something managers reading spread sheets about "productivity." Elimination of anything which does not add to profit, insistence on efforts which are medically worthless but which enhance profits are just too much to bear.
If they are lucky, these old docs have salted away enough to retire.
But, you know, it's not them we ought to worry about.
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