Sunday, September 23, 2007

Medical Crisis??

Hey folks, just occurred to me to put this thought out for discussion..

What is the "real" crisis in American Medicine?

I think it's that no one will want to be a doctor and there won't just be a shortage of specialty "A", but an absolute shortage of doctors..Medicine has changed so much in my 30 yrs..I really couldn't honestly advise someone to go down this pathway. And it's not just us (EM) it's every specialty..I can't think of a single doc who enjoys what they are doing.

The American public has brought this upon themselves with their attitudes and jurisprudence intervention..When I was interviewing residents/medical students some years ago, I thought they were going into medicine for the "right" reasons..But now, I have since seen those same doctors in practice and they are doing their best to plan a way out of practicing medicine..They'd do anything to get out of this "profession"..

What say you??


  1. Funny you should mention that...

    After watching and listening to what my dad (an MD) has dealt with, I was skeptical about going into medicine but still very interested.

    Then my PCP (young, female MD) asked me before my freshman year of college what I was going to major in or if I knew what I wanted do after college. I gave an off the cuff "not sure, thinking about medicine, but maybe political science or pre-law -- law and lobbying are pretty interesting"

    She was already running late that day (judging by the time I spent in the waiting room) and she stopped, put my chart on the counter and had a serious chat with me urging me to think long and hard before deciding to go into medicine -- she pointed out a lot of things, some I was aware of and some I was not aware of.

    Told her I'd look into it -- wasn't too surprised by anything she said. She finished my physical and signed the paperwork for my university, wished me luck and told me to let her know if I needed anything.

    When she was halfway out the door she kind of paused and turned back into the room and said "you know, if I could do it all over again, knowing what I know now, I wouldn't go into medicine. As much as I love what I do, it's really just not worth it"

    And that, my friends, is why this girl, who always wanted to be a doctor like her daddy, is a year away from completing her JD instead of working on her MD.

    (however, I hope to eventually use the JD to somehow effect some positive change in the field of medicine -- goodness knows we need more doctors and already have a surplus of worthless lawyers)

  2. I enjoy what I do.

    Sure, sometimes I bitch and moan about administrative hassles, patients who abuse the system and so forth. And I'd like to make more money, not work as hard, and have more time off. But it's sort of like can have a full day of frustration, bad bounces, thrown clubs and lost balls, but then you hit that one shot that makes it worthwhile and keeps you coming back for more. And you can still enjoy the weather and the company even when the game is not going as well as you'd like.

  3. Shortage of doctors? No, in the future there'd be no shortage of docs. There will be a shortage of US trained docs, but not total numbers.

    Overseas trained docs will fill the void when the shortage gets acute and legislatures act to relay training and licensure requirements "temporarily". Don't you worry about any doctor shortage.

    You'll be glad to know all this has been thought out.


  4. I typed a long response, but apparently I couldn't read the jibberish on the bottom of the screen well enough so it was rejected. I'll try again:

    It's a good question and one that I've given a lot of thought. Seems to me that the American people don't know what an "Emergency" is anymore. As I have said numerous times: "Emergency isn't defined by the fact that you are here and waited to be seen". Some of the wimps we see today could have never survived 150 years ago!

    I see 3 MAIN issues that effect us in the ED.

    1. Government. From EMTALA to governmental controled insurance (Medicare and Medicaid) and my friends at JCAHO (remember the useless pain scale? Seems almost all of the patients are a 10 or 12. It's 7 that really gets my attention. This is usually the kidney stone or the AMI in the reasonable and educated patient. Or my personal favorite: the "Time Out". We have to document that the RN stopped us and asked us on which side of the body we're sewing the laceration, draining the abscess, or reducint the dislocation. My usual response is "the one with the laceration/abscess/dislocation"). Though I wish it'd just go away completely, at a minimum, we need EMTALA clarified and specified. I should be able to bill for my time, not based on the paperwork that I complete (did you know that you get paid more for 'chronic kidney disease' than you do for 'chronic renal failure'...even though it's the same thing?). Those 4 inch billing books from Medicare, Medicaid, Blue Cross, etc need to go away. I want to spend less time on paperwork and more time on patient care. We should also be allowed to deduct our charity care from our taxable income. Allowing docs to deduct charity care would make "no pay" patients a little more attractive to our consultants as well.

    (An aside, I've been reading some of the old posts on this site and I saw some idiotic post several months ago chiding us for EMTALA complaints since the law was passed in the mid 1980's and revised a couple of years later. The argument was that we knew about EMTALA when we chose EM and therefore had no right to complain about it. As anyone who has been involved in EM knows, we all knew about the law and its prevent patient dumping. The thing didn't become a monster until the last few years as lawyers have used it's vague language to turn it into something it was never intended to be), and have used it to turn the ED into "the free clinic".

    2. Lawsuits. The 'lawsuit lottery' is alive and well. I get threatened every few shifts if I refuse to order a silly xray or MRI, or give a pain shot. Makes me wonder why I invested any brain power into learning the Ottowa Ankle or Knee rules since the patient isn't happy (and I obviously don't care and am incompetant) if I don't order an xray. Recently, I have noted the bottom-feeding trial lawyers sending patients to the ED with requests for MRI scans since some body part has hurt since an accident weeks or months ago. The higher the medical cost, the higher the payout for pain and suffering of which the lawyer is taking 30 to 40%. The "lawyer screen question" is part of my history in these cases. Tort reform in Texas has been a HUGE success at reducing our insurance rates, bringing more docs to the state, and dropping the number of frivilous cases. The patient still gets reimbursed for any ACTUAL damages from true malpractice, but the pain and suffering is capped making the cases less attractive to the lawyers. Also, before the reform was passed in 2003, there were only 2 companies that would insure EPs (one of them would only insure 'non-sued' docs). Now there are at least 12 companies in the market and our rates have dropped 20% as a result of the competition.

    3. Patient expectations. Patients watch too much TV. Everything on TV happens right away. The DNA test takes 20 seconds, the MRI of the head takes one commercial break. Dr. House can sort out complex medical cases in less than an hour, and don't even get me started on that ridiculous ER show. Since you can order a book, CD, or DVD from Amazon today and get it tomorrow, and you can get a complete meal at any fast food restaurant in 10 minutes, people expect medicine to work that way and it doesn't. I don't know a solution for this one. I DO know that Universal Health Care isn't the answer! Your outpatient MRI might take a few days, but it won't take a few MONTHS!

    Also, I believe a Tazer for any PCP or his nurse or secretary that says "go to the ER" because thir office is too "busy" or because it's 4pm should be manditory!

  5. The AAMC has mandated that US MD schools increas their enrollment 30% over then next few years. Because only ~40% of all applicants are successful, schools are in a seller's market. Doc production *will* increase. There are just too many people want to be a doc to hear detractors.

    Items I'm concerned about as a med student:

    The number of residency spots has not grown to match the 30% enrollment increase. How will this effect residency placement?

    There is talk about cutting GME funding (because training residents =/= patient care).

  6. First, to the future JD: I have about 10 friends from college who are practicing lawyers - 9 are severely depressed and miserable; the other one is suicidal. Law is a soul-sucking, parasitic, vile profession. Hope you enjoy it.

    Next: there will not be an MD shortage - just a QUALITY MD shortage. It doesn't take Adam Smith to figure this one out: worse pay, poor treatment, administrative bullshit, astronomical school debt = less top-notch people attracted to the career.

    The irony is that I actually love my job (pathology) - but I'm also a fake doctor (like derm, rads, optho, gas ...) - zero patient contact does wonders for one's psyche.

  7. etotheipi

    you should be forced to take care of at least one live patient per month, both to keep your skills up and to see why direct patient contact (in this day and age, not the old doctor patient relationship) make you depressed. you would love your job even more.


  8. I've been in medicine for 409 days now. I've spent $122,000 and what do I have to show for it? 20 more gray hairs, a bunch of cool looking books, and no social life.

    What do I have to look forward to?

    -Sitting in the library for the next year studying Robbins
    -Shelling out about a grand for an exam.
    -Paying for 2 years of abuse from everyone in the hospital from the janitors on up.
    -Shelling out about 3 grand for 2 exams.
    -Shelling out about 10 grand for interview flights/hotels/food/ERAS.
    -3 years of sustaining a hospital 2-3 nights a week while getting paid less than the janitors, at a location that will be determined by a computer program. More abuse from everyone but the janitors who now just feel bad for me.

    Then it'll all be smooth sailing with my six-figures of loan repayment, six-figures of insurance coverage, and whatever legislative "fix" the next administration comes up with to lower the cost of health care (cutting my salary, I'm sure).

    I could have had a nice, quiet, debt-free life as a chemist in big pharma or a brew master...but noooooo, someone had to put the bright idea to go into medicine into my head.

    Bottom line is that someone has to do it, might as well be some brilliantly mediocre sucker like me instead of the best and brightest of my generation.

  9. agree there might not be a ''numbers of doctors'' crisis. but there certainly will be a quality crisis. it's already happening. i think there will be pockets of physical paucity of qualified physicians, especially in smaller towns, and this will be most critical with the sub-specialties. ETOTHEIPI reasons it well.

  10. As long as we're calculating number of days in medicine, I'm just starting my 3rd year out of residency. I'm double paying my loans, renting a cheap apartment, don't have cable, investing every miserable cent I can squeeze out of my paycheck (which is more than many of my friends bring home in the first place, so no complaints there). I started my own company, unrealted ot medicine that will bring in about 10% of my c urrent income if it's successful and I am paper trading stock options to the tune of a 100% profit in only 3 months. Time too start the real trading so I can quit my doctor job.

    I plan to still practice medicine, but on a volunteer basis...overseas, homeless, etc.

  11. You docs aren't paid enough money, too much regulatory influence, and too many commercial insurance companies with uber paid execs. I've worked in hospital finance for 30 years, and shake my head every day at some of the things we see. (And I love you guys, and have great relationships with the docs at my hospital).

  12. Thank you all for your comments..I didn't even think about the obvious answer Allen and some otheres so intelligently answered..FMG's will be the answer!

  13. Great thoughts...for a big problem. No question. We will have a quality shortage. Prior to the appearence of medical blogs only those in medicine knew how difficult a career in medicine was. Now potential docs need only look online and they are exposed to the "truth." While I enjoy what I do---about 75% of the time---I would never let my children follow in my footsteps. Sad.

  14. I've given a LOT of thought about how seriously FUCKED American health care is.

    I work as a paramedic in a major metropolitan city. Lots of calls, lots of patients, lots of bizarre things and situations. When I say a lot of calls, we're doing 300-400 calls per day.

    I think back on the number of truly critical calls. By that I mean calls which absolutely necessitated emergent treatment or transport. In the last 500 calls I've run, I'd put that number at about 20-30. I'm even going to be generious in this number and count all the obviously dead asystolic patients that were dead when I got there and dead when I stopped working the code 20 minutes later. They weren't emergent as they were a triage of type black -- dead and unsalvagable.

    The rest span the spectrum of acuity. But the bulk of my patients are bullshit. Complete and utter bullshit.

    Before you continue, anonymous reader, please save the lecture about "it's not your emergency it's the patient's emergency." No, when summoned, it becomes an issue I have to deal with and no matter how you want to slice it, "Hungry" isn't a medical emergency and neither is, "chest pain" when you just got booked into jail on the 24 city warrants, and this chest pain mysteriously resolves without problem immediately upon your release from jail. Neither are bunions, or a spider bite from last week that seems to be healing quite fine on its own.

    You see, it is bullshit. Most of the service's bills go unpaid. The industry average in EMS is to collect 40-45% of your bills. That's including the pathetic reimbursement from medicare and medicaid.

    People don't understand what emergency medicine is for. They don't understand that I, as a paramedic, am woefully unequipped to handle anything outside of acute, life threatening conditions. I don't "clear" people so they can be taken to jail. I don't "check it out" when you have an obviously broken wrist. Oh god help me if I have to hear, "He just wants to be 'checked out' more than twice in a shift." Check it out? Looks like it hurts. Better go to the hospital and get that 'checked out.'

    Maybe it's broken. You can move your fingers? Okay. You heard that it wasn't broken if you can move your fingers? So what you can move your fingers. It's just a guess that it's broken. I don't do x-rays or have x-ray vision. I don't know how to do more in-depth ruleouts or know the differential diagnosis flow for chronic conditions. It's not in my scope of practice, I was never taught how, and I'm not permitted to offer that dirty D-word -- diagnosis.

    I know this: Are you going to crap out on me in the next 30 minutes or not? And if you are, I can handle that. If you are not, then I can do what yellow cab or the bus can do: give you a ride to the hospital.

    People use EMS and EDs like they're a fast food restaurant. That's an analogy I heard a while back. Fast food is the most inefficient, unhealthy, expensive way to get a meal. But it works to put something in your stomach.

    You cannot live on fast food. It's just too unhealthy. Emergency medicine is just like that. The quick fix. Treat em and street em. It's expensive, and not particularly suited to the expectations placed upon it.

    Theres no way we can continue to provide $800 taxi rides for people too lazy to get a ride, too cheap to take a bus or cab, and too dishonest to man up and say, "Hey, that chest pain thing was total bullshit. I just wanted out of jail. Don't waste the time transporting me."

    The patients I transport have sucked up more ED resources than I can even fathom. Nurses cringe when I walk in with a patient saying, "This is Roger. He comes to you from home. For the last three weeks, he's been having a numbness in his leg and pain in his back. Roger sought treatment at another hospital earlier this week and was discharged with a possible pinched nerve. He said he can't sleep and wants to be evaluated."

    I don't get to pick and choose. If it were up to me, I'd say, "Roger, there's not a damn thing this hospital can do for you that the last one didn't. Go to PT and do your exercises. I know they hurt. PT is the most barbaric things in the world, but that's what this hospital is going to tell you too. So quit being such a pussy about it and make an appointment on Monday with your PCP if you don't like it."

    But the reality is that I really do like my job. I get paid almost as much as a nurse, and have a lot more autonomy than most in health care ever dreamed of. Yeah, I have my protocols that I need to follow, but so does everyone. And most of those protocols are things you really should be doing anyway. It would be nice to do a little more on standing order, but I can always call and ask mother may I. I know there's a lot of stupid paramedics in the world who really should have to ask because they're inept and dangerous. So I can understand the need.

    I can't speak with any authority on what it's like to work as a physician, since I'm pretty much at the bottom of the rung in medicine to outsiders. But I'll tell you this: I would love to have the autonomy to do what I thought was necessary without being encumbered by rigid protocols. The benchmark I use to evaluate my care and my impression is the advice of the ED physician.

    So you have a lot of people looking to you for answers. Hearing, "I don't know" is just as reassuring and hearing, "Well, you did pretty much what I would have done."

    I enjoy spending a lot of time with patients. I read a study on the amount of time spent with patients. I, as a paramedic, spend more 1:1 time with a patient than the physician. I'd miss that if I worked as a physician. That makes no sense to me. I'm with a patient for maybe 30-40 minutes on a long call.

    How are people okay with that? How are physicians okay with that? People don't call an ambulance to see a paramedic. They call an ambulance with the eventual goal of seeing a physician.

  15. a little over a year ago I was talking to one of the nurses in my ER about how I wanted to go to medical school. This conversation was over heard by a bunch of docs at the desk. It was unanimous,"Are you sure?", "Its not worth it," "PA school is better!" It wasn't just ER docs, but a bunch of consulting physicians too.

    Made me stop and think a little. But here I am in an SMP (thought I wanted to be a chemist for a while and the extra math killed my GPA) studying (or procrastinating as I write this) for my MMCB exam.

  16. Quality is the issue. I'm reminded of when I was both GME& CME at a teaching hosp. We had an intern who was lazy, careless, stupid, and would not follow protocols. This intern was kicked out. The intern appealed and won the case from the RRC,because the Residency Director and Chief Resident didn't complete the right forms of documentation. This person had NO business in medicine, got through because the person met a quota requirement. When reinstated, the comment from the Director was, Well at least (this person) is going into PM&R, so (this person) can't do too much damage.
    As someone who works in healthcare and is a consumer of healthcare, this scared and still scares the shit out of me.

  17. I would have to agree with some of the posts above me; there will not be a shortage of doctors, just US doctors. I have nothing against Indians, but a good third of the doctors I see are of Indian descent.

    On another note, I would have to say that one of the main problems of medicine these days is the corruption in the drug industry.

  18. dear PofR,
    it is certainly held as gospel that the drug companies are 'corrupt' or even evil, but this has always puzzled me. It's to the point in academic medicine that the drug reps are treated worse than criminals and have been banished. also, if I accept a drug co. pen or flashlight then i am 'in their pocket'... i hope you will expand on your statement a bit because the American drug companies are the best in the world and responsible for most of the advancements in treatment and cure of a host of diseases. i believe they are reviled because they are based on the profit motive... the most efficient business model that exists. thoughts?