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Monday, April 26, 2010

The Doctor is Out.

Where is the door?

I miss Mike


Thai said...

Oh, don't be so dramatic. Doctors are going no where.

I think you and I may have a (healthy) disagreement on this issue (and please remember, I think the idea of spending more on health care is silly).

For imo if ever there was a group that misses the big picture in this discussion, it is the health care providers (that is not a comment about you, rather our colleagues).

As Okie likes quote Upton Sinclair: "It is difficult to get a man to understand something when his job depends on not understanding it".

Also, was it intentional to juxtapose a article on the results of a poll with another that criticizes polling as a prediction science?

Physician salaries are going to be what they are going to be, polls aside.

Articles like this sometimes remind me of a dialysis patient I saw a few years ago who was complaining on and on about how no one cares about her because her disability check was too small. She was in her late 40's, she was approx 285 pounds and around 5' tall and renal failure/dialysis was a relatively new experience in her life from med non-compliance.

Sometimes the level cognitive dissonance in people is... shall we say... odd to say the least.

And of course, I was getting paid by medicare to see her so don't misunderstand my point which is rather again along the lines that no man is an island and we are all connected whether we like it or not.

Edwardo said...

Here's another perspective on this issue.

Thai said...

Amen Edwardo, amen

I'm not sure one way or the other about physician retirement.

If it happens in mass droves, I don't think it will be Obamacare that is responsible.

But please remember, Dr. Rich is spot on that this is the only way payers (in this case government but the same applies to insurance companies) will ever get control of costs.

And so it will get back to one of those public school-private school debates again.

The more things change, the more they stay the same.

JP said...

From the article:

"It’s also stupid because it didn’t ask key questions, such as: Do you know how much education and training it takes to become a physician?"

Uh, that has nothing to do with anything. The amount of "education and training" that doctors get doesn't have anthing to do with how much they "should" get paid.

That's like saying, "look at how long it took me to get my double Ph.D. in linguistics and theoretical physics! I deserve to get paid $1,000,000 per year!"

First year BigLaw attorneys get $165,000 per year for 3 years of education.

No one in the general public spends much time complaining about them.

JP said...

That's base salary. Then you get the bonus.

Thai said...

I 100% agree JP

Thai said...

My bigger frustration is what a waste that talented people need to do some of the stuff they do in the first place. Lack of social cooperation, or social friction as it were, is an unbelievable waste of perfectly good resources

Dr John said...

I will say I have no problem with Drs making 50k if that is what the market dictates. I would prefer that the market dictate this by producing lots more docs as apposed to central planning that is slowly evolving. Why not in law or supermarkets for that matter? What is so damn special about being a Dr? I do not find most Drs primary complaint is about the money they are making. It certainly is not mine.

My articles were chosen for exactly the reason you mentioned Thai. I do not take much stock in polls. I am glad they stir debate.

I think many Drs will leave medicine earlier than they otherwise would but it is quite possible they will be replaced by many more. This will certainly require more state support of medical education. It is getting too expensive to make it a good investment. I would not want any of my kids to choose my line of work. It is why I am going back to college in the summer.

Dr John said...

Also I certainly do not buy into the silly statement that Drs should make a certain amount of money because they went to school. Such a statement is as ridiculous as "they should make around 80k". How arbitrary. Value should be built into the system based on demand. Any attempt to build moral equivalency into it is doomed.

This is what is going on with the current healtcare debate as "right". Is it more so than food or shelter? If not why are we not doing this with farmers and home builders. It would appear from what I read of Dr Rich he also believes we are heading to a future were it will be impossible for Drs to deliver healthcare outside of a relationship whose terms are dictated by govt.

I run a small specialty clinic caring for pts. I accept only cash or credit card. In exchange pts have my personal cell phone number with access to me 24hrs a day 7 days a week. No exceptions. I expect this kind of arrangement to be illegal before I reach retirement age. It already is if I opt to take medicaid or medicare pts which I do not or any with private insurance for that matter.

I always laugh when I hear people claim teachers are underpaid and athletes too much. Most of the teachers I know love Labron James. Me I would never think of spending 2 cents to see any organized sporting event ever.I loathe spectating.Lebron however should get every dime he can manage as long as it lasts and be damn glad he was born into a 21st century western world that values ball handling skills in ectomorphs. Athletes will continue to be able to play by rules of the game which are changing, much for the worse in my opinion for Drs.

Thai said...

Re: "This will certainly require more state support of medical education."

Indeed, I sometimes think you can use the regulators as a marker of perfect inverse timing. So whenever all these new grads start completing their residencies (about 7-10 years from now) is when the health care bubble will pop.

Here the problem is we provide too much medical care in this country and now "they" want to produce even more physicians. And who are they borrowing that money from?

... Of course if people were not thinking of health care spending as someone else's money, they would not be paying for a lot of the nonsense we see or the might be focusing on better value per year of life extened like preventative medicine (even if preventative medicine increases costs overall if there is no rationing of care at the end, etc...)

Okie, should physicians be beholden to the decisions of the collective when they care for you?

Or should they be, like attornies, their individual patient's advocate regardless of the consequences to the system? E.g. like attornies try to get murderers released, etc... if the murderer is their client?

Or should they be some hybrid of both?

And would you trust someone who told you they were a hybrid of both if they were your physician?

JP said...

Thai says:

"Okie, should physicians be beholden to the decisions of the collective when they care for you?"

They already are beholded to the decisions of "the collective."

There isn't really any way around that, unless you want to get rid of licensing and let anyone practice medicine wherever and however they please.

Thai said...


Thai said...

JP, I haven't really thought if the same with attorneys.

Would you say it is just as true?

JP said...

Dr John says:

"I would not want any of my kids to choose my line of work. It is why I am going back to college in the summer."

Out of curiousity why did you chose it in the first place?

"What is so damn special about being a Dr?"

Nothing, except the medical profession decided, en masse, years ago, to accept lots of money from the government in the form of Medicare/Medicaid.

Plus, public health is implicated, too.

And the public generally apparently thinks it should be "free." That's the most important problem. No one is used to paying for medical care out of pocket. The government pays for it, their employer pays for it, or they get it for free by not paying for it.

People pay for groceries (absent food stamps) and attorneys out of their own pocket. No pay, no service.

JP said...

Thai says:

"Would you say it is just as true?"

Which part are you talking about?

The fact that law and medicine are both regulated guild-type "learned professions" and bound by "the collective"?

If, so, then, yes, it's just as true.

Thai said...

I thought so

Re: compromising for $

To be fair to the medical profession, it did try to fight Medicare but the money became so corrupting we ended up with the medical-state blending we have today just like the church-state blending of yesteryear.

Plus other physicians used the power of government to protect their union monopolies with licensing and we ended up with our current mess.

... In fact, were you aware physicians were once required to have a license to use a stethoscope? (Or so I'm told though I have never verified this)

Mid-level providers (MLPs- e.g. nurse practitioners and physician assistants) are very much changing this equation right now (I'm a big fan of MLPs when used in the right circumstances- they can be a disaster when used in the wrong ones) against physicians.

In fact, I'm not sure if you are following this whole alleged shortage of primary care physicians (which is a real issue from one perspective)?

It is the ultimate non-issue.

The truth is the numbers only look like we have a shortage of primary care physicians if you do the classic divide and conquer approach of keeping MLPs out of the equation. But when you include them in the data, we clearly have a national glut of primary care labor so all these attempts at pushing even more doctors into primary care (and using taxpayer dollars to subsidize it) are making this real glut even worse- and all these people are looking for work and so will "make work" with more unnecessary testing, visits, etc...

For if you were unaware, there have been many studies now that have shown zero difference in long term outcomes in primary care settings when comparing mid level providers with physicians.

But since someone else is paying, people say they want a physician to be their primary care provider and not an MLP when one is so much cheaper than the other- crazy.

So now we see people pouring even more good money after bad to train even more people we do not need.

... Although I will say the trend to drop the number of years required to train a family physician (FP) is a very positive and long overdue trend.

Dr John said...

"Out of curiousity why did you chose it in the first place?"
Confusion. What the fuck does a kid with good grades in college know? I thought I would get chicks as a Dr.Instead I got married as a first year med student. Thank God as I have the best woman in the world for 24 years and she has given me 4 great kids.

"Nothing, except the medical profession decided, en masse, years ago, to accept lots of money from the government in the form of Medicare/Medicaid."
The medical profession did not really "decide" to do this. LBJ and congress did. Many Drs protested but not nearly loud enough and they should have refused in mass. This is where my brother the dentist was much smarter than me.

Thai I agree way too much medical care is delivered in this county. Until people must pay out of there own pocket and I do not mean through taxes, this will not change. If my Dr tells me it will be 2k to run a scope up my ass and I must pay 1k I am sure as hell asking why. If I am paying nothing I am not asking nearly as many questions.

I agree with you completely JP that the problem is the public has been given free health care. They will pay 1k for a new flat screen and not blink but scream bloody murder when it comes to their own health. I am afraid it is hard to get the cheesewiz back in the can after it is out.

I am hopeless on this front. Good posts though! Thanks

Dr John said...

Thai, thanks for the links. My APRN friends will love me for this paper. I find the bloviating by psychiatrists on Carlat hard to take at times on this issue. This would help shut them up.

Thai said...

There are much better articles out there if you really need them. I simply pulled that one as the first to come up in my Google search.

The guys at Dartmouth are out to pop every illusion in health care except of course the biggest one of all, namely: "we have met the enemy and he is us", but that is another issue entirely as it would me that both liberals AND conservatives are simultaneously correct/wrong.

Anyway, Dartmouth published long term MLP vs. MD data and the MLPs did just as well.

Thai said...

PS- I noticed that the Governor of Oregon vetoed the bill allowing psychologist prescription privileges.

While I'm not a big fan of the idea of more people being mediated, I do think it a shame the Governor did this.

And we completely agree on the insurance issue. As Edwardo and I once discussed, I'm unsure why people get so upset at the improper use of credit default swaps but are completely non-pulsed by the improper use of human default swaps.

Somehow there is this bizarre national notion that death is a manageable (read avoidable) inconvenience we can risk manage away through better regulation.


JP said...
This comment has been removed by the author.
Thai said...

John, don't confuse me as saying there is never a difference as this is clearly not the case.

I use the model of complexity. As complexity increases, the level of sophistication required by a health provider increases as well so I'm not a fan of mid-levels for situations where there is a lot of complexity and things change frequently.

Complexity with little variation they can be "OK" for, but this is complicated and always a local issue imo.

Simplicity is fine for MLPs however- e.g. ankle sprains, blood pressure checks, etc...

The problem physicians have in a "keep it relevant" argument is the low complexity/low cost care is also where medicine provides its best ROI or bang for the buck.

I.e. MLPs literally threaten physicians where they provide the most value from a societal point of view.

Although I should add that you need to be careful and say this with a caveat as MLPs may earn 1/2 what physicians earn but they often make worse utilization decisions when compared with their physician peers when you look at their test ordering, etc... and this poor utilization can eliminate much/all of the cost savings they otherwise bring to the table.

... Indeed in some cases they are actually more expensive compared with physicians as they are often less productive than physicians on a patient per hour basis (e.g. many MLPs see significantly fewer patients of similar complexity per hour compared with many of their physician peers) and when you combine this lower productivity with worse utilization decisions, they can literally break the bank so to speak if this is not recognized.

All this is a long way of saying this is a much more complex issue than many policy wonks give lip service to.

Thai said...

Bipolar is a more socially acceptable diagnosis. Patients tend to get much less angry when their providers hand them this label than they do when it is a label like schizophrenia or depression.

And you have to remember, physicians compete on patient satisfaction, not price.

Thai said...

Re: practice makes perfect


But the curve looks something like this, i.e. big jump in the beginning and then the marginal improvement diminishes.

And this is only one factor and it also has a lot to do with what procedure you are talking about.
An individual patient's surgical risk can be a MUCH larger factor.

Thai said...

Can ask John but there is the whole association with artistic creativity and genius that comes along with mania

Dr John said...

Yes JP I am returning to school. I have two goals. One is to just teach high school. I am going to get a degree in teaching and philosophy and try to teach kids to think like philosophers. My goal is to escape psychiatry like a deranged mental pt in a B grade movie. My other goal is to do a primary care refresher and spend at least some time in South America delivering basic care to the poor.

I am glad you read my article JP. I hope you liked it. I guess you can learn about psychiatry in the same way you can learn about astrology. There is room for much epistemological debate in both.

Please do not get me started on Bipolar Disorder

The belief that artistic creativity is tied to "mental illness" has not born out when people have attempted to study this. The problem is no one really knows what they are studying. The terms have become so watered down as to be meaningless. Mania to me is bat shit crazy running down the street naked fleeing from aliens. I tell the story of the masters level teacher I once treated who was insanely manic. He was convinced he was bringing Disneyland to Youngstown Ohio and during this Ed McMahon was going to present him with the million dollar prize during super bowel half time. Mind you all this was going to happen while he was on a locked psych unit. When he came down he was just depressed and not particularly creative. When he was manic he created a piece of bad contemporary art for me I still possess. In 20 years I have not seen one creative crazy person. They are just crazy.

Dr John said...

And Thai I get you. There are clearly things that need a Dr. I do not want someone who knows how to fly a single engine plane taking a crack at a 747. Most primary care is not cardiac surgery. Psychiatry in general could be performed by chimpanzees with minimal training. :)

Thai said...


I guess I meant association in the mind of the patient receiving our diagnosis. I did not know if the association has ever been scientifically prospectively validated.

Or do you find there is another reason patients tend to end up with the diagnosis of bipolar illness? I have simply found they find the label more socially acceptable.

Dr John said...

I think it has to do with the same reason I saw a healthy young man on TV last night telling me I may have a problem with the "Big T". All I need is to talk to my doctor and I will live a fuller life. Play better golf, be happier and a crazy sex machine. You know this low T is a real disorder right? All I could think of was I love low T. I don't chase people who give me the finger. I drive the speed limit. I almost never raise my voice and have little desire to have sex with any woman but my wife. Low T rules!!

Life in general has become one big medical problem. Psychiatry as a field in my mind is the undisputed king of selling disease as being mainstream.BAD, ADHD, Social Anxiety.(I have not seen a pt with Social Anxiety Disorder since Paxil went generic.)
See my latest malady here. We cloak it in some BS about it in reducing stigma for the pt. That is a pant load. This is ALL about what is good for the DR and generating business. If I had more space in my article I would have expanded on this issue. People get the DX "Bipolar" because everyone wins. The pt gets to be relieved of any responsibility. The Dr gets to pretend he is providing needed medical care while making a nice living and at some point if we are really lucky and the pt has learned how to be a terrific mental pt the lawyer gets to make some money on the disability claim.

There was a time when being mentally ill was a source of shame and no one would want to be "Bipolar". I long for such times.

Thai said...

Your talking about receiving psychiatric care in general or the prevalence of the diagnosis of bipolar over all other diagnoses in psychiatry.

Why is bipolar the dx du jour?

Dr John said...

I am talking about psychiatric care in general. I turn on (insert derogatory word) Oprah and I see an even bigger(derogatory word) Dr Oz telling all the woman in the audience that "depression is just a medical problem like any other" and they sit there nodding their heads like mindless automatons. The rates of psychiatric disorders have exploded. There is absolutely no reasonable explanation for this other than market expansion and the broadening of flimsy diagnostic criteria. Much of this is going on in primary care. Taking the lead from psychiatric "experts" primary care docs are telling almost everyone with any complaint they have a major mental illness. I tell all my pts I could walk into any psychiatric office in the country and fake my way through any psych dx. People want this. That is why they get on the internet. Who does not want to be told that all their drugging and wife beating is do to unchecked Bipolar Disorder or ADD or some other tired overused psychiatric construct.I do not blame people. Doctors should know better.

As for why BAD. Why not.It's criteria have become so broad it is hard NOT to be BAD. The primary reason however is purely related to meds and marketing.All the money being spent in the past decade has been to treat depression and newly dx "community BAD". There are very few really insane people with psychosis. You cannot expand this market too much. Who does not have irritability and mood swings?

There are a lot of strong contenders for runner up. ADHD, Autism, Social Anxiety was HUGE for a while. Look at the hx of psychiatry Thai. It is all fad. I strongly recomend you read this book It is a blistering spot on critique not only Freud as fraud but how psychiatry has jumped from one loony fringe to another.

My God you were around for the entire ritualized satanic, sexual abuse/multiple personality ride a decade ago right? You could not swing a dead cat without hitting a sexual abuse victim who was just on the verge of remembering it all with a little more help from their therapist. Ugh...I think I'm gonna be sick.

Thai said...


OMFG yes!

I noticed the "I almost remember my abuser" trends quite well!

In fact I even remember thinking a few years ago "how odd it is that we are seeing so much of this" but simply shrugged my shoulders at the time.

I still see some but not like I did a few years ago.

Thai said...

I'll look for the book

Thai said...

But psych is not my thing. I see a ton, I want to help people with it (honest), I find the mind a fascinating thing and I think there is a vast "make work" jobs program in the psych world that we could eliminate with very little reduction in actual patient outcomes but in the end psych is not my passion.

Also I do love medicine. For all its problems (and there are many) I do love medicine and still think there is a lot of good we do in health care (along with a lot of nonsense).

To me it is both

Dr John said...

Almost all of psych could be eliminated and the vast majority of today's pts would be better off. For sure.

I agree we can do a lot of good as Drs. I try to do what I can. We can do a lot of bad too. I wish Drs were more attune to this Thai. They should spend a bit more time on this concept in training.

JP said...

Dr. John says:

"I am glad you read my article JP. I hope you liked it. I guess you can learn about psychiatry in the same way you can learn about astrology. There is room for much epistemological debate in both. "

Yes, I did like your article. I printed it out and showed it to a few people in my office.

We have to deal with psychiatric/phychological issues here on an ongoing and continuous basis. It has been my sense that there was something fundamentally wrong with the direction psychiatry was headed, in the sense that it seemed off the tracks, so to speak.

I found it odd that patients themselves were included in the setting forth of the diagnostic criteria.

Thai said...

It is a great article John

Dr John said...

Thank you both. It means a lot to me. John

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