Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It’s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction, “burn out” and even suicide. In fact, some believe that up to a third of the US physician work force is planning to leave the profession in the next 3 years – an alarming statistic.

Direct primary care practices are touted as the best way to restore patient and provider satisfaction. Those brave enough to cut out the “middle man” (i.e. health insurers, both public and private) find a remarkable reduction in billing paperwork, unrecovered fees, and electronic documentation requirements. I know many physicians who have made the switch and are extremely happy to be able to spend most of their time in direct patient care, unfettered by most rules, regulations, and coding systems. They can solve problems via phone, email, text, video chat, or in-office as the need arises without having to worry about whether or not their manner of interaction will be reimbursed.

Direct primary care is probably the best way to find freedom and happiness in practicing outpatient medicine. But where does that leave physicians who are tied to hospital care due to the nature of their specialty (surgeons, intensivists, anesthesiologists, etc.)? Is there any way for them to find a brighter way forward?

I have found that working as a locum tenens hospital-based physician has dramatically improved my work satisfaction, and it may do so for you too. Here’s why:

1. You can take as much time off as you want, anytime you want. Do not underestimate the power of frequent vacations on your mental health. The frenetic pace of the hospital is much more tolerable in short doses. My attitude, stamina, and ability to stay focused is dramatically improved by working only 2-3 week stretches at a time. When I feel good, I can spread the cheerfulness, and I am happy to spend longer hours at work to give my patients more of my time.

2. You can avoid most political drama. Hospitals are incredibly stressful environments filled with hierarchical and territorial land mines. Being a short-timer allows you to avoid many conflicts. Administrators never nag you, or hold you responsible for perceived departmental deficiencies. You don’t need to attend committee meetings or become involved in personality quirk arbitrage. You can stay above the fray, focusing purely on the patients.

3. You learn all kinds of new things. Exposure to different patient populations, hospital expertise and different peer groups exposes you to a broader swath of technology and humanity. No longer will you be tied to the regional practice idiosyncrasies of a single hospital – you’ll learn how to tackle problems from many different angles. That knowledge earns you respect, and serves to cross-pollinate your own specialty, making you – and those you learn from – better doctors.

4. You are free to leave. There’s something refreshing about knowing that you can leave a place that you don’t like without any repercussions. No matter how unpleasant a locums assignment, it will end, and you can saunter off to brighter pastures.

5. You make more money. Believe it or not, locums work can be quite lucrative if you find the right assignments. I know a team of hospitalists who travel the country together, negotiating higher rates since they are a “one stop” solution. Their housing, travel, and cars are paid for by the agency, and they have take home pay (before taxes) around $350K per year. I personally think that working that many hours as a locum tenens physician kind of defeats the purpose of avoiding burn out, but some people like to do it that way.

6. You can live in the warm states in the winter, and the cold ones in the summer. Enough said.

7. You can try before you buy. Maybe you’re not sure where you want to sink down career roots. Or maybe you’re not sure you’ll like living in a certain city or part of the world? Maybe your family isn’t sure they want to move to a new location? Locum tenens assignments are the perfect way to try before you buy.

8. You can use your experience to become an excellent consultant. With long term exposure to various hospital systems, you are in a unique position to develop an encyclopedic knowledge of best practices. Sharing how other hospitals have solved their challenges can spark reform at other institutions. You can become a real force for positive change, not just on a micro level, but system and state-wide.

Working as a locum tenens physician may enhance your career satisfaction and promote professional advancement. What it will not solve, however, is the following:

1. You still have to work within the framework of bureaucracy endemic to hospitals. You’ll need to learn to use multiple different EMR systems and fill out most of the same paperwork that you do as a full-timer. This is painful at first, but once you’ve mastered the most common EMR systems (I’ve only really encountered 5 different ones in 2 years of locum tenens work) you’ll find a clinical rhythm that fits into most frameworks.

2. You will be living out of a suitcase. If the disruption of frequent travel is too much for you (or your family) to bear, then perhaps the locums lifestyle is not for you.

3. You will be annoyed by the process of getting multiple medical licenses and hospital credentialing. Agencies try to help with this burden, but mostly, you’ll need to suffer through this part yourself.

4. You will have to live with some degree of uncertainty. Part of the nature of working as a locum tenens physician is that clients (hospitals) change their minds frequently. They try to fill open positions with local staff or hire additional full-timers, using locums as their more expensive back ups. Assignments fall through frequently, so you’ll need to be ready to change course quickly.

Overall, I believe that locum tenens work can provide the practice freedom that many hospital-based physicians crave. If you’re eager to get off the unrelenting clinical treadmill, this is an easy way to do it. At a recent assignment near New Hampshire, I mused at the license plates that I passed on my way to work: “Live free or die” is their state motto. And I think it captures my sentiments exactly.

“Healthcare Diplomacy” And A Night At The White House

It’s not often you get invited to the White House. I had my chance this week, when I was a guest at the White House’s Hanukkah party. Now, when I say “guest,” I mean I was a guest of the president — of Hadassah, that is.

My mother, Nancy Falchuk, is the president of one of the largest Jewish charitable organizations in the world, Hadassah. Her organization sponsors many different charitable activities, particularly related to healthcare (here she is in Jerusalem speaking at the ceremony lighting the walls of the Old City pink in honor of the Susan G. Komen Foundation.)

One of the terms she uses a lot is “healthcare diplomacy” — the idea that part of the solution to intractable problems of war and peace is building bridges through something that we all share – the need for healthcare. Her organization does incredible work to realize this mission. She has been a regular guest at this annual event at the White House. Read more »

*This blog post was originally published at See First Blog*

America Has A Heart

As an American, I was proud when I heard the news. I grinned to myself. It was on my way to work, through a beautiful city park, with the sun rising over the hillside. The morning radio program reported the news that a California judge overturned their state’s ban on gay marriage.

I know what you’re thinking: A medical blog is running amuck right into a political hornet’s nest. But isn’t it true that a nation’s kindness is a defining characteristic?

America and Americans do much that is good and right. Examples of such goodness are too numerous to list. If you are a victim of a calamity, you can be sure that America will help. Ask Haiti. And it’s not just foreign countries, we help each other. There’s a flood and then there are volunteers. A power outage and there are cords across the streets. It’s not controversial to say we are a kind nation. Read more »

*This blog post was originally published at Dr John M*

Counter Point: Healthcare Reform Won’t Impact Your Freedom

Congress is going into recess without completing its work on health insurance reform, and the advocacy groups are eager to use this time to whip up voter sentiment for or against reform.  Unfortunately, the anti-reform pundits are all-too-ready to dip right back into the 1993 playbook that gave us Harry & Louise, playing on the fears of consumers with distortions and outright lies.

Ramona alerted me to one such piece published in the CNN/Money-Fortune segment, a “Special Report,” scarily titled:

5 freedoms you’d lose in health care reform

Nice lede, eh?  Can you guess without reading the article where this author is coming from?

The subsequent bits range from “accurate-but-deliberately distorted” to “complete BS that I made up but is really scary.”

Let’s start with the latter, as it’s more fun:

5. Freedom to choose your doctors

The Senate bill requires that Americans buying through the exchanges [...] must get their care through something called “medical home.” Medical home is similar to an HMO. You’re assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.

Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. [...]

The bills do not specifically rule out fee-for-service plans as options to be offered through the exchanges.

So, just to recap: You won’t be able to choose your doctors because your primary care doctor (that you chose) might, under certain reimbursement schemes that aren’t actually mandated in the bill, have a hypothetical incentive to limit access to specialists.

Um, what?

Never mind the fact that TODAY, right now, your access to a specialist is limited by some drone at your insurance company who doesn’t have a medical degree and does have a very powerful direct financial incentive to deny authorization for referrals.  Never mind the fact that there is nothing in the bill which states you will be “assigned” to a primary care doctor.  Never mind that fact that the “Medical Home” is not in any way related to an HMO, conceptually or practically. This “gatekeeper” function isn’t in the bill at all!  The medical home concept is designed not to ration care (which is the unspoken subtext of the above passage) but to coordinate and improve the quality of care.  Never mind that, if a referral is granted by the wicked & parsimonious gatekeeper, your choice of a doctor is still not restricted under the bill.

Never mind all those inconvenient little facts that each individually or all together totally invalidate the thrust of the author’s argument.  The problem for the whole concept is that there will be many plans offered for purchase on the exchange. If you don’t like the one you picked because it is too restrictive, you can switch to another plan! If WellPoint requires too much hassle to get to see a specialist, then you can dump them and pick Cigna!  Granted, the ones which are more restrictive are also probably going to be cheaper, but that’s for the consumer to choose!

And yes, before you bother to say it, yes, this might result in adverse selection of sicker patients into the more lenient plans, but they will be risk-adjusted to correct for imbalances in their patient populations.

So that’s the easy point to debunk, and I would think that finishing up with the BIG LIE like that, there would be little need to review the rest of the hit-piece, but I’ll make the effort, my love of truth and good policy being as strong as it is.  Other “freedoms” you would lose, according to the esteemed and honorable author:

1. Freedom to choose what’s in your plan
3. Freedom to choose high-deductible coverage

I put these together, because it’s a bit of a cheat on the author’s part to list them separately.  I mean, it’s the same thing, innit?  This is basically an assault on the concept of the mandate that all Americans be insured: you can’t just buy crappy insurance that doesn’t really cover anything meaningful and say that you’re covered.  I respect those libertarians I have clashed with when they say that they should be free to “go naked” if they so choose, and have no or minimal insurance if that is their choice.  I disagree, but I respect their honesty.  This piece is a little less direct, but it’s basically the same thing — defending the right of people to choose crappy insurance that wouldn’t actually cover their health care needs should they fall ill.

There are two problems with that sort of policy approach.  First, a fig leaf just ain’t clothing.  You can glue one on and walk around town without getting arrested, but everybody who sees you knows you’re naked.  Insurance that has the “We never pay” clause just isn’t actually insurance.   It doesn’t accomplish the actual goal of getting every American access to quality health care.

The other problem, a bit more subtle, is that letting people opt out of health insurance, either explicitly or de facto by buying cheap fig-leaf insurance, defeats the purpose of the individual mandate: risk pooling.   It’s a certainty that some of us are going to get sick.  It’s also certain that those of us who do become sick will not be able to pay our individual costs, as health care is now so expensive that no individual can hope to pay their actual bills.  By requiring all of us to have insurance, you create a situation where those huge costs are spread out among the largest possible number of people.  Allowing opt-outs ensures that everybody who can, will, and these will be the healthier people who don’t see a need for insurance, at least not today.  The result is a concentration of costs among the sick people who generate the most costs, which, as noted, exceed the ability of these individuals to pay.  Of course, as people who were healthy become ill, according to nature’s inexorable dictates, they will transition from the low-cost insurance products they previously favored to the ruinously expensive plans that actually cover for people who are sick.  And the system literally falls apart.  No funding exists for the sick to pay for their (hugely expensive) health care, and the healthy contribute little (until they become sick).

2. Freedom to be rewarded for healthy living, or pay your real costs

This is pretty tightly related to the above point, with a slight distinction.  Again, as pointed out, nobody who is sick can pay their real costs.   So again, there’s the risk-pooling issue.  But there’s another, more pernicious assumption here: that health is a controllable feature of lifestyle.

Bullshit.  I’m healthy, and I like to assume that’s because I’m virtuous and athletic and take care of myself.  Right?  Except that it’s strictly a matter of luck that it was not my kid that got sick and died of neuroblastoma.  Or medulloblastoma.  It was a matter of luck that my wife pointed out a funny-looking freckle that turned out to be a very thin melanoma (and lucky for her that she married someone who could tell the difference).   Cancer is easy to cite, but the list goes on and on of health conditions that have nothing to do with lifestyle: crohn’s disease, MS, bipolar, Type 1 diabetes, glomerulosclerosis, etc, etc, etc.   And none of us know in advance when our — or our family’s — number is up.

So we are all in this together.  We all pay a premium: and bet or a hedge against illness.  Those of us who win the genetic lottery and stay healthy lose the “bet” and wind up paying for a service we didn’t need.   If you let some people hitch a free ride and pay a minimal premium, they are not paying their fair share to cover the cost of those who have already become ill.  When President Obama talks about “Shared Responsibility,” this is what he means.

There’s a lot more chicanery in this article — I’ve neglected Point #4 entirely, as I covered that the other day.  No plan will remain the same in perpetuity.  I’ll stick to the main policy points and leave, for the moment, the sly little insinuations and falsehoods scattered throughout the article like so many candy sprinkles on an ice cream cone.

Strangely enough, I’ve finally found a point of serious, substantive agreement with (former) Alaska governor Palin.  She and I are united in wishing that the gosh-darned liberal media would just stop making stuff up.

*This blog post was originally published at Movin' Meat*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »