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Goodbye Marcus Welby, Hello Hospital Employee MD

Close your eyes and think of a doctor.  Do you see a Marcus Welby type? A middle aged, smiling and friendly gentleman who makes house calls?   Is his cozy office staffed by a long time nurse and receptionist who knows you well and handles everything for you?  If that is what you envision, either you haven’t been to the doctor lately or you are in a concierge practice where you pay a large upfront fee for this type of practice.  Whether you live in a big city or a rural community, small practices are dissolving as fast as Alka Selzer.  Hospitals and health systems are recruiting the physicians, buying their assets (unfortunately not worth much) and running the offices.

Doctors are leaving small practices and going into the protection of larger groups and corporations because of economic changes that have made it harder and harder for small practices  to survive.  The need for Read more »

*This blog post was originally published at EverythingHealth*

The Myth Of The Rich Doctor

This is my column in June’s EM News.

‘But you’re a rich doctor, right?’ Have you had that conversation? There’s a certain expectation of physicians, that we’re all just filthy rich, overflowing with boxes of cash tucked neatly away beneath our gilded beds.

When we were building our house, our builder talked with my wife: ‘Jan, I want you to meet me to look for counters and cabinets. Don’t bathe the kids. Put them in dirty play clothes and don’t wear anything nice. Don’t ever tell them your husband is a doctor.’ He’s a wise man. What he knew was that the word ‘doctor’ means ‘cash.’ Or at least, means ‘cash’ to the popular mind.

I wonder if this perception is the reason patients come to the emergency department and say things like this: ‘I don’t have any money to go to the dentist, so I came here.’ It’s the belief that we come to our jobs already in possession of large amounts of money. Granted, there are some physicians who come from wealthy families. The majority, however, do not. And no one does that to any other professional. ‘I’d like a house built to order, and I know you’re a rich contractor. I can’t pay you, so get to work! Or else I’ll sue!’

Nevertheless, from patients to insurers, real-estate agents to contractors, attorneys to government and hospital officials, the belief is straightforward. MD means ‘Mucho Denaro.’ Witness the hospital in Pennsylvania that recently began Read more »

*This blog post was originally published at*

Salaried Physicians Don’t Necessarily Provide Less Expensive Care

The Happy Hospitalist, generally an excellent blogger, wrote yesterday about how salaried docs must be delivering better care than those greedy FFS docs, because the Cleveland Clinic does a terrific job with docs on a salary.  I suspect their excellent outcomes have nothing to do with reimbursement model and a lot more to do with systems and a strong gatekeeper model.

He totally missed the elephant in the room in the Big Group Clinic model: who gets the money for doing the work.

He cites as an example a GI doc who left the Clinic for independent practice and quadrupled his income.  Let’s say he’s working as hard as he did in the Clinic; is he billing more than the Clinic did?  I doubt the Clinic wasn’t billing the usual amount for the work, so 3/4 of this docs’ billing went where?

I suspect it went into the overhead of the Clinic.  This isn’t a knock on them, it works for their group, so fine.  Other groups do essentially the same thing.  It’s legal and morally defensible, and some docs don’t mind being salaried.

Salaried docs in a big Multispecialty Clinic have different incomes, but not as radically disparate as the non-clinic model.  As a way to somewhat equalize RVRBS issues it works (I wouldn’t want to be in the room when salaries come up, though).

What salaries do not do is get docs to work harder, see more patients.  Some docs are very dedicated, motivated people who would work for rent and grocery money.  Others on a salary would do the minimum: if every patient is more work and more liability without more pay, well, why work more/harder?  As an incentive to produce nothing beats getting paid for it.

(This isn’t an endorsement of excessive or un-necessary procedures; there are greedy jerks in all professions).

Also, a happy side effect of getting paid for what you do rather than for having a pulse is those who work hard resent those that don’t (but who would make the same on salary) a whole lot less.  Way less inter-group stress.

Salaries aren’t all bad, but they’re not the Key to Great Healthcare.

Discolsure: I’ve worked ED’s both ways, and much prefer fee for service.

*This blog post was originally published at GruntDoc*

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Latest Book Reviews

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

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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…

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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…

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