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      02-16-2013, 03:50 PM   #89
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I left my 'autonomous', fee for service, private practice group for Kaiser...I am a Chief at Kaiser...and while I agree with your point that the more you work (production) in fee for service equals more pay...I had partners that made more and less than me based on how much they wanted to work...and that our system at Kaiser can have the opposite effect...The reality is that with good Chiefs and leadership there is no better system. Shareholders can and do get fired...Pay and bonuses are withheld if you do not meet certain goals...and the 'model' you work in, and that I used to work in, is short-lived with Obamacare and ACOs around the corner...Work-Life balance is one of our mottos in our Permanente medical groups...For the most part 40hr work weeks...with health and malpractice insurance covered 100%, paid vacation, matched 401Ks, and a pension...plus many other benefits...We can practice patient-centered medicine and know that we have job, income, and retirement security...and leaving us plenty of time for our families, hobbies, etc...

I would be happy to discuss in more details the benefits of working at Kaiser with anyone...just PM me...
Hey, I'm not saying Kaiser is a bad system. There are definite perks. I know my buddy gets an astronomical time off (I think 3 months) and then there's that pension when you retire.

Everybody has to figure out what they want. It's just not for me. Like I said, I love the autonomy and having nobody to answer to other than the bottom line. You may be right that the private practice model will die out and probably it will die out for the solo group/private practitioner. Currently, our group is within a larger group. We are made up of many different individual practices and number 170 or so orthopods, ENT, and general surgeons. The advantage of this is that it gives you the bargaining power of a big group, but still allows your group to operate autonomously.
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      02-16-2013, 11:26 PM   #90
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I almost went to med school; went to law school instead (and became an intellectual property attorney). some days I think that I made the right decision, others I don't.

The grass is always greener, etc.

To the OP: med school is a monumental olibgation - an obligation that requires a lot of time (~10 years) and, unfortunately, an absurd amount of money (some schools are apparently now charging 70k a year in base med school tuitition?).

whether or not you should be buying a M3 should really be the last thing on your radar.
Smart move on law school. You'll never work for free like private guys do all the time when some person with no insurance gets hospitalized and you get called to see them.

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Hey, I'm not saying Kaiser is a bad system. There are definite perks. I know my buddy gets an astronomical time off (I think 3 months) and then there's that pension when you retire.

Everybody has to figure out what they want. It's just not for me. Like I said, I love the autonomy and having nobody to answer to other than the bottom line. You may be right that the private practice model will die out and probably it will die out for the solo group/private practitioner. Currently, our group is within a larger group. We are made up of many different individual practices and number 170 or so orthopods, ENT, and general surgeons. The advantage of this is that it gives you the bargaining power of a big group, but still allows your group to operate autonomously.
I'm with you dude. I tried Kaiser. Couldn't stand a dumbass nurse telling me what I could and couldn't do. Or a secretary plugging a pt into an open slot when from an hour ago. Or a consultant giving me a hard time when I ask for some help because they have no incentive to see any extra patients.
Having said that, the Pension, 401 and Common plan are badass.

How do you structure the group within a huge group nthats something I'd like to do in my area.

.
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      02-17-2013, 06:51 AM   #91
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Hey, I'm not saying Kaiser is a bad system. There are definite perks. I know my buddy gets an astronomical time off (I think 3 months) and then there's that pension when you retire.

Everybody has to figure out what they want. It's just not for me. Like I said, I love the autonomy and having nobody to answer to other than the bottom line. You may be right that the private practice model will die out and probably it will die out for the solo group/private practitioner. Currently, our group is within a larger group. We are made up of many different individual practices and number 170 or so orthopods, ENT, and general surgeons. The advantage of this is that it gives you the bargaining power of a big group, but still allows your group to operate autonomously.
I think what we should all realize is that there is no one practice model that is best. So much of it depends on the dynamics and variables of one's specialty, one's geographic region, and with the hospital or system itself.
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      02-17-2013, 08:51 AM   #92
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I'm not a fan of being a hospital employee. One of the biggest perks for me is autonomy. Not only financial, but personally. If I want to make more, I work more. If I want to take a vacation, I take it off. There's nobody telling me how hard to work or how to work. Also you know that the hospital is making money off you.

In my practice, the difference in pay from the lowest earner to the highest earner is astronomical. The guy who makes the most, takes a ton of call and goes to 3 separate locations. That's the way it should be. You should be rewarded for hard work.

A friend of mine is chief of Ortho at one of the Kaiser's in Cali. The problem there is that there are surgeons in his group who are barely working, but they all make the same. He says he can't fire them, because they are shareholders and have been there a long time. Over time it really builds up animosity between the physicians.

I paid off all my student loans in 1 1/2 years. I took call from my partners and was basically on call 5 of 7 days during the week. I was averaging 15 cases/week. I'm grateful that I was able to ramp it up to pay off those loans. I'm also grateful now that I can ramp down and live the lifestyle I see fit.
Totally agree. Most of the recent urology grads I know are working hard, taking extra call, doing extra cases, etc, etc, to pay of debt, "live it up", yada yada. They should be paid for the extra work. Then, when you get a bit older and have some financial stability, ramp it down and enjoy other things.

I'm hoping I can join a decent private practice once I get out in 3 years to do the same....we'll see what the environment is like at that time.
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      02-17-2013, 08:54 AM   #93
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I'm with you dude. I tried Kaiser. Couldn't stand a dumbass nurse telling me what I could and couldn't do. Or a secretary plugging a pt into an open slot when from an hour ago. Or a consultant giving me a hard time when I ask for some help because they have no incentive to see any extra patients.
.
This sounds identical to where I'm currently doing residency....not surprising, as it's a similar model....makes me cringe.
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      02-17-2013, 08:57 AM   #94
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My wife is currently a first year resident and specializing in anesthesiology. She still has a long way to go. Seeing what she goes through, I am glad I got a degree in Engineering. We already begun paying her student loans which is a total of 180K @ 6.8%. I plan to have that loan fully payed off after she completes her fellowship but man does it suck. I am also not able to write it off on my taxes which pisses me off the most.

I feel for all you docs. My wife got pregnant with our first baby and took a year off med school, then a month after we had the baby she was diagnosed with cancer (neuroblastoma stage 3). I transferred her to St. Jude in Memphis, TN to get the best care which was one of the best decisions I made in my life (I live in New Orleans). Then we had our 2nd baby during 4th year and she took no time off. Through all that her grades were still excellent and was chosen to be in AOA. We have had a tough road. I have the utmost respect for you guys since I know what you have to go through.

Ryan
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      02-17-2013, 09:17 AM   #95
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This sounds identical to where I'm currently doing residency....not surprising, as it's a similar model....makes me cringe.
I worked academics for a year, before I went private. The nurse administrator had more power than the docs in the clinic. Needless to say, nothing got done. Nurses and staff were untouchable, regardless of inefficiency or incompetence. If you dared to try and improve the workflow, complaints went directed directly from the staff to clinic administrators (none of whom were doctors) who would reflexively slap you down. I was unable to see more than 13 patients a day. The staff made sure of it. A few years of that and you'll stop caring and just go with the flow.

Disgusting. I worry that it's the future of medicine.
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      02-17-2013, 09:32 AM   #96
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Wow some interesting takes and answers.

For the dude looking at the (used or new) M3...
a. you don't have time to dick around- i.e. car breaks down, needs maintenance or not there to get you to work/school is not meaningful use.

b. adding debt (car loan) to more debt (school loan) with added interest is a poor financial situation. There will be many people who will want to cut your paycheck and I don't believe starting before med school is the way to go.

c. when you become an attending years later, work hard for yourself or private company and buy what you like before you get married. not all women would agree with a coupe that bucks like a donkey at low speeds and costs 75K.

d. dont base your living on the salaries posted. you will be miserable, you will hate your patients who depend on you and most of all you will burn out. as with anything else in life, pick something you enjoy doing whether it be sticking your 5 inch needle (LOL nice one), repetitive highly skilled procedures or subspecialty areas of sub set skills.

where is medicine going? not sure. wherever it goes, literally and metaphorically, I know I will have a job for what I do to support my family. I may need to work more or harder, move to another country, but I would be happy for what I am doing.
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      02-17-2013, 10:12 AM   #97
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Current student here (MS3). I purchased my M3 at the beginning of medical school. However, I also worked for a while prior to starting, where I saved up enough cash for this car and maintenance/ancillary expenses.

I would say that the decision to buy an M3 depends on your financial situation as well as your priorities. I also advise against driving your M3 to or from class, work, etc. It will stand out like a sore thumb, particularly in the Northeast.

My decision to buy an M3 was not financially prudent, but it was the right decision for me. Medical school can be a dehumanizing experience, so having a hobby or an escape to which you can turn to is crucial to getting through it. Whenever I need a break, I can always take the M3 for a spin; and when I have a day off, I'll often take it to a track. My fascination with cars is a big part of who I am, so I'm very grateful to have owned this car for the past three years. I plan to either keep this car in residency or upgrade to something else.

The only suggestion I would make is to not mention or flaunt the car while in school. It will stick out like a sore thumb. The nicest car in the student parking garage will probably be something like a GTI or a 328.
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      02-17-2013, 10:27 AM   #98
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      02-17-2013, 10:49 AM   #99
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I cannot speak to other 'employed' models...but regarding the Permanente model for all the naysayers who 'know' someone in the model or spent a short amount of time in it...No nurse has ever told me or another physician how things are going to be done. They work for the Health plan, not the Permanente medical group. The Permanente medical group for each Kaiser region is separate from the Health plan...The medical group is solely run by physician leaders...and just like 'shareholder' physicians, if the nurses or health plan employees are not up to snuff, they can and do get fired. Is it more difficult to get rid of someone than in a smaller private practice...sure...but it is done all the time.

I have practiced in the USAF, private practice (fee for service), and now Kaiser...every model has its positives and negatives...for me, this has been the best model (most fulfilling professionally) I have worked in...by far...

As I mentioned in a previous post...I am a Chief and due to a large expansion for us where I practice I have had the opportunity to hire many (12) anesthesiologists in the past year...I have had many more CVs than candidates and the docs I have hired are all stellar candidates...most leaving private practice. For residents, across all specialties, we are getting the best candidates from the best programs applying for our positions. You can be in denial about the changes on the horizon...but there will be a price to pay if you bury your head in the sand...my 2 cents anyways...
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      02-17-2013, 09:51 PM   #100
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I am another MD and although I definetly have had the same thoughts of "Maybe I wouldn't recommend this gig to kids," at the end of the day I would ask all of you other docs what else you would recommend?

The people saying you can make more in business etc is just absolute b.s for 99 percent of most people. The road, ass kissing (probably pound for pound more than we all did in med school and residency, plus it never ends) and other crap to get to anywhere near a position where you are making a non-comission based salary of 200 plus k on a steady basis is really few and far between. It is an endless road of climbing the corporate ladder, doing meaningless work for most if not all of a life and at the end of the day have absolutely NO job stability as well as a HUGE factor nobody is touching on is ability to live ANYWHERE in the damn country.

I agree the Obama system and insurance system is just utter chaos and a sad state. The devaluing of doctors and replacement with mid-level NP's and PA's is just pathetic and the worst part is 99 percent of the public do not know any different. Many actually measure "good care" as how friendly someone is and how much time they spend and therefore PA's and NP's are actually becoming preferable to some. (although as the mid-levels are taking on doctor-like case loads this quality is disapearing and voila, they no longer are friendly and taking time when stuck with loads of patients the horrible doctors were!)

I am blessed, although I came out with a crapload of debt, I operate in a cash pay speciality with no insurance involvement and its lucrative and more protected than most fields but even if it were not and I was working for a 200k a year hospital based employed position, I would still be hard-pressed to truly do anything else that is really going to give you that same income, same flexibility of location and same security of job.

Yes the hospital CEO's are making more than the docs but they are not the norm for a business person. Most bankers, business people and all the financiers are either working in a profession that has no stability, live and die by stock sales and an enormous amount of pressure.

Plus at the end of the day, being an MD is still regarded as the most noble profession and as much as we all hate what we do, helping someone, saving someone and coming to someone in their time of need with a skill only you have is simply priceless and atleast for me is why primarly I went into this field.

So yes, please tell me any other close legitimate alternative to match a 200k/ year job starting at about age 30 with the perks I mentioned. Even lawyers are hard-pressed to find jobs out of school and if they do they are making nothing these days starting and taking a long, hard road to being a partner and breaking the 150k mark with again less flexibility or stability.
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      02-17-2013, 10:38 PM   #101
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So yes, please tell me any other close legitimate alternative to match a 200k/ year job starting at about age 30 with the perks I mentioned. Even lawyers are hard-pressed to find jobs out of school and if they do they are making nothing these days starting and taking a long, hard road to being a partner and breaking the 150k mark with again less flexibility or stability.
1st year lawyers start 160k, albeit only at the "big" firms (and those jobs are becoming increasingly more difficult to get). The road to partnership at these firms is typically ~7-9 years - during the latter phase of this period, senior associate will be close to 300k if not over. If they make partner, the salary increases significantly after that. Some of the "heavy hitters" at the mega firms will make professional athlete type money.

The problem, of course, is that no one is making partner anymore and layoffs are becoming the norm. Big law goes as corporate American goes.

My dad is both a practicing physican and a professor of medicine, and yet he did everything within his power to talk me out of the profession. I really enjoy the practice of law (the critical thinking, the writing, etc.), but career stability is a huge concern for me. Tomorrow, some law firm administrator could wake up in a city far, far away and decide that my salary is no longer justifiable and poof, just like that, my career is over. My dad, however, has his patients - and no one can ever take them away from him. His patient base is also a great bargaining chip when it comes to dealing with the hospital managers. I think that the stability aspect of medicine is something that he tends to take for granted as he has had it for the duration of his career. Where he has never felt the fear of potentially losing his job, why would he recognize this element? I think that this tends to be overlooked by most MDs, especially during these uncertain times.
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      02-17-2013, 11:15 PM   #102
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For my kids I tell them to do what they want. Try to find something which will satisfy them. I believe it's different for different people. You want to be a ski bum? Hey, it's your life, so do what you want. You want to be a surgeon? Great, I'll even pay for that. Lawyer? Please re-think your decision

For sure, I wouldn't recommend medicine for it's financial benefit. I believe you give up way too much for just the financial benefits. Four years of medical school and six years of training takes a huge chunk of your life. Those 10 years were not fun. Sure there were times when it was very gratifying. However there was also an ungodly amount of work, extreme stress, and a lot of times, dehumanizing.

After college, I worked for a couple years for a very prestigious firm in systems and management consulting. There is no way you can compare that stress to the ones you face in medicine. Nothing to take away from people in business, but it's just the fact.

As for 200K/year starting, that may be the norm for surgical fields, but you choose primary care and you are not going to make anywhere near that. My wife as an OB/Gyn worked like a dog and barely made 120K. After 6 years, she tried to work part time for the kids, (which was still 30 hrs/week) and made 60K (her malpractice insurance was 125K/year). After taxes, that's what we paid our nanny. Family practitioners, Internists, OB-Gyn, and pediatricians are all struggling. Imagine, coming out with 200K in loans and making 100K/year. It's not a pretty picture.

I do still like what I do. As I said, using a skill to help someone that not many can do and has taken thousands of hours to hone is very gratifying. However, you do have to be prepared for the financial and personal sacrifices, which are unique in medicine.

My wife on the other hand, would definitely not do medicine again and in fact has quit. Having to deal with the huge cost of malpractice and having to practice defensive medicine kind of took the wind out of her sail.
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      02-17-2013, 11:34 PM   #103
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1st year lawyers start 160k, albeit only at the "big" firms (and those jobs are becoming increasingly more difficult to get). The road to partnership at these firms is typically ~7-9 years - during the latter phase of this period, senior associate will be close to 300k if not over. If they make partner, the salary increases significantly after that. Some of the "heavy hitters" at the mega firms will make professional athlete type money.

The problem, of course, is that no one is making partner anymore and layoffs are becoming the norm. Big law goes as corporate American goes.

My dad is both a practicing physican and a professor of medicine, and yet he did everything within his power to talk me out of the profession. I really enjoy the practice of law (the critical thinking, the writing, etc.), but career stability is a huge concern for me. Tomorrow, some law firm administrator could wake up in a city far, far away and decide that my salary is no longer justifiable and poof, just like that, my career is over. My dad, however, has his patients - and no one can ever take them away from him. His patient base is also a great bargaining chip when it comes to dealing with the hospital managers. I think that the stability aspect of medicine is something that he tends to take for granted as he has had it for the duration of his career. Where he has never felt the fear of potentially losing his job, why would he recognize this element? I think that this tends to be overlooked by most MDs, especially during these uncertain times.
Whatever, I know 9/10 law grads are not going out making 160k. Its like saying yes doctors are making 600k a year because you look only at the highest earning orthopedic surgeons.

Far and away law has way less job availability, stability, flexibility or salary stability without working up the food chain. So sure if you can assure you go to a top law school and get a job at a top partnership than yes you make 150k plus, however bottom of the barrel medicine jobs make 150k right out of residency.

My point is yes for the work we put in and time, the money is not a heck of a lot but given the other factors and benefts its tough to argue any job where there is an ensured path of making 200k and having job stability and flexibility of location. Plus being an MD is noble to most and respected. Being a lawyer (no offense to anyone here) is quite frankly looked upon by 99 percent people as being a bottom feeder person. Not really desirable to me but that is another topic!
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      02-18-2013, 12:11 AM   #104
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Whatever, I know 9/10 law grads are not going out making 160k. Its like saying yes doctors are making 600k a year because you look only at the highest earning orthopedic surgeons.

Far and away law has way less job availability, stability, flexibility or salary stability without working up the food chain. So sure if you can assure you go to a top law school and get a job at a top partnership than yes you make 150k plus, however bottom of the barrel medicine jobs make 150k right out of residency.

My point is yes for the work we put in and time, the money is not a heck of a lot but given the other factors and benefts its tough to argue any job where there is an ensured path of making 200k and having job stability and flexibility of location. Plus being an MD is noble to most and respected. Being a lawyer (no offense to anyone here) is quite frankly looked upon by 99 percent people as being a bottom feeder person. Not really desirable to me but that is another topic!
if you re-read my post, you'll see that we are essentially in agreement
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      02-18-2013, 01:34 AM   #105
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dont base your living on the salaries posted. you will be miserable, you will hate your patients who depend on you and most of all you will burn out. as with anything else in life, pick something you enjoy doing whether it be sticking your 5 inch needle (LOL nice one), repetitive highly skilled procedures or subspecialty areas of sub set skills.

where is medicine going? not sure. wherever it goes, literally and metaphorically, I know I will have a job for what I do to support my family. I may need to work more or harder, move to another country, but I would be happy for what I am doing.
After reading through this I am convinced this is a medicine forum that happens to also have BMW's.

I was going to add the above. I hate medicine (clinic) but I love surgery and I'd operate until midnight if they'd let me but all the lazy scrubs and nurses want to go home after 12 hours.

Going back to the OP, I drove an Acura Integra through med school and residency. It broke a few times and I learned how to start it and drive to work with no clutch when I didn't have the money or time to get it fixed. Whatever car you get, make sure it is very reliable. 10+ year old M3 doesn't fit that bill very well. It's not just the money, it's the time, and you're not going to have any.

Now I need to stop procrastinating and get back to finishing last Friday's charts before I start clinic tomorrow.
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      02-18-2013, 08:02 AM   #106
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that's the magical thing about studying @ McGill. Barely 7 grand a year tuition and a top 20 medical school!

the debt you create in US schools is really unreal to me
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      02-18-2013, 08:31 AM   #107
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After reading through this I am convinced this is a medicine forum that happens to also have BMW's.

I was going to add the above. I hate medicine (clinic) but I love surgery and I'd operate until midnight if they'd let me but all the lazy scrubs and nurses want to go home after 12 hours.

Going back to the OP, I drove an Acura Integra through med school and residency. It broke a few times and I learned how to start it and drive to work with no clutch when I didn't have the money or time to get it fixed. Whatever car you get, make sure it is very reliable. 10+ year old M3 doesn't fit that bill very well. It's not just the money, it's the time, and you're not going to have any.

Now I need to stop procrastinating and get back to finishing last Friday's charts before I start clinic tomorrow.

+1
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      02-18-2013, 11:22 AM   #108
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Just to add my $0.02

Practicing surgeon here. I work for a large IPA in So Cal and fortunately for us we have whole department trying to make of whats going on with rapidly changing healthcare delivery system. At this point, I am convinced that fee for service business model of healthcare is on it's way out. As ACAs come into place in every states, lion share of current fee for service patients will be forced into some form of managed care further and further shrinking the pool of available patients for fee for service providers. I do think that KP is one of very few models that will be sustainable in the future, so listen to what Sandman99 is telling you; he speaks the truth. KP spots are going to become more and more competitive in the future.

Any MD on here who disagrees with me in this should spend some time on Sermo.com. You will be convinced then.
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      02-18-2013, 11:43 AM   #109
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Originally Posted by rjdoc74 View Post
Just to add my $0.02

Practicing surgeon here. I work for a large IPA in So Cal and fortunately for us we have whole department trying to make of whats going on with rapidly changing healthcare delivery system. At this point, I am convinced that fee for service business model of healthcare is on it's way out. As ACAs come into place in every states, lion share of current fee for service patients will be forced into some form of managed care further and further shrinking the pool of available patients for fee for service providers. I do think that KP is one of very few models that will be sustainable in the future, so listen to what Sandman99 is telling you; he speaks the truth. KP spots are going to become more and more competitive in the future.

Any MD on here who disagrees with me in this should spend some time on Sermo.com. You will be convinced then.
Just because the employed physician model is the future doesn't mean we have to like it. I recognize the reality that the world of independent physicians is on the wane, but I will not celebrate it.

Personally, I think it's a damn shame. My .02.
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      02-18-2013, 11:47 AM   #110
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Plus at the end of the day, being an MD is still regarded as the most noble profession and as much as we all hate what we do, helping someone, saving someone and coming to someone in their time of need with a skill only you have is simply priceless and atleast for me is why primarly I went into this field.
That is an excellent point, and one I have to constantly remind myself when I start getting "down" about how much I hate residency....
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