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      02-18-2013, 11:48 AM   #111
M3takesNYC
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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.

I am quite well-versed in the changing times and I can't agree on the fee-for-service disapearing unless you are speaking of something different than I am thinking. A surgeon, unless plastics or maybe some uber high profile neurosurgeon or orthopod will not ever be able to do fee for service, however I only see more and more docs, atleast in affluent areas which is where fee for service makes sense, increase. As more docs pull out of the insurance game, more fee for service docs will actually arise and although there will be more of them, they will make a bit less as the increased supply will drive down prices they will be able to charge.

Unless obama mandates that docs have to take a single payer national system which is a ways off, than fee for service (ie not taking insurance) is continuing to grow. The docs doing it will need to either offer something else nobody else is doing (ie house-calls etc) or take a lower fee than they are now given more competition.

The managed patients will see more and more of the mid-level NP's and PA's with doctors seeing complex or rather playing more of a supervisory role in the primary care sector including OB, neuro, psych etc.

Ultimately things will balance with a bunch of MD's staying in the insurance game (still the majority) but playing a much different role than they do now which includes much more integration with mid-level's. The other bunch of docs will go fee for service and prices will be driven down from being only accessible by affluent as it largely is now, to being accessible by more average consumers given the competition driving prices down.

However a further division among the fee for service docs will emerge as the one's catering to the affluent still who will be providing either more services or going off of a better reputation to charge a premium "affluent consumer" price point and than the other tier will be the average PCP who will do a fee-based service but really provide nothing more than most people are getting now if they do see a doctor rather than mid-level. Essentially people will have to pay some fee out of pocket to see an actual physician, even if they provide limited other services as in the future people will have a hard time seeing a physician through the insurance system without going through a dense mid-level NP/PA level of service.

So I actually think the opposite is true and many PCP's (I am not a PCP) I know and are friends with see the exact same path.

I guess we all will adapt. For example if Obama "required" doctors to take a single payer system and not able to opt out of the system, than it would be linked with their ability to prescribe which means doctors wanting to do fee for service would simply hire a mid-level PA or NP and charge a fee as a medical consultant and not prescribe a thing but rather have a PA who does take the government insurance, prescribe under them. This is what the PCP's I know have already started brainstorming about.

So in the end doctors will find a way around the system to keep making a pretty consistent income and that is why the US is great. Even medicine can be conducive to being a really lucrative business if you have some creativity and business sense.

At the end of the day big changes are coming but doctors will be fine and still make about the same average income, same flexibility and roughly the same workload. It is the older docs who are not wanting to adapt (I don't blame them" who will just retire or get really screwed over as a level of adaptation will need to happen to really survive this world as a doctor and not be totally miserable
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      02-18-2013, 12:14 PM   #112
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That is an excellent point, and one I have to constantly remind myself when I start getting "down" about how much I hate residency....
Depending on what your doing of course, it will very likely get much MUCH better after residency. My personality was simply not one to enjoy residency as residency in this day and age is far far far less indepedant as it used to be with insurance and medicare regulations requiring attendings to be increasingly involved, malpractice scaring all docs to not wanting to be as hands-off etc. I felt I was not able to truly be there for people with my best skills until I was out on my own and as much as I love the toys, money and fun stuff that goes with making money, I actually enjoy the feeling of the families and patients thanking me for helping them so much more than anything.

I think its a bad cycle for docs that lose sight of this. The more miserable docs who just go through the motions, really are not able to help patients and families as much as the docs that really have the desire to go out of the way to help, heal etc. (save a surgeon who miserable or not can heal!) But any doc where you talk to patients or think about diagnosis as your primary function will get much less praise from patients which in turn even further demoralizes you and makes you miserable as you watching the crumbling of healthcare.

If you go above and beyond to make a patients day or families day, than you get the extra appreciation which makes you wake up and not think about the crap system nearly as much which keeps you happy and the cycle of positivity continues.

The biggest lesson you can learn IMO, which took me until leaving residency and doing my own thing to really learn, was there is WAY more to helping a patient than simply doing the objective, tangible tasks we learn in residency. Ie. Prescribing meds, ordering the right test etc. All of that is important but the intangible smiles, jokes and ability to connect and comfort a patient is responsible for atleast half of the entire healing process and one that a lot of sterile residents and then physicians never get.

I used to think if I did not have a pill or a test to objectively use and order to "heal" someone, than I felt useless. I learned as I had more time to connect with my patients being in private practice (again it depends on your field and gig whether you have more or less time out on your own), I learned the healing comes from the moment I walk into see a patient: my smile, happy to see them, remembering something important about them, encouraging them, being available to them when they call outside of regular appointments, being INTERESTED in them as a person and interested in their medical situation as a whole. All of that has gone further in healing my patients regardless of what medical condition they had.

Sure the right medication and lab test is easy but honestly you can do that in your sleep after residency and I think we as physicians are missing the boat on fending off mid-levels by neglecting to see the value we provide outside our prescription pad.

Society is learning that you can stick a PA in for half the cost to write 90 percent of the prescriptions we do. However there is a confidence people still have in an MD and we do not use that to our advantage to apply it to the things I discussed. A person who feels their "doctor" is that caring and interested in helping them is someone who pays and values an MD vs. a doctor who walks in, does nothing but stare at a computer and writes a prescription which at the end of the day is replaceable on most fronts by a mid-level.

So while most docs sit back and bitch and moan about the system not valuing doctors or paying doctors, majority of docs are doing nothing to step their game and value up with the intangible's, the basic humanistic side of medicine that is almost forgotten.

We are the masters of healing and the public still views us as that but the public perception is not going to last as we continue to offer percievably nothing different than a PA/NP does to the public patient's eye.

I learned this on my own but if I could advise any young resident in here who probably thinks I am full of total BS, to remember next patient encounter to spend more time on the intangibles, while still clinching your diagnosis and prescribing/doing procedure, I believe you will start to see a reaction from patients that you may have never or rarely seen before.

Just my .02 as a guy out of residency 1.5 years who has done more learning about being a good doctor in 1.5 years than probably through 4 years of residency. I wish I could have hoaned the skill in residency but simply had nobody who talked about any of this stuff with any real conviction outside the context of lawsuit avoidance or hospital feedback scores
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      02-18-2013, 12:26 PM   #113
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We(MD's) own the means of production-shame on us for not holding out - if we are out of network to a large enough extent patients, forced to pay us, will preasure the insurers to cover them or increase in network fee payment so they can find competent in network docs.
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      02-18-2013, 02:06 PM   #114
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Originally Posted by M3takesNYC View Post
Depending on what your doing of course, it will very likely get much MUCH better after residency. My personality was simply not one to enjoy residency as residency in this day and age is far far far less indepedant as it used to be with insurance and medicare regulations requiring attendings to be increasingly involved, malpractice scaring all docs to not wanting to be as hands-off etc. I felt I was not able to truly be there for people with my best skills until I was out on my own and as much as I love the toys, money and fun stuff that goes with making money, I actually enjoy the feeling of the families and patients thanking me for helping them so much more than anything.

I think its a bad cycle for docs that lose sight of this. The more miserable docs who just go through the motions, really are not able to help patients and families as much as the docs that really have the desire to go out of the way to help, heal etc. (save a surgeon who miserable or not can heal!) But any doc where you talk to patients or think about diagnosis as your primary function will get much less praise from patients which in turn even further demoralizes you and makes you miserable as you watching the crumbling of healthcare.

If you go above and beyond to make a patients day or families day, than you get the extra appreciation which makes you wake up and not think about the crap system nearly as much which keeps you happy and the cycle of positivity continues.

The biggest lesson you can learn IMO, which took me until leaving residency and doing my own thing to really learn, was there is WAY more to helping a patient than simply doing the objective, tangible tasks we learn in residency. Ie. Prescribing meds, ordering the right test etc. All of that is important but the intangible smiles, jokes and ability to connect and comfort a patient is responsible for atleast half of the entire healing process and one that a lot of sterile residents and then physicians never get.

I used to think if I did not have a pill or a test to objectively use and order to "heal" someone, than I felt useless. I learned as I had more time to connect with my patients being in private practice (again it depends on your field and gig whether you have more or less time out on your own), I learned the healing comes from the moment I walk into see a patient: my smile, happy to see them, remembering something important about them, encouraging them, being available to them when they call outside of regular appointments, being INTERESTED in them as a person and interested in their medical situation as a whole. All of that has gone further in healing my patients regardless of what medical condition they had.

Sure the right medication and lab test is easy but honestly you can do that in your sleep after residency and I think we as physicians are missing the boat on fending off mid-levels by neglecting to see the value we provide outside our prescription pad.

Society is learning that you can stick a PA in for half the cost to write 90 percent of the prescriptions we do. However there is a confidence people still have in an MD and we do not use that to our advantage to apply it to the things I discussed. A person who feels their "doctor" is that caring and interested in helping them is someone who pays and values an MD vs. a doctor who walks in, does nothing but stare at a computer and writes a prescription which at the end of the day is replaceable on most fronts by a mid-level.

So while most docs sit back and bitch and moan about the system not valuing doctors or paying doctors, majority of docs are doing nothing to step their game and value up with the intangible's, the basic humanistic side of medicine that is almost forgotten.

We are the masters of healing and the public still views us as that but the public perception is not going to last as we continue to offer percievably nothing different than a PA/NP does to the public patient's eye.

I learned this on my own but if I could advise any young resident in here who probably thinks I am full of total BS, to remember next patient encounter to spend more time on the intangibles, while still clinching your diagnosis and prescribing/doing procedure, I believe you will start to see a reaction from patients that you may have never or rarely seen before.

Just my .02 as a guy out of residency 1.5 years who has done more learning about being a good doctor in 1.5 years than probably through 4 years of residency. I wish I could have hoaned the skill in residency but simply had nobody who talked about any of this stuff with any real conviction outside the context of lawsuit avoidance or hospital feedback scores
Excellent advice, and not $0.02, it's golden.

I like to think of myself as a personable person who cares about the person as a whole, and it truly only takes a few extra seconds with a smile, or some humor, etc, to help people see you're not just some guy in a whitecoat.

However, there are so many residents (and attendings) around me who simply do not have this, and it shows. There are a few of my own attendings who, after seeing a patient with me, the patient will look at me and say "I don't ever want to see him again. He has no bedside manner". To which I pretty much just have to agree, because it's true.

I think part of my disgust for residency truly is all the lack of independence and the new regulations/red tape added every WEEK (it seems). I realize the attendings have to be more hands on, but it doesn't help me be more motivated.

I think part of it is that I'm 33 years old (waited awhile to go back to med school), and I have a huge independent streak in me as well....which doesn't bode well for just being a little pee-on in residency.

I look forward to graduating and getting out. I think in my field (urology) we get an awesome experience with our patients, as it's quite "intimate". That will only get better for me once I have more control over my clinic and my OR schedule, etc. Regardless of the State control of medicine, I still look forward to relieving urinary retention, removing stones, taking out prostates, etc, etc. It's quite a fun field, and the relationship with the patients is priceless.

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      02-18-2013, 02:16 PM   #115
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Wow. So many doctors here. How many lawyers reading this thread besides TTMG?
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      02-18-2013, 02:20 PM   #116
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I am quite well-versed in the changing times and I can't agree on the fee-for-service disapearing unless you are speaking of something different than I am thinking. A surgeon, unless plastics or maybe some uber high profile neurosurgeon or orthopod will not ever be able to do fee for service, however I only see more and more docs, atleast in affluent areas which is where fee for service makes sense, increase. As more docs pull out of the insurance game, more fee for service docs will actually arise and although there will be more of them, they will make a bit less as the increased supply will drive down prices they will be able to charge.
Other then probably PCPs, psychiatry and a few non-hospital based specialties, it is yet to be proven that this system works long term.

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Unless obama mandates that docs have to take a single payer national system which is a ways off, than fee for service (ie not taking insurance) is continuing to grow. The docs doing it will need to either offer something else nobody else is doing (ie house-calls etc) or take a lower fee than they are now given more competition.
Plans to tie YOUR medical license to accepting government insurance are in the works as we speak.

http://www.forbes.com/sites/scottatl...vitably-fails/

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The managed patients will see more and more of the mid-level NP's and PA's with doctors seeing complex or rather playing more of a supervisory role in the primary care sector including OB, neuro, psych etc.
Yes, and this system is and will be working quite well within an HMO based model such as KP.


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However a further division among the fee for service docs will emerge as the one's catering to the affluent still who will be providing either more services or going off of a better reputation to charge a premium "affluent consumer" price point and than the other tier will be the average PCP who will do a fee-based service but really provide nothing more than most people are getting now if they do see a doctor rather than mid-level. Essentially people will have to pay some fee out of pocket to see an actual physician, even if they provide limited other services as in the future people will have a hard time seeing a physician through the insurance system without going through a dense mid-level NP/PA level of service.
Please imagine a scenario where 90% of fee for service patients (PPOs/EPOs, etc.) are forced to convert to some form of HMO-type model. How do you think you proposed system will hold up purely on cash paying patients?
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      02-18-2013, 02:24 PM   #117
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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.
No one says I like it either. It's is whats coming though.
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      02-18-2013, 02:47 PM   #118
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Wow all this response from an EMT going to med asking about getting an M3? hell of a tangent.

someone mentioned about the change taking place with NP/PA: NY has been holding strong on this front particularly the older generation of Docs. in NJ i felt the approach was the opposite plug a hole with NP/PA. Some NP and PA's felt there is no difference in their skills...well i for one noted the difference in practice of medicine by a lot (failure to recognize the sick vs bogus, keeping radiology busy with tons of studies).
few people really don't know they don't have further training once they complete school. Some NP/PA swear by what they learned from their MD mentors and dont realize medicine has changed. Keep an NP/PA in certain areas and you will see the medical errors, medical mismanagement and what not.
sorry for the detour but NP/PA in place of MDs topic is very frustrating. Sure they have a place, just don't think belong in certain places...
fee for service will be more like free for service....
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      02-18-2013, 02:55 PM   #119
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Other then probably PCPs, psychiatry and a few non-hospital based specialties, it is yet to be proven that this system works long term.



Plans to tie YOUR medical license to accepting government insurance are in the works as we speak.

http://www.forbes.com/sites/scottatl...vitably-fails/



Yes, and this system is and will be working quite well within an HMO based model such as KP.




Please imagine a scenario where 90% of fee for service patients (PPOs/EPOs, etc.) are forced to convert to some form of HMO-type model. How do you think you proposed system will hold up purely on cash paying patients?
Making docs take a single payer system will simply never happen here. So that is not of concern.

And doesn't matter if people are forced into an HMO system as every single cash payer who pays cash to a pcp/psych or whoever doing cash pay still carries insurance, they simply pay above and beyond to get quality care and then use insurance to cover tests, hospitalizations or expensive procedures.

American's are creative. Just like in Canada now where they used to be a single payer system, province by province is now seeing all the craze of cash-pay private doctors opening up clinics and laws are changing in the other direction. So its quite funny how we are tauting canada as the great system when they are now moving largely toward a private system of cash pay with a gov't option which is fine by me and I think the best of both worlds.

People with cash who want the best care will simply pay to have a doctor with the highest credentials and ability to know them, spend time with them and be available to them regardless of cost. Them having a PPO privately, HMO or a gov't run plan will do nothing to this group of affluent people with whom I am talking about and who consumes 99 percent of private cash pay doctors.

The system sucks but doctors wanting to provide good care will find ways and patients will pay. You can pile on legislation but as I said any doctor can simply ditch their liscense, and become a consultant. Hiring a PA to do all the orders, scripts etc. Easy way around. So its of no concern to anyone familiar or practicing a cash model now.

Anyway, bottom line is we will all be ok, make decent money and have job security. It will be less than perfect for most but its already that way. I still would recommend anyone wanting to do medicine to do it if their prime reason is to really help people.
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      02-18-2013, 03:09 PM   #120
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I need to clarify. Not every doctor can ditch their liscense obviously. But inherent in this arguement assumes PA/NP's will have ability to practice completely independantly as it is already in many states. If they are able to practice completely independantly they do not need any MD oversight to care for the full spectrum of patient needs. Doing cash-pay is limited to derm, PCP,psych and neuro (and plastics obviously). The specialities that are doing it now can easily drop their liscense if they have a NP that can work completely independantly from a clinical standpoint and simply hire them to do all the prescribing, ordering etc.

Not all states are there yet with NP's being independant but as they continue their take-over, they will need independance to perform the role that is being carved out for them by the new system so by the time talks of tying doctors to taking a single system would happen, I forsee every state allowing NP/PA to do their own thing.

I think the worst hit are gen surgeons. They already make no money and obviously cant do a cash practice. Ortho, urology, neurosurg already make 450k plus and will probably be trimmed to 300k plus which still is a great salary, even they would likely attest once they actually think about it.

So yes it sucks but those making 300k now will continue to do so. Those making 150k will likely continue to do so and ironically those making 120k such as many PCP's will probably make more because reimbursement rates are improving for many of them.

Bottom line is medicine will look VERY different but it will have the full span of options as it does now for consumers.
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      02-18-2013, 03:22 PM   #121
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Excellent advice, and not $0.02, it's golden.

I like to think of myself as a personable person who cares about the person as a whole, and it truly only takes a few extra seconds with a smile, or some humor, etc, to help people see you're not just some guy in a whitecoat.

However, there are so many residents (and attendings) around me who simply do not have this, and it shows. There are a few of my own attendings who, after seeing a patient with me, the patient will look at me and say "I don't ever want to see him again. He has no bedside manner". To which I pretty much just have to agree, because it's true.

I think part of my disgust for residency truly is all the lack of independence and the new regulations/red tape added every WEEK (it seems). I realize the attendings have to be more hands on, but it doesn't help me be more motivated.

I think part of it is that I'm 33 years old (waited awhile to go back to med school), and I have a huge independent streak in me as well....which doesn't bode well for just being a little pee-on in residency.

I look forward to graduating and getting out. I think in my field (urology) we get an awesome experience with our patients, as it's quite "intimate". That will only get better for me once I have more control over my clinic and my OR schedule, etc. Regardless of the State control of medicine, I still look forward to relieving urinary retention, removing stones, taking out prostates, etc, etc. It's quite a fun field, and the relationship with the patients is priceless.
I could have written the exact same words to express my experience in residency. I honestly felt my role ended up being closer to a medical student some rotations it was ridiculous. At the end of the day it served its purpose and I did learn. I feel well prepared to handle my field and to perform at a high level but I can only speak to my field or experience. The less indepedence and experience (especially the lack of call experience which honestly was the ONE time I had true autonomy and probably learned 30 percent of what I needed to in residency on call) I can't say that future docs will leave unprepared. Glad we were not quite there yet.

I just cannot sit back and take instruction and orders when I simply don't even agree with them. It was tough I will say that but I learned its all part of the game. The whole process of medschool is a game. Its tougher to play for some than others which for a guy who absolutely hated memorization and kissing ass, was a nearly futile game!! I am the type who wanted to understand mechanisms, pathophysiology etc. Not memorize for tests yet that is what is demanded in most of medschool. Hence the game I had to learn to play.

Clinical years and residency is the "You need to learn to suck up, kiss ass and take orders" to play the game. Simply won't make it through without doing much of this.

So I can atleast encourage you it is heavenly when you are done so keep at it, bite your tongue and work on hoaning your skills so you can be the best doc possible upon leaving.

I did much better when I stopped looking at residency as something that should be: fair, enjoyable or for the best interest of the resident's education. Instead I learned its: politics, dealing with attendings own control issues, problems and burnout, and realizing its one more hoop and game in the process.

With that new understanding I instead focused on finding atleast one thing, no matter how minute, I could learn from each different attending or fellow resident, even when I absolutely despised them, and figured I would have the widest set of tools to use when done. Instead of getting distracted by my distaste and focus on how boneheaded the attending was, I just focused on that one little thing they did well. Honest to god there was only one attending out of dozens that I truly found NOTHING worth learning from lol. Sometimes it was something in the way they documented or whatever-usually something there.

So with that mindset my last couple years of residency were much more enjoyable!!
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      02-18-2013, 03:36 PM   #122
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I could have written the exact same words to express my experience in residency. I honestly felt my role ended up being closer to a medical student some rotations it was ridiculous. At the end of the day it served its purpose and I did learn. I feel well prepared to handle my field and to perform at a high level but I can only speak to my field or experience. The less indepedence and experience (especially the lack of call experience which honestly was the ONE time I had true autonomy and probably learned 30 percent of what I needed to in residency on call) I can't say that future docs will leave unprepared. Glad we were not quite there yet.

I just cannot sit back and take instruction and orders when I simply don't even agree with them. It was tough I will say that but I learned its all part of the game. The whole process of medschool is a game. Its tougher to play for some than others which for a guy who absolutely hated memorization and kissing ass, was a nearly futile game!! I am the type who wanted to understand mechanisms, pathophysiology etc. Not memorize for tests yet that is what is demanded in most of medschool. Hence the game I had to learn to play.

Clinical years and residency is the "You need to learn to suck up, kiss ass and take orders" to play the game. Simply won't make it through without doing much of this.

So I can atleast encourage you it is heavenly when you are done so keep at it, bite your tongue and work on hoaning your skills so you can be the best doc possible upon leaving.

I did much better when I stopped looking at residency as something that should be: fair, enjoyable or for the best interest of the resident's education. Instead I learned its: politics, dealing with attendings own control issues, problems and burnout, and realizing its one more hoop and game in the process.

With that new understanding I instead focused on finding atleast one thing, no matter how minute, I could learn from each different attending or fellow resident, even when I absolutely despised them, and figured I would have the widest set of tools to use when done. Instead of getting distracted by my distaste and focus on how boneheaded the attending was, I just focused on that one little thing they did well. Honest to god there was only one attending out of dozens that I truly found NOTHING worth learning from lol. Sometimes it was something in the way they documented or whatever-usually something there.

So with that mindset my last couple years of residency were much more enjoyable!!
It feels good to not be alone!

I was/am the exact same way as far as hating "memorizing" everything. I was the guy in medical school that was hated for actually wanting to know they WHY's of pathophysiology. How dare I.

And I am finally getting to the point you're talking about...just suck it up and try and learn all I can, and realize life is short and that this part of the "game" will be over before I know it.

And on that note, I'm on call tonight
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      02-18-2013, 08:32 PM   #123
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System 1
Kaiser or any large health plan that has their own
1. clinics
2. powerful electronic medical records
3. own hospitals
4. own physicians

is probably the best system for the average consumer. It is the best system for cost effective medicine. High percentage of patients will get the standard of care.

This is the closest place to practice academic medicine without being in an academic center.

System 2
the Rich, a cash system on top of health insurance works best

System 3
the Poor, even with cheap health plans, or Medicaid will always have to wait and will be subject to unsupervised medicine.

The Seniors with sponsored medicare will be placed in the private health plans shortly to mimic System 1

Solo practice will be getting more and more challenging as the bulk of the population gets roped into system 1.

For all the med students and residents, it is best to truly understand how you get paid as a attending and where the money comes from. It can change your life dramatically when you start looking for a job.

I trained at an academic center, I had NO clue about the business of medicine before finishing. Their motto was residency was for learning medicine only. Which sort of sucks when you graduate, there will be tons of business folks, other doctors willing and wanting to take advantage of you.
If I was smarter before coming out to private practice I would have went another direction with my career.

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      02-18-2013, 10:27 PM   #124
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Originally Posted by firstkill View Post
System 1
Kaiser or any large health plan that has their own
1. clinics
2. powerful electronic medical records
3. own hospitals
4. own physicians

is probably the best system for the average consumer. It is the best system for cost effective medicine. High percentage of patients will get the standard of care.

This is the closest place to practice academic medicine without being in an academic center.

System 2
the Rich, a cash system on top of health insurance works best

System 3
the Poor, even with cheap health plans, or Medicaid will always have to wait and will be subject to unsupervised medicine.

The Seniors with sponsored medicare will be placed in the private health plans shortly to mimic System 1

Solo practice will be getting more and more challenging as the bulk of the population gets roped into system 1.

For all the med students and residents, it is best to truly understand how you get paid as a attending and where the money comes from. It can change your life dramatically when you start looking for a job.

I trained at an academic center, I had NO clue about the business of medicine before finishing. Their motto was residency was for learning medicine only. Which sort of sucks when you graduate, there will be tons of business folks, other doctors willing and wanting to take advantage of you.
If I was smarter before coming out to private practice I would have went another direction with my career.

fk
Like your summary...must be a Kaiser doc

But in all seriousness...I do wholeheartedly agree that med students and residents better understand how they get paid and who writes the checks before embarking on their career...
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      02-18-2013, 10:30 PM   #125
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Like your summary...must be a Kaiser doc

But in all seriousness...I do wholeheartedly agree that med students and residents better understand how they get paid and who writes the checks before embarking on their career...
actually I have my own practice in los angeles.


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      02-18-2013, 11:10 PM   #126
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I have to say as much as I agree its theoretically a good idea to understand the business side as a resident, it really is not time well spent. Until you really have to do it day in and day out, it really does not compute to much of anything. When in residency its more of an extra task. We used to have to fill out the billing sheet but we were so busy there was little learning involved.

Also you only see one side of billing in academia and to be honest is not applicable to most future docs who do PP or employed position. Its relevent but I don't known if its worth the time.

I do think residents should be taught more about the health care system in general and how the changes will effect people. Within this context there needs to be education on how the money is spent and how it gets into the doctors pockets
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      02-18-2013, 11:49 PM   #127
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I appreciate your generosity everyone. I with no means was anticipating to buy a brand new M3 worth upwards of $60K-$70K. If anything it was to be a used e46. Although from the sounds of it, thats not even plausible. I don't want to do medicine for the money or toys (if thats even a possibility anymore with todays healthcare) although I thought that if I came here to listen to some first hand experiences I could get an idea of what the auto side of finances cost while in med school. I figured it would be best to just ask here first
You won't have time to enjoy a car in med or grad school really.

Graduate and then get a job...took me 6 years after finishing my PhD to afford a 335i new. And that's in industry, not academic medicine/research.
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      02-19-2013, 11:59 AM   #128
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hold your residency money for daily living costs, im a general practice physician in PR, got out of med school with 100+ debt, im beign working 6years now, my car was a mitsubishi mirage with 120k miles( awesome by the way, never gave me any trouble, wish i had kept it). i recently change the car for a 2011 135, and sometimes i think money on the car is kind of money down the drain. yes, itts fun, and i like it, but at the end of the days, salaries are not that high, insurance and cost of living gets most of your paycheck. i work in a ER, get pay by medical insurances ( so i have to pay for billing also) and every single day the medical plans find a way to cut the pay to the doctors....
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      02-19-2013, 11:00 PM   #129
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Originally Posted by mdyaman View Post
+1

join the military and have them pay for med school. Do your payback tour, get experience. profit

OR

you can look into government education loan payback program. Not a bad deal. https://www2.ed.gov/offices/OSFAP/DirectLoan/index.html
+3

A little late to the party, but I will throw in my two cents......

I was an enlisted Army Reservist to help offset my undergrad loans and looked to Uncle Sam again when I entered medical school. As this was 1998, there was not OIF/OEF, so I ended up with a 3 year HPSP scholarship as the four year scholarships had gone quickly. Now there scholarship is even better with a sign on bonus and a higher monthly stipend as they typically cannot get enough slots filled given the current climate.

I left medical school / undergrad with about $90K in loans when combined with my wife's undergraduate degree. I drove a trusty, but un-cool Toyota through medical school and civilian internship and residency in internal medicine. We bought a fixer upper home just after graduation from medical school and got lucky with market timing on the sale when I entered active duty three years later, having worked on its rehab when time allowed. That paid off the all o student loans. My wife also worked in sales while I attended school and internship and residency, making about twice my salary after medical school, so that did help to defray the household costs and those associated with the kids that "arrived" in those three years.

My first duty assignment in the Amry was Germany where we spent over 6 years. We did a lot of traveling, but that also included 27 months in Iraq and Afghanistan for me. In retrospect it was a formative experience. It is not too often that an IM doc gets to do a crich and run a morgue.....YMMV.

The pay from my first deployment bought our E93 with cash.

I am now back in the US and am heading to a combined MHA/MBA program on the Army's dime this summer. I get paid my normal "attending" salary to be a student, which is a nice bonus. I do plan on keeping my clinical skills current, but wanted to hedge the bets on the future of medicine by obtaining the managerial degrees. Other docs will get out after their initial "payback" commitment and that makes sense for many.

My experience is a unique one as my prior service is computed into my current pay, but I am in the high $170s with my monthly "housing allowance" thrown in there. We made a pact to not buy another house while moving around in the military but feed a "house fund" that would now cover the cost our first home in cash. Once you get used to living a bit frugally, it can stick...M3 excluded ;-).

It is not for everyone, but Uncle Sugar has been very good to me. At this point, I plan on hanging out for twenty, accumulating the pension while still dedicating 15% of my income to retirement. (I tend to hedge bets a lot.) I have friends in managed care who hate it, so as long as I don't take anymore trips to the desert, my ambulatory care life /patient load is actually better than theirs.

I would offer to the prospective student that it is amazing what some luck, sacrifice, and alternative school funding options can do for you in the long run. Driving a Camry may not be sexy, but every dollar not borrowed, is MANY dollars saved down the road.

I am intrigued by the many comments of the other attendings on this board as well. It is interesting to watch the world medicine from this "foxhole".
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      02-19-2013, 11:43 PM   #130
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+3

I am now back in the US and am heading to a combined MHA/MBA program on the Army's dime this summer.
Wise move...PPACA is eroding the pay for doctors, and management/healthcare degrees will pay dividends moving forward in the "new" era of healthcare.

I'm finishing my MBA in healthcare management right now...
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      02-20-2013, 01:49 AM   #131
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Having health care management positions is great, they just do not generally pay as much as you can earn doing bread and butter medicine.

Much better life style though.

If I could do it over, I would be in manage care, collecting a salary. Enjoying 3 day weekends, and quiet nights.

Unfortunately I was dumb and money hungry. Its hard to back out of this hole.

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      02-20-2013, 05:24 PM   #132
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And for those of us who have saved a human life, what greater thing is there in this world that one could possibly do?
LarThal, I have seen your posts on the boards for a few years now, had no idea you were an anesthesiologist. I agree with you one hundred percent about what we do...

Quote:
Originally Posted by phecht View Post
I appreciate your generosity everyone. I with no means was anticipating to buy a brand new M3 worth upwards of $60K-$70K. If anything it was to be a used e46. Although from the sounds of it, thats not even plausible. I don't want to do medicine for the money or toys (if thats even a possibility anymore with todays healthcare) although I thought that if I came here to listen to some first hand experiences I could get an idea of what the auto side of finances cost while in med school. I figured it would be best to just ask here first
So phecht, add on my two cents. If you want to be a doctor, become one. I don't care what the rest of these guys/gals are saying, if that is your dream then do it. It is a great job when you compare it to what 95% of people do on a daily basis. I love what I do.

I went in-state tuition (with some scholarship money) and had a paid off Nissan Pathfinder when I was in medical school, ended up with 130k in government backed debt (luckily interest rates were ridiculously low and I have consolidated all my loans to a 2% interest rate). With the loans I had more than enough to live, comfortably as a student. I kept my Pathfinder all the way through residency (8 years, still have it now actually) and resisted the urge to buy or lease a new car. As soon as I paid off all my high interest debt I bought my M3. From a financial standpoint, I would say get a reliable car (preferably paid off) when going through medschool/residency. Money is tight. An e46 will be expensive to maintain, I would rather have money to burn on leisure time (what little you have) instead of fixing my car.

There is some good advice here, one person, I think heartdoc mentioned getting yourself financially secure for the future. That is the best thing you can do. As a single, and pretty young attending I allowed myself a few years of financial (and a few personal) indiscretions (chased a few nurses in my time, not a good idea when they are 7 years younger and work on your unit ). But now I've buckled down, maximized all my retirement contributions and am saving for long term. My M3 will be paid off in a year and a half. And my bank account is pretty healthy.

I guess my advice is to try and keep it simple through the lean years, stay away from high interest debt (credit cards especially) and chase after your dream. Sometimes it's best to sacrifice a little now so you can enjoy it later.

FYI - I am an academic hospitalist, I am 2/3 clinical and 1/3 academic/administrative (I direct a med school course and I do some administrative stuff in the hospital). And my lifestyle is great... I'm currently on an 8 day break, and I am not even digging into my vacation. I have a couple of meetings I will have to go in for, but no clinical shifts. I don't make huge bank (like the private guys do) but I make more than my parents combined (ICU Nurse and airline manager). I feel like I live very comfortable. And I feel very fortunate to do what I do.


Quick rant, how soft are interns now? Soft I tell you... with their 16 hours limits and 10 hours off between shifts.
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