How Early Is Too Early?

As much as I truly do like what hospital medicine represents, I have come to the very strong conclusion that there are greener pastures.

As the days of my contract tick ever-so-slowly away, I wonder how soon is too soon to seriously start the job hunt. Given that I'm looking to geographically relocate a not-insignificant distance, and that I really don't even have a solid idea about what state I'm shooting for, I figure it's not too early to put the feelers out and ask for some courtesy tours.

But I did get a lil bummed out by some of the Sermo posts talking about how it took one guy 3 hospitalist jobs before he found one he was happy in. For reasons mostly out of my control, I think I've had more jobs post-residency than I had before it. It would be nice to settle down in a position that I can think of as a career rather than a means-to-an-end.

As a lifelong Midwesterner who has lived in some pretty great Midwestern cities, I'm bracing myself to find that as the Quality-of-Life index goes up, the quality of the hospitalist job plummets. Maybe that's not universally true. But as someone who lives in a great city and commutes to work in a town precious few would voluntarily choose to live in, I can tell you that small town hospitalist jobs can be as malignant as any in a cosmopolitan city. (Even if you've read your contract with a fine-toothed comb.)

I suppose I need to decide if I would ever work directly for a hospital again. As many cons as that comes with, one of the most regal screw-jobs I've ever heard of came at the hands of a private physician group (granted, that friend is in Emergency Medicine, so maybe that's more par for the course).

I'm glad I've found a profession I like. Now I need to find the good peeps I want to work in a town I want to hang my hat for years.

Hasta Luego Chicago

So, I am finishing up the Society of Hospital Medicine 2009 meeting. I walk away with mixed feelings.

For one, it was refreshing to hear that many of the struggles that our hospitalist program has are not unique. On the other, it's clear that a lot of places "get it" and are light years ahead of my program when it comes to clearly defining the limits and scope of what a program of a certain size can/should do. As a Med/Peds physician, the special interest group was mostly cathartic, but did give me renewed purpose in trying to effect positive changes.

While my current job is decidedly NOT where I want to practice (geographically or operationally), hospitalist medicine IS the environment I want to stay in. I'm hopeful that when it comes time for me to find the next hospitalist job, our profession will have matured (with hopefully the leadership of SHM) enough that there is consistency and stability in the market.

I thought the discussions on Quality Initiatives summed up the issues very succinctly, and I especially enjoyed the fact that SHM convinced one of Satan's Minions from United HealthCare to weigh in. I thought Dr. Susan Freeman (of the Jedi Knights) was exceptional. Watching her counterpointing Steven Stern was tremendous. But at the end of the session, it had the feel of two warriors shaking hands, knowing that the real war was about to begin.

I didn't hear anyone bring up the fact that "bundled payments" in 2009-2010 has very different implications than it did the last time it was tried. A shit-ton more of us are employed by hospitals now. When trying to divvy up the breadcrumbs, and as "not-for-profit" hospitals guard their profit margins, what's the place of the hospital-employed physician at the table?

The discussion of readmission rates and post-hospitalization care was important, but I was quite disturbed at the murmurs of suggesting that hospitalists now take over some of those outpatient duties post-discharge. Hospitalist medicine emerged because primary care doctors could no longer effectively do clinic AND inpatient medicine. In our community, the primary care doctors that we started admitting for immediately boosted their clinic schedules. And that's fine... unless we can't get your damn inpatients to follow up with you. I think that this is an area where the onus does fall back on the primary care doctors. In our community, they used to be responsible for all the unassigned admissions AND their follow up. I just bristle at the suggestion that the job of the hospitalist needs to start morphing back into the very profession we all found so dissatisfying.

Finally, as someone who drives a fair distance to serve a rural-esque population, it struck me at the "Exhibition Hall" how disingenuous recruiters are when trying to convince physicians in a hot market to give up major aspects of what make a location desirable in exchange for promises of cash. I almost wish they would be banned from the whole enterprise next year. I realize they represent a significant revenue stream for SHM, but can we at least separate the people who have clinical information for us from the snake oil vendors? We're not stupid. A hunting/fishing "paradise" that's less than an hour (55 minutes at 85mph) from a regional airport makes lofty compensation promises that always always come with strings attached.

I really wish they would just say, "This place sucks, but here's what we're going to offer you in terms of compensation/work schedule that we hope makes up for it." Instead of pictures of babbling brooks and fields of wildlife, those booths need to read like an offer letter. Just a suggestion.

All in all, it was a great experience, and I look forward to next year. But for the love of god, get more chairs.

Does Congress Get It?

While working directly for a hospital has some advantages, I have become increasingly aware of how the conflict of interest between hospitals and the physicians they employ is bad for healthcare. For quite some time the way hospitals get paid and the way physicians get paid has been in direct conflict. This is why "Length of Stay" is a term laced with gold. While I do not believe I have ever discharged a patient inappropriately, I would be lying if I said that it didn't cross my mind when a patient that is in that illustrious "gray zone" wants to stay "one more day". I have yet to decide if this is a good thing or not. It certainly becomes an issue with my customer... I mean patient satisfaction.

But when Congress talks about cutting payments to physicians, do they freaking realize that an increasing number of physicians (and almost NO primary care physicians) are not the ones who receive these payments? The hospitals get them. Most primary care physicians under the age of 40 are working directly for a hospital under a contract that has a payment structure that may or may not take into account how much cash the hospital collects from insurance companies and (increasingly) the government. When the government attempted to Robin-Hood from the proceduralists and give a lil to the little guys (the primary care doctors), a lot of hospitals, including my own, they attempted this by increasing the RVUs granted to PMDs and reducing the RVUs granted to proceduralists. So a lot of hopsitals convinced proceduralists that they would have to take a modest pay cut because they couldn't bill as many RVUs. And did most hospitals pass said-cash-flow on to the intended recipients? No. They pocketed it. And now the PMDs were genereally left in the exact same position having to see just as many patients for the same salary.

So if we actually cut physician payments 21%... tell me, Dear Reader, how do you think a hopsital who employs a physician is going to take that? Are they going to sustain the salaries of the primary care doctors (and the rest of us for that matter) out of the mountains of profit these not-for-profit hospitals make? Or are they going to continue to do business as usual, and give their doctors a take-it-or-leave-it offer? Or are primary care doctors now going to be instructed to see 60 patients a day to maintain their already-behind-the-curve salaries.

I was hoping for some real healthcare reform. There do need to be changes. But what I see coming down the pipeline scares the living shit out of me. They know not what they do.

Maybe our lawmakers should be required to have Medicare/Medicaid. Shit. Give it to them on my dollar, I don't care. Let them try to find a doctor who's able to spend an appropriate amount of time with them and still make more than the receptionists.

Idiots.

Just Tell Me Where My Obligation Ends

Nothing has lit up the blogosphere quite like the infamous human litter. I would feel like I'm slighting my duties as a semi-intermittent blogger if I did not chime in.

As a Med/Peds physician, I have no problem with saying that our society does have certain obligations (entitlements) to certain populations. Children and the elderly. Everyone else in between is another discussion for another day.

The problem I have with the way our healthcare system is structured is not that we have decided as a society to provide assistance to these groups (I think that we should, which is vastly different from saying that we have to) but that the public at large has translated this initially-voluntary offering of assistance into the mantra of "healthcare as a right".

Should an elderly couple, having worked their entire lives, be entitled to some help with prescriptions at the age of 65? I do not think this is unreasonable.

If we decided, as a society, that we can no longer afford to do so, are we somehow denying that couple civil liberties? Absolutely not.

As a disclaimer, I am not really sure how to categorize myself politically. I think it would be a tragedy to live in a world where we subsidize some of the most outrageous BS ever and let infants waste away because we aren't offering assistance for formula. But I do start to take deep offense to those who see such assistance as a means to an end, rather than a safety net. Like our new friend Nadya Suleman.

As most physicians who have spent any time in outpatient primary care, the patients who seek disability for back pain are suspicious at best. (Have you really given physical therapy a decent shot? Really?) Given Ms. Suleman's observed pattern of behavior, I would guess she had to browbeat her physician (or change PCPs a few times) to get that disability paperwork filled out.

And how does a woman who is "disabled" able to "work double shifts" to "save up" money for more in vitro? If you could save up for that much in vitro, maybe we need to assess how much gets paid out for SSI.

Rumor has it one of her pre-octuplet kids is autistic. If that's true, I truly take an exception to my rant. Autism is a horrifically underfunded chronic condition that only lots of expensive speech therapy, etc. has been shown to significantly affect. (This is where No Child Left a Dime fails.) If I had an autistic child, it would be a 2nd full-time job to give that kid the attention he/she needed to ensure peak potential. The kind of care an autistic child needs is truly out of the price-range of most Americans to pay for out of pocket. I have no problem subsidizing that.

But all sympathy for her struggle with an autistic child evaporates when you see what decisions she made next. It reveals her to be pathologically selfish. If she gave a rat's ass about her autistic child, she wouldn't take the little time she had for him/her and divide it amongst 8 more. Oh yeah... AND go back to college.

Her deftness at filling out disability paperwork must have made it quite easy to get 2 of her other kids on the federal/state subsidy payroll. Let me guess.... "bipolar disease" and "ADHD". What normal child growing up in this environment wouldn't start showing some signs of these conditions?

Now that we hear (shockingly) that this hospital wants the state to reimburse them for this care, I am waiting on bated breath for SOMEONE in power (ahem.... Obama) to comment on where the Era of Responsibility begins, and where the Era of "Oh, don't worry about that horrifically boneheaded decision you made.... let us take care of that for you" ends.

I'm actually hoping she gets piles of cash from a bunch of moronic sympathetic viewers. But I want to hear when my obligation ends. If I lived in California, I'd be even more pissed. How many book deals does one need to sign before you can't get food stamps anymore?

I think my rage over this selfish woman has peaked. But if I find out that she has ever put a cigarette to her lips in the last 10 years, I will probably have a stroke myself. Then all of you, dear readers, will be paying for my tube feeds.

Forfeitted Freedoms

So, despite the fact I have a better life as a hospitalist than I had as an outpatient slave, I am finding that the experience of being a hospitalist is making me ever-less hopeful about the state of our country.

Back when I was a wee-tot in residency, I really didn't give a thought to where my taxes went.  I made less than most tenured cashiers at grocery chains.  I just wanted to know what the hell I was doing with patients.  I just wanted to get through another night of call.  I was striving for competence to heal the sick.  I gave very little thought to my post-residency future (since I was in the extreme-minority not scraping for a proceduralist fellowship).  Only 5% of my training was spent in the outpatient setting -- the environment I would be spending 95% of my immediate post-training years.

When I became a hospitalist, and that number went to 0%, my perspective had changed dramatically.  Here I was trying to pay off mountains of debt, negotiating to become the employer of a not-for-profit profit machine, and paying more in taxes than my gross income had been throughout my residency years.  By the time I had managed to set aside some cash into the 401(k), I watched it vanish.  And now I'm watching trillions of dollars of my future being prostituted to keep the imaginary-wealth of the last 10 years from vanishing.

I've become pissed off enough at the corporate suits for asking me to help their multimillion salaries remain inflated while the public-at-large groans that doctors make too much.  I'm in the trenches -- the front-line -- of healthcare in this country, and I'm scraping for my piece of the pie.  I will never make a million dollars a year (at least, not practicing medicine).  But my job is indirectly subsidized by the federal government, as now a huge sector of the automobile and banking industries are.  So to hand irresponsible owners of companies that make shitty cars, and banks that make horrific choices, astounding piles of cash, while our government cannibalizes medical education subsidies to pump more money into the failed and pathetic "quality" incentive programs to physicians, cases me tremendous anger.  

"Expanding healthcare" does not mean giving more people the same shitty government-funded "coverage" that no physician with any degree of autonomy will accept.  They'll still pay (and I'm making numbers up here) the same insulting $40 to for the 30 minute office visit for an elderly person with diabetes, and the same outrageous $30,000 to cut off their feet.

Hospitals are employing an increasing number of physicians.  Our government has made sure the economics are stacked against doctors trying to actually open their own practice.  Those of us unlucky enough to be employed directly by hospitals know that they have absolutely no desire to see people get healthier.  Their bottom line will suffer.  If primary care physicians were empowered to spend the time they need with people to better manage chronic illness (and I really think they're doing the best they can under the current borderline-immoral conveyor belt of patients many are browbeat into seeing) then you're going to see less hospitalization.  Less mindless flow of cash to the hospital to proceduralize people to death.

I'm constantly brainstorming about what we need to do to fix this.  I'm not terribly optimistic about Obama's ability to do this, since I am increasingly hearing the outraged voices of people who have come to demand access to taxpayor-funded entitlement-based reimbursement of medical services shouting that no one has the right to tell them how to live their life.

Under normal circumstances, I agree.  I would have no problem with people who want to eat themselves into oblivion.  It wouldn't bother me if I saw the COPDer on oxygen smoking at the casino.  It would hardly phase me to see the IV drug abuser using her PICC line to shoot up crushed oxycontin mixed with spit.  EXCEPT THAT I'M PAYING FOR THIS  SHIT.

If I have a stake in paying for you healthcare, then hell yes I can tell you how to live your life.  And this is independent of my standing as a physician.  I think this goes for anyone playing by the rules who is not reliant on the government to pay for their healthcare.  You want to live your life as you please?  Fine by me.  When those choices make you sick, you're ON YOUR OWN.  Oh, you want me to pay for your CPAP and Q2 month admissions for COPD?  Put down the fork (or the hamburger wrapper), get off your ass, and put out the cigarettes.  Or buy your own health insurance.

And we really need to stop using the term "insurance".  Think about what would happen if we treated car insurance and homeowners insurance in the same vain that we talk about "healthcare insurance". I would demand that Geico pay for my oil changes, new tires and brakes, even though I drive my car like a rental.  When the lightbulbs go out in my house, I'd call up AllState and demand someone come over to replace them... even though I just leave the lights on all the time.  What would our motivation be to take care of our vehicles and homes if the government just took care of it?  Oh... but they'll only pay for 60% of the cost of the oil changes... what do you think that would do to Jiffy Lube?

Something has to change.  Fast.  The healthcare bubble is going to pop.  But I fear that our concern is being misdirected.  Americans are unhealthly largely because of their refusal to take care of themselves.  And if I read one more article about an outraged smoker who is simultaneously pissed off about not being able to smoke in public, and about the cost of her COPD medications... I might just lose my mind.

Too Big to Fail?

So I've been pondering the very real prospect of a healthcare bubble bursting, and what form it would take.  I do believe that a lot of our country's leadership will see the solution as being a single-payor Medi-doesn't-care-for-all system.  I must admit, this scares the crap out of me.  Even though the way I, as a hospitalist, am paid assigned disproportionate value to fixing broken people over keeping them well, any meaningful change to our healthcare system could make my contract obselete.  What if RVUs went away?  What if the financial interests of the hospitals were no longer in opposition to that of their employed physicians?  How can I know I'm going to be able to pay my bills?  The thought of being forced into government employment makes me want to wretch.

But something occured to me that gave me solace.  When billions of dollars of banks and financial institutions were ready to crush under the weight of their incompetence and greed, our government deemed them too large to fail.  I have no numbers (but I would love it if someone were able to direct me to them), but I wonder how comparatively "big" all of the country's health insurers are.  What is their annual revenue?  How many people are employed in aggregate by all of these institutions?  It may not eclipse the financial sector... but I imagine it's not insignificant.  If we can't fathom the loss of Ford... what about Blue Cross/Blue Shield?

I have no idea how one could create a single payor system, and yet preserve all of these institutions that have made a career out of keeping money out of the hands of those providing the healthcare, and filling their coffers.  Are they all going to be voluntold into federal/state employment?  With all the resources we had, we couldn't figure out how to get a company that makes shitty cars to make better cars.  How the hell would these same people figure out how to restructure the entire healthcare system?

I think for once, all these companies who have restricted my practice of medicine may protect me from the absolute destruction of physician autonomy.

The enemy of my enemy...

I Think the Tide is Turning

It would take a lot for me to go back into outpatient medicne.  More than I think the beancounters are willing to concede.  Nonetheless, in the short time since I opted out of Primary Care, I sense a change in the national discourse.  I am hearing less and less about the problem of the uninsured, and more and more about the pending disaster of those-with-insurance-with-nowhere-to-go.  While most of the information in this article is not new to most of us, it does highlight that the crisis is growing if a major metropolitan area is starting to worry.

Rural communities have had trouble keeping doctors since before I went to medical school.  But the pool of primary care physicians has shrunk enough that larger and larger rural communities have begun to feel the pinch.  I would venture to say that the new generation of physicians wants to live near more "stuff" than previous ones.  Just look at residency programs.  

Program directors of most internal medicine, pediatric and family practice programs have known for some time that recruitment to the Midwest (even to major cities) is inherently harder than places with 320 days of sunshine, oceans or mountains.  If you're going to work 120 hours a week for less pay than a tenured grocery store cashier, you might pick the hospital in paradise versus the one in the frozen tundra.

This is why I think that the loudest cries are going to start coming from the larger cities in the nation's midsection.  I'm not seeing a lot of Locum Tenens agencies begging for help in Manhattan or San Francisco.  

It's going to be a while before there aren't physicians willing to work for the CMS pittance in exchange for a 1-bedroom rental in a cultural epicenter.  But when we've reached the day when an above average primary care physician salary can't attract anyone to a smaller city with imperfect weather, but major sports teams, an art museum, a symphony, an international airport, and premium shopping... maybe that salary isn't so above average...