Home Forums Discussions General Discussion Are physicians letting themselves get screwed?

To the best support group I have:

This is for everyone but especially solo doctors. As you know, over the past 5 to 10 years, there has been a lot written about physician burnout. I was wondering what people think about that.

I thought this telemed thing, which is a lot easier, was going to be really fun. But, the downside is it has given me extra time to evaluate everything. I think I was happier working from 8 am to 8 pm to 10 pm non-stop with a lot more referrals and difficult situations. But, I was so busy I didn't really have time to get off the merry-go-round.

Anyway, if anyone is open enough and honest enough to comment, I would appreciate hearing your thoughts. You know we talk about everything else, but we don't talk a lot about what each other does and where and why, etc.

Hi Bert,

Interesting perspective. Let me think about this for a bit and I shall try to post later.

Thanks

Gene

Don't just try. You are a moderator. They do.

Bert,

Great topic!!! I tell you what keeps me sane. Apple music/airpods and running 5 miles every morning chasing the deer! And my evening walks with my wife. I can focus and think about things while I run my anxieties to a controllable level. Of course downhill skiing winter and hiking in summer. I was painting a few years ago but got another painter's block, so the painting has dried up a bit. My son has been working on replacing the front end of his truck so being his helper has been rewarding and eating all of my daughter's pandemic baking makes me glad I run. Having the kids again under one roof this past month has been very good for the anti-burnout maneuvers too.

Wow! I think that would take up half my day. I think AC was named after you. You are amazing.

LOL, not sure my wife would agree with you Bert, but for years I did not have any "me time" and got pretty burn out and as I have slowed down trying to not grow my practice, stopped doing the hospital and Nursing home stuff and out patient office only, has freed up more hours in the day for "me time" which I don't plan on ever willingly giving up again. I never realized how good exercise was for me till I got into the groove of it and maybe I am addicted to the exercise but I figure there are worse addictions, and I am one of the lucky ones that get the endorphin kick that usually lasts most of the day.

I don't really like the telemedicine consultations. Throws another piece of asynchronous chaos into my day. I'm still seeing office patients, those who will come in. I'm used to the linear process of check in, room 'em, see 'em, check 'em out & chart...next.

But I also need to keep track of patients & bring in some income from those who won't come in. So i'm doing telemedicine, partially video but mixed with some followup texts and messages. But it's like having 5 or 6 exam rooms filled with patients who stick out their heads, say something and then nothing for 10 minutes. Now who was it that said to send their meds to what pharmacy? I pay staff for this stuff, but they are too busy teaching 80 year olds how to do a video consult on their iPhones.

Hi everyone,

This is a difficult topic. There are so many levels, and so many aspects to it.

Bert, I think we are of roughly the same generation, I am 63 years old. I suspect that many of the posters on this board are of about the same generation.

Professionally, medically, we are the "awkward in between generation".

I remember, probably about 5 years into practice, one of the order drug reps came in on a busy Monday morning. He saw me rushing around, when I stopped to talk to him, he said "Doctor, I think I know what your problem is." This clearly took me aback. My mouthwash? My deodorant? My personality?

He said "You were born about 10 or 15 years too late. I have been in this business for a while, and I have seen what you guys go through, and it has gotten so much worse for you over the last 10 years." And this was probably about 25 years ago.

I think the generations before us had it worse in terms of time and professional demands. But, financially and in terms of professional and societal respect, they had at all over us.

On the other hand, the newer generations are much better at balance in their lives. There were no restricted residency hours when I trained, and basically the expectation is you would put the entire rest of your life on hold, as long as necessary, for your career, both day today and long-term. This becomes internalized.

So, at least for myself, we have this awkward situation where we still have the internal expectation to be everything for everybody, always available and always perfect, but having largely lost the financial benefit. Certainly I make a decent living, but if you figured it out hourly, a lot of nurses make more.



Which leads to current practice. I am in a solo practice, so I am my own boss and answer to no one right?

From day 1 of practice, there was always the specter of medical malpractice. Which, of course, still exists. There is OSHA. And HIPPA. And narcotics over prescribing. And clinical practice guidelines. (By the way, anyone else who listens to Audio Digest Family Practice, over the last few years there have been a few excellent speakers on the lunacy of the tyranny of clinical practice guidelines. A few speakers have actually brought up the heresy of questioning tight control of diabetes, especially in the elderly.) Charting. Addressing labs. Forms. And prior auths. And prior auths. And prior auths.......

And the patients are not getting any easier. I have been practicing in the same area for just short of 33 years, and still have many of the original patients. Those who were young are now middle-aged, those I recall as being middle-aged are now old with multiple medical problems. The average age of the practice has definitely gone up, as have the complexity of the medical situations.



Finally, if you really look in the philosophical, I am probably around three quarters of the way through my life.


So do I understand you talking about burnout? Absolutely. Do I understand being busy enough to put such thoughts out of your mind? Absolutely.

How to handle it? Poorly. That will be another post.

Gene

Great post. And, it's great to get both perspectives. I am struggling right now not only due to medicine, but some other medical things of my own. Which don't improve with the stress of practice. The biggest thing I didn't take into account when I went from a group practice to a solo practice was that at some point I would be trapped. If I get to where I feel overwhelmed and want to be out of it, it isn't a simple thing to do.

The other issue is massaging the issues of 25 to 30 year old employees who don't listen (not all) but are hard to fire because there are only three, and the system they have come up with is quit/be terminated, walk out the door, find a lawyer on contingency who faxes one letter suing for $40,000 for hostile work place environment (which wasn't hostile five days before), drag it out for two years, then settle for $5,000. It's like a playbook. You can't go to court for five days and have lies thrown at you in front of your peers. You can't have your staff testify as of course they would.

As far as patients, mostly MaineCare. Pays well, but it is the best insurance in the world, and they are the one who are entitled, need, need, need then complain that they can't get Lunesta over trazodone calling MC pathetic. Meanwhile, I have no insurance due to issues I had nothing to do with and have to pay $7500 for a colonoscopy. YES JON YOU ARE GETTING RIPPED OFF. I wouldn't do one for less than $500.

Again, the problem for me is I don't see a way out. There is the moral and ethical issue of giving patients plenty of time to find a new doctor. And, while that time is going on, the money is going down.

Sorry, just throwing some stuff out there. Oh and everyone wants a referral. And, MaineCare: I can get five MRIs in two weeks. Literally. Try to get an MRI of any body part of a BC/BS patient and you have to clear it through Texas.

If there were no barriers to closing your practice tomorrow, what would you do?

Gene

Retire? Do something else medical? Nonmedical?

Can't retire yet. It's just so easy to say that. One thing about a high-paying job, it limits other job opportunities.

Got tired of reading the "news" and thinking about Covid, so back to AC userboard!
Nuggets of sanity here where there is mostly just gravel everywhere else.

I see pretty much the older crowd of doctors here on the Board -- is that because younger ones are all employed and on Cerner or EPIC? I'm thinking they miss a lot of professional camaraderie by being stuck in their silos, and that must contribute significantly to "burnout'. I miss the old days of a mixed hospital and office practice with occasional home visits thrown in -- peer contact in the morning in the surgical locker room, lunch at the hospital in the medical staff dining room, easy curbside consults and chat with other physicians all day long. We used to have the back office numbers of all the specialists we normally referred to, and a human being would answer the phone, and usually we could speak directly to the specialist about a problem in real time. All gone now.

I'm 77 -- I was making noise about retiring because while I can't claim to be "burnt out" -- I am so fed up with prior auths and second guessing by pharmacists and insurance companies with their ridiculous practice guidelines and distortions of "Beers List" -- I am ready to give in and recognize that medicine is now a corporate enterprise, run by hedge funders and bean counters, and there is no room for real doctors any more. And besides, they are going to be replaced by AI anyway. But my wife and medical partner who is 10 years younger says she isn't ready to give up.

But I didn't have to decide to retire -- COVID-19 came along, and we are now seeing about 6 patients a day. We try to do some telephone and video visits, but our demographics are wrong -- the patients don't have modern electronics for the most part, and they can't hear well enough to talk on the telephone. We cut back staff, stopped paying the clinicians and are running a hobby practice which for now, suits just fine.

So ironic, just complaining to my receptionist. Spent a whole hour on two PAs. One was to Tennessee (I am in Maine) to approve an MRI of the brain for a 7 yo with chronic headaches, getting worse and now fever and vomiting. I even tested him for Covid-19. Got the MRI and propofol sedation and set up in 48 hours, because pediatric sedation and MRI care. I mean you friggin' pay your $1,000 a month for our "wonderful private insurance" and they won't pay for a procedure when needed. Usually, I get this when it is for a knee or shoulder.

I am about 15 for 15 on peer-to-peers. They key is just being nice. Plus, the brain tumor (if it is -- which it won't) would be all on them.

The curbside consults are a great point. Being able to talk to them at rounds. And, they would "have" to consult on an inpatient within 24 hours. I remember when I would admit a patient with 8 ear infections and the consult would be in two months. S. pneumo being resistant to even high-dose amox, sometimes required hospitalization with IV Rocephin. Then consult ENT who would see that patient, agree then schedule them for a week later.

The whole key is concierge medicine or the IMP. No insurance bullshit. Plus, the guy I am leasing from is doing that. He has no issue with the Corona thing. Plus, he has done Skype from his phone from Paris so no need to even be here.

I think the key is that doctors never got together like a union to stop this bullshit. You don't see this with attorneys, but then are kind of set up to deal with this stuff. But, where was the AMA when this all started 15 years ago?

Really good information here. Gene hit the nail on the head regarding us being in the "in between" generation.
My take is that the current situation in medicine (loss of autonomy, prior auths, devaluation of primary care, increased paperwork, decreased pay) is not going to change anytime soon. Doctors missed the boat on getting organized to stand up for the profession.

I would suggest that we are not imprisoned in our current situation. We can go do something else. I have seen several colleagues do just that.

Developing a hobby outside of medicine is important, as jimmie suggested.

Can users put down in they are solo or have a partner or group? I figure most are solo.

In a group of 7, lost Dr Mel, he is now a hospitalist, but getting a NP in a month or so, so will be back up to 8 soon.

Husband and wife joint practice.
One employed physician.
It's a small group -- a group like a small herd of cats.

Solo practice. Me ,1 nurse, & 2 part time receptionists job sharing.

I agree with all of the above. I to am in the in between generation.

I am a Pediatrician, like Bert. I have a practice that is 60+ percent Medicaid in inner city Chicago and underserved suburbs.

Bert, unlike you, Illinois has some of the lowest rates of pay in the country for medicaid patients. Now it has gone to managed care and many of them have restricted policies for taking on physicians. Plus the state will sometimes change them from 1 plan to another without telling them. Thus patients come in the next month and can't be seen because they are on a different plan. I currently take 2 of the 6 plans. I can't get credentialed with the others despite being board certified. The system is designed to cut costs by making it difficult to chronically take care of patients. Then the state sponsored vaccine program tightened up and many of the FP providers just gave up giving immunizations. Many more hoops.

I worked in 2 different Community Health Centers for almost 15 years but they were poorly managed and finally I decided to go into private practice. I had a nurse practitioner working with me, but had to let her go because of reimbursement. It was a choice of paying her or me!

Burnout? I don't think I have that, FRUSTRATION is a much better term for me. I am somewhat in control of my environment. I would suspect that a lot of the burnout is with the younger docs who are trapped in a corporate environment that treats them no better than clerks. Those systems expect more and more of them and hobble them with EMRs that can be frustrating.

Yes, I have to do a lot of prior auths. Every plan has a different formulary and my main MC plan changes it twice a month. Sometimes flovent is covered and sometimes not. Again, not really saving money, more just making it more difficult to provide necessary meds. But this is the world we live.

The AMA set the system up. It started with CPTs, which they hold the copyright and sell licenses. They then went on to develop RVUs. Congress (mostly lawyers) decided that unionizing doctors would be anti trust. But it was OK for insurance companies to collude. Follow the money!!! The AMA has never been a spokesperson for the average physician, especially in primary care. But again, this is the world we live.

Retirement? Sure, sounds great. but I don't have enough put away (remember, I couldn't keep paying my NP). If I actually was paid for what I do, I wouldn't have to worry about money. Not sure I would retire, but it might be nice to have the option.

Private practice is dying because of increased regulation. Corporations are becoming king. It was telling for me to learn that there are corporations that do nothing but medicaid. If you can make money at 2/3 Medicare rates what does that say?

I have closed except for routine newborns and healthy children. Only seeing patients a few days a week. I do telemedicine but it's not the same. It's a fascinating time when I tell patients "if you're sick don't come to see the doctor" Once more this is the world we live.

Just me in the back(doc,nurse,cleaning man, IT specialist); wife up front(office manager, receptionist, billing assistant, patient advocate). We don't understand what that retirement thing is.

Thanks everyone. I didn't see all of these in my email. Just one from Wendell. But, that allowed me to all of them. Fascinating.

Yes we are lucky here with MaineCare. Only because of one governor. Close to private reimbursement. There is only two plans, the difference being referrals. PAs suck, but pretty easy to navigate. They do Drug Utilization Reviews and if Symbicort outbids Advair, it's preferred for that round.

One great thing about MaineCare is NO COPAYs and unless they lose it, no back balances. Plus, one MC patient means two or three as the parent just asks to have the other two seen without a copay. The difference in entitlement though is unbelievable.

I don't want to be too melodramatic, but even after all these years of being an internist ( I am the first and only doc in my family) I still have to pinch myself at times because I never envisioned doing this as a job when I was a kid or teenager. It sort of just fell into place when my Pre Vet advisor suggested med school over vet school because my grades weren't conducive to getting into vet school with the first try, but since the state of WV had/has 3 med schools he figured I would get into one of the med schools at least on my first try, which did happen. And I never did apply to any vet school, figured I was more infatuated with James Harriet's books than really becoming a vet when I had to start being practical about my eventual vocation. So I do think you meet certain folks along your journey and my pre vet advisor gave me the best advice ever, when I most needed it. I do enjoy, even with all of the crap mentioned above doing this gig, and I have had a lot of fun with the secure video chat implementation, albeit not without some stress. My nurse mentioned today, how the practice has changed significantly in her 3 years of working with me, she helped get me started with secure texting and now the telehealth stuff, which is comprising I bet at least 75% of my total daily visits now.

I just don't get why doctors do the PA's.
It's one thing if it is a monoclonal antibody prescription and the ins. co. wants to make sure it is an appropriate Rx.

But PA for cyclobenzaprine because your patient is 65 and a month-- "Beers List"??
Or PA because the insurance company wants doxycycline hyclate instead of monohydrate -- or vice versa ??

I refuse to do PA's. I tell the patients they need to call their insurance company and demand to know why their doctor isn't smart enough to prescribe without insurance oversight. It's surprising what sometimes happen when you get the patients involved.

Their other option is to pay for the drugs themselves. I give them GoodRx coupons, and often the coupon price is less than their copay.

I am a physician, not a clerical functionary. I will not beg for scraps from bloated bureaucrats.

Prior auth's are a tricky thing. I frequently will not do them and tell the patients that they need to call the insurance company.

I do try to follow their formularies, but that can be difficult. The more important the medicine is, the more likely I am to get prior auth.

Sounds like we would all LOVE the forest but for all the trees.

SORRY TO SAY......

This is the fault of ALL PHYSICIANS and ALL, PHYSICIAN'S fault. We let this happen to us while we were so busy TRULY making the patient the most important aspect of our lives. SADLY... we are the only ones that can change it OR even have the will or ANY motivation to change it. The system works too optimally, for those that are not providers, for them to want to change ANY of it. Who doesn't love a free ride on the backs of the frontline workers.


https://www.youtube.com/watch?v=L_1PNZdHq6Q

You know. I agree 100%. But, it is difficult. Remember Reagan and the ATCs. Fired and replaced by scabs. Kinda scary. Like you said, we are too busy working to notice? Did this happen to attorneys? No, but it is what they do. Not take this stuff. We could all go on strike. And, they would just take our licenses away.

The problem as I see it, is we have these huge associations like the AMA, and they do nothing to fight for the doctors. They are part of the problem.

AMA / AOA are rackets, designed to collect fees and make a few richer while they fein protecting doctors and the profession.

If we want our profession to be what we all know it needs to be, we are going to have to create some Martin Luther King moments. The hilarious thing is.... every one of my colleagues I discuss this with tells me, " I could never do that to my patients." To which I respond, how many of your patients appreciate the state of the current healthcare system and ..... do you think you're providing the best level of care that you and your patients deserve????

We are worse than deaf dumb and blind cats......

because we are the Orcas Whale (KILLER WHALE) swimming around in the ocean TERRIFIED by our own shadow with everyone else looking on, knowing full well that we are truly the only ones that can fix this system and the only ones who have the POWER to fix this system, yet we exist in a milieu of fear and irrationality that exists only in our own minds and is the whole reason that this horribly corrupt system is allowed to persist.

Orca Whale...... They can't stand to loose any doctors, especially right now. NOT ONE OF US SHOULD LOOSE OUR LICENSES, especially not if enough of us join the movement.

If 10% of ER Docs refused to treat ANYTHING that wasn't life threatening, it would bring the system to it's knees.

ONLY WE HAVE THAT POWER!!!!!

ALL THAT POWER AND NONE OF THE WILL..... =====>> WHAT WOULD MLK SAY???

My apologies.....

What are you apologizing for? I don't see anything. Besides:

Posting to the board means never having to say you're sorry.

"From the movie, Love Story"

Hi SnowDO,

I certain agree with Bert, absolutely nothing that you have to apologize for. This board runs hot and cold, busy and slow, I greatly doubt any one is specifically avoiding you or the topic. I, personally, have been very busy recently.

Having said that, I have mixed feelings about your viewpoint. Is the practice of medicine difficult, and worse than it was generations ago? In many many ways, absolutely.

Can we/should we/could we have done anything about it? I do not have a clue.

Medicine is so diverse, different specialties, different practice models, different eras of physicians, I am not sure anyone could say, with absolute unanimity, "We want…"

Well okay, we are could agree we want more money, better hours, less regulation, and less interference with our practice. But I doubt we would be of unanimous opinion on the details.

How do you divide the pie between specialists and primary care? Between procedures and office visits? Between hospital and outpatient?

In my years of practice (I am 64), I have seen two "primary care is not paid enough, specialists are paid too much" movements. Both of these basically led to divides among physicians, and the end result was cutting specialist reimbursement.

The idea of a work stoppage is interesting. For a physician in private practice, I think it would be more or less shooting yourself in the foot. Also, I could imagine attorneys gleefully looking at bad outcomes because the patient could not be seen by their usual provider.

Employed physician striking, you use the example of ER docs, might have less personal liability, but I am really not sure what 10% of ER docs striking would accomplish.

This is a serious question. Let us saying, hypothetically, that all emergency room providers would agree not to work, or not to see non life threatening situations (itself a somewhat challenging concept), until certain demands were met. What would those demands be?

I am not writing this to be argumentative, I am interested in your thoughts.

Thanks.

Gene

I agree it's a good topic. And, I agree a lot of the blame is on the doctors. But, doctors' lives and work are so hectic (all over the place) compared to the attorneys sitting behind their mahogany desks worrying only about billing every ten minutes. I don't think a lawyer can get disbarred for not taking cases.

If I decided to not see patients that came in because I didn't think they had a high enough acuity level or just at all, the board would be all over me. Not sure how the bar works, but the Board of Licensure in Maine is vicious. They live for suspending and removing licenses. Even if a patient reports you to the board for putting one too many signs on your window or having paper on the floor, the board "must investigate." They have no authority to call something a frivolous complaint.

This is why I have always thought, "What if every doctor stopped seeing Medicaid for 30 days? Well, we would receive a letter stating that if we went another five days, our license would be revoked. Even if it were suspended that would be the same for me. No coverage.

Our fight should be with the insurance companies. They are the real problem.

No our fight is NOT just with the insurance companies.

Bert, while you have said in the past that Mainecare pays well, throughout the country, Medicaid pays about 70% of private insurance. Isn't that slightly about 3/5 of a human being?

And why should we have no right to collective bargaining while insurance companies can do what they want. They are certainly part of the problem, but the real issue must be dealt with through congress/legal means.

I am convinced that the myriad of different requirements that insurance companies have for billing is just another way to avoid paying. Why can't there be a truly standard format?

We were docile while the AMA colluded with the insurance companies. While there may be some value in CPTs, why should they have a copyright on them. ICDs were designed for death monitoring, but have been pushed into service for live patients, thus the large number of irrelevant topics (hit by a meteorite) while no good description for gastroenteritis. Total waste of time.

The problem with Congress besides their having perfect insurance, is they aren't physicians or medical people. They think it is all about Big Pharma, etc. Interesting, that they want to do away with Big Pharma except for those who get kickbacks. One thing they have no idea about is the waste due to patients going to the ED all the time.

We should be able to negotiate. Insurance companies, especially Medicaid negotiate all the time with pharmacies. Self-pay for Accutane: $1,000 per month. Accutane for Medicaid free. Why? Because Maine is 65% Medicaid.

___________________

By the way, how would I find out statistics on solo or private or solo/private physicians in my state?

This is a great topic, and I appreciate everyone sharing! I think I missed out on a lot of the earlier generation doctor benefits. I have some old charts that show a single line note for a visit, especially for pediatric well visits. The doctors were just trusted to do their jobs. Now it's writing a book every day to satisfy billing and any future lawyer related "concerns." Some of my best practice was in India and Peru on medical missions, filling out just a note card like you see on the Doc Martin show in the UK. Just doing medicine, and not worrying about senseless documentation and billing!

I've been in Solo practice for 10+ years in Alaska. Recently I hired a PA. I grew from renting a single room from another doc, doing all the phone calls, blood draws, and everything myself. Slowly we added staff, computers, equipment, and changed buildings. In the last couple years, we were able to build a brand new commercial office building and add enough space to ultimately have 2 MD's, a counselor, and a PA. Speaking of this, I will be looking for another doctor before long. We are in a growing area, despite the decline in healthcare payments. We run traditional Family Medicine. I stopped doing OB, colonoscopy, and inpatient hospital work for lifestyle reasons. I used to pride myself in admitting all my own patients. But they were almost always Medicare and at 3 AM. You get paid 50 dollars for 3 hours work! While I loved it, it was a season in life and the personal time has been important beyond measure. I think my practice has been very successful, but insurance companies and the driving forces of government are killing traditional medical practice.

I grew up in Oregon, and when I considered returning there after residency, I found the insurance monopolies has completely locked down the region. The Blue Cross and Aetna are able to completely monopolize a region or a state. They collude to make deals, parsing up their "market territory." Many regions in this country have only one insurance monopoly. All the doctors work for that one insurance company. Meanwhile, it is a Federal Trade Violation for two of us to even discuss not taking Aetna, unionizing, or any other agreement.

Why has this happened? The US government is incredibly corrupt and I believe has become fascist. That's because the government exists to serve corporations and visa versa. An executive at Monsanto goes to sit on the USDA. Then he goes to work at the FDA. Then, it's over to Pfizer. The insurance monopolies have powerful lobbies that control the arms of the government. The idea that you are protected by government agencies is a joke. Did you know that all your meat comes from one of 5 companies that control everything from farm to table? But I digress.

When I first came to Alaska, it was traditional medicine. Insurance companies had reasonable premium prices and mostly paid what you billed. You could have insurance for your family on a personal plan for 600 dollars a month. Then "affordable care" was passed. You can't get an individual plan for less than $2000 per month, thanks to government meddling. I lost my insurance.

Then, just like Oregon 30 years ago, the PPO's moved in. Doctor's sold out by joining, giving up all autonomy to try and compete with each other for patients. The insurance co said, "Join our PPO, and you can have all the patients. Just take a 20% pay cut." Once they had done so, all the doctors had to join or they would get no patients. (One of my patients has 1500 dollars deductible in network, which I didn't joint, and 9000 out of network. I see her for free after 1500 dollars.) Then another PPO came in, and said you can take 50% or you will lose all your patients down the street. They successively ratcheted down the payment to doctors, who stood all alone and could not unionize, have meetings, or in any way organize under the government laws protecting the insurance cartels.

We still have it pretty good in Alaska. Medicare is the worst payer. However, Aetna is getting really close to Medicare on payments. Medicare is about 50% of most insurance payments, and we could not keep our doors open on Medicare. It's an expensive environment where you can pay 5 dollars for milk and 5 dollars for eggs at the store. Our overhead is about 60%. Nurses have not taken any pay cuts, neither have the snow plowers, the electric company, or the internet provider, or Amazing charts. Costs keep going up and payments keep going down. When all the insurance companies pay at Medicare rates, or when Bernie/Biden get "Medicare for All" it will be time to retire.

Perhaps some doctors will continue, supervising armies of NP's and PA's, but the era of someone seeing their Family Doctor will be over.

My biggest frustration is actually AC. It crashes every time I try to write a prescription. I don't bother with PriorAuths. I tell the patient it isn't on their formulary, and if that's a problem, call the nasty insurance company. Often that PA is over $7 they could pay themselves.

I actually love my job. I do a lot of procedures, from derm to orthopedics. It's the only job that keeps me fascinated, allows me to make a good wage, and also allows me to help people. (the perfect trifecta!) Much of that is because I went into Family Med, which never gets boring. I think I'd have quit long ago if I was a specialist.

Interesting discussion--

Those of us of a certain age have seen a lot of change in the profession, but of course, we were warned by our elders when we were in training that the future would be very different from what we experienced in the 60's and 70's, and so it has been.

The changes we have all been discussing and commiserating with each other about really started a very long time ago -- probably in the early 19th century, when medicine actually became useful and not just the province of the elites -- but therefore of interest to the the general public and the government. Different countries and different governments have taken somewhat different approaches -- but in all cases, what was once a very private matter between a physician and his (mostly his) patient has become commodified-- that is, controlled by the market, and industrialized -- that is, controlled by an administrative class. This is true whether you are discussing "socialized" medicine like England or Sweden, or "free market" medicine as in USA. In any case, physicians have lost the ability to control the agenda.

Hippocrates' first aphorism states -- although we have all heard it, few have actually read it in context:
In other words, a major part of the "art of medicine" is to be like a theatrical director -- no matter how good the script or the individual actors, you have to be able to manage all of the elements of a play to make it work. The directorship has been taken from us -- given to functionaries and "bots" in insurance company and government offices -- or to the "C-suite" of large medical institutions. It remains to be seen if they will rise to the occasion. It doesn't look good to me.

Paul Starr, Princeton University professor of sociology, wrote an amazing book in 1982, which I first read in about 1983, but remains relevant -- most of his history has proved to be accurate and most of his predictions have come to pass: Paul Starr: Social Transformation of American Medicine

The Social Transformation of American Medicine: The Rise Of A Sovereign Profession And The Making Of A Vast Industry
Paul Starr
Basic Books, 1982 - History - 514 pages
1 Review
Winner of the 1983 Pulitzer Prize and the Bancroft Prize in American History, this is a landmark history of how the entire American health care system of doctors, hospitals, health plans, and government programs has evolved over the last two centuries.

"The definitive social history of the medical profession in America....A monumental achievement."—H. Jack Geiger, M.D., New York Times Book Review

At this point, I regard my practice as something of a social aberration -- more a hobby than a real job. Like Cervantes' Don Quixote, I am still tilting at windmills -- with no effect on the system that has squashed me. But I have a quiet hidey-hole where my wife and another anachronistic doctor associate can practice mid-20th century style medicine, and we are happy, and the patients love us for it.

Maybe flattened a little, but not squashed.

Thanks Jon.

What has been squashed is my naive belief that with more and better information, people would behave better.

It's interesting to read the hateful, partisan troll responses in Medscape, for example. People who claim to be doctors and nurses but who don't seem to have a nanogram of empathy or any sense of scientific curiosity or intellectual rigor. That sort of stuff is being originated and propagated by an organized system -- not a conspiracy, for it is all out in the open -- a system which apparently intends to amass power by simply eliminating all non-believers and other enemies. And those folks are very clever; well educated people fall for their lies.