Healthcare in the USA today.

[smitcompton]

Hi,

I am going to weigh-in on this conversation. Dr.s themselves created the group practice, which sounded sensible at the time. This was done for financial reasons and convenience for patients., who would be able to walk down the hall to see another Dr for related or unrelated ailments. Some group practices grew into factories and hospitals began to look at group practices as both profit centers and convenience for their hospital patients.
One of my doctors( a neurologist, was thrilled Rush-Pres St Lukes in Chicago bought their group practice. He is a man in his mid-forties and told me he was relieved. They would have none of the administrative responsibilities. He did speak about DR.s earnings. As he said, Dr.s today don't want to make $400,000, but want a million. This might have been 20 yrs ago, when the real big beef was insurance companies asking for pre=approvals.

My last two hospitalizations I noticed Drs were spending more time with me. Sometimes I had trouble keeping the conversation going. I thought, I'm dying. About 5 different Dr.s. It was only when I read the billing for medicare that I realized that medicare was paying the Dr.s for 35 and 25resp. minutes for their visit. This hospital was taken over by Northwestern, an excellent hospital. These Dr.s were spending time with their patients. I was floored. I have had 10 minute office visits with another group practice and I stopped going to them when I heard the young women complained of the 10 minute hour. I never look at that practice the same way.

My present GP never rushes me, and he always, always reads my chart before he walks in the room. He has the information in his head. I am so impressed with him. Its a very large regional group practice he belongs to. They e=mailed teir patients over 65 to come get the shot. They set up 2 or 3 different locations to go to.

I don't want you to think its all glowing, I have had a few bad ones, one terrible one in England, and a few here. Truthfully I'd rather be here for medical care.

Whats broken is the high cost. And, my opinion, is that Drs want to be paid more. They definitely want the million or more. Dr.s don't think they should be told by anyone what to do--insurance companies or takeovers..

Dr.s complain too much. And we have lost the personal in medicine. As a child our Drs knew us, our parents, and if you met them on the street, they would know. who you are. Very little real human contact. We are just numbers to the Dr.
They would get more satisfaction if that could change.

Annette

 

[missy]

Whats broken is the high cost. And, my opinion, is that Drs want to be paid more

I respectfully disagree with you. Doctors study long and hard and work to get their degrees to help others. They deserve to be paid more IMO. Depending on the speciality and other factors I won't go into here. Because some specialties do get a lot of money but I do not begrudge them that at all.

My goodness when I see what other professions earn I see such an imbalance. Why should CEOs, actors/movie moguls, sports teams, athletes, etc. earn so much while teachers, nurses, etc earn so little? There are no more noble professions IMO than teaching or nursing and yet look what little value we as a society place on them? Surely they deserve higher pay.

I am glad you have good experiences Annette with your physicians and may that continue. But I do not think we should criticize physicians for wanting to earn more. Who doesn't want to earn more? They put in a lot of time and energy and money working towards their degree and I am not saying some specialities are not compensated fairly but for example I think internal medicine physicians deserve to earn more depending on their situation.

Of course if one takes a job, no matter the compensation, my grandfather always taught us you do the job to the very best of your ability. If you don't like what you are getting paid leave it and find another. Easier said than done but just sharing my grandpa's philosophy in life. Work hard and do the best you can if you are taking the job. And don't complain (him talking) and give it your all and be grateful for the job. Of course the mentality was different back then and my grandfather faught in the war and left home at 14 (nasty stepmom) and he was a tough cookie. So he was shaped by his experiences in life. As we all are.

But I refuse to denigrate an entire profession. No, there is much disparity in earnings and we as the general public, IMO, put too much importance on things like sports and entertainment and those professions get so much money while professions like teaching,nursing and the like are underpaid. Not fair, not right. But if you go into those professions kudos to you for caring and make sure you go in with your eyes wide open. That way you know what you are getting into and you have my utmost respect for taking on careers where you truly want to help others. Kudos to you.

And we have lost the personal in medicine.

Yes, I agree with this. We have lost so much and the personal touch and the caring concern is one casualty. It is a shame. I don't how to fix this but I will say big pharma needs to be stopped. They are a big part of the problem. Talk about evil corporations.

Did you read that thread on PS about a medication that can save cats from a terrible disease that is not allowed on the market? It could save cats from horrible suffering and death and yet the evil pharmaceutical company refuses to allow it to come to market. Yes, I know it is for cats but we can tell a lot about a nation by how the animals are treated can we not? And it is just one short step to humans. And If one cannot afford or even get (for whatever reason) their (life saving and /or quality of life altering) medications all is lost.

How can we in this 21st century allow people to die because they cannot afford healthcare or their medications?

It is happening and it is unacceptable.

Good healthcare including medications should not be a privilege. It should be a right. For all.

 

[smitcompton]

Hi,

First, let me say that nurses are paid pretty well, far better than teachers. As I read the discussion it seemed to me the blame for the problems were put on everyone else, except the Dr. Nobody that I know wants Drs to be poorly paid. Your point about the highly publicized salaries of the sports figures and entertainers is well taken. However the whole society has come to believe that their jobs are worth a lot more than they are paid.
Dr.s are one more profession that wants more.

Missy, everyone complains too much. That seems to be the new philosophy, especially on the internet.. My recurring theme is too many demands put on the society by everyone, will bring it down. I think Dr.s should be well paid, but I don't think they should follow in the footsteps of the sports figures and entertainers. Drs no longer want to be upper middle class, they want to upper class. Its true, you can want anything in this world, but the rest of us don't have to pay for it. I love Dr.s, but lets not blame everyone else and then say, poor me. I have to leave the profession. I can't be a 1%er.

Annette

 

[Arcadian]

My dogs have better insurance than I do.

 

[missy]

My dogs have better insurance than I do.

I hope sweet Ms. Lucky is doing better @Arcadian.

 

[missy]

Opinion | The End of Job Security in Healthcare

We need to reverse several dangerous trends

www.medpagetoday.com

"
The current model of healthcare in the U.S. has been unsustainable for decades with costs out of proportion to the level of care provided.

As we've witnessed firsthand, hospitals continue to be overwhelmed. They needed greater provider support but could not afford nor protect them. Yet, many hospitals recorded huge profits from federal stimulus programs last year.

The following are 5 disturbing trends that signify the end of "job security" in healthcare, and potential solutions to address the problem:

Losing the healthcare workforce. In addition to typical retirement at the end of a long career, the profession is losing a large portion of its younger workforce due to burnout, lack of career fulfillment, and career exodus from physicians less than 5 years out of training. According to the American Association of Medical Colleges, the U.S. is predicted to have a massive shortage of physicians estimated between 37,800 and 124,000 physicians by 2034. Staffing shortages are leading hospitals to replace physicians with nurse practitioners and physician assistants. In other cases, hospitals are closing or merging with larger entities.



Increasing physician unemployment. To combat the predicament of a physician shortage by 2034, new medical schools are opening across the country, and existing schools are increasing their enrollments. However, residency-completion and board-certification are prerequisites for practicing, and the Accreditation Council for Graduate Medical Education (ACGME) is increasing the number of residency positions and programs at a rate significantly less than the total number of residency applicants each year. Many of these physician graduates carry large student loan burdens and have spouses and children to provide for. Because of this trend, too many graduating physicians will be forced to defer a year or more to obtain a residency, or abandon their dreams of clinical practice altogether.

A model towards hospital-based W2 employment. With the consolidation of healthcare systems and physician practices, the trend for physician employment will be towards large hospitals and organizations as opposed to the solo private practitioner model. Smaller entities will not be able to sustain a competitive advantage in today's healthcare marketplace. From a tax liability standpoint, a W2 income statement offers the least benefits, and severely limits a physician's choices in terms of practice location and choice of employer.



Replacement of physicians by other providers. While the reasons for this trend are multifactorial, an increasing number of physician assistants and nurse practitioners are being employed to provide patient care in roles typically held by physicians. The long-term effects of this trend have started to raise questions among physicians from a financial and patient care standpoint.

Buyout of physician practices by private equity. With the for-profit business model in U.S. healthcare, a number of private equity firms have targeted physician group practices for acquisition. According to a research letter published in JAMA in 2020, the number of physician practices acquired increased from 59 to 136 from 2013 to 2016. Anesthesia and multi-specialty groups were targeted as the most attractive, followed by specialties such as emergency medicine, family medicine, and dermatology. While these numbers remain relatively small, this trend is concerning since these practices have the potential to be solely controlled by the interest of shareholders and Wall Street in the future. This places shareholder interests above those of patients and providers.

We are on a fast-moving train on a collision course. Our society is in need of a healthy and robust healthcare workforce, but we are witnessing an aging profession, obsolete paradigms, an inability to afford, train, and educate the workforce, increasing regulatory requirements, and an aging population. All of this is happening in the midst of a strained healthcare system brought on by COVID-19. Hospitals have responded by cutting pay, furloughing, laying off workers, increasing requirements, and hiring cheaper replacements, while maintaining their profit margins. These measures serve the business model, while neglecting the underlying provider workforce and compromising patient safety and satisfaction.

Looking back in history, this trend can be seen in the auto and airline industries, among countless others, as a result of clinging to outdated Industrial Age business models. Physicians need a more entrepreneurial mindset and greater advocacy. We need to develop early financial literacy and create multiple streams of passive income independent of our clinical practice so that we can practice medicine on our own terms as opposed to being at the whim of hospital-based decisions. Physicians must wake up and do something about the dire future of the healthcare landscape.

Christopher H. Loo, MD, PhD, is a retired physician, author of "How I Quit My Lucrative Medical Career and Achieved Financial Freedom Using Real Estate," and the host of the Financial Freedom for Physicians Podcast.

"

 

[Arcadian]

I hope sweet Ms. Lucky is doing better @Arcadian.

She's doing quite good, living the good life having mom do all the cooking....lol We've got appt for the Scans mid November.

 

[Karl_K]

an increasing number of physician assistants and nurse practitioners are being employed to provide patient care in roles typically held by physicians.

The majority of my care team are nurse practitioners and as a patient I will say I am happy with that.
Not because they are better or worse, its that they are not scheduled as tight and have more time.
My shoulder shots this time were done by the Dr but have been done by PA's and med students the majority of the times.
It is interesting how different departments set it up different.

 

[wildcat03]

I'm reading a lot of indictment of "greedy doctors" here but I sense that most people aren't taking into account the opportunity cost and real cost of becoming a physician. My med school loans were well over 300,000. I spent from age 24-33 in medical school, residency, or fellowship barely able to save anything. When I entered practice at age 33, finances were a very real concern. I work for a state institution. I make about 65% of what my colleagues in private practice do. I work evenings, nights, weekends (usually 2 evenings/week, 3 weekend shifts a month, and 6 nights/month). There has been no "work from home" option as I navigated fertility treatment and subsequent high risk pregnancy through a pandemic (although there certainly were opportunities, I was told that my full time position would not be held for me postpartum - this was a risk I couldn't take). When I developed an excruciatingly painful condition at 34 weeks pregnant I worked through it, taking breaks in a small communal office to tend to myself. When it recurred at 36 weeks one of my surgical colleagues squeezed me in to her office. I asked for long-acting local anesthetic so I could work my shift that afternoon. The recommended time off work for the procedure is 10-14 days, but that wasn't available to me without stealing from the only maternity leave available to me - FMLA. In 7.5 years of practice, I've not once wished for a bigger salary. I've rarely cared about working the evenings, nights, and weekends. What I have wished for is the recognition that I am HUMAN. That I can get sick AND have a baby in the same year. That leaving a new baby (and in particular a breastfed baby) at 12 weeks is practically inhumane - especially when it involves overnights away at work. In the last year, in particular, I (and my colleagues) have been so demoralized by the death of expertise that has taken hold of this country. We are exhausted and no amount of money thrown at us can fix that.

 

[smitcompton]

Hi,
Oh please, don't tell me these Group Practices that were formed by Drs for the very same reasons that hospitals are now buying them, are unable to say no, you can't buy us out. You are stealing our profit centers. No, they sell, and then tell us the big, bad hospitals have taken over and I have to retire or teach.(It seems thats popular.)

I can't continue to sound as if I don't like or support our Drs. Nothing could be further from the truth. So, I will leave this conversation by pointing out that the article that Missy posted, proves, I think, more my point than hers. This retired Dr. is now a financial advisor who wishes to make Dr.s financially independent by investing in Real Estate. Hes going to put them in the !%.

Dr.s have gone through changes before. Perhaps they should make getting in to medical schools easier, as in the European model, and or make more grants available, so they won't have the big financial burdens that accompany med school. After all, interns and residents used to make almost nothing, until there was an outcry. Being a Dr still holds honor in our society. I think many Drs will still want to be Drs.

I'll raise my glass to our doctors. Here, Here!.

Annette

 

[missy]

I'm reading a lot of indictment of "greedy doctors" here but I sense that most people aren't taking into account the opportunity cost and real cost of becoming a physician. My med school loans were well over 300,000. I spent from age 24-33 in medical school, residency, or fellowship barely able to save anything. When I entered practice at age 33, finances were a very real concern. I work for a state institution. I make about 65% of what my colleagues in private practice do. I work evenings, nights, weekends (usually 2 evenings/week, 3 weekend shifts a month, and 6 nights/month). There has been no "work from home" option as I navigated fertility treatment and subsequent high risk pregnancy through a pandemic (although there certainly were opportunities, I was told that my full time position would not be held for me postpartum - this was a risk I couldn't take). When I developed an excruciatingly painful condition at 34 weeks pregnant I worked through it, taking breaks in a small communal office to tend to myself. When it recurred at 36 weeks one of my surgical colleagues squeezed me in to her office. I asked for long-acting local anesthetic so I could work my shift that afternoon. The recommended time off work for the procedure is 10-14 days, but that wasn't available to me without stealing from the only maternity leave available to me - FMLA. In 7.5 years of practice, I've not once wished for a bigger salary. I've rarely cared about working the evenings, nights, and weekends. What I have wished for is the recognition that I am HUMAN. That I can get sick AND have a baby in the same year. That leaving a new baby (and in particular a breastfed baby) at 12 weeks is practically inhumane - especially when it involves overnights away at work. In the last year, in particular, I (and my colleagues) have been so demoralized by the death of expertise that has taken hold of this country. We are exhausted and no amount of money thrown at us can fix that.

@wildcat03 I appreciate you and your colleagues and so do many people. I’m sorry you have been made to feel less than valued. Your sacrifices and your skills and your caring service is the best of our healthcare system. Thank you.

Hi,
Oh please, don't tell me these Group Practices that were formed by Drs for the very same reasons that hospitals are now buying them, are unable to say no, you can't buy us out. You are stealing our profit centers. No, they sell, and then tell us the big, bad hospitals have taken over and I have to retire or teach.(It seems thats popular.)

I can't continue to sound as if I don't like or support our Drs. Nothing could be further from the truth. So, I will leave this conversation by pointing out that the article that Missy posted, proves, I think, more my point than hers. This retired Dr. is now a financial advisor who wishes to make Dr.s financially independent by investing in Real Estate. Hes going to put them in the !%.

Dr.s have gone through changes before. Perhaps they should make getting in to medical schools easier, as in the European model, and or make more grants available, so they won't have the big financial burdens that accompany med school. After all, interns and residents used to make almost nothing, until there was an outcry. Being a Dr still holds honor in our society. I think many Drs will still want to be Drs.

I'll raise my glass to our doctors. Here, Here!.

Annette

Annette you and I are not quarreling. At least I don’t feel we are. I know you value good physicians because you have good physicians. I hope you are right that many good and caring people will still want to go into this profession. We need as many skilled and caring physicians as we can get. The population is getting older and people need quality care.

 

[wildcat03]

Hi,
Oh please, don't tell me these Group Practices that were formed by Drs for the very same reasons that hospitals are now buying them, are unable to say no, you can't buy us out. You are stealing our profit centers. No, they sell, and then tell us the big, bad hospitals have taken over and I have to retire or teach.(It seems thats popular.)

I can't continue to sound as if I don't like or support our Drs. Nothing could be further from the truth. So, I will leave this conversation by pointing out that the article that Missy posted, proves, I think, more my point than hers. This retired Dr. is now a financial advisor who wishes to make Dr.s financially independent by investing in Real Estate. Hes going to put them in the !%.

Dr.s have gone through changes before. Perhaps they should make getting in to medical schools easier, as in the European model, and or make more grants available, so they won't have the big financial burdens that accompany med school. After all, interns and residents used to make almost nothing, until there was an outcry. Being a Dr still holds honor in our society. I think many Drs will still want to be Drs.

I'll raise my glass to our doctors. Here, Here!.

Annette

I find your objection to physicians investing money somewhat puzzling. A physician who is financially independent is one who is not beholden to private equity or a health system and can practice as he/she chooses. Yes, My husband and I have investments including real estate - that doesn't play into my practice of medicine at all (except for my retirement date). I suspect we are in the 1% but I really don't know (and anyone who was a casual observer of our life would never be able to tell). That doesn't make me any less of a physician or devalue my experience at all.

 

[erislynn]

Where to begin…. first, I’ll say I agree with what missy’s said about the state of healthcare. It’s become increasingly commercialized and is continuing to do so at a faster rate every year. It’s because of a combination of low insurance reimbursements, MBAs and other administration who bring their business mindset into healthcare and overstep boundaries, increasing costs of medical technology that has a subscription or per use fee or required update, for-profit level competition even from not-for-profit hospitals, and high medical liability which leads to high professional insurance premiums.

So on the front end, you see dr’s charging more while spending less time per appointment. On the back end, the insurance companies are cutting their reimbursements anywhere from 20-100%. The MBA’s are squeezing more and more appointments out of their schedule. How else would the MBA’s get paid? The advanced equipment that the hospitals buy to keep the standard of care competitive, that has to be paid for somehow. And this equipment isn’t sold by some old-school medical device company. It’s sold by cutting edge tech companies who know how to protect their margins. Sometimes the majority of the fee you/insurance pays actually goes to the medical device company. Would you mind if someone else was paying one tenth of what your insurance pays but got the same level of service and appointment time? The administration sure doesn’t. Pack em all in. They’re paying salary to the drs anyway.

And lastly, I don’t know of any other industry where the frontline workers have to invest so much of their own time and money into their training, pay exorbitant amounts of money for the privilege to work, hire extra admin to deal with insurance companies so that they can ultimately get paid less, and offer services upfront just to possibly not even get paid. All this is because of the philanthropic culture of the profession. If you compare this with how lawyers do things, you’ll learn to appreciate what drs do. Ya, drs get paid “a lot” but if you really look at the work/pay ratio, it is behind a lot of other industries. Drs spend four to eleven years in residency at wages that are just enough to cover living costs, while people in other industries who are earning a market rate for that same decade might have already bought their first home. Before they’re even allowed to work or continue working, drs either have to pay up to six figure insurance premiums themselves or sign a contract with hospitals, which is what most of them end up doing. Can you imagine paying six figures upfront for any job before you’ve earned a dollar? This also doesn’t include licensing and continuing education fees. So yes, healthcare costs are high and continuing to rise but drs should be the last one to answer to that. Let’s re-examine the education system that has also become commercialized and is turning out physicians with ever rising student loans. Let’s re-examine the administration, governmental and organizational, that adds a layer of unnecessary cost with the coding, billing, and overregulation. Let’s look at the insurance companies who add no value to patient care and are adding middleman markups.

Aside from the monetary aspect, the sacrifices in their own personal health and family time that drs (and nurses) make to be available for patients, especially now in this pandemic, where every day they are coming in taking a life-or-death risk to take care of others, that’s why we should respect our drs and be grateful. Other people wouldn’t and couldn’t do that for any amount of money.

 

[smitcompton]

Hi,

Hi Missy and Wildcat,
Its not quarreling Missy, its that I know how is appears when I take the other side of the "poor me doctor" I took the money angle from what was in the first article you posted. It was more male Drs complained about what they earned*47% and said they would leave. So, I told you about what my Dr. said 400,000 20 yrs ago, and they wanted a million. Its an unpopular position and I also have personal experience listening to young Dr.s talk about what they think they will earn. Honestly, I never participate in Education threads. If there is any small possible criticism of teachers, there are just no words for what happens.

Wlldcat-- I don't mind at all if Dr.s make passive income. But don't tell me you have to leave medicine because you are not paid enough. And yes, so rural Drs and I suppose others aren't paid s well as others, but still most are paid well. Somehow, they don't turn up in low income figures.(I know I didn;t need to say that.)
Wildcat, I think you practice in Canada. Might be a little different there.

Annette

 

[wildcat03]

Hi,

Hi Missy and Wildcat,
Its not quarreling Missy, its that I know how is appears when I take the other side of the "poor me doctor" I took the money angle from what was in the first article you posted. It was more male Drs complained about what they earned*47% and said they would leave. So, I told you about what my Dr. said 400,000 20 yrs ago, and they wanted a million. Its an unpopular position and I also have personal experience listening to young Dr.s talk about what they think they will earn. Honestly, I never participate in Education threads. If there is any small possible criticism of teachers, there are just no words for what happens.

Wlldcat-- I don't mind at all if Dr.s make passive income. But don't tell me you have to leave medicine because you are not paid enough. And yes, so rural Drs and I suppose others aren't paid s well as others, but still most are paid well. Somehow, they don't turn up in low income figures.(I know I didn;t need to say that.)
Wildcat, I think you practice in Canada. Might be a little different there.

Annette

I practice in the US. And while I will never leave practice because I "can't afford" it (because in my field the overhead is fairly low) I can easily see a day where I say, "the hassles of work and the constant threat of litigation are not worth the income anymore."

 

[smitcompton]

Hi Wildcat,

Its funny you mention litigation. There was a time when malpractice was the topic for Drs leaving. The insurance rates were too high, and people sued more.. But, in the above articles I don't remember seeing a mention of that as a reason for Dr.s leaving. Its just an interesting point.

I'm glad you are paid enough and are staying in medicine. I really do appreciate your work.

Annette

 

[Karl_K]

I hope my comment on nurse practitioners was not taken as being anti-doc I have some awesome doctors on my care team, one while working the ER saved my life by getting into a major argument with another doctor over treatment.
I just meant that I am happy with the care provided by the nurse practitioners and they do have more time the way they schedule them where I go.

 

[wildcat03]

Hi Wildcat,

Its funny you mention litigation. There was a time when malpractice was the topic for Drs leaving. The insurance rates were too high, and people sued more.. But, in the above articles I don't remember seeing a mention of that as a reason for Dr.s leaving. Its just an interesting point.

I'm glad you are paid enough and are staying in medicine. I really do appreciate your work.

Annette

I think it probably varies by specialty and geographic location. I work in a city with a reputation for a very poor malpractice environment in a particularly high risk specialty. Of note, in the last year, 4 of my friends have left the clinical practice of medicine for other jobs. One to the health insurance/care management sector, one to the FDA, and two to industry jobs (those two had MD/PhDs so very unique, specialized skill sets). The first two took pay cuts in order to do so, the third got a raise and the fourth I am unsure but assume an increase in pay. One got a better schedule (like me, she worked evenings, nights, and weekends). The second has the same schedule as she previously did (M-F 9-5). Two have slightly better schedules. They all say that life is much better now. 3 of the 4 were hospital/health system based physicians. One mentioned that she is treated with much more respect than she ever was in her prior job (she worked with a very challenging patient population, but I don't think that is what she was referring to - I think it was more administrators, etc). At the end of the day I think we do our own healthcare a disservice by assuming that physicians leaving clinical practice are doing so solely for the money. I have also heard some say that these physicians "lack resilience" but I disagree and I think their training history speaks against that.

I appreciate your and @missy 's kind words.

 

[wildcat03]

I hope my comment on nurse practitioners was not taken as being anti-doc I have some awesome doctors on my care team, one while working the ER saved my life by getting into a major argument with another doctor over treatment.
I just meant that I am happy with the care provided by the nurse practitioners and they do have more time the way they schedule them where I go.

I did not take your statements as anti-physician at all.

 

[missy]

Opinion | What Happens When All the Great Doctors Are Gone?

In commemoration of the late Elihu (Eli) Estey, MD

www.medpagetoday.com

"
"Thought you would want to know" -- that is how I learned early Saturday morning about the death of Elihu (Eli) Estey, MD, professor of medicine at University of Washington.

Eli Estey was a cancer doctor who specialized in caring for people with acute leukemia, and someone I had come to know over the last few years. He was the product of a different era. He graduated from Yale University in 1968, finished his MD at Johns Hopkins University in 1972, and came of age in oncology in the late 1970s and early 1980s.



Cancer medicine was different then. The majority of cancer research was funded by public sources and philanthropy, and the role of the biopharmaceutical industry was virtually absent. Research moved fast and chaotically. A clinical observation could rapidly transform into an investigational protocol, and paperwork and bureaucracy had not yet metastasized and sapped the strength of clinical researchers.

Professor Estey spent over 2 decades at MD Anderson Cancer Center before moving to the University of Washington in 2008. He published hundreds of articles on the stock and trade of oncology -- clinical trial results and basic science experiments -- but also a steady stream of curious and unique observations about risk factors, predictors, surrogates, statistical interpretations, and treatment strategies in leukemia.

A career in academic oncology was different when Professor Estey embarked on his. It was not possible to enter the field and build several spin-off companies of which you held substantial equity. It was not conceivable that you would spend 10 years at a university, and then transition to be the External Vice President of Something Important at a large pharmaceutical firm. Instead, the only carrot for the person who pursued clinical research, who remained in the academy, was to make a vital observation, contribute to a scientific debate, or refine a treatment or combination. You entered cancer medicine to do good, and were under no illusion you could stay to do well.



And that is what Eli Estey talked about most with me: the shifting nature of what it meant to be an academic physician, the changing career goals and incentives. His goal was always to apply his intellect to help people with cancer, but in the modern world that increasingly felt like the afterthought. Now the principal goal is to network, to partner, to promote (the interests of major pharmaceutical firms), and the system works to reward those collaborations.

Many adjectives have been used to describe Eli Estey: iconoclastic, skeptical, brilliant, original. All of those are true, but a friend put it more simply. His death, she wrote, is a big loss to, "people who liked common sense." She is right of course. More than anything, that is what Eli Estey stood for: a basic and unyielding common sense in medicine. He applied it mercilessly as drug companies sought to promote costly, novel products that were no better -- or only marginally so -- than older, cheaper drugs. He applied it with vigor when investigators tried to pull the wool over his eyes, and get him to think a flawed, limited, broken study was good enough to change his practice.



In the years I knew him, Professor Estey frequently found himself at the microphone after the speaker. There, patiently, he asked a series of questions that often left the speaker in doubt, and the audience dazzled. Everything he said was just common sense, but boy did he know how to ask it.

Occasionally, Eli was direct with me. When I wrote an article he liked, he told me so directly, and cited the paper. But at other times, he was indirect. He often made it a point to tell me about some bit of oncology history -- some example where despite pushback, often fierce pushback -- someone pushed against the status quo. Eventually, I figured out why he made it a point to tell me these stories: it was his way of giving me encouragement.

Like many, I am saddened by the loss of Eli Estey, but I want to think for a minute about what happens when they are all gone. When all the Eli Estey's are no longer with us. By that I mean when all the doctors of a certain generation who trained in medicine -- who lived through unprecedented changes in American medicine as it entered the age of the medical-industrial complex, as Arnold "Bud" Relman, MD, put it in 1980, but retained their common sense -- are no longer with us. What happens when they are all gone?



I fear that medicine won't be the same. The baton will be dropped. Academic medicine will slide even further into the hands of corporate and donor interests. Freedom of inquiry and scholarship will diminish. I recently heard from a colleague who had criticized just one (!) cancer drug trial that their cancer center had advised them to take it easy, as the company had several more trials on site. More of that will come. Careers will increasingly be made by being the oral presenter on a multinational trial that the speaker didn't conceive, didn't analyze, and didn't write, using slides they didn't make. At the oral presentation, every new cancer drug will be a miracle, revolution, gamechanger, or cure, and when the lights rise, the first comment from the microphone will be, "Terrific talk, I agree."

Eli Estey was a leukemia doctor who benefitted the lives of thousands of trainees and many more patients. He knew what he stood for and was unapologetic about it. In his honor, I am re-releasing an interview of him on my podcast Plenary Session. You can find it here or wherever you get your podcasts. Episode 4.22.

Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer.

"

 

[smitcompton]

Hi,

I have had the privilege of knowing someone very like Dr. Eli Estey. He was such a wonderful man and raised two Dr. sons, He worked in a very large hospital, did research, was the head of his Department, taught at the Medical School and when we went to dinner there was an endless array of people who would come to our table to say hello. He was the best of the best. He had just escaped the Nazis in Vienna by one day. His life reflected gratitude every day.
He used to tell me, after he asked his sons, "Where is the future of medicine going to be?" "Pharmacology", was the resounding answer. Of course, that is where it has gone. We now have to watch the Medical Industrial complex, so that humanity enjoys the fruits of the efforts of our researchers.
Medicine will continue to do well. We need it so much.

Annette

 

[missy]

Seems appropriate to add this here.

"

Americans Have No Right to Healthcare​

— It's high time we change that​

by Cedric Dark, MD, MPH, and Kyle Fischer, MD, MPH January 31, 2022

The United Nations' Universal Declaration of Human Rights, signed in 1948, set up the framework that healthcare is a human right. Article 25 of the document stated that, "everyone has a right to standard of living adequate for the health and well-being of himself and his family including...medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control."

President Franklin D. Roosevelt previewed these sentiments in his State of the Union Address where he described the four freedoms. The first two, freedom of speech and freedom of religion, are codified in our First Amendment. But the third and fourth, freedom from fear and freedom from want, remain nebulous in our view. And nowhere in our nation's founding documents does it explicitly state that Americans are entitled to have access to a physician or any form of medical treatment.
Some people might interpret the values espoused in the Declaration of Independence, with its notion of inalienable rights to "Life, Liberty, and the pursuit of happiness," as denoting that "life" equals an explicit right to healthcare. This is simply not a reality in America.
The preamble to the Constitution mentions providing for the "general welfare." Could this be recognition enough that healthcare is a right for the individual? No, for one's individual welfare does not necessarily equate to the general welfare. Although there have been Constitutional Amendments proposed in the past -- most recently by Rep. Betty McCollum (D.-Minn.) -- as yet, there is no enumerated U.S. right to healthcare.

But, you may ask, doesn't a pregnant woman have the right to choose whether or not to have an abortion? Isn't that a right to healthcare? Yes, the Roe v. Wadedecision determined that this form of healthcare is legal. However, the Supreme Court based their decision on an individual's right to privacy in their medical decision making. It did not stem from a right to healthcare.
But, others may say, the emergency department is open to all -- doesn't that mean Americans have a right to healthcare? Unfortunately, the 1986 Emergency Medical Treatment and Labor Act (EMTALA), which made access to emergency care a right for all Americans, is exceedingly limited in scope. It only guarantees treatment for life and limb threatening conditions and treatment of women in labor. It does not guarantee treatment for chronic conditions such as high blood pressure or heart disease. It does not cover cancer care. Moreover, one must ask if a single, limited law could be construed as a right.

Senior citizens have a right to healthcare once they age into the Medicare program. More recently, Americans with specific diseases, such as end stage renal disease and Lou Gehrig's disease have this right to healthcare extended to them. But as simple laws, the right to emergency care, to care for seniors, and for those with certain deadly conditions could easily be ripped away. A future Congress could repeal these laws if it chose to do so.
It wouldn't be the first time. We have seen that health laws, such as the Medicare Catastrophic Coverage Act of the late 1980s, can easily be repealed. Other laws, like the Affordable Care Act, show that a single law can be sabotaged whenever a political party has control of both Congress and the White House. And the will of the people can be ignored by dithering politicians who intransigently refuse to implement lawful extensions of healthcare. As just one example, this occurred in Maine in 2018, when the former Governor failed to execute a Medicaid expansion ballot initiative approved by the state's citizens.

All our patients desire is a chance to be healthy and to keep their families healthy. Should they not be allowed to do this without squandering their life's savings or risking bankruptcy? Since the 1940s, following the defeat of Nazi Germany, our country has made bold steps towards securing this human right to healthcare and making Americans free from want.
If nothing else, this last year showed us that moving toward the right to healthcare for all is possible. With the federal government ensuring access to COVID-19 testing and vaccinations, everyone in this country had a right to the most aggressively developed medical care the world has ever seen. The pandemic has shown us what we can do when we recognize that an individual's welfare actually is dependent upon the general welfare. So, although an explicit right to healthcare does not formally exist in the U.S. for all people regardless of age or medical condition, the past 2 years have revealed why every American should be assured of that right.

America must make the healthcare of its citizens a protected right. As difficult as it may be in these polarized times, the U.S. needs a Constitutional Amendment to guarantee healthcare as a right. Anything less would fall short of the needs of everyday Americans. Until then, in America, healthcare is not a right. But its high time we change that.
Cedric Dark, MD, MPH, is an assistant professor in the Henry J. N. Taub Department of Emergency Medicine at Baylor College of Medicine. Kyle Fischer, MD, MPH, is a clinical assistant professor of emergency medicine and fellowship director in health policy at the University of Maryland School of Medicine."

 

[missy]

Our Healthcare Workers Are Still Drowning​

— Providers from UVA Health in Virginia share their experience during the Omicron surge​

by Emily Hutto, Associate Video Producer February 3, 2022


"
Two years into the pandemic, hospitals are overwhelmed by the Omicron surge and staffing shortages. Healthcare workers struggle against their own fatigue to care for patients. Three providers from UVA Health in Charlottesville, Virginia -- Katarine Egressy, MD, Katie Cecere, RN, and Kyle Enfield, MD -- reflect on the pandemic after a normal day of work.

The following is a transcript of their remarks:

Egressy: I am a pulmonary critical care provider and have been on the front lines of the COVID-19 pandemic for the past 2 years. And here I am at 8:45 p.m. since being at work at 7 a.m. in the morning.



The kind of tiredness that I feel, and [that] is probably shared by my colleagues, can't really be described in words. It's sort of the bone-weary tiredness, um, that really covers your whole body.

Cecere: I have been a critical care nurse for the past 14 years. Just to tell you about a recent shift that I had a couple weeks ago, I kind of thought that I was at my breaking point. I came to work; I was in charge that day. My co-charge ended up having to go home sick. And the unit was on fire. Unfortunately that day, there were no other nurses in patient care that could do charge. I had a patient coding in one room, a patient pre-coding in another, and it was just this helpless feeling of -- when I think about it, sorry, I still tear up -- it's just this helpless feeling of not being able to be everywhere that I was needed. Just this horribly vulnerable feeling that you're letting everyone that needs you down.



And so I spent half of that shift in tears. I texted my husband that day and I said, 'I'm done. I'm done with nursing.'

Enfield: In addition to my time in the ICU, I take all the outside hospital transfer calls for ICU transfers for our hospital. Just having the need to say 'no' more than I want to because we don't have enough beds to care for all the patients who need our service is really draining. It's what kind of makes all of this even more tiring than just what it would be taking care of the patients that we have in front of us.

We all go into the profession that we did because we want to help people, and particularly critical care doctors like myself who really thought about pandemics and how we prepare for them for a long time. I don't think I was prepared for the need to triage patients from a distance for the services that we have at our hospital. And some of the stories are really challenging to say 'no' to. But you also know that if we can't take care of the patients that are already in beds in the hospital, it makes it that much more difficult.



Egressy: The feeling of despair comes to mind, as we have been battling this pandemic for 2 years. And it feels that every single day we are reliving history and we're reliving yesterday. It feels lonely to battle by oneself. It feels lonely to be, at times, gaslighted by the community.

Enfield: So I'd say my reflections on this surge and the last one is: It sucks. It's tiring. And I'm hopeful that it will end soon. But I'm also proud of the fact that I can be on the front lines, taking care of patients and doing everything I can to make sure that the team that I'm working with has what they need. Both the physical PPE [personal protective equipment], and hopefully the emotional support, and the fact that I hope that they know that I have their back if anything goes wrong. That's what gets me back in the hospital tomorrow, which is what I will be doing.



Egressy: I remind myself that I'm grateful and fortunate to be here, to have my colleagues, to have the hospital, and to be able to provide the best care that I can to my patients. I remain grateful, but extremely tired. And I remain hopeful that change will come.

Cecere: Yeah, we're going through hell right now, but we will be okay. I'm not gonna quit. I'm gonna show up. I'm gonna do what I know that I love. And I'll take the good days with the bad. It's made me more vulnerable, but that's okay. I'm here. If I have to cry through a shift, I'll be there. Thanks for listening.

"

 

[kenny]

missy, I don't see how can a newspaper be used for healthcare.

I guess you could use one as a compress to stop heavy bleeding ... but otherwise ....

 

[missy]

missy, I don't see how can a newspaper be used for healthcare.

I guess you could use one as a compress to stop heavy bleeding ... but otherwise ....

USA Today could probably do a better job.

 

[MakingTheGrade]

Count me as a physician who will be largely leaving clinical care this year.
I’m sad to leave patient care as I adore my patient population and I feel some guilt as a sub specialist knowing that my hours will be hard to replace. But it was time. I can’t keep doing the same thing but harder and longer forever. I work for a great academic hospital system and consequently make 50% less than my private practice counterparts since I supposedly get time to teach and develop other skills “at this prestigious institution”. Which I did and enjoyed until the pandemic when all that went out the window. But now the powers that be seem to think the new work load can be the new normal. Nope.

It’s never been about the money, if I cared to make more I wouldn’t have stayed in academic medicine. It’s more about the moral injury of feeling unappreciated by both patients and management and watching your peers fall apart. General sense of being taken advantage of because we have a sense of mission.

So I’m going back to school for a bit before I return to clinical practice to pick up some skills that I hope will help me influence how we approach the problems that won’t make clinicians quit their jobs out of frustration and burn out.

 

[Calliecake]

Thank you for all you have been doing the past two years @MakingTheGrade. Many of us here have been thinking of you and hoping you are well. Please do what you need to do to take care of yourself.

I don’t know how anyone could continue putting in the hours that have been expected of doctors, nurses and staff at our hospitals on a long term basis. Two years is a long term basis. Seeing this much death and sadness has also had to have an impact on their mental health. Major changes need to be made to our healthcare systems and yet it seems we have learned very little from the past few years.

The group of people who refused to take the vaccine and mask for the good of everyone still has me shaking my head. We live in a selfish country full of very selfish people.

 

[whitewave]

We have been looking for 2 surgical specialists for years now. We even went to the graduation ceremony from where DH did his residency in order to try and recruit from that group. Nothing. I live in a small semi rural area in the sticks with a very high violent crime rate now. We are never going to be able to get more surgeons.

Also, our area is small, but the draw from all the surrounding communities is about 100k-175k (I guessed) patients. Remember when I said on the covid thread about the heart surgeon who had Covid and was in the ICU? Well, he recovered and was supposed to come back March 1, but the other day, he turned in his hospital privileges!!!! He is around 70, so my personal guess is that he decided now was no time to die for his profession, not this close to retirement anyway.

We had a heart surgeon leave in the summer. Now we only have 1 left in the city!! If anyone has a heart attack and needs surgery, I guess you are getting life flighted somewhere else now! It’s frightening.

DH and I keep having the occasional conversation of are we late to move away? Should we go like everyone else has? DH is very loyal to our community and he knows if he leaves, then it’s all a disaster for the people left. Plus, we have lived here nearly 25 years now so it’s home. It’s not perfect and there is a lot wrong, but we have enjoyed the laid back no traffic lifestyle. Low cost of living. Surprisingly competitive schools where our kids were able to compete nationally in terms of national test scores etc.

For DH, he could survive on his own and not in a group. So far, his group has evaded purchase by a hospital system, but that is always a possibility. Plus, we are invested in this community (financially. Morally. Ethically)

I don’t know how it ends though. God forbid any of us has an abdominal aneurysm or needs a chest tube. DH has now become the default CVT surgeon (cardio vascular and thoracic), which is surreal. He is capable for sure but hasn‘t done heart surgery in 25 years And he doesn’t have enough time in any day to see all the patients who want to see him for the surgical issues he attends to.

The retiring heart surgeon started sending his patients to see DH for post op and wound care etc. (kinda funny though that they had to take his cell away while he was in ICU because he was trying to manage his patients while he had covid).

(So I was joking as DH really wouldn’t do heart surgery, but he has bought some new books and spent last weekend reviewing the literature on chest tubes and aneurysms because he is also a surgical hospitalist in addition to his clinic practice so he is figuring sooner or later this is going to come up and he wants to be prepared).

A bunch of rambling from me this morning…

 

[whitewave]

Sigh. As if on cue, DH just texted me saying it’s his special day. That means he needs me to cook a good comfort meal and we will watch Netflix tonight and he gets a lot of “poor yous” from me.

He was on call this weekend and it was just nuts. Patients in the hallway for over 24 hours in the ER and hospital on diversion, but the transfer center kept calling for surgery placements but they couldn’t do it because the ICU is full (Plus the patients in the hallways waiting for beds).

 

[whitewave]

Hi,

I am going to weigh-in on this conversation. Dr.s themselves created the group practice, which sounded sensible at the time. This was done for financial reasons and convenience for patients., who would be able to walk down the hall to see another Dr for related or unrelated ailments. Some group practices grew into factories and hospitals began to look at group practices as both profit centers and convenience for their hospital patients.
One of my doctors( a neurologist, was thrilled Rush-Pres St Lukes in Chicago bought their group practice. He is a man in his mid-forties and told me he was relieved. They would have none of the administrative responsibilities. He did speak about DR.s earnings. As he said, Dr.s today don't want to make $400,000, but want a million. This might have been 20 yrs ago, when the real big beef was insurance companies asking for pre=approvals.

My last two hospitalizations I noticed Drs were spending more time with me. Sometimes I had trouble keeping the conversation going. I thought, I'm dying. About 5 different Dr.s. It was only when I read the billing for medicare that I realized that medicare was paying the Dr.s for 35 and 25resp. minutes for their visit. This hospital was taken over by Northwestern, an excellent hospital. These Dr.s were spending time with their patients. I was floored. I have had 10 minute office visits with another group practice and I stopped going to them when I heard the young women complained of the 10 minute hour. I never look at that practice the same way.

My present GP never rushes me, and he always, always reads my chart before he walks in the room. He has the information in his head. I am so impressed with him. Its a very large regional group practice he belongs to. They e=mailed teir patients over 65 to come get the shot. They set up 2 or 3 different locations to go to.

I don't want you to think its all glowing, I have had a few bad ones, one terrible one in England, and a few here. Truthfully I'd rather be here for medical care.

Whats broken is the high cost. And, my opinion, is that Drs want to be paid more. They definitely want the million or more. Dr.s don't think they should be told by anyone what to do--insurance companies or takeovers..

Dr.s complain too much. And we have lost the personal in medicine. As a child our Drs knew us, our parents, and if you met them on the street, they would know. who you are. Very little real human contact. We are just numbers to the Dr.
They would get more satisfaction if that could change.

Annette

Annette, maybe it’s where you live, but the only doc I know who is making a million is the heart surgeon who left to go to a larger town and he is now medical director of their heart center. He is getting paid for administration duties as well as heart surgery and clinic.

I’m astounded by what you said. A million dollars?
I don‘t think even our interventional radiologist make that much. Idk though, I sincerely doubt it.