by rcentor on August 31, 2010
I have spent my career in academic medicine – a career at 30 years and counting. Fortunately I have had success on my own terms.
My original reason for taking a job in academic medicine involved teaching. Readers know that I love teaching internal medicine – to students and residents. When the light goes on in the learner's eyes, we teachers have ultimate joy. When former learners seek you out to thank out, our hearts flutter.
Academic medicine, like our sister disciplines, has focused excessively on grant funded research. Academic medicine has let money define it.
I wish we could return to an ideal academe. An academe in which knowledge ruled the day. As I understand academe, we should create knowledge and impart knowledge.
We should champion those who impart knowledge. The great educators do much for their learners and thus they do much for society. We should champion those who truly create knowledge, judging them not on the dollars they attract, but rather the impact of their knowledge creation.
We should champion those who create an atmosphere that stimulates thinking and learning. The great teachers do this, but too few very good teachers last in the arena. We need great teachers, but we need very good teachers also, because there are not enough great teachers to do all the work.
We need creative research, and unfortunately much creative research cannot get funded. We need smart people who can and will think outside the box – people who approach every problem with intellectual skepticism.
As I observe academe at many institutions, I worry. I worry that we are not building an academy based on ideals, but rather based on dollars. I have no solutions, but this morning I have uncomfortable questions.
by rcentor on August 30, 2010
As I wrote last Friday, I believe primary care docs are rebelling against the system. The system has made primary care physicians suffer emotionally and financially. The system has taken the greatest form of medical care – that consisting of continuity, comprehensiveness, complexity and completeness – and denigrated it.
Now I talk about "the system" in an anthropomorphic sense, but "the system" is virtual. "The system" has no conscious, it is not deliberate, rather it represents the constellation of ignorance that the insurance companies, CMS and policy works have wrought.
The system has constrained primary care fees while systematically increasing overhead. The system has listened to well meaning researchers and -ologists to declare primary care physicians in need for quality improvement. The system has undervalued the value of a good primary care physician. The system has, without consciously meaning to, held primary care in contempt.
So what do primary care physicians do? They do what any sensible economic citizen would do, they alter the rules to their benefit.
So decreasing numbers of primary care physicians are taking medicare or medicaid. So primary care physicians are leaving their jobs to do hospital medicine. So many primary care physicians are leaving the CMS/insurance company grid and retreating to retainer practices or cash only practices.
The rebellion is a quiet one. No one has declared this rebellion. This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera. This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable.
Some believe that NPs and PAs can fill the void, but those who believe it do not understand the complexity of primary care. Retreating from physician led primary care will increase costs by increasing subspecialty referrals. The problem is that too many see primary care as simple, when in fact it is complex.
So I believe the rebellion will continue. Every anecdotal sign that I see tells me that the rebellion is gaining speed and power. Now if Congress is dumb enough to once again fail to fix the SGR, they will encourage more rebellion.
One day the wonks on Capitol Hill will realize the problem. AAFP and ACP (amongst others) have tried explaining the problem to the politicians. Until they understand that their constituents are angry because they cannot find a physician, they will not focus on the problem. The quiet rebellion will eventually stimulate a response. Unfortunately, the fix will cost so much more then than it would have 5 or 10 years ago. Our health care system will be changed, and likely in a very negative way.
And the quiet rebels will not be the ones suffering.
by rcentor on August 27, 2010
how bad does it have to gt before PCPs rebel instead of just complaining?
In response to one of many, but most recent, rants about performance measures, a reader wrote the above question. PCPs are rebelling in droves!!!
The primary care rebellion has two major foci:
- Docs leaving outpatient medicine to either retire or become hospitalists
- Docs developing retainer practices
The first is clearly measurable, although I do not know the numbers. This rebellion is palpable and large (anecdotal information).
The second is sneakier. Pauline Chen wrote about this yesterday, but she did not ask the big questions – Can Concierge Medicine for the Few Benefit the Many?
This past weekend I had a wonderful 4 days visiting old friends in Virginia (of course golf, dining and wine were involved). We talked about many issues, but one issue that surprised me was the issue of retainer medicine. This conversation echoed conversations I recently had in Alabama. Internists (and to a slightly lesser extent family physicians) are leaving standard practice in droves, opting instead for retainer style practices.
Many bemoan this move. Read the comments attached to the accompanying discussion piece – Having Your Own Doctor on Call
We should rather work to understand the movement (as I write repeatedly). Retainer medicine succeeds because physicians are happier (even at the same take home salary) and patients are happier (even with paying these fees). Retainer medicine represents a classic economic interaction – I have a service that I can provide at a costs – and you are willing to pay the cost.
Why does retainer medicine exist? The current payment system is so badly broken and comes with so many strings attached that it ruins the joy of practicing medicine. Practicing medicine is difficult but rewarding (emotionally, intellectually and financially). But Medicare and the insurance companies have made outpatient medicine a miserable experience.
If one reads books about management and leadership, one quickly understands the problem. Everyone wants relative autonomy in their workplace. We all hate micromanagers. The insurance companies and Medicare represent micromanagers. Many physicians would work for less money to remove the rules, billing procedures and pre-authorizations from their life.
Physicians like caring for patients; they dislike the paperwork and bureaucratic nonsense that the insurance companies and Medicare have brought to the practice.
Too many critics blame those physicians choosing retainer medicine for decreasing patient access to primary care. Those critics expect anyone who does primary care to sacrifice their happiness and enjoyment of their profession. Many primary care physicians are unhappy because they know that they are providing care that they cannot take pride in – because of the rules!
Unless the wonks and insurance companies wake up, they will find no primary care physicians left to care for the population. And do not tell me that NPs and PAs will pick up the slack – because they will not (that is another very long blog post). Wake up America; Wake up Congress and the White House. The rebellion is underway – it is just a stealth rebellion.
by rcentor on August 26, 2010
Recently Bob Sutton offered to send pre-prints of his new book to bloggers. I wrote an email and described my blog; voila I received a copy of good boss, bad boss. This offer give me the good fortune of reading a wonderful book that puts on paper ideas I have considered over the past 20 years.
I highly recommend you read the book. Please visit his website first – Bob Sutton: Work Matters – and read some of his posts.
I am a boss and have been one for over 20 years. But I am also a physician and even were I not a "boss" this book would help me understand how doctors interact with other health care professionals.
As a clinician educator I have a great interest (including a research interest) in what makes attending rounds work well. The 5 topics in the Mindset of a Good Boss pertain to ward rounds. I have modified this table, but as I read it I was struck by the wisdom Bob put into these 5 categories.
- Balance assertiveness with gentleness – the boss sometimes must assert a position, but the skilled boss can lay out a goal and still allow the team members to manage the task without micromanagement.
- Grit – great bosses have a long view of success, and the stick-to-it personality to succeed
- Small wins – good bosses find excuses to celebrate the steps required to achieve the long success. They make the team feel good on the journey
- Bosses act right – because the team is always watching them. Bosses are under a microscope and how they act matters
- Good bosses have your backs! Good bosses fight for their team and run interference against those who try to criticize the team or make life unnecessarily difficult for the team.
Note that I use the term team, because as I read the book, I imagined a good boss as a team leader.
Bravo to Bob Sutton for writing the book. Please go read his blog and his book(s).
