Supply and demand


Category : General, Medical Rants

Riding on a plane yesterday, sitting next to a woman lawyer, we started talking about medicine. She started complaining about not being able to find an internist. This was not a new experience for me. I have many friends who ask me about finding an internist.

We do not have enough outpatient internists in this country. It is all about the money. I understand that I am beating a dead horse, but our problems all stem from reimbursement.

The concept of our reimbursement system is bankrupt. If you pay me for a unit of care, regardless of how much time I spend, I will look for ways to decrease the time of that unit of care. If I can see 7 patients in 2 hours rather than 6, I have increased my gross income by 17%, without significantly changing my overhead! But I also had to decrease each patient visit by approximately 3 minutes.

Those 3 minutes matter! They allow the physician to ask a few more questions and answer a few more questions. They improve the doctor patient relationship. Without 3 minutes, we may leave out something important from the visit.

I suspect that the continued undersupply of general internists (and also family physicians) will eventually change our thoughts of reimbursement. I certainly hope so. Every chance I get (and I do get chances) I discuss this concern. We must publicize the problem of generalists in our current reimbursement system.

The lawyer with whom I had this discussion understood perfectly. She understood that shortchanging a client leads to less adequate lawyering. Providing incentives to see patients faster (and make NO mistake – our current system rewards speed over thoroughness) leads to undesirable externalities. We must fight hard to rethink this system.

I know the cognitive physicians (those who do few if any procedures) all understand this. We commonly discuss this issue over lunch or dinner. We must expand that discussion to politicians and thought leaders. We must write op-eds about this problem.

I believe supply and demand will work. But a little marketing may also be necessary. What do you think?

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Comments (20)

“What do you think?”

I think the notion of insurance as the means to pay for outpatient care is a failed experiment. This goes for both public insurance as well as private. Patients need to reconnect with payment to their doctors, and the amount of that payment has to be detached from the amounts reimbursed by the carriers. The patients should have to pay the entire bill thamselves and handle the claims process themselves too, or pay someone else to do that for them. Amounts will surely vary from place to place and doctor to doctor, as they should. This is the only hope there is for fair reimbursement and to connect payment to value.

I have a little different view. Marketing first looks at potential, product, and profit. Moving forward we look at customer. This is where I see a problem.

Is the doctor the customer. He or she has a large investment in time and education. Is the payoff a good income and a room of waiting patients to help the ego. Many offices are run this way with hour waits, low paid staff, and an attitude of we are doing you a favor.

Is the insurance company the customer. They pay the bills and dictate the level of care. The coder is often the most important person on staff.

Is the patient the customer. They don’t pay, and they do not set the level of care. Often they are viewed as a burden to be endured by a superior doctor.

As a patient I feel I am the customer. I have chosen the doctor, spent time in transit, and often spend much too long waiting in a dull area with a less than plesant staff.

If doctors want to improve their reimbursement they need to drive the market from the bottom. Big pharma is not doing DTC ads to inform me. They are doing this to create a demand for a product. Doctors need to create a demand for their product. My understanding is ER and stat care visits are up by insured patients due to time and convience. How many doctors run their offices on time? How many have evening hours even once a week?

You need to create a value to me I can not find elsewhere in the market. You need to create a loyalty by knowing me as a single person. Going over the same information for each visit tells me you do not know me. Suggesting the most invasive solution to a problem tells me you are more concerned with income than my well being. Spouting lines from a drug ad tells me there may be another reason you are pusing that specific drug.

Take care of your customers and push your value to them and society. We need you guys.

“As a patient I feel I am the customer. I have chosen the doctor, spent time in transit, and often spend much too long waiting in a dull area with a less than plesant staff.”

To the second poster: I understand your point of view, but your expectations as a consumer aren’t backed up by anything much more than your willingness to choose and consume. You resent the wait, but probably expect that someone on the doctor’s payroll is going to go through all the paperwork your insurer requires to file your claim for you, and you don’t expect to pay anything more than your co-payment when you go to collect your services. That is an attitude of entitlement. Might I suggest that between you and your insurer–collectively as a patient, don’t take this personally–you aren’t really holding up your end of the bargain. Taking more time for your visit, and allowing others to take more time, in order to satisfy your desire for a sufficiently long encounter and to keep an orderly schedule, you will need a larger proportional share of your doctor’s day. Are you willing to personally accept
responsibility for the cost of your extra consumption even if it means you pay more? Or do you insist on doffing that to your insurer? You can’t have it both ways.

I will give you my take on patients and insurance. Many patients will express a wish to see a particular doctor, and will say all sorts of nice things about that doctor, but if that doctor is not available any longer on their insurer’s preferred panel, they won’t
go to that doctor out of plan. They may resent the insurer, and perhaps even the doctor for dropping a plan, but even those with the means to choose will seldom pay anything more out of pocket to someone they say gives superior care. I have seen and heard this over and over and I hear the same stories from my colleagues.

Medical doctors are professionals, but if they are in private practice, they must also be businessmen. That is simply the way it is. Is the patient’s interest important? Certainly. Is the money important? Absolutely. You can’t run a practice without it.

You are equating your consumption of medical service with all the other things you consume and appear to be judging it by the same standard. I think that is a fallacy.
You are asking for a highly-trained and vetted individual to give you individualized, personal time and attention, and as much as you want to consume, you seem to desire nice office accommodations and well-paid and courteous staff to service you.
You speak of demands for better service and say you think of yourself as the customer. I suggest to you that you are a customer only if you do the paying. I know that if I want to eat at a very good restaurant, with a nice dining room and an attentive waitstaff, I am going to have to pay for the privilege. You can’t expect Ritz service for McDonald’s money.

Steve, you are right, except for one thing : medicine is not a free market anymore, not from the perspective of payment. There is price fixing by the state (via medicare) and the insurance industry. Doctors can change that only by refusing as a group to deal with any kind of insurance. You will pay for the excellent and prompt service and then sort the money issue with your insurance. That would be a free market, nou what is happening now.

the opinion offered Chenry highlights a major problem in our health care system. I would just add that the insurance companies (“third party” ) also add huge costs to our system without providing care.

How many thousands of people work for insurance companies as ‘representatives’?.

their are armies of insurance company employees who work full-time to find ways to deny payments for services, while hospitals and most medical offices hire their own legions of staff to counter fight the low ball tactics by the insurance companies. this is a major cost of health care that takes energy and money away from patient care.

Steve lucas misses a couple of key facts.

Very few doctors ever have a problem in trying to recruit patients. Almost universally physicians are too busy, have too many patients calling to be seen. In particular internists are usually saddled with 2,000-4,000 patients/physician. most internists who have been in practice 3-4 years are not taking new patients.

it’s kind of hard to know someone if they are one patient out of 350 seen that month. it is easier to know someone well if they are one of 200/month. THr problem is that Very few doctors can meet their operating expenses seen less than 250 patients/month

internists do not need to create more demand, we need more internists to keep up with the population which is growing by millions/year and aging …. with the epidemics of obesity/HTN/Diabetes pushing people into illness faster than we can cope.

ER visits are up out of convenience? I have never seen an ER where a wait was not 3-6 hours unless the patient was truly dying.

All good ponts. So my next question is: With a 2000+ patient load and no expectation of any type of personal care, why should I select one doctor over another?

Is the insurance paper work a reason or an excuse to have patients wait?

Does the low insurance reimbursements and constant flow of new patients negate the need to be civil?

If all of this is true, then I have no ties to any one doctor and should only expect a Wal-Mart experience on my next visit.

This is a good discussion. Doctors should make these points in an open forum where we see each others point of view.

The problem also comes back to incentive. There is no incentive to spend more time with a patient. I get paid the same for an annual exam whether I spend 30 minutes with a patient or 60 minutes. The incentive from the physician’s perspective is to run patient’s through as fast as possible. There is no incentive other than your own conscience to spend the extra time with people. (Fortunately there are many physicians who find this enough of an incentive, but they suffer for it financially.) There is no supply/demand pressure for better service, because there are more patients than there are internists/family physicians to see them. The only way for supply/demand to make a difference is if there are more doctors than necessary or if doctors can charge what they want for a particular service. The supply of primary care doctors is getting worse, not better and Medicare/insurance companies don’t give us the option of pricing how we want. However, there are some physicans reverting to a cash only practice and/or a retainer system. Both of which solve the problem by going outside of the system. This may work well with people who have HSA’s.

I’ve always been a little mystified by people’s unwillingness to pay for a doctor’s visit out of pocket. My fees in private practice weren’t that high, yet people often complained. But when I compared our fees to other professionals – my optometrist, vet, & plumber – my fees were actually lower that theirs. I finally decided the problem is that people often don’t feel they should pay anything for medical care. Many view it as a right or an entitlement. This attitude needs to change. There ain’t no such thing as a free lunch. Certainly if you’re poor you may need some assistance, but the average person can afford $50-100 for a visit to the doctor. It’s no more than going to the dentist, seeing the optometrist, having the plumber over to fix something, or filling up the gas tank on your SUV. Certainly you need insurance to cover a $10,000 appendectomy, but not a visit to a pediatrician, internist, or family doc.

Many patients underestimate the added costs of us working through their insurance company. If we had stopped working with insurance companies altogether and switched to a cash only clinic, we could have cut our fees in half and had no change in income.

While hunting for a reasonably competent physician who would be less likely to kill me I came across a website called “thyroid top docs”. Basically it is a list of patient recommended physicians. You get to nominate a doc who is really great-most of the comments involve listening skills, patient skills, willingness to consult on care rather than dictate care, overall docs that really seem to care. Granted it’s a patient’s idea of what a good doc is.

My first endocrinologist Dr. Satan was on that list so it isn’t perfect, but what I noticed is that some of the most “favorite” docs with the most recs don’t take health insurance at all. Everything is out of pocket. However people still love these guys and seem willing to pay cash to see them. Thes docs have to be nice or they don’t get business.

I think the folks that see these out of network physicians are more complex cases. The “fast food” style visit to the physician is not enough to solve the problem and the “fast food” physician cannot cost effectively give the complex patient the attention needed to solve the problem.

If I wasn’t paying 350 bucks a month already for health insurance plus all the associated deductibles, fees, copays, and out of PPO expenses for my beloved ER physicians, I would be very willing to consider paying cash for visits to a physician who would take five extra minutes to really listen to me and actually help me. 50-100 bucks a visit is perfectly acceptible.

Perhaps as more Health spending accounts become more common, more physicians might move towrds this model as a way to escape paperwork and give better patient care.

tina, I think you are correct

as many other commentators note on multiple prior occasions…. medical care is impaired when any of multiple distractors interfere with basic interaction of patient and physician. haggling with insurance companies, pharmacy benefit plans (AKA restriction plans)

, countless federal and state regulations, documentation requirements etc….is only going to impair the essential interaction between patient and physician.

just imagine you wan’t a haircut or wan’t to receive counseling from your rabbi or pastor.

but you find out that your hairdresser or clergy
must see a least 20 individuals/day to survive economically

and they must get pre-approval to make sure they can provide a service to you,

and must get approval from some large
religiuos or cosemetic organization prior to some extensive interaction.

and must spend more time documenting and writing down a plan and less time doing the actual service(so they don’t get sued by cosmetic or theologic malpractice lawyers) in the event that a bad haircut or bad clerical advice is rendered.

I think I would rather see the hairdresser who takes cash and clearly posts their fees on the door. I would rather see the clergy person who is not bogged down with regularatory protocols but rather free to sit down with me and listen

steve lucas writes
”Is the insurance paper work a reason or an excuse to have patients wait?”

yes, but some other compelling reasons account for long wait times

1. there are @ 6,000 less physicians doing primary care in 2005 than there were in 1998

2 there are 15 million more people to serve from 1999 to 2005

3. people are living progressively longer and having more illnesses. (I have over 100 patients older than age 88)

4. there is a ever growing physician shortage, and now post 911 there is a significant drop in foreign medical grads practicing in the U.S.

5. reimburesement rates are not keeping up with costs, so doc’s are seeing more patients/day to earn an income.

6. Personally, I have seen an ever busier ER call duty.
( the ER duty is a mandatory 24 hour time period that I must do every 25 days. during this period I must admit any patient, irregardless of their isnurance coverage, who is ill enough to present to to the ER and must be admiitted for hospital care. I spend about 40 hours/month or more to provide care to these people. I do not wan’t to. My practice has been closed to patients for 4 years but I cannot take care of my own patientsm who ned hospital services unless I agree to provide ER services for every 25 days. By the way I have one patient who smokes 3 packs/day x 30 years now approaching 6 weeks in the hospital for a devastating episode of respiratory failure. I first met this fellow six weeks ago in the ER. He has no insurance and will never ever be able to pay for any of the services I or any one of the services provided by specialist physcians who have provided services.

what is the point?

40 hours/month taking care of very sick patients who are not part of my practice will cause waits for everybody. at least once a week I am called to the hospital urgently in the midlle of the day to help a sick patient. I cannot predict when I will be called…and i cannot refuse to come….so regular scheduled patients end up waiting.

Interesting points. Let me add to the discussion on ‘patient satisfaction’ as a marker of good medical practice. I have seem many people absolutely convinced that they have some illness that requires agressive investigation or treatment when in fact they DO NOT need antibiotics, xrays, physical therapy, thyroid supplementation etc. They are not happy to hear this and sometimes complain. Some come in with a legal pad full of complaints and symptoms and expect that I will spend hours of time going through this. I would be happy to do this for an hourly charge but this of course is not acceptable.

So much for the ‘free market’, marketing approach.

I have a question for you guys. Why don’t more of you step away from the insurance? Why don’t you simply say that you will only take private pay, offer more patient access, and market yourselves as physicians giving a higher level of personal service than one would get with their insurance plan? Could you not set people up on retainers for base service and just skip the insurance middleman?

I realize it’s not THAT easy, but I fail to see why it’s not tried more. Is it just the security that even with having to take insurance payments, you still make (on average) well in excess of $100K?

why don’t docw step away from insurance?

many doc’s are doing just that, but only a very small minority. the number is growing but not rapidly

the major reason is safety,

it took me @ 5 years to pay off med school debt . while in debt, it is safer to work 70 hours/week to earn 120,000/year than to work 45 hours/week and make 70,000/year.

once out of debt then the decision to accept insurance
has mainly to do with perceived demand from patients.

the estimates are that 45 million folks in the US have no insurance, I would guess that perhaps 5 million have insurance but would pay cash if they found a doc who they perceive as a high quality doc. (i do not think they would pay cash on a regular basis and thus see a cash only doc only occasionally)

I would also guess @ 10 million folks who have no insurance would not pay for any health care under any circumstances. trust me on this one.

Thus that leaves about 40 million people in the US who would pay cash for their health care.

its a pure guess …….but I suppose that would equate to 1/in 12 people who would see a doc for routine health care and pay cash on a regular basis.

I provide this estimate as those cash paying individuals can also walk into any office ) as almost all docs who bill insurance companies also take accept cash)

it seems then the volume of potential patients who would just receive care in offices that take cash only
would be quite small and so would be the income of the doc.

some major expenses of offices are fixed whether or not the doc earns a lot or a little. malpractice premiums do not drop if you treat only 9 people/day or 22 people/day. medical education costs also are not discounted nor are the other customary costs ( fsmily health insurance, disability insurance, etc…)

I suspect as our national economic debt conitnues to rise
and companies like walmart employ people withoutoffering insurance and companies like Delta, United Airline, GM
start slashing health benefits more people will revert to cash and so will more doctors.

the topic of the business of medicine is directly related to the quality of medicine. I think this is far more important to outcomes of care than people realize.

careful, well considered, well researched care should lead to better outcomes and happier patients. Insurance companies create the opposite climate.

Hi Grasper,

The uneeded “thyroid supplementation” issue is a big reason why that site was put together. I guess you can be symptomatic of thyroid hormone defieciency at a TSH of 3-5. The old guidleines were to only treat at 5 and above. It turns out that autoimmune thyroid disease is so common that in reality the original test ranges established included a large number of mildly hypothyroid individuals who went on to become more ill. So now the endocrinologists are at war with one half saying treat at 3 and the other half (mostly old guys) saying treat at 5.

Did you know that? Perhaps you did but more than likely it hasn’t hit your radar unless you are an endocrinologist or have a patient coming in your office claming “uneeded thyroid hormone treatment”. So what happens is the patients end up more educated than the drs about the specific illness and then get treated like they are stupid when they bring in new recommendations for thyroid hormone treatment.

The use of combination T3/T4 is another area where physicians assume thier patients are too dumb to really understand the issue. A lot of those folks swear they feel better overal taking both forms rather than just T4. When you check out the lit biochemically the enzymes responsible for thyroid hormone metabolism are actually regualted by T3 not T4. There are also some clinical studies that suggest patients do do better wih both. These both suggest the combo approach may be better. Did you know that? You might but I think you may not. That doesn’t mean the lady who brings this info in on a legal pad is a hyperchondriac, but she may have done some research on her own and is being proactive in her own care.

Yours is a very good example of fast food medicine and how it can hurt the patient when you don’t take time to listen. It is the exact reason many of those folks go to cash doctors. It may be very well true that 90% of those folks are wrong with thier pads of paper but by listening at least a few minutes you might find the other 10% are right.

You guys don’t have enough time. You can’t spend you time reading basic literature and keeping track of new developments in every field. So let your patients do some of the walking and don’t be dismissive when they have suggestions.

I am currently being treated for hypoaldosteronism. Nobody knows why. My adrenal glands are fine, my kidneys are fine. I am the one who looked at my symptoms after six ER trips and two endocrinologists and then requested a mineralcorticoid to address the shortage. Magic! I am fine now, not from a drs suggestion but my own suggestion. My Dr listened to me, and followed my suggestion and that is how I got better. Don’t dismiss patients please. You could kill them

So what we have is a system where people are paying, often a large percentage of their income, to insurance companies to receive a service that doctors are not being compensated for in an amount to be profitable.

People view their insurance payments as part of the doctors compensation and therefore have certain expectations.

Our mutual complaint seems to be with the insurance companies.

We pay too much, you receive too little, and the outcome is a decline in patient care.

Well Tina, thyroid supplementation is always good for a debate. That however was not my point. The point was that patient satisfaction may be a relatively poor marker for quality of care, especially when patient expectations are unreasonable or plain wrong. We all see many “empowered’ patients that don’t really want independent advice, they want their opinion validated and treated as they see fit.

As for educated patients – bring ’em on, I love ’em. I review web sites and sources with them in the room. I usually don’t accept a giant pile of internet droppings they have printed for “you to look over and call back”, usually from poorly sourced sites, done on my time and at my own cost.

Try taking a big legal pad of questions to your lawyer. Ask your mechanic to run a lot of unecessary tests on your car “just in case”. I suspect that you will not be happy with the bill and learn to more appropriately use the services. The amount of waste in the current system could probably finance appropriate healthcare for 1/2 of the uninsured. And don’t even get me started on obesity and diabetes, the 2 horseman of the medical apocolypse.

way off topic but what the hell

Tina you state that concerning the treatment of hypothyoidism

“The old guidleines were to only treat at 5 and above.”
and you assert
“So now the endocrinologists are at war with one half saying treat at 3 and the other half (mostly old guys) saying treat at 5.”

you might be interested (or not interested)

in a 2004 consensus report for
Subclinical thyroid disease: scientific review and guidelines for diagnosis and management

it is suggeseted to treat subclinical hypothyroidism at tsh levels greater than 10

this clinical consensus group (comprised of representatives from the Endocrine Society, American Thyroid Association, and the American Association of Clinical Endocrinologists).

Most docs treat SYMPTOMATIC hypothyroidism to get the TSH into normal range

I do consider 2004 guidelines fairly recentut other might consider them very out of date.

Tina you also mention that in relatin to t3 and t4 therapy

These both suggest the combo approach may be better. Did you know that?”

the question of whether hypothyroid patients might benefit from substitution of some T3 for T4, an idea which has now been evaluated in eleven randomized trials [18-28], most of which are negative.

for example:

In a placebo-controlled trial, 46 patients were randomly assigned to receive their usual dose of levothyroxine or combination therapy (50 mcg less than their current T4 dose with T3 added (7.5 mcg bid)). After four months of treatment, there were no differences in measures of cognitive function or health-related quality of life between the two groups.Combined levothyroxine plus liothyronine compared with levothyroxine alone in primary hypothyroidism: a randomized controlled trial.
Clyde PW; Harari AE; Getka EJ; Shakir KM
JAMA 2003 Dec 10;290(22):2952-8.

another example
Using a regimen designed to mimic normal thyroid physiology more closely than in other trials, (100 mcg T4, or 75 mcg T4 and 5 mcg T3), there was no difference in cognitive, affective, or quality of life testing, although patients preferred combined therapy to T4 alone . Thyroid hormone replacement therapy in primary hypothyroidism: a randomized trial comparing L-thyroxine plus liothyronine with L-thyroxine alone.
Escobar-Morreale HF; Botella-Carretero JI; Gomez-Bueno M; Galan JM; Barrios V; Sancho J
Ann Intern Med 2005 Mar 15;142(6):412-24.

despite the negative data that t3 is effective many doc’s will use it , but sparingly

you then try to explain the bichemistry of t3 and t4
“When you check out the lit biochemically the enzymes responsible for thyroid hormone metabolism are actually regualted by T3 not T4”

a more accepted explanation exists:

T4 is a prohormone with very little intrinsic activity, which is deiodinated in peripheral tissues to form T3, the active form of thyroid hormone. This deiodination process accounts for about 80 percent of the total daily production of T3 in normal subjects; as a result, serum T3 concentrations are within the normal range in hypothyroid patients receiving adequate T4 therapy. The prohormone nature of T4 is an advantage over other thyroid hormone preparations, because the patient’s own physiologic mechanisms control the production of active hormone.

you also mention

“Magic! I am fine now, not from a drs suggestion but my own suggestion”

there is some explanantion for that as well

An important placebo effect was observed in a randomized trial of 697 patients in whom 50 mcg of T4 was replaced by 10 mcg of T3.
Partial substitution of thyroxine (T4) with tri-iodothyronine in patients on T4 replacement therapy: results of a large community-based randomized controlled trial.
Saravanan P; Simmons DJ; Greenwood R; Peters TJ; Dayan CM
J Clin Endocrinol Metab 2005 Feb;90(2):805-12. Epub 2004 Dec 7.

I DO NOT DISCOUNT THE POWER OF PLACEBO IN HUMANS, IT IS A VERY POWERFUL FORCE. IT DOES MATTER. It is what people benefit when their doc spends a lot of time listening.

Poor DB, , my apologies for dragging this so off topic. I was sort of trying to make a point about docs should pay attention to input patients have to offer. The thyroid infor was just for example. I’ll try to stay on topic next time so please forgive this long blurb.

Gasper, I am glad you are open to at least educated pateients. I understand the pile of paperwork problem. I avoid taking my car to mechanics or my poor pets to the vet. I can’t afford “the problems” they find.\

Pj, check that about treating a tsh of 10 or above. I think that might be a bit of an error. I myself am down from a tsh of 200 to a tsh of 7. My endo is very keen on heading towards 1 or so. The TSH new guidelines I am quite certain are correct-maybe look a bit further:

The T4/T3 thing is totally out there at the moment. I only take T4 myself and do just fine. Perhaps the T3 supplement is placebo but I am more inclined to think it a pharmacogenomic varaition. Some folks metabolism keeps em great with T4 and some need the T3 to really do okay. I worry about broad population studies as I wonder if the “odd” ones get missed. You create a new rule or observation that applies to 95% of folks but 5% get left out. We are just now starting to understand how that 1% of genetic diversity that makes us unique influenecs our health. I have ran across way too many folks who swear by the combo and some endos who say thier patients swear by it. I don’t need it but they may.

As for the enzymes I actually found that in a website (thyroid manager) with chunks about T4 metabolism. It wasn’t my idea. In hypo or hyper thyroidism, the diiodinase (enzyme converts T4 to T3) expression levels are altered with respect the to the particular tissue. The expression levels of those enzymes are regulated by T3 not T4, thus if you want to restore the entire thyroid processing system to order more smoothly and quickly it might be best to add in some T3 to yield more correct enzyme expresion levels. Otherwise you might be setting up some odd kinetics. I am a dorky biochemist. I think this stuff is cool.

As for my “magic” moment and treatment suggestion that was mineralcorticoid supplementation for the presumed aldosterone shortage. It isn’t in any of your textbooks so you guys don’t think it’s real. It doesn’t matter if I go to the ER six times, it should just go away because it isn’t real. I came up with the suggestion of florinef and went from being unable to tolarate any T4 to being now at 75ug of T4. I’ma wierdo I guess. I educated my endo-the second one as dr satan sent me home to die.

tina, this topic of thyroid treatment actually does relate to DB’s original rant

no doubt you have invested a lot of time researching, questioning your thyroid condition. you particularly comment that correct treatment studies and paradigms target the 95% of the population and that the 5 % people who demonstrate pathophysiologic patterns out of the “norm” are getting short shrift, getting misdiagnosed and mistreated.

you further state you have had a variety of physicians including endocrinologists mis treat you.

what you corectly wan’t is individual physician to pay attention to you and spend enough time to establish good diagnsotic plan and therapeutic plan. you lament the fact that the 5 % of the population who do not present with symptoms typically are neglected.

you are right.

DB in his opening salvo comments
” But I also had to decrease each patient visit by approximately 3 minutes” due to the ugly economic climate of medicine.

Obviously if a doc is being pressured to cut visits shorter and shorter, people will lose out. DB is describing an all too common occurrence :
15 minute appts are being cut down to 12 minutes, the 9 minutes vists become 6 minutes.

you point out that the medical system had failed you for quite some time. the fact that visits are forced to become shorter does not bode well for personalized care.

According to the data there are less endocrinologists/person in 2005 than there was in 2000.

there are huge decreases in Family docs and Internist per capita. given the current debt loads of new doc’s and reimbursement climate, this trend is getting worse every year.

your dissatisfaction with physicians exactly mirrors
physician dissatisfaction with the system.

physicians are dealing with the dissatisfaction by choosing specialties that have higher pay, less stress.
thyroid care is not on the list of desirable specialty care.

DB comments
“Providing incentives to see patients faster (and make NO mistake – our current system rewards speed over thoroughness) leads to undesirable externalities. We must fight hard to rethink this system.”

no wonder your frustrated. so are doc’s.

as far as your specific thyroid ideas.

remember that there are several items which are discussed in the thyroid literature and they are broken down in a variety of ways.

1. diagnosis of clinical hypothyroidism
2 treatent of clinical hypothyroidism
3. diagnsosis of subclinical hypothryoidism
4. treatment of subclinical hypothyroidism

each of these entities is very different and you seem to be lumping the diagnoses and treatment of hypothyroidism into one entity. also clinical consensus statements published in 2002 0r 2003 will take several years to work their way into the actual mainstream practice of medicine , unless you are working with a specialist who is very current. also, you point out that their is debate on how low a TSH should be.

well your right, there is a debate.

anyone who thinks that medicine is fixed and static is wrong. it is an everchanging science. debate will alwasys exist. you are right about genetics, perhaps in a few decades genetic tests will be available to fine tune treatments. by that time global warming, pollution and drivers using cell phones will have killed off most everyone.

Very good thoughts Pj. My mistake as I do lump all the thyroid treatments together. I did mix up the subclinicala nd clinical hypo. I keep meaning to go back and read the lit on the T3/T4 studies but time is always an issue.

As a scientist fixed, static ideas were “beaten” out of me in grad school so I think I get a little more frustrated than the ave patient when I get a fixed static idea from a dr. It is second nature to question everything and be open to the unknown factor.

When will the system collapse do you think? Is there a global solution? If you admit more more students than you will have more physicians in five years. Could you begin admitting students with the requirement that they practice in certain fields? Maybe “track” them and charge them different rates of tuition depending upon final workplace? This might sting a bit but, maybe admit lower caliber students to fill some of these empty PCP slots. Not saying PCPs aren’t smart-just a suggestion. You guys do turn away half the applying population. Perhaps loan forgiveness programs for PCP or GI positions? Maybe encourage more on call work by having some payment gaurentees for PCPs ang GIs.

Got a taste of the cognitive vs procedure reimbursement rate myself just last month. My ER physician exam costs about 400 usually. My husband fell and dislocated a shoulder ligament and got a 400 exam fee plus a 700 fee for a dislocation. The dr didn’t actually do anything but tell my husband it was dislocated and to go home. No cast, no repairs, nothing. My poor ER docs were stuck with a totally wierd case with high cognitive requirements and a high risk they might get sued if I dropped dead. Yet they get a third of the charge that the other guy got.

And yes, the cell phone drivers may kill us all soon.


several issues please see data below

as you can see there has been a huge decline in med school applicants since 1995

intersting to note that the US has 1.4 million lawyers

certainly med schools have increased enrollments but the cost to train someone exceeds 90,000/year.

most state governments are in running budget shortfalls, med school funding is on the low list when compared to all the other pressing needs.

private schools generally cannot expand class size as they barely can fill their own slots. most people who apply to med school cannot and will not pay the 40 -45,000 dollar/ year tuition costs

essentially anyone who has a b aversage can go to med school.

remember that osteopathic schools often take the folks who do not get into MD granting schools. DO degrees are essentially identical to MD degrees.

also note that 50% of med school enrolles are females who are much more likely to wor part time.

there is expected a 50,000 doctor shortan 10 years.

since 911 there has been a dramatic drop in foreign trained doc’s.

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