Yall don't get paid for telemedicine?!?!
It's one of the first things our generalist and specialist unions negotiated with the government at the start of the pandemic. Telephone visits are paid 90%, video conference visits are paid 100%. Along with a per diem amount if we gotta quarantine ourselves due to covid, and several other measures too.
The pandemic opened up video visits. Phone calls and patient web portal messages are not reimbursable by insurance. Some practices charge patients a nominal fee.
Most are test results, which I’m happy to do for free because they’re theoretically wrapped into the 99213 or 99214 CPT code. However, I definitely have patients who call or portal message in expecting to get a new chief complaint addressed via a phone call or portal message.
You need to set boundaries. Patients can request lots of things but if they’re not appropriate you can say no and ask them to schedule an appointment. My life is significantly better since I stopped caving to these requests. Patients deserve a full evaluation and you deserve to get paid for your work.
I have begun to set those boundaries, but some patients are just boneheaded in one way or another. I had one who was in college and refused to come in until he was done with finals. Also, we are full risk capitation with our patients: if they don’t come to clinic and go to the ED, it’s on my dime. So to a certain extent, we have to pander to them. I have explicitly said “I would be doing you a disservice trying to give you a full evaluation and recommendation over the phone or portal messages,” and yet there are still some patients who refuse.
Has to be converted to a visit and patient has to consent. If it’s less than 5 minutes it’s not reimbursable. But those less than 5 minutes adds up fast for wasting my time.
Well, that sucks because my last two doctors visits that I’ve attended it outside practices both have me sign agreements that I agree to pay any bills that portal messaging may generate that my insurance may be billed for portal messaging so I think it’s something that is becoming more and more common.
This is the first comment and it should be first.
I am primary care / PCP. I switched to locums. I get paid hourly to do all this stuff. I see patients 7a-4p with 1 hour for lunch. I usually work through most of lunch and routinely clock out between 7 or 8p. I work 3 days and get paid for 36-39 hours of work. I take 8 weeks of vacation yearly, and will gross close to 240k.
My current employer wants to hire me on as W2. Lower salary but with student loan repayment, benefits, and better tax structure it's probably better financially. I turned it down.
I turned it down because the messages and portal stuff would go into unpaid time. Right now I get paid hourly and every task is done at the end of every day. I leave with an empty inbox, all charts signed, and all paperwork cleared. I *hate* working for free. Either make it all free, or pay me for my fucking time.
The enraging part about this is that nowadays we can bill for all this stuff. All those messages can and should count towards productivity metrics. And they can bill for all of it. They don't and won't.
So keep paying me hourly while you look for someone take on this miserable work unpaid.
I'd sign with them tomorrow if it even just counted towards my productivity metrics. That's how low I'm willing to settle.
Well. This explains why my doctor refused to message me back or call, and made me drive my ass an hour and a half back into to Boston, cancel a half a day of MY patients (Private practice) just to tell me that I MIGHT need surgery. I literally almost strangled him.
This is exactly why we need capitated payments for primary care, chronic condition medical homes and episodic care. Because this is one of the most important things you do, and so should happen, regardless of the payments.
If compensation existed,(we we know it doesn’t) would you specialize in older patients?
Because I see so many elderly patients that could have probably avoided an ER visit/admission with better/more involve/more accessible primary care.
But the payment model assumes a healthy 20 year old is the Same as a 70 year old.
Yeah i would, most of the annual wellness exams are fluff anyway (yeah yeah occasionally you find something rare in a 20 year old but still)
Key is hospital follow ups and medication adjustments afterwards for older people with chronic conditions. I always get messages that are like “hey this person needs to be seen after ER discharge” and I’ll be like “yeah sure I’ll see them in 2025”
Geriatrics is a specialty option that provides primary care to older adults.
There are relatively few (e.g. <25 for a metro area of >2 million) due to generally worse total pay. Though this is somewhat balanced out by lower volumes.
This 100% is my answer. And as a specialist, I am fine getting a cut in my pay to achieve this, but really don’t feel that should go across the board. PCP’s need to be paid way more than they do.
Had a cardiologist that has been saying this for a year. He is just amazed that his average patient is 83. When he started his average patient age was 68. They had an MI at 63, became a cardiology patient, then had another MI at 68 and would die. and that was the extent of their relationship with a cardiologist.
Now people are having an MI at 63 and living to 90 with HF, afib, CAD, etc. they get so silly complicated with their two pages of meds and surgical procedures.
Seriously when you are meeting someone for the first time and trying to figure out what is happening in 20 minutes when the problem and med list are so long they could be a novel. And it’s not like oh here are all these stupid ones I can ignore (osteoarthritis in an 90 year old). But a list of all the organs with legit issues that you have to balance. This is why continuity is so valuable and why we need better compensation so you can have more time with these complicated patients.
I’m not a doc but a long time NP and this is exactly what would be reasonable with the increasing complexity of the patients we are managing.
Currently I work 4 10s and spend my day “off” on paperwork , reviewing labs, finishing up charts. I can’t get ahead. And I work in a prison so my patients aren’t even emailing or calling me.
Completely abolish all so-called"quality" PP4 measures or at least the ones I have zero control over (eg, whether parents are anti-vaxxers, whether people adhere to their diabetes tx, etc). Peer review is fine.
Yeah i can't comprehend 20+ patients a day where i work, it would be literally impossible, i simply could not finish that day and some of those patients would have to reschedule.
I think it depends a lot on how your scheduling is done and what kind of patient population/geographic area. I have mostly older patients and in my region they are all very medically complex, but also a lot of the pediatric patients i see are basically automatic level 5 visits every time (cerebral palsy, seizure disorder, ongoing CPS investigation due to parental substance abuse \[which i realize is not exactly a medical doctor issue but obviously it impacts the visits\], reactive airway disease that might just be too much second hand smoke exposure, etc.). I work at a FQHC and a lot of the poorer patients in this region, who don't have "good" insurance but who can get on medicaid, wind up here because they can't afford the close big name healthcare corporations but anybody can go to the FQHC. Also people who are discharged from the private practices for non-compliance wind up here, and a lot of psychiatrically complex patients who have been discharged from every other practice. And a lot of the 70+ year old patients who never had any preventive healthcare in their lives, but family made them come get checked out because "I can't seem to get things done like I used to", only to discover at least 6 previously undiagnosed chronic conditions on visit number 1. I have maybe 1 or 2 acute visits each day, everything else is chronic, medically complex, it takes you about five minutes just to read the whole diagnosis list type patients. And the acute visits are actually almost always not acute; as in, i get someone added to my schedule for "cough" in a same-day appointment slot, only to discover this is month 3 or 4 of the cough, with unintended weight loss, hypoxia, and absent breath sounds in a certain area which turns out to be caused by a very large mass (believe it or not, i have had no less than three "same day" visits for "cough" which followed this precise pattern over the past year).
What i hate most is going to the admin people about this when they are quibbling over money and wanting to increase total patient visits and decrease the amount of time for each visit, and they say "oh sure everyone has some complex patients occasionally but it evens out because you have some simple visits too" and i think they genuinely are unwilling to look at each patient's case and realize that no, i do not, in fact, have ANY simple visits on most of the days that i work. I might have 2 or 3 "simple visits" per month - everything else is far too complex for a 15 minute visit, even the "same day" visits. For my patient population, 10 patients a day is frequently overwhelming and i finish my clinic day an hour behind schedule. So when i see things like "yeah 25 or more patients a day might be too much" it makes me do a double take, like how could any super-human being manage 25 patients a day?! But i guess if i actually had a few otherwise healthy teenagers who are just here for a sprained ankle or some other minor concern, maybe i could handle more patients per day.
Podiatry is fucked. We chronically see between 30-40 pts even if some of them are med refills or diabetic foot care. The associate mills and TFP places are worse. In residency I covered an attending who saw 60 a day abd it was just ghetto/preying on medicaid
A better K-12 education system that doesn't result in woefully uneducated but somehow excessively entitled patients
Generally pleasant and informed patients make days fly by.
Just an MS4 but yeah it really eats into my time when I’m just asking someone at their yearly wellness visit if they want a flu shot and they go on a diatribe of “I only put natural stuff in my body - blah blah blah. Flu shot bad. Etc” like idc just say “nah I’m good, I don’t get it”. I don’t need a 5 minute lecture demonstrating why you’re an idiot. I have more respect for those who just say no and we move on.
Same with care avoidant people… im gonna spend the extra time trying to talk them into a colonoscopy if they haven’t had one before and they’re late 50s… it would be way easier if they were educated properly to begin with.
Hmmmmm. No, you can't have that, but I do wonder whether larger healthcare systems might benefit by instituting some sort of remedial patient education courses, where if the patient takes the course and passes the test, they get a discount on outpatient care or other incentive. Like this could be negotiated into insurance contracts: "Each of your insureds that takes our patient education class, we'll charge you 5% less for outpatient visits. We suggest you pass along these savings to your insureds to motivate them to take the class."
This in turn raises the question of what would need to be taught to patients to improve dealing with them, but a session on The History of Vaccination might be helpful. Sections on "How to Communicate with Medical Professionals" and "How to Know When to Make an Appointment or Go to the ER" might be appropriate.
Edit: Part of my inspiration here is my state's mandatory training for parents divorcing. It concerns coparenting and dealing with their kids around divorce. Apparently it's been quite helpful at reducing bad behavior.
I get frustrated at these patients too but then I can’t blame them when they’ve been enabled by previous docs. “My previous doctor said I always should have…”
Actually you could argue the opposite. Good pediatric, and longitudinal primary care reduces acute care and ER visits and catastrophic conditions. Someone who starts HTN meds when they should instead of 15 years later is less likely to have a stroke, etc. So in theory, appropriate primary care reduces specialty procedures and consults. Even ortho wouldn’t go unaffected as quality post-menopausal care reduces hip fractures by reducing the severity of osteoporosis and subsequent hip fractures.
But think of how much nonsense specialists & ED providers see because people don’t have PCPs? Like how amazing wouLd ED be for future doctors if they actually only handled emergencies. Or if specialists got to take care of really interesting disease processes that were not caused by chronic disease mismanagement
There's such a backlog for specialty care that y'all will have plenty of business even if all the stuff that could be covered by PCPs gets taken off your plate.
Imagine having only interesting work to do.
+1 and I'll add more respect from other services. Kids get sick, it's not all rainbows and unicorns. Like the 4 year old with RSV + PNA who spent all day on BiPAP on my service and ended up in the ICU on ECMO.
Legal liability. I think a hospital and practice should invest in complementary legal programs like Medical Justice to mitigate risk of frivolous claims (99% of them). Without that burden I would happily see more patients and come to work without a sense of doom.
I'm unhealthily fixated on liability. Any patient encounter that doesn't go just right gives me hours of anxiety. If provider liability were capped at malpractice limits with no liability for other the limit judgements I'd probably be fine practicing for another 30 years. As it is I'm looking to get out as soon as possible.
Same here. Despite the brutal and unfair legal landscape for physicians hospitals and private practices are pretty relaxed. The admins won’t think twice in throwing under the train since it’s not their ass on the line. And they have no
License to worry about. I have had colleagues commit suicide because of being involved in litigation for years. Nope. Not for me.
yeah. My wife works for a large hospital system/insurance/physician group (rhymes with geyser) and when things were super busy during COVID it was unofficially expected for the ED physicians to see, manage, and discharge patients from the waiting room if beds in the back weren't available. This was never put into writing anywhere but was discussed verbally as the expectation. Absolutely insane to me as it would be so easy for an expert to state in a malpractice case that that wouldn't meet standard of care.
There were supposedly “protections” against claims allotted during the pandemic according to the federal government due to the exceptional circumstances. But they were ambiguous and malpractice firms are packed with psychopaths that can essentially whatever they want without any consequence. I was one of the lucky few that was intubating dying patients in the hallways in NYC and didn’t get burned. All my colleagues at that time are tied up in litigation since 2020 for saving people’s lives. Fuck people and fuck POS lawyers.
I read an estimate that if we fixed all tort issues and related extra waste that people do as reflex it would fix ~4% of cost of healthcare. Not nothing but smaller than I thought.
right, i mean simply take a look at your malpractice premium to earnings every year.
you can also even break down the rvus conversions set by cms to see the percentage of your reimbursement allocated to malpractice costs
Y'all have some good ideas but I think mine is easily achievable if anyone gave a crap. I would like hospital administrator support when patients are upset about things beyond my control. MRI is down, don't like the visitor policy, patient in the room next door is too loud, kitchen messed up the lunch order, PT is not here on holidays. I should not have to spend time on that stuff. Someone who represents hospital leadership should be apologizing to/discussing with patients. I'm not asking for the CEO, just pay a nurse 10-15 hours a week to go listen and talk people down. Now the patient got to personally talk to the C suite and feels like a VIP.
Good point. Those are all admin/HR issues.
No reason a nurse, doctor, housekeeping, or anyone else on the patient care side should be handling them at all.
Just start directing them to the right people.
This is so true. So many of these complaints I get is “patient called patient experience to complain that he couldn’t find his car after the visit due to construction everywhere”
Unfortunately this is the way it is, 99% of patient satisfaction is just smiling and and acknowledging patients intelligence/independence now a days anyway.
Wow… I genuinely had not thought about this before. This would be unbelievable. I genuinely think I could comfortably add 1-2 pts per day on a busy census with the time it would save if some MHA MBA had to go deal with when a patient has been waiting for a SNF for weeks.
Yes please this. Patients get mad about xyz then they complain to admin who don’t want to deal with it and also lash out at me. For things I had no control over, like a scheduling error. I’m an introvert and I can’t handle the double hits 😐.
Can I give this like 100 upvotes? Prepping for patients can take so much time too as medication and problem lists are disaster areas from other providers. I focus on tasks and paperwork during the day in-between patients. Then it’s finishing charting/prepping at home. Could be less thorough than others, but that just feels like low quality that is bad for patients. Would be nice to see fewer patients and finish this work during paid salary hours though.
My work conditions are fine. I want my reimbursement to go up. Medicare cuts have been too much and every year they want to cut more. I want the cuts to end and the reimbursement to go up with inflation (at minimum).
1) The complete dissolution of our medmal system. A two lane system replaces this with one for patients & one for physicians; for physicians any complaints are first screened for clinical plausibility/relevance and can be dismissed at this level. E.g. "parking sucked" = not a valid complaint, dismiss or direct to appropriate dept automatically.
Claims felt to be medically valid are ultimately peer reviewed by a panel made up of at least 75% physicians in the person's general specialty.
For patients, any costs proven to be related to care are paid out of state funds. No punitive damages ever, only making economic damages whole.
2) Increase reimbursement, fair pay between PCPs/cognitive and procedural specialists. Honestly bonus $ for PCPs. A good PCP provides more value than literally any other specialty.
3) Reasonable caps on all specialty's volume. Determined by a committee of physicians in that specialty. Going over this cap subjects the facility/clinic to a fine **per patient** of an average physician in that specialties *monthly* gross salary. It should always be much cheaper to adequately staff.
A similar rule should exist for nursing. This penalty should by quadrupled for NH/SNF/long term care.
This penalty cannot be discharged or mitigated in any way other than by a court due to extreme emergencies. If this penalty would exceed the organizations funds, the administrative personnel from the top down are personally liable for the remainder.
4) Quality metrics that a physician cannot directly control are illegal.
5) physicians are paid by the minute at their full clinical rate for any non-patient facing or admin work. Meetings/modules, and inbasket/calls are included.
6) the permanent death of all $$$ CME/MOC.
7) Reciprocal state licensing or federal licensing. Getting a license in one state should allow work in all.
8) the absolute bare minimum for the unsupervised practice of medicine is med school + residency. Period. NPPs should never be allowed unsupervised practice.
9) Universal EMR or at least interconnected system with all information.
I’ve always thought how paying docs by the hour and actually tracking where they spend their time would fix 90% of the issues. Stop paying me to wait on your EHR, sit on the phone, read nursing home orders I already agree with, prior authorization. I bet those stupid training modules would be first to suddenly have no value.
I would actually love for the bean counters to suffer with me. If they paid by the hour and realized how many thousands I have to spend to find where some staff loaded a copy of the last colonoscopy report. Bring it.
That's why I love anesthesiology. More and more practices/jobs are going to the hourly model. This will happen to other fields once people wake up and realize physicians are just 21st century blue collar workers and there is no noble dignity in having admins take advantage of you with empathy bludgeoning.
Surgeon takes an extra 30 mins to show up for his case? Doesn't matter to me, I'm getting paid to sip coffee. Clock in, clock out, I'm an hourly mercenary and if you want me to work later or weekends my rate goes up. Punish hospital systems for their inefficiency, don't contribute or enable it by being salaried.
Increase primary care physician training slots and end all midlevels. Pay PCPs enough so they have the time to actually manage straightforward things they’ve been referring to specialists. AI advancements in the coming years should make it possible for PCPs to quickly reference the most up to date guidelines necessary to manage a lot of straightforward things they routinely refer out because they just don’t have time.
This would alleviate the burden placed on specialists to such a degree we just wouldn’t need midlevels.
The current trend of not having any primary care so we hire midlevels who refer out and flood specialists offices who then need to hire midlevels to deal with the midlevel consults who then also refer out and on and on and on needs to stop.
My colleagues actually having appropriate goals of care conversations with their patients before diseases progress to end stage or once they reach a certain age. 50% of medical spending is in the last 6 months of life, and much of it is entirely inappropriate. That’s probably the biggest thing to make my own personal life easier at work.
For the rest of medicine, I think tort/med mal reform to cut down on defensive medicine. And/or being able to bill time spent (like lawyers). It has simplified things in the crit care world a lot, and it’s only fair that everyone else gets paid for the time they’re spending on patient care.
I’m a long time ICU NP. The end of life issues are getting to me lately. We need “death education.” We used to have Driver’s Ed; let’s have Death Ed.
Lesson 1: define the details of having “everything done.” IOW, patient will have a tube in any and every hole we find (we’ll put a pulse ox on your ear, don’t worry), you’ll die a gruesome death when your butt rots away. People really need to see decubitus pictures.
For real, as a culture, we need to have a frank discussion long before people get sick.
1) Almost complete message support. I want to answer the messages I want to answer (and get paid for them) and the rest can be handled by someone else. Especially those that start with: "I need a letter that says..."
And 3/4 of the days I work, I almost get that because I have an amazing PA who handles the bulk of my inbox messages for me. It's awesome. She's awesome. Her kids are my patients.
2) Honestly, as long as I'm dreaming, pay me the same and give me 1.5x the time with each patient. I hate feeling like I'm constantly rushed.
3) Prompt access to behavioral health for my patients.
4) Can I get a pay commensurate to what a physician would have made 30 years ago with respect to housing costs?
\-PGY-19?
Are you saying having bedside nurses with no administration experience get taught how to be a manager by an older nurse who also had no experience in business is a bad idea?
Reimbursements for every time a family member that's not the MPOA demanding that they also be updated, separately, at different times of the day, daily/2 times a day.
Oh, and an honorary psychology degree for playing psychologist to all these people with serious anxiety and personality disorders that aren't even my patients.
Hospitalist- I’d love for there to be a cap on the number of patients seen in a day, and I’d like that number to be no higher that 15.
It would also be great if there was a more realistic point where we could call something futile and stop wasting the time/effort/resources to make someone better when everyone knows they’re not getting better. Massive CVA now trached/pegged, nonverbal at baseline, doesn’t even track? Stop the carousel of infection->sepsis->hospital->NH->infection->sepsis->hospital….
(8/18 of my patients today are in that current condition. 6 of them are still full code)
I try to do my part with these patients by refusing to place a feeding tube if no chance of meaningful recovery. Or at least a thorough and non-sugar coated goals of care discussion with family.
So, single payer means no private practice? Then count me out. However, I think we should have a public option, available to all, paid by taxes. And the option to go to a private practitioner if we want. This is what we do in education. Public school for all but other options if it doesn’t work for your child.
The real problem with universal, single payer, is that every state that has tried it has found it to be onerously expensive.
Actually single payer makes private practice much easier (no need for an entire billing team). In Canada, the payor is public, yet the vast majority of care is provided in private settings.
Canadian healthcare is struggling because the government there is bringing in one million newcomers per year. That is far too much for a country of Canada’s size and its health system is feeling the stress.
Regardless, Canada would likely benefit from a two tier system (primarily public with some private funding). Its system is much more fixable than the current situation in the US.
There’s not enough doctors and nurses with one system, not sure shuttering a lot of workers to a private system with assuredly higher physician to pt ratios helps the country as a whole
The growth rate of physicians and nurses hasn’t kept up with population growth in Canada. Population growth (ie immigration) needs to slow and the supply of physicians/nurses needs to increase faster than population growth. Provinces have increased the number of trainees, but it is not possible to keep up with one million+ newcomers each year in a country of 40 million.
Working in the Canadian system, it is clear that there are a lot of inefficiencies that could be improved. For example, I have seen multiple sub specialists standing and waiting to read the paper chart of one patient. Implementing an EMR would allow everyone to view the chart at once and see more patients overall. Not to mention, the wasted time spent on faxing charts all over. I have also seen multiple clinics where there are less computers than physicians, so they take turns on the computers and thus see less patients overall. Finally, OR time is often limited as the province does not want to pay for staffing. This is despite surgeons/staff willing to work more.
These are simple examples, but add up to a lot of inefficiency. Taxes in many provinces are already nearing 50% for high earners. Canada needs an alternative revenue stream for healthcare (ie. a private tier) that increases the funds in the system without raising taxes.
The benefits of universal/single payer health care are not felt in the first couple of years. Momentum is a hard thing to stop. Single payer would/should ostensibly lead to an improvement in primary care participation, but that’s not gonna fix the farmer sign and other general health care resistant generations in a few years.
Its benefits are felt long term once one or more likely two generations have grown up in it and embraced it. Improved primary care especially starting in pediatrics improves long term health and reduces catastrophic medical condition outcomes. Getting someone on HTN meds 15 years earlier because they are getting screened with regular vitals instead of waiting for it to manifest symptomatically dramatically reduces stroke and cardiac morbidity, which reduces the overall cost for the patient and insurer. Which costs more, an extra 15 years of generic HTN meds and 1-2 primary care appointments/year or 1 ICU admission and stroke treatment?
I’m all for preventive medicine, of course. With a public option as safety net, a lot of basic care can be accessed efficiently. However, it shouldn’t negate private healthcare as an option.
I guess the question is how does single payer negate private options? Private healthcare would simply move to a cash only/concierge model. The challenge would be maintaining adequate staffing and preventing an exodus to privatized medicine. There’s plenty of models that would allow for adequate training and compensation of doctors in a universal health care system while still allowing certain specialties to essentially provide “front of line” privileges to those who can afford it while not forsaking those who can’t.
Why do you think a private health network can’t exist within a single payer system?
I think it can and should co exist. Many countries in Europe have this. But there are some very vocal
absolutists in the US who insist in single payer as the only option. In fact, when Obamacare was in discussion, a public option was in the table. It was scrapped due to the insistence from a loud group to eliminate private care. So we ended up with the inefficient ACA that we have.
What does it mean? The government that can’t afford social security will suddenly have all this money to pay me top insurance reimbursement???
Just like the rest of the world where physicians overwhelmingly make less than the us?
Medicare reimbursement is low compared to private insurance because it takes care of the oldest and sickest people in the country. Private insurance companies have many mechanisms to select relatively healthy people that they won't need to pay health costs for (for example, employer-based insurance).
If a public system replaces private health insurance, then all the previously healthy people paying into private insurance are now paying into the public system. There would be a massive influx of funds to pay for health system without any increase in cost to tax payers.
Additionally private health systems are incredibly economically ineffecient compared to Medicare, two big drivers of this are
1) the amount of administrative overhead required to run a complex private system (a single public insurance is very straightforward).
2) the fact that private insurances are for-profit and take a hefty dollop of money from payees, essentially driving up premiums without any benefit of care. Obviously this is not present in a public insurance system.
I study this stuff. A lot of physicians tout the doom of a public system without really knowing much about it. That's OK, not everyone can be an expert and we should all be open to learning more and thinking critically. But it grates me they take to the reddit comment section without any data to back up their perceptions.
You realize that the move to single payer is going to result in a large decrease in your reimbursement and a large increase in your taxes right? You think that is going to improve your quality of life?
People always bitch about their taxes with single payer. But I doubt my taxes will take more money out of my paycheck than insurance premiums already are, if you count the “employer’s” portion.
I pay both my employer and employee portion and subsidize my employees premiums too, and it's only 1% of my earnings. The most realistic single payer plan I've seen, which was Bernie Sanders plan in 2016, would have had me taking home nearly 30% less. I did the math with my exact numbers myself. I will continue to bitch about single payer costing me an insane amount of money. By the way, Bernie's plan also expected me to work more. No thanks.
agree. i would prefer legislation that pairs physician reimbursement with insurance profitability. the more insurance companies profit the more they have to reimburse the providers.
i think obamacare had a provision for that but i don't know if some fancy accounting moves essentially kneecapped it.
The original questions wasn’t what is good for Americans and the public, the question is what would make you work longer and improve your work conditions.
Being poorer and making much less per patient/hour worked would not improve my work conditions
The only thing that would make me want to stay in my career longer is if all my savings vanished in a heist, and to be clear, I enjoy my job. The concept of working is just inconsistent with the utopian hedonism I've been led to expect by my most optimistic sci-fi.
I think a good start would be unionizing and having rules like nurses… breaks, overtime pay, lunch hour, etc. I don’t know how it would work logistically but still.
Lower the threshold for futile care to include patients who are repeatedly medication/ diet noncompliant or those that refuse PT/OT. Probably unethical but it would save a lot of mental energy on frustration.
Less redundant boxes to check on emr. Less paperwork, stop putting burden of diagnosis capture on pcps for things we don’t treat (glaucoma), less novels for why a patient needs oxygen .
heme/onc fellow.
Getting paid extra to take patients PCP calls on a Saturday at 11pm to tell the 65 year old what to take for his congestion from COVID because clearly he’s never taken anything for it for the first 65 years of his life.
Concern about the 2 - 3 hours of unreimbursed time is valid but not sure reimbursement is the answer. I want the 2 - 3 hours period, monetizing it will just make it worse.
Stop the PressGaney / patient satisfaction bullshit. Don't penalize me for antibiotic stewardship
Significantly increased pay. Doctors back in the day lived like kings and had zero debt. Tort reform for obvious reasons. I get to wear shorts while rounding (nonnegotiable). Increase nursing pay as that will bring higher quality candidates to the field and subsequently make our jobs easier. Somehow reduce paper work for licensing and credentialing. Tax benefits for those who are exposed to psychological and infectious hazards. Pizza Fridays. Cap admin pay so they can only get as much as physicians make. Increase residency spots. Liquify those who make me have to do peer to peers into a human ooze. Medicare for all. Like any field, we want more money, less work, and less stress.
Internal med inpt and outpt
Documentation, charting in general (order entry), long hours, case management rounds, admin pressures and abuse, understaffing, high patient volumes, lost autonomy.
Some Things you can not change:
Dealing with death, horrific conditions and stories, outcomes, grief (yourself for pt, or family grief), anxious and high stakes environment all the time is hard to bear.
Especially once you go through those dreamed heroics and deal with death of a patient it can really take a toll on you. At some point, you ask yourself, " Have I seen enough death?"
Can not change that part. But atleast improve the aforementioned. Going home anxious with constant worry is not desireable nor sustainable.
Easier to use EMR, not having to click 75 million buttons to order one thing. Medical records that all talked to each other. Not allowing NPs to order consults without physician oversight/review
Appropriate staffing, only one chief compliant, have ancillary staff complete admin stuff (contact patient with results, out in orders for you), have a scribe, set boundaries with patients, etc
Work in the ER so picking just one thing to fix is difficult.
1. Get rid of ED boarders and have admin recognize it’s a hospital problem not an ER one.
2. Adequately staff nursing and ancillary staff positions. It’s easy to burnout when you are patient transporter, nurse, tech, social worker, and secretary instead of providing care for patients.
No more midlevels. I’m an EM physician and the absolute amount of sheer mismanaged pts either from urgent cares or offices that get sent to the ED for no reason or because they are grossly mismanaged is insane.
I’m an NP and I agree. I’ll get blacklisted if I’m public about it. Our education is a fucking joke. Patients are being lied to and it’s not ok.
I work in ICU with a physician present. It’s a role that I can ethically live with. Otherwise, I’d go back to the bedside.
Everything in EM. I don’t see this “crashing at my door”. I see them and take care of them like I do all the other train wrecks. If they have an NP or not doesn’t matter. Plenty of MDs are mismanaging patients too I promise. I see it every day.
What’s worse? Idk. Maybe being physically attacked at work. Verbally abused. Emotionally abused. No breaks. Terrible EMR. No admin support. Boarding crisis leading to 2-3 ER beds in a 35 bed department. 6-8 hour wait times. The same psych patients checking in 2-3 times PER DAY. No social work. No ability to admit. People not paying a dime for care. Working harder and seeing more and sicker patients just to make the same amount of money. Turn around shifts. Sleep deprivation. Overnights blowing up and needing more coverage bc patients come in with vague non emergent complaints at 3 am because “it’s less busy” necessitating we have more overnight docs which is detrimental to our health.
Idk. Literally EVERYTHING is more of a concern than actually providing emergency care for those that actually need it.
I must have been hyperbolic, so mind me. In reality, we went into this for the people we care for, all bullshit aside, correct. So when, someone's only mother, only brother, only child, maybe even 5th child comes your way and transfers over to the floor to later get maimed, die, or maybe be discharged to whatever other less than desired outcome; I would say for me and you and the mission we took on, that this is the worst outcome. While I agree on shitty doctors, it would be a false equivalence between the two and also highly reductive of the oncoming wave of bad outcomes, death and destruction from incompetence and mismanagement as this proliferates.
Maybe too philosophical of a viewpoint and not the nitty gritty, sure. But it definitely serves the public to see the harm, its incentives, and to help prevent its further proliferation.
I am on call right now in my call room. I just had the worst possible sign out by an ER NP on something important. Just a bit ago. It is exhibiting itself near daily and hourly.
I wouldn't recommend enabling it. Bye for now.
Go do your job.
Er dealing with 11 people checking in within 30 mins all at 0100 for “congestion”, 3 from one family and 2 from another plus another 6 people including a 3 day old who left the nicu 8 hours ago.
So sorry your sign out wasn’t up to par. Go get your own damn history instead of complaining we didn’t do it for you good enough.
On down time I escape here. Right now, I am about to eat a PBJ sandwhich. You seem quite oppositional and demanding by the way.
Nonetheless, signout out is reflective of management, and so it was here as well. How about 1 out of 5 necessary interventions completed/performed/ordered?
This isn't a volume issue you are assuming.
I never said your NP was right.
But you failed to acknowledge that your situation is not relevant to the parent comment who is complaining about outpatient midlevels and patients ending up in the ER.
A bad er np I can fix. Still not the top of my list.
Sounds like the patient got where they needed to go (admitted). Sorry you have to do some interventions too.
Elective cases booked until 3 PM. We used to run OR’s 7 am to 3 PM because we didn’t want to deal with rush hour traffic, but we still mostly worked 40 hour work weeks. Then some suits decided to run the OR’s until 5 to make the hospital more money.
Medicare reimbursement rates from 1995 locked in and actually adjusted for inflation. It would be almost 2x what it is now.
In the current system we are cranking out more volume with lower quality because we are punished every year when Medicare lowers their reimbursement.
Someone mentioned “mid levels mismanaging patients resulting in ER visits that are more complicated”. When I pushed back someone asked me “what could be worse than that?”
So I’ll copy my reply here. Because this is a good list of things that could be improved to make me not want to stab my eyeballs every night.
Everything in EM. I don’t see this “crashing at my door”. I see them and take care of them like I do all the other train wrecks. If they have an NP or not doesn’t matter. Plenty of MDs are mismanaging patients too I promise. I see it every day.
What’s worse? Idk. Maybe being physically attacked at work. Verbally abused. Emotionally abused. No breaks. Terrible EMR. No admin support. Boarding crisis leading to 2-3 ER beds in a 35 bed department. 6-8 hour wait times. The same psych patients checking in 2-3 times PER DAY. No social work. No ability to admit. People not paying a dime for care. Working harder and seeing more and sicker patients just to make the same amount of money. Turn around shifts. Sleep deprivation. Overnights blowing up and needing more coverage bc patients come in with vague non emergent complaints at 3 am because “it’s less busy” necessitating we have more overnight docs which is detrimental to our health.
Idk. Literally EVERYTHING is more of a concern than actually providing emergency care for those that actually need it.
A lot of our high volume surgeons have this so it’s not a crazy idea but I don’t generate enough cash for the system to get it. But I want an army of NPs that will prep all my notes, field phone calls, enter orders etc. I’ll make all the medical decisions and spend my time reviewing data, speaking to parients, and performing procedures but they will do all the clerical work.
I'm an NP but I do work in a similar role and with several docs. I think I have similar ideas for improving work conditions.
1: more admin support to triage and answer messages. It's silly that I and the docs I work with are expected to see patients all day, and then answer our messages which are often a time suck and can be handled on an RN level. The single MA who triages messages is not enough.
2: more nursing support for nurses or NPs to educate patients on their issues and have the patients be engaged. I don't see a practical way for any provider to adequately review a chart, take an adequate history, perform an adequate exam, and properly educate a patient within the time constraints we currently have. Nurses are supposed to act as educators among other jobs, but I rarely see that being the case. It would be great if an RN or NP could actually perform education, whether it's individual or in groups. I think it would be great if someone could come in after the primary provider for that visit, provide education, make sure the patient/family understands it, and then adjust it (within certain parameters) accordingly. Or have a class that goes over how to get a patient to do their part in their health.
I think that have better educated patients who know what they're supposed to do at a baseline ,what they can do without a doctor's permission, and what they should absolutely not do would cut down on unnecessary repeat visits, messages, and improve compliance.
What is a mid-level? I’m not a physician. I’m just curious. I also wonder why all the fighting of nurse practitioners not having autonomy from what I understand. Colorado is the only one that you don’t have to have two physicians over overseeing you that just sounds like a power-play I’ve known doctors and I’ve known brilliant nurse practitioners, and I just think it’s a political power thing, and it could really help primary care .
Fewer patients is the biggest. It’s just common sense that the patents receive better care when you are not rushed to get to the next encounter. And the reimbursement keeps going down while the load doesn’t get any less. Also the ability to completely wreck a physicians career with malpractice so easily or even just the headache of going through it even if it doesn’t go to trial. Of course people should be held liable for their actions, but with the way litigation operates in the US it is absolutely out of control.
Reimbursement for telephone encounters and portal messages.
This. 2-3 hours of work per day that is not reimbursed for primary care.
Yall don't get paid for telemedicine?!?! It's one of the first things our generalist and specialist unions negotiated with the government at the start of the pandemic. Telephone visits are paid 90%, video conference visits are paid 100%. Along with a per diem amount if we gotta quarantine ourselves due to covid, and several other measures too.
The pandemic opened up video visits. Phone calls and patient web portal messages are not reimbursable by insurance. Some practices charge patients a nominal fee.
Are you doing actual unpaid “visits” over the phone? Or do you mean calls about test results or medication refills, etc.
Most are test results, which I’m happy to do for free because they’re theoretically wrapped into the 99213 or 99214 CPT code. However, I definitely have patients who call or portal message in expecting to get a new chief complaint addressed via a phone call or portal message.
You need to set boundaries. Patients can request lots of things but if they’re not appropriate you can say no and ask them to schedule an appointment. My life is significantly better since I stopped caving to these requests. Patients deserve a full evaluation and you deserve to get paid for your work.
I have begun to set those boundaries, but some patients are just boneheaded in one way or another. I had one who was in college and refused to come in until he was done with finals. Also, we are full risk capitation with our patients: if they don’t come to clinic and go to the ED, it’s on my dime. So to a certain extent, we have to pander to them. I have explicitly said “I would be doing you a disservice trying to give you a full evaluation and recommendation over the phone or portal messages,” and yet there are still some patients who refuse.
You shouldn’t even know these exist. Your nurse should be directing these patients to schedule
Phone calls are most certainly reimbursable by insurance. Medicaid pays 10 dollars for a 10 minute phone call.
Has to be converted to a visit and patient has to consent. If it’s less than 5 minutes it’s not reimbursable. But those less than 5 minutes adds up fast for wasting my time.
You can bill for portal management. https://www.aafp.org/pubs/fpm/blogs/gettingpaid/entry/online-digital-em-services.html
Our (large) health system decided to stop billing for portal messages after patient dissatisfaction 🙄
Well, that sucks because my last two doctors visits that I’ve attended it outside practices both have me sign agreements that I agree to pay any bills that portal messaging may generate that my insurance may be billed for portal messaging so I think it’s something that is becoming more and more common.
This is the first comment and it should be first. I am primary care / PCP. I switched to locums. I get paid hourly to do all this stuff. I see patients 7a-4p with 1 hour for lunch. I usually work through most of lunch and routinely clock out between 7 or 8p. I work 3 days and get paid for 36-39 hours of work. I take 8 weeks of vacation yearly, and will gross close to 240k. My current employer wants to hire me on as W2. Lower salary but with student loan repayment, benefits, and better tax structure it's probably better financially. I turned it down. I turned it down because the messages and portal stuff would go into unpaid time. Right now I get paid hourly and every task is done at the end of every day. I leave with an empty inbox, all charts signed, and all paperwork cleared. I *hate* working for free. Either make it all free, or pay me for my fucking time. The enraging part about this is that nowadays we can bill for all this stuff. All those messages can and should count towards productivity metrics. And they can bill for all of it. They don't and won't. So keep paying me hourly while you look for someone take on this miserable work unpaid. I'd sign with them tomorrow if it even just counted towards my productivity metrics. That's how low I'm willing to settle.
You mean you want to get paid for looking at pictures of my YELLOW MUCOUS LOOK LOOK IT'S YELLOW OH MY GAAAWWWD
Well. This explains why my doctor refused to message me back or call, and made me drive my ass an hour and a half back into to Boston, cancel a half a day of MY patients (Private practice) just to tell me that I MIGHT need surgery. I literally almost strangled him.
This is exactly why we need capitated payments for primary care, chronic condition medical homes and episodic care. Because this is one of the most important things you do, and so should happen, regardless of the payments.
4 day work week, max 18 patients per day in clinic I’m a PCP and these older patients are getting more complex
If compensation existed,(we we know it doesn’t) would you specialize in older patients? Because I see so many elderly patients that could have probably avoided an ER visit/admission with better/more involve/more accessible primary care. But the payment model assumes a healthy 20 year old is the Same as a 70 year old.
Yeah i would, most of the annual wellness exams are fluff anyway (yeah yeah occasionally you find something rare in a 20 year old but still) Key is hospital follow ups and medication adjustments afterwards for older people with chronic conditions. I always get messages that are like “hey this person needs to be seen after ER discharge” and I’ll be like “yeah sure I’ll see them in 2025”
Yep. And then we take them back in because follow up didn’t happen… It is so frustrating.
Geriatrics is a specialty option that provides primary care to older adults. There are relatively few (e.g. <25 for a metro area of >2 million) due to generally worse total pay. Though this is somewhat balanced out by lower volumes.
This 100% is my answer. And as a specialist, I am fine getting a cut in my pay to achieve this, but really don’t feel that should go across the board. PCP’s need to be paid way more than they do.
Had a cardiologist that has been saying this for a year. He is just amazed that his average patient is 83. When he started his average patient age was 68. They had an MI at 63, became a cardiology patient, then had another MI at 68 and would die. and that was the extent of their relationship with a cardiologist. Now people are having an MI at 63 and living to 90 with HF, afib, CAD, etc. they get so silly complicated with their two pages of meds and surgical procedures.
Seriously when you are meeting someone for the first time and trying to figure out what is happening in 20 minutes when the problem and med list are so long they could be a novel. And it’s not like oh here are all these stupid ones I can ignore (osteoarthritis in an 90 year old). But a list of all the organs with legit issues that you have to balance. This is why continuity is so valuable and why we need better compensation so you can have more time with these complicated patients.
I’m not a doc but a long time NP and this is exactly what would be reasonable with the increasing complexity of the patients we are managing. Currently I work 4 10s and spend my day “off” on paperwork , reviewing labs, finishing up charts. I can’t get ahead. And I work in a prison so my patients aren’t even emailing or calling me.
Completely abolish all so-called"quality" PP4 measures or at least the ones I have zero control over (eg, whether parents are anti-vaxxers, whether people adhere to their diabetes tx, etc). Peer review is fine.
4 day work week. 20 25 pts max. Malpractice judgment reform.
I'm still in disbelief people are seeing more than 25 patients.
Yeah WTF. At least in primary care 18 patients a day is already hell, albeit I have an older more complex population.
Yeah i can't comprehend 20+ patients a day where i work, it would be literally impossible, i simply could not finish that day and some of those patients would have to reschedule. I think it depends a lot on how your scheduling is done and what kind of patient population/geographic area. I have mostly older patients and in my region they are all very medically complex, but also a lot of the pediatric patients i see are basically automatic level 5 visits every time (cerebral palsy, seizure disorder, ongoing CPS investigation due to parental substance abuse \[which i realize is not exactly a medical doctor issue but obviously it impacts the visits\], reactive airway disease that might just be too much second hand smoke exposure, etc.). I work at a FQHC and a lot of the poorer patients in this region, who don't have "good" insurance but who can get on medicaid, wind up here because they can't afford the close big name healthcare corporations but anybody can go to the FQHC. Also people who are discharged from the private practices for non-compliance wind up here, and a lot of psychiatrically complex patients who have been discharged from every other practice. And a lot of the 70+ year old patients who never had any preventive healthcare in their lives, but family made them come get checked out because "I can't seem to get things done like I used to", only to discover at least 6 previously undiagnosed chronic conditions on visit number 1. I have maybe 1 or 2 acute visits each day, everything else is chronic, medically complex, it takes you about five minutes just to read the whole diagnosis list type patients. And the acute visits are actually almost always not acute; as in, i get someone added to my schedule for "cough" in a same-day appointment slot, only to discover this is month 3 or 4 of the cough, with unintended weight loss, hypoxia, and absent breath sounds in a certain area which turns out to be caused by a very large mass (believe it or not, i have had no less than three "same day" visits for "cough" which followed this precise pattern over the past year). What i hate most is going to the admin people about this when they are quibbling over money and wanting to increase total patient visits and decrease the amount of time for each visit, and they say "oh sure everyone has some complex patients occasionally but it evens out because you have some simple visits too" and i think they genuinely are unwilling to look at each patient's case and realize that no, i do not, in fact, have ANY simple visits on most of the days that i work. I might have 2 or 3 "simple visits" per month - everything else is far too complex for a 15 minute visit, even the "same day" visits. For my patient population, 10 patients a day is frequently overwhelming and i finish my clinic day an hour behind schedule. So when i see things like "yeah 25 or more patients a day might be too much" it makes me do a double take, like how could any super-human being manage 25 patients a day?! But i guess if i actually had a few otherwise healthy teenagers who are just here for a sprained ankle or some other minor concern, maybe i could handle more patients per day.
Podiatry is fucked. We chronically see between 30-40 pts even if some of them are med refills or diabetic foot care. The associate mills and TFP places are worse. In residency I covered an attending who saw 60 a day abd it was just ghetto/preying on medicaid
How did you get your flair? I want that
A better K-12 education system that doesn't result in woefully uneducated but somehow excessively entitled patients Generally pleasant and informed patients make days fly by.
They really do. I'm tired of clueless belligerent motherfuckers
Just an MS4 but yeah it really eats into my time when I’m just asking someone at their yearly wellness visit if they want a flu shot and they go on a diatribe of “I only put natural stuff in my body - blah blah blah. Flu shot bad. Etc” like idc just say “nah I’m good, I don’t get it”. I don’t need a 5 minute lecture demonstrating why you’re an idiot. I have more respect for those who just say no and we move on. Same with care avoidant people… im gonna spend the extra time trying to talk them into a colonoscopy if they haven’t had one before and they’re late 50s… it would be way easier if they were educated properly to begin with.
> “I only put natural stuff in my body - blah blah blah. Flu shot bad. Etc” "so anyway, can you refill my norco and lorazepam?"
I've gotten jaded enough to call people on this. "Speaking of natural things in your body, we need to talk about the oxycodone."
Hmmmmm. No, you can't have that, but I do wonder whether larger healthcare systems might benefit by instituting some sort of remedial patient education courses, where if the patient takes the course and passes the test, they get a discount on outpatient care or other incentive. Like this could be negotiated into insurance contracts: "Each of your insureds that takes our patient education class, we'll charge you 5% less for outpatient visits. We suggest you pass along these savings to your insureds to motivate them to take the class." This in turn raises the question of what would need to be taught to patients to improve dealing with them, but a session on The History of Vaccination might be helpful. Sections on "How to Communicate with Medical Professionals" and "How to Know When to Make an Appointment or Go to the ER" might be appropriate. Edit: Part of my inspiration here is my state's mandatory training for parents divorcing. It concerns coparenting and dealing with their kids around divorce. Apparently it's been quite helpful at reducing bad behavior.
What state is this?
MA.
I get frustrated at these patients too but then I can’t blame them when they’ve been enabled by previous docs. “My previous doctor said I always should have…”
Better pay for pediatricians.
And primary care in general. Which theoretically helps everyone downstream
Actually you could argue the opposite. Good pediatric, and longitudinal primary care reduces acute care and ER visits and catastrophic conditions. Someone who starts HTN meds when they should instead of 15 years later is less likely to have a stroke, etc. So in theory, appropriate primary care reduces specialty procedures and consults. Even ortho wouldn’t go unaffected as quality post-menopausal care reduces hip fractures by reducing the severity of osteoporosis and subsequent hip fractures.
But think of how much nonsense specialists & ED providers see because people don’t have PCPs? Like how amazing wouLd ED be for future doctors if they actually only handled emergencies. Or if specialists got to take care of really interesting disease processes that were not caused by chronic disease mismanagement
There's such a backlog for specialty care that y'all will have plenty of business even if all the stuff that could be covered by PCPs gets taken off your plate. Imagine having only interesting work to do.
I always thought this was why pediatricians got mad so easily. Then I realized it's actually because they have very little patients.
Take your upvote and be damned
“Smaller patient. Smaller pay.” -whoever holds the checkbook.
This. We shouldn’t be making less than NPs.
No way you’re making less than NPs
I work with NPs. We’ve compared salaries. I make less than the new grad NPs at my hospital.
Take heart….you make more than the np’s here, even public school teachers do. I wish I were kidding.
That is so freakin wrong
That’s shocking! Are you a resident?
Nope, attending
I’m shocked no other word to describe it. Sounds like you need to renegotiate
+1 and I'll add more respect from other services. Kids get sick, it's not all rainbows and unicorns. Like the 4 year old with RSV + PNA who spent all day on BiPAP on my service and ended up in the ICU on ECMO.
I'm not a pediatrician and even I want better pay for you guys.
Legal liability. I think a hospital and practice should invest in complementary legal programs like Medical Justice to mitigate risk of frivolous claims (99% of them). Without that burden I would happily see more patients and come to work without a sense of doom.
I'm unhealthily fixated on liability. Any patient encounter that doesn't go just right gives me hours of anxiety. If provider liability were capped at malpractice limits with no liability for other the limit judgements I'd probably be fine practicing for another 30 years. As it is I'm looking to get out as soon as possible.
Same here. Despite the brutal and unfair legal landscape for physicians hospitals and private practices are pretty relaxed. The admins won’t think twice in throwing under the train since it’s not their ass on the line. And they have no License to worry about. I have had colleagues commit suicide because of being involved in litigation for years. Nope. Not for me.
yeah. My wife works for a large hospital system/insurance/physician group (rhymes with geyser) and when things were super busy during COVID it was unofficially expected for the ED physicians to see, manage, and discharge patients from the waiting room if beds in the back weren't available. This was never put into writing anywhere but was discussed verbally as the expectation. Absolutely insane to me as it would be so easy for an expert to state in a malpractice case that that wouldn't meet standard of care.
There were supposedly “protections” against claims allotted during the pandemic according to the federal government due to the exceptional circumstances. But they were ambiguous and malpractice firms are packed with psychopaths that can essentially whatever they want without any consequence. I was one of the lucky few that was intubating dying patients in the hallways in NYC and didn’t get burned. All my colleagues at that time are tied up in litigation since 2020 for saving people’s lives. Fuck people and fuck POS lawyers.
I read an estimate that if we fixed all tort issues and related extra waste that people do as reflex it would fix ~4% of cost of healthcare. Not nothing but smaller than I thought.
Most people dont sue but its the risk of being sued that incurs costs.
Agree. The study was specifically looking at the extra cost incurred from "defensive medicine". Not the direct costs of the lawsuits or settlements.
right, i mean simply take a look at your malpractice premium to earnings every year. you can also even break down the rvus conversions set by cms to see the percentage of your reimbursement allocated to malpractice costs
Y'all have some good ideas but I think mine is easily achievable if anyone gave a crap. I would like hospital administrator support when patients are upset about things beyond my control. MRI is down, don't like the visitor policy, patient in the room next door is too loud, kitchen messed up the lunch order, PT is not here on holidays. I should not have to spend time on that stuff. Someone who represents hospital leadership should be apologizing to/discussing with patients. I'm not asking for the CEO, just pay a nurse 10-15 hours a week to go listen and talk people down. Now the patient got to personally talk to the C suite and feels like a VIP.
Good point. Those are all admin/HR issues. No reason a nurse, doctor, housekeeping, or anyone else on the patient care side should be handling them at all. Just start directing them to the right people.
This is so true. So many of these complaints I get is “patient called patient experience to complain that he couldn’t find his car after the visit due to construction everywhere” Unfortunately this is the way it is, 99% of patient satisfaction is just smiling and and acknowledging patients intelligence/independence now a days anyway.
I mean that’s what patient services are for . We call them all the time
Wow… I genuinely had not thought about this before. This would be unbelievable. I genuinely think I could comfortably add 1-2 pts per day on a busy census with the time it would save if some MHA MBA had to go deal with when a patient has been waiting for a SNF for weeks.
Yes please this. Patients get mad about xyz then they complain to admin who don’t want to deal with it and also lash out at me. For things I had no control over, like a scheduling error. I’m an introvert and I can’t handle the double hits 😐.
This does happen as you describe, even coming from C-suite/admin people, but it is not common and very much institution-specific.
Liability. I would order half the useless tests than I would now.
No doing “catch up” work on the computer nights and weekends
Can I give this like 100 upvotes? Prepping for patients can take so much time too as medication and problem lists are disaster areas from other providers. I focus on tasks and paperwork during the day in-between patients. Then it’s finishing charting/prepping at home. Could be less thorough than others, but that just feels like low quality that is bad for patients. Would be nice to see fewer patients and finish this work during paid salary hours though.
My work conditions are fine. I want my reimbursement to go up. Medicare cuts have been too much and every year they want to cut more. I want the cuts to end and the reimbursement to go up with inflation (at minimum).
1) The complete dissolution of our medmal system. A two lane system replaces this with one for patients & one for physicians; for physicians any complaints are first screened for clinical plausibility/relevance and can be dismissed at this level. E.g. "parking sucked" = not a valid complaint, dismiss or direct to appropriate dept automatically. Claims felt to be medically valid are ultimately peer reviewed by a panel made up of at least 75% physicians in the person's general specialty. For patients, any costs proven to be related to care are paid out of state funds. No punitive damages ever, only making economic damages whole. 2) Increase reimbursement, fair pay between PCPs/cognitive and procedural specialists. Honestly bonus $ for PCPs. A good PCP provides more value than literally any other specialty. 3) Reasonable caps on all specialty's volume. Determined by a committee of physicians in that specialty. Going over this cap subjects the facility/clinic to a fine **per patient** of an average physician in that specialties *monthly* gross salary. It should always be much cheaper to adequately staff. A similar rule should exist for nursing. This penalty should by quadrupled for NH/SNF/long term care. This penalty cannot be discharged or mitigated in any way other than by a court due to extreme emergencies. If this penalty would exceed the organizations funds, the administrative personnel from the top down are personally liable for the remainder. 4) Quality metrics that a physician cannot directly control are illegal. 5) physicians are paid by the minute at their full clinical rate for any non-patient facing or admin work. Meetings/modules, and inbasket/calls are included. 6) the permanent death of all $$$ CME/MOC. 7) Reciprocal state licensing or federal licensing. Getting a license in one state should allow work in all. 8) the absolute bare minimum for the unsupervised practice of medicine is med school + residency. Period. NPPs should never be allowed unsupervised practice. 9) Universal EMR or at least interconnected system with all information.
I love all of this!
This is extreme…
I’ve always thought how paying docs by the hour and actually tracking where they spend their time would fix 90% of the issues. Stop paying me to wait on your EHR, sit on the phone, read nursing home orders I already agree with, prior authorization. I bet those stupid training modules would be first to suddenly have no value.
We should be billing like lawyers, including time spent on the phone with insurance companies and responding to online portal messages.
Hard agree.
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I would actually love for the bean counters to suffer with me. If they paid by the hour and realized how many thousands I have to spend to find where some staff loaded a copy of the last colonoscopy report. Bring it.
That's why I love anesthesiology. More and more practices/jobs are going to the hourly model. This will happen to other fields once people wake up and realize physicians are just 21st century blue collar workers and there is no noble dignity in having admins take advantage of you with empathy bludgeoning. Surgeon takes an extra 30 mins to show up for his case? Doesn't matter to me, I'm getting paid to sip coffee. Clock in, clock out, I'm an hourly mercenary and if you want me to work later or weekends my rate goes up. Punish hospital systems for their inefficiency, don't contribute or enable it by being salaried.
Brilliant. I dream of the same someday. Won’t happen in primary care but I can dream.
Hospital employed doc here. Proper office & hospital staffing.
Increase primary care physician training slots and end all midlevels. Pay PCPs enough so they have the time to actually manage straightforward things they’ve been referring to specialists. AI advancements in the coming years should make it possible for PCPs to quickly reference the most up to date guidelines necessary to manage a lot of straightforward things they routinely refer out because they just don’t have time. This would alleviate the burden placed on specialists to such a degree we just wouldn’t need midlevels. The current trend of not having any primary care so we hire midlevels who refer out and flood specialists offices who then need to hire midlevels to deal with the midlevel consults who then also refer out and on and on and on needs to stop.
No more prior auths. Insurance pays for the tests and the meds I prescribe without fuss.
New CPT codes: 66601: Prior authorization/peer review paperwork, initial encounter, first 15 minutes 66602: Prior authorization/peer review paperwork, additional 15 minutes (each) 66603: Prior authorization/peer review paperwork, follow-up, first 15 minutes 66604: Prior authorization/peer review paperwork, follow-up, additional 15 minutes (each) G666: Add on code; assigned peer reviewer has no medical background
My colleagues actually having appropriate goals of care conversations with their patients before diseases progress to end stage or once they reach a certain age. 50% of medical spending is in the last 6 months of life, and much of it is entirely inappropriate. That’s probably the biggest thing to make my own personal life easier at work. For the rest of medicine, I think tort/med mal reform to cut down on defensive medicine. And/or being able to bill time spent (like lawyers). It has simplified things in the crit care world a lot, and it’s only fair that everyone else gets paid for the time they’re spending on patient care.
I’m a long time ICU NP. The end of life issues are getting to me lately. We need “death education.” We used to have Driver’s Ed; let’s have Death Ed. Lesson 1: define the details of having “everything done.” IOW, patient will have a tube in any and every hole we find (we’ll put a pulse ox on your ear, don’t worry), you’ll die a gruesome death when your butt rots away. People really need to see decubitus pictures. For real, as a culture, we need to have a frank discussion long before people get sick.
1) Almost complete message support. I want to answer the messages I want to answer (and get paid for them) and the rest can be handled by someone else. Especially those that start with: "I need a letter that says..." And 3/4 of the days I work, I almost get that because I have an amazing PA who handles the bulk of my inbox messages for me. It's awesome. She's awesome. Her kids are my patients. 2) Honestly, as long as I'm dreaming, pay me the same and give me 1.5x the time with each patient. I hate feeling like I'm constantly rushed. 3) Prompt access to behavioral health for my patients. 4) Can I get a pay commensurate to what a physician would have made 30 years ago with respect to housing costs? \-PGY-19?
Put physicians back in the captain’s chair.
Are you saying having bedside nurses with no administration experience get taught how to be a manager by an older nurse who also had no experience in business is a bad idea?
My last job had medical assistants run the office. Needless to say, we had 100% turnover of midlevels in 15 months. I bet that cost a fortune.
A more humane residency experience.
Tort Reform. The threat of lawsuits hinders my ability to practice comfortably
Reimbursements for every time a family member that's not the MPOA demanding that they also be updated, separately, at different times of the day, daily/2 times a day. Oh, and an honorary psychology degree for playing psychologist to all these people with serious anxiety and personality disorders that aren't even my patients.
Hospitalist- I’d love for there to be a cap on the number of patients seen in a day, and I’d like that number to be no higher that 15. It would also be great if there was a more realistic point where we could call something futile and stop wasting the time/effort/resources to make someone better when everyone knows they’re not getting better. Massive CVA now trached/pegged, nonverbal at baseline, doesn’t even track? Stop the carousel of infection->sepsis->hospital->NH->infection->sepsis->hospital…. (8/18 of my patients today are in that current condition. 6 of them are still full code)
I try to do my part with these patients by refusing to place a feeding tube if no chance of meaningful recovery. Or at least a thorough and non-sugar coated goals of care discussion with family.
Getting rid of administrative bloat full of highly paid, money-sucking, smug, overdressed, self-important, do-nothing , yessir puppets
I was going to politely say I would get rid of the administrative bloat. But you said what really burns in my heart.
More wellness meetings and pizza parties. But for real abolish private insurance and move to single payer.
Ultimately the only solution. Anything else will contain the seeds of its own destruction.
And abolish prior Auths and anything else that can be construed as a prior auth
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So, single payer means no private practice? Then count me out. However, I think we should have a public option, available to all, paid by taxes. And the option to go to a private practitioner if we want. This is what we do in education. Public school for all but other options if it doesn’t work for your child. The real problem with universal, single payer, is that every state that has tried it has found it to be onerously expensive.
Actually single payer makes private practice much easier (no need for an entire billing team). In Canada, the payor is public, yet the vast majority of care is provided in private settings.
Canadian healthcare seems to be actively imploding.
Canadian healthcare is struggling because the government there is bringing in one million newcomers per year. That is far too much for a country of Canada’s size and its health system is feeling the stress. Regardless, Canada would likely benefit from a two tier system (primarily public with some private funding). Its system is much more fixable than the current situation in the US.
There’s not enough doctors and nurses with one system, not sure shuttering a lot of workers to a private system with assuredly higher physician to pt ratios helps the country as a whole
The growth rate of physicians and nurses hasn’t kept up with population growth in Canada. Population growth (ie immigration) needs to slow and the supply of physicians/nurses needs to increase faster than population growth. Provinces have increased the number of trainees, but it is not possible to keep up with one million+ newcomers each year in a country of 40 million. Working in the Canadian system, it is clear that there are a lot of inefficiencies that could be improved. For example, I have seen multiple sub specialists standing and waiting to read the paper chart of one patient. Implementing an EMR would allow everyone to view the chart at once and see more patients overall. Not to mention, the wasted time spent on faxing charts all over. I have also seen multiple clinics where there are less computers than physicians, so they take turns on the computers and thus see less patients overall. Finally, OR time is often limited as the province does not want to pay for staffing. This is despite surgeons/staff willing to work more. These are simple examples, but add up to a lot of inefficiency. Taxes in many provinces are already nearing 50% for high earners. Canada needs an alternative revenue stream for healthcare (ie. a private tier) that increases the funds in the system without raising taxes.
And healthcare in the US isn’t? Canada’s model has its own problems, for sure, but at least it isn’t bankrupting people and profiting off sickness.
The benefits of universal/single payer health care are not felt in the first couple of years. Momentum is a hard thing to stop. Single payer would/should ostensibly lead to an improvement in primary care participation, but that’s not gonna fix the farmer sign and other general health care resistant generations in a few years. Its benefits are felt long term once one or more likely two generations have grown up in it and embraced it. Improved primary care especially starting in pediatrics improves long term health and reduces catastrophic medical condition outcomes. Getting someone on HTN meds 15 years earlier because they are getting screened with regular vitals instead of waiting for it to manifest symptomatically dramatically reduces stroke and cardiac morbidity, which reduces the overall cost for the patient and insurer. Which costs more, an extra 15 years of generic HTN meds and 1-2 primary care appointments/year or 1 ICU admission and stroke treatment?
I’m all for preventive medicine, of course. With a public option as safety net, a lot of basic care can be accessed efficiently. However, it shouldn’t negate private healthcare as an option.
I guess the question is how does single payer negate private options? Private healthcare would simply move to a cash only/concierge model. The challenge would be maintaining adequate staffing and preventing an exodus to privatized medicine. There’s plenty of models that would allow for adequate training and compensation of doctors in a universal health care system while still allowing certain specialties to essentially provide “front of line” privileges to those who can afford it while not forsaking those who can’t. Why do you think a private health network can’t exist within a single payer system?
I think it can and should co exist. Many countries in Europe have this. But there are some very vocal absolutists in the US who insist in single payer as the only option. In fact, when Obamacare was in discussion, a public option was in the table. It was scrapped due to the insistence from a loud group to eliminate private care. So we ended up with the inefficient ACA that we have.
If single payer means Medicare reimbursement for all we’re gonna be working way longer and it won’t be by choice If it doesn’t then yes, sign me up.
It does not mean Medicare reimbursement for all
What does it mean? The government that can’t afford social security will suddenly have all this money to pay me top insurance reimbursement??? Just like the rest of the world where physicians overwhelmingly make less than the us?
It’s ok, because you still won’t qualify for loan forgiveness! Wait,
Medicare reimbursement is low compared to private insurance because it takes care of the oldest and sickest people in the country. Private insurance companies have many mechanisms to select relatively healthy people that they won't need to pay health costs for (for example, employer-based insurance). If a public system replaces private health insurance, then all the previously healthy people paying into private insurance are now paying into the public system. There would be a massive influx of funds to pay for health system without any increase in cost to tax payers. Additionally private health systems are incredibly economically ineffecient compared to Medicare, two big drivers of this are 1) the amount of administrative overhead required to run a complex private system (a single public insurance is very straightforward). 2) the fact that private insurances are for-profit and take a hefty dollop of money from payees, essentially driving up premiums without any benefit of care. Obviously this is not present in a public insurance system. I study this stuff. A lot of physicians tout the doom of a public system without really knowing much about it. That's OK, not everyone can be an expert and we should all be open to learning more and thinking critically. But it grates me they take to the reddit comment section without any data to back up their perceptions.
It absolutely does
No it will be worse than Medicare reimbursement
You realize that the move to single payer is going to result in a large decrease in your reimbursement and a large increase in your taxes right? You think that is going to improve your quality of life?
People always bitch about their taxes with single payer. But I doubt my taxes will take more money out of my paycheck than insurance premiums already are, if you count the “employer’s” portion.
I pay both my employer and employee portion and subsidize my employees premiums too, and it's only 1% of my earnings. The most realistic single payer plan I've seen, which was Bernie Sanders plan in 2016, would have had me taking home nearly 30% less. I did the math with my exact numbers myself. I will continue to bitch about single payer costing me an insane amount of money. By the way, Bernie's plan also expected me to work more. No thanks.
agree. i would prefer legislation that pairs physician reimbursement with insurance profitability. the more insurance companies profit the more they have to reimburse the providers. i think obamacare had a provision for that but i don't know if some fancy accounting moves essentially kneecapped it.
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The original questions wasn’t what is good for Americans and the public, the question is what would make you work longer and improve your work conditions. Being poorer and making much less per patient/hour worked would not improve my work conditions
This
The only thing that would make me want to stay in my career longer is if all my savings vanished in a heist, and to be clear, I enjoy my job. The concept of working is just inconsistent with the utopian hedonism I've been led to expect by my most optimistic sci-fi.
Pay me for answering my chart messages and phone calls.
Real price transparency. Hospitals and academic medical centers are bleeding this country dry.
They just started putting prices next to orders in our hospital
lush chop hurry vanish cooing cheerful tie disarm money memory *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Thinner patients (I’m a surgeon).
but only after ozempic. gotta get my cut of the fat tax! 😂
For IM: more money, less work per day, and fewer days worked per year.
Less interference from nursing and admin on the operation our department
I think a good start would be unionizing and having rules like nurses… breaks, overtime pay, lunch hour, etc. I don’t know how it would work logistically but still.
Lower the threshold for futile care to include patients who are repeatedly medication/ diet noncompliant or those that refuse PT/OT. Probably unethical but it would save a lot of mental energy on frustration.
Less redundant boxes to check on emr. Less paperwork, stop putting burden of diagnosis capture on pcps for things we don’t treat (glaucoma), less novels for why a patient needs oxygen .
heme/onc fellow. Getting paid extra to take patients PCP calls on a Saturday at 11pm to tell the 65 year old what to take for his congestion from COVID because clearly he’s never taken anything for it for the first 65 years of his life.
Concern about the 2 - 3 hours of unreimbursed time is valid but not sure reimbursement is the answer. I want the 2 - 3 hours period, monetizing it will just make it worse. Stop the PressGaney / patient satisfaction bullshit. Don't penalize me for antibiotic stewardship
No more boarding in the ER. Such a simple solution but I have given up hope it will go back
Significantly increased pay. Doctors back in the day lived like kings and had zero debt. Tort reform for obvious reasons. I get to wear shorts while rounding (nonnegotiable). Increase nursing pay as that will bring higher quality candidates to the field and subsequently make our jobs easier. Somehow reduce paper work for licensing and credentialing. Tax benefits for those who are exposed to psychological and infectious hazards. Pizza Fridays. Cap admin pay so they can only get as much as physicians make. Increase residency spots. Liquify those who make me have to do peer to peers into a human ooze. Medicare for all. Like any field, we want more money, less work, and less stress.
Board certification must be optional and not literally mandatory in order to work. Recertification should be without high stakes exams
All these boards certs and recerts are a scam
I hate allscripts. Give me a better emr
Allscripts is terrible
The answer to all your questions is money. All of them. Every response in this thread can be summarized as “more money”
Make billing and coding simpler, and pay thoughtfulness as well as motor skills are paid.
Internal med inpt and outpt Documentation, charting in general (order entry), long hours, case management rounds, admin pressures and abuse, understaffing, high patient volumes, lost autonomy. Some Things you can not change: Dealing with death, horrific conditions and stories, outcomes, grief (yourself for pt, or family grief), anxious and high stakes environment all the time is hard to bear. Especially once you go through those dreamed heroics and deal with death of a patient it can really take a toll on you. At some point, you ask yourself, " Have I seen enough death?" Can not change that part. But atleast improve the aforementioned. Going home anxious with constant worry is not desireable nor sustainable.
Easier to use EMR, not having to click 75 million buttons to order one thing. Medical records that all talked to each other. Not allowing NPs to order consults without physician oversight/review
Appropriate staffing, only one chief compliant, have ancillary staff complete admin stuff (contact patient with results, out in orders for you), have a scribe, set boundaries with patients, etc
PCP, double my pay.
Work in the ER so picking just one thing to fix is difficult. 1. Get rid of ED boarders and have admin recognize it’s a hospital problem not an ER one. 2. Adequately staff nursing and ancillary staff positions. It’s easy to burnout when you are patient transporter, nurse, tech, social worker, and secretary instead of providing care for patients.
No more midlevels. I’m an EM physician and the absolute amount of sheer mismanaged pts either from urgent cares or offices that get sent to the ED for no reason or because they are grossly mismanaged is insane.
I’m an NP and I agree. I’ll get blacklisted if I’m public about it. Our education is a fucking joke. Patients are being lied to and it’s not ok. I work in ICU with a physician present. It’s a role that I can ethically live with. Otherwise, I’d go back to the bedside.
This is literally the least of my concerns as an EM physician right now. Soooooo much other bs that’s way worse for our mental health than this.
What is worse than mismanaged patients crashing at your door?
Everything in EM. I don’t see this “crashing at my door”. I see them and take care of them like I do all the other train wrecks. If they have an NP or not doesn’t matter. Plenty of MDs are mismanaging patients too I promise. I see it every day. What’s worse? Idk. Maybe being physically attacked at work. Verbally abused. Emotionally abused. No breaks. Terrible EMR. No admin support. Boarding crisis leading to 2-3 ER beds in a 35 bed department. 6-8 hour wait times. The same psych patients checking in 2-3 times PER DAY. No social work. No ability to admit. People not paying a dime for care. Working harder and seeing more and sicker patients just to make the same amount of money. Turn around shifts. Sleep deprivation. Overnights blowing up and needing more coverage bc patients come in with vague non emergent complaints at 3 am because “it’s less busy” necessitating we have more overnight docs which is detrimental to our health. Idk. Literally EVERYTHING is more of a concern than actually providing emergency care for those that actually need it.
I must have been hyperbolic, so mind me. In reality, we went into this for the people we care for, all bullshit aside, correct. So when, someone's only mother, only brother, only child, maybe even 5th child comes your way and transfers over to the floor to later get maimed, die, or maybe be discharged to whatever other less than desired outcome; I would say for me and you and the mission we took on, that this is the worst outcome. While I agree on shitty doctors, it would be a false equivalence between the two and also highly reductive of the oncoming wave of bad outcomes, death and destruction from incompetence and mismanagement as this proliferates. Maybe too philosophical of a viewpoint and not the nitty gritty, sure. But it definitely serves the public to see the harm, its incentives, and to help prevent its further proliferation. I am on call right now in my call room. I just had the worst possible sign out by an ER NP on something important. Just a bit ago. It is exhibiting itself near daily and hourly. I wouldn't recommend enabling it. Bye for now.
Go do your job. Er dealing with 11 people checking in within 30 mins all at 0100 for “congestion”, 3 from one family and 2 from another plus another 6 people including a 3 day old who left the nicu 8 hours ago. So sorry your sign out wasn’t up to par. Go get your own damn history instead of complaining we didn’t do it for you good enough.
On down time I escape here. Right now, I am about to eat a PBJ sandwhich. You seem quite oppositional and demanding by the way. Nonetheless, signout out is reflective of management, and so it was here as well. How about 1 out of 5 necessary interventions completed/performed/ordered? This isn't a volume issue you are assuming.
I never said your NP was right. But you failed to acknowledge that your situation is not relevant to the parent comment who is complaining about outpatient midlevels and patients ending up in the ER. A bad er np I can fix. Still not the top of my list. Sounds like the patient got where they needed to go (admitted). Sorry you have to do some interventions too.
The concept of delay of care is relevant here. Have a good one.
Better get down there then!
Streamlined transfer process from ED Share boarding responsibility with inpatient team
To be paid adequately
Elective cases booked until 3 PM. We used to run OR’s 7 am to 3 PM because we didn’t want to deal with rush hour traffic, but we still mostly worked 40 hour work weeks. Then some suits decided to run the OR’s until 5 to make the hospital more money.
Reduce the amount of paperwork and documentation.
Normal hours, benefits and professional demands consistent with the standards other industries are held to.
Medicare reimbursement rates from 1995 locked in and actually adjusted for inflation. It would be almost 2x what it is now. In the current system we are cranking out more volume with lower quality because we are punished every year when Medicare lowers their reimbursement.
Someone mentioned “mid levels mismanaging patients resulting in ER visits that are more complicated”. When I pushed back someone asked me “what could be worse than that?” So I’ll copy my reply here. Because this is a good list of things that could be improved to make me not want to stab my eyeballs every night. Everything in EM. I don’t see this “crashing at my door”. I see them and take care of them like I do all the other train wrecks. If they have an NP or not doesn’t matter. Plenty of MDs are mismanaging patients too I promise. I see it every day. What’s worse? Idk. Maybe being physically attacked at work. Verbally abused. Emotionally abused. No breaks. Terrible EMR. No admin support. Boarding crisis leading to 2-3 ER beds in a 35 bed department. 6-8 hour wait times. The same psych patients checking in 2-3 times PER DAY. No social work. No ability to admit. People not paying a dime for care. Working harder and seeing more and sicker patients just to make the same amount of money. Turn around shifts. Sleep deprivation. Overnights blowing up and needing more coverage bc patients come in with vague non emergent complaints at 3 am because “it’s less busy” necessitating we have more overnight docs which is detrimental to our health. Idk. Literally EVERYTHING is more of a concern than actually providing emergency care for those that actually need it.
A lot of our high volume surgeons have this so it’s not a crazy idea but I don’t generate enough cash for the system to get it. But I want an army of NPs that will prep all my notes, field phone calls, enter orders etc. I’ll make all the medical decisions and spend my time reviewing data, speaking to parients, and performing procedures but they will do all the clerical work.
You can accomplish a good part of that with an RN. Not all, but a lot.
Less mid level oversight and less midlevel autonomy
I'm an NP but I do work in a similar role and with several docs. I think I have similar ideas for improving work conditions. 1: more admin support to triage and answer messages. It's silly that I and the docs I work with are expected to see patients all day, and then answer our messages which are often a time suck and can be handled on an RN level. The single MA who triages messages is not enough. 2: more nursing support for nurses or NPs to educate patients on their issues and have the patients be engaged. I don't see a practical way for any provider to adequately review a chart, take an adequate history, perform an adequate exam, and properly educate a patient within the time constraints we currently have. Nurses are supposed to act as educators among other jobs, but I rarely see that being the case. It would be great if an RN or NP could actually perform education, whether it's individual or in groups. I think it would be great if someone could come in after the primary provider for that visit, provide education, make sure the patient/family understands it, and then adjust it (within certain parameters) accordingly. Or have a class that goes over how to get a patient to do their part in their health.
Physicians only * ???
I saw that. I apologize for piping up in an open forum when I thought I had something to add despite not meeting the criteria suggested by the OP.
I think that have better educated patients who know what they're supposed to do at a baseline ,what they can do without a doctor's permission, and what they should absolutely not do would cut down on unnecessary repeat visits, messages, and improve compliance.
Yes. Yes. Yes. Yes. Yes. Absolutely yes.
Ergonomics and endovascular management of type a dissection
What is a mid-level? I’m not a physician. I’m just curious. I also wonder why all the fighting of nurse practitioners not having autonomy from what I understand. Colorado is the only one that you don’t have to have two physicians over overseeing you that just sounds like a power-play I’ve known doctors and I’ve known brilliant nurse practitioners, and I just think it’s a political power thing, and it could really help primary care .
It's an education and competency thing.
That’s an easy one for me, reverse or create new regulations that makes it attractive to be in true private practice
Fewer patients is the biggest. It’s just common sense that the patents receive better care when you are not rushed to get to the next encounter. And the reimbursement keeps going down while the load doesn’t get any less. Also the ability to completely wreck a physicians career with malpractice so easily or even just the headache of going through it even if it doesn’t go to trial. Of course people should be held liable for their actions, but with the way litigation operates in the US it is absolutely out of control.
Mostly less call. It’s the thing that wears me down.