WhiteCoat

Accepting Our New Normal and Finding New Opportunities

by Birdstrike M.D.

It Is Here To Stay

The 2012 Presidential election is over. Obamacare is the law of the land and is certain to remain so.  There was tremendous uncertainty not knowing whether the law would be repealed, revised or remain.  Many of us opposed the bill, and there certainly are negatives.  Like it or not, it is time to “get over it,” and not a second later than now.  The new-found certainty offers an opportunity to reassess and adapt to the coming changes.

In addition to Obamacare, other pillars of our “new normal” include patient satisfaction surveys, threats of reimbursement cuts, increasing pressure from administrators obsessing over “metrics,” more time drained by cumbersome electronic health records, resentment from patients who blame us for the failings of the healthcare system, as well as a steady stream of frivolous lawsuits with no end in sight.  It’s time to adapt to our “new normal.”

Comparing and Contrasting With Other Industries

In this modern age of Medicine, these factors have been piled on top of the traditional responsibilities of physicians such as life and death, health and wellness, and paradoxically have seemed to rise above them in importance like unstoppable flood waters drowning the ghosts of Hippocrates, Osler and Marcus Welby M.D.  This contributes to poor morale among physicians and understandably so.  Other industries have had to deal with the same concepts for decades, however.  The service industries are bound by “patient satisfaction” measures and always have been.  Businessmen also have to guard against lawsuits. They expect them and manage the risk and accept it as a norm. I doubt they perceive a lawsuit where they did nothing wrong, as life altering like so many physicians do.  Companies often times have decreases in sales just as our reimbursements may drop and constantly have to adapt.  Just about everyone else in the “real world” has to deal with a “boss” of some variety and a necessary part of their job is to keep that person or entity happy, regardless of whether they like them personally or not.  So why do we find it so difficult to deal with such factors?

Are we special?

Are we different?

In a word, “No.”  Not anymore.  It’s time to accept that fact and move on.  We are now cogs, replaceable de facto employees of a massive business-medico-legal-political machine; nothing more.  All indications are that it will remain this way.  Much can be learned from such other industries that have had to adapt to the stark realities ahead of us.  I think for the profession of Medicine to reinvigorate itself, and for us to truly value what we do have again, we must properly manage expectations.

What Government Will (or Will Not) Do

Though we might each individually be very replaceable, the reality is that we still have extremely high paying jobs in a profession that is relatively recession proof with greatly increasing demand for our services. There are some other positives and ironic realities that I think many physicians are glaringly overlooking.  One is that Obamacare proposes to commit about 1 trillion more dollars towards healthcare over the next 10 years, with tens of millions newly insured.  Necessarily, demand for our services will go up, way up.  And the best (or worst) news is that despite all the talk about “severe rationing” and “draconian reimbursement cuts” there’s good reason to believe that talk is a big load of….nonsense.  That’s right; they’re not going to cut a damn thing.  How can I be so sure?

There has been essentially no real political will, whatsoever, by either political party to make any significant cuts from the federal budget, ever.  Even the most “harsh” and “cruelest” proposals only call for a decrease in the rate-of-increase, of overall spending.  There never has been any, and there’s no reason to predict there ever will be, any policy other than kicking the can down the road until after the next election, and the next one and the next one. The voters have spoken and they want to spend an extra $1,000,000,000,000 on healthcare.  Santa Claus is in fact coming to town!  That may be terrible for the country, but it may well be very good for doctors; that is the smart ones.  There may be more hoops to jump through, more requirements and regulations, as well as creative strategies needed to get a “piece of the pie,” but demand for doctors’ services will necessarily increase, and tremendously so.  Also, despite much posturing, tough talk and threats of showdowns year after year, the SGR-fix has always been passed and the budget debt ceiling has always been raised.  Medicare expenditures will necessarily continue to go up, and up, and up. More patients will be insured wanting our services. The elderly baby-boom population will be sick and growing older and need us desperately.

I was told a story by a retired physician about his long deceased cardiologist father who practiced before Medicare was instituted.  He tells of his father who was a very compassionate physician, but a staunch free-market conservative who like many physicians at the time vehemently opposed the proposed Medicare system.  His father would say that physicians provided charity care for free to the disabled and elderly all the time and that Medicare was just a Trojan-Horse for socialists who wanted to take over the American healthcare system.  He may or may not have been correct, but ultimately to his dismay, Medicare passed and became law.  All of a sudden and very unexpectedly, his salary……doubled.  He never complained about Medicare again.

The point of this anecdote is not to suggest that physicians’ salaries will double as a result of Obamacare.  They will not.  However, it is to suggest that despite the 2000 pages of regulations and requirements in the cloud of Obamacare that hangs over our heads, there will be an unexpected silver lining, somewhere.  I think we can simultaneously work vigorously to reform our profession, yet shed the “culture of victimhood” that has grown like mold upon physician attitudes and search for positive opportunities.

Some Physicians Will “Opt-In”

Such new opportunities will not be the same as in the dead era of Osler, Hippocrates and Marcus Welby M.D.  Also, I cannot say that chugging along with the same old strategy, expectations, and disappointments of a bygone Golden Age will be a winning plan, either.  It may involve simply being content as a cog in a large machine or “system.”  It may involve thriving in the role of “corporate soldier,” learning how to “play the game” while finding ways to save costs, increasing efficiency for your group or other groups and “promoting” your hospital.  Others may move into the government side of healthcare and find opportunities in healthcare policy planning and consulting.  Clearly, knowing “the medicine” isn’t enough anymore and in fact, seems the least important of that which is expected of us.

Other Physicians Will “Opt-Out”

Greater numbers of physicians will find opportunity in opting-out of the system by making their practices cash only, concierge, or declining to participate in Medicare and a more dominant Medicaid system.  Another option may be for more Emergency Physicians and surgeons to exploit technicalities in Obamacare and States with liberal certificate of need laws and open their own centers that offer services for a flat fee outside of traditional government or private insurances.  As more insurance plans require deductibles in the thousands of dollars and refuse to pay for certain services entirely, such centers may gain more traction where they are feasible.

Others may “opt-out” more insidiously.  The new generation of physicians may very well evolve into protocol-following, brown-nosing, corporate mantra-spewing clock-punchers, indistinguishable from other “providers” all while refusing to make the tremendous sacrifices of doctors past, such as incredibly long hours, over-burdensome call schedules with great sacrifice to marriage, family, and personal well-being.  Maybe that’s okay, and maybe that’s what our new Overlords of Healthcare want and will reward.  More primary care physicians and other specialties likely will take the “9-5, no call” route and leave the after-hours hassles to the ED and hospitalists.  More medical students may pick careers in cosmetics over critical care.  More Emergency Physicians may leave high-stress clinical shift work in the Emergency Department for Administration, group management, Hospice and Palliative care fellowships, Urgent Care ownership or anything else seen as less stressful.  More surgeons and specialists may opt out of emergency call for a less stressful life and a focus on elective cases with higher reimbursement to liability ratios.  I see more Anesthesiologist moving to “lifestyle” positions at ASCs doing elective cases, or pain procedures with little or no call.  Many physicians will consider early retirement.

The Silver Lining

The pioneers of Medicine did not have to worry about our “new normal” of Obamacare and all of its 2000 pages of regulations and requirements.  They didn’t have to worry about $300,000 of medical school debt, mega-million dollar frivolous lawsuits or being fired over patient satisfaction surveys based on complaints that may or may not even be valid.  But they also didn’t have our modern-day luxuries, salaries, exploding technologies, or a nation of patients soon to be more widely insured and in demand of our services than ever.  There is much worth fighting to reform, yet even more worth fighting to preserve.  All things considered, we are tremendously better off.

Be sure, Obamacare will change modern medicine, and it will change it mightily.  Also be sure, that with us or without us, and whether we look forward to seize new opportunities or look back upon shattered expectations, the profession of Medicine will be alive and well, and thriving more than ever before.

 

22 Responses to “Accepting Our New Normal and Finding New Opportunities”

  1. Ð says:

    The problem Dr. Birdstrike is that whoever’s left to pull the wagon is going to see an increase in workload and burocracy, and a decrease in pay and satisfaction. I think we both agree socialized Medicine is overall bad for society but unlike yourself I can’t convince myself to be optimistic about it, even if I do agree that demand will increase sharply. When you have a single payer system, the market rules go out the window. That being said, I really hope you are right in your predictions, because I have 30+ years in Medicine to look forward to. Thanks for a great article!

    • Birdstrike says:

      Thank you very much.

      What do we have to lose by searching for the positive opportunities in the cards that have been dealt to us?

      Could doing the seemingly irrational thing, that is rejecting the “culture of victimhood” amongst physicians actually pay off in spades?

  2. joebob says:

    Insidious opt-outer, right here.
    Seeing patients is a job. not a calling. And I owe this society nothing.

  3. Canuck ER MD says:

    From a Canuck observing from up North : superb analysis, and excellent take on reality : kudos.

    And folks, “socialised” medicine does not HAVE to suck. I earn a comfortable living up here – no Maseratis, but after homework, I’m not convinced that I’d be better off down south : even BEFORE “Obamacare”.

    I don’t have Press Ganey scores, I tell patients what they need to hear when needed, and I don’t practice defensive medicine : I practice evidence based medicine.

    • Birdstrike says:

      Thank you. I’m curious as to what allows you to be able to practice evidence based medicine, and not defensive medicine, that we lack here in the States?

  4. You make an excellent and very relevant point. While none of us can predict exactly how the ‘cards will land,’ we would all do well to accept the hand we have to play (and acceptance is NOT agreeing or condoning) and find opportunities in the current circumstances to survive and perhaps excel. I’ve owned and run my own GI practice for 31 years. I agree that it’s difficult to be forced to deal with rising administrative costs and red tape, and the ‘flat’ payor system that has NEVER rewarded quality (and, despite all the talk, probably never will). The healthcare system doesn’t recognize the commitment and sacrifice that all of us have made, the training it took to do what we do, and kinds of decisions it takes–again, I don’t know that it ever will. But at least I can walk out of my office each day feeling like I’ve done the kind of job I can be proud of. There are times I had to make changes (like leaving my old practice to create a new on one where I could have the kind of work environment I wanted)and some of those choices weren’t easy. If all I did was complain (and I admit I have don’t plenty of that)I wouldn’t have done the thinking and taken the actions that resulted in the practice I have now. I would have been too busy blaming someone or something for my situation. That is the real cost, as Birdstrike calls it, of ‘victimhood.’ Most non-medical businesses have faced serious threats to their survival. If they had spent their time blaming someone else, or even themselves, they never would have made it (read the famous business book Built to Last if you want to hear some inspiring stories of companies who became leaders in their field by dealing with breakdowns in their industry). Sometimes you have to look outside your ‘normal’ everyday business model to do what others aren’t doing or find a new area. 11 years ago, I created an office based cancer screening center that allowed me to practice more efficiently and really improve the quality of my care. It was a risky venture to leave my old practice, but it paid off. Now I have to keep looking for other kinds of opportunities to do the kind of work I like and find a business model that works better than the average. It’s not easy to do some real thinking about what you, as a physician, COULD do, but I, like the author, think there currently are and will continue to be new opportunities in medicine if we are really willing to look for them. I have a son in his 3rd year of medical school. My brother, father and grandfather were all surgeons practicing in the traditional model. My Dad LOVED his work. My advice to my son was–find something you love to do but something (like concierge medicine) that makes you as independent as possible from the standard insurance model. I’m exploring some ways that I could use my skills and training to develop ‘parallel’ businesses (like weight management, etc.)which aren’t as tied to the current reimbursement model and are more ‘future proof.’ Perhaps we should spend more of our time collaborating with each other on what new opportunities we have found, or thought about–I think that could potentially make a huge difference.

  5. Birdstrike says:

    “You are welcome. Have you ever considered starting a discussion group/think tank for ideas?”

    As far as a discussion group goes, I think it already exists to a certain extent on physician blogs such as this one, KevinMD.com, Sermo.com, the attending sections of Student Doctor Network (forums.studentdoctor.net) and others.

    As far as a “think tank” or formal organization specifically for creative solutions, free-market adaptations or other ways to thrive rather than “just survive” in the new era of healthcare, no, I had not thought of that. It may already exist, if not, it is a great idea, whose time may have come.

  6. Bobby says:

    This is a pretty negative stance in my book. To say that physicians are replaceable cogs is a pretty sad and pessimistic view, regardless of the fact if it’s true or not. In fact, many of your criticisms are true but I don’t think they are beneficial. Saying that medicine’s old era is gone (Hippocrates, Osler and Marcus Welby M.D) is kind of silly. You mean to say that a piece of legislation can completely change your attitude or perspective as to why you work or your purpose. Saying that a good alternative is to become a clock punching brown noser isn’t positive either. You can work a reasonable # of hours a week without becoming a clock punching brown noser. There aren’t only extremes: Work endlessly and like a slave or be a clock puncher… there are many options between there that don’t have such a negative vibe. Imagine telling your patients, “I’m a clock punching brown noser” or your kids, hey kids, work hard so you can one day become a clock punching brown noser or a replaceable cog in a giant machine.

    I chose to focus on the positives of the work rather than the negatives.

    • Birdstrike says:

      “…many of your criticisms are true but I don’t think they are beneficial”

      You seem to be implying that it would be more “beneficial” if I wrote a post full of untruths. I don’t see how that would be more beneficial.

      “Saying that a good alternative is to become a clock punching brown noser isn’t positive either.”

      I didn’t write that it’s a “good” alternative or the one that I will choose, but that we may see more of this attitude, especially if it is rewarded by the system. I’m not the one who “corporatized” Medicine, brought it under greater government control or designed the system. However, people will adapt one way or another. I suspect there will be as many adaptations as there are doctors, nurses and mid-levels. Some may look for positive and creative adaptions like commenter #4 above, and others like commenter #2 will view it as “…a job. not a calling.” I personally, will not judge either one for adapting to a situation they did not create. We’re already seeing these changes occur, and I’m not the only one making the observation:

      http://www.nytimes.com/2011/04/02/health/02resident.html?pagewanted=all

      “To say that physicians are replaceable cogs is a pretty sad and pessimistic view, regardless of the fact if it’s true or not”

      One of the stark realities of the new trend away from physician private practice, towards physicians being hospital employees means that a physician can easily be hired or fired like any other employee. There are definite advantages to employment vs. independent practice, but one disadvantage is “replaceability.” In my own personal experience, I’ve already seen several physicians including highly trained specialists quickly hired, let go, and replaced. As much as I’d love to think that as a physician, I’m irreplaceable, it helps to be realistic. You don’t seem to be denying that this trend is real. Whether it is “sad and pessimistic” to observe what is occurring, I suppose it depends if you think that glass is half empty, or half full.

      Personally, I’ve had to accept some unpleasant realities about our current and coming system, to see that there is much “worth fighting to preserve…” and that “all things considered, we are tremendously better off.”

      • Bobby says:

        I wasn’t implying you should write about untruths, but rather the truths that are positive, rather than all the truths that are negative.

        If a person just lost their legs in an accident, they could spend hours thinking of all the things they can no longer do or hours thinking of the things they can still do. Both true, yet one is positive and the other is negative.

        Just because a person is replaceable doesn’t mean they have to have a poor attitude. Your attitude of how you approach the job is independent of private practice or being an employee. So yes, I do think adopting a poor attitude is “sad and pessimistic”.

        I did enjoy the video you posted of a group of physicians finding a free-market way around the system. That was fantastic and showed the waste in the system and how it could become more efficient. I think you’re an intelligent guy and that if we can get people who see all these problems and start a movement for change towards something positive (like that video in your post), then maybe it would help everyone. But seeing things as the new normal and then taking advantage of the situation to serve yourself in the best way possible doesn’t seem like a great plan. Part of the premise of this whole article is that somehow the legislation is burying the ghosts of Hippocrates, Osler and Marcus Welby M.D… I don’t believe that’s true. I believe there is still hope as long as people continue to fight for positive change.

      • Birdstrike says:

        “Part of the premise of this whole article is that somehow the legislation is burying the ghosts of Hippocrates, Osler and Marcus Welby M.D… I don’t believe that’s true.”

        Hippocrates was a physician that lived over 2000 years ago. Osler practiced before the era of antibiotics, the era of $250,000+ of student loan debt, the defensive medicine crisis and electronic medical records. Marcus Welby M.D. was fictional. We practice in a very different environment than any of the above. That reality began long before Obamacare became law.

        “I believe there is still hope as long as people continue to fight for positive change.”

        We agree on this.

      • Bobby says:

        Good luck.

        I wish you the best.

        I agree we practice in a different world, but I don’ think that means it has to change your attitude. The attitude is a choice.

        My dream is that we can get physicians like you and many others together who can identify the waste and present solutions. If anything, this problem is a huge opportunity for all of us. If this is solved then patients and doctors win. Like I said, that video you posted was excellent, I wonder if we can get more physicians together with a united voice that helps everyone and saves $.

  7. girlvet says:

    Wow. I am flabbergasted. An honest assessment of reality by a doc. Impressive.

  8. One has to understand better. A criminal cult enterprise, the lawyer profession, has total control of the three branches of government. Itself, it is in total failure as far as the goals of all law subjects. However, it uses its power to extract rents from the taxpayer, and is now taking over the one sixth of the economy that constitutes health care.

    It is destroying the family, the church, the schools, and all competing sources of moral and actual authority. They are in competition with government.

    As with all other criminal enterprises, especially ones that control a government, making 99% of its policy choices, there is no legal recourse.

  9. Onefootoutthedoor says:

    >The new generation of physicians may very well
    >evolve into protocol-following, brown-nosing,
    >corporate mantra-spewing clock-punchers,
    >indistinguishable from other “providers” all
    >while refusing to make the tremendous sacrifices
    >of doctors past

    This is what has happened in every other national health system. The difference in America is that Obamacare will still leave the lawyers free to prey upon physicians for providing government-mandated substandard care.

    As physicians, we are the designated whipping boys of a president who belives that we perform amputations because they pay better than managing HA1C.

    Count me out.

    • Onefootoutthedoor says:

      Also, I’m going to add the following…

      The importance of the Hippocratic oath was not the time in which he practiced or the technology available to him. It represented a philosophy of medical practice that rose above the needs of business and profit to serve the needs of the patient.

      Perhaps one of its most important statements is: “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice”

      Now that intentional injustice to the individual has been institutionalized in the name of collective fairness, Hippocratic medicine is indeed dead.

    • kris says:

      “The difference in America is that Obamacare will still leave the lawyers free to prey upon physicians for providing government-mandated substandard care.

      As physicians, we are the designated whipping boys of a president who belives that we perform amputations because they pay better than managing HA1C.”
      It is interesting you feel free to malign and stereotype one group of people (lawyers) while in the next sentence are appalled that another group (physicians) are being maligned and stereotyped.

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