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Thursday, April 1, 2010

Choosing a career

I remember chosing medicine as a career because I wanted to use whatever talent I had to help patients with their health and lives. At that time I was studying engineering. I was one of those people that could not make up their mind what I would do with the rest of my life. I would pick a topic, master it, and then move on to the next interest. Even after I earned my medical degree it took some time for me to pick a specialty. I stopped for a bit of time to direct an emergency medical group and practiced general medicine for several years. It was very interesting and stimulating. Perhaps I learned as much in those four years as I did in medical school and internship. I had no problems in finding specialists to manage problems that went beyond my relative inexperience to help my patients where I left off.


I left emergency medicine because at that time it was not a recognized medical specialty, and only after I left was the specialty formalized with board certification. I was one of the founders of the American College of Emergency Physicians. However I did not see a 'future' for me in ER medicine. There was little if any long term patient involvement.

I rarely had any follow after the patient was discharged from the ER, unless they were admitted. I also found out quickly that ER physicians do not have hospital privileges. (perhaps this has changed). Surgeons, orthopedists, internal medicine doctors openly looked down on ER doctors as those who did not or could not finish specialty training. Becoming an ER doctor had a negative implication on your intelligence and capability..

In those days it was a challenge to have a specialist come in to see an ER patient. Many were uninsured, and less than socially desirable patients. (things have not changed very much), although more patients, and even those with insurance resort to the ER when their physicians are not available. It has always functioned as a pressure relief valve or safety net for those otherwise unable to see a primary care doctor.

There are many reason why medical students chose not to enter general medicine..


The status of nurse practitioners and physician assistants has been elevated to the point where they can diagnose and/or treat 90% of common problems, and they do not have to have hospital staff privileges. Throughout medical school, unless one is fortunate enough to have a family medicine or clinic rotation the general consensus is that the best and brightest do not enter primary care medicine. Those who chose this field are looked askance at and trivialized as not requiring advanced clinical skills. The training programs are top loaded for gaining skills not at medical school, but later in postgraduate training, beyond the internship.


The reimbursement equation has not favored primary care, pediatrics, or internal medicine. The American system is based on procedural coding, not cognitive time or processing. Even the codes presently in existence for evaluation and management are inadequate, especially for time intensive issues. There are no codes for administrative time, medical record keeping, telephone consultations, telemedicine, or patient education time, hence it is either left to medical assistants or worse, ignored entirely.


Health reform will not alter the science of medicine. It will obstruct the smooth flow of our activities, and create time wasting administration which physicians will pay for as an operating expense, whether in private practice, group or government medicine. Administrators have and will control executive functions and physicians


Physicians will continue to care for patients, do research, do surgery, have good and bad outcomes regardless of fines, audits, quality assurance, pay for performance, EMR, incentives, penalties or other nameless ideas.

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