Dream job for doctors

[Nords]

You're quite right - the system is deeply broken at many, many levels. It will be challenging to maintain at least decent quality as we worm our way out of the current mess. It's not the Walmart issue here, it's the doc-in-a-box no-time-to-think-or-talk piece that concerns me.

When I was on active duty, if I was sick then I rarely saw a doctor.

I'd go to see a corpsman. Now, first you should understand that the quality of Navy medicine, while uniformly pretty good, tends to have its quality gaps. Open sick call could take a couple hours and you had to let your chain of command know that you'd be missing work, so you couldn't just fake a symptom and not show up for morning muster. After waiting an hour or two t's not unusual to get an occasional corpsman who couldn't diagnose his way out of a paper bag or who felt obligated to give you a little lecture on malingering. So you tended to take care of yourself ("Not me, I don't wanna have to explain that at sick call!") and you made sure that you felt really really sick before you went to sick call. So the Navy was very good at inspiring its people to practice preventive medicine.

When you were seen at sick call, you were seen by someone who had some medical training but was not a doctor. They could diagnose, tell you what to do to get better, give you a chit for bed rest if necessary, and either write prescriptions or have a doctor write one out for them. If you were on sea duty then the corpsman was probably part of your crew. A submarine crew of 100-150 had its own enlisted corpsman, either a senior E-5 or an E-6. Most of them were at the level of your average EMT, and the shipboard ones were easily a level or two above that.

Admittedly liability insurance was not an issue and the patients were legislatively required to make an attempt to keep themselves fairly healthy.

Would a similar system work with civilians?

 

[Rich_by_the_Bay]

When I was on active duty...Would a similar system work with civilians?

Well, Nords, it's complicated. Such a system is in place with nurse practitioners and/or physician's assistants but only in a spotty manner. Patients sometimes insist on seeing the doctor even when they don't need to. There are some liability issues but that varies. NPs and PAs demand a pretty high salary, so while they can be cost-effective, it is rarely a slam dunk financially.

I've had good experience with NPs where I work but do maintain a very close dialog with them, often amending their plans or findings; OTOH, I work with the sickest and most complicated patients you can imagine almost exclusively nowadays.

Bottom line: it can work in a well oiled close practice environment, with good gains in efficiency if not revenue.

 

[Martha]

100 patients a day, day after day, is too many people for anyone too see, corpsman, nurse, PA or doctor. I think you would get confused and tired.

 

[cute fuzzy bunny]

Well, Nords, it's complicated. Such a system is in place with nurse practitioners and/or physician's assistants but only in a spotty manner. Patients sometimes insist on seeing the doctor even when they don't need to. There are some liability issues but that varies. NPs and PAs demand a pretty high salary, so while they can be cost-effective, it is rarely a slam dunk financially.

I've had good experience with NPs where I work but do maintain a very close dialog with them, often amending their plans or findings; OTOH, I work with the sickest and most complicated patients you can imagine almost exclusively nowadays.

Bottom line: it can work in a well oiled close practice environment, with good gains in efficiency if not revenue.

I was going to say the same thing. In my area its a rarity to actually see a doctor. You usually get an NP or PA that starts writing you a prescription before you're done telling them whats wrong with you. My wife knew the last one I got; said she was a retired nurse that didnt 'cut it' at the nursing business, took ten years off and here she was NP'ing for one of our regular doctors. She didnt seem to have a clue. The next month she had "Taken a better opportunity elsewhere".

That doctor (dermatology) seems to have a good gig going on. My wifes been going there off and on for 10 years and i've been there a couple of times. No sign of the doctor, neither of us has ever seen her. Looks like she's hired a pair of NP's to do the routine work and only shows up on occasion. Has added everything from extensive cosmetic surgery options to massage and spa packages.

The better NP/PA's that I've seen worked out pretty well though. What concerns me is having someone with only partial training/education and experience mistaking something serious for something benign and trying to buff me off with a bottle of pills.

 

[saluki9]

My question is this, what quality of MD are they going to bet if they are only grossing $100-$120 per hour?

I'm sure they will get a lot of docs just lining up to work for walmart wages!

I guess the old joke is right, every medical school class does have some guy who graduates last, and they do call him doctor.

 

[OldAgePensioner]

With 3 emergency room visits (taken straight in like a gunshot victim). With 3 different inpatient stays of 5 days, 11 days and 2 days.

I have a bit to tell.

First ER visit I was tachycardic, arrythmic, and diapheretic and it drew a huge crowd of RN, PN, students, Residences and a Doctor. The diagnosis was hypokalemia. Not even close. Try KIDNEY CANCER. Try Coronary Artery Disease.

But hey, there were only 10 of them in one of the best hospitals in the world. NMH.


After testing and finding the real causes. I underwent 8 hours of surgery from what was considered the best-o-the-best. And after a brief visit home, back to Er with massive blood clots from penis and spent 11 days fighting for my life. Tranfusions, infections, fevers, sweats, lost 36 lbs in 11 days. Massive internal bleeding thru my penis and transfusions, blood clots, radiology interventions.

That experience left me with the impression that most initial investigations are pretty superficial. If it requires surgery and you have the where-withall. Go all out and find a good situation for yourself.

After doing my homework. If my loved one was very ill and required serious surgery.

Mayo Clinic
Cleveland Clinic
Johns Hopkins
Sloan-Kettering
Duke University

 

[justin]

Duke University

Good thing I got one of those up the street

 

[OldAgePensioner]

Re: Dream j*b for doctors

Justin,
I not kidding. Just imagine getting your triple bypass at Angier General.

Dr. Willie Lewis Spivey, graduate of Barbados Medical School.

 

[Rich_by_the_Bay]

Re: Dream j*b for doctors

With 3 emergency room visits (taken straight in like a gunshot victim). With 3 different inpatient stays of 5 days, 11 days and 2 days.

I have a bit to tell.

OAP,

Sorry to hear of your tribulations, and wish you well in your recovery. Working in a major cancer referral center, I can appreciate how such a diagnosis can really put your whole world on hold.

Good doctors and a few not so good ones everywhere (both high profile institutions and less so), and sometimes even the best are not good enough. Let's hope you can find competent and compassionate care as you sort through your decisions.

All the best,
Rich

 

[OldAgePensioner]

Re: Dream j*b for doctors

Rich,
it took Northwestern Memorial Hospital 2 months to diagnose that I had kidney cancer.

If on day 1: Ultrasound Testing.


Found on day 1.


Too much to ask.?"////

 

[justin]

Re: Dream j*b for doctors

Justin,
I not kidding. Just imagine getting your triple bypass at Angier General.

Dr. Willie Lewis Spivey, graduate of Barbados Medical School.

Oh, I know you're not kidding! My grandfather recently passed away after the "Angier General" hospital forgot to give him insulin for 9 days straight while he was under their care. They turned the insulin back on, and he partially recovered for a few hours before dying. I've said before, I'd take a nice hospital in a developing country (like Thailand) over some of these rural hospitals in the U.S.

 

[OldAgePensioner]

Re: Dream j*b for doctors

Rich,
are Doctors reluctant to use ultra-sound.  It seemed pretty harmless, didn't take much time and found my cancer early enough to give me a fighting chance.  But it took them 2 months to decide to do it.  

Reason I ask is a friends father is 78 and started wetting himself about a year ago, doctor did no testing just gave him Depends or something.  Finally he was passing blood and ultra-sound showed lemon sized cancer on kidney.  Had it been diagnosed a year earlier who knows how much better chance of survival he might have had.

Justin,
Sorry to hear that.

IIRC you are also a Civil Eng and most likely had classmates that could not remember that deflection is P Lcubed over 48EI. Yet someone is living in a building that they designed.

I'm allergic to aspirin and had a red wrist band indicating that, in comes a nurse from Ghana and trys to give me an aspirin. I showed her the wristband and she just shrugged. Kinda like well if refuse it, it's up to you.

Comment: If I could, I would take my laptop to the hospital and look up every aspect that was being foisted on me. Some of the drugs I was given were things that the nurse had no explanation for. Just, "that's what it shows on your orders".

 

[justin]

Re: Dream j*b for doctors

IIRC you are also a Civil Eng and most likely had classmates that could not remember that deflection is P Lcubed over 48EI. Yet someone is living in a building that they designed.

Nah, those guys ended up at the Department of Transportation designing bridges and culverts. Keep that in mind next time you cross a bridge.

In reality, most of those guys got F's in enough engineering classes and then went on to be very successful business or communications majors.

 

[Rich_by_the_Bay]

Re: Dream j*b for doctors

Rich,
it took Northwestern Memorial Hospital 2 months to diagnose that I had kidney cancer.
If on day 1: Ultrasound Testing.
Found on day 1.
Too much to ask.?"////

OAP,

From your perspective, that is not too much to ask, and it is more than understandable that you feel let down and pissed off. I don't want to diminish that fact - it's your well-being at stake here. I am really sorry for the suffering this delay must have caused you. Period.

Your recovery is a big job. Don't let recriminations stand in the way of that. There will be plenty of time later to sort those out however you see fit; it's usually much more complicated than it seems to any one party. Screw that stuff for now in favor of finding a doctor you trust (there are a lot of great ones out there, honest), get staged and treated. It will work out, but leave little energy for other issues for a while.

BTW, notwithstanding your top 10 list of medical facilities, the reality is that closer to home is best. If no such facility exists, find at least a regional medical center. I would reserve cross-country cancer care for those cancers where only major cancer centers have the experience and expertise (and that depends on the specific diagnosis).  It's pretty well standardized nationally for most types. Closer = more time home.

Rich

 

[OldAgePensioner]

Re: Dream j*b for doctors

Rich,
Yeah, me being a vagabond gives me a bit more ease of movement. I actually considered moving to Tampa to go to Moffitt Cancer Center. I got a good friend living there and his wifes a great cook.

But you are right I need to channel my energy to staying cancer free. Another friends father had his kidney cancer treated with RF ablationa and he recovered very quickly. That was my first choice with Dr. Horst Zienke in Mayo but the logistics were bad.
Thanks.

 

[MJ]

Re: Dream j*b for doctors

I feel for you OAP.
I have been very fortunate so far that I have not had to visit a hospital or have taken very little medicine for the last 30+ years. As I continue to age, I don't look forward to my 1st extended visit especially as a vagabond with very little family/friend support. I see the arm twisting, I have had to do, to help my father when he has occasional gone to the emergency room.
When you are alone, those places can kill ya!

 

[OldAgePensioner]

Re: Dream j*b for doctors

vagabond,
the more aloner I become and more isolated, the admittance to a hospital seems eerily like I may never come out. And what goes on in there is up to them.

During my last imprisonment inpatient stent, I asked to get transferred to UCSF Hospital and they ignored me. They had all my personal items, keys,wallet, money, backpack, clothing, etc locked up. Presumably to safeguard it. I asked to get it and they refused until the doctor said "release" me.

"Release" kinda implies some sort of imprisonment.

I can see where having a good family doctor that actually cared about you and your health is a Godsend.

 

[Rich_by_the_Bay]

Re: Dream j*b for doctors

I can see where having a good family doctor that actually cared about you and your health is a Godsend.

Right.

Nowadays in many hospitals, the equivalent of the outpatient primary care doctor is the hospitalist. These are usually internists who concentrate on inpatients only, and generally value the importance of knowing their patients, coordinating their care, etc. If you have an option, request admission by a hospitalists and they can arrange any necessary subsubsubsubspecialty care while keeping an eye on the big picture.

Surgical admissions are different, but hospitalists can consult should any nonsurgical issues arise.

Just a thought for the future, hoping it will never be needed.

 

[justin]

Re: Dream j*b for doctors

Nowadays in many hospitals, the equivalent of the outpatient primary care doctor is the hospitalist.

Educate me. Do you find hospitalists at the hospital, or how do you locate them? Does insurance typically cover their fees?

 

[OldAgePensioner]

Re: Dream j*b for doctors

Rich,
I did initially have a hospitalist and he was the one who ordered further testing which found cancer and coronary artery blockage. But once I got involved with the Urologist Surgeon and the Cardiologist, I lost contact with him. Not knowing what you've just told us, I missed the boat and dropped making appointments with him.

Now I see what value he would have been. Could have kept me informed and coordinated the two specialists.
Thanks

 

[brewer12345]

Re: Dream j*b for doctors

Right.

Nowadays in many hospitals, the equivalent of the outpatient primary care doctor is the hospitalist. These are usually internists who concentrate on inpatients only, and generally value the importance of knowing their patients, coordinating their care, etc. If you have an option, request admission by a hospitalists and they can arrange any necessary subsubsubsubspecialty care while keeping an eye on the big picture.

Surgical admissions are different, but hospitalists can consult should any nonsurgical issues arise.

Just a thought for the future, hoping it will never be needed.

Hmmm, my SIL is a D.O. in training and wants to become a pediatric hospitalist. Good career move, Rich?

 

[REWahoo]

Re: Dream j*b for doctors

I'm not familiar with the role of a hospitalist and just found this definition on http://www.hospitalist.net/

Although in Europe and Canada most hospital care has long been provided by specialists in inpatient medicine, only recently in the United States has the potential advantages of using hopitalists been considered. Robert M. Wachter, MD proposed the following definition for the term "hopitalist": Hospitalists are physicians who spend at least 25 percent of their professional time serving as the physicians-of-record for inpatients, during which time they accept "hand-offs" of hospitalized patients from primary care providers, returning the patients back to the care of their primary care providers at the time of hospital discharge. ("Introduction to the Hospitalist Model", The Emerging Role of Hospitalists in American Health Care: A National Conference, December 5-6, 1997, San Francisco, California, presented by Department of Medicine, University of California, San Francisco School of Medicine)

The ability to rapidly coordinate inpatient care and react in real time throughout the day to clinical data and changes in patients medical status by full-time hospital based physicians has distinct advantages both in terms of quality of care and potential cost savings. Potential disadvantages include patient dissatisfaction secondary to being "assigned" a new physician during an acutely stressful time and potential lack of adequate communication between inpatient physicians and outpatient primary care providers both at the time of hospital admission and discharge.

 

[OldAgePensioner]

Re: Dream j*b for doctors

I've got an appointment today at UCSF and will discuss the hospitalists role with my cardiologist.

Here is the cardiologist at UCSF that I'm seeing and his colleages give him rave reviews.

http://cardiology.ucsf.edu/clinical/interventional/faculty/TomPorts.html

He did the first angioplasty at UCSF.

 

[Rich_by_the_Bay]

Re: Dream j*b for doctors

Nowadays in many hospitals, the equivalent of the outpatient primary care doctor is the hospitalist.

Educate me. Do you find hospitalists at the hospital, or how do you locate them? Does insurance typically cover their fees?

Justin, this all takes place at the time of admission. If you are coming through the Emergency Room, they arrange it. If you are referred by your PCP, she arranges it. Yes, it is covered by insurance.

Not something you set up on your own, but clearly something you can request if available.

OAP - you did not drop any ball - you probably got transferred from the hospitalist service to the Urology Service. That's usually OK once the diagnoses become clear and the surgery issues are the main focus. Still it's nice to have one involved if available.

 

[OldAgePensioner]

Re: Dream j*b for doctors

Rich,
Went to UCSF Medical today and visited a very will respected Interventional Cardiologist. This gentlemen also asked if I need refrerral to a Urology Oncologist.

How the heck does "Referral" work?