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Medical Practice Insights 2015

Medical Practice Insights Archives from 2010 to 2014 can be
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 Dec. 2015

Topic:

It seems to me...

 

 Nov. 2015

Topic: Where does the satisfaction in medical practice come from?

It seems to me... that I had times in my medical career when I felt satisfied, inspired, and motivated, but it was cyclic in nature, up one year and down the next. Since then I have reasoned that most of that intermittent satisfaction was the result of my circumstances and decisions at the time.
     Up to the time that I made the decision to begin private medical practice I had been under the control of the medical school system, US Navy/Marines, OBG residency, and Kaiser Permanente. Although it was all exciting and interesting, I never felt fulfilled or free to make my own decisions, didn't hate it but didn't love it either. So when I cut the cord at Kaiser, it became a new world for me.
     Delving into my new private medical practice in 1973 was the most inspiring time in my life. My first year I grossed about $75,000 and knew that it would get better for sure. So my family would be supported and not have to worry about going broke.
     Over the next 20 years the most exciting times for me were the times that I "experimented" with my medical talents. Kaiser forbid me to do any infertility work because insurance paid nothing for that. But my interest was in doing a lot of that. I researched the literature on infertility, found no medical courses being given on that topic. For the next two years I was blessed to get many referrals of patients for infertility. No other private doctors were doing it in any serious fashion. 
     I began doing reparative tubal-plasties using the ENT instruments. It expanded into reanastamosis tuboplasties, reimplantation of oviducts in the uterus, and more. It was a wonderful feeling to know that what I did was helping a lot of patients that other doctors wouldn't touch. About two years later, in 1975 infertility courses came around. Other doctors took the courses and my referrals dropped off quickly.
     My next peak was getting into laparoscopy procedures. I took Dr. Curt Semm's first course in America early 1980s I believe. Dr. Semm had developed and taught the laparoscopic techniques all over Europe, later in America. My associate had taken the course a few months earlier in Europe so he and I teamed up to start the new kind of surgery at our primary hospital. Then introduced it to other local hospitals. That expanded into advanced laparoscopic procedures and we were the only two in Northern California doing them early on. I became aware that my surgical talents were far more than I had anticipated. I loved doing surgery.
     Following that my associate and I began the LAVH (laparoscopic assisted vaginal hysterectomies) procedures and taught it to other doctors. This surgery was safer, easier, and in demand by patients later. Then surgeons who had criticized us so much began doing laparoscopic surgery for gall bladders. They were ashamed to ask me and my associate to teach them the procedure I believe, they learned from another general surgeon who came in new to the hospital with the training.
     It was rather humorous to know that the new doctor for the first two years did over 90% of gall bladder removals via laparoscopy, which made the other general surgeons angry him stealing all those cases from them. That made it important for them to learn the procedure themselves, which they did.
     These were the source of my inspiration at doing new surgical procedures and teaching them to other doctors. They were the greatest source of satisfaction to me over all those years. These events gave me immediate feedback on how well I was doing in medicine, got me a lot of PR, and could never have happened during my 14 years as an employee.

 

 Oct. 2015

Topic: Medical practice is much more complicated than in 1980--

It seems to me... after reading a large number of books about medical practice, starting a medical practice, dealing with all the many licenses and requirements, and about the business of medical practice, I have come to the conclusion that medicine must be not only the hardest career to qualify for, but also the most difficult business to start compared to what I found in 1972.
     I probably today would never get into medical school, let alone be able to handle the business of medical practice requirements of today. I likely would get my medical school training in England, lots cheaper. Wouldn't it be interesting if all American medical students did their training in Europe for money reasons, and American medical schools survived financially because they had to recruit the sons and daughters from wealthy foreign families.
     I knew the great advantage of having and using computers in my medical office in the mid 1980s. One day a computer dealer showed up in my office for a PC demo. I bought the whole computer package they offered for I think, $70,000 on a lease. They came to my office several times to teach my office staff how to use a PC.---first medical office in my town to get computers. They spent a small amount of time teaching me, because I was not interested as long as the staff knew how to use them.
     I never learned about computers and how to use them until 1997. It took another 5 or 6 years for me to really take seriously learning computers inside and out. I missed a great opportunity in the 1980s and have regretted it since, because I probably would have gained the PC expertise at the same time that kids were learning in grade school.

 

 Sep. 2015

Topic: How does one orient their mind to a life of constant change and unexpected incidents that force changes in their path.

It seems to me... that adapting the mind to constant and recurrent changes in a medical career, or any other career, should be a priority. It should inspire a person to become a deep thinker in order to have a knapsack full of acceptable backup alternatives. To have a brain full of experiences, is a great advantage in a world that is changing daily.
     I don't think that this approach to life is very prevalent among physicians. All they really know is how to practice medicine, nothing else to rely on later. Physicians don't ever seem to have a Plan B for their careers, which makes it much more troublesome when they have to give up their private practice as so many of them do today.
     Right after I started my solo medical practice, the malpractice insurance rates became so high that all the insurance carriers left California. It left thousands of medical doctors there without medical malpractice coverage... and for OBGs it was terrible. I used arbitration agreements for about two years before I could again afford to buy malpractice insurance in California. Totally unexpected.
     Soon after that the mandate for managed care in medicine was passed and then we all began losing our patients to the HMOs, IPAs, and Kaiser in the 1970s. It was unexpected because most of us never understood how it would effect our own practices. You see, we though we might lose a few patients and keep all the loyal ones. It was just the opposite effect, most lost a third or half of their loyal patients and had no idea how to recruit a bunch of new patients (no business or marketing knowledge) to make up the difference.
     These are reasons to train you mind for deep thinking to be successful. Get and read the book by John C. Maxwell titled, "How Successful People Think."

 

 Aug. 2015

Topic: Professional poverty doesn't seem to bother most doctors.
It seems to me... as long as physicians can quit private medical practice anytime they choose and get a job as an employee in some healthcare organization, the issues of income will never impress any of them. Eventually when the available jobs and employment in healthcare facilities become rare, as it will be soon, then private medical practice may get more attention. Those jobs are already hard to find.
     For non-specialists, jobs will likely continue to be available because there will be a continuous turnover of doctors leaving and coming into those jobs. For specialty doctors, however, job availability is now, and will become, more rare with time.
     For specialists, it involves many more barriers to finding a job position. It means finding a job position that matches their choice of city or state, licensure, family desires, compatibility with peers, and being able to practice their specialty in the manner they prefer. What is so obvious a problem is that there are many restrictions when practicing under an employer of any type. Some procedures you know how to do, won't be allowed. Some ideas about patient treatment and management you may have, may be forbidden.
     Forward thinking by physicians is commonly far short of adequate. Otherwise they might have made different decisions over time than they did. My experience in the military, Kaiser Permanente, and as a Hospitalist has solidified my mind about the huge disadvantages associated with being employed. Imaging leaving medical school all prepared to do great things in medical practice only to discover that you will only be permitted to do part of that expectation, because you do not control your income or your career.
     What a shame it is to meet reality head-on only to discover that in medicine things are not as they seemed to be. Take the medical school teaching curriculums. These have been re-oriented to teaching medical students how to get jobs and make decisions relative to spending their medical careers in employed positions. That should logically make all medical school applicants hesitant to continue in the profession. Yet they do, because they are easily kept ignorant about what lies ahead. Students are never told the truth about what's ahead.

 

 Jul. 2015

Topic: Could it be that what's happening to the medical profession today is just one example of many that lend strong evidence to Biblical prophesy?

It seems to me... to be all part of a growing disintegration of America as we used to know it, as well as an overall world wide economic, political, and educational deterioration of societies leading to the end of times. If in fact this might be the case, then there will come a time soon where there will be no great desire to improve anything especially in the practice of medicine.
     Maybe the sustitutionary changes (doctors being replaced by mid-level medical providers rapidly and extensively) happening over the last decade or so is in reality part of the decaying process already in healthcare, at the same time that the world societies are decaying. Is it a clear and present danger that we are too distracted to realize?
     Just think about it. Medicine is rapidly moving from physical diagnosis to technical diagnosis of disease. Physicians and PA's no longer ascult the lung functions through layers of clothing instead of directly on the skin. Patients are unable to afford the best medications for their health problems. Employment incomes are gradually leveling out, not keeping up with inflation. Patients can't afford nursing homes. Society survives on increasing numbers of handouts. Advanced education in now unaffordable and education is funded by ever increasing debt that will never be paid back.
     All of these issues point towards one final end. Politics are unable to fix it. Religion hasn't been able to change things around. The economy blunders escalates the situation. People are becoming incapable of changing anything except by violence and destruction.
     Medical schools in order to remain functional have resorted to recruiting students from many other countries, normally those who are wealthy enough to pay the tuition. Additionally, with government financial support fading and already bankrupt, medical schools now are marketing alumni for donations more than ever. A good number of the foreign doctors educated here go back to their countries to practice.
     Add to that the drop in number of Americans applying to medical school should tell where medicine is headed. Then add the inability of physicians to make enough income in practice to remain solvent, at least until they become employed and then are paid in one way or another with government money that won't last either.
     Why aren't doctors provided both a business and medical education? No one says that it is impossible to do, but that's what the medical education scholars think and propagate by their actions.
     If all schools beginning with elementary education provided economic and business education for all students, the world would be in a much better situation. The world runs on business. All money is derived from business.    

 


 Jun. 2015

Topic:  I wonder what the government will do when most private physicians choose a  cash-only medical practice?

It seems to me... if private practice disappears as most are predicting, then all physicians that have become fed-up with being an employee and those who choose to control their own careers will go for the only available option left in the USA---a cash-only practice method. Then again the reality of this happening is next to none. I see two reasons for that. First, the same problems will continue to thwart the cash-only medical practices the same as they are today for one big reason... physicians aren't being provided with a formal business education and most all will fail financially. It's inevitable.

Secondly, I would expect that the government and politicians wouldn't tolerate the exodus of physicians from government medicine and legislate physicians out of their cash-only practices. You may think that you can't be forced out of a cash-only practice, but remember that the medical boards and state politicians that run them make the medical practice rules in each state. They could easily increase the requirements for state licensure, require increased CME credits, and a dozen other restrictions that would or could bring doctors to their knees again.

I believe it is inevitable that with the outrageous education debts that keep increasing with no end in sight will serve as the primary leverage for forcing all medical school graduates into employed positions. Of course, medical education in Europe and other countries is much cheaper, especially in France. One could get the doctorate there and come back to the USA and practice. Actually, it's no different than the thousands of doctors from foreign countries now practicing in the USA today. Doctors from wealthy families who can pay cash for their education are left with the best options.

The one remaining and unresolved issue today is whether the Supreme Court knocks out ObamaCare, or if the new president and congress can overhaul the healthcare system will enough to bring medicine back to a level that satisfies all the doctors. 

Patient care will be neglected, the same people without health insurance will never change, and tax dollars now doled out to medical education and medical research by the government will control the whole system anyway. It's a no win system.

I have always been happy and privileged to practice in the way I chose for all those years and before I had to face the present day challenges that certainly would have made me miserable in my medical career. I never loved medicine that much!!

 

 May. 2015

Topic:  "American's Are No Longer Wishing to Join the Medical Profession"

It seems to me.......  that I can't blame them for that. Any smart American college student should have enough brains and intellect to discern where the medical profession is headed, and it isn't good. What is quietly hidden in the recruitment of medical students are the rapidly increasing numbers of foreign students joining the profession while carrying their biases, cultural tendencies, and behavior patterns with them. That's where the money is, needed by medical schools, and wealthy foreign parents or supporters more than willing to spend what ever is needed to make it happen.

Americans are quickly becoming the minority of medical students. Who wants to become a medical professional to be forced into being an employee to survive, having their medical career determined for them, earn much less than comparable business people, lose the freedom to practice medicine as they want. The thought that a physician can't earn enough to put the kids through college, fund a good retirement plan, keep their medical office open, meet their expectations for their careers, and to live above the poverty level is a national disgrace.

So foreigners are filling the gaps along with women doctors, half of which practice part time.

At the same time the medical schools contribute directly to the frustration and disappointment of the physicians they graduate. That's because of their complete and intentional avoidance of providing a business education of physicians, whom they know will probably not financially survive in practice, which we see the results of today. Doctors are blinded to the need for business knowledge in practicing medicine, so they don't know how to run a profitable medical practice business.

At least physicians who obtain business knowledge can see the truth for what it really is. There are a truck load of reasons to correct this deficiency and a truck load of ways today to do it effectively. No one gives a damn about upgrades when they are sliding downwards more every day.

 

 Apr. 2015

Topic:  " Quashing Every Doctor's Investigative Nature"

It seems to me.......that the government controlled healthcare program, in the name of cutting medical care costs, has awakened a monster within every practicing physician's soul. This is a monster that has been unleashed to feed on the motivation and passion of every doctor's investigative mind compromising not only the quality of medical care delivered, but also the intensity of their diagnostic abilities pounded into their heads while in medical school.

I see the problem every time my wife or I see a doctor for medical issues. What I see being done is a great disregard for good physical examination, barely being examined close enough to catch any unexpected sign or symptom that could lead to a different diagnosis completely. For example, my wife had developed a chronic dry cough which persisted for months, sometimes interfering with sleep and daily activities. I listened to her lung fields but heard no rales or other pathologic signs. Finally took her to the ER when her breathing became difficult, and no cause for it.

Not only did she wait an hour to be seen by a doctor, but had to urge the doctor to listen to her chest and lungs which took maybe 20 seconds through her clothing. No lab was done. His diagnosis was "just a virus that is going around". So I asked him if the virus he was talking about was one that lasted 6 months or more without improvement. I never heard about a virus like that in my medical career. He never even considered a differential diagnosis of lung cancer in a 77 year old, allergy to something, or something related to a secondary mycoplasma infection I read about.

They knew I was a physician and hadn't brought her to the ER for a unessential or dumb medical reason---this was a significant medical problem and worsening and with no diagnostic work done to corner a tentative real diagnosis. I finally told the ER manager that if he missed a serious problem by not ordering a chest x-ray that night that they would have a malpractice suit to contend with. I was pissed.

The Internist she saw soon after --- almost exactly the same thing. For the medical care in an HMO I expected such poor care, like my three years at Kaiser Permanente where I witnesses a lot of that. It is obvious, at least to physicians who were trained 50 years ago, that the pressure to do less, spend less, and save money for the HMO was a direct influence on what doctors are coerced into doing for patients today. It sickens me what I'm seeing. I can give you about 20 more good examples of this, but you probably already see what I see as well.

 

 Mar. 2015

Topic:  "The Millionaire Physician I Met Recently"

One that beat the odds, never had a business education, and started medical practice in OBG about the same time I did.

It seems to me.......that this serves as a testimonial to the fact that an academic business education or an MBA degree is not required to make all the money you care to have... whenever you need it for something. But you have to understand that it still requires a business knowledge of a reasonable degree no matter how or where it came from. The amazing and intuitive ability he had about business building came from somewhere. 
     For one thing he understood that medical practice was a business right from the start. It was his daily affirmation. Even Wayne Dyer, a world renowned expert in self improvement, said, 
"If you change the way you look at things, the things you look at change!"  And it did for my doctor friend. 
     He started his practice in a southern state without considering the economic and demographic effects on building a medical practice in that area. Was he just lucky? Maybe. A few times during his career he has dealt with business and marketing experts and found them to be money-sucking predators, even though he had no trouble with paying them. 
     I immediately knew he was highly intelligent and was the kind of self-confident person
  you feel like trusting from the start. I can't equate his background and family ties to the degree of wealth he created for himself. The remarkable thing to me was that he had been marketing his medical practice without knowing that he had since he started been doing it... just seemed right to him.

     This doctor is an excellent example of what can be done in solo medical practice when you have the right mindset for business... something that is never instilled in the minds of students by our medical education academics. The educational concept that seems to be working here is that most belief systems are formulated at an earlier age. If such people are later confronted by a new or different system that they have never been exposed to previously, rather than giving the new system your ear for a while, most outright go to and use their early beliefs and standards instead. 
     It's an automatic response to what seems to be a barrier that our mind creates. Therefore, most people must first be exposed to the new system for a period of time before they can recognize the value of adopting that system. And the person must be able to understand and accept what they are being taught or told about it. When these things are missing, people will naturally reject it from the start, even to the point where they tune-out the further teaching and instruction on the new system. 
     It's almost like having to desensitize a person to new ideas and information first, then they are ready to learn and accept. It's a matter also of decreasing a person's resistance, arrogance, and objections. The strength of these three things is different for every person. The defensive nature of most people in today's world prevents most of new and reliable information from being recognized or accepted. 
     This is why there are very few physicians who by the time they finish medical school  have any interest, inclination, or personal desire to either recognize medicine as a business or accept the business of medical practice as a legitimate entity.

 

 Feb. 2015

Topic:  "Survival Skills for Today's Gynecologist"

It seems to me........that this being the title of an upcoming CME conference in NYC, would entice a large number of private practicing gynecologists who are feeling the sting of governmental fee restrictions and regulations. On reading the mail flyer I received about this educational event, I again discovered that their approach to helping physicians is to learn more and higher skills in gynecology that are "solidly reimbursable" elements of medical practice.

The question that immediately comes to my mind, "How is a struggling gynecologist going to have the income to afford to attend this conference, especially when it's being held at a high-priced hotel in Times Square?" I do know that I could never have afforded to attend it even at the height of my OBG medical practice years in an affluent area of the country.

The second question I have is, "Doesn't the thrust of the conference mean that to survive in the specialty one must work harder instead of smarter; maybe skinny down their practice focus to doing only those new "solidly reimbursable" procedures primarily?"

It brings up another question, "Wouldn't that narrowing down of practice focus automatically reduce the number of patients joining the practice because it would use up the time for the care of routine gyn patients forcing doctors to accept only patients needing those special procedures?" When I focused my practice on infertility patients and tubal microsurgery, patients began asking if I also did routine gynecology work.

The overwhelming and still incomprehensable inability of high-powered medical educators to recognize the real core problem of medical practice failure--lack of business knowledge and education--will remain my nightmare until I die.  Instead of providing physicians with an offensive weapon (business education) they continue to provide only the defensive weapons (work harder) and they will continue to fail financially.

The obstructive nature of medical education politics, tradition, and permanently implanted and untouchable educational infrastructure continues to be the fatal bullets for private medical practice survival. The tragedy of all this is the fact that medical education scholars are too close to the profession to recognize where the real problems are for the survival of the profession.

So, I ask myself every day, "If (maybe the education scholars already know) the medical education academics are at the seat of the cause of the problem and do nothing to resolve the issue of offering or providing a business education as well to all physicians, then healthcare in our country will certainly continually degenerate in all aspects." It's not a guess, it's a prophetic reality.

 

 Jan . 2015

Topic: "Remote Medicine May Be The Biggest Malpractice 
                      Trap of The Century"

It seems to me........that the smart phone technology contains a significant danger to all physicians in spite of the convenience it offers to both doctor and patient. I was brought up in medicine to interact person to person with patients. If Dr. Hopkins caught us listening to the heart of the patient through a shirt or blouse, or not taking the time to specifically listen very quietly for diastolic murmurs against the skin, he would round up a patient with significant pathologic murmurs that we weren't able to hear unless the stethoscope was on the skin.
     Today doctors depend on x-ray, ultrasound, and CT or MRI to make diagnoses rather than by hands on techniques. It increases the cost of healthcare, reduces the diagnostic skills we were taught, and leaves us dead in the water if those machines are not available. Once you lose your skills you become hostage to the machines.
     I'm much more concerned about the misdiagnosis risks associated with relying on technology. It used to be that a man would walk into the clinic for a laceration of his leg that he got from work and during the undressing process noticed his scrotum hanging down to his knees full of small intestine. Usually men put up with the defect for long periods of time. No visits to doctors, did his own treatments, usually the old fashioned truss support my uncle wore for 20 years or so. 
     It had what looked like a polished wooden doorknob on each side that strapped in directly over the inguinal canals. Men rarely went to a doctor for medical problems that they could put up with and still do their job. When we as medical students found a patient like this we knew that it was a perfect opportunity for being the first "doctor" to find something else, maybe 3 or 4 other medical problems that needed treating. That puts me in mind of the test patient I was assigned to examine when taking the Part-3 of the National Board exams at Duke Univ.
     I knew that if I missed an important medical problem he had, I'd flunk the Board Exam. So I examined him head to toe carefully. He had an obvious large inguinal hernia that he didn't complain about. He had several systolic and diastolic heart murmurs, and had an active melanoma on his arm. I thought I had scored well by diagnosing all three things and doubted I'd missed anything. When I listed all of the diagnoses I had made, the examiner asked me if I had done a breast exam also. The patient was about 80 and rather obese. 
     I told the professor that I usually don't examine men's breasts except by my manipulation while listening to the heart. The man had been admitted for breast cancer, not for any of the other problems and I had missed the breast lump completely. We discussed male breast cancer---5% occur in males---I never knew that or even thought of it. Luckily he passed me. But, I never forgot the lesson, nor the patient.
     All of these things remind us that many patients have many medical or surgical problems that they never tell doctors about, hide some issues, and we only find them by physical examination of the patient. When we find them, patients are willing only then to listen to the dangers of delaying treatment, what should be done, and what is recommended. 
     All of the digital technology used will never come close to doing what needs to be done for patients. My concern is that doctors are becoming too trusting of remote medical tracking and monitoring. I think it is easy to get into that groove. And when fetal monitoring becomes a home process, all the OBs will run for the hills. It will be a field day for all the plaintiff attorneys.

 

masonic emblembright colored American flag  Curt Graham, M.D.
   2404 Mason Ave.  Las Vegas, NV 89102
    E-mail = cgmdrx(at)gmail.com
 
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