Hi everyone,
Does anyone have any thoughts about what health care reform will mean for those of us interested in becoming doctors?

Hard to say, since the bill being most seriously considered is over 1000 pages long and no one seems to want to discuss specific provisions of it when asked by their constituents. Given that Obama is not friend of doctors, having accused them in public of doing unnecessary tonsillectomies for profit and blatantly lied about surgeon's fees for amputations, I suspect that doctors may not fare too well under whatever new plan comes from this administration. Physicians are joining the Million Med March in Washington DC on Oct 1. Med students and pre-med students are welcome to join us at noon in front of the Smithsonian Castle.

It seems to me that one can criticize a particular practice by some doctors without being an enemy of physicians at large. By this logic we shouldn't criticize anything unless we are its enemy. To the contrary, if one cares about something it is one's obligation to criticize and improve that it, not keep quite and watch it deteriorate out of cowardice.
As for this plan in particular, I have no idea what so many physicians are so upset about other than the fact that conservatives seem set against this bill. As I see it having a plan that competes with the current health insurance companies can only improve things for patients and if more people have access to health insurance more people will see doctors who can bill for more procedures. Also, the idea that if suddenly you lost your job or whatever that you could have health care seems like a good idea. I am not so arrogant as to assume that I will never be in need and so I am willing to help others who are in that situation.
Introducing competition that is optional for people to benefit from seems like the essence of capitalism. I cannot imagine what logically trecherous course one takes to conclude that this plan would not benefit everyone.

Well said pistachio. I am also very dissappointed by the level of hatred and fear that has been stirred up in this debate, It is time that people of all parties and industries get together for a rational discussion of what the issues are. There are things that need to be fixed in every aspect of the healthcare delivery process - insurance, patients, physicians. No one can claim to be blameless for how we got here, and defensiveness helps no one. I for one think it is unconscionable that our society allows people to go into bankruptcy due to a medical condition, or that people receive different quality of care due to their socioeconomic status. I also think it is reprehensible that a orthopedic surgeon can make $800,000 a year, while a family practitioner barely makes 6 figures. And the rate at which insurance premiums and medicare costs are rising are seriously threatening the viablity of our country's economy. There are perverse rewards in the way things work now and it should change. You can add to the debate with thoughtful and intelligent commentary and discussion or you can stymy it with fearmongering, which will get us no where.

Bill Moyers had an excellent program last night covering this debate http://www.pbs.org/moyers/journal/blog/2009/08/towards_a_healthier_debate_on.htm l

I found myself particulary agreeing with comments by David Frum, a former Bush speechwriter, on how doing nothing and preserving hte status quo will in the long run hurt our economy and our individual liberties.

"Criticize a particular practice by some doctors"? Being a student pistachio, I'm not sure you realize what's involved in getting prior authorization to do a tonsillectomy these days, and how unlikely it is that unnecessary tonsillectomies are being done in great numbers, not to mention how little reimbursement there is for them anymore. By saying what he did about that, Obama slandered ALL physicians and demonstrated that he has either surrounded himself with incompetent advisers on health care, or he has competent advisers and doesn't listen to them. His comment about surgeons being paid 30 or 40 or 50 thousand dollars to amputate a diabetic's foot likewise shows the same lack of knowledge or lack of competent advising. BO and Michelle have demonstrated on several occasions that they have little respect for physicians, and I suspect that one of his goals is to have massive amounts of health care delivered by nurse practitioners. My main objection to HB 3200 is the complete lack of transparency, the reluctance of democratic congressmen to answer specific questions about it, their propensity to declare that something is not in the bill when a constituent is standing in front of them reading directly from the bill, the complete absence of ANY discussion of malpractice reform, and most of all, the lack of any rational plan to pay for the democrats' plan. Yes, something needs to be done, but HB 3200 is not the answer.
DocM, I am not seeing hatred anywhere in this debate. I am seeing people asking questions and getting frustrated because they are not getting answers.

I think people forget that Obama is a Lawyer first, so it's no suprise to me that he speaks ill of doctors and has no interest in protecting them.

It seems like basic common sense to me. If given a choice between giving an 80 year old a heart by pass and a 30 year old the same operation, who will get the operation in a system where care has to be rationed to contain costs? This isn't inciting irrational fear IMHO, this is a logical, rational fact that people prefer to bury their heads in the sand about. Personally, I'm just not convinced that under what the Obama admin is proposing this exact thing isn't going to happen in time and in greater numbers than it already occurs today, albeit with the poor substituting for poor ol' gradma. In fact I find it strang that so many middle class folks blindly support the bill when from what I can see, they will be the ones who would be most adversly affected by this plan in the long run.

"Being a student pistachio, I'm not sure you realize what's involved in getting prior authorization to do a tonsillectomy these days, "

What is involved? Given that you are basing your argument on authority (i.e., that you are a retired physician) perhaps you could inform me of what is involved instead of simply stating that I am a student which doesn't provide anyone with any information that wasn't readily available.

Obama's statement about unnecessary tonsillectomies was prefaced by this "Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there."

First of all, he said that doctors a lot of times are forced to make decisions based on a fee payment schedule. Being a retired family practitioner perhaps you did not face this problem. I don't know whether you had a private practice or worked in a large hospital. I do know that in some larger hospitals doctors are encouraged to bill as high as they can and are even compensated, i.e., the physician who bills the most in one month receives a bonus.

The purpose of this reform is to free up doctors from having to make decisions based on reimbursement so that they can provide the best care possible.

Physicians are not immune from making poor decisions sometimes, including decisions based on compensation.

"By saying what he did about that, Obama slandered ALL physicians"

Again, this is exactly the type of rhetoric I was commenting upon in my first response. When a person criticizes a practice they are not criticizing everyone who is in that profession. Doctors are not morally infallible. To expect some practices by some doctors to be infallible or the profession as a whole to be so demonstrates a bias founded on exaggeration that I doubt you would apply to other professions.

"Some" does not equal "all".

First of all, I retired fully last September, so I am not old or "out of the loop". I am not quite 55. What is involved in getting prior approval for a tonsillectomy is having the doctor pull together documentation of the necessity for the surgery from the patient's chart (number of episodes of tonsillitis documented in office, ER, walk-in clinics, and out-of-town docs, strep screen results from any of those places, sleep study results if being done for sleep apnea, etc), then having the doctor or his/her nurse sit on hold with the insurance company until a marginally-trained person on the other end picks up the phone and asks a series of questions in order to determine if the surgery is justified. Often a paper form needs to be filled out and submitted in addition to the phone call. A physician can't just schedule a child for a tonsillectomy because the kid had a couple of sore throats. If the child is on Medicaid or SCHIP, as an increasingly larger percentage of children are, the amount reimbursed to the surgeon who removes the child's tonsils is not even enough to cover overhead. Though figures vary by state and I could not find recent ones, I can tell you that in 2005 New York Medicaid reimbursed an ENT $60 for a tonsillectomy/adenoidectomy in a child under 12, and that included pre-op, surgery, and all care related to the tonsillectomy for 90 days after. Just out of curiosity, what did you pay your auto mechanic the last time s/he did a 20-minute oil change and lube on your car?

Doctors are not forced to make decisions based on a fee payment schedule. They make decisions based on medical data. They are required to provide documentation to support their decisions, and woe be to the doctor who did not use and document sound medical decision-making when s/he is audited by the insurance company, or when things go wrong and complications ensue.

"I do know that in some larger hospitals doctors are encouraged to bill as high as they can and are even compensated, i.e., the physician who bills the most in one month receives a bonus."

When a physician bills s/he is billing for a service that was provided. A physician cannot just run around the hospital submitting bills. One or more diagnosis and procedure codes must be submitted, and the documentation of the service must support those codes. Yes, doctors sometimes receive bonuses for working harder. I worked for a large university that operated under a bonus system. It was based on the number of Relative Value Units of service that we provided in a year. In order for me to bill a given number of RVU's, I had to provide and document that much service. If i worked harder, I got a little bonus at the end of the year, usually amounting to about 1% of my salary. Mostly the system was instituted to encourage us to actually submit the charges for what we did, as many of the guys in our system did a lot of work but didn't do the paperwork to submit the charges. You wouldn't believe the amount of care that was given and never paid for in my former office. It also encouraged us to learn proper coding, which is no easy task in the current system. Studies have repeatedly shown that, on average, docs who do their own coding tend to UNDERCODE rather than overcode, being afraid of large fines that are levied against docs who have been found to be overcoding. Interestingly enough, undercoding is also illegal anytime any kind of insurance, medicare, or medicaid is involved.

Obama's statements implied that most or all doctors operate that way. Physicians are FURIOUS about his statements. You can't join Sermo, as you are not a licensed physician, but if you could, you would have seen the universal outrage in the postings on the board, even from some of the docs who support his plan. Obama is no friend of doctors.

I think instead of focusing on the fact that some Physicians make poor decisions which ALL humans make, the focus should be on why.

From what I've seen in 25+ years of observing Physicians both as a student and patient, I'd say avoiding litigation was the main reason some Physicians make "poor decisions".

In other words, if there isn't any substaintail tort reform as it relates to medical malpractice included in this heath care bill, then it will only be usefal as toilet paper as far as I'm concerned. And of course, I don't expect Obama to go after his "own".

Path, once again we agree on something. I think the last time was before the election.