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The way we receive health care and how doctors deliver it is changing with the passage of last year's health care reform laws. For medical residents, the new laws may influence not only what they must learn to become doctors, but also which field of medicine they choose to enter. One area of medicine that some officials say is the most important in prevention and cost control is primary care, but fewer and fewer med students are becoming primary care physicians.
Popular TV shows like Grey's Anatomy and House M.D. portray the lives of doctors-to-be in dramatic episodes that blend fact with fiction. But how close to reality do such shows come to the real lives of medical residents? A Portland author has written books about just this; embedding himself for months with Oregon Health & Science University surgery residents to learn what it's really like to become a doctor.
Exactly what health care will look like in the future is still being hashed out, but Oregon is one of the states where provider models called "medical homes" exist. These centers provide people with primary care from a medical team, and are coordinated through electronic access points.
Last week legislators in Salem considered a bill that would set aside $400,000 to establish a research and training center at OHSU to study the transformation of primary care into the medical home model.
Are you a resident? If so, what factors are you considering as you complete your medical training? Are you a patient wanting to know more about the future of health care reform and how it may impact you?
Tagged as: care · health · reform
Photo credit: johnnyalive / Creative Commons
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Health is not something you buy, it's something you do. Doctors and patients need to work together to achieve and maintain health.
As a person who has lived the last 10 years without health insurance, I've been paying a lot more attention to my diet, activity and taking a few supplements. I'm in my mid-60s and I'm in pretty good shape...
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I've always believed that the individual is primarily responsible for their health and NOT a doctor. In my own case I am 77 and have never been in a hospital except to have a cataract removed, and I take no pills of any kind.
A child hood spent in southern CA and later in Oregon, I was blessed with a mother who did not think what we term junk food today was healthy. As a result until I was in high school and ate lunch down town, I rarely ate hotdogs, hamburgers or drank fizzy sodas. In the Marines I learned the importance of regular and vigorous exercise..a regimen I continue to this day. I never have smoked and drink only an occasional beer. My diet is simple and light on red meat. As a result, my weight is within 5 lbs of what I weighed when I left the Marines.
I find that most people live in a very undisciplined way until mid life when they suddenly fall ill from poor diet, insufficient exercise and smoking, boozing and perhaps heavy drug use. At that point they go to the doctor and expect to be made well, again. It is this attitude that makes doctors and the pharmaceutical companies wealthy and hooks everyone on medications of one kind or another by their early fifties.
I read that the ancient Chinese had a system of health care we might want to emulate. The family physician was only paid while the family was well. When one of them fell ill, the payment to the doctor was suspended until the family member recovered.
Our own system of 'cure for fee' medicine places the well being of the patient and physician's monetary interest in opposition. NOT a good relationship for the patient. But quite nice for the doctors, as the sicker we become, the richer they become.
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I liked "Scrubs" when it first started out. Funny, sweet, mean, caring, cynical, and all that stuff.
All of the characters looked lke normal everyday people.
But after a show makes it for a year or two, the characters get "Hollywood-ized", the hair and make-up people tart them up with too much makeup and give them the all too typical "Hollywood" look. And that counts for both men and women.
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As a 3rd year medical student at OHSU with an interest in primary care, I am terrified by the staggering amount of indebtedness I face upon graduation (500k between my wife and I) and out of neccessity must consider the implications of pursuing a less lucrative medical career and the impact that will have on my future financial security and ability to work in a rural or underserved area. Will the cost of medical training eventually surpass earning potential?
-Jay Williams, MS3
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As a fourth year medical student at OHSU, lack of continuity for inpatients has been the most frustrating element of my medical training thus far. As a society, we tend to believe that individuals are responsible for their own lives in most situations. However, we tend to draw a somewhat arbitrary line between individuals who are acutely ill and those who are not. We offer very few resources to individuals who are at risk of becoming ill or are in the process of getting ill, but once one actually becomes ill they are inserted into a system that offers unlimited resources. These resources are applied with the goal of making them less ill to the point where they can go back to operating autonomously (at which point they will likely go back to having few resources), inevitably leading to a cyclic pattern of illness. We desperately need outpatient continuity for ill patients.
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I'm interested in the apparent disconnect between mainstream physiological medicine and dentistry. Is there anything that could occur at the educational level that might reunite the disciplines? Perhaps it would even contribute to reuniting the parts of the body. There are many studies that demonstrate the relationship between healthy oral hygiene and heart health and immune health, etc. As a patient, there seems to be a different ethic in dentistry -- less of an obligation to serve patients and more of a for-profit motive. Even in this program, dentistry does not seem to be included. This may be in the process of occurring with thinking of mental health as connected with physical health.
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I am not a medical resident but I had a recent conversation with one who told me she would not practice in Oregon after her surgical residency because of the level of her student loans and the low pay she could expect here relative to what she could make in other states. She specifically was thinking of going to Tennesse. For her, it was Orgon in general, not the speciality.
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I have come to believe that we need to separate wellness care from illness care.
It disturbs me that we've somehow become a nation where the people managing our health care have a vested financial interest in keeping us chronically ill or in ongoing "management/intervention" rather than completely well.
I want a system where my primary care team profits most when I am vibrantly healthy.
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In a good, well organized, efficient heath care system the doctor should be the last resort, NOT the first person seen.
I'm talking about a national health care system based on primary and preventive medicine. Health educators and health counciling services should be the first line of health care providers. Most degenerative disease of our middle years are caused by poor life style choices. Much of which is based on ignorance, low income and a lack of supporting services.
But both the physicians, their lobbies and the pharmaceutical industries are addicted to cure for fee medicine, rather than preventive services. A national health care service would probably cost less than half what we currently spend on our wasteful, inefficient and disorganized farrago. Where maybe a third of its costs are related to late detection of early onset of disease, various addictions and chronic poor diet.
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regarding your current guest's concern about the cost of tuition and compensation in primary care...
i am a primary care physician. i took a scholarship through the national health service corps, which paid for my tuition in medical school. in return, i worked in a wonderful community health center / migrant farm clinic in hood river oregon. there are PLENTY of NHSC sites in oregon, both rural and urban for loan repayment. don't be discouraged! i make a very good salary now (though am no longer at the chc due to burnout).
one issue i think deserves more focus in the educational realm of medicine, especially in primary care, is RESPONSIBLE management of chronic pain. for example, rather than dispensing #240 vicodin per month to a patient who has a myofascial pain syndrome, let's TEACH this patient coping mechanisms, options to help keep them moving, focus on yoga, or exercise prescriptions. i think there needs to be a new field in medicine called "MOVEMENT MEDICINE"! too many primary doctors are TOO busy and don't have the time or energy to help patients with chronic pain syndromes learn how to function without the use of chronic opiates. opiate addiction is rampant and quite frankly, out of control. there is no evidence to suggest that long term opiates improve patient outcomes from chronic pain. they tend to create more problems, including dependence, bowel dysfuntion, weight gain, and depression, to name a few.
let's be more responsible about the psycho-social aspect of medicine!
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Why are first year residents supposed to learn discharge planning, insurance coverage, and where to get the least expensive prescriptions? Every hospital I have had contact with has social workers, discharge planners, or "just nurses" who do this very well. They are trained to do it and are paid to do it. Doctors should know these folks exist, and the work they do, but I see no need for doctors to be trained to do these things too. Is this a throwback to the old saw "The doctor is the leader of the team"?
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As a public health student and current medical school student, I'm left wondering what is OHSU doing to help ensure a viable, retainable, primary care physician workforce in Oregon for the future? Where are the incentives to practice primary care? Where is the recruitment? Primary care shortages are rampant in this country (especially Oregon), yet as an informed student, I see only limmited efforts to address this.
~ Rob Chamberlain
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Of course these shows are overly dramatic, but that is not the only inaccuracy. The majority of medical professionals are simply book smart and lack the critical thinking one sees on television. Yes, it is hard to be a doctor because it takes discipline, determination and time, but the profession rarely requires extensive higher level thinking. Many medical professionals do it for the money, and when you speak with them they seem to have little interest in the holistic experience of medical care for its own sake. They are just individuals with advanced technical degrees going to work to get paid---it is terribly disappointing!
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None of your guests are building much confidence. These folks are coming off as mercenary technicians (sorry, but the vibe is very costs/benefits oriented from the doctor's point of view, not the patient's)
The model represented by your guests is based on our present system where the scale of dollars involved is just out of line. Everybody seems to be totally invested in the system as it is.
How about some discussions about alternative training and wellness related medical practice.
interesting topic, but the guests are not making me any more willing to go see a doctor for any reason.
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Why is there no emphasis on Preventive Medicine in medical schools curricula?
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It sounds like we ought to take drastic steps to get the bankers out of medical care. Bring back anti-usury laws and regulations.
Historically interest rates were around 2 or 3 percent and were often useful for people who needed to borrow money
Now the bankers are more like tapeworms or even malignant cancers, diverting an unhealthy amount of money away from being useful in the economy, our body politic, and to themselves.
Now these med students are looking more like old time indentured servants working for the bankers instead of for themselves and their patients.
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In reading article after article on how we can cut the costs of medical care, I have yet been able to determine why it costs so much money in the first place. There is an onslaught of work involved in how the consumer can be better managed to simply incur fewer costs through preventive measures and smarter choices. All the cost savings seem to be on the receiving end. Where is all the research devoted to how medical services can just, simply, cost less? We don’t only need cheaper ingredients, and smaller portions, while the cooks and owners all get paid the same.
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I had a semi retired pathologist tell me a few yrs ago (actually about 25 yrs ago) that the AMA was the force that kept medical schools from expanding enrollment. They want to maintain that high patient to physician ratio that is highly lucrative, But makes for very poor and dangerous care for the patients.
My late wife who died from cancer had both private health insurance and MEDICARE and access to the best doctors in the Las Vegas area. But the lack of coordination between the various practioners and hosital doctors and the screening services was a one long nightmare for the two of us.
Her oncologist was a partner in a corporate practice owned by three doctors. One of the clerks confided to me me when I asked, that the number of open cases was over 2000!! These doctors took one month vacations and worked four day work weeks and patients had to wait sometimes as long as three weeks for an appointment to see one of them. I timed her doctor several times during visits, and the average time he spent with her was 14 minutes. Much of that time was spent with him leafing through her file. He NEVER recalled her name or exact diagnosis!!
We need more doctors, or nurse poractioners and it is the doctors themselves and their lobbies in DC and the AMA that keep the numbers restricted.
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I have to disagree with the idea that doctors are the best and brightest and that is why they are entitled to earn the amount of money that they do. I do not believe that a doctor has any higher of an IQ as the nest person.
Thanks for the opportunity to add my view
Jim
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If I could change one thing in the way that we are trained in medical school, it would be to encourage students to practice in the outpatient setting. The vast majority of our rotations during our 3rd and 4th years of medical school are hospital-based. Compared to how much time we spend in the hospital, we get very little exposure to how medicine is practiced in a clinic or doctor's office.
I had a new doctor say to me the other day that she felt more comfortable, at the end of her residency training, putting in a central line than treating a simple ear infection or cold. It's a shame.
Sasha (4th year medical student at OHSU)
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We have to remember that medicine and science go hand and hand; working together in order to advance society. But, what no one is talking about is what happens when all of the very well educated, very talented group of scientists that are trained in the US either leave science all together or move to other countries where they are better compensated. I know several post-doc students who have been in training for 8+ years in science and are still qualifying for low income housing assistance. When they get their first tenured position in academics, they might make $70-80K a year. Why then is a scientist in our society worth $70K and a physician is worth $150-400K when they both have the same level of training?
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Good point. One I have thought a lot about since pursuing medicine after graduate school. A few thoughts are that it actually takes 8 years of college to get an MD then another 3-10 of residency and fellowship training. Another reason for greater salaries have to do with the work schedule which may entail over 80 hours/wk. Lastly, I agree, researchers who are providing the basic science needed to advance the medical sciences deserve adequate compensation. Unfortunately their salaries are largely dependent on grants which are subject to multiple forces including the economy, funding agencies, direction of research.
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Is medicine part of the military-"medical"-industrial complex? I think so. Until we remove healthcare from the realm of industrialization and the dehumanizing monetarized "market" for medicine, we will never have an affordable, fair, and state of the art health care system in the U.S. It's like college football...everyone cashes in except for the players. Patients are the "players" that supply the market with new opportunity for exploitation and profit but most unlikely to benefit themselves(except for the elite whose celebrity and wealth make a benefit irrelevant).
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The Truth about the Physical Exam is in rare cases it can be valuable, but in most cases it is unrevealing.
Frequently a CT Scan is by far more comprehensive and will likely lead to an accurate diagnosis, versus empty reassurances or letting time play out a disease.
Unfortunately new graduates can become too overly reliant on technology. A CT cannot be a simple substitute for an accurate History and Physical Exam.
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I recently read both "Every Patient Tells a Story," by Dr. Lisa Sanders (tech consultant for House, MD), and "The Checklist Manifesto," by Dr. Atul Gawande, and both seem to express the opinion that the physical exam and complete history are vital tools for a timely diagnosis and proper treatment.
I highly recommend both books as a good read to anyone who is interested.
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Why isn't "supply" side of the health care issue ever addressed? How about a solution of federally funding building of twice the number of medical schools, twice the number of specialty schools, nursing schools also? Give incentives for the specialties that are needed. Doubling the number of physicians and nurses would drastically reduce the cost of health care. Tripling would do even better. And while we're at it, how about also building factories that make MRIs and CAT scans, and even pharmaceuticals, that would drive prices down. This is not a rocket science solution but it would reduce cost of health care and also improve access. Then we could afford a single payer program. We could also provide more financial support for medical and nursing students. There are solutions that can work.
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The radiologist who treated my wife or awhile actually said that his machines cost so much he could not afford NOT to use them to the maximum!
I suspect that the over radiation of dental patients and all others is directly related to the high cost of the devices and the doctor's need to amortize those costs by using the hell out of them and any possible damage to the patient is a secondary consideration.
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I was a lucky med student in 1957 -- my GP father paid for my education. [NB - in Norway at that time med school was at government expense, but the med school graduate was then assigned a year or two at usually remote locations as a pay-back.]
My most practical medical "training" was informal -- I needed a job for the summer between my first & second year of med school. The Children's Hospital in Columbus, Ohio was only too happy to hire me on at minimum wage. After a month or so of on-the-job training on emergency room daytime shifts, I was handed the opportunity to "run" the emergency room on night shifts. I sat at the front desk, out in the waiting room, where I waited for a patient to come in. As the E.R. secretary I got their complaint and stats on the log book, then escorted them back to an actual patient room where I now became an orderly, getting weight, blood pressure, temperature.
Then I became clerk, phoning the intern on-call. After his (her) exam, I took orders. If an xray was needed, I became orderly, wheeling the patient upstairs to x-ray. If a shot was needed, I became nurse, getting the medication and giving the injection. I then advised the patient, if necessary, on how to take the treatment advised by the doctor. If a cast was needed, I assisted; surgery - I helped the patient change into hospital dress and wheeled them to the O.R.
At end of patient visit, I logged them out at the front desk. What I was told I wasn't good at was Janitor. After the patient left, I was expected to clean everything up!
Although this job lasted only 3 months, I never forgot who does what in the hospital -- or in an office. Each worker thinks he runs the place -- in most patient encounters, even in the emergency room, the doctor is actually called last!
Eventually I learned another role on that job -- teacher! Eventually the interns and residents declared, "Huffman, you're becoming a doctor. Why don't we teach you how to sew?" Once they did, I could help the intern challenged by the first time he had to suture a wound all by himself.
Dave Huffman, retired M.D.
Longview, WA
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I am writing in response to the last caller's comments regarding MD's salaries. The general public tends to forget the amount of education debt incurred throughout undergrad, med school and residency. Physicians also have delayed entry into the workforce therefore delaying saving for retirement and other adulthood milestones such as buying a home. If you want to reform healthcare, you also need to focus on a change in doctor's education costs. The lure of a higher income after residency quickly fades once a person realizes the staggering amount of education and malpractice insurance costs.
Another caller discussed the overuse of unnecessary procedures such as extensive imaging. Occasionally physicians tend to order expensive tests in the off chance if they don't and miss something they will be sued. Our society is extremely litigious. And physicians have a healthy fear regarding being sued. Have we talked about tort reform yet?
The best and brightest students are steering clear of medicine because they realize the cost of high education debt, malpractice, stress and delayed entry into the workforce doesn't out weight the benefits.
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I am getting my graduate degree in Nursing to become a Family Nurse Practitioner, and I believe that this profession will truly help address the cost issue of providing health care to more Americans. Although I will be paid less per visit than an MD, my total graduate degree will cost me around $26,000, and I can apply for loan forgiveness for some of that if I agree to practice with designated underserved populations.
Family Nurse Practitioners approach health care from a more holistic perspective (that from the perspective of Nursing care, not Doctor care, which is very different and tends to look more at chronic conditions and whether the patient will be able to comply with your advice or not). FNP's tend to spend more time with the patient by listening longer and conducting careful history taking. As a nurse I have had a lot of hands-on patient care BEFORE I will go into practice, so when I am training in clinicals I can focus on what is NOT normal. This gradual training, first in nursing school, then with several years of hands-on patient care, and then finally graduate level education, is in my opinion the best way to prepare a health care professional in the long run...it is economical, does not throw me to the wolves as a completely inexperienced clinician who has hardly had any hands-on experience, and along the way sharpens my ability to relate to the whole person I am seeing, not just the condition they have. This is what Nurse Practitioners do, and it is different than a Doctor.
What I find sad is the patient that thinks that because I do not have an MD after my name, or I don't have a nametag that calls me "Doctor Blank," that I cannot provide them the best care for their condition. I have also heard the statement "I don't want to see a Nurse, I want to see the DOCTOR!", and as one of your guests pointed out in the show, the Doctor may not be the health team member that could best address their concerns. Health care is very much a TEAM effort: the PATIENT, the Physician, the Nursing staff, the Physical Therapist, the Laboratory Tech, the Pharmacist, even the Office staff all contribute to the wellbeing of the patient. But please note that the FIRST member of the team is the PATIENT! If your health care advice comes from a Doctor, a Nurse Practitioner or any other team member, you are STILL the one in charge of your health care, and your primary care provider should be YOU. If you find you prefer a Family Nurse Practitioner for your office visits, you can save yourself and the health care system a lot of money in the long run.
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They need to learn effective communication skills, meaning they share the hard truth, projected symptoms, and possibilities to treat or not treat the illness according to the patient's quality of life.
Most of the new physicians I encounter as a board certified professional chaplain in the hospital setting are aware they won't last long as Superman/woman and they do rely on other disciplines to fill the holistic needs of every patient. They utilize social workers, case managers, and chaplains to meet the emotional, logistical and physical needs patients have at discharge. Unfortunately it is often the seasoned physician that doesn't do the full-spectrum care and leaves loose ends for the vulnerable patient, support system, and registered nurse to discern and reconcile.
From a patient advocate standpoint, every physician needs to remember the power they hold as the caregiver in the white coat. They need to compassionately and directly communicate the reality of illness, the symptoms associated, and ALL of the options possible in treating, or not treating, an illness.
We, as patients, need to remember that our physicians are only people too- those that love to bike, enjoy Indian food, and have their own preferences for their personal healthcare. They may benefit from more practice in knowing themselves through required counseling, mentoring, and pratices of self-care that will help them survive the rigorous preparation these physicians are experiencing. If we had more healthy physicians, we may have more healthy people.
It is my hope and prayer that health reform allows for better quality of life due to better education and practice of all involved- less student loan debt, more time allowed for preventative care, respect for the options available at the time of a poor prognosis, and better coordination between interdisciplinary staff that work more effectively together than alone.
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My late wife was a practicing Catholic. She died of cancer after a prolonged illness. The first time she was hospitalized in a hospital administered by the Dominican order she was visted by the chaplain while i was in her room. He said a short prayer for her, then standing over here started moving his hands all around her, not touching her, just waving his hands about in a very unsettling way and doing this with his eyes closed. I asked him what he was doing and ge replied: "I am messaging her aura" WHAT??? And this man was a Dominican priest. Both my wife and I were dumbfounded.
Just a few months earlier her favorite priest in the next town was caught by police paying young boys to tie him up naked and whip him him with leather straps. There was probably more involved in that which I have blocked out. Hospitals need more medicine and fewer spiritual guides.
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With our current economic troubles making us look like a third world country, I wonder if Oregon med students would qualify to be sent to Cuba to be trained like other third world students have been?
Cuba has quite a record of training doctors and sending them back to their original countries.
Well, that's tongue in cheek of course, but what can we learn from how Cuba trains doctors?
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I think the med school on Greneda might still be running..that's the one Bush I invaded on some kind of trumped up BS. Also India has good med schools and I think some still use English as the teaching language.
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part(not all) of the issue of rising cost is a lack of trust both between doctors and patients...and patients and doctors.
doctors sometimes are mistrustful of their patients-
for example 2 out of 3 of my chronic pain patients fail their urine drug screeings - either not taking the pain medications I'm prescribing(which means they are potentially selling it) or, more commonly, by having another medication in their urine that I'm not prescribing - such as oxycodone, vicodin or even methadone. I'm at risk of losing my license if something bad happens to that patient and am wary of any patient in pain requesting narcotics. It rarely seem to be an effective way of controlling pain. I've seen 2 doctors pulled from their practice recently regarding prescribing pain medications and patient's taking other pills at the same time. It's hard to trust my patients when they tell me one thing in the office, but then do another(especially when I advise against using other narcotics at the same time explicitly). this occurs 2 out of 3 times - both with patient's i suspect and those i would have never guessed.
patient's don't trust doctors - I try to convince patients that expensive imaging tests such was ct scans/mri's aren't always indicated (or helpful)for back pain, and other symptoms. a scan doesn't always tell us an answer. but of course, I'm quick to order one when i think it is needed. for example, a patient came in to see me just last week, demanding mri of his knee and hip before trying conservative care. He was unbelieving when I tried my best to convince him otherwise. another patient is upset that I won't prescribe a once a day antibiotic for her urinary infections rather then treating episodically with antibiotics(she doesn't want to take the time to bring in a urine sample three times a year. i won't even require an office visit!). she just wants the problem quickly fixed regardless of the risks or consequences such as bacterial resistance, diarrhea, etc. I only have 15 minutes to try to convince untrusting patients of these difficult decisions. it's easier and pleases the patient just to do what they want. patients prefer to see a specialist, because they believe it will provide better care, but they get upset when they have to pay the bill.
i'm sorry to sound cynical, I just finished residency 1.5 years ago. i am still fairly idealistic. i love working in primary care. but it gets difficult and trying when patients don't understand(or try to understand) the idea that more isn't always better.
i'm very certain that both the health care providers and patients both need to make concessions to help make health care more affordable. Trust is an important part of this.
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Defensive medicine, over billing, rampant malpractice... uncaring attitudes, and today, in the news, an FBI sweep catches scores of doctors and other providers bilking MEDICARE and MEDICAID out of hundreds of millions. No wonder most people don't trust the medical profession. It seems to be run by the mafia. At least its take is greater than that of the mafia.
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The National Health Service Corp loan repayment program will allow her to choose where her and her husband practice as long as the clinic meets criteria as underserved by federal standards. The NHSC scholar program will too, but fewer clinics meet the strict federal criteria. I am a 2nd year physician assistant student at OHSU. I want to work for a general internist or family physician and also focus on preventive medicine. Thankfully, my debt will be approximately $100,000 and not a quarter of a million! Two people in my class are NHSC scholars and are looking to work in Oregon upon graduation. Personally I could not make the large commitment to NHSC at this time, because my husband must work in an urban area and there are only a few clinics in Portland that qualify. Hopefully Oregon will develop other systems whereby physicians can obtain debt relief in exchange for providing critical access to medically underserved communities. Best of luck to the medical student and her husband on the show as they move forward with their education and decision making process.
As a side note, I would be interested to hear a TOL discussion on healthcare that includes the roles physician assistants play in providing care to Oregonians. PAs and Nurse Practitioners are relatively new professions and are commonly called “midlevel providers.” Laws concerning medical practices of PAs and NPs differ, but both can help attenuate the physician shortage we are currently facing.
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Reguarding TV portrayals of Medicine in Grey's Anatomy, House MD, Private Practice and E.R.
Except for the Sex, Drugs, Attractive People, and the high-flying Social Life--it is just as accurate as TV Crime, Homicide, Legal and Reality shows.
Very few of life's problems can be solved in 48 minutes...with commercial breaks.