Physicians Concerned About Their Career Choices

I read the blog titled "Young Doctors Worry About Career Choices" By Bruce Japsen on the New York Times - Health - Prescriptions.  I like it.  The blog article comments on the reults of a Merritt Hawkins' survey. 

It starts: "Even though young doctors still receive a lot of job offers in one of the worst markets in decades, nearly one-third would select another profession if they had to decide on a career all over again, according to a new study out Thursday."

This is significant, very significant.  Why?  Because it is the opinion of those who are just starting their medical career.  According to the article "... a growing number of these hot employment prospects still regret their choice of profession, citing large medical education debts, the changing economics of health care, and the health care law and how it might affect their future practices and profession."

Is this opinion related to their limited experience, and the reality is not that bad?  Or is it an indication that those are smart enough to understand that there are problems, even before getting into the career?  I favor the latter explanation, and I am impressed.  I am impressed that such a remarkable proportion of young physicians are doubting their decision to be in the career of their choice because of the factors cited in the article (debts, economics, and the impact of the health care laws on their practices and profession).  They were able to recognize the importance of those issues.  But, those are not even the worst worries that are out there.  There are actually other more profound reasons that they probably were not made aware of, and that can make the most resilient to eventually regret being a physician.  Here are things that come to my mind.

1.  Physicians lost a lot of autonomy because of the tremendous regulation that is happening now.  Doctors working in hospitals (whether as independent contractors or as employed physicians) are monitored in a way that no other profession to my knowledge is.  Even though that is in part due to the high standard required of being a practicing physician, the monitoring is actually not used to improve performance in a collaborative way, but rather to judge who need to be axed.  Essentially, there is an atmosphere of deep skepticism against physicians.  The excuses to start an investigation and end up with a disciplinary action have such low standards of fairness and impartiality that, essentially, almost any physician can be a victim.  Only with the grace of being connected, politically correct, and fitting in, that anyone can be reasonably confident that they will not be subjected to elimination.  If you do not fit in from so many aspects, there is a very good chance that sooner or later you will be ruthlessly eliminated.

2.  Physicians lost respect as leaders.  They actually are low down in the hierarchy of effectiveness in a hospital setting, unless they also hold political power, or are liked by those who hold such powers.  Some of the physicians who climbed the power ladder became more of bureaucrats and sometimes anti-physician executives than being part of the general community of doctors.

3.  Physicians are the only career that I know of where, once you become a victim of a disciplinary action of severe magnitude, no matter how unfair the process was to you (and there is nothing that guarantees, even remotely, that the process will not be heavily tilted against you as a physician), your reputation will be ruined by a mandatory reporting to the famous National Practitioner Data Bank, effectively destroying your career.  You'll be ostracised, marginalized, and you'll lose the ability to find an employment or obtain privileges or be credentialed.  I think most surgeons have felt threatened or actually became victims unless they are among the selected, or too young in their career that they have not yet been touched by malpractice claims, peer reviews, anonymous complaints, etc etc.

4.  If you dream of opening your own private practice, be aware that the current structure is evolving into an environment that is both economically and politically unsupportive (dare I say hostile?) to the independent physician.  Eventually the solo will seek a hospital employment.  If that has been your dream and aspiration when you went to medical school, congratulations!

Entering into a career of practicing medicine in the US is a gamble.  It is a profession that can break the heart of the best physicians.  It is merciless for some, and too forgiving for others.

URL of the article under discussion:
http://prescriptions.blogs.nytimes.com/2011/10/06/young-doctors-worry-about-career-choices/?smid=tw-NYTPrescription&seid=auto

Will You Attend the United Whistleblower Meeting Sept 18, 2011 in DC?

United Whistleblower Speak Sept 18, 2011:

"Americans must be free to practice their trade and to tell the public the truth."
 http://internationalwhistleblower.org/


Submitted by James Murtagh

WASHINGTON, DC – This September 18, the whistleblowers and persons of conscience will hold the fifth annual gathering on Capitol Hill. As the Nation's budget crisis continues to grow, lawmakers must look to corporate and federal whistleblowers to stop out of control spending. The united message is the nation’s top priority must be to protect whistleblowers so that truth-tellers can protect the public, the public’s health, and our national security.

Five years of concentrated advocacy led to this meeting. Dr. Jeffrey Wigand (aka, “The Insider”) helped to found, guide and shape the International Association of Whistleblowers (IAW). Other Advisors include Coleen Rowley, Reuben Guttman and Cyrus Mehri. Our ranks are growing stronger everyday.

America knows what is said about whistleblowers. This conference is a chance to hear from the whistleblowers in their own words. A spectrum of statements include:

• NSA whistleblower Thomas Drake, recently revealed on 60 Minutes that 9/11 could have been prevented. The IAW demands an end to counter-productive policies that make America more vulnerable to future attacks:

"If recent history is any guide, coming forward with the truth and blowing the whistle on evidence of gross waste, fraud, abuse, wrongdoing, corruption, malfeasance, illegalities or dangers to public health and safety within public or private institutions is increasingly viewed as a criminal act. In so doing, whistleblowers not only risk their personal lives and professional careers they are often relentlessly and maliciously dismissed, victimized, hounded and even prosecuted out of reprisal, retribution, and retaliation for speaking truth to power - a clear and distinct 'shoot the messenger' syndrome. Whistleblowers are often the only witness to wrongdoing where they work. Existing laws are simply not sufficient to protect whistleblowers. http://www.whistleblower.org/blog/31/1128

• Navy whistleblower Kirk Wiebe vigorously supports the IAW message:

Whistleblowers are not a threat to government or to any organization, rather they seek to ensure integrity of service to the people they serve. The IAW Conference provides an excellent platform for whistleblowers to find their voice and to meet one another in a positive environment of mutual support. http://www.whistleblower.org/blog

NSA whistleblower Randy Kelly amplifies:

These are sad and dark days in the history of America. The American taxpayer has little or no confidence in our elected officials or government in general. The American people should be outraged at the level of corruption and criminal activity within the federal government and politics in this country. It is easy to understand why many members of the Senate and of the House of Representatives do not want any level of whistleblower reform. Too many politicians fear they themselves will become publically exposed as to the atrocities they condone by being unwilling to take any action against the prevalence of fraud, waste and abuse within all levels and sectors of our government. All honest citizens are affected by government fraud, waste and abuse. These are intentional and criminal acts that benefit but a few. And, they are taking place to the detriment of, and at the expense of, the honest and hard working citizens of this country. It is the 'whistleblowers' that are trying to right the wrongs. Yet the term 'whistleblower' remains painted with a dark and sinister image. The American people must come to realize that the 'whistleblowers' of this country are some of the true patriots of America. Now, more than ever, whistleblowers need the understanding and support of the American people!

• Bill Binney points out the Constitutional issue:

When our Constitutional form of government does not function, that is, when Congress does not have effective oversight of the agencies of the executive branch, those agencies set their own agenda and spend money accordingly. That is exactly what has happened at my former agency (NSA). Over the past 30 years, my former agency has made acquiring money the main objective - not solving operational problems. Their vision statement over these years has evolved into "Keep the problem going, so the money keeps flowing." In other words,
don't solve the problem use the problem to keep getting more and more money. This is and has been a disservice to our people and country. In effect, these agencies are trading our security for money.

• Mike McCray, co-chair of the IAW agrees:
Starting today, every agency and department should know that this administration stands on the side not of those who seek to withhold information, but those who seek to make it known.

We encourage all 264 organizations and corporations that signed the Whistleblower letter to join us! We are already bonded by a shared principle that "whistleblower protection is a foundation for any change in which the public can believe. It does not matter whether the issue is economic recovery, prescription drug safety, environmental protection, infrastructure spending, national health insurance, or foreign policy."
The IAW is independent, transpartisan, and non-aligned. It is united by a single principle: that Americans deserve to be protected by the truth. Only truth-telling patriots with extraordinary courage to tell truth to power can stop the barrage of preventable disasters that beset America. We are uniting to lobby Congress, and we will be heard. Every whistleblower will tell their story, and will be interviewed for U-tube. An extraordinary archive of these American and International stories will be collected.
All citizens who want to make America truly stronger are invited to:

Contact today Atlanta Whistleblower

INTERNATIONAL ASSOCIATION OF WHISTLEBLOWERS (IAW)
CAUCUS IN WASHINGTON September 18, 2011
DC Public Library - Martin Luther King Jr. branch
Room A-5, 901 G Street, NW, Washington, DC 20001
(202) 727-0321

Peer review victims: Are your helpers doing a good job?

Do you have any stories about businesses that claim or advertise helping victims of peer reviews but not actually helping? Not delivering? Doing a lousy job? Only interested in the victim till the victim signs up for the services then they do not follow through?

Please keep those stories coming. Confidentiality and anonymity will be strictly respected.

You can contact me through the comments on this blog.  Your communication will not be published, since comments are moderated.  Your communication will come to me as a message. I will not post it online if you want it to be confidential.
You can also message me on facebook http://www.facebook.com/find-friends/#!/profile.php?id=100001893544204

Statistics of Physician Elimination - Career Destruction

Out of curiosity, I visited the National Practitioner Data Bank's (NPDB) website, and I found the "NPDB Summary Report" at
http://www.npdb-hipdb.hrsa.gov/resources/reports/NPDBSummaryReport.pdf
It is actually a good source of information.

The NPDB Summary Report starts by stating: "The following is a summary of reports submitted and accepted into the NPDB for each professional category. This data covers the period from September 1, 1990 through April 2, 2011. Professional categories which were not available for the entire time period are noted."

Then there is a "Data Disclaimer": Reports of adverse clinical privileges and professional society membership actions against practitioners other than physicians and dentists, (e.g., chiropractors, psychologists, podiatrists) are submitted voluntarily.

I pointed my attention then  to the column "LICENSURE,CLINICAL PRIVILEGES, PROFESSIONAL SOCIETY MEMBERSHIP, AND PEER REVIEW ORGANIZATION REPORTS.  I chose some categories just to have some idea as to how many individuals in which professions are subjected to that career assassination.

Dentists: 20,239
Nurse Midwife: 94
Nurse Practitioner: 921
Hospital Administrator: 0
Licensed Practical or Vocational Nurse: 78,421
Nurse Anesthetist: 337
Osteopathic Physician (DO): 8,129
Osteopathic Physician Intern/Resident (DO): 153
Physician (MD): 82,683
Physician Intern/Resident (MD): 588

So, the safest on that regards is to be a Hospital Administrator.  Interesting.  And, being a trainee resident or even an intern is no reason for mercy.  Career destruction and elimination based on arbitrary criteria is just the way it is, no matter how junior or advanced in the career someone is.

Breakdown of MD by State, from highest to lowest number of physicians (MDs) whose careers, livelihood have been threatened with career capital punishment. 

CA    10,019
NY    6,561
OH    4,414
TX     4,111
FL     3,885
IL      3,647
VA     3,411
PA     3,004
AZ    2,591
MI    2,525
NJ    2,481
GA    2,262
CO    2,088
MA    2,074
MD    2,025
WA     1,877
NC    1,832
KY    1,661
LA    1,399
MO    1,377
TN     1,299
AL     1,152
OR    1,116
IN    1,107
MN    1,021
OK    979
WV     972
SC     958
WI     936
IA    918
CT    897
MS    751
KS    748
NV    606
UT     565
AR    539
NM    523
ME    429
DC     393
NE    381
ND    376
NH    354
AK    343
RI     334
VT     296
ID    285
HI    278
WY     178
DE    164
SD     149
PR     44

Notice that these are raw numbers. To transform those into meaningful statistical values, in the very least I need a denominator.  Actually deciding what the denominator should be is not easy.  Is it the population of the state? The population of a certain age? The number of practicing MDs? If so, the current number of MD"s, realizing that the data cover from 1990 till 2011, so, which MD population would be used, etc. 

Regardless, for someone to become a physician, one endures a lot that is well known to everyone.  And not too many really would be willing to pursue that route if they know that more than 90,000 were kicked out.  And they were not kicked out by an objective, fair or impartial process, but were eliminated and destroyed by a flawed process that is open for exploitation and abuse, executed by their peers and called  the"peer review".  There is nothing Holy about it.

Peer Review Reform (1) - Need objective criteria for Career Capital Punishment

All the discussions everywhere indicate that we have a very flawed medical peer review system that lacks so much that it could be more harmful than beneficial.  Coupled with the National Practitioner Data Bank, the combination draws the picture of an unpredictable monster.  Let's start thinking of reforming the process, and finally having a set of guidelines that can be promoted for a proposed solution.

First of all, I do not know if there is anyway any set of hospital bylaws, policies and procedures can strike the right balance between the interests of the public in being protected from the rare dangerous provider, and being fair and impartial to the provider.  In fact, I do not think that any set of bylaws can be ganging-up proof.  Let's face it, even when a hospital clearly breaches its own bylaws, it takes so much litigation, resources and time to seek remedy that the victim may become exhausted or ruined while justice is taking its slow-paced process time.  The victim may succumb before any remedy.  Then there will be appeals, counter-appeals.  Essentially, even winning entails so much loss.

Therefore, my biggest idea for today is that a reform should set rules as to the exact conditions under which the extreme measure of restricting or diminishing a physician's privileges should be considered.  That is my one focused idea for today.  The subjective criteria do not work too well.  For example, what could be not acceptable by the one medical staff in small hospital A (eg, for financial or reputation reasons) and portrayed as being a danger to the patients, may be very well a reasonable expectation of the average practice in hospital B.  Hospital A may be essentially protecting its financial bottom-line by discouraging its providers from treating sicker patients (who normally would have higher incidence of complications by nature of their disease) under the disguise of quality and avoiding complications.  So, hospital B should really not be bound by an adversarial decision against a physician whose privileges are revoked or reduced in Hospital A.  Hospital B should be willing to accept that physician to practice, particularly he/she is willing to and is experienced in treating more complicated medical problems .  But, the reality is that once Hospital A made their decision, and that is reported to the National Practioner Data Bank (NPDB), the regulators in Hospital B system (not the professionals aka physicians) may not even give that physician a chance to be considered.  In essence, a physician's fault may not be what she/he did, but where that physician practiced.  This is because really there are no critera as to when to apply the death penalty (career capital punishment) to a physician's career.

So, my plea is that the major career-destroying disciplinary actions must be considered as serious decisions and therefore there has to be clear and objective (not subjective) criteria before applying them to a certain physician as a last resort.

Should Studying Law Be Mandatory for Physicians?

My understanding is that medical school is supposed to prepare medical students to be good doctors.  That has translated to teaching basic sciences, clinical sciences and clinical applications of the knowledge.  Also included is exposure to the healthcare system and its delivery, some medico-legal aspects, and medical ethics.  That indeed has prepared generations of fine physicians to the challenges of clinical medicine, where the challenges Time has changed.  The knowledge and skills taught in medical school do not give the prospective physician a clue as to many real challenges.  Not the challenges that will intrigue the clinical abilities, but challenges that will threaten the career entirely.  The environment of practicing medicine in the US is morbidly so highly litigated, that the legal aspects are making a very significant part of the mental energy, time and financial resources of physicians and their practices.  I dare say that the MD or DO degree alone is not sufficient to be a good doctor.  A good doctor has to be able to survive legally against many odds.  I believe that extensive exposure to the law, even with a modified JD degree, would be the least that is necessary to bring some sanity.  A disadvantage is that you will have doctors who know some of the law and may over-estimate their knowledge and legal capabilities, and get themselves in trouble.  But, I think there will be a big advantage in knowing the basics, to be able to navigate some of the witch-hunts against doctors.  Every doctor needs to learn law.  But, in case their are legal issues, still retaining counsel is absolutely necessary.  But, then, the physician will be a well-informed customer.

Another potential shortcoming is if the curriculum is designed to program the future physician to promote the current miserable state of affairs without actually preparing them for the real dangers (bad medical staff bylaws, lack of constitutional rights for physicians, etc).  Therefore, the course needs to be carefully designed to prepare the student to practice in the jungle of healthcare in the US, and to give a strong sense as to which areas need reform.

Article: How Courts Protect Unjustified Hospital Peer Review Actions

I have recently read a very inetersting article that I wanted to share with you, and you can reach at: http://www.jpands.org/vol16no1/kadar.pdf
Published in the Journal of American Physicians and Surgeons - Volume 16 Number 1. Spring 2011.

How Courts Are Protecting Unjustified Peer Review Actions Against Physicians by Hospitals
The author: Nicholas Kadar, M.D., J.D.

"Nevertheless, courts have consistently misinterpreted the legal effect of HCQIA’s presumption of immunity as increasing the physician’s burden of proof, and as creating an almost insurmountable obstacle to prove that the hospital’s actions did not meet the standards of § 11112(a). For example, a panel of the Third Circuit, which included future Supreme Court Justice Samuel Alito, declared: “The HCQIA places a high burden on physicians to demonstrate that a professional review action should not be afforded immunity.” This is simply not true. A physician’s burden to rebut the presumption of immunity is the lowest known to the civil law -

For the full article, go to: http://www.jpands.org/vol16no1/kadar.pdf

Nicholas Kadar, M.D., J.D., LL.M. is a gynecologic oncologist and member of the New Jersey Bar.