It’s only been a little over a month, but I have confirmed that the world of private practice American medicine is not my cup of tea. I’m not one to be influenced by money and I’m not really an entrepreneur so I would fashion things to please me. One might see my fictional solo practice and point out to me the myriad of ways I’m leaving money on the table or not reaping the full remuneration but I probably would still be content in that state.
I had already made the choice against a different private practice style where I would be employed by one of several infectious disease consultant groups competing for business in the same town and in the same hospitals. I won’t forget the head physician describing to me how sometimes he eats lunch 2 or 3 times a day because he goes to the physician lounge at several hospitals for the sole purpose of networking to increase his referral base. Nope, not my cup of tea at all.
The private practice I did choose to join has the luxury of being the only practice in the hospitals we go to. They’ve been so for many years. Though they are not the only group in the area, they are prominent enough already that there is a steady stream of referrals. This cuts out that nonsense of having to beg for consults.
That being said, they are still a private practice, as are many of the other medical and surgical specialties in this area. It remains a “you eat what you kill” world. I’m told that patient care is foremost but honestly, I don’t see that. What I see is that making money is foremost. You know, to keep the practice going. After all, each practice is a small business with employees to feed, clothe and provide health insurance and other benefits to, n’est-ce pas?
To illustrate the difference I’ll describe briefly what my practice was like as an employed physician with a salary in a setting of other employed salaried physicians. Of course, you have to give a little incentive for people, physicians included, to work a little harder so there are bonuses to be made based on various criteria such as volume of patients seen.
As a consultant, I’m asked by a hospitalist to see a patient for a specific issue, let’s say pneumonia. At a hospital where the hospitalists are self-sufficient for the most part I could count on this patient with pneumonia to have something unusual about them. Perhaps they have not yet responded to standard antibiotics, or maybe they are immuno-compromised, or maybe this is their 3rd admission in a month for pneumonia. That makes for an interesting infectious disease consultation right off the bat. Interesting is good. Interesting cases are what I live for. I would see the patient through their acute sickness and when they got better leave a plan to complete a course of antibiotics, let’s say 7 days. I would step away while they remained hospitalized for a different non-infectious disease related issue. I would rely on the hospitalist to call me back if they needed me.
In an incentivized model, including private practice, the physician is motivated to see the patient well after they are stable stating “doing well, day 5 of abx”, “doing well, day 6 of abx”, “doing well, last day of abx”, “doing well off antibiotics, continue to monitor”. You eat what you kill. “A patient seen is a patient billed”. Yet, it’s well within proper care to make sure that the patient tolerates each day of your recommended treatment course. It’s necessary even when the hospitalists are not the greatest. I’m just saying.
In an incentivised model where “you feed me and I’ll feed you” is the rule, the consults are plentiful. They also amuse me. Does a 40 year old healthy woman with mild-moderate influenza truly need an infectious disease specialist to see her in a hospital setting? Does the pulmonologist truly have to see her in addition. Does she even need to be hospitalized? These are the “silly consults” of fellowship. But the mantra now is “silly consults send little Jimmy to college”. Bring on the “1K VRE in urine [from Foley catheter], eval for UTI” consults. Sigh! And we wonder why healthcare is so expensive in America.
Anyhow, let me not bite the hand that feeds me.
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