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Why Doctors Hate Science

Rolfe said:
The Today programme on ITV (8 to 8.30) just spent half an hour saying exactly that.

Rolfe.
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I think most of the effect that shows up in the studies is probably not the result of unethical money grubbers (like the "bad vets" you know, who are rare), but rather a lack of extra compensation effectively muting the "more care is better care" bias.
 
It is not as easy as:

Salaried = good
FFS = bad

Here are the advantages and problems I see with both (and I have been both).

Salaried:

Advantages:
- patient care is not negatively impacted by demands on physician time.
- Physicians get the benefits of set hours, health benefits, and paid vacation.

Disadvantages:
- Physicians have NO INCENTIVE to see any more patients then THEY DEEM reasonable.
- With less patients per day seeing the salaried physician, more physicians will be needed for a given area.

FFS:

Advantages:
- Physicians, driven by the bottom dollar, will see more patients per day, and work longer hours. You will need fewer physicians for a given area to do the same work.
- Physicians get to set their own hours, take vacation at their convenience, come and go as they please.

Disadvantages:
- Less time per patient, as a result of caseload, will dictate either (A) multiple visits for people with many different medical problems, or (B) a brush over of each problem in a single visit.
- In some cases, PID will insure that some percentage of visits (though I think relatively small) might be deemed redundant, or over cautious in nature.

I am sure there are other issues, but the above is what jumps out at me.

examples of the extremely bad for each...

1. I knew a SALARIED pediatrician who would see no more than 6 (SIX) patients in a 4 hour half day.

2. I knew a FFS Physician who would brag that some days (granted 10-12h days) he would see over 100 (one hundred) patients.

TAM:)
 
T.A.M. said:
1. I knew a SALARIED pediatrician who would see no more than 6 (SIX) patients in a 4 hour half day.

2. I knew a FFS Physician who would brag that some days (granted 10-12h days) he would see over 100 (one hundred) patients.

TAM:)
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There are a few mixed systems that I believe are a compromise between both systems.

Some groups have a base salary with a percentage of the salary tied to performance or RVUs. Some will tie bonuses onto the productivity as well. Our ER group does this, we have base salary but a percentage of our salary and bonuses are tied to the productivity.

This allows for productive docs to be incentivized to see more patients effectively and chart better but if you are a slower and less productive doc and are happy to move at your pace(to a minimum degree of course), you get paid less.

This waters down both the pros and cons of FFS and salaried but I think it works well for our group.
 
paximperium said:
There are a few mixed systems that I believe are a compromise between both systems.

Some groups have a base salary with a percentage of the salary tied to performance or RVUs. Some will tie bonuses onto the productivity as well. Our ER group does this, we have base salary but a percentage of our salary and bonuses are tied to the productivity.

This allows for productive docs to be incentivized to see more patients effectively and chart better but if you are a slower and less productive doc and are happy to move at your pace(to a minimum degree of course), you get paid less.

This waters down both the pros and cons of FFS and salaried but I think it works well for our group.
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I agree it isn't a bad compromise. Like I said, I have worked both sides of this fence.

I found the Salaried position left me with too little control. The medical board controlled when you worked. They knew they had you by the kahunas, so they rarely bothered to find locums to fill in gaps, rather they made you and your colleagues work it out. Vacation time allocation was a nightmare. As well, I found myself angry with my colleagues, who would only see 6-8 patients in a half day, while I still saw 15-20.

Fee For Service, while I agree I have to work faster, and sometimes split up visits for patients, offers myself A LOT more flexibility, and control.

TAM:)
 
kellyb said:
Can you not see how it would appear that MDs in this thread are in denial about the fact that physicians respond to financial incentives?
Back on page one Yuri asked:

And the concensus was "Absolutely not, you heathen!"
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Since that is very much not the response that Yuri received, the answer to your questions is simply that you are not listening to what people are saying.

Linda
 
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All the companies I've worked for have had a really effective (and rarely used) incentive scheme for salaried employees who don't pull their weight as agreed in their contracts of employment. It's called "the sack".
 
T.A.M. said:
I agree it isn't a bad compromise. Like I said, I have worked both sides of this fence.

I found the Salaried position left me with too little control. The medical board controlled when you worked. They knew they had you by the kahunas, so they rarely bothered to find locums to fill in gaps, rather they made you and your colleagues work it out. Vacation time allocation was a nightmare. As well, I found myself angry with my colleagues, who would only see 6-8 patients in a half day, while I still saw 15-20.

Fee For Service, while I agree I have to work faster, and sometimes split up visits for patients, offers myself A LOT more flexibility, and control.

TAM:)
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Obviously I will want to see five or six randomised studies showing this effect before I even consider it to be plausible. After all, I'm sure employers responding to an incentive to exploit their employees is very rare.:)
 
Ivor the Engineer said:
All the companies I've worked for have had a really effective (and rarely used) incentive scheme for salaried employees who don't pull their weight as agreed in their contracts of employment. It's called "the sack".
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And if the contract says you need to see a minimum of 12 patients a day but they are 20 waiting? Apply that to 1000doctors under contract at a hospital.
 
fls said:
Since that is very much not the response that Yuri received, the answer to your questions is simply that you are not listening to what people are saying.

Linda
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You're right. It was the response Ivor recieved for answering "yes" and presenting evidence.
 
Ivor the Engineer said:
All the companies I've worked for have had a really effective (and rarely used) incentive scheme for salaried employees who don't pull their weight as agreed in their contracts of employment. It's called "the sack".
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ah yes, but here is the thing.

In areas of North America, RURAL areas in particular, the salaried doctor has that covered. If they were to "sack" him, then who would they find to replace him? These areas offer very little in the way of modern amenities for the young urbanite doc (of which most graduates are). If they sack the pediatrician, they will be left with either (A) neither one at all, or (B) extra workload added to the 1-2 that might be left. Even if they find a candidate, who do you think the candidate will talk to before making the final move to the area? You think the disgruntled remaining docs, or the "sacked" one will have positive things to say?

You see, in order to get many docs to work in rural areas, the employers already sacrifice much. Sure, they can demand that the doc work from 8 til 5, but they would not dare set a number to what that doc feels is a "safe" number of patients to see in that time period. They would not dare ask a doc to go faster than his skills would safely allow...he knows this, they know it.

Is this horrible, yes, but it exists, and I was using it as an example of the extreme case.

TAM:)
 
Ivor the Engineer said:
Obviously I will want to see five or six randomised studies showing this effect before I even consider it to be plausible. After all, I'm sure employers responding to an incentive to exploit their employees is very rare.:)
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lol...

Yes it is anecdotal evidence, but I presented it as nothing more.

TAM:D
 
paximperium said:
And if the contract says you need to see a minimum of 12 patients a day but they are 20 waiting? Apply that to 1000doctors under contract at a hospital.
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Then the hospital needs more doctors and/or the terms of the doctors employment needs to be renegotiated.

The other 8 patients getting to see a constantly tired, overworked doctor, making him/her more prone to mistakes, is not a good long-term solution to a staffing shortage.
 
Ivor the Engineer said:
Then the hospital needs more doctors and/or the terms of the doctors employment needs to be renegotiated.

The other 8 patients getting to see a constantly tired, overworked doctor, making him/her more prone to mistakes, is not a good long-term solution to a staffing shortage.
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What if they are not overworked?
Some of the docs could easily see 20 patients a day but a couple are only capable of 16 but are really really good with the families and elderly while a rare few could see up to 30.

Why should the most productive docs see more patients?
Do you fire the slower docs who are very good with their patients?
Who decides how many patients a doc must see?
 
T.A.M. said:
ah yes, but here is the thing.

In areas of North America, RURAL areas in particular, the salaried doctor has that covered. If they were to "sack" him, then who would they find to replace him? These areas offer very little in the way of modern amenities for the young urbanite doc (of which most graduates are). If they sack the pediatrician, they will be left with either (A) neither one at all, or (B) extra workload added to the 1-2 that might be left. Even if they find a candidate, who do you think the candidate will talk to before making the final move to the area? You think the disgruntled remaining docs, or the "sacked" one will have positive things to say?

You see, in order to get many docs to work in rural areas, the employers already sacrifice much. Sure, they can demand that the doc work from 8 til 5, but they would not dare set a number to what that doc feels is a "safe" number of patients to see in that time period. They would not dare ask a doc to go faster than his skills would safely allow...he knows this, they know it.

Is this horrible, yes, but it exists, and I was using it as an example of the extreme case.

TAM:)
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Perhaps the employer could offer physicians a higher salary, better holidays, etc. to work in less glamorous regions/specialties?

E.g., the civil service in the UK has "London pay" to compensate employees who work in the capital for their increased cost of living compared to other regions of the UK.
 
Ivor the Engineer said:
Perhaps the employer could offer physicians a higher salary, better holidays, etc. to work in less glamorous regions/specialties?
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They do. If I decide to pick up a job in rural Kentucky, my salary would be approx 40% higher with lower malpractice and a huge chunk of my student loans paid off but they still can't get those positions filled.
 
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