Thank you Dr Prasad. As always, I found this very interesting. It helped me not to feel so all alone in the soul sucking world of Corporate owned family medicine. Do you know I probably have 7 or 8 different user names? I spend many minutes in my day just signing in and out of my various platforms? I am a PA in fp for over 30 years now. The billing codes and the emr clicks are so very depressing. I love my patients though. They make it all worthwhile.
So much good stuff here, including "...your greatest challenge is not having something to do to patients, but whether you should do it". It all comes down to informed choice and decision making.
I think medical education has gotten better in many ways. There is a shift in focus on respecting the time and intelligence of the learner and teaching in a way that is uplifting rather than degrading. Furthermore, there is much more teaching of "soft skills" such as team work and interpersonal communication, which really do help multidisciplinary teams to function better.
I think worse is freedom. There is a real loss of physician autonomy and resultant degradation of the physician-patient relationship because of rules and regulations, and check list, defensive medicine. We're stuck clicking all the boxes we need to click to get paid even if those boxes aren't relevant for our patient. We rush through encounters. We don't have time for shared decision making. Plus patients are unhappy because they don't have freedom to choose their doctors or pharmacies.
When I 18, back n '80. I has a close friend diagnosed with cancer. When told what procedures my friend had to endure. My common sense kicked and I asked the head oncologist, "Why would you kill the entire immune system to fight one cell gone rogue?
Never got an answer. Was told I was too young to understand.
I stopped believing that Doctors were there to cure..
Only the Emergency medical treatments seemed to make sense after. Here I only heard "cure" once when it came to breast cancer.
It always has been hijacked for profit. Pushed by a system gone rogue like cancer.
When it gets turned around and the Physicians are once back in charge of their patients curing diseases?
As a nurse, it is fascinating to see the physician responses and to observe what they choose to focus on. Clearly, what has gotten better is the ability of younger doctors to function as a member of a multidisciplinary healthcare team. Most doctors trained in the last century find it hard to believe that their expertise and perspective isn’t the only thing that matters in determining patient outcomes.
What has gotten worse is the capacity of clinicians to focus on providing holistic patient care that effectively meets the needs of patients on an individualized basis. We’re creating a corporate chain of Jiffy Lubes populated by mechanics who all follow the same proscribed procedures within the dictated timeframes on a never ending assembly line.
The flattened hierarchy is the biggest change in what I’ve noticed from a clinical and educational perspective. Less power plays, abuse, and egos. Yet tradeoff is a void in leadership. Deferral of care to ‘shifts’ or ‘teams’ rather than ‘people’ is what grinds my gear. We used to take charge, commit, and take a stand. 5 notes in the chart and most impressions are unclear. Next steps in clinical care are passive. There is nothing more refreshing to me than seeing a team leader take action in the void.
🤖⚖️ “Man is born free, yet everywhere he is in chains.” AI in healthcare was meant to heal but now reinforces bias and suffering. Women in pain are dismissed, and predictive analytics dictate who deserves care. Who profits from this digital oppression? 💊⛓️
Better: CGM (continuous glucose monitor) technology to measure blood glucose trends has vastly improved our ability to pinpoint what changes in medication/diet/exercise will best help someone with diabetes. Remote access for the care team to the data helps patients before little issues become big ones. Plus it's basically eliminated callused fingers.
Worse: Cookie cutter care. No two people are the same, and thus no two people will respond identically to the same care pathway. More flexibility in when to use which treatment protocol, and allowing patients to abstain from treatment (especially when managing terminal illness) is in order.
Lots of positives are well-covered. I would add to the negative:
1. Health insurance has degenerated into a racket that demeans everyone
2. Consolidation has given large corporations too much power. Need to break them up.
3. Too much malinvestment in pharma and devices that yield very marginal clinical benefits at high prices. FDA needs to raise the bar for approval.
4. Too much incentivization for publication of marginally useful research creating too many manuscripts to review and too many articles to read.
5. Too little research into root causes of illness and non-pharmacologic primordial prevention. We need ways to help Americans live healthier lives.
6. Academic medicine has developed too much arrogance, grandiosity, and dogmatism. The AMC environment seemed more free and humble when I started 30 years ago.
Therapeutics. Far and away the most significant positive impact over my 40 years as a cardiologist has been the development of life altering drugs and devices. There are far too many to list but when I began my career we had no effective treatments for acute infarctions, heart failure, hyperlipidemia or pulmonary HTN, just to name a few common conditions. The impact on pain, suffering and mortality has been tremendously satisfying.
Technology. Diagnostic imaging (think MRI’s) and therapeutics (ICD/CRT) as examples. Our ability to simply access primary data (for example coronary angiograms) has improved time and patient management.
EMR. Cuts both ways. See below. Certainly has improved communication. No longer do I struggle to read a colleague’s note or review a hospitalization record page by page.
Hospital/health system corporatization. Probably more negative impact than positive. It has “stabilized” provider compensation.
Worse:
Therapeutics. What’s the value of life altering medications if patients cannot afford them? I find the discussions with insurance providers about the cost/co-pay of an SGLT2 inhibitor soul crushing.
Technology. I can access a patient record from virtually any location at any time. What does it mean to “sign out” in this environment? And regarding AI, yes, it will revolutionize the practice of medicine. But count me as one who considers unregulated AI (which seems inevitable given our political/tech bro environment) an existential threat.
EMR. Huge disappointment. Frustratingly user unfriendly (unless you’re a cost coder). Results all too often in long, useless notes in which the relevant information is obscured. No one was spending 1-2 hours/day on chart prep or completion prior to costly EMR deployment.
Hospital/health system corporatization. I think that the corporatization and commodification of physicians is the single most important contributor to the phenomena called “burnout”. Our new masters juggle financial performance and patient care often to the financial benefit of the corporation. And management? It is the rare health care system (think Mayo Clinic) that has a physician as CEO. When was the last time you saw your CEO in a patient care area? Their view of patient care is myopic. And the cost of this administration? We have 15 vice presidents “managing” our community hospital! Do they have any clue about the level of irritation that senseless meetings and video “learning modules” create? As VP would ask “Where’s the evidence?”
I have never regretted my career choice. I have found the rewards emotionally and intellectually satisfying. It has provided meaning to my life. But I also understand the challenges that our younger colleagues confront. I hope that thoughtful dialogue will evolve into some meaningful action.
I am a retired hospice nurse. My observations are that more and more people are relying on walk-in urgent care and ERs because their family doctors are so busy. This puts a strain on these systems which aren't meant or prepared for this, is costly and primarily does a "patch it up and send them out" job which doesn't attempt to fix the problem. Our current system of insurance-based medical care is bad, because what insurance companies want to do is spend as little as possible - they are profit-based after all. IMO, we need an overhaul of the whole system - it is not what works best for the majority of the population. Medical care has gotten much, much better - for those who can afford it without going into bankruptcy. For the rest of us, it is difficult to navigate, it often requires multiple visits to different doctors, and it is damned expensive. Is this really the way for us to provide the best care? I don't think so, but am happy to listen to those who think it is - persuade me!
As a dentist, I am proud to say that I spend 30-60 min with almost every patient. Every hygiene visit is 60 min and a lot of primary care and education can be accomplished within this dental visit.
The downside is that insurance companies are increasingly practicing medicine without a license. And what most patients don’t understand is that entities like dental insurance are not insurance at all and more accurately benefit plans. As such, they should not be dictating care.
I really enjoy reading colleagues reflections on what has gotten better and gotten worse during their careers. It triggered so many thoughts. My time as an OB/GYN subspecialized in Maternal-Fetal Medicine spans nearly 45 years since medical school graduation. It has included a stint as a National Health Service Corp physician, a few decades as an OB intensivist, and three periods teaching medical students, residents and fellows as an attending. The academics include my current final chapter at the University of Arizona College of Medicine in Phoenix.
So much has gotten better. During medical school in the late 1970s, with limited neonatal interventions, babies as late as 32 weeks were still dying of RDS. Subsequent developments such as steroids prior to preterm birth and neonatal surfactant administration have saved the lives of thousands. Intrauterine treatment is an ongoing triumph. One example is successful maternal medication treatment of fetal SVT and hydrops diagnosed at 26 weeks with a healthy newborn in sinus rhythm at term.
OB/GYN has evolved from a good old boys club with flashes of true misogyny to a specialty largely populated by incredibily smart women and a few equally talented men. Though we have a long way to go, the ongoing recognition of midwives as important colleagues is also helping to provide obstetrical care that seeks the safe sweet spot between "too much care too soon" and "too little care too late". Midwives are more than physican extenders. Physicians actually serve best as midwife extenders.
Unfortunately some things have gotten worse. Medication scandels have plagued OB. The outrage of Makena is a prime example: https://midwifeamy.medium.com/why-arent-we-more-skeptical-of-progesterone-for-preventing-preterm-birth-cb68ab681f14. The Covid pandemic was also a true test of courage if one dared to question guidelines. It is true that Covid struck some subsets of pregnant women very hard and the initial vaccinations were beneficial. However ongoing recommendations for boosters continued despite adverse event signals.
One example was a spontaneous otherwise unexplained hepatic rupture near term within a week of a Moderna booster. Fortunately mother and baby narrowly survived. When a report to VAERS was recommended an ICU attendings response was, "This had nothing to do with the booster. Besides, reporting it will only lead to vaccine hesitancy".
A final career frustration may soon be ending. My colleagues who substituted "birthing person" and "pregnant individual" for the accurate term, mother, may have been motivated by compassion but they seriously pissed off more than half of the women in the US. My daughters and their friends saw it as an affront meant to "gender wash" women and mothers. I am not surprised that it triggered a political backlash.
Overall I love being an MFM. I started out with a plan for family medicine which came to a quick end when I found that meant a heavy daily dose of crying children. As an MFM I have been able to care for a wide range of medical and surgical issues for at least two, and occasionally more patients at a time.
Apostle Paul said, "money is the root of all evil."
Bill Taylor said, "Just because you can, doesn't mean you should."
William Osler said, "a good physician treats the disease, a great physician treats the person who has the disease"
Hippocrates said, "....and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture....."
Florence Nightingale said, "... I will do all in my power to maintain and elevate the standard of my profession..."
As I see this, from the eyes of a nurse who has worked 50 years in my profession, the dazzling light and sounds of the Sirens portrayed in the Almighty dollar has led more people to their demise and/or lack of good sense.
Hospitals and Pharma have quietly, and sometimes not so quietly shoved physicians into a closet where they are fed rules, regulations, demands, etc. In this box everyone fears breaking out because it will surely end his/her career and ability to make money.
The lack of incoming nurses is dwindling and it doesn't matter why. The remaining nurses are overworked, unappreciated, and robot slaves to technology.
For me, there is more good lost than there is good gained.
We would bend over and place a sphygmomanometer around the patient's arm, place the stethoscope on the patient's brachial artery. This involved touch, and intimacy.
We delivered medications from a cart, with juice and water pitchers on top and watched our patients swallow their meds.
The evening shift nurses were ordered to give every patient a back rub with lotion (only if the pt. accepted this benefit)
Patients remained in the hospital for days, not hours. We were able to get to know each person which made delivering medical care easier than treating a stranger.
Shifts were 8 hours, not 12, which gave each shift time to be at home without being too tired to relax.
Shift change was person to person. The shift before charge nurse sat down with the current shift charge nurse and discussed each patient. We used names, not room numbers.
There weren't numerous machinery beeping and ringing keeping patients from a much needed sleep. The only "dings" we heard were the call lights which we had to actually walk down the hall and visit the patient to give aid to them.
We stood for doctors entering the nurse's station. (a gesture of respect which I have not given up)
Anyone could walk down the hall of any hospital and know immediately who was who - nurses wore white with our caps, CNAs wore (usually blue), doctors had shirt and tie and lab coat, housekeeping wore (usually green).
And finally, with no malice intended or an instigation for a gang war, NPs and PAs have invaded the space where doctors should be. (I can see the hate mail coming)
So, through my eyes, medicine has lost its touch, literally and figuratively. I know there must be positive outcomes of the advances in medicine, but right now, I'm tired and at a loss of finding any.
pediatrics, mental healthcare, palliative care, primary care, cardiology, GYN, ER, at a minimum
Guidelines and the business of healthcare is largely dependent upon insurance, pharma, and gov regulation. Doctors are dependent on guidelines, thus they are co-dependent by design. Doctors are hand cuffed.
Medicare/medicaid/gov/insurance dictate care. Can’t get an internal catheter in the hospital because Medicare only allows so many per year before the hospital is dinged. Can’t even private pay for one.
Couldn’t get a bag of fluids at ER for my 88 yo mom who had a virus, dizziness, confusion, and diarrhea for 10 days. The initial intake nurse insisted she wasn’t dehydrated. Said her tongue wasn’t swollen. Said people can live on one teaspoon of water a day because her nurse friend in hospice said so. Not kidding. I said my mom may not be clinically dehydrated, but her condition isn’t getting better and I think it will help her feel better. Dr came in and said I hear you want fluids, I’m happy to do so. We got the fluids and left. My mom bounced back in 6 hours, slept & recovered fully. It made me wonder if that nurse was the issue or if she had been trained to always deny first due to insurance or some business measure. It was a stand alone ER so certainly needed to stand alone financially. This makes medical care look bad.
Side note - I had already tried to hire a mobile iv business but they can’t treat the elderly.
I live in NE Florida and can’t get in to see an MD or DO. Big shortage. The practitioners are all 30 yo NP’s, ARNP’s and PA’s.
(Before 2012 or so, I only saw MD’s or DO’s. ) No offense to these people at all, but their role has changed to being the primary caregiver which works for patients that never got treated by MD’s I guess because they don’t know any different .
Nobody examines the patient anymore. Quick check with a stethoscope and that’s it. It’s all recipe medicine . If you have this symptom , prescribe this drug. For every patient. No one is listening, engaging, or questioning (any rashes with your main complaint ?) It seems there’s no discovery anymore. No detective work. No time for that because they have to hit metrics. Not really sure if the docs are doing it differently because my only experience is with the other practitioners.
Too much testing. 30 years ago doctors came to a diagnosis and used some testing to support the diagnosis if they needed more info. Now the tests diagnose the patient. Tests are imperfect, sometimes useless, and occasionally harmful. And they are a snapshot. Part of a bigger picture. We seem to have lost that.
One more example of my experience in the past 3 years:
I woke up with a swollen, red, burning, itching face. Swollen like rising bread dough in a pie plate. Ears looked like a volcano had erupted in each. Very, very uncomfortable/irritated/miserable. Looked horrifying. Went to nearby urgent care. Waited three hours because I didn’t have an appointment. One practitioner in the whole place. Finally got in. I’m guessing it was a nurse practitioner, but I’m not sure. She looked 30 years old. She stayed 8 feet away from me, way across the room. She said you’ve had an allergic reaction. She did not examine me or look in my ears, even though I requested her to check out my ears. They were wet in the night. Felt like sweat dripping out of them. She took her stethoscope to my back and had me breathe in and out. Then she backed way up again and said I’m gonna give you a steroid and an EpiPen. You need to keep an EpiPen on you at all times. I have never been allergic to anything and had not been using any different products or foods but, allergies can happen at any time so I considered it as a possibility. I took the steroid over a few days and my swelling reduced 50%, but I still had burning itching and volcano lava ears. I read up on the EpiPen and decided they are expensive, have a relatively short shelf life, and I had no difficulty breathing, so I passed on that, knowing I could always fill the prescription if I decided to later. It did not seem urgent to me to have an EpiPen and even if I’ve had one I wouldn’t have used it that week. Perhaps my thinking was faulty, but I was managing a lot and that’s just how the cookie crumbled.
Since I was still sleepless, very, very uncomfortable and still swollen, I called a dermatologist that I had seen six years prior. They told me I could not get an appointment because I was not a patient. Six years ago didn’t count. I would have to be a new patient and they didn’t have a spot for eight months. I am not surprised by this because the insurance companies and other regulators make you go in and be seen annually. The metrics work against the practice if a patient doesn’t come annually. And then they drop you. This was not the case many years ago. Anyway, I pleaded my desperate case and offered to send the receptionist a photo of my face. She declined, put me on hold and came back and said they had an opening the next day and I would be a new patient.
At the dermatologist office, I saw an ARNP. She was probably 35. She was attentive and listened. She said it’s an allergic reaction of some sort and we will never know what actually caused it. She did not think I needed an EpiPen. She gave me two topical prescriptions. I went to Walgreens and dropped them off. They called me and said these drugs need prior authorization you need to call the dermatologist. So I had to call the dermatologist and chase that down. That took 24 hours . Walgreens filled it and I picked them up, still suffering. They were expensive. My insurance didn’t cover them. They were probably new, expensive drugs. Desperate I paid almost $200 for one tube and $100 for the other tube. I applied one dose of one tube and within an hour my face burned worse and swelled up even worse. I stopped that treatment but continued the steroid which I think was seven days and after reading about steroids I understood that’s a long time to be on a steroid but again, I was desperate. I was sitting upright in a chair, trying to sleep at night and was absolutely miserable, ice packs, the whole deal.
I made an appointment with a traditional Chinese medicine doctor that I had used in the past. He had helped me in the past, and even if this was throwing spaghetti at the wall, I had to get better. Within 30 seconds of being seen by the traditional Chinese medicine doctor, he closely examined my face and closely examined my ears. He asked several questions about my ears. Was it a thin fluid? Was it thick? Did it have a scent? What position was I in when I noticed the liquid in my ears? Within one minute, he said this is auto immune thyroid. You have a blockage somewhere in your head that is blocking the cerebral spinal fluid from draining properly. Thus it is flowing out of your ears. The blockage could cause a stroke. He prescribed his medicine which was in the form of liquid drops. He told me to stay upright as much as possible, and not to lay down. I started reading about his diagnosis, and it is a real thing. I even found a support group online of people who have auto immune thyroid who do not have a blockage, but who frequently have a clear, unscented fluid leak out of their ears… Cerebral spinal fluid. Apparently it’s fairly common. Common enough that there’s a support group to exchange ideas. Anyways, I felt there was validity to his diagnosis. I took the drops & within seven days I had much much improvement and was fully back to normal in 10 days. Thankfully . 😅
Sorry for the length but I always feel examples are helpful.
I appreciate doctors and those in healthcare. You guys have killed yourself to become educated and trained. The system has become corrupted and you guys are caught in the middle. I am hopeful things will change.
Full disclosure: I was trained in the past century (and I'm definitely "the glass is half empty" kind of guy).
In neurology the adage was "if you have 10 minutes with a patient, spend 9 minutes on the history which will tell you how to focus your exam." I'm afraid the "RVU clock" pares time spent down to 2 minutes for history and 1 minute for the exam. Compounding the offense is that the history as recorded in EMR is lost to EMR's "baked in" elevated noise-to-signal ratio and the self-plagiarization of cloned notes, templates, etc.
The clinical exam, like life in Hobbes' Leviathan, is "nasty, brutish, and short" (if it is done at all). Surely you exaggerate Dr. Lepore. I ask you, "Do you really presume to think that a "Teleheath Exam" is anything more than a billable oxymoron?" I practice in a university medical center where ophthalmoscopy has become an arcane exercise. Again, surely you exaggerate Dr. Lepore. Nope,
to even hope to perform a barebones ophthalmoscopic exam, you need to dilate ~1/2 your patients. Does any resident or attending here carry 15 ml of mydriatic drops. I'll let you guess the answer. Am I consulted by other services because of neurologic expertise or because nobody else remembers or can chart the names of the 12 cranial nerves.
OK, Something must have improved in neurology. Of course, neuroimaging is nothing short of astonishing (from my perspective of clinical training prior to the advent of Hounsfield's CT) but we need to know what we're looking for which brings us back to the history and physical (which have surely seen better days). But what if the patient's diagnosis is not apparent on neuro-imaging? Houston, we have a problem. In my antediluvian world I encounter migraine, idiopathic intracranial hypertension, and post concussion patients who are severely afflicted ... and Mirabile Dictu have normal MRIs (don't murmur "empty sella" in IIH to get MRI "off the hook" ;"normal" patients can have an empty sella). So what's a clinician to do? Push the little red button on your ophthalmoscope and look for papilledema. You just might confirm a diagnosis with an instrument that's been around since 1851. Don't underestimate the physical exam and Thanks Helmholtz.
Thank you Dr Prasad. As always, I found this very interesting. It helped me not to feel so all alone in the soul sucking world of Corporate owned family medicine. Do you know I probably have 7 or 8 different user names? I spend many minutes in my day just signing in and out of my various platforms? I am a PA in fp for over 30 years now. The billing codes and the emr clicks are so very depressing. I love my patients though. They make it all worthwhile.
So much good stuff here, including "...your greatest challenge is not having something to do to patients, but whether you should do it". It all comes down to informed choice and decision making.
I think medical education has gotten better in many ways. There is a shift in focus on respecting the time and intelligence of the learner and teaching in a way that is uplifting rather than degrading. Furthermore, there is much more teaching of "soft skills" such as team work and interpersonal communication, which really do help multidisciplinary teams to function better.
I think worse is freedom. There is a real loss of physician autonomy and resultant degradation of the physician-patient relationship because of rules and regulations, and check list, defensive medicine. We're stuck clicking all the boxes we need to click to get paid even if those boxes aren't relevant for our patient. We rush through encounters. We don't have time for shared decision making. Plus patients are unhappy because they don't have freedom to choose their doctors or pharmacies.
When I 18, back n '80. I has a close friend diagnosed with cancer. When told what procedures my friend had to endure. My common sense kicked and I asked the head oncologist, "Why would you kill the entire immune system to fight one cell gone rogue?
Never got an answer. Was told I was too young to understand.
I stopped believing that Doctors were there to cure..
Only the Emergency medical treatments seemed to make sense after. Here I only heard "cure" once when it came to breast cancer.
It always has been hijacked for profit. Pushed by a system gone rogue like cancer.
When it gets turned around and the Physicians are once back in charge of their patients curing diseases?
Only then will I listen....
As a nurse, it is fascinating to see the physician responses and to observe what they choose to focus on. Clearly, what has gotten better is the ability of younger doctors to function as a member of a multidisciplinary healthcare team. Most doctors trained in the last century find it hard to believe that their expertise and perspective isn’t the only thing that matters in determining patient outcomes.
What has gotten worse is the capacity of clinicians to focus on providing holistic patient care that effectively meets the needs of patients on an individualized basis. We’re creating a corporate chain of Jiffy Lubes populated by mechanics who all follow the same proscribed procedures within the dictated timeframes on a never ending assembly line.
The flattened hierarchy is the biggest change in what I’ve noticed from a clinical and educational perspective. Less power plays, abuse, and egos. Yet tradeoff is a void in leadership. Deferral of care to ‘shifts’ or ‘teams’ rather than ‘people’ is what grinds my gear. We used to take charge, commit, and take a stand. 5 notes in the chart and most impressions are unclear. Next steps in clinical care are passive. There is nothing more refreshing to me than seeing a team leader take action in the void.
https://www.nejm.org/doi/full/10.1056/NEJMp2403370
I found that when it’s expected that “Everyone is responsible“, it really means “No one is responsible”.
🤖⚖️ “Man is born free, yet everywhere he is in chains.” AI in healthcare was meant to heal but now reinforces bias and suffering. Women in pain are dismissed, and predictive analytics dictate who deserves care. Who profits from this digital oppression? 💊⛓️
https://youarewithinthenorms.com/2025/02/07/from-kevin-md-ai-healthcare-disparities-and-the-chronic-pain-gender-gap/
Better: CGM (continuous glucose monitor) technology to measure blood glucose trends has vastly improved our ability to pinpoint what changes in medication/diet/exercise will best help someone with diabetes. Remote access for the care team to the data helps patients before little issues become big ones. Plus it's basically eliminated callused fingers.
Worse: Cookie cutter care. No two people are the same, and thus no two people will respond identically to the same care pathway. More flexibility in when to use which treatment protocol, and allowing patients to abstain from treatment (especially when managing terminal illness) is in order.
Forgot to mention--I'm a registered dietitian specializing in diabetes and CKD, 16 years in outpatient care.
Lots of positives are well-covered. I would add to the negative:
1. Health insurance has degenerated into a racket that demeans everyone
2. Consolidation has given large corporations too much power. Need to break them up.
3. Too much malinvestment in pharma and devices that yield very marginal clinical benefits at high prices. FDA needs to raise the bar for approval.
4. Too much incentivization for publication of marginally useful research creating too many manuscripts to review and too many articles to read.
5. Too little research into root causes of illness and non-pharmacologic primordial prevention. We need ways to help Americans live healthier lives.
6. Academic medicine has developed too much arrogance, grandiosity, and dogmatism. The AMC environment seemed more free and humble when I started 30 years ago.
What’s better and what’s worse with medicine
Better:
Therapeutics. Far and away the most significant positive impact over my 40 years as a cardiologist has been the development of life altering drugs and devices. There are far too many to list but when I began my career we had no effective treatments for acute infarctions, heart failure, hyperlipidemia or pulmonary HTN, just to name a few common conditions. The impact on pain, suffering and mortality has been tremendously satisfying.
Technology. Diagnostic imaging (think MRI’s) and therapeutics (ICD/CRT) as examples. Our ability to simply access primary data (for example coronary angiograms) has improved time and patient management.
EMR. Cuts both ways. See below. Certainly has improved communication. No longer do I struggle to read a colleague’s note or review a hospitalization record page by page.
Hospital/health system corporatization. Probably more negative impact than positive. It has “stabilized” provider compensation.
Worse:
Therapeutics. What’s the value of life altering medications if patients cannot afford them? I find the discussions with insurance providers about the cost/co-pay of an SGLT2 inhibitor soul crushing.
Technology. I can access a patient record from virtually any location at any time. What does it mean to “sign out” in this environment? And regarding AI, yes, it will revolutionize the practice of medicine. But count me as one who considers unregulated AI (which seems inevitable given our political/tech bro environment) an existential threat.
EMR. Huge disappointment. Frustratingly user unfriendly (unless you’re a cost coder). Results all too often in long, useless notes in which the relevant information is obscured. No one was spending 1-2 hours/day on chart prep or completion prior to costly EMR deployment.
Hospital/health system corporatization. I think that the corporatization and commodification of physicians is the single most important contributor to the phenomena called “burnout”. Our new masters juggle financial performance and patient care often to the financial benefit of the corporation. And management? It is the rare health care system (think Mayo Clinic) that has a physician as CEO. When was the last time you saw your CEO in a patient care area? Their view of patient care is myopic. And the cost of this administration? We have 15 vice presidents “managing” our community hospital! Do they have any clue about the level of irritation that senseless meetings and video “learning modules” create? As VP would ask “Where’s the evidence?”
I have never regretted my career choice. I have found the rewards emotionally and intellectually satisfying. It has provided meaning to my life. But I also understand the challenges that our younger colleagues confront. I hope that thoughtful dialogue will evolve into some meaningful action.
I am a retired hospice nurse. My observations are that more and more people are relying on walk-in urgent care and ERs because their family doctors are so busy. This puts a strain on these systems which aren't meant or prepared for this, is costly and primarily does a "patch it up and send them out" job which doesn't attempt to fix the problem. Our current system of insurance-based medical care is bad, because what insurance companies want to do is spend as little as possible - they are profit-based after all. IMO, we need an overhaul of the whole system - it is not what works best for the majority of the population. Medical care has gotten much, much better - for those who can afford it without going into bankruptcy. For the rest of us, it is difficult to navigate, it often requires multiple visits to different doctors, and it is damned expensive. Is this really the way for us to provide the best care? I don't think so, but am happy to listen to those who think it is - persuade me!
Love the candid dialogue here!
As a dentist, I am proud to say that I spend 30-60 min with almost every patient. Every hygiene visit is 60 min and a lot of primary care and education can be accomplished within this dental visit.
The downside is that insurance companies are increasingly practicing medicine without a license. And what most patients don’t understand is that entities like dental insurance are not insurance at all and more accurately benefit plans. As such, they should not be dictating care.
I really enjoy reading colleagues reflections on what has gotten better and gotten worse during their careers. It triggered so many thoughts. My time as an OB/GYN subspecialized in Maternal-Fetal Medicine spans nearly 45 years since medical school graduation. It has included a stint as a National Health Service Corp physician, a few decades as an OB intensivist, and three periods teaching medical students, residents and fellows as an attending. The academics include my current final chapter at the University of Arizona College of Medicine in Phoenix.
So much has gotten better. During medical school in the late 1970s, with limited neonatal interventions, babies as late as 32 weeks were still dying of RDS. Subsequent developments such as steroids prior to preterm birth and neonatal surfactant administration have saved the lives of thousands. Intrauterine treatment is an ongoing triumph. One example is successful maternal medication treatment of fetal SVT and hydrops diagnosed at 26 weeks with a healthy newborn in sinus rhythm at term.
OB/GYN has evolved from a good old boys club with flashes of true misogyny to a specialty largely populated by incredibily smart women and a few equally talented men. Though we have a long way to go, the ongoing recognition of midwives as important colleagues is also helping to provide obstetrical care that seeks the safe sweet spot between "too much care too soon" and "too little care too late". Midwives are more than physican extenders. Physicians actually serve best as midwife extenders.
Unfortunately some things have gotten worse. Medication scandels have plagued OB. The outrage of Makena is a prime example: https://midwifeamy.medium.com/why-arent-we-more-skeptical-of-progesterone-for-preventing-preterm-birth-cb68ab681f14. The Covid pandemic was also a true test of courage if one dared to question guidelines. It is true that Covid struck some subsets of pregnant women very hard and the initial vaccinations were beneficial. However ongoing recommendations for boosters continued despite adverse event signals.
One example was a spontaneous otherwise unexplained hepatic rupture near term within a week of a Moderna booster. Fortunately mother and baby narrowly survived. When a report to VAERS was recommended an ICU attendings response was, "This had nothing to do with the booster. Besides, reporting it will only lead to vaccine hesitancy".
A final career frustration may soon be ending. My colleagues who substituted "birthing person" and "pregnant individual" for the accurate term, mother, may have been motivated by compassion but they seriously pissed off more than half of the women in the US. My daughters and their friends saw it as an affront meant to "gender wash" women and mothers. I am not surprised that it triggered a political backlash.
Overall I love being an MFM. I started out with a plan for family medicine which came to a quick end when I found that meant a heavy daily dose of crying children. As an MFM I have been able to care for a wide range of medical and surgical issues for at least two, and occasionally more patients at a time.
Apostle Paul said, "money is the root of all evil."
Bill Taylor said, "Just because you can, doesn't mean you should."
William Osler said, "a good physician treats the disease, a great physician treats the person who has the disease"
Hippocrates said, "....and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture....."
Florence Nightingale said, "... I will do all in my power to maintain and elevate the standard of my profession..."
As I see this, from the eyes of a nurse who has worked 50 years in my profession, the dazzling light and sounds of the Sirens portrayed in the Almighty dollar has led more people to their demise and/or lack of good sense.
Hospitals and Pharma have quietly, and sometimes not so quietly shoved physicians into a closet where they are fed rules, regulations, demands, etc. In this box everyone fears breaking out because it will surely end his/her career and ability to make money.
The lack of incoming nurses is dwindling and it doesn't matter why. The remaining nurses are overworked, unappreciated, and robot slaves to technology.
For me, there is more good lost than there is good gained.
We would bend over and place a sphygmomanometer around the patient's arm, place the stethoscope on the patient's brachial artery. This involved touch, and intimacy.
We delivered medications from a cart, with juice and water pitchers on top and watched our patients swallow their meds.
The evening shift nurses were ordered to give every patient a back rub with lotion (only if the pt. accepted this benefit)
Patients remained in the hospital for days, not hours. We were able to get to know each person which made delivering medical care easier than treating a stranger.
Shifts were 8 hours, not 12, which gave each shift time to be at home without being too tired to relax.
Shift change was person to person. The shift before charge nurse sat down with the current shift charge nurse and discussed each patient. We used names, not room numbers.
There weren't numerous machinery beeping and ringing keeping patients from a much needed sleep. The only "dings" we heard were the call lights which we had to actually walk down the hall and visit the patient to give aid to them.
We stood for doctors entering the nurse's station. (a gesture of respect which I have not given up)
Anyone could walk down the hall of any hospital and know immediately who was who - nurses wore white with our caps, CNAs wore (usually blue), doctors had shirt and tie and lab coat, housekeeping wore (usually green).
And finally, with no malice intended or an instigation for a gang war, NPs and PAs have invaded the space where doctors should be. (I can see the hate mail coming)
So, through my eyes, medicine has lost its touch, literally and figuratively. I know there must be positive outcomes of the advances in medicine, but right now, I'm tired and at a loss of finding any.
Not in healthcare. Age 61.
Better: Substack !
Worse:
pediatrics, mental healthcare, palliative care, primary care, cardiology, GYN, ER, at a minimum
Guidelines and the business of healthcare is largely dependent upon insurance, pharma, and gov regulation. Doctors are dependent on guidelines, thus they are co-dependent by design. Doctors are hand cuffed.
Medicare/medicaid/gov/insurance dictate care. Can’t get an internal catheter in the hospital because Medicare only allows so many per year before the hospital is dinged. Can’t even private pay for one.
Couldn’t get a bag of fluids at ER for my 88 yo mom who had a virus, dizziness, confusion, and diarrhea for 10 days. The initial intake nurse insisted she wasn’t dehydrated. Said her tongue wasn’t swollen. Said people can live on one teaspoon of water a day because her nurse friend in hospice said so. Not kidding. I said my mom may not be clinically dehydrated, but her condition isn’t getting better and I think it will help her feel better. Dr came in and said I hear you want fluids, I’m happy to do so. We got the fluids and left. My mom bounced back in 6 hours, slept & recovered fully. It made me wonder if that nurse was the issue or if she had been trained to always deny first due to insurance or some business measure. It was a stand alone ER so certainly needed to stand alone financially. This makes medical care look bad.
Side note - I had already tried to hire a mobile iv business but they can’t treat the elderly.
I live in NE Florida and can’t get in to see an MD or DO. Big shortage. The practitioners are all 30 yo NP’s, ARNP’s and PA’s.
(Before 2012 or so, I only saw MD’s or DO’s. ) No offense to these people at all, but their role has changed to being the primary caregiver which works for patients that never got treated by MD’s I guess because they don’t know any different .
Nobody examines the patient anymore. Quick check with a stethoscope and that’s it. It’s all recipe medicine . If you have this symptom , prescribe this drug. For every patient. No one is listening, engaging, or questioning (any rashes with your main complaint ?) It seems there’s no discovery anymore. No detective work. No time for that because they have to hit metrics. Not really sure if the docs are doing it differently because my only experience is with the other practitioners.
Too much testing. 30 years ago doctors came to a diagnosis and used some testing to support the diagnosis if they needed more info. Now the tests diagnose the patient. Tests are imperfect, sometimes useless, and occasionally harmful. And they are a snapshot. Part of a bigger picture. We seem to have lost that.
One more example of my experience in the past 3 years:
I woke up with a swollen, red, burning, itching face. Swollen like rising bread dough in a pie plate. Ears looked like a volcano had erupted in each. Very, very uncomfortable/irritated/miserable. Looked horrifying. Went to nearby urgent care. Waited three hours because I didn’t have an appointment. One practitioner in the whole place. Finally got in. I’m guessing it was a nurse practitioner, but I’m not sure. She looked 30 years old. She stayed 8 feet away from me, way across the room. She said you’ve had an allergic reaction. She did not examine me or look in my ears, even though I requested her to check out my ears. They were wet in the night. Felt like sweat dripping out of them. She took her stethoscope to my back and had me breathe in and out. Then she backed way up again and said I’m gonna give you a steroid and an EpiPen. You need to keep an EpiPen on you at all times. I have never been allergic to anything and had not been using any different products or foods but, allergies can happen at any time so I considered it as a possibility. I took the steroid over a few days and my swelling reduced 50%, but I still had burning itching and volcano lava ears. I read up on the EpiPen and decided they are expensive, have a relatively short shelf life, and I had no difficulty breathing, so I passed on that, knowing I could always fill the prescription if I decided to later. It did not seem urgent to me to have an EpiPen and even if I’ve had one I wouldn’t have used it that week. Perhaps my thinking was faulty, but I was managing a lot and that’s just how the cookie crumbled.
Since I was still sleepless, very, very uncomfortable and still swollen, I called a dermatologist that I had seen six years prior. They told me I could not get an appointment because I was not a patient. Six years ago didn’t count. I would have to be a new patient and they didn’t have a spot for eight months. I am not surprised by this because the insurance companies and other regulators make you go in and be seen annually. The metrics work against the practice if a patient doesn’t come annually. And then they drop you. This was not the case many years ago. Anyway, I pleaded my desperate case and offered to send the receptionist a photo of my face. She declined, put me on hold and came back and said they had an opening the next day and I would be a new patient.
At the dermatologist office, I saw an ARNP. She was probably 35. She was attentive and listened. She said it’s an allergic reaction of some sort and we will never know what actually caused it. She did not think I needed an EpiPen. She gave me two topical prescriptions. I went to Walgreens and dropped them off. They called me and said these drugs need prior authorization you need to call the dermatologist. So I had to call the dermatologist and chase that down. That took 24 hours . Walgreens filled it and I picked them up, still suffering. They were expensive. My insurance didn’t cover them. They were probably new, expensive drugs. Desperate I paid almost $200 for one tube and $100 for the other tube. I applied one dose of one tube and within an hour my face burned worse and swelled up even worse. I stopped that treatment but continued the steroid which I think was seven days and after reading about steroids I understood that’s a long time to be on a steroid but again, I was desperate. I was sitting upright in a chair, trying to sleep at night and was absolutely miserable, ice packs, the whole deal.
I made an appointment with a traditional Chinese medicine doctor that I had used in the past. He had helped me in the past, and even if this was throwing spaghetti at the wall, I had to get better. Within 30 seconds of being seen by the traditional Chinese medicine doctor, he closely examined my face and closely examined my ears. He asked several questions about my ears. Was it a thin fluid? Was it thick? Did it have a scent? What position was I in when I noticed the liquid in my ears? Within one minute, he said this is auto immune thyroid. You have a blockage somewhere in your head that is blocking the cerebral spinal fluid from draining properly. Thus it is flowing out of your ears. The blockage could cause a stroke. He prescribed his medicine which was in the form of liquid drops. He told me to stay upright as much as possible, and not to lay down. I started reading about his diagnosis, and it is a real thing. I even found a support group online of people who have auto immune thyroid who do not have a blockage, but who frequently have a clear, unscented fluid leak out of their ears… Cerebral spinal fluid. Apparently it’s fairly common. Common enough that there’s a support group to exchange ideas. Anyways, I felt there was validity to his diagnosis. I took the drops & within seven days I had much much improvement and was fully back to normal in 10 days. Thankfully . 😅
Sorry for the length but I always feel examples are helpful.
I appreciate doctors and those in healthcare. You guys have killed yourself to become educated and trained. The system has become corrupted and you guys are caught in the middle. I am hopeful things will change.
Full disclosure: I was trained in the past century (and I'm definitely "the glass is half empty" kind of guy).
In neurology the adage was "if you have 10 minutes with a patient, spend 9 minutes on the history which will tell you how to focus your exam." I'm afraid the "RVU clock" pares time spent down to 2 minutes for history and 1 minute for the exam. Compounding the offense is that the history as recorded in EMR is lost to EMR's "baked in" elevated noise-to-signal ratio and the self-plagiarization of cloned notes, templates, etc.
The clinical exam, like life in Hobbes' Leviathan, is "nasty, brutish, and short" (if it is done at all). Surely you exaggerate Dr. Lepore. I ask you, "Do you really presume to think that a "Teleheath Exam" is anything more than a billable oxymoron?" I practice in a university medical center where ophthalmoscopy has become an arcane exercise. Again, surely you exaggerate Dr. Lepore. Nope,
to even hope to perform a barebones ophthalmoscopic exam, you need to dilate ~1/2 your patients. Does any resident or attending here carry 15 ml of mydriatic drops. I'll let you guess the answer. Am I consulted by other services because of neurologic expertise or because nobody else remembers or can chart the names of the 12 cranial nerves.
OK, Something must have improved in neurology. Of course, neuroimaging is nothing short of astonishing (from my perspective of clinical training prior to the advent of Hounsfield's CT) but we need to know what we're looking for which brings us back to the history and physical (which have surely seen better days). But what if the patient's diagnosis is not apparent on neuro-imaging? Houston, we have a problem. In my antediluvian world I encounter migraine, idiopathic intracranial hypertension, and post concussion patients who are severely afflicted ... and Mirabile Dictu have normal MRIs (don't murmur "empty sella" in IIH to get MRI "off the hook" ;"normal" patients can have an empty sella). So what's a clinician to do? Push the little red button on your ophthalmoscope and look for papilledema. You just might confirm a diagnosis with an instrument that's been around since 1851. Don't underestimate the physical exam and Thanks Helmholtz.