crime_writing_comic-scaled500Wayne Tarrance: How about you get down on your knees and kiss my ass for not indicting you as a co-conspirator right now, you chickenshit little Harvard cocksucker?

Mitch McDeere: I haven’t done anything, and you know it!

Wayne Tarrance: Who gives a f**k? I’m a federal agent! You know what that means, you lowlife motherf**ker? It means you’ve got no rights, your life is mine! I could kick your teeth down your throat and yank ’em out your a**hole, and I’m not even violating your civil rights!

From The Firm, a novel by John Grisham. In it Mitch McDeere graduates from law school and takes a job for a lot of money with a prestigious law firm, then discovers that they (and by extension he) are working for the mob. The discovery is courtesy of Federal Agent Tarrance.

We have 77 students in our medical school class. They chose their “senior advisors” this week. These are the people who will guide our students through the complex career choicces leading to a  a residency. There are specialties to chose, audition rotations to plan, and interviews to schedule. We had 3 select family medicine as their potential specialty. This is as opposed to 13 choosing surgery, 9 choosing psychiatry and 9 choosing medicine-pediatrics. Not what we want to see out of our class and, as only 4 chose family medicine from last year’s class, we have been doing some departmental soul searching.

As opposed to the other clinical rotations at our school, we send our students out with physicians in practice. We tell ourselves that this pulls them out of our safety-net hospital environment and teaches them what the real world is like. We also interview our students after their clinical rotation in family medicine. What we are discovering is that this exposure to the “real world” is turning them away from primary care in general and family medicine in particular. The most painful was the student who said “I can see myself doing Family, but I think I am going to do psychiatry. Family doctors don’t know their patients.” On the psychiatry rotation, we have found out, they see 3 patients a day, Monday through Friday. As students they really get to know these patients. It seems that the life of a psychiatrist seeing 3 patients a day has a certain appeal.

The federal government has released the payment information on physicians who took Medicare in 2012 (found in a searchable database here). Turns out, the Internal Medicine faculty member in our institution most engaged in teaching medical students took care of 32 Medicare patients in the hospital in 2012 and oversaw 100 outpatient visits. The psychiatry attending admitted 16 inpatients who stayed about 4 days apiece. Although they take care of other types of patients (these are only the ones over 65), they probably both had a lot of time to interact with students.

One of the community family physicians we send our students to had about $100,000 in Medicare payments in 2012 and the following numbers:

  • 815 office visits at $39.33
  • 179 less intensive office visits at $26
  • 89 more intensive office visits at $56
  • 66 hospitalized patients who were in the hospital an average of 4 days. He (or she) made $143 for the initial visit, $52 for the other hospital days.
  • Gave 264 steroid shots at 18 cents apiece.

These numbers are what goes to the practice, not home with the physician at the end of the day. Half of that, as our students are no doubt told, goes into paying the people required to generate the bill to get paid by Medicare.

Had the students spent time with the busiest community psychiatrist in town (based on $157,000 in Medicare payments), they would have seen a doctor with almost 660 hospital visits, over 200 nursing home patient visits and who supervised 300 medication visits with the medication given by a therapist. With the busiest community oncologist ($1.7 million)? Over 40,000 injections of levoleukovorin.

In The Firm, Mitch realizes, too late, that “the law” he learns in law school is not the law he signed a contract to practice at his new law firm. I’m afraid that in our Family Medicine clinical rotation we are providing a dose of unwanted reality to the students. They are seeing that the business of medicine is a lot about running people through as fast as you can in hopes of getting the insurance company’s $20 (or, in the case of triamcinalone, $0.18). As a consequence, the students are voting with their feet into other specialties only to find, once out, that to make the big money you have to sell a lot of antibiotic and steroid injections no matter the specialty.

I’m afraid that unless the payment structure changes, chasing $20 bills is what the real practice of medicine is about. Maybe to increase interest in family medicine we just need to do a better job of hiding this inconvenient truth from our students until they go into practice. As Mitch McDeere found out, it’s not like you can leave.