I was shocked, frankly, to read this recent 2010 article in the Journal of the American Medical Association titled “Trends in the Work Hours of Physicians in the United States.“

Forgive me, friends, if I come at you with the mentality of someone who has always worked in an academic setting – either in a podiatric medical school or more recently in an allopathic medical school/county hospital setting.

What I do know is that in a teaching situation the time demands are different. I talked with a close friend who desired to join me in the residency program thinking it would be a quasi-retirement and then she learned what the hours were! Her response was “Why would I want to go from work to hyper-speed work when I am trying to ramp down in my life?” Good question.

None the less, I was surprised by this article’s findings and I think that you may be as well. Check out these details for the hours worked by physicians during the following time frames:

1996-1998                 2006-2008

54.9 hours                  51.0 hours

The decrease in hours was greatest for non-resident physicians younger than 45 years old. The decrease was smallest for those aged 45 years or older and working in the hospital. Interesting. I guess you can’t teach old dogs new tricks after all!

Another interesting fact noted in the article and one that we don’t need to be reminded of is that after adjusting for inflation physician fees decreased a whopping 25% between 1995 and 2006, corresponding to the decrease in the hours that physicians worked. The only problem is that the physicians that I know INCREASED the hours that they worked!

It’s that same old story of working harder for less money. I know the statisticians say that most physicians are working fewer hours but I know personally that the University physicians don’t fall into that category (and in fact the statisticians agree with that.) So what is the solution?

Any ideas????

When I left private community practice for full time hospital based practice, the newly hired physicians were given an informal talk on "tips for success." Here they are:  1) Make sure your emotional committment to the institution is 24/7
2) Bring in big dollars in your faculty practices 3) You must write and do research 4) Writing and research is done at  night and on weekends 5) If your family, spouse, etc.  is not on baord with this, you will not be successful.

While slightly exaggerated to make certain points, these tips pretty much ring true for academic medicine in hospital/medical school settings. While traditionally the salary structure in academic settings has some drawbacks compared to private practice, it can be very lucrative if you can live with the aforementioned "tips."  Benefits packages available are typically very large and to duplicate in private practice it would could cost up to 100,000.00 gross income.(assuming a 50% overhead expense). And if you are in a major academic center, the opportunities for additional earnings in industry and consulting are enormous. However, you give up most of the control of your life. Additionally, waste of resources in the hospital setting can make someone who ran his own private practice go nuts.

So more to Dr. Satterfield's point, whether it be private office practice or academic medicine, the 9-5 day is a thing of the past.  For the most successful podiatrists I know, (with income and satisfaction as the major parameters), private or hospital based, a 50 hour week would be welcomed, because 60-80 is more like it. The amount of money that makes it worth it is a personal matter. We are all working more for less. Although my hourly "wage" may be pitiful, I could never imagine the practice of podiatry more glorious than the kind I am practicing now.

I read the threads here and contemplated why on average a physician's work week lessens by 5 hours  (although I agree with Kathleen, no one I know "works" less.) Several factors I think figure into such an explanation:

1. VOLUME, VOLUME, VOLUME....what I mean by this is that many "in-network" doctors see many more patients than "out-of-network" doctors. I would venture an educated guess that the proportion of these "out-of-network" doctors have increased dramatically to even include podiatric physicians over the past 15-20 years. Why this trend? Well, as we all know the Medicare limiting charges have taken a large decrease from the early 90s. The annual 1% increase never even keeps up with inflationary/operation costs. The LARGER gorilla in the room is that the private insurers base their "in-network" reimbursement formulas on the Medicare limiting charge and pay usually anywhere from "80-125% Medicare fees."  The "out-of-network" doctors are not "bound" by Medicare limiting charges and in many states (like New York,) the Attorney General has fought insurance company reimbursements to pay even more to these "out -of-network" physicians. If one ever hopes to keep healthcare costs down, "DOES ANYONE SEE A PROBLEM WITH THIS?"
Reimbursements to "in-network" physicians in many cases place them at a disadvantage. You have higher volume, see more patients, have more responsibility.....and in the UN-American way make much less. I know "out-of-network" doctors who see 3-4 patients a day and makes much more than I would with a fully scheduled day.
Then why be "in-network?" I am beginning to wonder. Early on with the early implementation of managed care, the benefit of  "in-network" status is that you may make slightly less but you have larger volume with no in-network deductibles, coinsurances, etc. Just collect a copayment. Has this remained the same? Now, you may have an "in-network" patient with a deductible that  may be larger than a surgical service pays. For eg. an Austin buinionectomy in the New York region under United Healthcare pays $678.00, however, "out-of-network" over 6-7 times that is paid.

2. HUMAN NATURE IS INHERENTLY CAPITALISTIC .....what do I mean by this? For most individuals, one will tend to work more if the financial gain is deemed appropriate. One reason why socialism/communism ultimately reveals lower GDP/productivity levels/innovation is that it does not take into account the inheritently "capitalistic" state of the human condition. Afterall, we were "hunters-gatherers" long before capitalism became a main economic engine. For eg., if  you have two individuals who work on an assembly line and one fabricates 20 radios per day and the other fabricates 10 radios and both receive SAME pay. How long will it be before the individual fabricating 20 radios fabricates 10 or even less? It is for this reason that "single-payer" would not work, in my opinion ( or even most government bureaucracies in most circumstances.) In New York State, there is a health plan called HIP. A capitation of approximately $125.00 per 6 months of care is paid irrespective of the patient's medical needs for podiatric services, in toto. Therefore, if you see a patient once, you are paid $125.00. If you need to see that patient multiple times, perform surgery or provide diabetic wound care....you are paid $125.00. Great plan, huh? (sarcasm here folks!) In fact, I see patients out-of-network with this plan who may be "refused" definitive treatments and pay for that service. Some physicians may in light of dimished reimbursement levels at thegreatly dimished  "in-network" levels view other issues in their life as having a higher priority.   

3. AUTOMATION AND TECHNICAL ADVANCEMENTS...One has to take into account over the last 15-20 years how medical practices have dramatically changed. Use of computers, electronic records, dictation systems, electronic submittals and automated remittances and postings have greatly "freed" up our time during the day....at least when they work....LOL.   

4. SOLO VS. GROUP.....No doubt, multiple practitioners within a group leads one to have more free time. It may come with a cost (personality differences, method of practice, marketing/philosophy differences, etc.) There is a greater proportion of multiple physician practices over the last 15-20 years. Several reasons account for this. There is lower overall employee costs, larger group purchase discounts, lower infra-structure costs with common usage (billing services, rent, utilities, etc.) One main reason is also due to substantial increases in overhead. 25 years ago, in "practice management" courses at school, if you stated you would have a 50% overhead potentially, your business model would have been an example of an adject failure.

5. PRIVATE PRACTICE OR INSTITUTIONAL PRACTICE?......Bryan makes a point. With the exception of Bryan who is continually lecturing/researching/teaching.....many instituional physicians do not have hours after 5 pm especially outside the podiatric field. Weekend hours through institutional practices are rare...although economic circumstances may change this in the future. 

                                                    

Both gentlemen have contributed great comments. I can just add this rift.

Don't apply to an academic institution thinking you can "end out your career" there. Bryan Markinson is right.

You won't make significant pay there unless you lecture/consult in addition to your base pay and those people are the exception.

I always say that my students and residents are my riches. You certainly won't see my riches in my bank account!

When I entered practice in 1971, I set my fees and hours.  Patients had indemnity coverage which paid my fees.  When I wanted to adjust my working hours or income up or down, I changed my hours and raised or lowered my fees.

Then “HMOitis” appeared in the 90's and things started to change.  As I was "In Plan", my fees were no longer adjustable but I accepted that because they were fair for that time and I mistakenly thought they couldn't go further downward but alas, the insurance industry had a different plan than I.

Hoops began to appear in order to be paid my stagnant and/or downwardly mobile fees. My workday now included additional investment in time and money in order to get paid lower fees and not in patient care.  My patients and I were paying the same money for less and less coverage because HMO’s and PPO's replaced indemnity coverage at the same price or higher.  I worked more hours to support a stagnant or downwardly mobile income (HMOitis:1997). 
Sorry, Dr. Satterfield but this is not a new issue, just a bigger fester appearing on more DPM radar screens.

Five years ago, I dropped out of “the plans”, one by one until today, I remain “In Plan” only with Medicare.  I regained my ability to control fees and because of my referral base, had some great years.

But there is an economic crisis in the world and more patients shopping for "the quality medical care I was trained to deliver" (sadly renamed "boutique medicine”) find it out of their means.

Increasing my hours of practice now leaves me with bigger gaps in my schedule as opposed to more pleased patients and profits.

Four years ago, I started The FootHelpers Orthotic Lab and replaced my lost professional income and passion but I had to do it outside of private practice (like Dr. Markinson).

I am down 10-15% in gross practice and I am adjusting my fees downward for the moment in order to meet my patient’s economic demands in reaction but how long will that tact (or your current plan) work?

For many years, I have been vocal about Modern Biomechanics being one of the practical and financial roads that we could control in the current system.  Insurance companies are covering orthotics less and when covered, the fees they pay force us to validate a $50 lab fee STJ Neutral generic device as state of the art just like we did the HMO’s. 

My opinion remains firm: 
Modern Biomechanics, when practiced by the average DPM, represents a neoteric road for delivering quality care to the foot suffering public and upwardly mobile income for podiatry. 

I ask the readership a question that is common to us all:
We know and live the problem but what are we to do about solving it professionally?

The Challenge that I face with regard to biomechanics in my community is that many of the private insurers that many patients have simply do not cover the cost of orthotic therapy.  I have some patients who are willing (and able) to pay cash out of pocket for these devices, but the majority of my patients do not have the disposable income to drop on a pair of custom orthotics.  I practice in a largely rural community, and we offer custom orthotics at a significantly reduced cost (as compared to the general cost of orthotic therapy where i did my residency training), and while every little bit counts, I wonder if I am not better off performing those procedures that insurers WILL cover (and perform them in volume) to strengthen my bottom line.

Ultimately, I don't think any ONE type physician will be as successful as a one who incorporates multiple facets of patient care into his (or her) practice.  There are few among us who can truly make a living being solely surgical, and i would posit that the same is true regarding a biomechanical practice.   Much like your stock portfolio, in your practice you should DIVERSIFY! DIVERSIFY! DIVERSIFY!

As Dr. Fitzgerald said so well above: Diversify, diversify, diversify.

Everyone on these boards knows how much I admired my mentor Gary Jolly but there was one thing that he did that drove me batty....he called podiatrists who did it all (nail debridements, callouses, padding, orthotics plus surgery....) TFP's....I'll let you figure out what the acronym stood for. The T is "typical" and the P is of course for podiatrist.

I am a TFP and I'm proud of it. And our new CPMS-36 trains us to be TFPs but the F stands for FABULOUS!! As Dr. Fitzgerald says, we should diversify because that is how we can best serve our patients, and even Gary, God rest his soul would agree with this one - you will end up making a better living by doing the whole picture. He would be laughing and shaking his head up and down in agreement about this one.

I always prided myself that I was a part of a practice where, when a patient walked through our door, whatever need they might have it could be met in our practice. An ingrown toenail - check. A bunion - check. Flatfoot - check. Charcot osteoarthropathy - check. Diabetic ulceration - check. There was someone in our practice who could handle everything, from soup to nuts. Of course, we also had Larry Harkless, John Steinberg, Rosemay Michael, Javier LaFontaine, David Armstrong and myself plus lots of fantastic residents who have gone on to make outstanding names of their own - Jon Moore, George Tye Liu, Chi Yen, Crystal Holmes, Khurram Khan, Yuki Morita-Izumi, Suhad Hadi and Johnny Alayon, Marque allen, Anthony Yung, Hienvu Nguyen, Mike Childs, Hiro Shibuya.... it goes on and on and on. I really could keep naming stellar residents and fellows endlessly. I know I have already left out some very important ones.

I am proud to be a Total FABULOUS Podiatrist, with apologies to Gary.  

I just wish we had more (and I know we do have a lot) FABULOUS teachers like Dr. Satterfield, who not is making her mark on a generation of residents...but is having such a mark made on her, by them. The enrichment in our lives that results when we mentor a student is a 2 way street.  Both the students and teacher are enriched. 

David Armstrong talks about the tradition of mentorship that is so badly needed in podiatry, that he believes is still under developed in podiatry compared with other medical specialties.  He feels the mentorship that he sees has traditionally been more about how to run a successful practice than how to contribute to the medical science, to the literature of podiatry.  I agree that we could use more academic role models in podiatry, but if you look carefully, there are some very shining examples.  

Physicians Shift to More Profitable Services to Offset Lower Medicare Fees, Study Suggests

What do we do when faced with declining reimbursement for particular CPT codes that we frequently use ?  We switch to different codes.

See the following article that just came out in Medscape (it's free, but you have to log in... I recommend that all of our members register on Mediscape):

SEE ARTICLE

I do not know Dr. Fitzgerald personally and therfore apologize if I have evaluated his words improperly or offending him personally.  That said:

Three questions to Dr F:

What is your confidence level in your orthotic's ability to prevent, treat or reverse pain and overuse syndromes of the foot and posture?

Do you have a biomechanical mentor (s)?

Do you have a plan (paradigm) for integrating and marketing the biomechanics (non operative) piece of your practice.

Dr. Fitzgerald represents the well trained and professional youth of Podiatry poised to lead the profession.  I am summarizing his post as follows:

If insurance does not cover a product/service that I professionally believe my patient needs, I first make a determination as to whether the patient can afford the product/service and if they cannot, I will adjust my practice and perform procedures that insurers do cover instead in order to maintain the fiscal health of my practice.

Do we work for Oxford or ourselves?

To use a non orthotic example of this philosophy, Medicare does not cover dystrophic toenail care (Routine Foot Care) if the patient is non diabetic and with patent circulation so when confronted with such a patient, if they have no out of pocket budjet, I offer them permanent nail avulsions 1-10.

In my biomechanical practice, I give my patients a “compelling why” they need non operative biomechanical care and quote my fees giving them an incentive to invest in the care.  That includes a preorthotic test drive with centering pads, orthotics, motor control therapy, manual therapy and eventual referral for advanced therapy or surgical care, prn.  If they tell me that they cannot afford my fees, I explain that I accept credit cards and payment plans and that I refund devices that don’t work for up to 60 days.  If still unable to afford the device I dispense devices for what they can afford (at a loss prn) or work pro bono in needy cases.

For every two new devices I dispense, I refurbish one old one in practice, I monitor, upgrade and adjust the total treatment plan prn, I cast for one new device a week to replace outworn or overused ones and I am billing for the foot centering pads, office visits, refurbish fees, etc. and I cross refer 2 surgeries a month to surgeons that “don’t believe in orthotics” as I no longer am performing bunion surgeries in practice.  I cross refer with therapists and I also market local pediatricians as to the need for certain foot types (like the flexible/flexible) to have early preventive biomechanical care. 

When covered services determine our scope of practice (at Oxford's dictum) all the training and all the kings horses   won' t be able to put Podiatry back together again. 

Certainly, no offense taken!

With regard to the above questions, I commonly utilize non-surgical, biomechanical constructs and modalities in my non-operative treatment paradigms, including the use of custom molded AFO and Arizona braces for my patients with complex deformities.  During my residency training, my mentor was a strong proponent of orthotic therapy, and he has the great fortune to practice in a geographic location where his patients have a significant amount of disposable income to apply toward these devices --even when insurances refuse the claims.

I do not have the luxury.  While I do make a certain number of custom orthotics, I utilize at least double those in high quality, OTC orthotics.  These are far less expensive for my patients and more often than not, they appropriately address my patients pain symptoms.   I am comfortable in the efficacy of the custom orthotics that I may, but i'm also comfortable presenting several OTC options (note: i don't SELL any OTC orthotics in my office, I refer them to a local vender if they wish...) I always present the OTC option as a lower-cost alternative (since they're likely to pay out of pocket anyway), which may improve their symptoms and that if there if the OTC orthotics don't completely resolve the issues, i can either make modifications or ultimately progress toward custom orthotics (and my patients know --and appreciate--that i've attempted to help them keep their costs low).  Sometimes it doesn't work and we end up making orthotics, and when that is the case, we certainly work with the patients to attempt to make it affordable. 

With regard to my statement regarding mainaining a high volume of procedures that are reimbursable by insurances companies, I mean only to suggest that such procedures are ulitmately where the money will come from (unless the physician has the opportunity to practice in a location where people have to means to pay cash regardless....).

Would i perform nail avulsions to manage dystrophic nails since routine nail care isnt covered? No.   It costs me 30 seconds to perform the procedure, and it is a service, which I don't mind performing.  I also take trauma call at a local hospital and often fix fractures for patients with no insurance --ALSO for free. Again, it is a service.

My point was simply that success lies in the middle ground, in the performance of a variety of procedures, modalities, and techniques to allow us to serve the greatest cross-section of the patient population.  There are very few among us who can survive being solely surgical or solely biomechanical.  If you are a reader who happens to be solely entrenched in one or the other group....Congratulations, but I would suggest that you are in the minority.  As for the rest of us, we're just trying to do right by our patients, pay our bills, and take care of our families, and to do that we must offer a variety of services, both operative and conservative, to our patients.

Podiatry (much like every other specialty) is evolving both in our understanding and our techniques for providing patient care.  While we certainly must maintain those elements of our heritage that make us unique (such as biomechanics), we must grow as a profession and embrace this brave new world in order to survive.

Biomechanics is more than just a non-operative modality.  I commonly utilize biomechanical principles in my reconstructive cases to attempt to return  my patients to normal function as quickly as possible.  Our practice is not (and should not be) one or the other.... Surgery or biomechanics.   These skills go hand-in-hand.

Chiropody became Podiatry.......imagine where our profession may go next!  It is an amazing time and we are an amazing, diverse profession, and we need to learn to incorporate all of these strengths to bring us into that next great frontier.....