Posts by Brad Flansbaum

Your Career Path. Did You Get Pushed or Pulled?

I recently read the following written by Daniel Ofri, MD in the NYT: The stereotype of specialists handling the more complex and intellectually challenging cases makes many generalists fume. Generalists observe that specialists get the “simplicity” of handling very narrow slivers of medicine. It’s much easier to be an expert when you only have a handful of diseases to worry about. And any issue that a specialist doesn’t want to deal with can be permissibly kicked back to the generalist. The generalist, however, gets no dispensation. Every issue that the patient raises must be addressed. Every symptom from any organ has to be acknowledged. Plus, every medication prescribed by every specialist must be accounted for. Every competing interest between the many medical cooks in today’s fragmented health care environment must be integrated. It brought to mind something else I saw of late--Modern Healthcare's physician compensation survey.  The publication obtained data from…

Hospitalists Get the Spotlight in NEJM

It has been twenty years since Wachter and Goldman published their first descriptive paper on the rise of the hospitalist.  To commemorate the occasion, they revisit the subject with a new commentary and highlight where the movement is at and portend the future of the discipline: When we described the hospitalist concept 20 years ago, we argued that it would become an important part of the health care landscape. Yet we couldn’t have predicted the growth and influence it has achieved. Today, hospital medicine is a respected field whose greatest legacies may be improvement of care and efficiency, injection of systems thinking into physician practice, and the vivid demonstration of our health care system’s capacity for massive change under the right conditions. A shadow piece by Richard Gunderman laments the ruin of the jack of all trades general practitioner who use to do it all.  Many of the criticisms, none new,…

The Next Hospital Decade: Broken Hips Versus Band-Aid Strips

  I had planned on writing on MACRA and the inability of those who criticize the law to offer up alternatives to fix the flaws.  I got tired of the conclusions from the skeptics: let providers be and they will do the right thing.  That is a recipe for the pendulum to swing too far in one direction.  The "right thing" will wind up costing the Treasury a ton of dough.  History has already born that out. I am one of the skeptics as well, though.  I had no idea how CMS was planning to stitch this whole thing together--and I was waiting for hints from Andy Slavitt, top dog at CMS, based on his testimony last week on the Hill. Well, if you shorted Kleenex stock, pat yourself on the back. You can put your hankies away because it looks like CMS may postpone the start date.  My screed…

The Last Days: Cash or Credit?

How often do you hear the following: the average senior utilizes  25% of their lifetime health spend during their last six months of life.  Too much. All that service use in such a concentrated period suggests possibilities. ICUs and inpatient care have great costs.  Our acute and post-acute institutions also do not hold up as models of efficient care delivery.  Most of them at least. What to do? I see the above observations as something akin to an emperor with no clothes. Because leaders with checkbooks have a focus on areas that will generate cost reductions, they seek opportunities they can wrap their arms around.  The more disadvantaged and disjointed ambulatory practices cause too many headaches.  Hospitals then seem like the right place.  Hospitalists and inpatient practitioners seem like the right people. The logic goes, with advanced directives and creative thinking, the right docs and facilities can make a dent…

What Kind of Car Will A Specialist Be Driving in 2030?

(Something I sent along to my PGYs.  Thought you might enjoy.  And think about where hospitalists fit into all of this) A Porsche or a Prius? Have a look at the two figures below and see if you can spot the dilemma: See it? I knew that you could. Here's the thing.  We have lived with an arrangement that reimburses specialists more than generalists for greater than fifty years.  You would think because that is so, the progenitors of the system knew what they were doing and assigned the right amount of compensation to each type of physician.  Specialists and proceduralitsts do stuff so pay them more. On one level, that makes sense.  After all, you can see the results specialists achieve quickly given all those high tech thingies they use that come with instruction manuals.  They produce big levels of patient satisfaction and often, get that instant cure.  Folks…
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