The De-valuation Of Pediatricians And The Death Of Pediatrics

Let's open with an oldie but goodie: "Pediatricians are a dime a dozen" - thus sayeth Steven Eblin, V.P. of Corporate Planning & Development at Randolph Hospital. In the fiscal year ending September 30, 2007, Mr. Eblin pulled down $222,350 in salary & benefits and had a $4,464 expense account.

Prompted by the opening of Randolph's Cancer Center (where "Healthcare Heroes" and grossly overpaid unconvicted felons abound) . . . as well as this post at Kevin's . . . not to mention a comment left by Jeff Sykes over at Joe's, I felt compelled to share my thoughts on primary care - especially Pediatrics - and especially as it pertains to rural medicine.

In the past (i.e. when I took the job with Randolph and accepted my NHSC assignment), my hometown of Asheboro was designated as a "rural" area. It was a bit of a stretch then. It's fairly ludicrous now.

Rural areas (real ones as opposed to fake ones) really are the bastard stepchildren of medical care. And Pediatricians in those areas are like dis-respected foster-parents . . . burning out as they try to save the errant/angry child from itself. But we'll get to that.

Jeff Sykes had this to say at Dr. Guarino's: I really do keep hoping that on the ground medical providers, such as yourself, will write extensively about their views of the health care system and where the system should be tweaked and improved.

I responded at Joe's and would like to expound (extensively) here. First my response:

Jeff, I've been writing about my horrific experience in the health care system . . . as an "on-the-ground" doctor in a government program working for a "non-profit" no less . . . for several years.

No one cares - unless it fits an agenda (my case doesn't - in fact, it thwarts the agenda).

Everybody will ultimately pay.

OBTW Stormy, while it's forsure an ultrasound of your carotid arteries should NOT cost nearly a thousand dollars, $140 is decidedly a low ball (given the tech that has to be paid, and the time/expertise involved) - negotiated as part of a larger/volume deal. I had a similar epiphany when I saw the difference between what the hospital billed for my hysterectomy a few years back - and what BCBSNC actually paid.

The healthcare system is broken because things are not being charged or reimbursed for what they are REALLY worth - consistently and across the board. And this is not happening because so many people now expect these things (and, in fact get these things) for free - and the rest of us are paying for it.

(Cue explanation of our tax system - which, with minor modifications, could explain our healthcare system. It's enough to drive primary-care doctors to drink.)

Nothing is going to get "fixed" or reformed until that changes. My sense is that, just like Wall Street, the system will meltdown and have to be bailed out. And then, we will have socialized medicine.

Then the question will beg, for those of us who have worked so hard to do what we do and be what we are - yet who see less and less reward . . . will it be worth it?

Good luck when we - and those who come after - decide that it's not.

Thrown out on the street by Randolph Hospital ten years ago . . . after living and breathing and slaving away for three years to build (from nothing) a hometown practice I could be proud of (a practice that the government "guaranteed" I would be able to transition into my own business) . . . after going the extra mile for a patient-not-my-own one-night-in-the-middle-of-the-night only to be stomped like a bug by arrogant/sexist-ignoramuses-in-suits only concerned with padding their pockets & wielding absolute power over a small-town market . . . I started doing Locum Tenens work.

And that's where (as the screw turned on the legal front) the REAL education began.

I am watching a profession/specialty slowly die. It's a mess . . . like watching a "slow-moving train wreck" (as one of my former colleagues once described my David v. Goliath battle with Randolph). And I don't like it. Ergo, I blog.

The lawyers that Kevin apparently is so afraid of (I'm still not linked on his blogroll) can kiss my butt. I am telling the truth and it hurts.

Just call me "The Straight-Talk Express";)

First, as the Boston Globe story cited at Kevin's describes, we have small hospitals doing everything they can to keep up with the big boys in the big city. It's all about "customer service" and convenience. Bigger, shinier buildings. Newer and more expensive equipment.

"Technology you can trust".

"Hospitals are spending millions on new specialty expansions rather than primary care . . . (and) the impetus is the payment system that skews towards procedures, and hence, to incentivize hospital building."

To see this play out on the home front (and these days I use the term "home" very loosely), you need look no further than Randolph Hospital's new "Armfield Building". (As an aside, to look at the small sign just inside the front door - a sign that you can only see going north on Fayetteville, "Billy" Armfield cetainly did not get much bang for his Foundation's buck . . . Bob Morrison strikes again).

Cancer is heapum BIG money. Especially in Asheboro - where Relay for Life and Hospice always do well with their fund-raising campaigns because the ordinary people of Asheboro are so fundamentally generous. The problem with the people of Asheboro is that they are also frighteningly gullible and apathetic and content to be patronized . . . so they do not ask hard questions of their local leaders until the wolf is at their door.

It's called "mill-town mentality" - i.e. if you go along to get along, the mill bosses will take care of you & yours.

Enter out-sourcing and Wall Street. Add alcohol. It's just not a philosophy that works anymore.

Meanwhile, as the "cancer-can" goes up, the hospital-owned specialities of Internal Medicine and Pediatrics still languish in the old RMA building (once owned by White Oak Family Practice). As a bit of background, hospital officials promised the doctors that they originally recruited way-back-when (I was the first of many who revolved through the door) that they were going to build a new building.

Indeed, Morrison & Eblin made this promise BEFORE the new Emergency Department went up (while I was still there) . . . and certainly before fighting cancer locally became all the rage.

The current RMA building had major environmental-type issues when I was still there. I don't want to even imagine what is growing in the air vents/carpets now.

Look at it like this. When you schedule your baby's well-check, you might as well book a visit a week later. Because he/she is going to catch something nasty while getting shots.

But hey (paraphrasing Bob), a lot of patients are going to be cured in the cancer building.

And consider this. That flashy new building on Fayetteville street is not going to do a young one with cancer much good anyway. The babies and small children with cancer are going to be referred out to the area's children's hospitals (Asheboro is fortunate in that its central NC location gives you a choice as to where you want your child to go - be it Baptist, Duke, Chapel Hill/Cone). Yes, there might be some small cooperation with lab-draws and low-risk chemo (when a child's counts are not in the tank) . . . but the bulk of a child's cancer care (including/especially imaging or anything involving radiation) is going to take place at a Pediatric center.

And (PAY ATTENTION HERE) if it doesn't take place at a center, honestly, someone is not doing right by your kid. Moreover, they're not doing right by your kid because it somehow puts money in their pocket.

So, in terms of healthcare dollars, all that money the taxpayer poured into Randolph Hospital's new cancer center (without any public discussion/debate or a vote), won't be doing a whole lot of anything for Asheboro's children . . .

. . . or their future that is "now" . . . you know . . . the one Bob secured alcohol for because it was so important for primary-care physician recruitment.

The Randolph County Commissioners and Asheboro City Council members who made the decision to "gift" Randolph with $500,000 apiece of the taxpayers' money (for the cancer center) did not give this disparity any consideration . . . because they don't listen to anyone but the economic-developers at Rotary and the Chamber of Commerce and the Country Club.

They for damned sure don't listen to Pediatricians. Been there (to the City Council meetings), done that.

But hey. It's a pretty building. And it shines at night.

(OBTW, I hear that Randolph Hospital will get a cut of the alcohol revenue too. They got 5% from Randleman's sales. Wanna bet that, as "steward of the profits", Mini-Schmid will probably front Morrison ten percent? Never mind that all the city could use the extra five percent to pick up all the beer cans that shine so prettily at night on the side of the road.)

Since this blog debuted in 2005, its primary focus has been the story of one homegrown Pediatrician who came back to Asheboro to build a practice . . . on the public's dime . . . and got royally screwed . . . while no one in a position of local, state or federal oversight did anything about it. And please don't get me started on our local journalists (especially the ones in the GSO blogosphere) - supposedly our last/best defense against corruption yet so totally "in the tank" for the local economic machine (a machine my story threatens). Never mind that this is EXACTLY the kind of suck-up journalism that let the fat-cats on Wall Street skate by until we found ourselves at the bottom of a frozen lake. I'm not going to belabor points I've made over and over again, but as it pertains to mistakes I've seen made (over and over again) by hospitals big and small all over this state, some of them are worth revisiting.

We've talked about cancer. Obstetrics is another money-maker for many hospitals - and in rural areas, it can be one of the mainstays for a hospital's bottom-line. This is particularly true since lawyers like John Edwards have forced Obstetricians to practice so defensively - thus cranking C-Section rates up to something near 30% of deliveries in many places - in turn, keeping the OR's of small hospitals hopping.

In terms of attracting "customers", the big thing these days is an LDRP (Labor/Delivery/Recovery/Postpartem) unit - where everything short of surgery happens in one room and the baby rooms in. Many of these places are done up very royally - to look like your living room. Insert a hospital bed with stirrups and an infant warmer - add 15 family members with their video cameras who have no business being in the room (I'm not kidding) - and WAHLA! You have a warm and inviting birthing experience.

Obstetricians rule these small worlds - and everyone within the realm is at their beck & call - including and especially the office Pediatricians who, in most places, must cover C-Sections as the price of having hospital privileges (so they can admit children with minor inpatient problems like pneumonia and gastroenteritis and asthma exacerbations, see babies in the nursery and provide the "comprehensive care" that Medicaid reimbursement demands).

Unfortunately, in this arrangement, Pediatricians are often treated like they are just there to dry off the baby. They are the Rodney Dangerfields of medicine - they don't get no respect.

Until they have to do much more.

Then they get respect for a little while - until people get comfortable again and forget.

(Or unless they get fired for being a "health-care hero".)

In addition to the respect factor, with the steep increase in C-Section rates over the last decade, Pediatricians are being pulled from their offices much more often . . . where the hoards of children they have to see (in order to make a small fraction of what a surgically-based specialist makes) must wait - and the parents who took time off from work (as well as the unemployed-albeit-entitled ones who didn't) seethe & steam . . . in order for the Ped to attend a surgical procedure which is usually not emergent in ANY sense of the word.

The compensation for being pulled away rarely justifies the hit the Ped takes at the office. Many OB's only pay the problem lip service.

Indeed, a long time ago, in Asheboro, a newbie OB being recruited was more interested in his Anesthesia back-up than his Pediatric resources. It foretold a lot when the chips were down for the Pediatrician who rescued a baby he delivered.

The other problem that rears its ugly head in a smaller/rural hospital are Obstetricians who do not recognize their facility's limitations, and push the envelope in terms of what they should deliver in that setting - i.e. routinely delivering premies (i.e. babies less than 36 weeks) and/or babies with additional/multiple prenatal risk-factors or known diagnoses who should, if at all possible, deliver at a tertiary center - and within walking distance of a NICU.

The first thing an administrator or OB is going to do when a community Ped balks at covering this stuff as a matter of routine is say, "Aren't you comfortable taking care of these babies (they must have a playbook somewhere)? Immediately the Ped is put on the defensive. But it's a BS question and they know it before they ask it - at least when they ask it of me.

Resuscitating/caring for these babies in a rural setting is not a matter of me being "comfortable" or not. If a Mother comes in and the delivery of her (viable) premie is imminent, I deal with it. I've resuscitated the smallest and sickest babies under the worst circumstances one might imagine. That's not the point. The point is, if a baby like that can deliver somewhere else - in a setting designed to meet to their every medical and social need, why push the envelope?

The Obstetricians who push for more argue that they don't want their hospital to be regarded as a "Bandaid Station". I wish I had a nickel for all the times I've heard that - but, again, it's an argument that falls pretty flat. I think people in most rural communities have a fairly good understanding of what their hospital can and cannot (or should and should not) do. They don't have high expectations - unless some moronic marketing consultant (sucking up to an executive he/she wants to impress) puts an absurd notion in their head.

For my part I'd rather be an outstanding BandAid station than a bad Steri-Strip.

Delivering a baby is the easy part. Women have done it without all the bells and whistles and technology for centuries. The thing is, taking care of a bad baby after its born does not fall to the OB . . . they can go home (or make tee time) and submit their big fat bill. The brunt of caring for a bad baby ALWAYS falls on the Pediatrician - when they are called to clean up a mess.

And let me just tell you, it RUINS your day at the office.

Over the years, I've encountered several community/rural hospitals that wanted to tell me they had a "Level 2" nursery . . . which means they routinely (key word - routinely) take care of babies 32 weeks/over 1500 grams. None of them actually were. At best, they're what I call a Level One-and-a-Half . . . i.e. they can do (hood/nasal cannula) oxygen for 48-72 hours, they can do peripheral IV's, antibiotics and (occasionally) short-term tube feedings. They can intubate/resuscitate/ship - but they don't keep ventilated patients or babies with central lines. They accept premies as back-transports to feed and grow - or (rarely) wean off a nasal cannula.

I'll note that Randolph Hospital bills itself as a Level 2. It was not when I was there. From what I have heard, it is not now. That's not a bad thing.

I just wish hospitals would stop trying to be something they are not and start telling the truth. Of course, we are talking about Randolph.

From the link: "Newborns that might require additional services beyond the basic newborn care are in good hands within our nursery." Of course, when I was there, Randolph's self-appointed "Chief of Neonatology" could not tell the difference between a pneumothorax and pulmonary hypertension/meconium aspiration (even with the X-Ray right in front of him). And I was fired for (1) knowing the difference and (2) rescuing his sorry ass.

You see, saving a baby's life after someone screws up (and complaining about it) plays hell with the high-power/high-dollar marketing.

But hey, you and your baby can trust the care.

I've digressed. A rural/small hospital that is several hours from a major center (Boone in a snow-storm comes to mind), is going to have to push the envelope a bit - they are going to have to find a way to get comfortable with some things. And not all 34 & 35 weekers need to go elsewhere (again, with some decent communication between the OB and Ped - something that often does not happen - you can weigh the risk vs. benefit for that Mother and that baby). But a nursery like Asheboro's (or indeed, some of the other places I have worked) . . . that is just an hour-or-so's drive time away from a tertiary-care NICU (less than 30 minutes by air) . . . has NO BUSINESS pushing the envelope very far. Again, it's about risk vs. benefit and readily-available standards of NICU care. It's about the staff experience that comes with higher-risk nursery volume. It's about ancillary services and respiratory/radiology support. It's about nurses and their training/level of comfort (i.e. staffing the nursery with something other than the newest newbie from the local community college). Sometimes it's even about the medical staff. It's about outcomes.

It's about what's best for the baby. Despite the Edwardian (excuse me, I meant Draconian) legal environment, you'd be amazed how many small-town hospitals still don't get that.

It has been my experience that OB's and hospitals do tend to push the envelope until Peds pushes back. Sometimes that gets ugly, because Pediatricians are among the most laid-back people on earth - and most hate confrontation. So they don't confront until they're feeling pretty put-upon, taken-for-granted and angry.

That was me in Asheboro - for a whole lot of reasons that culminated in one fateful night in January 1998.

It's been me in a couple of other situations too.

But when Pediatricians do confront/"attack", the facts are facts. Birth should not be a "procedure" unless it has to be. The best incubator in the world is the womb. It is best not to separate Mothers and babies by transfer after birth if it can be avoided before birth. Study after study has proven that neonatal outcomes for premies are ALWAYS better in a NICU - not in a community hospital pretending to run a Level 2. Moreover, if something goes wrong with a baby you kept whose Mother you could have shipped - the lawyers will never fail to ask you why you didn't ship.

Now, in terms of being the community Pediatrician covering a small-town nursery (and/or admissions for the ED), if you're in a group practice in a larger town . . . with three or four or five or six doctors . . . or sharing call with several other colleagues . . . that's one thing. You have help at the office and you have time off and you can have a personal life. But if you're Joe or Jane Blow M.D. out in the middle-of-fricking nowhere, the constant interruptions can be crippling to your practice and devastating to your income (especially since primary care continues to get the shaft from insurance companies - and the government).

Moreover, you don't have a life because you're "on-call" all the time. You're tethered to your hospital by a beeper and mileage limit (usually 15-30 miles). Chronic exhaustion sets in fairly quickly.

None of the 9-5 hospital executives . . . whose salaries are oftentimes bloated to something the Ped will never see (one can only hope this Wall Street debacle stops some of that crap) . . . get that. As I told one rural hospital administrator laying on the recruitment pitch with a trowel, it does not matter if you're thirty-five minutes from this destination or that weekend hotspot - if, as the only Pediatrician in the county (on 24/7), you can never go there!

And we have not even started to talk about "extended" & weekend hours - or "Mommy call" at all hours of the day and night. Even though they can be sued for the advice they give (I've seen that happen too), Pediatricians are still not reimbursed for those calls. It is my opinion that, in this era, of extreme societal entitlement and instant gratification (I like to call it "WalMart" medicine) . . . where many parents don't seem to know what "emergency" means any more . . . and no one respects the Peds' down time (as opposed to 30 years ago, when my head had to be dangling by a vein for Mama to call the doctor after hours) . . . phone calls should be reimbursed - even if it's just five dollars a dial.

Of course, most insurance companies and Medicaid will barely pay for an office visit - fat chance on a phone call.

If the Ped chooses to contract employ an nurse-answering service (in order to triage the after-hours calls and get some sleep), it costs a small fortune THAT IS NOT REIMBURSED. It's just another fiscal hit the doctor has to absorb - in addition to the reimbursement cuts he/she has already swallowed. Incredibly to me, most smaller/rural hospitals still don't even think of offering such services as a "perk" of Pediatric recruitment/employment/privileging.

Now these days, many larger hospitals in bigger towns train nurses & nurse practioners to attend all but the most risky deliveries. Some even employ Pediatric hospitalists (usually a Med-Peds) for all inpatient care. But small town hospitals (unless they are under a larger hospital's umbrella) simply cannot afford to do that.

And/so the rural/small town Pediatrician, with all of his/her fingers in so many dykes . . . outnumbered, under-appreciated, and poorly compensated for what he/she does . . . burns out . . . and oftentimes gives up/leaves.

Then the story becomes about access to care.

It is a fact that Pediatrics in many rural areas has become a revolving door. Hospital-owned or federal clinics often staff with newbies right-out-of-training who are working off a service obligation (and it seems that obligation is getting longer and longer - further devaluing the Pediatrician). Oftentimes, Foreign Medical Grads ("FMG'S") wind up in these places doing their prolonged stints of soul-sucking indentured servitude. Under such circumstances, when these people can bolt, they leave. They do not stay. There is no incentive to do so - because by the time they can leave, they're embittered and disgusted with the administration of the clinic that employed them - because they've been taken for granted so long.

And OBTW, on top of everything else, in your spare time, you're supposed to learn Spanish!

Totally disgusted. Taken for granted. That was me too. Except that Asheboro was home. And I had busted my ass to build something that (according to the governments I served) I could transition into something that was my own. The people who drove me from practice in my hometown were total morons to think that they could pull the stunt(s) they pulled, and Mary Johnson would just roll over and die.

It was a fundamentally stupid business decision then. It remains a stupid business decision now . . . not to own up to the lies and subterfuge and make ammends.

So (to answer the businessmen laughingly teasing Bob Morrison when he cozied up to my ex at Crisco's Dem fundraiser), damned straight I called the lawyer. I would not have had to do that if any of the executives involved had parked their smug arrogance at the door and used even one brain cell . . . if they hand put substance before style & slick marketing, and retracted their amoral threats & unethical ultimatums . . . or if the board members who were charged with overseeing them had not become suddenly & selectively blind.

A city of Asheboro's size should have a large, thriving/independent Pediatric group by now. It doesn't because Randolph Hospital got greedy - and the established Family Practioners in town (whose calls for help I answered EVERY TIME) only wanted Pediatricians around to (1) see the patients they didn't want so many of (i.e. Medicaid, Hispanic patients, the uninsured); and (2) clean up the bad messes. When I/my former partner needed someone at our backs - as opposed to calling us names like "arrogant and cliquish" - the FP's that had clammored for our services and accepted our help were adding our patients to their patient lists.

There's another side to the story of the devaluation of Pediatric services and the impending death of Pediatrics. And that has to do with the Pediatricians who have lived/practiced in rural area for years . . . giving and giving and giving to their communities . . . building practices they thought they'd be able to eventually sell on the premise that a successfull/profitable operation and "goodwill" would mean something in today's medical market.

Nothing could be further from the truth. Because the slick MBA's running today's hospitals will just open an operation across the street. The suits are not going to pay the Ped anything for his/her musty closet full of paper charts. And, more often than not, using their deep pockets (often filled by the taxpayer) and citing "increased access to care", they will bring in ignorant/gullible newbies to compete against the established Ped before he/she is even gone . . . sometimes forcing them into bankruptcy.

In short, hospitals have devalued the Pediatrician to the status of a glorified nurse . . . a pawn on a economic chessboard.

I've seen this happen - so many times I've lost count. I've watched entire practices implode. I actually loved it when one group of Pediatricians got so mad at a bunch of hospital administrators, they quit en masse and moved thirty miles up the road (just out of legal reach of their "no-compete"). Then they put up billboards on the highway - with their faces on milk cartons - to let their patients know where they had gone (because God knows the hospital wanting to keep "the business" was not going to tell these parents the truth).

I've also watched good/dedicated Pediatricians become overwhelmed and depressed and drink themselves to death . . . or go bankrupt . . . or die broken & embittered after debilitating illness.

I've also seen the shock and rage on the faces of doctors hoping to retire or slow down . . . when a hospital "generously" offered to "take over" their practice and employ them (as opposed to buy them out) . . . the moment when they realized a lifetime of hard work . . . "the business" they invested so much of themselves in . . . was/is worth virutally nothing to the hospital.

You see, these established/embedded doctors are not stupid. They understand they could take the "easy" offer of employment and be fired (in favor of a more pliable warm body) within the year - and then really have nothing. I've seen that happen too.

It's a great system we've got here. Medicine as a cut-throat business that eats its own - the people who give the most - the people who take care of our children.

Now some of this is going to change with the advent of electronic medical records - patient records on disk are going to be worth something (probably not a whole lot, but something). Alas, that will take at least a generation.

And that will be too late for many Pediatricians who labored long and hard for years and years under the notion that their hard work and devotion would be rewarded.

In some respects, I'm glad I learned young that it would not.

I'm trying to get to a point. And the point is that Pediatrics as we know it . . . the specialty where one person did it all (the kind of dream I once had in Asheboro) . . . is dying a slow and ugly death.

Rural areas in North Carolina are beginning to feel the pinch because the old business models that hospitals have been using (emphasizing volume, volume, volume while hammering 2-3 doctors into the ground) have been exposed for the pathetic long-term failures they are. Moreoever, more and more residency grads are steering clear of recruitment and retention programs (i.e. the state & federal loan repayment-for-service deals - like the ones I got screwed in) . . . as oversight is nonexistent . . . and whistleblower/other protections are not enforced.

The young Ped is alone and forgotten as soon as the ink is dry.

As a result, it is harder to recruit Pediatricians to rural areas - let alone keep them - because the young guns are deciding that some things are just not worth it.

You can take a job in the city - and pay off your own loans. It might take a little longer, but at least you'll have a life.

(I'm just "disgruntled" you say. I don't know what I'm talking about. But I do. You see, since the boys at Randolph worked their black magic, I have made a good portion of my living off the revolving door - and the living has gradually been getting better since less people walk through it.)

Moreover, younger doctors . . . trained under the newer residency work-hours limits & restrictions (I'm sorry, it does impact what a doctor can do when he/she gets out) . . . and uncomfortable as a solo in intense clinical situations (compared to doctors of my generation) . . . are not taking the rural bait . . . and if they are, they are setting limits before they sign.

If they do take the job, inthemiddleoffrickingnowhere, the young guns-with-no-experience negotiate for a premium salary (raising the cost of medicine) that put the old guys & gals with the experience to shame. And they're more likely to walk away if they're unhappy (recruitment money down the drain).

And, as is the case with Asheboro, the word is out on places that have a history of chewing up Pediatricians and spitting them out. Residency directors (at least the ones with souls) are going to advise their grads to steer clear of locations that have done previous bright-eyes dirty. Additionally, more doctors than ever are uprooting, moving around and networking and warning their colleagues about "bad" places to work.

Of course, then there are "Doctor Bloggers" (like me) - who are angry and disgusted enough to talking openly about their way-bad experiences.

What I'm trying to say is this: What goes around comes around. The "doctor shortage" in primary care - particularly Pediatrics - was brought to you by the "team players" at your local hospital - in Asheboro's case, the same one that wants to convince you that it now has the expertise to fight cancer (compared to the world-renowned centers just an hour away).

Finally, I need to say this: When we talk about "universal care", we are not talking about anything except about HOW CARE GETS PAID FOR. Because how much Pediatricians get paid - and how they are treated - is what is actually afecting your child's access to care - and will affect it for years to come. If a doctor's income is going to scrape the bottom of the medical barrel AND they're going to be treated like crap - they're going to chose another specialty.

If I had not already resigned from the NC Pediatric Society, I would risk excommunication for saying this: Expanding SCHIP (i.e. the State Children's Health Insurance Program) is NOT about "improving access" to care. It is about how the Pediatricians will get paid for providing that care - and increasing their incomes. It's about pumping up the volume of entitled children to make up for the slicing and dicing that has made making a decent living as a Pediatrician so hard.

(I wish I were clever enough to make the point with beer.)

You see we as a society "value" the people who take care of our children so much that we've cut their reimbursment (from insurance companies and the government) to the bone. And that's been done despite that fact that so many people are having children they cannot afford to raise - and these people think medical care should (1) be perfect (and if it's not they'll sue), and (2) be free.

It takes years to become a Pediatrician. My twenties and early thirties are a blur. Accordingly, my expertise and training should be worth something - and, in fact, are valuable commodities. Pediatricians are hardly "a dime a dozen". My dedication to the art and craft of taking care of children should have been appreciated and rewarded. But it was not. Since Asheboro, it's taken over a decade for me to get back on something resembling a fiscal even keel.

From a recent post:

It's my opinion that one should not invest well-over-a-decade of one's life in higher education - slaving away in classrooms and labs - living in libraries - playing the peon on hospital wards - only to come out/come home and be treated like I was by two blow-hard money-changers that Jesus himself would toss out of the Temple for what they've done.

Moreover, primary-care doctors are in shortage. The state of North Carolina has got to get its head out of its butt and start doing more to protect them from predatory hospitals.

Predators kill.

A predatory small-town hospital killed this Pediatrician's hopes and dreams for a life of quiet service in her hometown. I've watched variations of the same thing happen to Pediatric colleagues all over this state. Most doctors do not fight back - certainly not as hard as I have. They take the blows to their hearts and pocketbooks and move on.

A "Wall Street/greed-is-good" mentality currently rules our hospitals . . . and within those white walls, Pediatricians have been devalued to the point that there is nothing to do but leave or sell-out for a smooth sail.

In terms of state & federal (not to mention legal) oversight, there is currently NO accountability and no one seems capable of using anything but tired, worn-out, failed business models from the "evil hospital administrator" 101 class they must give in MBA school (IMHO, what should be a "dime a dozen" are mealy-mouthed, two-faced, lying oily suits like Steve Eblin).

Moreover, our politicians lack the backbone to craft the reform we need . . . and our so-called "physician advocacy" organizations, medical societies and licensing boards lack principle and have no teeth. They do not protect or defend their own.

Right now, might is not behind right. And in this country, when it comes to our kids, it should be.

The genius bloggers who've told me to "get over it" and "move along" (instead of confronting and addressing the despicable administrative behavior that destroyed my practice and put me on the road for a decade) do not get it. At the risk of talking about "rights", Pediatricians have the right to stable, happy lives . . . just like their procedure-happy friends who use the hospital more(as opposed to bouncing around two and three and four times - and I've seen this happen - as doctors accept "permanent" positions over and over again until they settle into something they can live with). Compared to their surgical/hospital-based colleagues, Pediatricians deserve a decent quality of life - they deserve to be treated like something other than a doormat. It is time for the people in suits (especially those in small towns and rural areas) to STOP wasting valuabe resources and start playing fair.

And if they don't play fair, it's time to do something about it. There are five executives at Randolph Hospital that together pull down over 1.2 million dollars a year in salary, benefits and expense accounts. Four of the five have been there for years - they are entrenched and have not budged. Meanwhile doctor after doctor has come and gone - many did not want to go. These executives would have you believe that their services and their "vision" are more important than that of the many doctors that have revolved through their doors - again, many of them leaving because they could not put up with BS these executives dolled out. Most doctors just silently move on.

But I was raised here. This is my home. The reason this blog exists is because two of these executives acted illegally in order to make sure one doctor they shoved out the door did not come back (in the process, sending a "message" to other doctors who might fight back) - and no one (from the hospital board room to the city councilroom to Raleigh to Atlanta to Washington) has held them accountable (and forget about any of our local journalists actually being journalists).

In fact, these crooks-in-suits got raises. Somewhere, somehow everything got warped. It's just damned wrong.

I know full well how Wall Street happened.

Meanwhile, those "consumers" screaming for "universal care" for their kids don't care or understand that Pediatricians have already given and given and given some more at the office. These consumers don't seem to understand that in order to get what they want, they are taking (you could say stealing) from others - consuming time - consuming lives - and those things are simply not covered by the bill they don't want to pay.

It gives "wealth redistribution" a whole new meaning.

No one can think outside the box. It's my opinion, after a decade on the road - working in every kind of setting - from private offices to trauma centers - that if someone does not start soon, the soul of this specialty will be dead. No one will stand and fight for what's best for the kids. It will simply not pay to do so. A Ped might as well be an auto-worker on the line - going along with whatever scheme that comes down the "team-player" pike - in order to get along.

In the end, that philosophy will make Pediatric care more expensive to the consumer.

For no one in their right mind would subject themselves to what I have been through for doing the right thing . . .

. . . courtesy of my own hometown.

Thus sayeth Mary Johnson, M.D., FAAP the "whack-job" Pediatrician who told Mr. Eblin he was wrong. Her 2007 salary was not anywhere close to his.

It really comes down to a question of what do you value.? Asheboro and Randolph Hospital have answered that question in spades.

*I hope this post fulfills Jeff's request.