Monday, July 30, 2007

14 Must Know Facts about Physician Recruiters

Physicians are not well informed about job search methods and about recruiters, about how they really work and about their limitations. Residents in particular lack awareness of the disadvantages of working with recruiters. Graduating residents are just stepping out of an educational, basically helpful environment. They are naive in business matters and rarely understand the economical pressures that shape recruiter behavior.

The fact sheet below was developed after years of personal experience with physician recruiters, based on being a candidate looking for a new job as well as an employer looking to hire a new associate for my practice. I am writing specifically about contingency recruiters, and that these facts and rules do not refer to retained recruiters, in-house recruiters or locum tenens recruiters.

Recruiters will deny all of these facts or at least try to gloss them over. Many actually will claim to be proud of avoiding one of the drawbacks below, which is ...just marketing. I leave it up to you whom to believe: a physician without any financial interest that reports out of personal experience and research, or recruiters who defend the living they make based on marketing slogans.

Also consider that there are always the "exceptions that confirm the rule". There are those recruiters that market less "aggressively", that really care about you, that do visit the practices they represent, that are straightforward about what they are able to accomplish and what they cannot, but that does not change the big picture I am describing.

As much as recruiters may try, as nice or good hearted or ethical or hard working or well-meaning they might be, some facts will never change:
a. recruiters are hired and paid by the employer
b. they charge a $ 20,000 fee for their services and
c. they only get paid after closing the deal.
These facts lead to all the consequences and problems described here. I am not trying to indict recruiters, I am describing the basic framework they practice in.

1. Physician Recruiters are hired and paid by employers to fill a vacancy. They are not hired nor paid by the candidate. This is much more important than candidates think! Their loyalty therefore is to the paying party, the employer, not to the searching candidate. They do not get paid to consider the desires, careers or preferences of the candidates. The candidate is useful as far as he or she fills the job the recruiter gets paid to fill. A recruiter for example will never "negotiate a salary" for you, as some claim. You really think they will go against the employer who pays them and create higher costs for them? When it comes down to it, recruiters are not on the side of the job seekers. They are on their own side: closing the deal and getting paid.

2. Recruiters charge $ 20,000 to fill a position. This is the biggest handicap for recruiters, something that no recruiter can overcome. This creates a barrier to hire them. This places recruiters at a severe disadvantage compared to you, the physician, when you are looking for a job and applying for a position. You come without the price tag and instantly are more attractive.
Obviously you could argue about the significance of those 20K. Maybe the hiring hospital is flush in money and can afford to spend it, maybe they consider physicians valuable enough to spend that kind of money on recruitment, maybe the loss of revenue with an open position is even more expensive, but 20,000 are still 20,000. Maybe the yearly collections of the physician (neurosurgeon) dwarfs those 20K, but to me as an ObGyn it means about 8 complete "9 months of prenatal care plus delivery" and to a family physicians it means seeing a whole lot of patients!

3. 80-90 percent of private practices refuse to work with physician recruiters, since they are very expensive. The usefulness of recruiters in medicine is reduced dramatically by the fact that they cannot reach that 80-90% of the job market - which is most of the private physician job market and pretty much the whole job market in desirable areas.
Keep in mind that 50-60% of physician jobs are filled through networking, 10-30% through advertising by employers on Job Boards and 15-25% by recruiters. What kind of help can you expect from someone who can only reach 20% of possible jobs?
What do recruiters do in response to this? They tell you that those areas are "oversaturated" and try to lure you to under served areas, where recruiters do get jobs.

4. What does a day in the life of a recruiter look like? Recruiters are salespeople and spend their days on the phone. Recruiters spend part of their day cold-calling practices, groups and hospitals to see if they are interested in their services. Then they pay large fees to NTNJobs, eHealthCareers and numerous other Internet boards to post job descriptions. Then they spend a few hours each day cold calling physicians, sending fliers, postcards or e-mails to program directors, specific departments and numerous physicians fishing for applicants.
Candidates will usually respond to recruiters by e-mail, submit their CVs and recruiters then forward these CVs with names blacked out to the potential employers.

Recruiters love to give you the impression that they have resources or skills that you don't possess, yet, once you see what they actually do, you realize that you can do it perfectly well on your own. No, they don't have secret sources in high positions; they just want you to think that. Unlike what they sometimes claim, most recruiters do not visit practices and they do not get face to face with physicians. Usually they work nationally and seeing offices and physicians means travel and would be very time consuming and expensive.

5. Most recruiters subscribe to a background database, usually the NAPR "Job Bank". Paying subscribers store short profiles of jobs and candidates in these confidential, recruiter-only databases. Since thousands contribute to these databases recruitment becomes more efficient due to sharing of resources and combining efforts. "Maybe my candidate fits your job". Fees are usually split between the recruiter who has the candidate and the one who has the job. This is the same model that Realtors use. When a recruiter says "we personalize a search for you", (I love that slick line) he means that he enters your name in the recruiter background database and checks if there is a matching job for you. The only problem is: the whole database is filled with left-over and hard-to-fill jobs.

6. Occasionally recruiters market themselves as "screening candidates and practices carefully" to give themselves an air of quality. Based on my personal experience I doubt this. Screening does not fill positions and only filling vacant positions gets them paid.

7. Recruiters are first and foremost salespeople, not helpers. Given the fact that recruiters only get paid their $20,000 if they close the deal, they are highly motivated to sell.
This explains their behavior:
They contact as many physicians as possible per day, hoping to find the one that can fill the job. They try to convince you that the jobs in "Desirable city" are not so desirable and that the countryside jobs they have actually might be better for you.
Recruiters loose interest in you immediately if you insist on a job in very desirable area or if you are looking for part time jobs. Their chances of getting paid in all these scenarios are very low and therefore the interest in you vanishes.
Because of the pressure to sell and the strong competition, all too often the candidate becomes just a number, a meal ticket, a means to fill the job, to close the deal and get paid.

8. Physicians can easily find 2-5 times more jobs than the best recruiter. Doctors have been the target of marketers for a long time. They are all listed in multiple databases. List of doctor contact info can be easily bought from a large number of sources, some of them in a few minutes online. Check out! Since physicians are so easy to reach, candidates do not need any help from recruiters. Medicine actually does not appear to be an appropriate field for recruiters.
Please refer to my blog for excellent information how you personally can find more jobs than any recruiter.
Physicians applying to an employer without a recruiter do not have a 20,000 price tag attached and they immediately become a preferred candidate. Recruiters vehemently deny this in public, but admit it privately. In the end recruiters are more of a distraction and burden to a job seeker rather than a benefit.

9. Recruiters are not "free for the candidate". This is a common marketing myth. Yes, the employer formally pays the fee. This fee is "recruitment cost" and therefore part of the overhead, the expense, caused by the candidate. The employer will recover this cost from the employed candidate in one way or another. Getting a job through a recruiter usually means a lower salary or fewer benefits, at least in the frist year.
Although, the true price of working with a recruiter is less visible and much higher: you get a less desirable job!

10. Recruiters may have many jobs, but they do NOT HAVE GREAT JOBS. Here I have to declare my own bias. I consider jobs in attractive, large cities "great jobs", an opinion that not everybody shares.
No matter if we talk about city or countryside though, the recruiters tend not to get the best jobs. The most attractive jobs are never advertised and are filled by word of mouth or direct mail. The moderately attractive jobs are advertised in print and on the Internet. Only those jobs that employers just cannot fill, even though many physicians look at them and decline, are handed over to recruiters to fill.
Recruiter told me" We get jobs in areas where there are more jobs than applicants" and "The function of recruiters in medicine is to fill the less desirable jobs", and Pam Pohly, another recruiter writes "Recruiters get the hard to fill jobs". Do you really want one of those jobs?
Ask yourself before talking to any recruiter: Do I really want a less desirable job?
After all, why would any employer pay 20,000 to a recruiter if a job can be filled by word of mouth of with $400-800 of advertising in a few journals?

11. Physician recruiters advertise using their own language: "easy access to", "a short drive to" means the locations is 1 to 2 hours from an attractive city. "Easy access to city A and B" is even worse, this job is in the dead middle between 2 separate suburban areas. "A great place to raise a family" means there is absolutely nothing to do in that town. If you are single, you are dead!
Much more important is what recruiters do NOT mention, such as high turnover of associates, low salary, high-buy-in and other hidden drawbacks.
But how can a recruiter find out in a 10 minute phone conversation what goes really on in a practice or hospital? They can't and the candidate is the one who suffers the consequences.
Recruiters sometimes "forget" to mention drawbacks of jobs, since that disclosure would hurt the sale.

12. Recruiters advertise insidiously by masquerading as "job search experts" and "advisers". This kind of marketing is much more dangerous, since it is often not recognized as the advertisement it is. This misleading marketing includes posing questions such as "How do you choose the recruiter that is right for you?” The implication of this question is that there is actually a recruiter that is right for you. Posing this question is similar to "Should I shoot myself in the left or right foot?" NO, you should not shoot yourself at all, and NO, you should not use a recruiter at all!
Often recruiters post tidbits of helpful info on their websites, such as links to licensing boards, short "5 points to improve your CV", but that is all marketing fluff to attract you or to make your CV more marketable. They will never give you advise how to best find a job - outside of recruitment. That would be bad for business and would threaten the basis of their existence. Therefore this info is never complete nor truly useful. In the end is only a means to get you as a client. Nothing wrong with that, you just have to be aware.
Anytime you read - anywhere - that someone recommends recruiters or even considers them a good alternative to networking, you are dealing with either a recruiter or someone who just has no clue about how the job market works.

13. Recruiters are NOT advisers, helpers, career counselors, CV writers or job market experts. They are usually neither qualified nor versed in any of these matters. They may read a lot of CVs, but that does not make them experts at writing or editing them. They will not take the time to go over your CV and advise you. They check your CV mostly for one single question: Can I sell this candidate?
They are not experts in the job market, even though they spend their time trying to fill job vacancies. Recruiters know only a small segment of the job market, the segment that is available to them. Do not trust their opinions in that matter, their opinions are shaped by the marginal 10-20% of jobs they are aware of.

14. Worst of all: recruiters do not disclose their limitations. They will not tell you that they cannot get jobs in desirable cities and locations. They will not tell you that they cannot get jobs with desirable practices. They will not tell you about alternative ways of finding jobs. This is a serious ethical issue - imagine a physician not treating a patient, just because he personally is unable to perform a certain surgical procedure! We send our patients to someone else who can help them. Recruiters never do that. Physician recruiters simply tell you that the great areas where you are looking for a job are " oversaturated". In reality this is a code for "unreachable for recruiters who charge 20K to fill a job". They will never tell you: "Just mail a letter to every doctor in Desirable City and you will get a job", because this might threaten the foundation of their existence. Imagine all physicians just mailing letters to eployers and getting jobs! Instead recruiters tell you "Call back in a few weeks, maybe I have something then". The obvious idea is to keep you as a client and maybe get that commission later, in blatant disregard of what you want and need! I consider this a lack of responsibility towards clients.

Summary: AVOID physician recruiters!

The better way to find a job is a simple and very successful method: mail a letter containing your CV with a cover letter to every physician of your specialty in the area where you want to work. You buy the list of contact info online from e.g., then load it onto your computer and mail-merge it with your cover letter in Word. Voila - hundreds of personalized letters addressed to every single physician in your area of interest. Most successful!!
See my previous blog post for a detailed description.

How can all this come up after recruiters have been serving the physician community for 20 years?
Personal computers and then the Internet have changed our lives. Contact information for physicians, once hard to find and expensive, can now easily selected and downloaded on the web within a few minutes. A PC can easily produce hundreds of customized, personalized letters and the new Internet fax services allow us to fax a letter to thousands of doctors with a few clicks.

That, together with Internet job boards that are becoming easier to navigate and with physicians and hospitals becoming more computer savvy, leads to a future of job searching directly without middlemen. More and more candidates will contact employers directly and

So, what keeps recruiters in business?
It is those employers who sadly do not know how to find candidates and those employers who do not have the personnel to recruit themselves. It is those colleagues who pay recruiter fees, who allow recruiters to pay for their advertising avalanche on the web. It is all paid by us, the physicians! This can change! I have described in detail the know-how that employers need to recruit successfully. Please check past posts in my blog for this.

Friday, July 27, 2007

Short and Sweet Summary of What Physician Recruiters Do

I found a nice comment on one of the discussion forums of the "Student Doctor Network" about what recruiters do, from yet another physician (LAdoc) who agrees with me:

"Never use a recruiter. Their job is to fill crappy jobs with YOU, and take a decent chunk of your salary to do so. You get doubly screwed."

This pretty much sums it up. Truly short and sweet. To me, it replaces the previous motto: "The function of recruiters in medicine is to fill the less desirable jobs". I love this new quote.

Thursday, July 26, 2007

A Former Recruiter Supports My Judgement

Comments about my blog come in two flavors.

One is "yes, that is just what I have experienced" and "excellent post", "residents need to know this", "Why do they not tell us this in residency" or something along those lines. This opinion usually comes from fellow physicians, who ran into similar problems and experienced similar frustrations with recruiters.

The other flavor is "You have no idea what you are talking about" "Of course there are a few bad apples among the recruiters, you just have not spoken to enough of them". That view would be, you guessed it, from active recruiters themselves.

I have plenty of experience, ooohhh, yes, do I have experience with recruiters. Too much for my liking. That is exactly what turned me against recruiters. But in the last few posts I have happily demonstrated that my views are actually shared by recruiters themselves, or by former recruiters. Of course they know what they are doing, they are not blind....And here is another one of these statements from a former recruiter. It could have come from my keyboard, I love it...

By Rahulazcom, "Senior member", SDN student doctor network

Start quote...

I used to be a recruiter before I went to medical school...

...I would advise you to not use recruiters at all. Recruiters are like Real Estate Agents. They provide the impression that they have certain resources or skills that you don't possess until you see what they actually do and realize you can do that on your own. This is what they do. They cold call groups and hospitals to see if they are interested in their services. Then these recruiters pay a large fee to Monsterboard or some other major search engine to post job descriptions. No, they don't have secret sources in high positions like you think. That's what they want you to think. Candidates will usually respond through e-mail and then they forward their resumes (with their names blacked out) to the hiring person. Recruiters will also send flyers or e-mails to program directors or specific departments "fishing" for applicants.

Be aware that the best companies are not actively looking for people. The companies that are willing to shell out 30-60K in recruiting fees are those that are desperate to find someone or are really struggling to find someone. This is not alway true but it's true most of the time.So if a recruiter is discussing a job opportunity, please keep that in mind. Ask yourself why is that job open and why have they contracted a recruiter?

Also, see if you can assess the experience of the recruiter. The bad leads are dumped on the new guys to see if they can close them; the senior guys will not want to work those bad leads. Also, if a recruiter calls you and starts rehashing information from a database, that's usually the newbie that is calling old leads that is stored in a database which is an ominous sign.

Back to my original point...., by applying directly to hospitals and groups, you will actually increase your chances of landing a job because the group/hospital doesn't have to pay a larger recruiting fee (30K to 50K) to hire you.

Okay, so here is what I would advise all of you to do if you are in the job hunting stage.

1. Have an idea where you want to settle down. Narrow your search to one or two cities

2. Create a portfolio by having your CV, photo and LORs photocopied and placed inside a large envelope.

3 Mail the packages directly to groups and hospitals and make certain to let them know you are not being represented by a recruiter and that you are representing yourself. Make sure to address your portfolio to one of the physicians. Don't address it to the title of the practice or the hospital department because it could end up in the HR/Office manager's hands and they could just dump it in the trash.

4. Follow up with them to see if they received your portfolio.

5. Be aware that the best groups are not actively looking to hire someone, but if the right candidate lands on on their desk and they don't have to pay a large recruiting fee to hire him or her, they will strongly consider hiring that individual.

6. AVOID the HR! That's a recruiter basic! Talk to the decision-maker or one of the partners. You can talk to the HR later in regards to benefits etc. but the physicians/partners are much easier to deal with.

End of quote....

He has it almost right. Just mail a letter to every single doctor in your area of interest, not just to the groups and hospitals! And I should mention that "" could do it for you for a modest fee...

Wednesday, July 25, 2007

What happens when you register at the recruiter job bank

The following quote is from the "" blog, written by Jim Stone and Bob Collins, two competent and smart recruiters from the search company Medicus Partners, who work in committees of the NAPR as well. It lists in great detail what happens when you, the candidate, registers at the recruiter tool "World Job Bank". Extremely enlightening!

Here is the blog post. I do not like to quote that much, almost a complete post, but this quote is so full of data that it cannot be shortened without loosing impact.

Start quote:

"A World Job Bank Physician Registrant’s Experience

Ever thought about the kinds of contacts our physicians receive when they register on the World Job Bank?

This will give you an insight into one physician registrant’s experience: Dr. X, a female, board certified internist, registered on the World Job Bank. She wanted a traditional, permanent internal medicine position and limited her geographic preference exclusively to New England.

Within hours she received numerous voice mails and e-mails. Over the course of six and one-half months, she received 189 e-mails from recruiters at 35 search firms and 72 voice mails from recruiters at 20 search firms.

The following is a breakdown of the e-mails Dr. X received: She received 66 e-mails with brief practice descriptions from one recruiter. Of the 66 e-mails, three positions were for geriatricians, one was for emergency medicine, one was for a hospitalist position and 60 were for general internal medicine. Sixty-five of the 66 e-mails were for geographic areas in which Dr. X was not interested. Only one of this recruiter’s e-mails was for a position in New England. Dr. X also received 33 generic e-mails containing no practice information (e.g., “Are you still looking for a position?”). Of those 33 e-mails, six had nothing in the subject line and one recruiter sent a questionnaire for the doctor to fill out (requesting her geographic preferences which Dr. X had just listed on the World Job Bank). Another 32 e-mails were from one recruiter. One of his e-mails described a practice opportunity in Dr. X’s desired geographic area, the remainder (31) gave brief practice descriptions for geographic areas in which she was not interested. Fifteen e-mails were received from a second recruiter at the same firm, none were for the geographic area in which Dr. X was interested. Dr. X received another 43 e-mails from other recruiters which contained brief practice descriptions. Seventeen of the 43 e-mails gave brief practice descriptions for geographic areas in which Dr. X was interested, the remaining 26 were of no interest to her.

The following is a breakdown of the 71 voice mails she received: One recruiter left 14 messages asking if Dr. X was “entertaining practice opportunities,” but did not mention any opportunity. Another recruiter from the same search firm left three voice mails which were identical in wording to the first recruiter’s messages. A recruiter from another firm left 14 messages stating he had a practice opportunity but gave no details and stated he would “take her off his list” if she indicated she was not interested. A recruiter from a different firm left three messages about Dr. X’s supposed preference for jobs in the Chicago area (she only wanted New England.). One recruiter gave brief information about a practice opportunity but didn’t provide a state or even a general geographic area where the practice was located. Another recruiter apparently dialed the phone and forgot, or didn’t realize the doctor’s voice mail was recording. No actual message was left but Dr. X got to hear a recording of the person chewing and crunching on what sounded like a carrot! Thirty-three voice mails contained nothing more than the recruiters’ names, phone numbers and infrequently their companies’ names. Only three voice mails gave some information about practices in Dr. X’s desired geographic location.

To summarize: Dr. X received 260 contacts (both e-mail and voice mail). Of the 260 contacts, only 20 contacts provided information about practice opportunities in her specified geographic location that were potentially of interest to her."

End quote.

I am speechless from the shock that a recruiter would actually publish this. I have nothing to add, except that it matches my personal experience exactly! Dr. X, I feel for you! Since I have this representative story, I can postpone counting and examining the statistics of the response that I have received. You may have read it in my previous posts, I have been looking in one particular Desirable City, where recruiters typically just cannot find jobs. We all know why. Who in their right mind would be sitting in a practice or hospital in a fabulous location and pay a recruiter $$$$ to have a position filled, when a simple ad in a few journals, at NTNJobs and eHealthcareers would bring in dozens of applicants?

The other remarkable point is: Recruiters are in such a marketing and selling frenzy that they simply do not pay attention to what candidates want. Right from the start I found this rude and careless. I always wondered why on earth recruiters did not read my profile and kept on sending me positions that were as far away from my desired city as could be.
Now I know that they are just too busy emailing and cold calling and mailing anybody that leaves their contact info within their reach that they cannot think. It is a selling frenzy.
And by the way, no wonder recruiters have "to work so hard" if they waste their time in this fashion. They spin their wheels for nothing, or worse, they get a backlash. I am part of that backlash, by the way.

My humble opinion: I you do not want to be the next victim of time-wasting spam called recruiter advertising, don't bother using recruiter job banks!

Instead, read my blog for better ways to find the great job you want!

Monday, July 23, 2007

7 Reasons why I Admire Physician Recruiters

1. They have a "positive mental attitude" (as written by Jim Stone of They are able to see a "great place to raise a family" and a "great place to build a practice", where I see just, well, Desert Gulch, a place where I would neither want to exile my family nor would want to build a practice. And where in general I would not want to be caught dead after sundown.

2. They have magical, mystical, truly superior means of transportation, very much like Harry Potter's broom. A town they see as "only a short drive from LA" to me is 75 miles away and it takes me an excruciating 3 hours on a good day to get to the city.

3. While they can "enjoy all Boston has to offer" from a small town on the New Hampshire border, I get frustrated with all the woods and rocks. And for me the hour plus drive to Boston pretty much takes the fun out of it. I believe one-hour commutes are overrated.

4. They know much better than I what to do on the Internet. They know that you best use Google to "find physician recruiters where you want to go to" (Healthcarerecruiter blog), while I merely have been able to find employers that offered me jobs.

5. They know that the "best practices" are located far outside the city, while I sheepishly was looking INSIDE the city for a practice.

6. They know that a good job search starts by contacting a recruiter, one single recruiter, preferably in a small firm (recommended by recruiter Rebecca Gresham on a product-placement article on the otherwise very respectable MomMD), while I erroneously thought that starting your search by contacting recruiters is the equivalent of shooting yourself in the foot.

7. They know that it is much more ethical and professional NOT to tell your clients about your limitations. They know that it is absolutely wrong to refer your clients to someone that might be able to better help them. Meanwhile I am still making the horrible mistake of sending my patients to a specialist or a more appropriately talented or equipped colleague as soon as I cannot solve a specific problem myself.

Thursday, July 19, 2007

We have a Physician Oversupply, not a shortage

How will health care look and feel like in the year 2020 when we have the "physician shortage" that Dr. Cooper predicted in his shaky and dubious study? When we supposedly will be short 200,000 physicians?
Will people die in the streets? Lines in the ER around the block? People traveling hundreds of miles for cancer treatment? Mortality at an all time high? Women delivering babies in buses?

I believe those will be everyday scenarios - or not?

Well, this kind of future is very easy to foresee. It actually is already here. In Oklahoma. Just fly there and look around, go to the offices and hospitals, get treated at modern and pleasant ERs, have attentive doctors and nurses take care of you.

Oklahoma has numbers that Dr.Cooper foresees as catastrophic. The physician density is 1.6 for 1000 Americans. The US average is 2.6. The Massachusetts average is 4.3!!! And that is why you hear the whining of "shortage of primary care physicians" the loudest in Massachusetts.
Strangely, you do not hear "help, we are sinking into a health care crisis" screams from Oklahoma.

Does that make you a little skeptical of the "looming disaster"? It sure should.

Dr.Cooper is very wrong in important points, as I have laid out in a previous blogpost. I can only suspect who supports him and why...

It is time that the AMA, ACOG and other professional societies take a better look at his numbers and consider modern developments such as the exploding "Minute Clinics", growing telemedicine and the progress in genetics. And for the notion that the "coming generation of physicians is not willing to work hard", that is the old stuff that parents have ben saying about their children's generation for ages. Ahhh the good old times. Everything was better back then, right?

The "looming physician shortage" is blatant nonsense. In fact, we have an oversupply of physicians since the mid eighties. The proof is simple and does not require any fancy studies: Our incomes have gone down continuously since that time.

Do EMRs make a Difference in the Quality of Care we provide?

A new study released by Brigham and Women's Hospital in Boston discerned no difference in performance outcomes in terms of whether or not physicians use EMRs. The researchers reviewed office visits to non-federally funded, community, walk-in physician practices across the country, using 17 ambulatory quality measures. The lead researcher, associate physician Jeffrey Linder, claims that other studies have revealed that many electronic health records aren't much more than an electronic replacement for paper charts, which suggests a mass underutilization of an EMR's true capabilities.

For more details, read the article in The Washington Post or review the study in the Archives of Internal Medicine (abstract only, unless registered).

Very interesting.

Jeffrey Linder interprets this as "mass underutilization of an EMR's true capabilities". I hope he was not referring to the physicians underutilizing the EMRs. This is certainly not true. The present day EMRs simply fall short, massively short, of what a good EMR could be.

I have no doubt that EMRs have great potential. Sadly, nowadays it is mainly mere potential. My hospital bought Centricity, the former Logician and now the EMR of GE. I was very disappointed by the striking difference between what an EMR could do and what it really is able to do in daily life. It only fulfills a fraction of the dream and it creates a whole lot of unnecessary work. The difference between your dream and reality is just too large.

Let's see: Does your EMR print out instruction leaflets personalized to the patient and her problem after the visit? Does it automatically fax a good looking, well worded, well formatted letter to the PCP after each visit? (My EMR does not even know the PCP of a patient, and even if it knew, it would not know the PCP's fax number and even if it knew, it could not fax it).

Does your EMR tie in and cooperate seamlessly with your website? Can patients book their appointments on your website and they show up in the EMR? Does your EMR send appointment reminders to your patients? Does your EMR produce automated lists of outstanding test results and missed appointments?

Does it generate lists for marketing such as patients and PCP birthdays; does it allow you to record the personal preferences of your patients, starting with how they would like to be addressed and numerous others?

Does it allow your patients to enter their medical histories online? Does it allow the patients to check in online or electronically in the reception area? Does your EMR interview the patient after arrival in your office - about her complaints, her symptoms, her concerns, her compliance with the usual screening tests?

Does your EMR send automated emails to your patients with follow up recommendations, more information on the topic at hand?

and on and on and on...

So, your EMR does that? No? Why am I not surprised?

So, why do you think your EMR should have any more abilities than just a paper chart converted into software?

Once EMR companies start asking for the needs of physicians and actually building programs that really help and really take over some work instead of causing more work, then we will see an increase in productivity!

And that will not happen anytime soon! Now all our poor colleagues feel under pressure to adopt some kind, any kind of EMR and are just wrapped up in choosing among the bad, the somewhat bad and the very bad EMRs that are commercially available.

Someone please come up with a smart EMR

Wednesday, July 18, 2007

Disorder in the Court

These are from a book called Disorder in the American courts, and are things people actually said in court, word for word, taken down and now published by court reporters, that had the torment of staying calm while these exchanges were taking place.

Q; Are you sexually active?

A: No, I just lie there.

Q: What is your date of birth?

A: July 15.

Q: What year?

A: Every year.

Q: What gear were you in at the moment of the impact?

A: Gucci sweats and Reeboks.

Q: This myasthenia gravis, does it affect your memory at all?

A: Yes.

Q: And in what ways does it affect your memory?

A: I forget.

Q: You forget? Can you give us an example of something that you've


Q: How old is your son, the one living with you?

A: Thirty-eight or thirty-five, I can't remember which.

Q: How long has he lived with you?

A: Forty-five years.

Q: What was the first thing your husband said to you when he woke up hat morning?

A: He said, "Where am I, Cathy"

Q: And why did that upset you?

A: My name is Susan.

Q: Do you know if your daughter has ever been involved in voodoo or the occult?

A: We both do.

Q: Voodoo?

A: We do.

Q: You do?

A: Yes, voodoo.

Q: Now doctor, isn't it true that when a person dies in his sleep, he doesn't know about it until the next morning?

A: Did you actually pass the bar exam?

Q: The youngest son, the twenty-year-old, how old is he?

Q: Were you present when your picture was taken?

Q: So the date of conception (of the baby) was August 8th?

A: Yes.

Q: And what were you doing at that time?

Q: She had three children, right?

A: Yes.

Q: How many were boys?

A: None.

Q: Were there any girls?

Q: How was your first marriage terminated?

A: By death,

Q: And by whose death was it terminated?

Q: Can you describe the individual?

A; He was about medium height and had a beard.

Q: Was this a male, or a female?

Q: Is your appearance here this morning pursuant to a deposition notice which I sent to your attorney?

A: No, this is how I dress when I go to work.

Q: Doctor, how many autopsies have you performed on dead people?

A: All my autopsies are performed on dead people.

Q: ALL your responses MUST be oral, OK? What school did you go to?

A: Oral.

Q: Do you recall the time that you examined the body?

A: The autopsy started around 8:30 p.m.

Q: And Mr. Dennington was dead at the time?

A: No, he was sitting on the table wondering why I was doing an autopsy.

Q: Are you qualified to give a urine sample?

Q: Doctor, before you performed the autopsy, did you check for a pulse?

A: No.

Q: Did you check for blood pressure?

A: No.

Q: Did you check for breathing?

A: No.

Q: So, then it is possible that the patient was alive when you began the autopsy?

A: No.

Q: How can you be so sure, Doctor?

A: Because his brain was sitting on my desk in a jar.

Q: But could the patient have still been alive, nevertheless?

A: Yes, it is possible that he could have been alive and practicing law somewhere.

Natural Cures "They" Don't Want You To Know About

A short note about a book by Kevin Trudeau called... Natural Cures "They" Don't Want You To Know About

The author, who is mainly a marketer and salesperson and who has minimal or no medical training, tries to conjur a kind of conspiracy theory: medicine is driven by the commercial interests of big pharma, who ruthlessly abuse Americans. Government institutions such as the FDA, medical universities and physicians in general are in on this ruthless for-profit game.
What suprises me is the success of this book, which supposedly sold hundreds of thousands of copies.

The first upsetting issue is that the title insults your intelligence. Who really believes that absolutely everybody is in on a conspiracy, that nobody would step out of the conspiracy and get really rich with medications that work? "They" do not exist.

One of the important points in this book is - what does the author recommend that you do after reading all this?
And this is not a joke, he actually recommends NOT to see any healthcare provider that
a) writes prescriptions and / or
b) does surgery!
You need to wrap your mind around this.

The ability to write prescriptions and to perform surgery happen to be the things that require a state license. And they require a state licence because they are powerful, high impact actions that demand training, experience, intelligence and accuracy to do them right and use them for the benefit of others. It demands the committment to go through a substantial, difficult training and qualification process. Those 12 years for pre-med, medical school and specialty training demand quite a bit from you.

And the author recommends NOT to see anybody who has and uses those abilites. What would you think of someone who told you NOT to send your child to a school with licensed teachers? Would you trust someone who told you NOT to have your house built by a licensed contractor? Would you trust someone who recommended that you take your legal affairs to someone who is NOT licensed by the state?
But that is just what the author recommends. He suggests that you put your health into the hand of dubiously, if at all, trained individuals practicing far away from science and from the mainstream.

This recommendation nevertheless may explain the success of his book. Every "health care practitioner" that populates the twilight of the medical underground will most strongly recommend this book to all his friends and "clients". For a very good reason: They need clients and cash, they need credibility. Since they do not have a license to show, maybe a conspiracy theory will do.

Insurances somehow failed to comprehend the author's wisdom and trust those people who write prescriptions and do surgery. But then, they are in on the conspiracy...
The underground practitioners live from the cash payments of misled people. And to them, this author's book is money in the coffers.

The book looks like a planned, slick compilation of strange stories and myths from the medical twilight and health underground. It feels as if the stories were compiled to specifically appeal to those who frequent the medical underground - maybe due to disappointment with scientific medicine or due to sheer lack of knowledge. This is a sufficiently large number of people to make a book successful.

One of the many reasons why I like practicing in the US is that there are less people who believe in the nonsense presented in this book. The general level of edcuation and overall trust in science is very high, at a very enjoyable level. After all, it took humanity thousands of years to rise to the level of today's science. Evidence based medicine is simply...better.

And for the weird stuff, go to

Another book I do not recommend:
Asset Protection for Physicians and High-Risk Business Owners
by Robert J. Mintz, Paperback, from $10.85

This book is by far too general and does not offer truly usable advice.

The main message is: As a wealthy person, e.g a doctor, you are a target for lawsuits. Lawyers go after the deep pockets, meaning you. Asset protection is possible and provides a good shield, but the details are complicated.
Ok, and now you know what the book says.

Mintz writes a lot in vague terms about filing the "appropriate" documents, but never bothers to explain what "appropriate" really means. He implies that you should leave this whole complicated matter to an experienced attorney. An experienced attorney such as, you guessed correctly, the author himself.

The book is mostly a sales pitch for his legal practice. I consequently contacted him with a request to provide me with a structure for my few assets, in preparation for the future. I had very few assets at the time. He did not even bother to answer my email. I assume his fee depends on the assets under management and I assume he is fishing just for wealthy clients...

Monday, July 9, 2007

Stay Up To Date With The Best CME

I like the Harvard courses in Boston called "Annual Update in ObGyn" that are held in spring and fall. I attend one of these courses every one to two years. The courses in Spring and Fall are not the same in terms of faculty and content. Check for alternatives at Yale, Duke, Cornell, UCSF, etc - these alternatives may exist, although I am not aware of them. A further advantage is that you have the chance to get in touch on a personal basis with the outstanding and very approachable faculty of Brigham and Women's. You also receive excellent print materials. You may purchase excellent Video CDs of surgical techniques for a reduced price.

Audio-Digest CDs, "the spoken medical journal" is the best CME program I have found.
After you subscribe they send you a CD (or MP3) every two weeks with selected lectures of very good, renowned, expert speakers, many of them nationally known, on topics that really matter. Lectures are easy to understand. I listen to the CDs in my car on the way to work and back, over and over again - until I am bored. This is a very effortless way of learning. The material kind of diffuses in.
They send you a printed summary of each CD, you can get short abstracts of their website, you can download a list of these lectures from their website. This is something I include in my recertification / relicensing papers. Of course you have the ability to collect CME points.
Has proven to be incredibly effective, I would not want to miss it. The best bang for the buck in terms of CME.

The other best CME is the ABOG list of publications and the corresponding questionnaires they send out four times a year. Our hospital librarian finds the publications and copies them for all the ObGyns that participate. You can't beat this - a. you keep your board certification up to date, b. someone does the legwork of selecting interesting and relevant publications for you and c. you get CME credits

Consider a subscription to “UpToDate”, my favorite medical database and, yes, textbook. It is written mostly by Harvard faculty, very easy to read, very uptodate (as the name implies), very thoroughly researched. Easy to search.
Uptodate also has another very nice feature: the section on "what is new in..." and the section on ObGyn then reports about "10 important developments in the last year". Very nice, easy tool to keep up and make sure you have not missed anything during the last year!!

I also like two of the Throw-away journals:
1. "OBGmanagment" since Robert Barbieri is the editor. Barbieri, the chief of the ObGyn department at Brigham and Women's, happens to be incredibly smart, talented and also is a brilliant teacher. He and his editorial staff have an uncanny ability to find out which topics are relevant at the moment. The journal is presented very well, with hints how to read it fast, with hints as to what is important. And on top of everything he is nice if you meet him in person.
2.Contemporary ObGyn, which is Yale-powered. Similar praises as for 1.

Not so good and not recommended:
1. ObGyn Survey: somehow the selection of topics is off, I subscribed, ended up not reading it and cancelled.
2. Practical Reviews, ObGyn and Women's Health by Oakstone Publishing: they select articles, review them and comment them. The selection was just OK, the abstracts were good, the comments were just slightly changed abstracts without many new insights. Overall - not worth the time and money. Cannot hold the water to AudioDigest.

Saturday, July 7, 2007

Deciphering A Recruiter Ad

Looking for "Gynecology Jobs" in "Florida" in a larger recruiter database, I found two ads. These two ads seemed to represent two different jobs, but only at first glance. Recruiters do not tell you the locations of their "opportunities", but with just a few minutes of searching, you can sometimes find out.
Here are copies of the two ads, and here are the steps I took to find the name and phone number of the doctor in under 5 minutes.
And remember, recruiters fill the less desirable jobs. You may not want or need those jobs. The best way to find a physician job is direct mail!

Begin quote of ad one:

“A 129-bed full service hospital, located in Coastal Florida, is seeking a board certified Gynecologist to join an existing Gynecologist. This opportunity provides a competitive first year income guarantee, relocation, and marketing assistance.. The Medical Center is a progressive, community hospital providing personalized, quality health care for Indian River County and south Brevard County residents. The counties’ population total 250,000 with a catchment area of 80,000, and rapidly growing. The facility offers an array of inpatient and outpatient services including a new emergency services department, wound care with hyperbaric therapy, sleep disorders center, and an outpatient diagnostic center. This Medical Center has been recognized as a “Top 100 Hospital”, “Best Places to Work” for 2004 and 2005, Company of the Year for 2004 by the Indian River Chamber of Commerce and “Best Medical Center” by the Press Journal Reader’s Choice Award. Location Description Nestled in a surrounding of natural beauty and one of Florida’s authentic Treasure Coast communities on the Indian River Lagoon, this community is the famous home of America’s first National Wildlife Refuge, Pelican Island. You will discover beautiful beaches, attractive inland/oceanfront parks, plentiful shopping, libraries, live theater, and fine dining. Sebastian offers plenty of sites for fishing, marinas harboring boats of all sizes, fishing piers, a championship golf course, tennis courts, airport, and sports complex, including a newly renovated playground and skating facility. A sunny and warm climate lends itself to a variety of outdoor activities including various bike, jogging and walking paths throughout the area. This Community is an ideal location to live due to affordable housing, excellent public and private schools, as well as, several community colleges and universities nearby.”

End of quote of ad number one.

begin of quote of ad number two:

“Currently seeking a BC/BE Gynecologist to join an existing Gynecologist. This opportunity provides a competitive first year income guarantee, relocation, and marketing assistance. Medium-sized acute care facility that provides general medical and surgical services, a full service emergency room, an outpatient diagnostic center, wound care center, and home health services. This facility has earned reputation for providing quality healthcare for its patients with unmatched courtesy, competence, and compassion. Since its opening this hospital has maintained excellent survey scores by the JCAHO. Florida/No State Taxes!! Living and working is easy in this area, and the sleepy fishing village communities have come into the 21st century with a boom. Raising a family, seeking higher education, fulfilling employment, or just enjoying your retirement years, this is the perfect place to do it all. Located east of the famous surfing capital of the east coast of Florida, the inlet and barrier islands provide miles of oceanfront. Surrounded by water, whether you choice is the salty breezes of the Atlantic Ocean, the briny waters of the Indian River lagoon and the St. Sebastian river, or the fresh water bass fishing capital of the state, Fellsmere, we have it all.”

End of quote of ad number two.

I extracted the likely useful information from each ad:

Extracted from the first ad:
Join one other gynecologist (not a group)
129-bed full service hospital
Indian River County and south Brevard County
Medical Center has been recognized as a “Top 100 Hospital”, “Best Places to Work” for 2004 and 2005,
Company of the Year for 2004 by the Indian River Chamber of Commerce and “Best Medical Center” by the Press Journal Reader’s Choice Award.
community is the famous home of America’s first National Wildlife Refuge, Pelican Island

Extracted from second ad:
East of the famous surfing capital of the east coast of Florida, the inlet and barrier islands provide miles of oceanfront
Indian River lagoon and the St. Sebastian river, or the fresh water bass fishing capital of the state, Fellsmere

Here is what I searched based on the first ad:
“Pelican Island” turns out to be very close to the “Indian river lagoon”.
The website of Pelican Island” tells you that “the nearest community” is Sebastian, FL. Now I google “Sebastian, FL”, and check the Wikipedia entry on Sebastian.
The wikipedia article confirms all the data in both ads and now I am sure that it is actually only one position that both ads are presenting.

A look at the website of the hospital immediately confirms the “laurels” mentioned in the ad. The very informative hospital website further says everything you want to know about the hospital including the humble beginnings. It also confirms that it is a “129 bed hospital”. It turns out that the second ad is a pretty much an exact replica of the hospital ad, just with some of the identifying information removed.

What I searched based on the second ad:
I googled “Indian River Lagoon” and “Sebastian river” and “Fellsmere” in one line and this web search yields a little Google map with a town called “Sebastian” in the center. The rest of the steps are exactly the same as above.

The hospital website mentions exactly one solo physician in the specialty of gynecology: Dr. Jennifer XXX, with photo, address and telephone number. Pick up the phone and call her. What else do you need?

"Looming Physician Shortage" is Nonsense

You may have heard the rumors an "impending physician shortage". Dr. Richard Cooper from Wisconsin calculated that we will need 80-100.000 physicians more in 15 years, and is spreading alarming news about a "looming physician shortage". He recommends that we should enroll more students in medical schools, found new medical schools and expand existing residency programs and create new programs.

I disagree with the notion of physician shortage that resulted from Dr. Richard Cooper's study. I suspect the numbers and basic assumptions are wrong.

There is no shortage now. While we had 1.6 physicians per thousand Americans in 1970 (500.000 physicians total), in 2000 we had 2.4 physicians per thousand (over 800,000 physicians) and presently we have an average of 2.6 physicians per thousand Americans. Despite population growth, the ratio of physicians to patients has grown, has improved. Our present system of education is actually increasing the number of physicians per 1000 Americans.

In addition, in my opinion we have an oversupply of physicians since the 1980s. Here is why: I repeat: The cost of any service is determined by supply and demand.This is so simple that most people forget it, although the sudden rise of gas prices after hurricane Katrina should have reminded everybody. Physician earning power has dropped to about 1/3 of what it was in the mid eighties.

One example from my area: 20 years ago an ObGyn in Boston earned about 400 K and a very nice home in the best area of Boston cost about 400K. Nowadays the very same house costs 1.6-2 million and the same ObGyn (working a lot harder and seeing about twice the number of patients) earns 200K. Physician income has dropped dramatically. And that means that we have an oversupply of physicians. And we have an oversupply since the 80's. No study required. You have been reading about continuous and seemingly unstoppable decreases in reimbursements for physicians. Is that a sign of a balance between supply and demand? No, It is a sign of oversupply.

This means that Dr. Cooper is wrong in assuming that the present situation is "balanced" or "neutral". The present situation is not the "normal level", it is a level of oversupply.

There is no good way of planning physician supply. Who knows what will happen tomorrow and how it will impact physician supply and demand? Maybe we will find the gene for motivation to exercise or the gene for weight and obesity and the manipulation of that gene will make all the heart diseases shrink to 5% of what they are now?

When considering prediction for the future, do you remember what 60's thought the cars of the future were going to look like? There were pictures of large ship like cars with fins, rotating seats, driving fully automatically... which is just what we have now - right? That is how well predictions about the near future work, even if they are made by qualified people.

Dr. Cooper, the author of the unfortunate study, who now is making a living off the buzz around "physician shortage", did not foresee ...

1. The "minute clinics" that are sprouting like mushrooms in CVS stores, Walmarts etc all over the country. The numbers of patients seen in these clinics are rising rapidly and the number of visits are already reaching millions. These clinics, operating under the slogan "you are sick, we are quick", are rapidly gaining in acceptance, and not only the number of visits to these clinics are growing, but also the average payment per visit. The customer satisfaction is on par with the satisfaction in physician offices. These clinics will be a tremendous competition to physicians, or, in the eyes of Dr. Cooper, a "relief" of the "shortage ". The development and growth of these clinics alone may prove Dr. Cooper wrong.

2. Dr. Cooper did not foresee or consider telemedicine. Indian physicians are already reading numerous x-rays, CTs and ultrasounds at night, due to the fact that our nighttime is daytime in India. This trend will expand, since Indian labor is cheaper, and soon we will have a decreasing need for radiologists.

3. There are large numbers of very well trained and very competent physicians in Central Europe (Germany, United Kingdom, France, Spain and Italy) that could transition to the US. These physicians would only need residency training. They would not need medical school. The cost savings for the US would be dramatic and these physicians would be available much faster than physicians newly schooled and then trained in the US.

4. If, yes, if there really, really, truly more demand for health care providers it would be much more economical to train more nurse practitioners and physician assistants, who are very well suited to take care of routine cases. Physicians would diagnose and treat the more unusual and difficult cases.

And, training more physicians is very expensive. Physicians create their own demand, even if Dr. Cooper denies it. Every physician works to fill his or her practice, even if it is with minor issues. Young, unexperienced physicians are more expensive than experienced physicians, since they order more tests, since they need more diagnostic procedures to reach the same diagnostic goal than experienced physicians. American taxpayers would be punished with the extra expense of additional unneccessary medical schools and training programs and Medicaid contributions. The strain on Medicaid and Medicare would accelerate.

Overall, I seriously doubt we can reliably foresee the demand for physicians in 15-25 years and prefer to go with Yogi Berra's statement "predictions always are difficult, especially about the future". I do not see a shortage now and I see easy relief for any kind of "shortage" that may (or may not) present itself in the future.

Dr. Cooper's statements are extremely damaging for physicians and should be re-evaluated. This should be done before the present oversupply of physicians is worsened and perpetuated by creating more unnecessary and very expensive and costly medical schools and residency programs.

Who benefits from this alarming rumor? Who makes money from it? Guess who - the HMOs.HMOs make money by withholding payments, delaying payments and by lowering reimbursements. This is only possible because they can rely on a large number of physicians that have to put up with these shenanigans, because they do not have alternatives to the current HMO contracts and payment methods (or better witholding-payment methods). The HMOs exist only because of physicians need to contract with them. Physicians only need to contract with HMOs under the present conditions because there is an oversupply of physicians.

A very good example of this, and proof of my opinion is the comparison between Massachusetts and Oklahoma.
Massachusetts has the highest density of physicians per 1000 Americans - 4.3 and Oklahoma has the lowest density, 1.6 (only Louisiana is lower at 1.5).
The income of a primary care physician after residency in MA is arouond 120K, the income of a primary care physician in OK is 250K. No difference in training, no difference in work, just a difference in HMO contracts. Suprisingly, I have never heard news of a physician shortage in Oklahoma, but I hear complaints about "primary physician shortage" in Massachusetts. Even sophisticated colleagues wonder in public how we can have a shortage while reimbursemnents are going down. Dear colleagues - you are right to wonder, we just don't have a shortage as long as reimbursements go down, wake up, it's rumors and whining, not true shortage.

So, what does that tell you. We supposedly have a shortage in Massachusetts,in a state with the highest density of physicians, but not in Oklahoma, where we have the lowest density.

What I conclude from this is: Demand for physician services has a subjective component.

What would happen if we actually would even have a balance of physician supply or even a mild undersupply? Physicians would be busy enough to "fire" their most abusive, payment-delaying, under-reimbursing HMO and simply stick with the HMOs that pay a little more realistically.
Good for us, bad for the abusive, greedy, bottomline oriented HMOs.

Oh, you say this is "hyperbole"? Well, read the lawsuits that were decided in favor of physicians that clearly find that HMOs routinely underpay and try to cheat physicians out of their money using multiple tricks. It is a fact, not hyperbole.

It would be a disaster for HMOs if physicians could demand better payments. The future of HMOs depends on the ability to have a large supply of physicians, an oversupply of physicians, willing to work for less and less. Actually, the future of HMOs is at stake here. What do YOU want to do about it?

Friday, July 6, 2007

Letter to a recruiter - Why I am disappointed

Here is a letter that I wrote to a recruiter with whom I had worked in the past. He came across my blog and was very upset. We exchanged a few emails. Here is the last of them that summarizes what I think about recruiters and why I promote other ways of finding job for physicians.

Beginning of letter:

You are right, I may have generalized my personal experience to "all recruiters". Nevertheless, I have been searching for jobs since 1999, in excess of 7 years. I therefore have been in touch with recruiters for about 7 years. I have spoken on the phone to dozens, maybe a hundred recruiters, seen countless recruiter websites, aggregator websites that publish ads from multiple recruiters, and read innumerable newspaper and magazine ads. I may not be the "national expert", but I think I am most certainly knowledgeable enough to voice an opinion. I am definitely more knowledgeable than your one time job seeker.
In case you were wondering, I have been searching for that long due to quirky personal circumstances that have nothing to do with my training, my performance at work or with any kind of legal issue. It's just personal.

I have stopped job searching in March 2007 and at the same time started a blog about my experiences with my search, because other physicians need to know what I experienced. Other physicians should not have to go through the same thing.

The fact that made me search for so long is in part due to insisting on very select locations, such as inside Boston and inside Miami. Due to this the same sequence of events kept repeating over and over and over and over and over again: Recruiter: "Contact us, we have lots of great jobs" Me: "Well, do you have something in Miami?" Recruiter:"No, but ...30-50 miles away". And after the hundredth or so phone call and email that goes exactly the same way, you start to get frustrated, then you get aggravated and then you get cynical. I did become cynical when I read "great jobs everywhere, the best jobs, the best practices" etc etc.

For me, the preferred place to work is in a large city. Since it is my preferred place, I call it the "best place" and the jobs in the large cities the "best jobs". That may not be everyone's opinion. But, like it or not, the majority of physicians prefer larger cities. And therefore, the jobs in large cities are filled without any help. Job is large cities are filled because physicians network their way to those jobs.

My mistake was that I mainly searched passively and not actively, meaning I kept on looking at print ads, internet ads, recruiter emails etc.
Since I could not find a job that I liked, I even started to believe that good jobs (good according to my definition, meaning in large cities that are attractive to live in) were just not available to me, that somehow I could not get them! That was painful and made me feel helpless.
My beef with recruiters is actually that they do not have jobs inside cities such as Boston and Miami (you are literally the exception that confirms the rule) and that nobody, but really nobody told me that recruiters are just unlikely to get them. I would have been ok if recruiters told me "Hey if you are looking inside Boston and Miami, you have to approach your search differently! Do this or that and you will find a job". Only one recruiter ever told me, and it was an older, seasoned recruiter. And he added before telling med: "I believe that I will be rewarded for this some day somehow".

It is my firm opinion that recruiters should tell physicians about their limitations, about the areas where they either do not find jobs or are very unlikely to find jobs. It would dramatically cut down on criticism. Disclose your limitations and drawbacks. Even home sellers have to disclose what is wrong with the home they are selling.
Now I know that recruiters do not get the desirable jobs in the big cities. Now I simply do not ask anymore. But now I know how to find jobs in highly desirable locations myself without any outside help. I am not helpless anymore.

After a while I started asking the recruiters head on: Why do you not have jobs in Miami? One of the answer was: "we usually get positions in areas where there are more jobs than applicants. In Miami there are more applicants than jobs and therefore we tend not to get them".
That is the kind of answer I had hoped to get several years ago.

But recruiters all act as if there "simply are no jobs", the term is "that area is oversaturated". What they convey between the lines is "If I don't get jobs there, then there simply are no jobs there". I sometimes think they even believe that nonsense themselves.

And then of course there is that other cute sales answer that I received 6 or 7 times: "I will call my clients in Miami and see what I can do" - meaning he or she actually has "clients" in Miami, meaning he or she is in regular contact, has good business connections to them etc. Sounds impressive at first. But the being impressed faded away, when, not surprisingly, I never ever heard back from any of those people.

So, I think I write from experience. I know that recruiters are human, I know that there are a lot of good people among them. I mentioned that I like the two owners of Medicus Partners that write the blog "Dochunterdiaries". I like their blog, I like their opinions, I like what speaks through the blog, I like what I perceive as the people behind the blog. They are great guys and I agree with most of what they write. But there are also a lot of people that just sell. And nobody, not the good ones and especially not the bad ones tell you how to find a job in the desirable cities.

And, no matter what, for recruiters it is exceedingly hard to overcome the 20K handicap. And, of course, you get called to fill the positions that are difficult to fill for many reasons.


End of letter

Sunday, July 1, 2007

Physicians Slow in Adopting Expensive and Inefficient EMRs

It seems to be fashionable to complain about doctors and present them as old fashioned and technophobic. Here we have Scott MacStravic wondering why on earth physicians seem to have difficulties transitioning to electronic medical records. Wise and heavy words are being used, concerns are expressed, motives speculated. Academic reasons are considered. Oh, my, oh my. We physicians are the same as everybody else. We are just a little more independent and demanding. We want things to be done quickly and easily. If you present us something that is easy, we'll do it. Scott MacStravic writes about "The hidden reasons"... Scott, you know what, do us all a favor, use those things for a few days and the reasons will no longer be "hidden".

Why are we not running to adopt EMRs? We all have seen the websites where doctors ask for help in deciding which EMR will be the least damaging to their practice and their pocket book! We are not rushing to buy them, because most EMRs today are clumsy, klutzy, slow and expensive systems. None of these software people has had the smarts to start with the consumer. Nobody has studied what physicians do in everyday practice, how exactly they do it, studied it down to the smallest detail, studied the exact work and documentation process. That is what they should do, and then, please take that process and take all, but all the routine work out of it, leave only the "presidential decider" part in, throw in a little help in the deciding department too, give the system some AI, make it adaptable, so that we can have it "our way" - like Burger King. Then make it smart, build in "favorites" everywhere, make the system able to learn our specific style, our specific preferences in diagnoses, billing codes etc. Make it able to link to literally everything and put it on a graphical surface, maybe one that you can also click on with your finger or your regular pen or with one of those fancy computer pens. And you will have a system would sell like the proverbial hot cakes.

Look at what we have in reality? We have overpriced systems that look more like Windows 3.1! Programmers, have you ever heard of MAC or have you seen Vista? Have you ever been to Have you thought about "ease of navigation"? I doubt it.

The system my health care system has presented me is a prime example of a clunker. The core was programmed 20 years ago, and you see it and feel it. History and tradition are a good thing, but not in software. It is so old fashioned, you see the Windows 3.1 still peeking through the creaks. It is crystal clear that it is a patchwork of not very well integrated components. It is embarrassing. Amount of work that has gone into investigating consumer needs and making it easier to use: Minimal. Price: Maximal.

And, talking about money. The clumsy Centricity that I am using has a completely separate billing component. The billing component knows nothing about what goes on in the EMR. This is the biggest stupidity I have ever seen. Billing should be done fully by the software based on the documentation. And should you fail to immediately understand this, you do not belong here in this discussion. We document what we do and we bill according towhat we do. Billing is 100% dependent on what we do, straightforward. So simple, a caveman could do it. And the famous software package Centricity of the famous American company GE should be able to do it too. It should be designed to do it in the first place. It should not even be separate from the documentation part, it should be a completely integrated part of documentation.

With all due respect, Scott is not a physician and has never used an EMR in daily life. I just finished implementing an EMR in my practice. As a hospital employed physician I did not have to buy the system, I just received the hardware and software and started using it.I am a computer enthusiast. And I was very, very disappointed by the EMR (Centricity from GE). It slows me down, it drains my productivity, it makes simple tasks complicated, every little thing takes clicks and click and clicks and more clicks and then some more clicks. It does not provide good access to data, it does not give me the same quick overview of a patient that I had in my paper chart. upon opening my paper chart I had the "summary", a kind of history of the patient with some personalizing remarks and notes and reminders - all on the left side. one glance and I remembered the patient and knew what was going on. My EMR does not allow that, it only gives me the stupid ICD 9 codes, uncoded comments, notes and remarks are "forbidden". When I protested about the lack in functionality I heard the sadistic comment "We try to keep the system standardized". Hey, that works in big corporations, not in private practice. Another one is "We have to do this for patient safety" of "it is a HIPPA requirement". Patient safety is such a fabulously chic buzzword at the moment. But it is a very bad excuse for a clumsy, klutzy system that makes you confirm and confirm and confirm again the most simple steps!

I drive a Volvo for security and it drives as well or better as any other car. Security happens behind the scene. My Volvo does not force me to stop every 100 feet to look around and it does not limit my speed to 25 mph in the name of safety, my car does not force me to stop before making a right turn and confirm that I really plan to make a right turn and so on.

Everybody out there, please understand. The sole idea of software is efficiency and ease of use.
The idea is the Three Click Visit. First click to confirm the history entered by the patient or the nurse, second confirming the template that the system chooses for you and third confirming the prescriptions that will be faxed to the pharmacy, the education leaflet printed for the patient and the automatic letter being faxed to the PCP.That would be a system everybody runs to adopt. Please do not try to find contorted far fetched theoretical reasons for "lack of adoption".

And that, my dear concerned observers, is the reason that physicians are slow in adopting EMRs! EMRs on the market today are complicated, user unfriendly, inflexible and expensive. What a winning combination! We can't wait to buy one of those systems. Did I mention that they drain productivity, but we get paid less instead of more? Physicians are just a tougher clientele. We are not employees in a big corporation where you can simply slap a computer on each desk and say: put up with it or leave. We actually (still) have the freedom to choose (still). We would love to have EMRs, but we are not going to put up with crappy ones. So, make some good ones, and keep the price down. Is that so hard to understand? If Yahoo was as difficult and clumsy to use as my EMR, it would already have vanished from the net.

Can someone please design a systems with a surface like Vista or Mac OS, a system that is built after careful user studies and user analysis, after studying what physicians do all the time, systems that physicians can adapt and mold exactly to the way they want.

And then make those systems cheaper. Forget the abusive purchase prices and the high maintenance costs. Doctors are not rich anymore!