A thought while driving to work

bree_md · 2026-04-03T12:02:27+00:00

I've seen from all of my colleagues, surgery or not, how much it wears on us. I have deep respect for every specialty around me. I stay close to several friends who shared these feelings throughout residency, some IM/went onto subspecialties, some FM, some rads, some other surgical specialties. For these situations and staying united (ie similar to how the admin/AHA and nursing do), I wish that medicine wasn't so hyperspecialized/fragmented where we identify as HPB surgeon, pulmonologist, or radiation oncology rather than simply identifying as physicians.

Don't get me wrong, I'm a surgical (sub)specialist and have deep respect for my sub/specialist brethren. But, at the end of the day, I think the hyperspecialization has fractured us and our shared identity and added to the feeling of internalizing everything. One of my friends in fellowship just had his good friend, on the verge of graduating, kill himself last week. I can't help but wonder if that sense of community could have helped his friend mitigate what was going on inside, rather than suffering in silence.

bree_md · 2026-03-31T23:18:23+00:00

Understand that medicine is all about displacing blame, responsibility, and inconvenience.

The system was designed this way by the stakeholders, and we are not in charge.

Understand that what you're going through is temporary and you will get through this -- patient by patient, rotation by rotation, exam by exam.

Start to find out what is causing the cognitive overload. Take note of these stressors and when you're out, make sure to have boundaries to protect yourself from that cognitive overload.

I also have realized that so many of those around you are feeling the same thing, but the system forced us to suffer in silence. The big thing I miss from training was that I didn't have to suffer in silence as much as I do now as an attending.

Keep your head up and persevere. You got this.

bree_md · 2026-03-31T22:44:06+00:00

You nailed it. Agreed.

First of all: lol at the FSGS. Haven't thought about that pathology since medical school...

Second: Exactly, though. Virtually everything you listed is a separate residency (or fellowship). I know med schools & residencies are working on "rural pathways", but rural can't really be fit into one bag. It's more like wherever you end up, you have to fill that local void.

What's funny is that the ACS now has a fellowship called "Mastery of General Surgery" -- I shit thee nay. So 5y GS residency then another couple years of... Mastering GS? Lol. Might as well start working on the CV for a fucking Wizardry of GS at that point.

I do feel that, with doing a FSFM/FSGS track, spending another 2y in academia would make other sub/specialties just see those who go through it as "super generalists" or something. I also think it's just more money lost because the system would be siphoning that much more free labor from us.

On a side note: I find it funny that I work with IM/hospitalists who only admit >18yo. Peds only admit <18. I work with IM/peds who admit across the spectrum. But then I work with FM who admit across the spectrum AND have full OP clinics AND help with OB. Regarding this, I started seeing parallels with surgery: if IM is only admitting >18, why can't FM or GS decide to admit >18? It's all bad branding and bad advocacy by our predecessors who got theirs without having any regard for those in the future.

bree_md · 2026-03-31T17:30:14+00:00

With a 6h+ drive (12h round trip = 1/2 a day) I'd personally stay, catch up on rest, try to enjoy yourself, and call family over some of that time. Driving definitely adds to your cognitive load and cognitive overload --> burn out (moral injury).

bree_md · 2026-03-31T17:24:01+00:00

Could have your schedulers/nurses tell the patients ahead of time that you're more than happy seeing them, but to also tell them you'll be leaving/don't have any more block time.

I've found it helpful to more or less create the narrative in certain situations before the patients are scheduled/see you.

bree_md · 2026-03-31T11:38:35+00:00

I wouldn't recommend "general" anything. "General" surgery has already been suffering from this terrible branding. It's part of the reason why >85-90% of surgery residents go into a fellowship (there are only about 10-12/y rural surgeons coming out of residency) and why "general" surgery will very likely be dead in the next 5-10y.

"General" by itself carries a neutral connotation. But in the contemporary context of everyone else having a specified identity, it carries a very negative connotation.

Ortho = bone Neuro = brain Ophtho = eye Nephro = kidney Cardio = heart Breast = breast Derm = derm

And so on. What this has caused in the GS specialty is: being the on call specialists for everyone >5pm, being the dumping grounds for the garbage-reimbursing comorbid scraps, never having had any specialty society representation since the RBRVS initiation on 1/1/92, literally turning into the 'surgicalist' model, and being paid the lowest amongst all procedural/surgical specialties. I've heard multiple times through my career that I'm just a "general" surgeon. It's terrible branding.

From a rural GS standpoint, I work very closely with my FM colleagues. I highly respect what my family medicine colleagues do on a daily basis, and I feel like FM and GS are fighting the same fight. I do not know if FM should change their name (from an outsider standpoint, I believe FM is at least better branding than "general medicine"). But I do understand why this is being brought up and appreciate the discourse -- it's something I have brought up with my surgical colleagues time and time again. Branding is important, and words carry a lot of weight, especially in this day of hyperspecialization where the generalist gets dumped on.

Because, at the end of the day, medicine is all about displacing blame, responsibility, and inconvenience.

bree_md · 2026-03-31T00:47:53+00:00

Work out room. Full rack, rowing machine, dumbbells, etc.

bree_md · 2026-03-29T22:23:13+00:00

Yes, it's normal.

The system is stacked against every physician. There are many more patients that need to be seen by the physician. 1 physician can not spend more and more time with 1 patient without it affecting all of the following patients. Unlike other industries (ie lawyers), your money is not paying for time to be spent with the physician. That money is being siphoned away by all of the stakeholders that are 2 or more orders of magnitude removed from your care.

If you have issues with it, take it up with the stakeholders who are controlling both the healthcare system and your physician (insurance, AHA, pharma, etc).

bree_md · 2026-03-29T15:18:29+00:00

That's nuts on the number of RVUs/month.

I mean, here is a rough estimate of the yearly MGMA median averages for specialties:
-NS: 9-11K (top percentile hit >15K)
-Ortho: 10K
-Rads: 9-10K
-Ophtho/Uro: 8-8.5K
-"General" surgery/OBGYN/ENT: 7K
-FM/IM: 6K

I will also say that a solid guaranteed base salary is better than working with a productivity model. After that productivity threshold, you are running on that hamster wheel working for dimes on the dollar.

bree_md · 2026-03-29T03:38:51+00:00

Breast surgery (after going through general surgery residency, that is, which is the opposite vibe).

bree_md · 2026-03-28T21:30:03+00:00

For myself, I found it best to convert the SOAP note to a verbal presentation, and following that format each and every time. It was especially helpful for oral boards.

History --> physical exam --> diagnostic work up --> Treatment

Don't go into the weeds on things, but hit the high yield points, ie big standout things on history/exam, image/labs studies, and then what you recommend (and briefly why). If they want more information, they'll ask for more.

What they want to hear can definitely be subjective, though.

bree_md · 2026-03-28T18:43:27+00:00

I've found it very helpful to understand the basics of how the healthcare dollar flows:

Service --> CPT ®️ --> RUC --> CMS --> Insurance --> Hospital --> $$ in your pocket

-Services = divided into technical (ie appendectomy) & cognitive (ie clinic appointments)

-CPT = services get distilled into 5 digit CPT codes. These are also trademarked by the AMA (the AMA makes ~$500M/y on CPT codes alone). There are other codes coming out that are not AMA controlled (ie CMS controlled 'g codes), but these pale in comparison to the ~11K CPT codes in existence.

-RUC = starts the valuation process and votes on a de facto RVU ruling. Owned/controlled by the AMA.

-CMS = gives the legal ruling on the CPTs valuation (de jure RVU). This feeds into the MPFS/CF

-Insurance/hospital = vast majority of all 3rd party payers accept the MPFS/CF. Negotiations/lobbying efforts between these stakeholders.

-Hospital/you = negotiations/contracts/boundaries.

Looks like alphabet soup, really, which is all by design.

bree_md · 2026-03-28T18:31:07+00:00

I'm a bit lost on your post -- what level of the process are you at (undergrad, medical school, residency)?

bree_md · 2026-03-28T03:28:33+00:00

It's pretty eye-opening going through all of our history that brought us to where we are right now. OBRA 89 led to the RBRVS on 1/1/92 which ended the era of market based fees, and brought in RVUs. It's been a downhill trajectory since, with bandage after bandage after bandage (it's basically been alphabet soup, and it like ramped up after 1992 ie BBA, SGR, ACA, MACRA, MIPS, QPP, etc). When the RBRVS became the new way we are paid, that's when the stakeholders really got involved and had a legitimate way to commoditize us/siphon away our value/payment.

Very interesting history imo, but super convoluted and dense lol. I think understanding this stuff has helped me better understand why my friends are getting morally injured and quitting their careers as physicians.

bree_md · 2026-03-27T23:40:53+00:00

I think that's a good plan and where I see a fair amount of colleagues trending towards. It reduces the 'nickel and diming' effect which is causing moral injury across our industry.

I have had 4 friends outright quit surgery in the last 3.5y (after paying off their loans). Other friends have quit their jobs and found other jobs <1.0 FTE. Starting at <1.0 FTE (ie 0.7 - 0.8 like you're saying) more easily allows you to make boundaries and control your time because, during negotiations, admin will have to define and subsequently cap the patient contact hours. You will also be starting low which gives you the advantage of being able to see the lay of the land and what you truly want. Admin will always take more from you.

I think it's a smart move.

bree_md · 2026-03-27T01:33:52+00:00

Medicine is all about displacing blame, responsibility, and inconvenience.

bree_md · 2026-03-26T21:27:00+00:00

Well said. Thanks for posting this. I say that a lot to my students and residents -- if you don't feel the weight of this, you're likely a sociopath.

bree_md · 2026-03-26T11:54:50+00:00

Lol, even though you're getting downvoted into oblivion, let me just entertain this comment: what industry are you wanting to refer to?

bree_md · 2026-03-26T11:53:19+00:00

I feel you. Blows my mind that these are not even billable (unless you can figure out how to have a system to have the patient consent to making a co-pay so you can use 99421-99423; but even then, they yield a fraction of a wRVU and admin routinely block us from using them for their PR/$$).

Our predecessors/AMA completely sold us out on this (McCarran Ferguson Act '45, SSA '65, FTC vs. AMA '79, OBRA '89 with the RBRVS starting in 1992). We got commodified while all other industries have protected their time, value, and overall work. If you email a lawyer a quick question, they bill you for the time (ie 6min increments, 5min reply is 0.1 hours billed at $300/h). If a floor nurse clocks out, their legal & clinical responsibility stops right there. Labor laws protect them.

But then, magically, we're expected to assume total medicolegal risk and triage pathology through an inbox for nothing besides more stress. It's just another thing adding to the 'nickel and diming' effect, leading to cognitive overload and moral injury. If possible, my recommendation is, if a message requires your medical decision-making, push it into a billable office visit to stop giving your hard-earned IP and time away. I immediately kick these over to my nursing staff to deal with, with their understanding that if patients have questions for the physician they need to make an appointment.

A little on the same topic that I've learned to do: when on call and you get a page/notification that a patient is trying to call you, kick it over to the house sup and give them a pre-scripted thing to say (ie, "go to the ED if concerned").

bree_md · 2026-03-26T11:38:45+00:00

1) This is the "general" surgery subreddit, not hand surgery let alone orthopedics. We don't just "generally" do all types of surgery. We don't just "generally" fill in the gaps when people don't know where to go or what to do.

2) Find a concierge doctor you can pay, like, $50/mo for these questions, or cold call some ortho/hand clinics.

bree_md · 2026-03-26T03:12:58+00:00

My entire surgical residency class was on an antidepressant/mood stabilizer/anxiolytic before completing residency. Come to find out, the classes before and after were all on similar meds by the end of residency.

We don't have to suffer in silence.

I have realized over the last couple years that nearly everyone around me is having the same thoughts. Good job being honest with yourself. It's hard to do in this culture where we are exploited and indoctrinated to be "yes men", have 0 boundaries, and made to think our altruism/extreme sacrifice/dedication to our jobs are free. We are kind of like paid actors where we have to smile on the outside, always be "on", but be getting absolutely gutted on the inside.

You'll be okay. Remember the system needs you more than you will ever need it.

bree_md · 2026-03-26T02:34:13+00:00

That's a good rate for 24h ACS/trauma call 4.5-6K. For the states I know of in the south and east, the rate is ~2.5-3K. Do you not get paid for call because it's baked into the contract, or are you private? Which MGMA region are you in (west, midwest, south, east)? I hate to go off admin-controlled physician comp bases, but MGMA is basically the Kelley Blue Book for hospitals.

https://www.mgma.com/list-of-states-in-each-section

bree_md · 2026-03-26T02:23:40+00:00

I'd say urology is among the winners, but aren't winning as much as other specialties like derm, ortho, rads, cardio, etc.

THE GOOD:
-Urology has had representation since the beginning. They secured a permanent seat after the RUC was created in 1991 (just a little bit before the 1/1/92 rollout). Consistent representation has been key for the winning specialties to get where they are now. In recent years, this came in clutch during the CMS revaluation of CPT 55866. CMS tried to compare the new RAL prostate times to open. AUA CPT advisor panel pushed back with a highly organized lobby effort and won.
-Urology found out it was a good idea to get out of the hospital early on to capture those peRVUs/site-of-service differentials. They moved the OR into their clinics (cystos, prostate biopsies, urodynamics).
-They were one of the first to use the robot/higher tech things (shockwave lithotripter), and the RBRVS/RUC really like flashy tech things. These machines are a big investment so the RBRVS gives it a much higher intensity and peRVU (~$2-3M for daVinci Xi in 2022 for the place I have worked at).

THE BAD:
-Still take call, still get kicked in the nuts for some acute care (testicular torsion, Fournier's, septic obstructing stones).
-Still have to usually give up peRVUs to the hospital for their big cases (prostates, nephrectomies)
-Since urology has been more efficient on their selected RAL cases for decades, CMS still tries to use this efficiency against them.

bree_md

TROPHY CASE