Race, Income Tied to Late Colon Cancer Diagnoses, Study Finds

Race, Income Tied to Late Colon Cancer Diagnoses, Study Finds

Delay raises risk for complications, death

By Mary Elizabeth Dallas

Wednesday, October 17, 2012

WEDNESDAY, Oct. 17 (HealthDay News) — In the United States, 29 percent of people with colon cancer are diagnosed after an emergency, such as an obstruction or perforation of the bowel, according to new research.

A study from the University of Texas Southwestern Medical Center at Dallas also revealed that blacks and those in high-poverty areas are more likely than others to be diagnosed with colon cancer in an emergency situation. The researchers noted when cancer diagnoses are delayed until an emergency arises, the risk for complications and death increases.

“Overall, there are high rates of emergency presentation of colorectal cancer in the United States,” said Sandi Pruitt, assistant professor in the university’s department of clinical sciences.

“Screening for colorectal cancer using tests including colonoscopy is recommended for all healthy, asymptomatic adults starting at age 50,” Pruitt said. “But these high rates of emergencies indicate that there are multiple missed opportunities for screening.”

For the study, the researchers analyzed national data collected between 1992 and 2005 on adults aged 66 and older with advanced colon cancer.

Of the nearly 89,000 patients identified, 29 percent were diagnosed following an emergency. Of these, about 81 percent required hospitalization — 32 percent because of bowel obstructions and 4 percent with bowel perforations.

After taking factors such as the stage of cancer and overall health into account, the researchers noted that black people were 29 percent more likely to be diagnosed with colon cancer in an emergency and those living in poverty-stricken areas were 10 percent more likely to be diagnosed under these circumstances.

“We already know that African-Americans and economically disadvantaged populations face an increased risk for death from colorectal cancer,” Pruitt said. “In future research, we will attempt to understand how emergency presentation of colorectal cancer contributes to racial and economic disparities in death from colorectal cancer.”

Colon cancer is the fourth most common cancer among U.S. adults. It is estimated that nearly 52,000 people will die of it this year.

The study was scheduled for presentation Wednesday at the annual cancer prevention conference of the American Association for Cancer Research, in Anaheim, Calif.

Data and conclusions presented at meetings are typically considered preliminary until published in a peer-reviewed medical journal.

SOURCE: American Association for Cancer Research, news release, Oct. 17, 2012


Weighing Physician Assistant Autonomy in Medical Practice

Weighing Physician Assistant Autonomy in Medical Practice

I have seen a significant evolution of the form and structure of physician/physician assistant teams in the 30-plus years that I have been a PA. Depending on the level of experience and the agreements set between PAs and their physician partners, PAs can be practice medicine with near autonomy, or have less experience and need more guidance than others.

For the most part, PAs have been employees of physicians, group practices, and sometimes, institutions. I have worked in each, yet my current position reflects the maturity and evolution of the PA profession in a way that follows the experience and example of our physician partners.

My California corporation is my sole employer, and the physician who is my practice partner is exactly that, my partner. I don’t feel that I work for him, but with him. Being a surgical practice, we perform a lot of consults and surgeries each year. I bill directly for the work that I do, just like him, and take the risks, just like him. Doing emergency reconstructive surgery and taking calls for the ED, means that we perform a lot of surgery that never gets reimbursed along with the surgery we are compensated for.

It is difficult for PAs to be considered “independent contractors” under the current rules of the IRS, which is a complex issue and beyond the scope of this blog. I came to the conclusion after consulting counsel and reviewing the laws and regulations, and found that I had to go a different route to achieve more control over my professional life and career.

The level of supervision required of PAs, and the associated state laws, have evolved dramatically since I began practice in 1982 in California. It varies state-by-state, so it is important for physician / PA teams to know their local laws and requirements. Over the years, my physician team partners and I have developed a high level of trust and experience with each other that allows me a higher level of autonomy in the practice of medicine than say a new graduate.

Physician supervision is a fundamental aspect of the PA profession, and in fact, something that all PAs embrace. Yet the level of supervision is determined by state practice laws and by the practice itself.

It has been a difficult road at times because anytime you do something different in a traditional environment like the healthcare system, it presents challenges in that people in positions of authority don’t know what to do with you or how to relate to you.

The other physicians with whom I work contract with my corporation for “PA services.” I am considered a “leased employee” in the eyes of the law, and practices pay my corporation by the hour for my services. This allows them to treat me like an independent contractor, thereby avoiding a lot of employer-side employee costs like payroll taxes and workers’ compensation. Physicians have been doing this for decades, and PAs are beginning to take advantage of these sorts of corporate structures in greater numbers, which I think is a win-win for everyone involved.

I have definitely run into some challenges with large California managed care companies. It took a long time to get a contract with one (even though they continued to pay my first assist services on a non-contract basis), and the argument they gave me went from: 1) we don’t contract with non-physicians; to 2) how do we ensure that you are properly supervised as a PA?

I had to repeatedly remind the companies that how a PA is supervised (a legal and regulatory issue), is unrelated to how a PA is employed and paid. It took about a year. I was persistent, and it was beneficial to work for a specialty surgeon who was their only source of plastic and reconstructive surgery in our community. We became a “package deal,” and I was grateful for his support. I became one of the first non-physicians to get a provider contract with their organization, and I’m sure now that others will follow as the healthcare system continues to evolve and mature in its recognition of PAs and other non-physician providers, incorporating and changing how they interface with the system.

I have to say that my situation has been very positive in achieving more control over my destiny as a professional. It has been also been positive, in my opinion, for the physicians with whom I practice, and has freed them from at least some of the hassles shared by employers in managing their human resources.

Physicians should be open to alternative relationships with PAs and others with whom they practice and everyone will benefit.

Primary Care: Not Worth It for Women?

Primary Care: Not Worth It for Women?

By Bob Keavene


American healthcare’s most fundamental problem — we don’t have enough primary-care doctors because primary care simply doesn’t pay well enough — has also long been its dirty little secret. The public is only dimly aware of the doctor shortage, oblivious to its causes and solutions.

But with the Affordable Care Act’s insurance expansions and mandates coming online in 15 months, the problem is about to move to DEFCON 5, at which time there will be no hiding it. The public will see the shortage for the health crisis it truly is.

New research, meanwhile, by a pair of Yale economists offers insight into how the basic pay problem at the heart of the shortage affects women physicians especially hard — a grave problem not only because of the fundamental unfairness of it but also because women comprise the majority of American medical students and are more likely than men to choose careers in primary care. The economists found that a woman who wants to spend her career in the noble business of getting patients to say “aah” would be better off financially becoming a physician assistant than an MD.

Doctors earn more than PAs, sure, but medical school costs so much more than PA training that the long-term economic benefits must far outweigh the upfront cost difference. And since the additional costs come well before the added benefits, inflation comes into play, too. Economists Keith Chen and Judith Chevalier applied a metric called Net Present Value (NPV) to account for these factors.


“We found that, for over half of woman doctors in our data, the NPV of becoming a primary-care physician was less than the NPV of becoming a physician assistant,” Drs. Chen and Chevalier (both PhDs) wrote in a summarization of their findings for The Atlantic.

For male primary-care doctors the value of an MD over a PA degree is still worth it. This is due partly to a wage gap: men earn more per hour than women, on average. But a bigger factor, the economists found, is that the female physicians are more likely to work less than full-time schedules, depressing their incomes even further.

We’ve long known that today’s generation of doctors want different things from their careers than their doctor-fathers and grandfathers did. They want a balanced life with time for the kids. Employment is increasingly appealing to younger physicians because the terms of employment are seemingly more negotiable than the terms of ownership, and schedule flexibility is high on their list of demands. All of this is true of under-45 doctors generally and of women doctors in particular, it seems.

But the Chen-Chevalier study, beyond clarifying that the male/female wage gap exists even in medicine (where one would have hoped for a more enlightened worldview), also sheds light on the systemic challenge posed by the new generation of physicians’ changing career demands. About half of all doctors responding to our Great American Physician Survey (our cover story starts on page 12) say they wish they worked fewer hours, but only among the youngest cohort was a plurality willing to sacrifice some income in exchange for schedule flexibility. Lori Schutte, president of physician recruiting firm Cejka Search, told us that women aged 35-44 make up the fastest-growing group of part-time physicians.

But if it becomes clear to women that many of their career goals could be satisfied by becoming PAs and NPs, and that they’d start working sooner and be better off financially long-term, you don’t need to be a Yale economist to figure out how that will affect our primary-care physician shortage.

Bob Keaveney is the editorial director of Physicians Practice. Tell him what you think at bob.keaveney@ubm.com or on Facebook:


When Physicians Leave: Giving Your Notice of Resignation

When Physicians Leave: Giving Your Notice of Resignation

By Melissa Young, MD | October 1, 2012

A few weeks ago, I posted about a colleague who decided he couldn’t continue his solo private practice anymore and stay afloat. Apparently, he wasn’t the only one leaving the area for greener pastures. I don’t know the full details of their new positions, but I do know that one departure has been somewhat, let’s say, controversial.

The sticking point of said controversy was the amount of notice given to his partners. They were apparently taken by surprise when, two weeks before his intended departure, he announced to them they he was leaving for another practice on the other side of the state. This did not give them any time to look for a replacement. They had to redo their call schedule.

It’s one thing if you are in a big group. What’s the difference if you are on call once every eight weeks versus nine weeks? But when you go from a being on call every third week, to being on call every other week? That’s a big deal. I don’t know if they had any upcoming vacations planned, but if they did, this could sure put the kibosh on that.

They have, fortunately, been able to find a new physician to join them, but he had to give his current practice three months notice. “He had to do it the right way,” is how it was put. Now I don’t know if he “had to,” or if he felt he had to.

What is the proper amount of notice to give when one is leaving, not because there is necessarily a problem, but more to pursue a better opportunity? Naturally, if there are major problems in the practice and that is the reason for leaving, one may anticipate that a partner or associate could just up and leave with little notice. But if one is leaving for more money, or better hours, or to be closer to family, how much time is reasonable for both parties involved? Maybe I should say for all three parties – the physician who is transitioning, the practice he is leaving, and the practice who is waiting for him to start.

When I left my old practice, I gave them plenty of notice. I knew full well how hard it was to find our most recent associate, and I didn’t want to put my colleagues in a position where they had to take over all my work. I gave them six months’ notice, which was three more months than my contract required. Speaking of which, how enforceable is a clause that states how much notice must be given? And would anyone even try to enforce it? Say Dr. X said, “I’m leaving in two weeks,” would you try to make him stick it out for two-and-a-half months against his will if that’s what his contract says? Seems to me it would be a very uncomfortable situation.

I feel for my colleagues who have been left in the lurch. It will be a tough couple of months for them. I can only hope the same never happens in our practice.