In my humble opinion, hospitals are the most evil organizations around. The avoidance of the bureaucratic bullshit associated with working in a hospital and the headaches of dealing with third-party payers are key reasons why I'll be starting a solo, cash-based practice when I finish my training. In order to keep in touch with what I see as a real social responsibility to provide care to those who need it regardless of ability to pay, I'll simply institute my own sliding-scale payment scheme to make my care as affordable as possible (interest fact: it's illegal for physicians to charge different copays to patients covered by identical insurance plans administered by the same insurer; even if a physician wanted to, he/she couldn't charge one Medicare beneficiary $0 if they have no ability to pay while charging another the standard copay allowed under their association agreements). Physicians really are becoming little more than highly paid corporate drones. These trends are resulting in a complete deprofessionalization of medicine and the surrender of key clinical decision making responsibility to administrators and third-party payers from physicians. This all the while physicians are portrayed in the public as greedy and money-hungry with no real care for patients - most prominently by President Obama. Oh, the cost of healthcare is going up? BETTER CUT PHYSICIAN REIMBURSEMENT - WHICH, AT MOST, ACCOUNTS FOR 10-15% OF OVERALL HEALTHCARE COSTS. Don't worry, that won't demoralize a profession that is already overworked and under-appreciated if not outright villanized from all sides. That's not to say that physician reimbursement shouldn't be included in the discussion of cost reduction. But you'll have to forgive us for resisting these cuts so ardently when pharm, medical device, and insurance companies posting billion dollar profits every quarter somehow remain immune from attack.

Practicing medicine is nothing like what it used to be. The avoidance of primary care specialties by the next generation of physicians thanks to ever increasing costs of education (the average indebtedness is now north of $150k and continuing to go up) and ever diminishing reimbursements to control costs (despite going after the real costs of the healthcare system, i.e., administrative costs, pharmaceutical companies, and medical device companies; as an example, there as an ever-hanging threat of a ~25% cut across the board to physician reimbursement that is very graciously averted by our Congress each year - often corrected in a retroactive way months after the reduced reimbursement has already been in place) will, unfortunately, result in substandard care to patients. As midlevel providers come in to fill in this need (e.g., our good friends at the AANP which, as I mentioned in another comment, vehemently denies the need for more rigorous clinical training for their independently practicing NPs despite the fact that their training is both shorter, less extensive, and more variable in quality than that of the typical graduating medical student), the result will be less rigorously trained providers managing a population with increasingly complex and chronic disease.

Remember that before crucifying us when these issues come up in politics. The overwhelming majority of physicians want little more than to do what's best for their patients. Political influences, however, are making it more and more difficult for physicians to do what they need to do in order to make that possible, and it's easy to create a strawman of the Porsche-driving physician making millions of dollars a year that "clearly" is making too much money.

Change we can believe in?