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Wednesday, February 27, 2013

Medical Training


The medical training and compensation world has changed a lot in the past 30 years. The millionaire physicians of the '80's have largely died out thanks to the cost of medical education and the rise of interest rates and insurance companies following Medicare's lead in lowering compensation.  I have a concerned doctor's response to Slate's America's Overpaid DoctorsTime’s long investigation of American health care prices missed one thing: We pay our doctors way too much." 

As an aside, Time magazine's feature article this month,  Bitter Pill: Why Medical Bills are Killing Us, I would recommend to anyone to better understand the behemoth that health care in the United States has become after the emergence of large hospital groups, which in turn arose in response to the rise of medical supply companies and insurance companies. Healthcare indeed gets higher profit margins than anywhere else in the private sector. Generally speaking - this doesn't mean that doctors and all hospitals operate this way, and particularly not smaller community doctors and hospitals.

Here's the response to the Slate article, though: found in the comment section.
This "journalist" needs to interview some doctors.  
 
Pardon me if I am myopic about this topic and only examine it from my perspective, but my perspective is important and deserves to be noted. 
 
I am a Family Physician, practicing in the medical trenches of rural Kansas. I deliver babies, take care of inpatients, run a busy outpatient clinic, all for approximately $30 per hour, usually working over 100 hours per week. ON TOP of that, I cover call for our very busy ER for our community about 20% of the time. For this additional load, I am paid $17 per hour. I could make much more working in the city, but I love rural America, and I feel like I make a difference and that I'm appreciated for it. I don't complain about my income, but compared to many I have a right to. 
 
My young children have asked my wife "if daddy is coming to visit today" because I'm gone to the hospital so often. My family pays the price for my career calling. 
 
Meanwhile, our small hospital, due to bad debt and declining payments from Medicare, Medicaid, and insurance companies barely breaks even from year to year, and hasn't been able to invest in infrastructure. Our hospital staff (myself included) has had one small raise in 5 years, and it was a fraction of the cost of living for a single year. 
 
I recently quietly endured the whining of an entitled patient who is a 20 year-old union truck-loader for a well-known shipping company as he complained about his hourly wage, which was twice what I make. Where I get my 12 year old pickup serviced, they charge $60 per hour for labor. 
 
I'm not trying to be a martyr here, honestly. I went into this work with eyes wide open, and this lifestyle was my choice. But there are few people like me. And this brings me to my point: 
 
I should be paid LESS? REALLY? Let's get out of the ivory tower and enter the real world. Who do you know in the current "Millennial" generation who is willing to go to college, med school, and residency for a minimum of 11 years, accumulate a quarter-million dollars of education debt, and then work 100+hour weeks (minimal fun personal time!) for less than the neighborhood mechanic? Seriously, with Obamacare expansion, we're going to need you to give us about one hundred thousand names of motivated socialist humanists who are ready to make such a Mother Theresa-esqe commitment (oh, and they need to be able to get into, survive, and pass medical school).  
 
"OK, well we can just hire an army of nurse practitioners!" you assert. Your quoted research is not based on reality. The average nurse practitioner has an average of 500 hours of supervised medical practice, where the average Board Certified Family Physician has over 18,000. Whom would you have take care of you in the ER when you have a difficult to diagnose and potentially life-threatening problem? Does this question even need asked? 
 
I have helped scores of patients who were misdiagnosed and mismanaged by a mid-level practitioner (PA or NP--Physician's Assistant or Nurse Practitioner) who was practicing virtually on their own. Mid-levels have a major role to play out here, but it's NOT in solo practice. We have 4 mid-levels in our group and they all do an excellent job, partially because when there's something that they can't handle, they call a doctor and we help them. Which, is, of course, the idea. 
 
Last year a member of this community who had Lou Gehrig's Disease had been misdiagnosed for over a year. After his 3rd trip to his local solo-practicing NP, he finally sought an opinion from one of my partners, a Family Physician, who quickly made the diagnosis from his history and exam alone. The man died 2 weeks later from this devastating illness. Had he gone to a Family Physician or a mid-level with proper supervision, he would have had a year to plan, get what treatment is available, and make arrangements. We have many stories like that.  
 
If you're trying to save money, here's something you can take to the bank. I *GUARANTEE* that replacing the primary care workforce with undertrained "mid-level practitioners" will save money, but that savings will come at a devastating price: human life and human suffering. I'm already seeing it every week. 
 
Real solutions to this crisis: 
1) MAJOR TORT REFORM. This has been avoided by current administration altogether because of political corruption. Savings: tens of billions. 
2) COMMON SENSE END OF LIFE CARE. This sounds harsh, but the fact is, we all die eventually. We must stop putting people who are doomed on dialysis, in the ICU, & in the cath lab. Savings: tens of billions. 
3) ENCOURAGE QUALITY PRIMARY CARE AND PREVENTION. You won't get this product without paying for it. Pay good primary care docs what the specialists make. 
4) INSURANCE REFORM. Allow competition. Punish corruption. 
5) STRICT TERM LIMITS. Minimizing legislative corruption will help achieve the first 4 items in this list. 
6) MINIMIZE GOV'T INTRUSION: Face it, they bankrupt everything.

Here's a current medical resident's comment on the same subject:
As one currently training in medicine I can tell you that given the amount of work I’m putting in (and have put in), the amount of debt I’ve undertaken, and my future earning potential, medicine is definitely NOT worth it financially. I am doing to this to care for others, not for the money. However, even at present levels medical school is almost financially unfeasible for many young people. Lowering physician compensation will discourage the brightest minds out there from becoming your doctor, as well as lead to increasing numbers of physicians leaving medicine sooner which will only worsen current shortages.
Allow me to enlighten you of the plight that young people thinking about a career in medicine face. I was a good student and had a full ride scholastic scholarship for college so I had no undergraduate debt. I went to a top ten medical school with an $80,000 scholarship, and my family was on Medicaid to further help us save $40,000 in insurance premiums during that time. We lived frugally, but in spite of the $120,000 assistance I’ve just mentioned, after four years of medical school I had $230,000 of debt. Interest rates are 6.8% and compounding throughout my residency training so by the time that I will finally have a physician salary, at age 36, I’ll have around $340,000 to pay off. If it had not been for my $120,000 in assistance, I would have around $520,000 debt from medical school alone.  
My specialty’s average salary for a newly practicing physician is about $160,000 per year. So while I pay off my loans let’s assume that I will live at the standard of the US median household income of $46,000, the government will take about $39,000 in taxes (FICA, fed/state income tax), which leaves me $75,000 to pay toward those student loans (which are still compounding at 6.8% costing about $23,000 in annual interest).  At this rate, it will take me six years to pay off my loans, at which point I will be 42 years old when I can finally start living above the average US household standard of living and saving for retirement. If I had the full $520,000 debt it would take me ten years to pay off those loans, at which point I would be 46 years old when I could finally start living above the average US household standard of living and saving for retirement.  And remember that I had no undergraduate debt either, but many students do.
In the meantime, for years on end I have been sacrificing almost all of my evenings and weekends to studying, waking at 3:15 am to begin long days of surgery training, working 30 hour shifts, and otherwise giving all of myself to the pursuit of serving others through medicine. That is what physicians do. So I’ll let you ask yourself the question posed by this article, do we really “pay our doctors way too much”? You can be the judge. 

1 comment:

  1. No. Anyone in or around medicine will tell you that it is certainly not the road to wealth untold. I'm frankly surprised anyone is still going into it. This is just another villianization of hard working people by a clueless administration and media that is getting so, so tiresome.

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