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Who Would Want to Become a Doctor?
To become a medical doctor in the coming years, a person would need to be extremely dedicated—and a glutton for punishment. I’m beginning to wonder how many people will decide that becoming a doctor is simply not worth the sacrifices.
Many of us already know about some of the costs that a student faces to go to medical school:
The median four-year cost of medical school (including expenses and books) was $278,455 for private schools and $207,866 for public schools in 2013 according to the Association of American Medical Colleges. While grants and scholarships account for some of this total, lowering eventual debt to an average of $170,000-interest accrues while doctors are still completing their residencies, sometimes adding as much as 25% to the total debt load.
Since this study is from 2013, I’ll assume costs have gone up. For the record, doctors end up $416,216 in the hole.
Making their lives even more financially difficult is Medicare reimbursement . Many doctors are simply turning down new Medicare patients. Part of the reason is the onerous paperwork required by Medicare; even worse, Medicare reimbursement only pays 80% of what private insurance pays. As the aging population continues to grow with more health issues, more demands will be made on the health care community and less medical assistance will be available to patients.
But the latest difficulty that affects both doctors and patients are the hidden costs that hospitals are imposing on everyone in order to improve revenue. Doctors are now being pressured, sometimes contractually, to refer patients to services and doctors that are within the hospital system. Losing patients to competitive services is known as “leakage”; keeping patients within the system is known as “keepage”:
The efforts at “keepage” can mean higher costs for patients and the employers that insure them—health-care services are often more expensive when provided by a hospital. Such price pressure and lack of transparency are helping drive rising costs in the $3.5 trillion U.S. health-care industry, where per capita spending is higher than any other developed nation.
I have several problems with this policy:
- Doctors are often told that they aren’t required to refer patients internally for services such as MRIs, chemotherapy, blood tests and to other doctors, but referrals are tracked, and doctors are asked for the reasons that patients were referred and not treated internally.
- Services can be twice as costly, or more, when they are provided by the hospital.
- Patients are often not told that services outside the hospital can be less expensive, or that they can locate a doctor on their own outside the system.
- Physician contracts can restrict referrals except for a limited number of exceptions.
- Doctors may be reluctant to refer patients to doctors with special expertise due to pressures from their own hospital systems.
Some organizations are taking a pro-active approach to the “leakage” problem, trying to determine the specific reasons for referring patients outside the system, and determining options that could put less pressure on doctors to increase revenues. I’m disturbed that most organizations, however, are demanding, subtly or overtly, that doctors must comply with “keepage” expectations. I think that doctors are entitled to maintain a level of independence, given that they can be dealing with life-and-death issues. The question is whether these hospital systems are ethically entitled to hold physicians accountable for helping to increase their bottom lines at the possible expense of the patient.
This paragraph sums up the dilemma:
‘We do not use our referral tracking data to put pressure on our physicians to refer to their partners within our system,’ said Suresh Lakhanpal, president of Phoebe Physicians, the medical group. ‘However, if an employed physician routinely refers patients outside of our group without good reasons to do so, then that physician is not demonstrating commitment to the best interest of the patients and may not fit well within our team of outstanding health-care professionals.’
So who gets decide what “good reasons are?” At what point is a physician “routinely” making referrals outside the system? How is keeping a patient in the system necessarily in the patient’s best interests?
Published in Healthcare
I have the most sympathy for Doctors who got into the field maybe 20-30 years ago and have had it change around them. My current GP – who is retiring at the end of this year – is a good example. His practice has gone from being a private practice in a small country town to being part of a much larger enterprise. I think he is a good doctor, he keeps up with advances in medicine, but since the business change, he spends all his time with me entering data on a terminal. I don’t think he has touched me in the last five years.
To the point of the post – I don’t understand why anyone would want to get into patient care these days. Maybe research, but not patient care.
Haha, ‘the best interests of the patients” my butt. It’s the best interests of the group’s bank account that she is concerned about. Your point, Susan, is well taken. We are looking at a serious deficiency of medical providers (Doctors, nurses, etc.) in the not too distant future. That was always one of my gripes with the ACA law. It supposedly brought millions of needy people into our healthcare system. But it made zero allowance for expanding our flock of practitioners.
I agree. It can be difficult for a doctor unaffiliated with a hospital to survive. The gap is being filled to some degree with nurse practitioners and physician assistants, but I’m not sure that’s a great remedy. I just don’t know enough about those fields.
I have no idea where the ACA stands at this point, either. We’re heading for turbulent times with a decrease in physicians and a huge increase in patients who will need more care. I just hope I continue to have good health!
Yes. Medicine has become an industry and not a practice. It will increasingly appeal only to persons who fit that model well. And those individuals are not the kind of caregivers with whom I am comfortable. And this is the problem with Obamacare (or whatever name you give it): It is managed care. It is a centrally-planned economy and not market driven. And because the richest and most powerful among us can always seem to escape the rationing of socialized systems, the inequity of power privilege will become even more evident.
I guess that’s where the “boutique” practices come in. And I can’t really blame the doctors, but there are lots who will lose out . . .
Actually I use a boutique doctor and I fear that what I am describing is quite different. Boutique doctors are closer to a form of market economics. They have created freedom from rationing by the insurance companies for themselves but not the system. What I am describing is an increasingly socialized system where certain highly capable physicians and institutions (think Univ of California San Francisco, Stanford Medical, Mayo, Johns-Hopkins, Boston, Mt Sinai in New York) are only available to people of status and not available to others regardless of their ability to pay.
Medical doctors who practice the art and science of medicine are supposed to have become employees. Don’t forget that we started down the slippery slope of managed care/conglomerate hospital corporations/employee physicians thanks to one young lawyer with a dream.
Ah, so true. And the slippery slope has become a swamp (in more ways than one). I can’t see how we can find our way out.
I get lots of kids trying to get into med school who ask me what to do.
I tell them to go for it if they really have a passion for it. It’s no where near the wonderful field it was when I started in 82.
I also tell them to pick a specialty that makes them as independent of the hospitals and insurance companies as they can be. That means areas like Plastic surgery and Ophthalmology. Next are things like Ortho, GI and Radiology where you can own the equipment and your location and practice. Avoid primary care , Hospitalist, ER like the plague. You are now a cog in the machine and an interchangeable part as far as administration and the bean counters are concerned. I was recently told that I ( ER doc with 30 years experience) was no different then a PA or Nurse Practitioner. Although for some funny reason, they always come to me with a difficult case or looking for an answer.
I think that was part of the plan.
I anticipate that type of practice will be illegal in the near future as it’s “not fair”.
That is what I fear as well.
That’s terrific that you can give that advice! They are certainly going to need it. With your input they can meet their dreams but maintain their independence to a great degree. I so appreciate your input, @kozak. Thanks!
This is my fear…that the current environment will squelch some talented kid’s passion.
There would still be the huge debt that they’d have to pay off. I can’t help wondering how much passion would encourage you to take that on.
Now, does anyone still question my determination to never participate in Medicare? I am 69 and still working full-time, accumulating savings so when I really do retire I will not have to worry about “what Medicare will pay for”. My doctor has a “membership practice”, not quite boutique, and I gladly pay her monthly retainer. I get instant access via email, office visits on short notice, and as much time as we need for exams and discussions about my care. She is way younger that I am, too, so I probably don’t have to worry about her retiring any time soon. Now, she is a sole practitioner, with a side business in laser hair removal, so she has an insurance-free income stream, which was a very smart thing for her to do.
I read that article in the Wall Street Journal about doctors who sell their practices to hospital systems, then discover that they have intense pressure to refer their patients to in-house services. I wonder, too, about what would happen if a hospital-tied surgeon refused to perform “sex-reassignment” surgery? That hospital system would wield immense power, and perhaps that doctor might find him or herself on the short end of that transaction. Maybe more physicians need to take back control of their practices from the big hospital systems.
Powerful comment, @rushbabe49. It sounds like you’ve found an ideal situation with your doctor. My own GP is about my age, and has shown no indication of retiring any time soon. Also, I almost never have to go to the doctor; I go once a year for a wellness visit (which is uneventful) and have blood tests done for him on the outside, and that’s about all. He also has a wonderful nurse practitioner, but I rarely see her since she tends to deal with patients who have sudden problems. Anyway, your points about expectations of doctors growing with the hospitals is likely spot on. It could get really ugly. Thanks!
They once had, and probably still do, at Hopkins a whole floor for which the staff only spoke Arabic.
I should let a real doc post on this, [Edit: or read down to at least post #10 to see that one already had] but it seems to me that PAs and NPs are less knowledgeable than MDs no matter how you slice it, and so are less likely to make those Housean discoveries that make medical dramas so popular, but it is fair to say that a lot of patients’ problems are fairly cut and dried;s long as there is adequate triage it’s probably a good division of labor.
I don’t write about this topic because it makes me so sad.
I entered this profession because I felt a higher calling. Now my caring profession has become a heartless industry and I’m just a cog in an enormous machine. It’s hard to describe how soul-crushing that is for someone like me.
I’m 50 years old. If I were younger I’d change professions. If I were older I’d retire. But I’ve got 3 kids in college (or soon to be in college). So I guess I’m stuck.
Fortunately, I own a concierge style practice and I do well, so my situation is worlds better than most of my colleagues. I am thankful. I sometimes wonder if my type of practice will be banned as it is in Canada, but I just don’t think that wealthy Democrat donors would permit that. They want poor healthcare for you, not for themselves. And they’re all members of concierge practices. All of them.
But when I look at what has happened to this honorable profession during my lifetime (Medicare was passed just before I was born), it makes me want to throw up.
Tragic.
With all due respect to NPs and PAs, that’s an understatement.
On the other hand, the one guy in my county I’d trust to be my doctor is a PA, but he was an Army medic before that, so he has a lot of prior experience.
ty for saying that. NPs and PAs are not chopped liver. They’re knowledgeable professionals, and as you point out, experience is extremely valuable.
The obvious solution will be to import more foreign-trained doctors, people who’ve already been through the rigorous (hopefully) process. Of course, you can probably guess how these imported medical professionals will vote once they become citizens . . .
I’ve had a good experience with those added staff, and when there is a serious situation, they go to the doc. But who knows if a doctor will always be available to back them up?
I’m so very sorry for your predicament and the situation for your colleagues. But I am relieved to know that docs are still practicing who may not believe in their profession, but care about the patients. Thanks for weighing in, @drbastiat.
My doctor lost his practice in part due to Obamacare, but mostly due to an overabunance of Medicare/Medicaid patients. He now practices for a health care organization that caters to lower income people, yet I still go to him. Why? He’s a damn good doc, and he spends time talking to his patients about their health issues instead of rushing them through to meet a quota.
I am on Medicare and also have a “concierge” Primary Care Doc who’s been my friend for 50 years. He’s great, but today’s medicine is one of specialists. The PC Doc is like the quarterback and I am the ball. He distributes my medical issues to various other doctors who are specialists. That is where Medicare comes in handy. Fortunately my needs have been minor. But that is why I pay for insurance…just in case my needs become more than minor.
This seems to be an overstated claim.
Just curious–you don’t think that the seeds were planted by the work of Hillary?