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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 will concede ignorance of the details of how the healthcare industry developed in the U.S. So it’s possible.
The best analogy I can think of to describe what I’m thinking is – It’s as much her fault as The internet is Al Gore’s fault. It might be accurate, but overstated.
Not quite . . . for more
The president had campaigned heavily on health care in the 1992 presidential election. The task force was created in January 1993, but its own processes were somewhat controversial and drew litigation. Its goal was to come up with a comprehensive plan to provide universal health care for all Americans, which was to be a cornerstone of the administration’s first-term agenda
IIRC a physicians assistant is called that because he works under a doctor’s license; his mistakes are that doctor’s mistake so the doctor has strong incentive to be available (or even micromanage) whereas the NP has an autonomous license.
Thanks for clarifying! Do you know anything about how their training compares, that is, the PA to the NP? Sounds like the PA would be more advanced?
Mrs. TBA is a nurse who did the bulk of her work in the military. I met both PAs and NPs, and my impression is that both groups had some resentment towards the docs (who got a rank bump for their degrees and got to run almost everything) and some resentment towards each other as their rather new tiers in a very old pecking order were still in flux. PAs and NPs didn’t agree about which was more advanced. I suspect it varied by field and circumstance.
Again, this is the time for a Real Doctor™ to chime in to correct the record.
That’s the way it’s supposed to work. The reality is the doctor reviews the charts after the fact. In a good sized practice that can be a lot of charts for 1 supervising doc to review.
PA’s do 2 years after college. Nurse practitioners do 2-4 years after their BSN degree.
As an example I did 4 years of college, 4 of med school and 3 years of post graduate training.
Lots of specialties require 4-6 or more years of post graduate training. Then you can toss in a fellowship of 1 to several years.
I did a post with almost the same title last year (2017).
Go into nursing. It’s a cheaper and faster degree, you’ve got more versatility in both your career and your life, and you don’t have a quarter-million dollar debt when you start working.
Without getting into the structure issues, and based on the published income data I have seen, the cost/reward calculation argues against trying to become a medical doctor. Sure, doctors have higher reported incomes than other professionals, but it seems to me not enough higher to justify the up front educational expense.
Depends. If you go into the right specialty you can make pretty big bucks. Things like Plastic surgery, Ophthalmology, Hand surgery, Orthopedic surgery, Interventional Cardiology, Radiology etc. The common denominator for these jobs is primarily surgery and the opportunity in many cases to work for cash, and operate your own site. They have huge earning potential.
You can make good money in ER. There are jobs out there in ER advertising salaries of 350K and up a year. Now, you will work like a dog, but you can make plenty to pay off your med school debt.
One last thing. Many docs end up paired up in Med school now. Since more then 50% of the classes are now female the two doctor couple is really common. Pair those two incomes and you can have a hell of an income….
I wonder about how professional oversight compares. An NP friend, since relocated to be closer to grandkids, gave trustworthy advice a number of people I knew that could have afforded much more costly care were well cared for. OTOH, I have since then seen three NPs I would counsel against. My experience over the years has been much better with MDs. We now see an Internist, emigrated from India, with whom we are pleased. (Last time I was there he was mumbling about having no time for patients, cursing ACA and the keyboard.)
Another consideration: If you are male, it’s a lot easier to get into nursing compared to med. school.
It’s interesting that you see a problem where I actively seek this out.
I refuse to use a doctor outside the Florida Hospital network. Their ties to the Seventh Day Adventist Church assures me I won’t be pressured into anything I find unethical – or that my doctors won’t be forced out of practice because of ethical concerns.
I was actually very upset when I found out too late to change that my obgyn had changed delivery hospitals right before I had my 3rd. If I had known, I would have found a new doctor to stay in the hospital I wanted.
But then, at 35 I don’t have a solid relationship with any pcp except my kid’s pediatrician. From the very first attempt at finding a doctor in Orlando, I was disappointed with the options I ran across. The first main doctor I interacted with failed to diagnose my hyperemesis in my first pregnancy – and that led to issues at work due to my erratic attendance thanks to it.
It’s so messed up. My good friend is an internal medicine doc. Burnt out from all mentioned in this article, but committed to the best care for her patients. She’s been trying to dissuade her daughter from going into medicine, to no avail. Thank goodness!
I have a few conditions that have caused me to seek out support groups online. So many people finally get a referral to a speciAlist – in 18 months. Guess what their health coverage is? Did anyone say NHS?
Nurses, already low-ish on the professional pecking order to start with, have been hit with the same professional devaluation as physicians, in terms of professional judgment, autonomy and responsibility; being similarly enslaved to a digital taskmaster who takes up all your time and fealty.
When I advise young folks — though they never listen to me — I tell them (unless they’re really smart and can handle a STEM curriculum) to become plumbers, electricians and mechanics — something they can do, and will always be needed, and will have a unique body of knowledge which can be adapted to other pursuits. They eventually make $60 and hour working for themselves, and can apprentice into it, and make money while they learn. Or else, get a genuine liberal arts degree, studying something that will give you a fairly rounded education, take some pedagogy, and go for your teaching cert. as a back-up in life.
It saves an awful lot of hassle in life. Money is great, when you have it, but you all know it’s not worth chasing as much as most people think. Though, being a physician does get you a very nice house, a very nice car, and stuff.
Eventually, perhaps.
You’re right, of course. I have to write in generalities in 500 words or less, and it’s my preference anyway. There are a lot of millionaire doctors. But I do know a doctor who, last time I saw her was still driving the same 20-year-old Camry (by choice). There are no, say, vape-shop attendants driving Mercedes where I live.
As a matter of fact, all the master plumbers and master electricians I know are in high demand and very well off financially.
[Heck, even all the nurses I know seem to drive Lexi.]
And (according to a friend of mine who is a physician and has to deal with hospitals, administrators, insurance companies, and HMOs) this is all so that someone who has had four years of college and two years of business school gets to tell you(the doctor) how to practice medicine.
<not being sarcastic >
<cynicism exceeding even what I thought was previously possible >
And it’s not just the education it’s the bottom line. The doctor’s is healing, the MBA’s is profit.
And I forgot to mention Board Certification, which is no longer a sign of excellence among your peers but technically, from everything I’ve seen mandatory for insurance reimbursement after the first 5 years post-residency. So when everyone is board certified no one stands out — cool, eh? This test needs to be repeated every 7 to 10 years, or so. And passing this is a big, big deal to many doctors. I know one MD who took a year off just to study for it, to pass it, just to keep his job.
And then there are hundreds of hours spent accruing CME’s which can be done in large part by taking a week-long class in Orlando or Honolulu; and then annual Board testing via computer. You specialty may vary.
And because you are often not in private practice which you can mold to your own and your patient’s likes, but are working for a for-profit employer who sets clinic sites, like turfs in dr–g districts, based on business contracts and employers, so then patients who would come to see you because they like you, often can’t. And patients who don’t like you, have to come to you, and often complain to your employer if they don’t like the approved vocal tone or introductory phrase or question you chose to use that day (there really are such things and they often are self-contradictory or change from year to year).
Yea, we now have to ask everyone over the age of five if they are suicidal. That’s a popular question.
I know from all the patients we transport that it seems the likelihood of seeing a PA as opposed to an MD in the ER is very high for walk-ins (as opposed to those that we bring in). I know from when I have worked shifts in ER triage as part of my training that maybe 70 percent of walk-ins were more appropriately seen someplace else. Generally they didn’t need ER level services. The EMS experience is analogous; a lot of people who call us would be better served by being driven to the ER, or an urgent care clinic, or their primary care doc’s office. We are in the midst of discussing community paramedicine as an alternative to running ambulances all over the boonies for non-emergent care.
I think this is great advice, @flicker. If there are other kinds of pursuits they want to look into, they can do it offline, rather than have to bow to others’ expectations.
My doc asked me three times if I was depressed. We were laughing together through most of the exam, and I swore to myself if he asked me one more time, I’d give him something to be depressed about.
It’s good to know that some people are at least looking at these kinds of issues! Thanks, @tex929rr
The answer to “Do you have any guns in the house?” is “Not enough”
I just took my ER boards for the 4 th and final time ( I said that 10 years ago!) but this time I mean it. And yeah I mainly did it to be able to get a job even if I’m not working ER anymore.
Third-party payers/state regulation of coverage means that the sick and injured have almost no ability to assess their own level of need.
My wife worked Peds in the AF and far too many kids were brought in for common colds and low-grade fevers.
‘Better safe than sorry’ is a good rubric, but a bad law.