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Derm being wrongly targeted by NYTimes
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He "called plastics" beforehand -- it would have been a coordinated case. You have a few choices -- not coordinate the case and do the Mohs... only to dump a problem on the oculoplastics folks emergently after the fact (and they are busy, too, as a general rule and not exactly sitting around on their thumbs). That makes you a professional douche. You can consult with them beforehand and then call them afterward telling them "nah, I didn't need you after all". That makes you an even bigger douche. You could be a cowboy and just do everything yourself. That makes you an irresponsible -- and possibly negligent -- douche. Or you can do what the doctor in the article did -- coordinate it such that you have the best person for the job performing the important procedures.
You decide.
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...a word about derm group compensation structures: they all have their flaws. Every system ever devised has an incentive structure built in it; no matter the incentive structure there will exist the potential for (even likelihood of) negative incentives.
Let's take the two extremes: eat what you kill and equal share. In eat what you kill the incentive is to treat everything yourself and refer as little as possible to anyone else. Sure, anything you don't want to deal with or anything you think might come back to haunt you gets referred on, but that marginal case is subject to judgement. In the equal share method, the most profitable (or highest revenue) treatment is incentivized. Often people believe this is Mohs -- I believe that would make for another interesting conversation and do not believe that is often the case -- but whatever.
Most groups do a some kind of blend of those two systems; whatever the blend, it will have its own incentive program that people within it figure out. Some view referring the Mohs / pathologist / radiation guy as a passive revenue stream.... and we all know that it is better to make money off of someone else's labor than our own. This creates a problem that is common in dermatology (but worse in urology).
Again, bad medicine pays better than good.
Let's take the two extremes: eat what you kill and equal share. In eat what you kill the incentive is to treat everything yourself and refer as little as possible to anyone else. Sure, anything you don't want to deal with or anything you think might come back to haunt you gets referred on, but that marginal case is subject to judgement. In the equal share method, the most profitable (or highest revenue) treatment is incentivized. Often people believe this is Mohs -- I believe that would make for another interesting conversation and do not believe that is often the case -- but whatever.
Most groups do a some kind of blend of those two systems; whatever the blend, it will have its own incentive program that people within it figure out. Some view referring the Mohs / pathologist / radiation guy as a passive revenue stream.... and we all know that it is better to make money off of someone else's labor than our own. This creates a problem that is common in dermatology (but worse in urology).
Again, bad medicine pays better than good.
There's really nothing new here. There's tons of problems that I really no longer have the desire to address (e.g. how what I'm saying supposedly applies to only solo practices - it doesn't, how I seem to still assume all dermatologists do all procedures - I explicitly don't, how we are talking about different things when we're talking about "questionable" tumors)
It's looks like you're never going to come around on this. Here's what it boils down to:
What would *most* general dermatologists who don't do Mohs themselves (in any setting, solo, group, academic, or whatever) benefit from most financially? A group of recommendations that says they should refer more tumors out for Mohs or a group of recommendations that says they should refer fewer tumors out for Mohs. I think it is beyond obvious that most dermatologists (who don't do Mohs themselves) would derive more financial benefit from a group of recommendations that fewer tumors should be referred for Mohs. I think that if you asked a bunch of dermatologists at least 4/5 would agree with this statement. It looks like you must be that 5th guy. Of course, there is always that guy. Getting universal consensus on anything is difficult.
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I'm not in derm but I was pretty pissed off after reading such a sensationalized and misleading article by NY Times.
The reporter conveniently ignores the amount of education, high level of academic performance, sacrifice, time and money that it takes to become a doctor (pre-med (4 years) --> medical school (4 years) --> residency (3-7 years) --> fellowship (1-3 years) and this doesn't include if you take a gap year which is becoming increasingly required due to the competitive nature of medical school admission and some professions like radiology and pathology are requiring multiple fellowships before one is able to find a job). Plus the insane amount of debt that is accrued over our training (quarter of million for tuition alone assuming you got some scholarships plus interest, not including living expenses). The amount of income potential that is lost within that decade of training is conveniently ignored. No other profession requires this much education, training, time, money or sacrifice. We live in a capitalist society and when every other profession is out there making money (lawyers, bankers, dentists, pharmacists, nurse practitioners, CRNAs, etc) it's pretty naive to think doctors should or will take a pay cut for doing a "noble cause." I don't blame doctors for trying to increase their income as long as they are not hurting their patients or making them undergo unnecessary procedures. And yes it is not fair that primary care doctors make so little. There should be talk about increasing their pay instead of decreasing the specialists pay.
The reporter also compares incomes in Europe vs. incomes in US--training in Europe is also relatively easier than here in the US. Their work hours are typically restricted to 50 hours a week during residency, they do not have 4 years of pre-med (a money-making scheme) because they go to medical school straight from high school (which is why medical school is traditionally called undergraduate medical education and the MBBS degree is an undergraduate degree that is equal to the MD degree) and their education is ridiculously cheap compared to the US. She also didn't mention the insane malpractice premium physicians/surgeons have to pay here in such a highly litigious culture.
There is absolutely no discussion of why hospitals have to charge so much. They're trying to cover for all the lost revenue from patients who do not pay and from insurance companies/government when they fail to reimburse. Thus, the costs gets directed on to other patients who have insurance or who can pay leading to insane bills. They're not doing it out of greed, they're doing it for sustainability. The government and insurance companies have too much power in the health care industry which ultimately drive up costs. A doctor's salary is a small cause of the increasing health care costs even though thats what is being targeted by the government and media. When the government and insurance industry make decisions they are not taking into account the best interests of the patient. The government is inherently inefficient and has bankrupted the post office, social security, medicare/medicaid and play politics with important issues and people still want them to take over health care? On the other side you have the insurance industry, which is for-profit and their goal is to minimize costs while maximizing profits at the expense of what is best for the patient and now with Obamacare they just received a blank check to maximize profits. Tort reform is never discussed because the government is run by lawyers and the person that currently determines physician reimbursement and operates Obamacare and medicare/medicaid is Kathleen Sebelius, a former lobbyist for the Kansas Trial Lawyers Association. Despite these real issues that are conveniently ignored, the political leaders and media are obsessed with selling the story that doctor's salaries is a major cause of health care costs.
Just like any other profession, not all doctors are equal. The reporter did not even attempt to differentiate between the quality of doctors (academics vs. non-profit hospitals/clinics vs. for-profit centers vs. for-profit solo private practice). The main issue that the article discusses is confined to doctors in for-profit practice who joined medicine primarily to make money but the article fails to make that distinction. This is seen in every field and it's not at all specific to medicine. Think of the shady lawyers and dentists that you've seen or heard about. Yes there are some shady and unethical primary care doctors, specialists and surgeons--it's these people that need to be exposed instead of painting an entire field of medicine as "evil." NYT has published several articles criticizing different fields of medicine and blaming them for the cause of high health care costs. It's not black vs. white. It's extremely irresponsible for them to write such sensationalized articles without giving the full story or presenting the alternate side to the story.
Unfortunately, it's the system that has failed our patients (the money hungry malpractice lawyers and all the misleading advertisements that they air on TV to take advantage of people who are already suffering, the stingy for-profit insurance companies that currently enjoy a monopoly by being able to restrict patients to a certain geographical location even though we live in an increasingly globalized society, the failure of Obamacare from preventing insurance companies from increasing the premiums/deductibles on the already struggling middle class, the government bankrupting medicare/medicaid)---doctors income is not the major issue despite what they want you to believe. We're easy targets because we are so divided. They're trying to paint a picture of the doctors being evil because we're the politically safest target, the average person is not going to have sympathy for us. Doctors need to go on the offense to take on the political leaders and media and to educate the public on what doctors have to go through, unfortunately that will not happen because we're so divided.
The reporter conveniently ignores the amount of education, high level of academic performance, sacrifice, time and money that it takes to become a doctor (pre-med (4 years) --> medical school (4 years) --> residency (3-7 years) --> fellowship (1-3 years) and this doesn't include if you take a gap year which is becoming increasingly required due to the competitive nature of medical school admission and some professions like radiology and pathology are requiring multiple fellowships before one is able to find a job). Plus the insane amount of debt that is accrued over our training (quarter of million for tuition alone assuming you got some scholarships plus interest, not including living expenses). The amount of income potential that is lost within that decade of training is conveniently ignored. No other profession requires this much education, training, time, money or sacrifice. We live in a capitalist society and when every other profession is out there making money (lawyers, bankers, dentists, pharmacists, nurse practitioners, CRNAs, etc) it's pretty naive to think doctors should or will take a pay cut for doing a "noble cause." I don't blame doctors for trying to increase their income as long as they are not hurting their patients or making them undergo unnecessary procedures. And yes it is not fair that primary care doctors make so little. There should be talk about increasing their pay instead of decreasing the specialists pay.
The reporter also compares incomes in Europe vs. incomes in US--training in Europe is also relatively easier than here in the US. Their work hours are typically restricted to 50 hours a week during residency, they do not have 4 years of pre-med (a money-making scheme) because they go to medical school straight from high school (which is why medical school is traditionally called undergraduate medical education and the MBBS degree is an undergraduate degree that is equal to the MD degree) and their education is ridiculously cheap compared to the US. She also didn't mention the insane malpractice premium physicians/surgeons have to pay here in such a highly litigious culture.
There is absolutely no discussion of why hospitals have to charge so much. They're trying to cover for all the lost revenue from patients who do not pay and from insurance companies/government when they fail to reimburse. Thus, the costs gets directed on to other patients who have insurance or who can pay leading to insane bills. They're not doing it out of greed, they're doing it for sustainability. The government and insurance companies have too much power in the health care industry which ultimately drive up costs. A doctor's salary is a small cause of the increasing health care costs even though thats what is being targeted by the government and media. When the government and insurance industry make decisions they are not taking into account the best interests of the patient. The government is inherently inefficient and has bankrupted the post office, social security, medicare/medicaid and play politics with important issues and people still want them to take over health care? On the other side you have the insurance industry, which is for-profit and their goal is to minimize costs while maximizing profits at the expense of what is best for the patient and now with Obamacare they just received a blank check to maximize profits. Tort reform is never discussed because the government is run by lawyers and the person that currently determines physician reimbursement and operates Obamacare and medicare/medicaid is Kathleen Sebelius, a former lobbyist for the Kansas Trial Lawyers Association. Despite these real issues that are conveniently ignored, the political leaders and media are obsessed with selling the story that doctor's salaries is a major cause of health care costs.
Just like any other profession, not all doctors are equal. The reporter did not even attempt to differentiate between the quality of doctors (academics vs. non-profit hospitals/clinics vs. for-profit centers vs. for-profit solo private practice). The main issue that the article discusses is confined to doctors in for-profit practice who joined medicine primarily to make money but the article fails to make that distinction. This is seen in every field and it's not at all specific to medicine. Think of the shady lawyers and dentists that you've seen or heard about. Yes there are some shady and unethical primary care doctors, specialists and surgeons--it's these people that need to be exposed instead of painting an entire field of medicine as "evil." NYT has published several articles criticizing different fields of medicine and blaming them for the cause of high health care costs. It's not black vs. white. It's extremely irresponsible for them to write such sensationalized articles without giving the full story or presenting the alternate side to the story.
Unfortunately, it's the system that has failed our patients (the money hungry malpractice lawyers and all the misleading advertisements that they air on TV to take advantage of people who are already suffering, the stingy for-profit insurance companies that currently enjoy a monopoly by being able to restrict patients to a certain geographical location even though we live in an increasingly globalized society, the failure of Obamacare from preventing insurance companies from increasing the premiums/deductibles on the already struggling middle class, the government bankrupting medicare/medicaid)---doctors income is not the major issue despite what they want you to believe. We're easy targets because we are so divided. They're trying to paint a picture of the doctors being evil because we're the politically safest target, the average person is not going to have sympathy for us. Doctors need to go on the offense to take on the political leaders and media and to educate the public on what doctors have to go through, unfortunately that will not happen because we're so divided.
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It's funny - we're divided because of the pay disparities between fields. I wonder if pay parity would strengthen the physician body, and that our outrageously disparate incomes (one radiologist makes as much as five pediatricians!) are a government tactic. Who influences the RUC?
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Reno, I think it was a lively discussion. I may disagree with you but I've tried to remain respectful even though I've said that I disagree and believe that you are misjudging the situation. However, you've now resorted to a condescending attitude. Also, making up statistics on 4/5 (totally made up by you on a whim) is poor form. Like I preemptively said in my earlier post of this thread, I'm not a non-derm or a medical student that you can just blow off. I'm not gonna take your bait.
You've avoided the internal ethics of physicians. They do not exist only to make money and you have to take into account that they will do the right thing when they have a malignancy. Many times cutting out the malignancy is not an good option because you honestly know that it is better done by a person who performs Mohs and the repair. So if a set if recommendations that says that they could refer into their own practice by hiring a Mohs surgeon (who may also work as a general dermatologist as well) and take a portion of the collections, then I think that would be a better situation than either of the scenarios that you set up. That is what is happening. Obviously setting up these financial relationships can be quite complicated (as mohs_01 pointed out and would be an interesting conversation). Some of these will do well and some will fail...but it's happening because people perceive the incentive in doing such a thing.
Whether you agree or not, practices are hiring their own Mohs surgeons, and even in cosmetics heavy practices. However, if you believe that financial incentives don't exist then so be it.
Returning to the crux of the thread, I personally would prefer to refer to a Mohs surgeon who does it all the time and has dedicated himself/herself to it. I don't need that extra case when I know that someone is really going to do it better or at least assess the situation better than me and then decide whether Mohs really is the best way to go or not. This isn't on every malignancy but on those that I really do think would be better served in the hands of a Mohs surgeon. This NY Times articles belittles all those that truly take their work seriously and work hard for it. The Mohs surgeon did not do anything wrong in this article (if anything did the right thing to coordinate for the repair) and to rope dermatology as being out of line in the example was totally asinine.
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Amen! This could have been published in the nytimes as a letter to the editor.
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The other aspect is that I wonder if the panelists on the appropriate-use guideline group tended towards dermatologists that were more established/older (since I imagine more well-known people were selected). I know that older general dermatologists are much less comfortable with many procedures. I know older general dermatologist that couldn't imagine excising a 3mm nodular basal on a cheek whereas I do that all day and would never refer that to mohs.
In any case, it was a good discussion and hope issues like these are highlighted in the future rather than sensationalist and smear tactics that happened in that article.
In any case, it was a good discussion and hope issues like these are highlighted in the future rather than sensationalist and smear tactics that happened in that article.
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It's been so long since I've seen a 3mm BCC that I wouldn't know what to do..
What margin would you happen to be taking?
After the game I'll open this one up a bit. Maybe another thread.
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Neat what's that iPhone app called? Crappy game... In any case I'd probably take a 3-4 mm margins depending on how well demarcated it looked. But I guess I was generalizing- if the pt was for example a young cosmetically sensitive woman I would send to mohs in hopes the scar would end up shorter but in older sun damaged skin -which is the vast majority - you can barely see the scar in a few months later so no big deal if it's a cm longer.
In any case, I'm glad you can't remember the number of 3mm BCCs you've seen recently. It seems that many of the MOHs practices I've been at can't even find the tumor without a photo because the biopsy probably removed the whole tumor and the scar was tiny. As I said, I don't think the appropriate use criteria went far enough if they give a "green 7" to these cases. I would give them a "yellow 5" because they are appropriate in certain situations but maybe not others.
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^Agreed.
It's the Mohs appropriate use criteria -- free from the App store. Called "Mohs AUC"
on edit -- the only knock one can ever have against Mohs is cost; if excision is appropriate, Mohs can be... and the more they target and take Mohs reimbursement down, the harder the argument will be to make for anything but Mohs. Heh.
It's the Mohs appropriate use criteria -- free from the App store. Called "Mohs AUC"
on edit -- the only knock one can ever have against Mohs is cost; if excision is appropriate, Mohs can be... and the more they target and take Mohs reimbursement down, the harder the argument will be to make for anything but Mohs. Heh.
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That's an interesting point regarding moving towards Mohs.
Agree...that was a crappy game...unless you're from Seattle!
Agree...that was a crappy game...unless you're from Seattle!
Still nothing new here. All of what you say is true, but it still doesn't refute the very simple point that I'm making. I'm not blowing you off. I don't care if you're a lay person, a med student, or a dermatologist with 20 years of experience. Who you are is irrelevant in answering the question at hand.
The thing that I found most hilarious though was the charge that I'm "making up statistics". Here's what I actually wrote:
"I think that if you asked a bunch of dermatologists at least 4/5 would agree with this statement."
I think anyone with a reasonable grasp of the English language would see that I'm just speculating and not representing that I've conducted some sort of formal study and reporting statistics. If that counts as making up statistics, then no one is allowed to make a guess about anything.
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Which makes you a selfish and greedy douche trying to increase the patient's bill unnecessarily (at least according to the New York times)
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Aren't different medical specialties specifically trying to fight pay parity? There's a reason different specialties have different PACs: SkinPAC, RadPAC, etc. There has always been a fight between specialists and generalists, since the beginning. The govt. is obviously going to take full advantage of this rift bc it helps them to achieve their specific end: lower reimbursement in general. That's the "savings" they're going for.
The first arrow in their arsenal is to go after specialists, esp. those in which the lifestyle is pretty good, which the New York Times has done already: Dermatology, Radiology, Gastroenterology, Emergency Medicine, etc. But don't think for one second, that if somehow magically specialist care were to be dramatically lowered to equal PCPs, that it would be over. Then they'll go after ALL physicians for DARING to make a salary above the average American worker (or NPs or PAs). It's simple divide and conquer.
As far as the pay disparity being a govt. tactic, hardly. The govt. isn't that smart. The explosion of Radiology salaries was due to the explosion in new knowledge and innovative technology - thus affecting standard of practice, thus more attendings ordering more imaging, not to mention malpractice concerns (i.e. CT scans for everyone with abdominal pain).
By the way, if people think that if the reimbursement system was based on the amount of time spent with the patient (instead of procedures) that the system wouldn't be "gamed" they would be very much mistaken.
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http://www.msnbc.com/morning-joe/watch/patient-fights-back-against-big-medical-bills-122242627560
I can't believe the author of this article, a former Emergency Medicine doctor who quit medicine and wanted to become a writer so she now writes for the NY Times, and now lives in China, has the nerve to go on MSNBC (friendly territory for doctors, lol) and just outright lie. Instead of correcting the host about skin cancer, apparently skin cancer is now just a "tiny white spot", and when asked about it still being cancerous, she answered, "presumably yes." We all need to tell patients that their BCC/SCCs are just "tiny white spots" and their melanomas are just "tiny brown spots". No biggie.
Also, apparently, being a dermatologist and reading dermatopathology slides is "self-referral" and if you're a dermatologist you'll be making $472,000.
Is there a reason that the AAD doesn't respond to these things? Or do they think it will just disappear?
I can't believe the author of this article, a former Emergency Medicine doctor who quit medicine and wanted to become a writer so she now writes for the NY Times, and now lives in China, has the nerve to go on MSNBC (friendly territory for doctors, lol) and just outright lie. Instead of correcting the host about skin cancer, apparently skin cancer is now just a "tiny white spot", and when asked about it still being cancerous, she answered, "presumably yes." We all need to tell patients that their BCC/SCCs are just "tiny white spots" and their melanomas are just "tiny brown spots". No biggie.
Also, apparently, being a dermatologist and reading dermatopathology slides is "self-referral" and if you're a dermatologist you'll be making $472,000.
Is there a reason that the AAD doesn't respond to these things? Or do they think it will just disappear?
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Ridiculously ignorant and I'm unsure if she's truly uninformed (probably me being naive) or is viciously pushing an agenda. If we catch skin cancers as "tiny white spots", then we've done our job. Even middle school children can identify skin cancers when they're ulcerated tumors.
I've seen responses from the AAD and the ACMS (http://www.nytimes.com/2014/01/22/opinion/the-costs-of-a-trip-to-the-doctor.html) but predictably, rational responses are buried in the shadows whereas sensationalist attention-grabbing titles grace the front page.
Disgraceful.
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If Elisabeth Rosenthal is uninformed, (which I don't think she is - as we all have access to even Wikipedia) it's likely because she no longer practices medicine and has been away from it for a while.
- When you say things like "taking off these spots now counts as an operation" - this is being willfully inflammatory bc you're preying on what your typical patient believes the definition of an operation is.
- When you say something is "presumably cancerous" (as if MOHS surgeons do the procedure on acne) - this is willfully inflammatory.
- When you say that a dermatologist reading his/her own slides is "self-referral in any other field, but in that field it's accepted" - this is willfully inflammatory, as if sending out the slides to someone else, brings the costs down. With her logic, we should I guess just take out any dermpath teaching in dermatology residency training.
And according to the Dr. Emily Senay, a "Preventive" Medicine doctor, this cancer is "very unlikely to cause serious problems long-term, it's a simple skin cancer that a lot of people have" - so I guess the solution would be to let the cancer continue to grow and eat through your skin. Try telling that to this patient whose leg was saved from being having to be amputated bc of a MOHS surgeon: http://www.nydailynews.com/new-york/best-hospitals-mt-sinai-article-1.1389670. In listening to it again, I just realized that this woman described it as "how do incentives work where a lady can go in for a simple little skin tag and wind up with $25,000 dollars in medical bills". So I guess now dermatologists are idiots, and refer skin tags to MOHS surgeons. Yet in the same breath she wants to be reimbursed for a skin cancer that didn't occur, or that she "prevented".
God I miss Dr. Daniel Siegel as president of the AAD. http://www.liskincancer.com/dr_siegel.html
He was not only knowledgeable in his specialty, but was also very politically active in defending our specialty against those who just outright lie about it. Sigh.
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I've had pre med teachers and heard pretty much the majority of people talk about Derm docs as if they were ALL greedy money ******...literally never thinking about the little cancer thing..only about how expensive treating acne is. Pretty sad if you ask me.
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do you think this divide and conquer is being funded by the nursing lobbies? I can't understand why people want to shoot down and call out doctors as being greedy for going hundreds of thousands in debt to end up making people's lives better through hard work and knowledge...I WANT doctors making lots of money..they deserve it.
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I think some of it may be due to the general loss of respect for healthcare providers in this country.
As a side note, this has been a great thread. I've actually learned a lot by reading through it.
As a side note, this has been a great thread. I've actually learned a lot by reading through it.
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You'll learn very quickly that besides your family and close friends (even that's not always true) most of the general public does not believe that doctors deserve to make lots of money, from your PCP all the way to the top. If anything they believe that doctors make too much money, and the money you do make is due to being greedy and selfish and capitalizing off people's suffering. This is something you're shielded from as a premed and maybe even as a med student. It becomes clearer during the clinical years and residency.
I will admit that Dermatology gets the most flack from other specialties due to the best combination of pay, lifestyle, option for private practice, and the option to not even set foot in a hospital. There is a reason why Dermatology, again and again, has the most satisfied physicians.
That being said, I really don't think you can get through a derm residency and pass Derm boards if you truly don't like/love the material. After busy clinics, you have to be able to immerse yourself in your texts and journals, so you don't establish yourself as an idiot at Grand Rounds in front of faculty many of whom are at the top of their field. There's a LOT of reading involved and not just clinical derm but cell biology/basic science stuff. It never ceases to amaze me how people will think that Derm is the only field where it's not possible to like the subject matter, no the only reason you can like derm is lifestyle and money /sarc off.
You have to like medicine for yourself and for no one else, bc in general the public doesn't care about you. They don't care about your debt, they don't care about your years and years of studying and delayed gratification, they don't care the effect of medicine on your family life, etc. None of that stuff. That being said, at least for Dermatology, many of your patients are people who are truly thankful for the things that you do for them to help them with their skin disease. I didn't feel that this was the case with many other specialties.
Due to heavy media influence (tv, NY Times, etc.) and bc medicine as a profession, holds itself as a martyr for altruism - certain groups take advantage - politicians, nurses, third party payers, and the govt. many of whom believe that an alternative provider can do what doctors do for a cheaper price (i.e. DNPs and their dermatology residencies) as well as cutting overall reimbursement.
As far as many patients are concerned, they don't understand why they have to pay for medical services at all (the "healthcare is a human right" folks). We sometimes even have our own circular firing squads where there are some doctors (many of whom don't actually see patients) jump on this crusade. Contrast this with Dentistry (vs. dental hygenists) or Lawyers (vs. paralegals) that fight tooth and nail for their profession, and they are better off bc of it.
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"some doctors (many of whom don't actually see patients) jump on this crusade":
what do you mean by this? wouldn't that not be in a doctor's best interest? Are special interest groups paying these doctors to go against their profession and are they basically sellouts? Docs needs stronger lobbies.
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I'll give you 2 examples (there are more): Dr. Ezekiel Emmanuel (a good friend of Obama and one of the authors of Obamacare) and Dr. Donald Berwick (who briefly headed CMS which is in control of Medicare). You can see them both on Youtube.
The first one is more a political idealogue and makes more than enough money giving talks and gracing his presence on political shows like Hardball & Morning Joe, etc. that he doesn't have to see patients (he's actually a breast oncologist). He writes articles for the NY Times, and is an academic at UPenn: http://medicalethics.med.upenn.edu/people/faculty/ezekiel-j-emanuel
Berwick isn't as much of a face, but tends to hate specialists and believes specialist care is used too much and that believes care rationed by the govt. is A-OK. He is actually a Pediatrician. Apparently his qualifications are good enough, that he's running for governor of Massachusetts as a Democrat:
These are people who are hailed as wanting universal healthcare, specifically a single payer health care system. They're both Harvard Medical School graduates. And no they do not actively see patients currently. They do however, grace with their presence the cable news talk shows when it comes to health policy with their "expertise" expounding on how bad the system is. They are independently wealthy, so they have no skin in the game unlike the rest of us with six figure loans over our heads. Our "lobbying" group, the AMA is utterly useless in comparison to Hospital Associations, Pharma and medical equipment companies, and nursing unions who pour in billions of dollars.
I wish the American Academy of Dermatology would at least do PSAs on tv rebutting these lies but I guess that's asking too much.
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You make some good points for sure. Looking at the legal profession (which is pretty much a joke besides the top 14 schools), those folks are also going into massive debt with absolutely terrible career outcomes; yet folks still sign up for 3 years of law school. Noone cares that they are going into debt (meaning that doesnt equate to you should get paid more) and their top pay out of school is rare and about 160k with gradual steps up if lucky and not kicked out the firm within 4 years as it is a pyramid scheme nearly everywhere.
Most engineering disciplines have been screwed over for years on pay and very smart people still sign up because they like the fundamentals of the work. They are paid a bull**** wage, yes its only 4-5 years undergrad, but they don't get far ahead on earnings by working sooner (except Petroleum Eng who are making specialist money.)
Ultimately, people will still sign up for medicine even if they only make 100k a year because sadly, there are only a few places for the non 1% folks to make decent money. They will still go even with the debt they incur, they will still go even with Obongocare.
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this is a great post...so how can we keep docs from selling out? I wonder if these docs actually believe in the stuff they talk about on the news shows.
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You bring up some interesting points.
I think it's tough on people going into medicine right now because you have a total of approximately 7-8 years to get through medical school and residency. If they reduce the salaries that much, they have to reduce the debt/subsidize the education. Otherwise, it'll make people think twice if you also want to have family, children, etc. I fear then we run the risk for jaded doctors. The sacrifice of both time and debt is pretty taxing in the path to medical school. Glad I did it but it would be nearly impossible financially with all of my debts on a 100k salary unless med school was considerably less expensive.
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I think this is where there is a disconnect from older attendings/faculty vs. those coming out of residency now. The problem is many of the older attendings/faculty (esp. the famous ones) have made LOADS of money with the system as it is (cough, cough, Dermpath), and went to medical school where it didn't cost the ridiculous amount of money that it does now. The ROI no longer exists, as it was for them. Back then, one couldn't be an NP and practice Dermatology by graduating from your own Dermatology "residency": http://nurse-practitioners-and-phys...a-Dermatology-Foundation-for-NPs-and-PAs.aspx
The problem is that when you look at the United States as a whole, jobs in very respectable professions have been disappearing. Medicine as a profession never made a big deal when those jobs were disappearing, so naturally, the public isn't going to have any sympathy for us, esp. when every other faction and interest group (Hospitals, Insurance companies, Lawyers, Nurses, Pharma, mainstream media, etc.) paint doctors as fat cats.
Sorry to re up this thread but i still dont understand how a dermatologist can justify the 300k salary they make, the 4 year residency they claim to justify (when gen path itself is 4 years or IM is 'only' 3 years and both cover the entire body- i understand the depth and breadath of derm but the same can be said of EVERY specialty). Not once was this even mentioned in this entire thread (and that is precisely the 'agenda' behind the author and why it was discussed- to shed light on how these types of salaries could even be justified).
I've done quite well in med school thank you and im certain none of this material we laern from renal to anaphylaxis is of much relevance in the derm world and to sit back and discuss the ins and outs of payment plans without acknowledging the absurdity of the field and its pay for the number of hours worked etc in comparison to say a general surgeon is not only misguided it just shows how deeply removed the field seems to be from reality. The posters are either purposefully uncritical of this aspect (and or feign ignorance - especially when they imply the author to have a nefarious agenda other than this by saying 'she clearly has an agenda') or are so far removed from the reality of the rest of medicine that the thought has not even occured to any of the posters (highly unlikely).
There is no justification for a salary greater than a primary care or IM or gen surg for a dermatologist. No amount of blathering can rebut this statement logically and effectively
I've done quite well in med school thank you and im certain none of this material we laern from renal to anaphylaxis is of much relevance in the derm world and to sit back and discuss the ins and outs of payment plans without acknowledging the absurdity of the field and its pay for the number of hours worked etc in comparison to say a general surgeon is not only misguided it just shows how deeply removed the field seems to be from reality. The posters are either purposefully uncritical of this aspect (and or feign ignorance - especially when they imply the author to have a nefarious agenda other than this by saying 'she clearly has an agenda') or are so far removed from the reality of the rest of medicine that the thought has not even occured to any of the posters (highly unlikely).
There is no justification for a salary greater than a primary care or IM or gen surg for a dermatologist. No amount of blathering can rebut this statement logically and effectively
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Why? What if the demand is there? I don't understand why they should have a salary limit set to what you want.
Salary limits always exist. This is the essential concept of a free market enterprise. it does not mean that salaries will go up and up to stratospheres. They do in certain contexts but those are heavily dependent on what the market bears in aggregate (IE sports atheletes etc).
The physician marketplace is not in the same category. It relies heavily on the judgements of society that doctors are in an esteemed position to help us. Unfortunately the physician system is more protectionist than capitalist. The entire system is designed to benefit doctors. To a certain extent this is essential to maintaining the physicians status and place in society ( a position even Adam Smith argued was essential but had difficulty articulating). The problem arises when certain groups benefit inadvertently. The payment model that benefits derm is as you know due to procedure base. That wasnt necessarily because the creators deemed derm to be so valuable service it should be paid as such. it was merely an upshot of the system and derm succeeded due to its high volume and turnout compared to other fields- less time per procedure, more procedures etc.
I mean I'm basically rehashing all the arguments again here, and dont really see the need to mention them all. But the essential truth can be boiled down to a few key points. Physician payments is designed around a procedure system. This procedure system is meant to reward the effort and time physicians put into medicine. Not all of this time and effort involved is justified. When justified certain fields should benefit greatly due to the time and effort needed. Said benefits can be manipulated by other fields that shouldnt benefit as much. When one job has long hours, call, trauma, life and death and pays less than another field that has short hours, limited call, limited trauma, limited life and death there is a clear manipulation of the system unless you are willing to admit hte system purposefully was created to enable this obvious dissonance- in which case we have bigger problems.
If derm is making money solely because it is based on private pay- ie the patients are paying out of pocket then the jobs should not be as limited- ie if patients are willing to pay out of pocket they should have the same right as anyone to receive legal treatment from groups that are not necessarily medically trained within reason. Who defines within reason? I certainly dont, but if society says that a CRNA can do what an anesthesiologist does or that an NP can do what a pcp does (eg NY) and I'm not justifying either of these (definitely not justifying it) then there is no reason why an NP cant do what an MD does independently for derm - especially when i see PAs doing derm work at hopsitals (but of course billing it to the derm or gen surg who signs off their orders). This is another artifical net meant to protect derm in the face of capitalism
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0 out of 10 for that Emmy-winning performance.
It shows you definitely know nothing about the field of Dermatology (or Derm boards which covers more than just General Derm) vs. Primary care vs. IM vs. General Surgery.
The woman took one Mohs case and made so many assumptions and falsehoods about the care given it's not even funny. Maybe @MOHS_01 can explain it to you, but I'd say he's done a pretty good job explaining.
This from a reporter who quit medicine altogether to live in China and is now a full-time writer for a living. This same thing has been done to GI, Radiology, etc. as well.
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*head on desk*
1. go to www.dictionary.com and enter the search term "salary"
2. report back with your findings
3. ask someone to aid in the interpretation if you still find yourself struggling (maybe find a kid going into derm -- rumor is they're pretty sharp. heh)
4. look into how the practice of medicine is reimbursed and compensation is structured.
5. go back to step #3 if needed
6. with this newly acquired knowledge, reread your post and laugh at it for the nonsensical ignorance it represented.
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You are a better person now. More enlightened, less necro-threader. Good job.
1. go to www.dictionary.com and enter the search term "salary"
2. report back with your findings
3. ask someone to aid in the interpretation if you still find yourself struggling (maybe find a kid going into derm -- rumor is they're pretty sharp. heh)
4. look into how the practice of medicine is reimbursed and compensation is structured.
5. go back to step #3 if needed
6. with this newly acquired knowledge, reread your post and laugh at it for the nonsensical ignorance it represented.
-----------------
You are a better person now. More enlightened, less necro-threader. Good job.
So far the only two things that have been stated in response were obvious defensive posturing in the forum of glib remarks and ad hominim attacks. Neither of which provide any prospect of an intelligent rebuttal for what i've said. I have yet to hear anyone justify the arrangements that have been created for Dermatology in the medical field financially.
Stating that I am a med student without providing an real argument for your case doesnt help anyone. Please do tell how I am wrong, and dont attack semantics. The key argument here is what exactly justifies the salary in place for dermatologists over others. Attempting to discredit the author because he/she has chosen to become a writer makes your case only tenuous (it relies on belittling the author and not their content) - would you say the same about Atul Gawande who has made similar arguments (a Rhodes scholar, AOA and endocrine surgeon?)
It seems that character assassinations are more common in this thread and reactionary attitudes are the prevailing mentality rather than reasoning
Stating that I am a med student without providing an real argument for your case doesnt help anyone. Please do tell how I am wrong, and dont attack semantics. The key argument here is what exactly justifies the salary in place for dermatologists over others. Attempting to discredit the author because he/she has chosen to become a writer makes your case only tenuous (it relies on belittling the author and not their content) - would you say the same about Atul Gawande who has made similar arguments (a Rhodes scholar, AOA and endocrine surgeon?)
It seems that character assassinations are more common in this thread and reactionary attitudes are the prevailing mentality rather than reasoning
By 2012, dermatologists — whose incomes were more or less on par with internists in 1985 — had become the fourth-highest earners in American medicine in some surveys, bringing in an average of $471,555, according to the Medical Group Management Association, which tracks doctors’ income, though their workload is one of the lightest.
In addition, salary figures often understate physician earning power since they often do not include revenue from business activities: fees for blood or pathology tests at a lab that the doctor owns or “facility” charges at an ambulatory surgery center where the physician is an investor, for example.
“The high earning in many fields relates mostly to how well they’ve managed to monetize treatment — if you freeze off 18 lesions and bill separately for surgery for each, it can be very lucrative,” said Dr. Steven Schroeder, a professor at the University of California and the chairman of the National Commission on Physician Payment Reform, an initiative funded in part by the Robert Wood Johnson Foundation.
All accurate portrayals of the situation. Also, while the survey salareis are inflated, they dont take away from the reality that they make more than primary care/gen surg/etc by a significant margin.
In addition, salary figures often understate physician earning power since they often do not include revenue from business activities: fees for blood or pathology tests at a lab that the doctor owns or “facility” charges at an ambulatory surgery center where the physician is an investor, for example.
“The high earning in many fields relates mostly to how well they’ve managed to monetize treatment — if you freeze off 18 lesions and bill separately for surgery for each, it can be very lucrative,” said Dr. Steven Schroeder, a professor at the University of California and the chairman of the National Commission on Physician Payment Reform, an initiative funded in part by the Robert Wood Johnson Foundation.
All accurate portrayals of the situation. Also, while the survey salareis are inflated, they dont take away from the reality that they make more than primary care/gen surg/etc by a significant margin.
You seem to have a certain point in mind. Why not just come out and state it instead of couching it in the form of a question and creating an air of uncertainty?
Kobe can make as much as he wants. So can you. The problem is that the market is reacting to one and not in particular to the other. People will continue to spend their dollars on tv and watching games. In aggregate this will continue to employ kobe at high salaries. i already alluded to this but you have either chosen to ignore this or simply have not made reasoning a necessary priority when you communicate.
Medicine is trending downwards. We can inject control on this process or continue to bemoan the declining salaries by continued employment of the current free-market destructive system. I've already explained why its not free-market.
Please do tell me what I've said wrong earlier instead of blithe remarks that offer nothing other than a childlike reaction to reality.
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It's obvious that you don't understand several things:
a) the specifics and medical facts of this case - which since it is somehow being used to justify decreased reimbursement to Dermatology should be completely accurate, which we have already discussed ad nauseum and quite honestly, you don't justify rehashing of all that (yes, please accuse us of evading your question, ad hominems, strawman arguments, character assassination, yada yada yada)
b) you don't understand how medical services in this country are rendered and paid for in this country. The salary we make does not displace other physicians' salaries. Just bc we make more doesn't mean others automatically make less. You also need to understand the difference between BILLING and SALARY. They're not equivalent. All specialties work in the same system. Dermatologists are not doing skin biopsies and flaps on every single patient.
c) Atul Gawande is not AOA as he graduated from Harvard that doesn't have a chapter, but putting that aside which is irrelevant, any man who believes that the medicine should run like The Cheesecake Factory is an educated idiot. Any man who complains about the prices of medical care, when his institution that he WORKS FOR, Brigham and Women's Hospital has strongarmed insurance companies in Massachusetts to accept the prices they charge, or will take their hospital out of their networks due to their large monopoly over market share has no right to lecture everyone else about exploding health care costs.
http://www.forbes.com/sites/theapot...iver-of-health-costs-that-nobody-talks-about/
You make yourself sound stupid when you say things like
- anaphylaxis is of not of much relevance in the derm world
- There is no justification for a salary greater than a primary care or IM or gen surg for a dermatologist. (Where this is nowhere exclusive to dermatology, and the average dermatologist is not making more in salary than your average general surgeon)
again. the picking and chosing of arguments. Not once have you reasonable argued the point about dermatology salaries- instead, 1 deflecting (and cutely/ cleverly? admitting to this by dismisisng my use of these words) and 2. continuing your ad hominems. I had a feeling you would focus on the smaller points. So I use the word anaphylaxis because I'm thinking about acute care, not because its never involved in dermatology. And please, don't tell me its something of extreme relevance in your world because last I checked the ER docs dont consult you on it, but hey I'm only an MSIII, thanks for the sleuthing.
Actually, you sound really stupid by focusing on the niggling points instead of the over arching problems of medical financing - which is what this conversation is about.
Your argument about dermatology and general surgeons- are you saying they work the same hours because I'm pretty sure most derm is 40 hours or less and most gen surg includes night call and 60+ hours a week, and every major survey shows gen surg at less than or at most equal to derm in the same geographic/etc etc areas (save for a few here and there, the per hour salaries for derm is significantly higher). That this is not unique to derm is irrelevant that the disparity still exists, again thanks for the deflection.
The overarching article's goal is to highlight A the fact that derm salaries have skyrocketed and B in no small part due to their procedure heavy field. That there are inconsistencies with MOHS is irrelevant to the above two which are facts. You either have poor reasoning skills or don't care to understand how articles are written.
You clearly don't understand my points. I never argued derm salaries displaced gen surg salaries. Again with the straw man (did you mock that term earlier? Perhaps you don't understand that word- so I shall define- straw man: implies an adversarial, polemic, or combative debate, and creates the illusion of having completely refuted or defeated an opponent's proposition by covertly replacing it with a different proposition (i.e., "stand up a straw man") and then to refute or defeat that false argument, ("knock down a straw man,") instead of the original proposition. Straight from Wikipedia, thanks for playing.
I compared the two because payment should be commensurate to the services rendered. I mentioned Gen Surg because their activities were far more involved, deal with life and death, have call, longer hours all associated in the US with higher pay than another job that requires less hours etc etc. Derm fits this second category yet manages higher pay. The reason is because of an upended and broken payment system.
The issue of billing and salary is irrelevant to this argument, Derm make on average higher per hour than gen surg and other more intensive fields. There is no real reason other than an artificial system designed to reward higher procedures. Prior to the advent of procedural based payments derm salaries were similar to IM, historically this was the case- that derm make more is a relatively recent phenomenon.
Back to your absurd attacks and yes it is an attack when you couch your 'outing' of who I am by starting with the word 'We' when I highly doubt others have taken the time to identify who I am- thanks for pointing out that I'm DO- was that your intent to point out my 'inferiority', alongside my MS III standing? Because logic and reason don't necessarily improve because you are an attending. For what its worth my SAT and MCAT were probably higher htan most physicians (1520, 35)...on that note there are many derm DOs outthere. I guess one does not have to bee too bright in your opinion to become a Derm then (otherwise it would surely be impossible for Derm DOs to exist). And yes I know you didn't make direct disparaging remarks about DOs- but lets be real here, thats the only reason why you mention me being a DO alongside being MSIII- again with the passive aggressive- are my terminologies offending your sensibilities? Regardless, my position, standing etc is irrelevant to the obvious problems in the medical field today all of which are capably pointed out by non physician economists and policy makers.
Your desperate attempt to attack me merely shows how tenuous your own position is. Again, you fail to justify the salary for a Derm and why it should be higher than a Gen surg (ok at most equal to Gen surg in raw dollars in SOME places even though gen surg works far more hours etc etc). Instead, you attempt personal attacks on me in a passive aggresive voice (the most intellectually inferior method might I add- both avoiding aggression due to some sort of mental defect/fear and avoiding confrontation at the same time- due to a lack of confidence in one's own abilities).
Suppose I become a dermatologist one day which I well could do- would my standing change if I held the same beliefs? Or that Atul Gawande makes reasonable points about costs- you mention cheescake factory- he never claims that mediicne should model itself after that company- he evne points this obvious discord out- instead using it as a step off point to argue a more important idea that business processes need to be more efficient.
Dude went to Harvard, I don't care if he's AOA - are you seriously going to argue this point? Thats a lot of words to discuss something that irrelevant to his abilities which is what I was attempting to point out. Seems like you missed the boat on that one.
Again, you fail to justify the position. Its obvious you can't or won't
tl;dr? Still haven't made a cogent argument, devolve conversation to insults, straw mans, and passive aggresive attempts at mockery.
Recent posts on this thread deserve no more of my time than this.
Comments from some docs on clinical rotations deserved no more than a smile
On an unrelated note, I matched
!!! i just wanted to thank all of my future colleagues for your awesomeness and contagious happiness. it was truly my pleasure to meet you on the interview trail and to work with you in clinics. Looking forward to becoming a dermatologist.
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And just like clockwork, you accuse people of ad hominems, strawman arguments, etc. Yawn.
Billing and salary is relevant to this argument as the crux of the NY Times piece and her interview on Morning Joe is predicated on the connection between the two. In that case, the bill from derm was $1,833 out of $26,000 (of which $14,000 was charged by Plastics), but yet somehow it is all Derm's fault. Mind you in the end, the insurance company still ratched down the bill immensely.
You say: "I mentioned Gen Surg because their activities were far more involved, deal with life and death, have call, longer hours all associated in the US with higher pay than another job that requires less hours etc etc."
- So then are you advocating for payment to be made to doctors the way lawyers charge for their time in billable hours (which would be even more expensive than what we have now)?
- Who gets to decide what is "commensurate to the services rendered"?
- Who gets to decide which organ system diseases are more important than others?
- Or are you just whining bc Dermatology is a completely outpatient based due to the nature of the specialty, while General Surgery is not?
- "i still dont understand how a dermatologist can justify the 300k salary they make"
- "There is no justification for a salary greater than a primary care or IM or gen surg for a dermatologist. No amount of blathering can rebut this statement logically and effectively" (thus already your mind is closed off from having your mind convinced otherwise)
- "...there is no reason why an NP cant do what an MD does independently for derm - especially when i see PAs doing derm work at hopsitals (but of course billing it to the derm or gen surg who signs off their orders) - shows you know absolutely nothing about the type of cases PAs and NPs handle. I can count on more than I have fingers, cases we've gotten in our academic program in which a derm case was heavily mismanaged by midlevels which was thought to be something benign and common place, but was found by us to be much more complex and misdiagnosed.
Newsflash: the system doesn't revolve around Derm and there are no special rules made for us. All specialties work under the same rules since 1991. The same rules that Rads, Rad Onc, Ophtho, GI, and the field you're going for, Cardiology, works under. If you don't like or have criticisms about the system, then fine, but then don't blame it on Derm.
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Oh my. Oh my.
1. Pay in medicine is rarely straight salary.
2. Even when it is that figure is arrived at based upon assumptions of productivity minus costs.
3. You crack me the **** up, kid. Seriously, getting a good laugh at your expense right now. Keep up the strong work -- the win is strong with you. :thumbsup
1. Pay in medicine is rarely straight salary.
2. Even when it is that figure is arrived at based upon assumptions of productivity minus costs.
3. You crack me the **** up, kid. Seriously, getting a good laugh at your expense right now. Keep up the strong work -- the win is strong with you. :thumbsup
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By saying:
- "I've done quite well in med school thank you"
- "Suppose I become a dermatologist one day which I well could do" and my favorite
- "For what its worth my SAT and MCAT were probably higher htan most physicians (1520, 35)"
You of course try to be just as argumentative here: http://forums.studentdoctor.net/thr...editation-system.1057223/page-3#post-14951160
Funny how you quibble over Gawande being AOA (when you're the one who mentioned it as a credential, and I said it was irrelevant) and you leave out the part where I said he voluntarily works for an institution which is KNOWN to strong arm insurance companies to yield to their charges due to their monopoly of the market. It's institutions LIKE HIS that have lead to health costs skyrocketing like they have. Not physician salaries that are such a small percentage of OVERALL healthcare spending. It wouldn't be the first time though that Harvard has done the "Do as I say, not as I do" dance,
The ones that make $471,555 usually have a high cosmetics clientele which does not involve insurance. Not to mention according to the same MGMA figures, Cardiologists make $532 K, which is a field you are going for. You're delusional if you think your average dermatologist makes more than your average General Surgeon or your average derm is making $472 K.
:troll::troll::troll::troll:
Again, with the snide comments about DO derm, the mention of me being DO etc etc are all relevant. They exist in the posts for a reason. It is central to the attitudes prevalent in this thread. Me posting about myself is a necessary pre-emption against the prevaling attitudes against certain types of physicians and for that I have no problem doing what I did- knowing full well i'd come across defensive.
I think its absurd that as soon as someone comes to question the attitudes of a specialty people become aggressively territorial. It shouldn't matter if the argument is about cards, or GI or any other field. Again you troll my posts to find something to out me with (yet claim no one is trying to attack). Let me point something out- I have made the same statements against other fields including cards and GI elsewhere. I'm not saying that Derm in particular should be singled out. I think the same applies to a variety of fields that charge absurd levels when it shouldn't be this way.
My attitude about Derm is not specific to derm, I posted about it because i saw it come up during a search- had this been ophtho or any other field I would have done the same and have before. I lef the part about gawande out simply because it was irrelevant to the point being made in an already long post - the guy is qualified surgeon, the guy practices medicine- the two points you claimed the nytimes author did not have.
Its funny through all these posts NO ONE has made any reasoned arguments for any justification for the current marketplace.
Again with the straw man. I havent claimed Derm is special. I'm simply pointing out the absurdities associated with it as a defense for questioning the current payment plan. If the article had been about something else I'd be happy to discuss it- as I have about GI elsewhere.
I would love to be convinced otherwise -but it is clear from the conversation here that none of you are capable of making such an argument or are unwilling to do so because I have yet to see it.
I have no doubt that PAs and NPs botch these cases routinely. In fact, that is part of my thinking as to why they shouldnt be allowed to do so at all- BUT if society is letting them do primary care, then they should also be doing derm work as it is in no way more complicated (especially life or death level) than primary care - ie missing the guy with cauda equina syndrome and confusing his paresthesia with diabetes etc etc etc.
I dont know why but I get this feeling like everyone is beating around the bush.
Simply put, please explain, through reason and logic and clearly- why the current system is a fair for dermatologists in terms of their earned income. if that is too much to contemplate, explain why a dermatologist who made the same as an internist decades ago should have the significnatly higher per hour pay he/she does today than internists do. What justifications can possibly be made -and I am confident there aren't very many legitimate ones.
Not a troll, simply trying to provide context to the one sided debate here. This is a forum- a forum abou tmedicine and people can argue for both sides. I'm not sitting here saying kumbaya we should all make a pittance and look at all the poor bla bla. That would be trolling. This is trying to establish the problems with medicine today so we can fix it for the future.
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Here's the problem, your posts demonstrate:
1) You don't know what the free market is. You think you do based on your Econ 101 class, but what you fail to realize is that our medical healthcare system has not been truly free-market, even before "fee-for-service" took place, bc patients themselves, do not pay out of pocket for medical services. It is done thru a third party.
2) You definitely don't understand our payment system for medical services in this country and what are the factors that contribute to billing and the factors that contribute to salary, both of which are very different and vary based on contracts and practice settings. Your inability to understand this basic nuance, now for the umpteenth time, means there is no hope for you.
3) Your posts indicate that you don't wish to be convinced - such as "acknowledging the absurdity of the field", " No amount of blathering can rebut this statement logically and effectively", "What justifications can possibly be made -and I am confident there aren't very many legitimate ones", and many other examples, of which you are so utterly convinced as a 3rd year medical student that you have it all figured out. It's not the 3rd year med student that I'm criticizing you for. It's the fact that you believe you have it all figured out.
I will now leave you with what @MOHS_01 , told you before:
1. go to www.dictionary.com and enter the search term "salary"
2. report back with your findings
3. ask someone to aid in the interpretation if you still find yourself struggling (maybe find a kid going into derm -- rumor is they're pretty sharp. heh)
4. look into how the practice of medicine is reimbursed and compensation is structured.
5. go back to step #3 if needed
6. with this newly acquired knowledge, reread your post and laugh at it for the nonsensical ignorance it represented.
===========================
And now feel free to accuse us again of lack of "cogent argument, devolve conversation to insults, straw mans, and passive aggresive attempts at mockery". Make it a good one.
1) You don't know what the free market is. You think you do based on your Econ 101 class, but what you fail to realize is that our medical healthcare system has not been truly free-market, even before "fee-for-service" took place, bc patients themselves, do not pay out of pocket for medical services. It is done thru a third party.
2) You definitely don't understand our payment system for medical services in this country and what are the factors that contribute to billing and the factors that contribute to salary, both of which are very different and vary based on contracts and practice settings. Your inability to understand this basic nuance, now for the umpteenth time, means there is no hope for you.
3) Your posts indicate that you don't wish to be convinced - such as "acknowledging the absurdity of the field", " No amount of blathering can rebut this statement logically and effectively", "What justifications can possibly be made -and I am confident there aren't very many legitimate ones", and many other examples, of which you are so utterly convinced as a 3rd year medical student that you have it all figured out. It's not the 3rd year med student that I'm criticizing you for. It's the fact that you believe you have it all figured out.
I will now leave you with what @MOHS_01 , told you before:
1. go to www.dictionary.com and enter the search term "salary"
2. report back with your findings
3. ask someone to aid in the interpretation if you still find yourself struggling (maybe find a kid going into derm -- rumor is they're pretty sharp. heh)
4. look into how the practice of medicine is reimbursed and compensation is structured.
5. go back to step #3 if needed
6. with this newly acquired knowledge, reread your post and laugh at it for the nonsensical ignorance it represented.
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And now feel free to accuse us again of lack of "cogent argument, devolve conversation to insults, straw mans, and passive aggresive attempts at mockery". Make it a good one.
You and everyone here say the same thing over and over yet fail to establish these, apparently key, points. Why not elucidate them?
Apparently you've decided NOT to read my posts fully (other than to cherry pick arguments)- I've made it clear that the medical field is not wholly market based. I'm not disagreeing with that. What I am pointing out is that even within this framework the system is broken simply by pointing to the problems of compensation. I most certainly understand that there is an insurance system in place. Again no one is arguing with this.
Again salary and compensation are the only things important to this argument here. I'm not discussing reimbursements so Im not entirely sure why posters here constantly harp about billing. The question is, how is is that certain fields that are more intense are paid- PAID, salairied, income whatever- LESS than less intensive fields? That is the essential question. And before someone says they're hte same - I refer to the hourly wages.
I've said that over and over again.
yet you and others repeatedly argue over niggling points, make a mountain over molehills- ie even if i concede something you dont like it still doesnt make my overarching point any less meaningful.
Please explain to me why a derm should be making more per hour than a general surgeon or a trauma surgeon or an internist OR why the INCOME of derm and internists has split so dramatically in the past twenty years and how this is justified- ie why was it that twenty years ago derms were considered to be inline with internists but today they are not. And DO NOT tell me its simply about billing and this or that system in place- I am asking what the justification is for all of that.
In other words, are you conceding that derm makes more simply because of the system in place, or that derm genuinely deserves the salary a derm makes - and if so why should they compared to say an internist. If it is simply about how hard it is to get in- that doesnt really cut it in todays medical world where govt/society at large is looking at our practices with a microscope.
IE- if someone were to look at say surgeons and ask should they make this money- I think a surgeon can comfortably say well we work long hours, its a difficult stressfull field, it has life and death involvement etc etc that can reasonably argue they should make that much money.
But when you have retina surgeons costing medicare an enormously large expense in cost due to some overpriced medicine- I think its legitimate to question the current model and the argument that ophth and others including derm should be either reimbursed at the current levels or make more than other more intense fields.
Nothing you've said so far points out the fallacy of my arguments
