The coming residency bloodbath

[exPCM]

The attack on money by some here in regards to career choice is interesting.
When I interview a potential med student and the student includes money/financial as one of their reasons for choosing to become a physician I actually give the student extra points for honesty and integrity. I frankly think that all the students that interview and say that their only reason for choosing medicine is "to help people" are often feeding me BS. There are a lot of other ways that you can help people sooner than you can by going to medical school such as becoming a social worker or teacher, etc.

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[Eta Carinae]

The attack on money by some here in regards to career choice is interesting.
When I interview a potential med student and the student includes money/financial as one of their reasons for choosing to become a physician I actually give the student extra points for honesty and integrity. I frankly think that all the students that interview and say that their only reason for choosing medicine is "to help people" are often feeding me BS. There are a lot of other ways that you can help people sooner than you can by going to medical school such as becoming a social worker or teacher, etc.

 

[Eta Carinae]

I served on the admissions committee as an MS1&2 and I never really asked why they went into medicine...because I knew that for some, the reasons would change with time.

I spent more time trying to investigate what their expectations were, what they did outside of medicine/academics/volunteering and what plans they had for the future.

Every now and then, I had someone share an experience that demonstrated their critical thinking ability. I also would try to investigate their ideas of balancing work and family and what their approach was to avoiding burnout during the most protracted stressful periods of their lives (for most, preparing for the MCAT for 8 weeks or more nonstop). Those coping strategies, their intellectual capacity, avenues for creative outlet, ability to develop the entire person, those sorts of things were my priorities when screening applicants.

I never aimed to deceive anyone, nor did I appreciate attempts to deceive me. I like to think that back then I had a knack for distinguishing B.S. from sincerity

 

[howelljolly]

The realization that some of our colleagues were dishonest enough to feed medical school ad-coms sanctimonious lines of wanting to help people and improve healthcare in their communities, is disappointing.

Those of us who are ruffled by the thought that our colleagues are in it for the money do "deal with it". But rather than "achieving nothing", the constant whining really does make us feel a little better.

Also, the fact that in the US, medical specialty is a personal choice is an underlying point of contention. In other countries, it is not a personal choice - it is subject to the needs of the community. I know a doctor outside the US who was given a choice between internal medicine and orthopedic surgery, because that's what they needed. At this time, America needs primary care docs and child psychiatrists more than it needs dermatologists and radiologists. Since residency programs are federally funded, there's a simple way to address this issue. So, rather than "whining" some of us actually try to be proactive, like we said we wanted to be when we applied to medical school.

So, bringing up this issue is something that we like to do. It is only "irritating beyond measure" to those who are dishonest with themselves as to why they chose their specialty.

Bleh! That was some of my best discourse!

Para.1 - We got into med school because we spouted altruistic goals. If you tell the ad-com that you are in it for the money, you'll never get in. I am not sanctimonious, I wasn't lying about my altruistic goals. Anyone who goes into a specialty "for the money", was being sanctimonious and lying at that original juncture.

Para.2 - You're saying that we should get over it, and spare you the irritation of having to read about our gripes. I'm saying that in the very process of supplying you with such gripes, we are coming to terms with them.

Para.3 - The first line uses italics as a grammatical morpheme. My quote didn't make sense in your post, but it did make sense in mine. I said that there is an inherent problem with the fact that, in America, we can choose our specialty. I go on to explain how it is a privilege that we have - one that if we gave up, would solve a number of problems with our healthcare system. You're saying that we have a right to choose our specialty with whatever intentions we want. I'm saying that it's a privilege that we have abused and thus have contributed to our inadequate healthcare system. To me, when one offers suggestions for a solution, one isn't whining, theyre being proactive.

Para.4 - Brings back the original point of repeatedly bringing up the issue those who choose specialties for monetary gain and sums it up as being "something we like to do". It is a way for us to come to terms with what we see as a selfish and dishonest practice among our colleagues, and a springboard for sociopolitical change. I also point out that only those who choose a specialty for the money and do not admit this to themselves can be irritated, offended, or made to feel guilty by such a notion. Those who chose for other reasons and ended up in lower-paying fields wouldnt be irritated. Also, those who chose for financial gain and are honest with themselves about it wouldn't be so irritated either.

That should clear things up a bit.

 

[Eta Carinae]

Originally Posted by howelljolly
Para.1 - We got into med school because we spouted altruistic goals. If you tell the ad-com that you are in it for the money, you'll never get in. I am not sanctimonious, I wasn't lying about my altruistic goals.

+/- true
You may not consider derm or rads to have any altruistic elements, but they may beg to differ. Any level of involvement in the management of disease could be scripted to be altruistic, some may argue. After all, with the same level of intelligence and even fewer years in training, they could have all been wall street bankers making 2-3x what their projected max salaries will ever be in medicine (I know, my bro works on wall street).

Originally Posted by howelljolly
Para.2 - You're saying that we should get over it, and spare you the irritation of having to read about our gripes. I'm saying that in the very process of supplying you with such gripes, we are coming to terms with them.

nice

Originally Posted by howelljolly
I go on to explain how it is a privilege that we have - one that if we gave up, would solve a number of problems with our healthcare system. You're saying that we have a right to choose our specialty with whatever intentions we want. I'm saying that it's a privilege that we have abused and thus have contributed to our inadequate healthcare system. To me, when one offers suggestions for a solution, one isn't whining, theyre being proactive.

very nice.
Now that's a cogent argument I can actually assent to.

Originally Posted by howelljolly
Brings back the original point of repeatedly bringing up the issue those who choose specialties for monetary gain and sums it up as being "something we like to do".

It could be.

I don't think anyone chooses a specialty they abhor simply because of the reimbursement rates. Of course it's something we like to do AND, unlike most others who may also enjoy the nature of the work involved, we may have the necessary academic credentials +/- personality type to match.

If the top two guys in my class chose plastics and Derm, I think that says- this is "something we like to do", AND, "with our competitive standing/grades/scores, we actually can do".

That being said, nice comeback.

 

[howelljolly]

The attack on money by some here in regards to career choice is interesting.
When I interview a potential med student and the student includes money/financial as one of their reasons for choosing to become a physician I actually give the student extra points for honesty and integrity. I frankly think that all the students that interview and say that their only reason for choosing medicine is "to help people" are often feeding me BS. There are a lot of other ways that you can help people sooner than you can by going to medical school such as becoming a social worker or teacher, etc.

I disagree that they are often feeding you BS, I think that they are more often just unrealistic and naive, and actually believe that medicine is the best way to "help people".

Premeds somehow get blinders put on them early on. Everything they do in undergrad becomes geared toward medical school, and the real careers which "help people", like teaching and social work, get ignored. The truly high-paying careers in business and finance are ignored as well. Somehow in the rat-race, premeds ultimately "can't" do anything besides medicine. If they don't get into medical school, they keep trying 3 or 4 times, or go overseas to the Caribbean by the THOUSANDS, or settle for PA or RN school. Any other student who made a lofty career choice, take Law for example, just changes their career goals. Only in medicine are there "pathways" and "back doors", and people that try every-which-way to get into the profession. Because, if they cant then they dont know what to do with themselves.

I suppose its as simple as the question:
How can a typical bio major/chem minor premed, who spent all their free time volunteering in a hospital have a career that they want? Whether they want to help people, or make money their only option is to go to med school. The only other job (they think) theyre qualified for is to be a lab rat... and that doesnt meet their goals.

If they're so convinced that this is the most noble profession on earth, and the only thing that they can "possibly ever see [themselves] doing in a million years".... and the thousands of people who you dont see in the American med schools, or as physician colleagues prove this line of thinking every day.... then, I dont think you can say that the strange and shortsighted things they say at the med school admission intervew are BS.

By the way... I personally never mentioned any rot about "helping people" on my med school or residency interviews.

 

[Coastie]

My point in suggesting it exactly. The specialty road is pretty easy these days, with the high $$$ return sooner. If people had to do a general residency first perhaps they would think twice about going into the high-dollar fields purely for the money (and you know people do). Sure, there are some that go into the high-dollar fields because they're interested, but many go into the fields purely for the lifestyle and money return, which is a pretty fast course these days.

If these folks who just wanted the money faster had to do a PC residency first, then perhaps they would stop there and we'd have more PC doctors around.

How is the specialty road easier? It's harder to get into from med school, and the residencies themselves are harder. Finally, private practice in anesthesiology, for one, is no joke.

I think everyone should do a general intern year (do away with worthless TY years), but more than that? PC doctors generally make less money, are nearly legally equivalent with nurse practioners, and we are facing 101 programs (with 100 more coming online soon) of DNPs. Unless you're a PC doctor with some business sense, you're gonna be in alot of trouble very soon. Of course, anesthesiology faces many of the same threats, but even with CRNAs, the situation isn't as bad for us as it is for the PC guys.

 

[Coastie]

Also, the fact that in the US, medical specialty is a personal choice is an underlying point of contention. In other countries, it is not a personal choice - it is subject to the needs of the community. I know a doctor outside the US who was given a choice between internal medicine and orthopedic surgery, because that's what they needed.

And this is why America has the world's greatest GME, and is the world's greatest country. In fact, we're the greatest country that has ever existed: We provide the most freedom and economic boom to more people in the world than any other country dreamt about in the history of this world.

Is that an underlying point of contention?

 

[Coastie]

.

Bleh! That was some of my best discourse!

Para.1 - We got into med school because we spouted altruistic goals. If you tell the ad-com that you are in it for the money, you'll never get in. I am not sanctimonious, I wasn't lying about my altruistic goals. Anyone who goes into a specialty "for the money", was being sanctimonious and lying at that original juncture.

Didnt you go to a carib school? I'd think the admins would love it if someone said they were going into it for the money! After all, they are run by privately held corporations. Are they altruistic in their education of future doctors?

Para.2 - You're saying that we should get over it, and spare you the irritation of having to read about our gripes. I'm saying that in the very process of supplying you with such gripes, we are coming to terms with them.

Para.3 - The first line uses italics as a grammatical morpheme. My quote didn't make sense in your post, but it did make sense in mine. I said that there is an inherent problem with the fact that, in America, we can choose our specialty. I go on to explain how it is a privilege that we have - one that if we gave up, would solve a number of problems with our healthcare system. You're saying that we have a right to choose our specialty with whatever intentions we want. I'm saying that it's a privilege that we have abused and thus have contributed to our inadequate healthcare system. To me, when one offers suggestions for a solution, one isn't whining, theyre being proactive.

So, it's a problem that we have freedom to choose a specialty?

Para.4 - Brings back the original point of repeatedly bringing up the issue those who choose specialties for monetary gain and sums it up as being "something we like to do". It is a way for us to come to terms with what we see as a selfish and dishonest practice among our colleagues, and a springboard for sociopolitical change. I also point out that only those who choose a specialty for the money and do not admit this to themselves can be irritated, offended, or made to feel guilty by such a notion. Those who chose for other reasons and ended up in lower-paying fields wouldnt be irritated. Also, those who chose for financial gain and are honest with themselves about it wouldn't be so irritated either.

To quote jet: " why make 150k when you can make 450k ? "

That should clear things up a bit.

 

[howelljolly]

How is the specialty road easier? It's harder to get into from med school, and the residencies themselves are harder. Finally, private practice in anesthesiology, for one, is no joke.

I think everyone should do a general intern year (do away with worthless TY years), but more than that? PC doctors generally make less money, are nearly legally equivalent with nurse practioners, and we are facing 101 programs (with 100 more coming online soon) of DNPs. Unless you're a PC doctor with some business sense, you're gonna be in alot of trouble very soon. Of course, anesthesiology faces many of the same threats, but even with CRNAs, the situation isn't as bad for us as it is for the PC guys.

One of the perceived negatives of Primary Care is having to maintain an enormous breadth of knowledge. When people start realizing that midlevels don't generally have the breadth of knowledge that scares doctors away... something is going to change. But Im willing to bet that midlevels have the medical malpractice guys in their back pocket as well.

 

[Coastie]

One of the perceived negatives of Primary Care is having to maintain an enormous breadth of knowledge. When people start realizing that midlevels don't generally have the breadth of knowledge that scares doctors away... something is going to change. But Im willing to bet that midlevels have the medical malpractice guys in their back pocket as well.

Believe me, I'd love to see mid-levels disappear from the independent practice scene. I just don't see how it's gonna happen.

What incentive is there for change to increase quality in a massive socialized healthcare system? NHS has nurses performing surgery solo, for goodness sakes. Good luck, but AAFP sold you guys out for supporting Obamacare, and now we're all gonna suffer.

 

[howelljolly]

.

No, Carib schools are not altruistic in their education of doctors. But I didnt bring up wanting to make money in my interviews, so I don't know what they would have said. They did ask me what specialty I was planning to go into, and why. I talked to the guy who posed the question later on, once I was in the school. He told me that he just wanted to see my thought process, and was actually waiting for an answer like "Oh, I dont know yet, Im keeping an open mind". He said that would been interpreted as BS on the part of the applicant, or being forced to apply to med school by wealthy doctor parents.

anyway.

No, fool. It is not a "problem" that we have freedom to choose a specialty. I said it is a privilege. Residents are paid on taxpayer dollars. In other countries where GME is paid for by the government, the government decides what specialty it will train residents in. Like other privileges we have, we have put our selfish personal gain first in exercising that privilege. In doing so, we haven't helped the "healthcare crisis in America". Perhaps you read the newspaper and found out that there is a shortage of primary care physicians, and child psychiatrists in the US? The physician shortage? Now that's a problem. But you probably are as concerned about that problem as you are about some species of beetle that's going extinct in some south-Pacific island.

I actually consider myself fortunate to have experienced healthcare delivery in another country, and talked to physicians from around the globe about how medicine is practiced in their country. Its made me see things in a different way. And now I probably won't have the privilege of international rotations in residency....
Well, because residents are paid on the government's dime. And the government recently stepped in and said that they will no longer pay for residents to provide healthcare in other countries on US taxpayer money. Apparently programs had been abusing funds to do so. Oh well. I wonder if they might decide to use similar means to provide for primary care in America.

" why make 150k when you can make 450k ? "

Well, if that line makes any sense to you, then I dont know what to tell you.

 

[Coastie]

.

No, Carib schools are not altruistic in their education of doctors. But I didnt bring up wanting to make money in my interviews, so I don't know what they would have said. They did ask me what specialty I was planning to go into, and why. I talked to the guy who posed the question later on, once I was in the school. He told me that he just wanted to see my thought process, and was actually waiting for an answer like "Oh, I dont know yet, Im keeping an open mind". He said that would been interpreted as BS on the part of the applicant, or being forced to apply to med school by wealthy doctor parents.

I agree, Carib schools are definitely not altruistic. They are after the almighty dollar..A dollar, I might add, that is going away very quickly. I won't be shedding a tear when those factories shut down due to lack of financial aid.



No, fool. It is not a "problem" that we have freedom to choose a specialty. I said it is a privilege. Residents are paid on taxpayer dollars. In other countries where GME is paid for by the government, the government decides what specialty it will train residents in. Like other privileges we have, we have put our selfish personal gain first in exercising that privilege. In doing so, we haven't helped the "healthcare crisis in America". Perhaps you read the newspaper and found out that there is a shortage of primary care physicians, and child psychiatrists in the US? The physician shortage? Now that's a problem. But you probably are as concerned about that problem as you are about some species of beetle that's going extinct in some south-Pacific island.

The healthcare crisis doesn't come from too much freedom (to choose specialty), it comes from lack of freedom in the form of government control of healthcare. This control has demolished the free market within medicine, making it such that we are within a system where the prices are set by the govt. Subsequent salaries are low for PCP. Who is to blame now? The ones who see the light and don't choose PC? Like I said, don't worry: the primary care shortage will be solved shortly by the DNPs who are coming out, fully supported by Chairman Maobama...and part of a plan fully supported by the AAFP. Who is the fool now?

I actually consider myself fortunate to have experienced healthcare delivery in another country, and talked to physicians from around the globe about how medicine is practiced in their country. Its made me see things in a different way. And now I probably won't have the privilege of international rotations in residency....

Perhaps the privilege of doing residency in Haiti, or Jamaica, or some other 12th rate medical system is what you're looking for. Heck, I say forget American GME! What do we selfish, sub-specializing, cancer cure researching capitalists know anyway?

Well, because residents are paid on the government's dime. And the government recently stepped in and said that they will no longer pay for residents to provide healthcare in other countries on US taxpayer money. Apparently programs had been abusing funds to do so. Oh well. I wonder if they might decide to use similar means to provide for primary care in America.

Good, we shouldn't be paying for residents to provide healthcare to any nation other than our own. If you want to do missions as a resident, go ahead, but don't ask the USA to pay for it.


Well, if that line makes any sense to you, then I dont know what to tell you.

It makes perfect sense. Why make 150k when you can make 450k? You could work 1/3 the time in the 450k job, leaving more time for missions: whether they be medical in nature, or to save the beetle on some forsaken nuked out atoll in the south pac.

 

[howelljolly]

.

The healthcare crisis doesn't come from too much freedom (to choose specialty), it comes from lack of freedom in the form of government control of healthcare. This control has demolished the free market within medicine, making it such that we are within a system where the prices are set by the govt. Subsequent salaries are low for PCP. Who is to blame now? The ones who see the light and don't choose PC? Like I said, don't worry: the primary care shortage will be solved shortly by the DNPs who are coming out, fully supported by Chairman Maobama...and part of a plan fully supported by the AAFP. Who is the fool now?

Right, the government control is not helping. But free market wouldnt have helped either.... simple supply/demand economics doesn't even work in healthcare. If it did PCPs would make more money. The thing is, we work with what we have. Standard of care is subspecialist heavy because it's available.

I'm not saying that everyone should flood primary care residencies because they have to be altruistic, and that primary care is the only altrusitic thing out there. Thats absurd. This started whole argument started because of the idea that we dont have the right to violate someone elses right to choose a specialty. Well, if thats a "right", then it comes with social responsibility. If its a privilege, it comes with social responsibility as well. But if you're gonna go there, you have to go all in.

If it's simply a personal career decision, which actually does have some side-effect on everyone else's personal career decision. Then, it's subject to input, advice, gripes, and agreement from others.

So, take your pick... social responsability or unsolicited comments from colleagues. I'd take the second one.

Thats all.

 

[jdh71]

Right, the government control is not helping. But free market wouldnt have helped either.... simple supply/demand economics doesn't even work in healthcare.

Wait. Wut?! You want to tell me how a free market is not good for any commodity?

 

[Coastie]

PCPs with a good sense of business CLEAN UP. Unfortunately, PC isn't attracting those who can clean up. It's attracting the AAFP types.

PCPs gotta stand up and say enough is enough..

The healthcare crisis doesn't come from too much freedom (to choose specialty), it comes from lack of freedom in the form of government control of healthcare. This control has demolished the free market within medicine, making it such that we are within a system where the prices are set by the govt. Subsequent salaries are low for PCP. Who is to blame now? The ones who see the light and don't choose PC? Like I said, don't worry: the primary care shortage will be solved shortly by the DNPs who are coming out, fully supported by Chairman Maobama...and part of a plan fully supported by the AAFP. Who is the fool now?

Right, the government control is not helping. But free market wouldnt have helped either.... simple supply/demand economics doesn't even work in healthcare. If it did PCPs would make more money. The thing is, we work with what we have. Standard of care is subspecialist heavy because it's available.

I'm not saying that everyone should flood primary care residencies because they have to be altruistic, and that primary care is the only altrusitic thing out there. Thats absurd. This started whole argument started because of the idea that we dont have the right to violate someone elses right to choose a specialty. Well, if thats a "right", then it comes with social responsibility. If its a privilege, it comes with social responsibility as well. But if you're gonna go there, you have to go all in.

If it's simply a personal career decision, which actually does have some side-effect on everyone else's personal career decision. Then, it's subject to input, advice, gripes, and agreement from others.

So, take your pick... social responsability or unsolicited comments from colleagues. I'd take the second one.

Thats all.

 

[deleted87716]

PCPs with a good sense of business CLEAN UP. Unfortunately, PC isn't attracting those who can clean up. It's attracting the AAFP types.

It's possible to be both, y'know.

 

[howelljolly]

Wait. Wut?! You want to tell me how a free market is not good for any commodity?

I dont know enough about economics to comment. All I understand is that medical economics is its own ball of wax. None of the common economics principles apply to healthcare. I said that free market wouldnt work, without really thinking about it.

Off the top of my head... the patient/client side of the equation might be what complicates things. Free market economy depends a lot on what the supply and demand are, and what consumers are willing to pay.

What patients demand is one thing, what they utilize is another , and what they willingly pay for is yet another.... Their demands often dont make sense. The largest portion of a typical patients healthcare expense comes in the last few weeks of life - often whether they want it or not. What they'll willingly pay for? You know better than I do.

 

[jdh71]

I dont know enough about economics to comment. All I understand is that medical economics is its own ball of wax. None of the common economics principles apply to healthcare. I said that free market wouldnt work, without really thinking about it.

Off the top of my head... the patient/client side of the equation might be what complicates things. Free market economy depends a lot on what the supply and demand are, and what consumers are willing to pay.

What patients demand is one thing, what they utilize is another , and what they willingly pay for is yet another.... Their demands often dont make sense. The largest portion of a typical patients healthcare expense comes in the last few weeks of life - often whether they want it or not. What they'll willingly pay for? You know better than I do.

This is NOT a personal attack - whoever told you the nonsense in your first paragraph was an idiot.

Economics is nothing more than a simple understanding of basic human behavior within the marketplace, and the freemarket is a market free of outside manipulation.

Supply and demand applies to healthcare the same way it applies to mechanics and plumbers or computers and cars.

The free-market would solve any of these pesky demand issues you speak of because people would have to PAY for each demand wether in a pay for service situation or by buying insurance.

 

[howelljolly]

This is NOT a personal attack - whoever told you the nonsense in your first paragraph was an idiot.

Economics is nothing more than a simple understanding of basic human behavior within the marketplace, and the freemarket is a market free of outside manipulation.

Supply and demand applies to healthcare the same way it applies to mechanics and plumbers or computers and cars.

The free-market would solve any of these pesky demand issues you speak of because people would have to PAY for each demand wether in a pay for service situation or by buying insurance.

Quite possibly. Im really bad with economics. But it made sense to me.

I was thinking something like this - elective cosmetic surgery aside, lets say healthcare "demand" can be estimated by what's used in the ERs and ICUs. Our patents don't plan for anything, and most commonly they get care when they absolutely need it, or when they "think" they need it. And ICUs and ERs are the biggest money sink for hospitals.

Free market won't force patients to pay for the care they receive. Free market doesnt only mean free from governmental control. It gives providers the freedom to set prices, but also gives consumers the freedom to pay whatever they deem to be reasonable (creating market competition etc). We KNOW that they'd rather pay $7 for a cup of coffee, or $50 for a bag of heroin, before they pay the $20 copay at the docs office.

How can free market work in our healthcare system if we cant get them to pay for the services, after the fact, let alone upfront?

Forcing them to pay would require governmental intervention, which they won't do. Theyve already told us that we have to treat everybody regardless of their ability to pay.

 

[Coastie]

It's possible to be both, y'know.

If you're a business-minded PCP supporting the AAFP after the sucking up they've done to Obama, then you're either schizophrenic or just plain clueless. Seriously, how can anyone that has business sense support Obamacare?

I forgot...isn't there a thread on the FP forum that says Obama "gets" primary care? Dude, he gets flooding the market with DNP's with one hand while feeding an imaginary 5-10% raise to you guys with the other.

I've said it before, I'm pro-PC physicians. Everyone knows I'm against the takeover of medicine by DNPs. Don't you guys see which side Obama is truly on?

 

[deleted87716]

If you're a business-minded PCP supporting the AAFP after the sucking up they've done to Obama, then you're either schizophrenic or just plain clueless. Seriously, how can anyone that has business sense support Obamacare?

Nobody I know supports "Obamacare," including the AAFP.

Politics is what it is. There's more going on behind the scenes than what you hear in media sound bites.

 

[Coastie]

I don't support "Obamacare," and neither does the AAFP. Stick to what you know, which obviously isn't this.

http://www.physiciansnews.com/2009/...enate-for-passage-of-health-care-reform-bill/

Title of Article from Dec 24th, 2009: AAFP Commends Senate for Passage of Health Care Reform Bill

Dude, who are you kidding? You better recheck your organization.

Note the commending of the Senate by Dr. Epperly, Board Chair of AAFP, for "recognizing the value of primary care by creating a 10 percent bonus for five years for physicians whose health care services are more than 60 percent primary care."

 

[deleted87716]

Note the commending of the Senate by Dr. Epperly, Board Chair of AAFP, for "recognizing the value of primary care by creating a 10 percent bonus for five years for physicians whose health care services are more than 60 percent primary care."

Better than a cut, no?

Politics is what it is.

That healthcare bill could've been a helluva lot worse than it is, trust me.

 

[Coastie]

Better than a cut, no?

Politics is what it is.

The point was that the AAFP does support Obamacare, contrary to what you said in the pre-edited post.

The cut is coming. Making a deal with the devil never ends well...It's going to come in the form of massive gov't control, destruction of the private insurance companies (who can outlast mandates that state you must take everyone, regardless of pre-existing conditions), and finally, the real kicker for PC docs especially, the non-discrimination clause in the bill which finally elevates DNPs to their own perceived "rightful" place.

Nah, politics doesn't have to be this way. I just wish the "leadership" in medicine realized that.

 

[deleted87716]

The point was that the AAFP does support Obamacare, contrary to what you said in the pre-edited post.

No, it doesn't.

The term "Obamacare" refers to the government takeover of healthcare, not simply healthcare reform. They aren't synonymous.

The cut is coming. Making a deal with the devil never ends well.

We fight our battles one day at a time.

 

[exPCM]

I have gotten an email from an SDN administrator that it is not appropriate to post volatile topics and this thread has been classified as a volatile topic so I will signoff on this thread.
Good luck to those who are in the upcoming match.

 

[jdh71]

Quite possibly. Im really bad with economics. But it made sense to me.

I was thinking something like this - elective cosmetic surgery aside, lets say healthcare "demand" can be estimated by what's used in the ERs and ICUs. Our patents don't plan for anything, and most commonly they get care when they absolutely need it, or when they "think" they need it. And ICUs and ERs are the biggest money sink for hospitals.

Free market won't force patients to pay for the care they receive. Free market doesnt only mean free from governmental control. It gives providers the freedom to set prices, but also gives consumers the freedom to pay whatever they deem to be reasonable (creating market competition etc). We KNOW that they'd rather pay $7 for a cup of coffee, or $50 for a bag of heroin, before they pay the $20 copay at the docs office.

How can free market work in our healthcare system if we cant get them to pay for the services, after the fact, let alone upfront?

Forcing them to pay would require governmental intervention, which they won't do. Theyve already told us that we have to treat everybody regardless of their ability to pay.

Perhaps this recent article will help out discussion. Let me know what you think. (I'll bold some stuff I find interesting)

What Will the Doctors Do?

by Robert Anderson

Getting more for less is what our economic well being is all about, assuming we acquire more through greater productive effort rather than from plundering our fellow citizens. While the coming government involvement in medical care has received extensive news coverage regarding its costs, its impact on the Federal budget, its many specific exemptions, and its mandated provisions, one of the most important aspects of Obamacare has seen scant coverage.... What will the doctors do?

How will private practice physicians respond as politically imposed prohibitions and fee-lowering mandates are imposed upon them? The answer to that question is going to be a harsh economic lesson with both unseen and unintended adverse consequences. Whenever any valuable commodity, in this case personal medical care, gets treated as a free good the result has been and always will be economic chaos.

Without question Obamacare will surely increase the demand for medical services from millions of new patients seeking personal care for little or no cost to them. But who will supply these additional services? Virtually ignored in public debate is how government mandated free medical care will impact on the professional behavior of private medical practitioners. One of the most fundamental principles of economics gives us the answer to that question: As prices fall, more will be demanded and less will be supplied.

Medical service is not a free good, but when treated as such by arbitrary government edicts, its future supply will be undermined and severely reduced both in quality and quantity. Doctors are dedicated but they are not saints or dullards. They, like everyone else, will respond to getting less by offering less. While inertia may slow the process of a shrinking supply of medical care as lower mandated fees and arbitrary edicts are imposed upon doctors, inevitably a decline in medical care and its quality will be the ultimate, unintended result.

Medical care is a valuable service provided by trained professionals. Often unseen is what is required for doctors to provide their medical skills to their patients. At a minimum, at least a decade of schooling beyond high school is necessary, followed by several more years of specialized training. During that time not only do doctors forego an earned income but they also incur large educational debts along the way. People who have the endurance and ability to achieve the status of a medical doctor do so through great effort by their own free choice. Believing a new supply of medical doctors will suddenly appear out of nothing as a free good to meet the coming explosion of medical care demand is a chimera.

Private physicians have already experienced the bureaucratic edicts that have been inflicted upon them through the ubiquitous third-party payment systems with their falling fees, dictates, and voluminous paperwork. With the imminent threat of more to come from Obamacare, a flood of doctors will react to their worsening professional situation by either reducing their practice of medicine or taking early retirement in utter disgust. This is the unseen and unintended future outcome which many people are failing to comprehend today.

Getting something for nothing by imposing the cost on others may at first appear attractive to some people, but at what price? When both personal ethics and economic law are violated by a process of political plunder which imposes short-sighted partisan edicts on those who will bear the costs, the outcome to the general welfare is always harmful. Tragically, the more we become addicted to such a political process, the more individual liberty with its material well being will be lost along the way. (Is it possible this may be what Obamacare has really been about?)

So, where are we headed? The coming government take-over of medical care is destined to become an era of doctor shortages, rationing, delays for medical care, and an undermining of future medical technology and discoveries. I have little doubt that patients seeking medical care will soon be hearing that old socialist refrain, "It’s free, but we ain’t got none!"

January 5, 2010

Robert Anderson [send him mail] taught economics at Hillsdale Collage and was executive secretary of FEE.

Copyright © 2010 by LewRockwell.com. Permission to reprint in whole or in part is gladly granted, provided full credit is given.

http://www.lewrockwell.com/orig6/anderson-r6.1.1.html

 

[Winged Scapula]

I have gotten an email from an SDN administrator that it is not appropriate to post volatile topics and this thread has been classified as a volatile topic so I will signoff on this thread.
Good luck to those who are in the upcoming match.

ExPCM has misunderstood the message from SDN Administration. I do not know the exact content of the PM sent to him but was involved in in discussions about the issue.

Posting volatile topics is not a TOS violation and users are not prevented from posting such. They are asked to follow the TOS which does prohibit posting topics for the express intent of trolling, flaming or harassing users. Posting multiple threads in mutiple forums, even when wildly off topic or not relevant to the forum, is considered a TOS violation. Numerous complaints have been made by other users about this activity...not about the content of the threads per se.

No one was asked not to post in this thread or to pretent that everything is "hunky-dory". Users are asked to stick to the topics relevant to the forum they are posted in, to not go into specialty forums with the express intent to harass the users there about their specialty and to in general, incite flame wars.

I'd ask users to not assume everything another member has told them is necessarily true; which is the case here. SDN is not censoring any users; they are simply being asked to follow the TOS and not use SDN as a personal soapbox, alientating other users.

 

[medicinesux]

They are asked to follow the TOS which does prohibit posting topics for the express intent of trolling, flaming or harassing users

I'm sorry but this is such crap! SDN is trying to save face now and I can see right through it. I vehemently disagree that ExPCM's posts are solely to "express intent of trolling, flaming, or harassing users." Nor do I see how he violated any of the other TOS. His posts have always been TRUTHFUL and INFORMATIVE and don't feed you any fluff. Need I point out that 3 of his posts are among the highest viewed on the front page of the forum right now? I wonder why that is???? Caving into those complainers who can't handle the truth, have a financial stake involved, or want to continue promoting medicine as the ideal profession is far more disturbing and disruptive than anything ExPCM has written.

 

[Coastie]

I'm sorry but this is such crap! SDN is trying to save face now and I can see right through it. I vehemently disagree that ExPCM's posts are solely to "express intent of trolling, flaming, or harassing users." Nor do I see how he violated any of the other TOS. His posts have always been TRUTHFUL and INFORMATIVE and don't feed you any fluff. Need I point out that 3 of his posts are among the highest viewed on the front page of the forum right now? I wonder why that is???? Caving into those complainers who can't handle the truth, have a financial stake involved, or want to continue promoting medicine as the ideal profession is far more disturbing and disruptive than anything ExPCM has written.

Concur.

Giving people information about future trends in residency placement is harassment?

 

[howelljolly]

Perhaps this recent article will help out discussion. Let me know what you think. (I'll bold some stuff I find interesting)

I think the article is interesting, informative, and outlines the probable effect of the proposed legislation. But it restricts the discussion to private practice.

What about the healthcare providers that can not reduce their supply accordingly? What about the state and county hospitals, every Emergency Room, and ICU, and anyone else that treats on implied consent (like inpatient Psych). Its basically against the law for them to turn patients away.

These docs might take an early retirement as the article suggests. But these particular specialties are all hospital based. Hospitals all over New York City are closing because the ER has eaten up all their money. Thats going to get exponentially worse.

That's going to happen whether you have obamacare, or a true free-market system. I guess the underlying problem is the utilization of healthcare... Bush's healthcare plan - go to the ER.

 

[Bart Clarridge]

...
No, fool. It is not a "problem" that we have freedom to choose a specialty. I said it is a privilege. Residents are paid on taxpayer dollars. In other countries where GME is paid for by the government, the government decides what specialty it will train residents in. Like other privileges we have, we have put our selfish personal gain first in exercising that privilege. In doing so, we haven't helped the "healthcare crisis in America". Perhaps you read the newspaper and found out that there is a shortage of primary care physicians, and child psychiatrists in the US? The physician shortage? Now that's a problem. But you probably are as concerned about that problem as you are about some species of beetle that's going extinct in some south-Pacific island.

I actually consider myself fortunate to have experienced healthcare delivery in another country, and talked to physicians from around the globe about how medicine is practiced in their country. Its made me see things in a different way. And now I probably won't have the privilege of international rotations in residency....

...

" why make 150k when you can make 450k ? "

Well, if that line makes any sense to you, then I dont know what to tell you.

I don't see how we are paid on the government dime. Not well all of us who actually end up practicing for any length of time will more than pay for the $45k/year they pay us. Do any of you have a break down of where that Medicare money goes? I seem to have lost mine--you know the one that all programs are forced to give residents as part of full disclosure.

Have you seen that article that decreaseing resident hours to 56/wk would cost about $1.6 billion? We aren't being given anything by anyone.

I can't see the poster's quote you used in full, but I ask the same thing: "why make $150k when you can make $400k?"

BTW, in most of the word it seems like the only people who have $ are aristocrats and atheletes. Doctors and other useful people should make good money. Money is not king, but it is potential energy. We should never apoligize for the money we make as long as the government can bailout the banks (and give bonuses since no one else can unwind the loans ) and cry that they have no money for healthcare.

 

[howelljolly]

I don't see how we are paid on the government dime. Not well all of us who actually end up practicing for any length of time will more than pay for the $45k/year they pay us. Do any of you have a break down of where that Medicare money goes? I seem to have lost mine--you know the one that all programs are forced to give residents as part of full disclosure.

Have you seen that article that decreaseing resident hours to 56/wk would cost about $1.6 billion? We aren't being given anything by anyone.

I can't see the poster's quote you used in full, but I ask the same thing: "why make $150k when you can make $400k?"

BTW, in most of the word it seems like the only people who have $ are aristocrats and atheletes. Doctors and other useful people should make good money. Money is not king, but it is potential energy. We should never apoligize for the money we make as long as the government can bailout the banks (and give bonuses since no one else can unwind the loans ) and cry that they have no money for healthcare.

As far as I know the government pays 100K per resident per year. Part goes to the stipend, part goes to benefits, part goes to the program. The one program I know about gives 50% to the resident, and additional 30% pays for their benefits, and 20% goes into the program. We arent being "given" anything. But the money is coming from somewhere.

I don't see how we are NOT paid on the government's dime. Your money comes from them, not the hospital.

To me, that quote is like "why have one cheeseburger, when you can have 45 cheeseburgers?" Why in the world would I want 45 cheeseburgers?

 

[deleted87716]

To me, that quote is like "why have one cheeseburger, when you can have 45 cheeseburgers?" Why in the world would I want 45 cheeseburgers?

 

[howelljolly]

Thats actually what I was thinking of when I came up with that analogy.

 

[Bart Clarridge]

...

I don't see how we are NOT paid on the government's dime. Your money comes from them, not the hospital.

To me, that quote is like "why have one cheeseburger, when you can have 45 cheeseburgers?" Why in the world would I want 45 cheeseburgers?

I don't know about your breakdown since I have enough trouble figuring out how much they get ( I know it varies).

They way I look at we are subsidizing their indigent care with cheap labor. And I think of my older self subsidizing my younger self. They are basically loaning us $45k/year, which we pay back at heavy interest

As for the cheeseburger thing, maybe french fries or peanuts is a better analogy

 

[howelljolly]

I don't know about your breakdown since I have enough trouble figuring out how much they get ( I know it vaires).

They way I look at we are subsidizing their indigent care with cheap labor. And I think of my older self subsidizing my younger self. They are basically loaning us $45k/year, which we pay back at heavy interest

As for the cheeseburger thing, maybe french fries or peanuts is a better analogy

I see your point.

 

[mercaptovizadeh]

http://www.cdc.gov/nchs/FASTATS/lcod.htm

Leading Causes of Death
(Data are for the U.S.)

Number of deaths for leading causes of death
Heart disease: 631,636
Cancer: 559,888
Stroke (cerebrovascular diseases): 137,119
Chronic lower respiratory diseases: 124,583
Accidents (unintentional injuries): 121,599
Diabetes: 72,449
Alzheimer's disease: 72,432
Influenza and Pneumonia: 56,326
Nephritis, nephrotic syndrome, and nephrosis: 45,344
Septicemia: 34,234

Hmm, not sure which of these are addressed by derm or plastic surgery...

 

[Eta Carinae]

http://www.cdc.gov/nchs/FASTATS/lcod.htm


Quote:
Leading Causes of Death
(Data are for the U.S.)

Number of deaths for leading causes of death
Heart disease: 631,636
Cancer: 559,888
Stroke (cerebrovascular diseases): 137,119
Chronic lower respiratory diseases: 124,583
Accidents (unintentional injuries): 121,599
Diabetes: 72,449
Alzheimer's disease: 72,432
Influenza and Pneumonia: 56,326
Nephritis, nephrotic syndrome, and nephrosis: 45,344
Septicemia: 34,234

Hmm, not sure which of these are addressed by derm or plastic surgery...

Hmmm, maybe that should be addressed with whoever sets RVU, DRG, ICD etc payment schedules/reimbursement rates.

 

[Slack3r]

I disagree that they are often feeding you BS, I think that they are more often just unrealistic and naive, and actually believe that medicine is the best way to "help people".

Premeds somehow get blinders put on them early on. Everything they do in undergrad becomes geared toward medical school, and the real careers which "help people", like teaching and social work, get ignored. The truly high-paying careers in business and finance are ignored as well. Somehow in the rat-race, premeds ultimately "can't" do anything besides medicine. If they don't get into medical school, they keep trying 3 or 4 times, or go overseas to the Caribbean by the THOUSANDS, or settle for PA or RN school. Any other student who made a lofty career choice, take Law for example, just changes their career goals. Only in medicine are there "pathways" and "back doors", and people that try every-which-way to get into the profession. Because, if they cant then they dont know what to do with themselves.

Care to elaborate on these elusive careers?

 

[Journals009]

Duration of training: Clinical base year (intern year) plus 3 years of residency
training—Total = 4 years.
• Fellowship training after completion of core program: ACGME approved
fellowship training programs are available in Adult Critical Care Medicine (1
year), Pediatric Anesthesiology (1 year), and Pain Management (1 year).
Fellowships also are available in other subspecialties of anesthesiology, but
these are not accredited or monitored by the ACGME. These include
Cardiovascular Anesthesiology (1-2 years), Neurosurgical Anesthesiology (1-2 years), Obstetric Anesthesiology (1-2 years), Regional Anesthesiology (1 year), Ambulatory Anesthesia (1 year), and Research Fellowships (1-3 years.
• Prospects for jobs after completion of training: Job opportunities are
extraordinary at this time and not likely to change much in the next 10 years.
There is a severe shortage of anesthesiologists, both in private practice and academic settings. Jobs are available in all states, although the West Coast has fewer opportunities than elsewhere in the country.
• Range of compensation that might be expected for a graduating resident:
Academic anesthesiology: $100,000 to $140,000; Private Practice: $130,000 to $200,000. There is considerable variability according to region of the country.
Both types of positions offer significant increases after the first 1-2 years. Many anesthesiology practices offer partnership tracks that result in partnership in <3 years.

 

[Coastie]

Duration of training: Clinical base year (intern year) plus 3 years of residency
training—Total = 4 years.
• Fellowship training after completion of core program: ACGME approved
fellowship training programs are available in Adult Critical Care Medicine (1
year), Pediatric Anesthesiology (1 year), and Pain Management (1 year).
Fellowships also are available in other subspecialties of anesthesiology, but
these are not accredited or monitored by the ACGME. These include
Cardiovascular Anesthesiology (1-2 years), Neurosurgical Anesthesiology (1-2 years), Obstetric Anesthesiology (1-2 years), Regional Anesthesiology (1 year), Ambulatory Anesthesia (1 year), and Research Fellowships (1-3 years.
• Prospects for jobs after completion of training: Job opportunities are
extraordinary at this time and not likely to change much in the next 10 years.
There is a severe shortage of anesthesiologists, both in private practice and academic settings. Jobs are available in all states, although the West Coast has fewer opportunities than elsewhere in the country.
• Range of compensation that might be expected for a graduating resident:
Academic anesthesiology: $100,000 to $140,000; Private Practice: $130,000 to $200,000. There is considerable variability according to region of the country.
Both types of positions offer significant increases after the first 1-2 years. Many anesthesiology practices offer partnership tracks that result in partnership in <3 years.

Why the frown face?

BTW, double your academic numbers and multiply the PP ones by 3.

 

[howelljolly]

Care to elaborate on these elusive careers?

Off the top of my head....
CEO/COO/CFO, investment banking, venture capitalism, managing a hedge fund, law, "wall street", nursing+business-sense (>200K), engineering+patent, or engeneering+business management, own a liquor store, business consulting. Actuaries make a lot of money for the time and education they put in .

And none of these require 8 years of school + 300 grand in debt + three to seven years of backbreaking work, 80hrs/week earning 45K.

 

[tony montana]

and finally, the real kicker for PC docs especially, the non-discrimination clause in the bill which finally elevates DNPs to their own perceived "rightful" place.

Why would anyone think, the no discrimination clause 152, would increase the scope of practice of midlevels when clause 238 reaffirms each state's authority in regulating scope of practice of health care providers???

SEC. 238. STATE PROHIBITIONS ON DISCRIMINATION AGAINST HEALTH CARE PROVIDERS.

This Act (and the amendments made by this Act) shall not be construed as superseding laws, as they now or hereinafter exist, of any State or jurisdiction designed to prohibit a qualified health benefits plan from discriminating with respect to participation, reimbursement, covered services, indemnification, or related requirements under such plan against a health care provider that is acting within the scope of that provider’s license or certification under applicable State law.

 

[michaelrack]

http://www.cdc.gov/nchs/FASTATS/lcod.htm



Hmm, not sure which of these are addressed by derm or plastic surgery...

If you survive your accident, plastic surgery has a role

 

[Slack3r]

Off the top of my head....
CEO/COO/CFO, investment banking, venture capitalism, managing a hedge fund, law, "wall street", nursing+business-sense (>200K), engineering+patent, or engeneering+business management, own a liquor store, business consulting. Actuaries make a lot of money for the time and education they put in .

And none of these require 8 years of school + 300 grand in debt + three to seven years of backbreaking work, 80hrs/week earning 45K.

CEO/COO/CFO? Lol! Assuming you actually do get one of these careers, the average is $600k. But how many people that go into business end up as the CFO of a large company?

I-banker average is $165k assuming you're lucky enough to get a job at a large bulge-bracket firm. Most aspiring i-bankers will not. You'll need stellar grades, internships (i.e. kissing the right ass), and most often an Ivy-league pedigree.

Since venture-capitalism isn't really a salaried career, I'll ignore that one.

Hedge-fund manager...see I-banker, but tack on some more competition and there ya go.

Average lawyer salary is around $80k. And law is so saturated you'll need a top 20 school's reputation to land a decent paying job.

I think we already went over wall-street twice...

Nursing+business...not sure what you mean here. The average nurse-practitioner will make about $85k per year.

Average engineer management salaries are just over $100k per year. It takes quite a bit of experience as a regular engineer to be offered one of these jobs, which will average around $80k as a non managerial engineer.

Own a liquor store? I'm not sure your local corner liquor stores is netting the owner a six-figure income. Maybe if you start a liquor chain...

Average actuary salary is just over $100k as well.

Since we're talking averages....most average med students will end up in IM, FP, or gsurg. That's about $200k average salary, give or take $40k.

As you can see, most of the AVERAGES for these jobs will not make you as much as an average physician. Yes, you can start the next Google and make billions, but the odds are not in your favor. For most, they'll fall somewhere near the average (hence why it's called the average). You can patent a new surgery and make $12mil per year like this clown:http://www.drmatlock.com/ but it's very unlikely.

Also! Every single one of those professions you listed will take years of climbing the corporate ladder and working close to 80 hrs/wk, sometimes even more. You think i-bankers walk out of college into million dollar jobs while working 3 days a week? I'd say most of the guys at big banking firms (i.e. the one's you're citing as making a ****-load) are working well over 80 hrs/wk. Reports of 100hrs/wk are not uncommon.

There are pretty much no jobs (with the possible exception of dentistry) that you can walk into and be average and still clear a decent six figure income. Telling people they can walk into other careers and make millions is like telling pre-meds they can waltz into plastic surgery and be the next Dr. 90210 or some other absurdly salaried physician. Yea it happens, but I wouldn't be basing my career choice on it.

 

[Excelsius]

True, but to what end? So that they can accumulate $2-300,000 worth of loans and plunge into govt-funded care that barely covers the cost of care let alone leave them with enough to pay back loans along with the exhorbitant interest amounts they have accrued?

The rush to medicine is a poorly thought out venture for MOST premeds who are caught in the throes of living up to their parents', their families' or misplaced personal ideals of "success". And to open up the floodgates (into med school) does nothing but perpetuate the frustration, angst and lack of fulfilment that comes with having sacrificed a very crucial period of one's life to chase some foolish dream and having to face the uncertainties of the future of medicine.

It will do nothing, IMHO, to address the primary care physician shortage...because if historical trends of med students' selection of a specialty are anything to go by, most will be allured by prestige, reimbursement and lifestyle into the non-primary care specialties.

As has been mentioned earlier in this thread, the solution does not lie in increasing med school class sizes but in addressing the reasons med students by and large would prefer to avoid primary care ie reimbursement (primarily for internal medicine) and reimbursement + lifestyle/reimbursement comparable to lower-liability specialties (where gen surg is concerned).

There is still an advantage to distributing some of the student filtering to post-medschool rather than pre-medschool. Undergrads come from very diverse backgrounds and their performance in one subject or another says very little about what sort of doctors they will be. You also have variations of rigor among schools and large variations from one professor to the next in the same school. As such, regardless of methods employed, it is almost impossible to determine if one undergrad will be a better doctor than another undegrad. Academic performance is just not standardized enough to make any precise comparisons and it is not related to medicine to make the judgments accurate. Therefore, the quality of doctors should increase when more students are let in and then are evaluated specifically by their performance in the medical schools which teach almost the same material and test the students in the same clinical environments. It is not uncommon for academically weaker undergrads to outperform their peers in medical school. Thus, displacing at least some of the bottlenecking to PGY is not a bad step. Now "forcing" students into primary care is not great, but what would you rather have? No primary care spots either and let those unmatched be unable to become doctors? I view the primary care spots not necessarily as forcing students into it, but as a fall-back mechanism for those not qualified for other specialties to not be left out on the street. Even some of the most competitive specialties seem to have spots that go unfilled every year. So I am not sure if there are already enough well qualified and willing applicants for most specialties available.

 

[Bart Clarridge]

CEO/COO/CFO? Lol! Assuming you actually do get one of these careers, the average is $600k. But how many people that go into business end up as the CFO of a large company?

...

I've too notcied that people think they can make a lot of money doing other things, but that they tend to simplify things. You can make a lot of money doing something else, but you need a nack for that something. So I agree with you to a great extent.

I will add that while the average salaries for a lot of jobs are lower than physicians, anyone can do most of those jobs. What I mean is that anyone on these forms could get an MBA or a JD (and try to pass the bar ). No just anyone with an MBA or JD could get an MD or a DO. So, yeah they have to get into top programs. If law schools and business schools were more scrupulous we wouldn't have a surplus of these parasites. We'd only have the useful ones (sort of like medicinal leeches ).

 

[howelljolly]

There is still an advantage to distributing some of the student filtering to post-medschool rather than pre-medschool. Undergrads come from very diverse backgrounds and their performance in one subject or another says very little about what sort of doctors they will be. You also have variations of rigor among schools and large variations from one professor to the next in the same school. As such, regardless of methods employed, it is almost impossible to determine if one undergrad will be a better doctor than another undegrad. Academic performance is just not standardized enough to make any precise comparisons and it is not related to medicine to make the judgments accurate. Therefore, the quality of doctors should increase when more students are let in and then are evaluated specifically by their performance in the medical schools which teach almost the same material and test the students in the same clinical environments. It is not uncommon for academically weaker undergrads to outperform their peers in medical school. Thus, displacing at least some of the bottlenecking to PGY is not a bad step. Now "forcing" students into primary care is not great, but what would you rather have? No primary care spots either and let those unmatched be unable to become doctors? I view the primary care spots not necessarily as forcing students into it, but as a fall-back mechanism for those not qualified for other specialties to not be left out on the street. Even some of the most competitive specialties seem to have spots that go unfilled every year. So I am not sure if there are already enough well qualified and willing applicants for most specialties available.

agree strongly