Medicine worth $300k of debt?

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Forgive me if I'm repeating information that has already been stated, but I admit I didn't read every one of the five pages of posts. It's absolutely possible to graduate medical school without absurd amounts of debt (or wealthy parents). I went to a top university for undergrad and with the financial aid they gave me, I graduated with less than $20,000 of debt. They have since changed the rules for students from low-income families, and I believe I would have very little or no debt if I was graduating undergrad from there now. Certainly, if I'd gone to an in-state public school for college, I'd have no debt from undergrad.

I did go to an in-state public school for medical school. I was fortunate that I happen to be from a state where the cost of living is lower, so both tuition and living expenses were probably below average. In fact, I've heard some students at my school state that their OUT-of-state tuition here is cheaper than IN-state tuition would have been in their home states. I did apply for and receive a significant scholarship for two years of medical school, but even without that, my total medical school debt would have been less than $100k.

I lived comfortably though not extravagantly, and I took the full measure of what our school estimated as our living expense needs. While I plan to pay my debts off as quickly as possible, there are numerous loan forgiveness programs (not just the PSLF program, there are also state-based programs). While the debt burden of, for instance, a student who chooses to attend a private medical school in New England can be quite large, it is also possible to graduate medical school with much smaller amounts of debt and/or to get that debt paid for you.

As far as physician salaries go, it's true that the times are a-changin'. However, a licensed physician will never starve (perhaps I should add the caveat "with decent financial management skills"). It's a stable profession in that you will almost certainly be able to find a job and provide a comfortable lifestyle for your family. However, you might not be able to afford the villa in Tuscany.

If you truly want to go into medicine, the financial aspect is extremely manageable. But if you are just looking for a job with large financial returns, there are easier ways to make more money. In my opinion, a larger consideration should be the lifestyle changes medicine will require you to make -- significant dents in your social life (especially during parts of medical school/residency), less time at home with family, not necessarily being able to take the day off and go to your kid's school play, etc.
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rhiannon777 said:
I did go to an in-state public school for medical school. I was fortunate that I happen to be from a state where the cost of living is lower, so both tuition and living expenses were probably below average. In fact, I've heard some students at my school state that their OUT-of-state tuition here is cheaper than IN-state tuition would have been in their home states. I did apply for and receive a significant scholarship for two years of medical school, but even without that, my total medical school debt would have been less than $100k.
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Times have changed. Most of the cheapest public schools still have tuitions >$20k. My state school is $26k this year. If you took out $0 for living expenses, you'd still have $80-100k just in tuition debt.

(barring Texas schools, of course)
 
Slack3r said:
Times have changed. Most of the cheapest public schools still have tuitions >$20k. My state school is $26k this year. If you took out $0 for living expenses, you'd still have $80-100k just in tuition debt.

(barring Texas schools, of course)
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Ten bucks says thats where she is from.

Had a buddy who applied to every school in TX as an out of state resident and didn't even get an interview. He then moved to Texas and lived there for a year to get residency, applied and was accepted. Dudes tuition is like 12grand a year!!!! I will be done a year earlier and will owe 250K, he is younger than I and will owe about 100.

Girl in my class is from Boston, went to a big named school, owes 120 from undergrad, 75 for masters and will owe another 250 for med school.

Nuts!

If I could do it all over again...
 
undergrad and professional and/or grad school tuitions have been going up >> the rate of inflation for years. It's true that a doc won't starve, but I think that for a lot of people, taking out 300k loans just doesn't make a lot of sense, particularly anyone older than the average premed. I would think twice if it's going to cost you 300k loans, particularly if you are older or have kids. 300k if you go into derm or anesthesia would be manageable, but I had 132k at 3% interest and that's about all the debt I'd want to be paying back. When you start getting into the 200k plus range that's going to make a significant dent in your take home pay for years and years.
 
there's another thread on here from some person who has 500k in student loan debt. that's just insane.
 
I am scared as hell, I have ~300K in debt. I feel almost inclined to pursue a more lucrative speciality to help pay down these loans. My sincere interests are in EM, IM, NS. I really don't want to NS anymore with a baby on the way :) Between IM and EM, I am stuck! But when I keep looking at my financials, I keep thinking, maybe I should go back to NS.
 
DrVanNostran said:
I am scared as hell, I have ~300K in debt. I feel almost inclined to pursue a more lucrative speciality to help pay down these loans. My sincere interests are in EM, IM, NS. I really don't want to NS anymore with a baby on the way :) Between IM and EM, I am stuck! But when I keep looking at my financials, I keep thinking, maybe I should go back to NS.
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There are plenty of medicine subspecialties that pay quite well
 
cowme said:
Everyone needs to take most of this thread with a huuuuuge grain of salt and realize several points:

-The OP stupidly posted this question to a group comprised mostly of residents who are entering years 10-15 of accruing massive amounts of debt. At the same time, they are being worked to maximum extent that is humanly possible. They are getting crapped on by patients and attendings, and come home with no better place to vent than anonymously on this message board. I would hope most of you realize by now that the underlying emotions of most posters on SDN are these...

:mad: :bang: :annoyed: :boom:

To any pre-med/medical student actually worried about their future, why don't you go to a practicing physician and pose this question. You will undoubtedly find similar answers, but I can guarantee you that you will not find as many negative views out there in the real world as you will on the internet.

Look, facing that kind of debt is scary, and if that is the kind of debt you will be facing, don't go into peds or family practice, and you will be able to pay it off. Hell, even in Peds and FP you can pay it off, if you can live within your means until you pay off your debt. There are plenty of fields beyond the ROAD specialties that you can pay this off easily within 5 years.

Everyone needs to realize how lucky they are to have a guaranteed salary that will likely be over 200K for the rest of their lives. This country just faced an epic recession affecting every job opportunity in America, except for medicine. Yes, some job markets may have tightened and salaries may dip as a result, but 99% of physicians still have jobs/the guarantee of a job after training. "But my patients are lazy and Obama is out to get me." Crap like this sounds like a whiny 13 year old girl.

I know many law school graduates from 2010 who are still unemployed. This year the market is even worse for lawyers. Those that do have jobs are not making 6 figure salaries unless they graduated from Harvard or Yale. Why don't you ask a law school graduate with 250K in debt if he would trade his position with yours?
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I have been out in the "real world," for the past 15.
Medicine is a great profession to be a part of. The training that physicians receive is expensive. There is no way around it. Back in the day 100 k was thought of as being a lot of money.

Being a physician can be difficult at times. The training is grueling.It is easy to lose your humanity and become jaded and resentful. Nothing is ever all good or all bad. One must weigh their options and consider how much they really want something before they sign on the dotted line.

Cambie
 
DrVanNostran said:
I am scared as hell, I have ~300K in debt. I feel almost inclined to pursue a more lucrative speciality to help pay down these loans. My sincere interests are in EM, IM, NS. I really don't want to NS anymore with a baby on the way :) Between IM and EM, I am stuck! But when I keep looking at my financials, I keep thinking, maybe I should go back to NS.
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I dont think anyone should be scared about having educational debt - and then going for a specialty which would help pay those loans faster. You should do what you enjoy, and what fits. This is your life, you're not a slave to your lender.

Im also convinced that almost everyone overestimates the amount of money they'll need to pay down their loan comfortably.

Check out calculators like this and see where you stand. Apparently an educational debt to income ratio of 0.15 is reasonable. http://www.finaid.org/calculators/scripts/sloanadvisor.cgi
 
DrVanNostran said:
I am scared as hell, I have ~300K in debt. I feel almost inclined to pursue a more lucrative speciality to help pay down these loans. My sincere interests are in EM, IM, NS. I really don't want to NS anymore with a baby on the way :) Between IM and EM, I am stuck! But when I keep looking at my financials, I keep thinking, maybe I should go back to NS.
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If ability to pay back your loans is your only consideration for choosing a specialty, EM is probably the best choice.

Sure, you can make fat bank doing spine surgery but that's generally 7-10 years of PGY training (5 years of NSGY, most with 1-2 additional years of required research and then another year or so of fellowship, some with more research). Drilling bolts, scooping out GBMs and doing discs isn't really as lucrative as you probably think it is.

IM + Subspecialty training can be a good paying gig too but is 6-8 years depending on specialty (8 for IM+Cards+Interventional including peripheral, 7 for GI+advanced endoscopy).

Do 3 years of EM and you can probably make 75-80% of what the interventional cards and GI folks in your area are making while saving something like 4-5 years of indentured servitude as a resident/fellow (opportunity cost in the $1M vicinity depending on your specialty.

Alternatively, you could do what you love and actually want to do which is the only thing that will be sustainable over the course of a career.
 
Slack3r said:
$350,000 repaid over 10 years at 8% interest (thanks a lot Obama :rolleyes:) will cost you $4200 a month or $50,400 per year. Not the most ideal situation, but it's not the end of the world either. There are much worse thing you could do.
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How exactly is this one President Obama's fault?
 
I don't mean to intrude on a residents' thread, but I have a quick question. Is there a big difference between debt levels now and four years ago? My local medical school, UMass, has the average debt for students in 2008 at around 150,000. In-state around 120,000. I just want to know whether those numbers are still relevant.
 
gutonc said:
IM + Subspecialty training can be a good paying gig too but is 6-8 years depending on specialty (8 for IM+Cards+Interventional including peripheral, 7 for GI+advanced endoscopy).
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Since we're talking $$, GI+advanced endo is paycut from GI alone. Best way to make bank is to just do colons all day.
 
Gastrapathy said:
Since we're talking $$, GI+advanced endo is paycut from GI alone. Best way to make bank is to just do colons all day.
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I know...since the bulk of those gigs are academic, similar to the super-interventional cards guys - we have one dude who has done so many fellowships he has privileges for coronary, peripheral and neuro interventional stuff...I was just pointing out the training time vs. attending salary issue.
 
AntiHouseMD said:
I don't mean to intrude on a residents' thread, but I have a quick question. Is there a big difference between debt levels now and four years ago? My local medical school, UMass, has the average debt for students in 2008 at around 150,000. In-state around 120,000. I just want to know whether those numbers are still relevant.
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It goes up about about 5% per year. It's not that useful to look at averages though because this includes all the people who didn't take out any loans or very little because family helped. This is actually a considerable percentage.
 
ah money.....the single most important thing in life........

My favorite quote from the OP: "DrRobert, I like your magic number theory. 300 is mine, and I honestly hadn't factored in interest. And I am not willing to be "middle-middle class" until I am fourty."

LOL and what I ask is wrong with middle-middle class? What is it, between "middle-middle" and "upper-middle" that might make the OP happy? A brand new BMW every 2 years? A bigger, even more excessively large house? Will OP be happy with those things, finally satisfied?

Or maybe we can talk about opportunity cost, or "lost youth"? You might factor in "opportunity cost" if your only goal in life is to accumulate the largest pile of money you can. And lost youth? Those years will pass no matter what you do, being an investment banker, or engineer, or anything else isn't going to stop the march of time. Those people are just as dissatisfied I promise you, they just pass the time in a gray cubicle under flourescent lighting in front of a computer screen instead of in the library studying.

There is plenty of evidence, both in this thread as well as in other places, that demonstrate that med school debt is easily-manageable, even for someone entering school later in life. If money isn't your primary goal, and you don't mind "slumming around" for a few years in a middle-class suburban neighborhood, or having to wait maybe 5 years between buying a new German luxury car, you should be fine with medicine as a career, even with student debt what it is today.
 
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aerodoc said:
ah money.....the single most important thing in life........
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Adam Carolla does a great bit about how an alien comes down from some planet and wants to know why some people live in big safe houses and drive big safe cars, have hobbies that make them happy, can eat food that they like and can have medical/dental care, while so many others can not? A person then describes how the people who have all those nice things have figured out how to make a bunch of this stuff we call money, while the others couldn't get any of that green stuff. The alien logically decides that money is among the most important things on earth and decides that most of our education must be about how to obtain this green stuff. The person then explains how we don't talk about money or money management issues in school ever, and how if you pick a job just because of money you will be ostracized by others.

Money aint the most important thing, but it sure is a lot more important than most people would like to admit. Doctors too.
 
danzman said:
Money aint the most important thing, but it sure is a lot more important than most people would like to admit. Doctors too.
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I´ll concede that money is definitely important up to the point where someone can comfortably provide the basic necessities of their families, which by that I mean: a decent house in a clean, safe neighborhood, food on the table, children properly cared for, with some money left over for vacations and retirement and things of that nature.

However, there comes a point, where in my opinion anyway, all of those needs are taken care of, and I have to wonder why people continue to make earning more and more money the key to their happiness or even more absurdly, a gauge of "success". Shouldn´t our success be judged by how are patients feel about us? How well we work? How well we care for our families?

Let´s be realistic, none of the people who become doctors are ever really going to be working and simultaneously for want of the things they need in life for themselves and their families. Is the cost of medical school overly high? I think so, but as people in this very thread have shown through their calculations, each of us will still make several million dollars by the time we retire, which is plenty to live a reasonably luxurious existence anywhere in this country.

If you are worried about debt, which is totally understandable (I worry about it too), there are other things out there besides just the military and government scholarships. If you check out the Family Medicine forum at least you´ll find that most of the recent graduates from residency in there get hired on at places that have a loan reimbursement program anyway...

Finally, I like how the people who say that medicine is not worth it are essentially implying that there is some other profession out there that guarantees you a very good-paying job, affords you the freedom and scope of practice that medicine does, as well as allows you to help others all at the same time.....In my opinion, if you like medicine for what it is as a profession, it will continue to be worth it for a long time to come.
 
Slack3r said:
Times have changed. Most of the cheapest public schools still have tuitions >$20k. My state school is $26k this year. If you took out $0 for living expenses, you'd still have $80-100k just in tuition debt.

(barring Texas schools, of course)
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No, I'm not from Texas. I wasn't even aware they had special programs. I checked my state school and the state universities of a few other states that sprang to mind as pretty rural places and I found most of them have in-state tuitions of under $6000/year and out-of-state under $20,000/year (not including living expenses). It's unfortunate that there is such a disparity between those of us from states such as this, who can graduate with little to no debt, and those from other states for whom even in-state tuition is over $20,000 per year.
 
rhiannon777 said:
It's unfortunate that there is such a disparity between those of us from states such as this, who can graduate with little to no debt, and those from other states for whom even in-state tuition is over $20,000 per year.
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My home state had no medical school, nor did it have an agreement with an area medical school for in-state tuition. Some of us truly have no choice but to take on out of state tuition and living expenses.

The only way out for me was an MD/PhD program. I was very interested in research. But, if you're not interested in a research career, the four or more years of your life earning that PhD isn't necessarily worth $300,000.
 
So I felt compelled to chime in-- yes, I regret how much time i've lost, how much pain/stress/suffering med school has put me through, and how many more mountains I will need to climb in terms of more training and the future political nature of medicine....it never ends. However, there really isn't another job out there with so much job security and flexibility. The degree is forever (not so much your license...you don't have control over that sometimes)- you can do anything with it and still have a lot of credibility. Also, in the end you learn a lot of medicine, which applies to many aspects of ones life. In the end, it's worth it...it's worth the 300+ debt because you will have a job for life and the satisfaction in learning something so few people get to learn-- you can't say that in other fields or jobs. There are plenty of others that have made millions in a short amount of time, and have lost millions in the same amount of time-- medicine is steady, you will never be rich or poor, but it will allow you to put food on the table and have some sort of job satisfaction-- this can't be measured in amounts of money.
 
Neuronix said:
My home state had no medical school, nor did it have an agreement with an area medical school for in-state tuition. Some of us truly have no choice but to take on out of state tuition and living expenses.

The only way out for me was an MD/PhD program. I was very interested in research. But, if you're not interested in a research career, the four or more years of your life earning that PhD isn't necessarily worth $300,000.
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Its a waste of time unless you really want to go into research. Even if you just go into family practice you can easily make 300K in 4 years.

Tbh, everyone says "X is just 4 years, Y just 4 years, etc" Basically, by going into medicine you're already nickel-and-diming your life away with med school, residency, fellowship, etc. Let's not give up even more.
 
RadOncDoc21 said:
?? I know I'm probably opening a can of worms here but how exactly is Obama responsible for tuition rates?
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Not for tuition rates, but yes for this Obamacare crap. I doubt he consulted with actual physicians. I wish we had more spine to really put pressure and have a system that works better. Ultimately we are the providers.

Why not cut his own salary or that of Congress or stop giving pensions to everyone? If there is always money to pay teachers and police, and raises for everyone, why are there cuts to physicians? Physicians should really unite and say enough is enough. We should demand and expect at the bare mininum, raises that keep up with inflation.
 
Neuronix said:
Clearly the practice of medicine has drastically altered itself since Obama became president. I used to fight cancer with leeches, but now I have to use a linear accelerator. Damn you Obama!!!
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Well for many, the constant cuts and constant and upwardly mobile regulations have made the practice of medicine pretty unbearable. Medicine itself is not the issue, but the *practice* of it has gradually worsened.
 
DrAwsome said:
Not for tuition rates, but yes for this Obamacare crap. I doubt he consulted with actual physicians. I wish we had more spine to really put pressure and have a system that works better. Ultimately we are the providers.

Why not cut his own salary or that of Congress or stop giving pensions to everyone? If there is always money to pay teachers and police, and raises for everyone, why are there cuts to physicians? Physicians should really unite and say enough is enough. We should demand and expect at the bare mininum, raises that keep up with inflation.
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This has been going on for a long time before the inception of the ACA. I have mixed emotions myself regarding the ACA, but the issues you're citing here have to do with the issues with the SGR not the ACA.
 
LucidSplash said:
This has been going on for a long time before the inception of the ACA. I have mixed emotions myself regarding the ACA, but the issues you're citing here have to do with the issues with the SGR not the ACA.
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I"m talking about healthcare and Obamacare in general. The problem-we are bleeding money as a nation. Instead of doing what should be done, the low hanging fruit in a costly problem is being targeted, ie-us the doctors.

So for sure, the healthcare expenses as a % of the GDP in this nation are out of whack. but instead of fixing this hemorrhage and many others, rates and in turn salaries are cut constantly, and more and more regulations are put in place in an already bureaucratic system.

My point is-there is a great deal of financial hemorrhaging in all sectors. Instead of always nailing the same segment of people, and instead of always accusing those at the top of not doing/paying their fair share, why not actually have the gumption to fix things in a rational, and sensible way?

We have trillions of dollars in debt, and he can try and force all of us to work for free, yet that would only minimally reduce the ever increasing financial hole we have in this country.

So the point of this thread from my understanding is, is 300k of DEBT worth being a physician?

Maybe to some, the emotional/pride aspect of being a physician is worth 300k of debt. But from a financial perspective, which is what I believe is being asked, is whether it makes sense. To many people, it's not, given the continuously crappy reimbursement and the poor outlook overall.

Obama has a lot to do with that poor outlook. Add more taxes, add more regulations (ACOS, etc which are his baby), + more medicaid type patients, again = more crap for us, and this is all Obama. The ACA is part of the disaster, and the lack of fixing the SGR is also a disaster that if he truly wanted to *fix* healthcare he would address.

Unless I'm missing something, I don't think he at any point talked to any physician regarding any of the issues with his new, trillion dollar, inefficient, ineffective and punishing "healthcare plan."
 
DrAwsome said:
Not for tuition rates, but yes for this Obamacare crap. I doubt he consulted with actual physicians. I wish we had more spine to really put pressure and have a system that works better. Ultimately we are the providers.

Why not cut his own salary or that of Congress or stop giving pensions to everyone? If there is always money to pay teachers and police, and raises for everyone, why are there cuts to physicians? Physicians should really unite and say enough is enough. We should demand and expect at the bare mininum, raises that keep up with inflation.
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He froze the salaries of Congress in his first year so that they would not keep leeching off money from us peasants. Romney vowed in his election campaign to cut Pell Grants in order to contribute to deficit recuperation. A lot of students were scared that by cutting educational resources, they would be more in debt - not that medical school is gonna give much Pell Grants to begin with, but at least it helps minimize college debt.

Continuing further, Republicans tried to increase military budgets while cutting the costs elsewhere, such as in healthcare.

Also, in terms of raising Physician salaries, I feel that should be focused on primary care such as Pediatrics and IM. I feel all these Cardiologists and Derms making 250k+ a year or other fancy specialties (and I've seen 500k-1.5mil for directors here in NYC) are getting enough money as it is -- no offense.
 
OncoMD said:
He froze the salaries of Congress in his first year so that they would not keep leeching off money from us peasants. Romney vowed in his election campaign to cut Pell Grants in order to contribute to deficit recuperation. A lot of students were scared that by cutting educational resources, they would be more in debt - not that medical school is gonna give much Pell Grants to begin with, but at least it helps minimize college debt.

Continuing further, Republicans tried to increase military budgets while cutting the costs elsewhere, such as in healthcare.

Also, in terms of raising Physician salaries, I feel that should be focused on primary care such as Pediatrics and IM. I feel all these Cardiologists and Derms making 250k+ a year or other fancy specialties (and I've seen 500k-1.5mil for directors here in NYC) are getting enough money as it is -- no offense.
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Being pre-med I don't think you are fully informed. Primary care makes in the 200k + range, I personally feel that is excellent compensation for a 3 year residency, particular for a role that can be done for 1/2 by midlevels for a lot of the things that primary care docs do. Second, cardiologists and derms make far more than 250k + a year for one, and two, there is 0 incentive to be a specialist for an additional 3+ years if there is no extra income, and particularly with the increased liability and expertise.

It takes far more to be a specialist than a primary care doc. If anything, I think midlevels should be utilized far more in primary care, leaving only complicated patients to be seen by doctors. I also think that pathology should indeed be a PhD specialty as some of the people in the pathology forum are saying. I think it makes far more sense.

Psychiatry could also be potentially reduced from the MD ranks, with having psychiatrist doctors supervise a larger number of midlevel providers for simpler psychiatry patients, and seeing unstable/complicated patients mostly. I think one of the psych residents put it best when she commented on being hired to do a job that was previously done by a NP in saying that it made no sense that she would be paid almost 200k to do the job she was doing when it could be done just as well for 1/2 by an NP.

Lastly, if less loans were given, maybe students would not be so much in debt and colleges would have to accept a new, lower tuition rate. Something has to give-either we continue paying bloated tuition amounts, and in turn get bloated salaries, or everything goes to a more rational and sustainable level.

The same is happening with the dental world-some dentists are coming out of school with 400k+ in debt to be making 150-200k. That is just nuts. There needs to be some serious changes to the way we do things as a country.
 
DrAwsome said:
Being pre-med I don't think you are fully informed. Primary care makes in the 200k + range, I personally feel that is excellent compensation for a 3 year residency, particular for a role that can be done for 1/2 by midlevels for a lot of the things that primary care docs do. Second, cardiologists and derms make far more than 250k + a year for one, and two, there is 0 incentive to be a specialist for an additional 3+ years if there is no extra income, and particularly with the increased liability and expertise.

It takes far more to be a specialist than a primary care doc. If anything, I think midlevels should be utilized far more in primary care, leaving only complicated patients to be seen by doctors. I also think that pathology should indeed be a PhD specialty as some of the people in the pathology forum are saying. I think it makes far more sense.

Psychiatry could also be potentially reduced from the MD ranks, with having psychiatrist doctors supervise a larger number of midlevel providers for simpler psychiatry patients, and seeing unstable/complicated patients mostly. I think one of the psych residents put it best when she commented on being hired to do a job that was previously done by a NP in saying that it made no sense that she would be paid almost 200k to do the job she was doing when it could be done just as well for 1/2 by an NP.

Lastly, if less loans were given, maybe students would not be so much in debt and colleges would have to accept a new, lower tuition rate. Something has to give-either we continue paying bloated tuition amounts, and in turn get bloated salaries, or everything goes to a more rational and sustainable level.

The same is happening with the dental world-some dentists are coming out of school with 400k+ in debt to be making 150-200k. That is just nuts. There needs to be some serious changes to the way we do things as a country.
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I definitely agree with most of the points you are making. Excuse my inaccurate salaries markings.

I think that's why PA and NP are growing so fast now in hospitals, it allows the hospital to save money on primary care doctors (not that its good news for us or anything).

I also agree that a lot of schools are overcharging and they should be able to decrease tuition rates so that school can become more affordable because, you're right 400k is insane. Congress really needs to come up with a solid plan because i think there is too much going on and less people are thinking it through.
 
The reason midlevels are "able to do half of what primary care doctors do" is because primary care doctors have decided to stop diagnosing and managing everything that falls within the scope of their field (yes, that includes plenty of heart, lung, GI, kidney, endocrine, etc.) disease, and instead choose to consult and refer to subspecialists for every little thing. Subspecialists should be invoked only when 1.) you're incapable of diagnosing something, or are quite unsure of the diagnosis and the risk of treating incorrectly is significant or 2.) you can't perform a procedure that needs to be done (e.g. colonoscopy).
 
mercaptovizadeh said:
The reason midlevels are "able to do half of what primary care doctors do" is because primary care doctors have decided to stop diagnosing and managing everything that falls within the scope of their field (yes, that includes plenty of heart, lung, GI, kidney, endocrine, etc.) disease, and instead choose to consult and refer to subspecialists for every little thing. Subspecialists should be invoked only when 1.) you're incapable of diagnosing something, or are quite unsure of the diagnosis and the risk of treating incorrectly is significant or 2.) you can't perform a procedure that needs to be done (e.g. colonoscopy).
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A lot of this is sadly true. But more and more it's how it goes. Specialist overutilization is also inevitable with more midlevels so whatever is saved on using a midlevel vs a PCP is really not much of a cost savings given how much they consult specialists.
 
DrAwsome said:
A lot of this is sadly true. But more and more it's how it goes. Specialist overutilization is also inevitable with more midlevels so whatever is saved on using a midlevel vs a PCP is really not much of a cost savings given how much they consult specialists.
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That's the problem when you expect us to do everything in a 15 minute visit.
 
VA Hopeful Dr said:
That's the problem when you expect us to do everything in a 15 minute visit.
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I'm not saying that it's not a short amount of time, I'm just saying that this is what happens very regularly. I think unfortunately there is a great level of complacency by a large number of primary care docs unfortunately, and its not just a matter of lack of time in the outpatient setting. I would say a good 80% of the time when I was doing my internship, the primary care docs on admission in the inpatient setting would want consults-very little workup of issues, but more like let's consult cards, neuro, and ID. Inevitably if a different mentality is not put in place, they just become referral writers.

While there may be some excellent people who do try to work up and get to the root cause of the issues, many are not. And that's a big problem, because if that's the case, the midlevel can do the same for 1/2 the cost.

Complacency is never good. Same way that radiologists are trying to "take back the night" when it comes to telerads, or anesthesiologists wanted a more laid back schedule and introduced CRNAs, or how PAs are also heavily involved in derm now-complacency frequently leads to replacement. No reason to pay the big bucks if most of your role is to refer to the specialist.
 
Family medicine is a joke field. It's not even a specialty if you ask me. Medical school used to train doctors on how to practice in a general way, which made getting to the bottom of diagnosis and treatment of common conditions the norm for all doctors. Specialist referrals were the exception. Dental school still operates in such a way. They're doing fine.

Now, as a generalization, all the good students become specialists and the poor ones go into primary care, and since these students probably weren't that great to begin with (low board scores, FMGs) they don't even know how to work-up a patient in practice, so they just refer them all off. Plus, more importantly, primary care docs aren't paid to think. They're paid to move the meat. Referral is the procedure of the family doc, much like a colonoscopy for the GI, or Mohs' for the derm. It's how to fatten the wallet.

Family medicine seems to be defined by what it doesn't do, and the answer is ever so increasingly becoming "anything".

Midlevels are taking this field over - they can refer just fine for a fixed salary of less than 100k. Students should avoid it like the plague.
 
^

keep-calm-and-ignore-him-6.png
 
Substance said:
Family medicine is a joke field. It's not even a specialty if you ask me. Medical school used to train doctors on how to practice in a general way, which made getting to the bottom of diagnosis and treatment of common conditions the norm for all doctors. Specialist referrals were the exception. Dental school still operates in such a way. They're doing fine.

Now, as a generalization, all the good students become specialists and the poor ones go into primary care, and since these students probably weren't that great to begin with (low board scores, FMGs) they don't even know how to work-up a patient in practice, so they just refer them all off. Plus, more importantly, primary care docs aren't paid to think. They're paid to move the meat. Referral is the procedure of the family doc, much like a colonoscopy for the GI, or Mohs' for the derm. It's how to fatten the wallet.

Family medicine seems to be defined by what it doesn't do, and the answer is ever so increasingly becoming "anything".

Midlevels are taking this field over - they can refer just fine for a fixed salary of less than 100k. Students should avoid it like the plague.
Click to expand...

What is your specialty?
 
I disagree with the hating on primary care docs.
They have to try to do too much in too little time. I started out in internal medicine and had 3 years of IM resident clinic, etc. before going into cardiology. I think a lot of people on here commenting about PA/NP's being able to replace general IM or fp docs don't really know what they are talking about because they are specialists. Actually IM/fp can do a lot of damage if they don't recognize the occasional sick or potentially very sick ppl mixed in among the routine stuff. I also get irritated when people come to my cardiology clinic with anemia, renal failure, etc. that is not being worked up by the PCP, but I attribute this to their being awash in too much paperwork, too many patients and too little time to see them. This is also the reason I think that fewer students want to go into these fields - it is not just the money because then medicine residents would not be abandoning plans to do primary care for specialties like endocrinology, which I don't think really pays much more than general IM. People are just running for the doors because of the way things are...they get no respect and get every home health paperwork, random abnormal lab, etc. dumped in their laps. I also get irritated that some of them refer people to me for basic hypertension management, dyslipidemia, etc. but usually it's because they don't have time to talk to these people about what they need to do to control their high blood pressure, obesity, dyslipdemia. It's just the nature of the way things are.

By the way, if I had to be trapped in clinic 4.5 days a week I think I would slit my wrists...
 
dragonfly99 said:
I disagree with the hating on primary care docs.
They have to try to do too much in too little time. I started out in internal medicine and had 3 years of IM resident clinic, etc. before going into cardiology. I think a lot of people on here commenting about PA/NP's being able to replace general IM or fp docs don't really know what they are talking about because they are specialists. Actually IM/fp can do a lot of damage if they don't recognize the occasional sick or potentially very sick ppl mixed in among the routine stuff. I also get irritated when people come to my cardiology clinic with anemia, renal failure, etc. that is not being worked up by the PCP, but I attribute this to their being awash in too much paperwork, too many patients and too little time to see them. This is also the reason I think that fewer students want to go into these fields - it is not just the money because then medicine residents would not be abandoning plans to do primary care for specialties like endocrinology, which I don't think really pays much more than general IM. People are just running for the doors because of the way things are...they get no respect and get every home health paperwork, random abnormal lab, etc. dumped in their laps. I also get irritated that some of them refer people to me for basic hypertension management, dyslipidemia, etc. but usually it's because they don't have time to talk to these people about what they need to do to control their high blood pressure, obesity, dyslipdemia. It's just the nature of the way things are.

By the way, if I had to be trapped in clinic 4.5 days a week I think I would slit my wrists...
Click to expand...

They do have little time, no doubt about it, but even in the inpatient setting when there is a lot more time, the referral machine starts quite quickly, usually even from admission. That is part of the problem.

Also, I still believe that a significant number of patients can indeed be treated by midlevels, and patients who are stable/follow ups should for sure be treated by midlevels.

In my limited experience, I would say 50% of the patients that come through the door are routine. Why not set up a system where patients are categorized into complex/routine or whatever, and then either see an NP/PA vs. an MD/DO?

Even for younger patients there is no need to see an MD for most of the time. The current system just does not make sense.
 
DrAwsome said:
They do have little time, no doubt about it, but even in the inpatient setting when there is a lot more time, the referral machine starts quite quickly, usually even from admission. That is part of the problem.

Also, I still believe that a significant number of patients can indeed be treated by midlevels, and patients who are stable/follow ups should for sure be treated by midlevels.

In my limited experience, I would say 50% of the patients that come through the door are routine. Why not set up a system where patients are categorized into complex/routine or whatever, and then either see an NP/PA vs. an MD/DO?

Even for younger patients there is no need to see an MD for most of the time. The current system just does not make sense.
Click to expand...

A little thought would indicate to you that sometimes ominous diagnoses can masquerade as the trivial and (relatively) benign. That's why we have something called differential diagnosis and need well-trained MDs to make the distinctions.

It's sounds like you're arguing that that there should be a triage nurse who decides "complex" or "easy" and then turfs off "easy" to NPs/PAs. Why don't we try that with anesthesia too? Let's just decide when we look at the patient who's easy, then dump him on a CRNA without any MD supervision. Sure, it'll work 98% of the time. But don't come crying when 2% of the time the patient crashes and dies because the CRNA didn't know what to do and there was no MD around.
 
mercaptovizadeh said:
A little thought would indicate to you that sometimes ominous diagnoses can masquerade as the trivial and (relatively) benign. That's why we have something called differential diagnosis and need well-trained MDs to make the distinctions.

It's sounds like you're arguing that that there should be a triage nurse who decides "complex" or "easy" and then turfs off "easy" to NPs/PAs. Why don't we try that with anesthesia too? Let's just decide when we look at the patient who's easy, then dump him on a CRNA without any MD supervision. Sure, it'll work 98% of the time. But don't come crying when 2% of the time the patient crashes and dies because the CRNA didn't know what to do and there was no MD around.
Click to expand...

Are you even a medical practitioner? I don't know what world you are living in, but NP/PAs practice independently in tons of places around the country. Suggesting that all patients need an MD is silly in my opinion.

Second, as far as CRNAs, they ALSO practice independently across the US, and this has been instituted in I think 17 states across the country now, where they don't need an MD to supervise them, and for those that do need MD supervision, what you mentioned is exactly what happens. The 90 year old cardiac patient is taken care of by the MD while the 35 year old healthy hernia repair is taken care of by the CRNA. Are you unaware of this somehow?

I'm saying that for stable patients, acute care stuff, an MD is not needed many times. Look at many places where NP/PAs practice independently, look at care clinics staffed entirely by midlevels. And I would hope that if there is any question regarding a case the midlevel would have the clinical judgment to refer to an MD or specialist.
 
DrAwsome said:
Are you even a medical practitioner? I don't know what world you are living in, but NP/PAs practice independently in tons of places around the country. Suggesting that all patients need an MD is silly in my opinion.

Second, as far as CRNAs, they ALSO practice independently across the US, and this has been instituted in I think 17 states across the country now, where they don't need an MD to supervise them, and for those that do need MD supervision, what you mentioned is exactly what happens. The 90 year old cardiac patient is taken care of by the MD while the 35 year old healthy hernia repair is taken care of by the CRNA. Are you unaware of this somehow?

I'm saying that for stable patients, acute care stuff, an MD is not needed many times. Look at many places where NP/PAs practice independently, look at care clinics staffed entirely by midlevels. And I would hope that if there is any question regarding a case the midlevel would have the clinical judgment to refer to an MD or specialist.
Click to expand...

I think it is imperative for physicians to own the leadership role in primary care. Otherwise, the nurses will take it over, and then move on to the specialists. Patients will also receive substandard care from the nurses, whose operations are largely algorithmic.

Primary care, however, is a crap job. Lots of boring scenarios, patients don't respect their PC doc, insurance companies don't either, the pay sucks, the stress is high, and they're seen as lesser physicians by their peers. It's garbage. No wonder they all refer out.

The only way to save primary care would be to make general licensure common again. Family medicine does not require three years of residency. What needs to happen is a return to a medical education model that teaches medical students to be doctors, not just little suck-up machines.

What seems to be happening instead is that the family medicine pseudoacademics are so cocksure and egotistical that they would rather hand over their domain to nurses than to open up the practice of medicine to all physicians and admit that what they do isn't a specialty but is the practice of general medicine. It's just ******ed!

(disclaimer: this is a purely Canadian perspective, though it does seem applicable to the US as well)
 
DrAwsome said:
They do have little time, no doubt about it, but even in the inpatient setting when there is a lot more time, the referral machine starts quite quickly, usually even from admission. That is part of the problem.
Click to expand...

We go over this each and every time, but again....a general inpatient hospitalist is NOT the same thing as a primary care physician. Anything inpatient automatically means it is not primary care.

So please learn to distinguish general IM from primary care.

Substance said:
Primary care, however, is a crap job. Lots of boring scenarios, patients don't respect their PC doc, insurance companies don't either, the pay sucks, the stress is high, and they're seen as lesser physicians by their peers. It's garbage. No wonder they all refer out
Click to expand...

When people say this, it makes me think that they don't have much clinical experience in other fields either.

There are boring scenarios in every field. My boyfriend is in rad onc, which is about as specialized as it gets. But when he gets ready to see his 12th low-risk prostate cancer patient of the week, do you think he's excited and jumping for joy? Nope.

And insurance companies don't respect anyone. Do you think ANY physician enjoys interacting with insurance companies? I've commiserated about this with cardiologists, endocrinologists, pulmonologists.

And I don't refer out. I've talked about this in other threads but, for many PCPs, referring out is a pipe dream. Because of insurance coverage, which specialists take which insurance, and other factors, referring patients can be next to impossible for some of us.

Patients respect good doctors, regardless of the field. Maybe the specialists hear the patients complain about PCPs, but I hear patients complain about their specialists. "He has no bedside manner." "All he ever wants to do is run expensive tests. Doesn't he know anything besides checking a bunch of boxes?" etc.
 
smq123 said:
We go over this each and every time, but again....a general inpatient hospitalist is NOT the same thing as a primary care physician. Anything inpatient automatically means it is not primary care.

So please learn to distinguish general IM from primary care.



Well, I think maybe to you hospitalist is different from primary care, but as a characterization and for classification purposes, Internal Medicine, Family, and Pediatrics, are considered Primary care. Also, from your posts, it seems that you may be someone who is really thorough in your work up of patients, and who actually does a good job with your patients and does not refer for every single thing but I think you are very different from the typical/average PCP person and kind of the exception.

I think for most of us, the experience is that most PCPs are a fast and furious referral machine.

As far as insurance, I absolutely agree that they are hated by all doctors/specialties alike.
Click to expand...
 
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