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Are Physicians Being Squeezed?
- Thread starter Jojojo
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I will pay back my high interest private loans relatively quickly (planning on doing it in eight years) but the federal loans that I consolidated at 3 percent? Makes no sense paying them back, especially since the inflation that we are going to experience when the full folly of the Sun God Ra-Obama's gargantuan spending and borrowing hits the economy will essentially pay it back for me.
I could pay back all of my loans in a year or two but we have to live too.
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When you say $150k cost, is that for 4 years and including all costs like rent, food, transportation?
Borrow the max subsidized loans and pay the rest out of pocket, or something like that. Don't burn up all your cash, though. Even people with family money borrow, and then the family helps in repayment.
And be careful how you "invest" your cash. Always pay off your high interest rate debt first, namely credit cards.
And don't believe this theory about the benefits of borrowing heavily now and paying debt back in future years with massive inflation. Inflation only will help you pay back debt IF your future income grows at or greater than the inflation rate. Physicians incomes haven't done that for a decade. Paying back debt in the future with inflated dollars only works if your income has kept pace with inflation (your income has inflated), and I would not assume that for physician compensation.
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Strike a balance on how much to borrow vs how much cash to burn. You may need to borrow more than $8k per year since your cash pile isn't unlimited, but you definitely can make it by borrowing far less than the total COA and hoarding cash...not sure what the "magic number" is, but don't be too fearful of debt, just have a healthy respect for it, and if you can get out medical school with something under $100k in debt and avoid burning up all of your cash, that would be a good target.
I know that I fan the flames on debt discussions on SDN, but my main targets are the people who turn down State U for some "dream school" that puts them another $150k+ in debt over the State U debt, and then they respond with the pollyannaish "as a doctor you will make more than enough to service the debt."
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Law2Doc said:
Noted, although I would still say it's a very safe bet (assuming the current conditions hold, and barring any additional reimbursement slashing) to assume a 6 figure salary after residency. National average is what, ~$150k? And I don't believe there are too many doctors (working full-time, that is) with sub-$100k salaries, and if they are, they're generally $80-90k+.
While I will agree that, no, you're never guaranteed anything, but it's a pretty safe bet to count on at least 6 figures as a physician. The main point of my argument was that other careers in law/finance/business/engineering/etc. do not have this guarantee. All you can really expect is about $40-60k out of college. From there, you have all-stars that shoot to the top and reach executive/upper mgmt positions in under 10 years and are pulling salaries that can range anywhere from a few hundred thousand into the 7 figures. But you can also work your whole life in one of those fields and never break 6 figures, or if you do, not get there until much later in life (way after your doctor friends have finished med school and residency and once they've surpassed your earing potential).
I'm simply suggesting that medicine IS a safe bet, if you're fine with the low ceiling. Will you get rich? No, paying someone else for four years and then getting paid an entry-level salary for another 3-6 is hardly the way to maximize earning potential. So while I'd say it's safe to assume that you can expect $90-200k as a physician, the days of the mercedes-driving, mansion-dwelling, golf-playing physician are going the way of the dinosaur, and I don't see it getting any better anytime soon. Like you said in a previous post, you have a floor in medicine not present in other careers, but the lack of a ceiling in those other professions can make the risk worth a shot.
As to $300k in loans, I calculated my projected expenses....$288k for 4 years of med school + the $70k I have from ugrad.Law2Doc" said:
Law2Doc said:
As an anecdotal aside, I shadowed a successful plastic surgeon this summer. He was able to invest money while in residency during the dot.com boom. Got out at the right time and was able to make a pretty good profit that eventually funded his private practice start-up overhead. Impossible to invest? No, but I'd say there aren't too many savvy investors that can invest on a $45k salary and turn that ant-hill into a mountain.
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bump
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Yes, I agree. You should go ahead and enter this year...that job and big income could "go away" in this wacky economy, and there are other risks to applying again...
You are approaching the debt issue very intelligently. Minimizing debt is the way to go.
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Everyone on this forum needs to relax. As a physician, your skills are your greatest defense against lowering standards of living. If politicians succeed in lowering salaries, they'll exacerbate an already apparent physician shortage. In the long run, quality of healthcare will suffer and the voters will revolt.
Didn't a situation like this occur in England a while ago? Tony Blair supporting raising physicians' salaries to keep British doctors from leaving their homeland in search of fair pay/opportunity.
Didn't a situation like this occur in England a while ago? Tony Blair supporting raising physicians' salaries to keep British doctors from leaving their homeland in search of fair pay/opportunity.
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I disagree with this to an extent. Given the ridiculous measures taken by our government, inflation is going to accelerate. This makes my debt cost less, so taking extensive measures to minimize it are not really worth living like a hobo.
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That is repeated ad nauseum on SDN (elsewhere, too, I suppose) and it is only "true" if your future income growth exceeds inflation AND if the interest that accrues does so at a rate that is less than inflation.
There is no magic involved in borrowing heavily in an inflationary cycle as people here seem to believe - you still have to repay in real dollars, and the interest rates for med school loans have been significantly ratcheted upward in recent years, thus the interest that is accruing while you are in residency will far outpace inflation, too.
I agree though there is no reason to live like a hobo, and nobody should burn up all of their cash to avoid acquiring student debt.
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But this is going to happen regardless. There are only so many measures you can take to reduce debt while a student, and it becomes a cost benefit analysis. Is my happiness cost to live frugally while in a high stress environment worth the money I save? To some people it might be, but keep in mind the drastically changing landscape of the medical field as well as the economy. It is impossible for you or me to predict what the impact of these loans may or may not be relative to their future interest rates or my future salary. I do, however, know that buying more expensive healthier food and a gym membership will keep me happier and healthier, and that getting my own room or apartment will significantly reduce roommate drama issues etc. Yes this translates into more debt, but the benefit is worth it.
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I was simply pointing out the false premise that borrowing heavily works because you are paying back with "inflated dollars" - it isn't as simple as people think, especially considering that physician incomes have been declining against inflation for the last decade, and the interest rates on student debt have more than doubled in recent years, thus as the interest accrues, it is outpacing inflation, too.
The examples you offer for your happiness are marginal cost issues - the elephant in the room is the high tuition that people borrow money to pay to attend private schools and certain OOS publics. Eating a healthy diet, paying for a gym membership, and having an ideal housing situation will cost only marginally more when compared to the whopping tuition bills some people are facing.
The real cost benefit analysis that people on SDN seem incapable of doing is evaluating the cost of attending a cheaper instate school versus a higher ranked private at a higher cost - on the benefit side, the typical SDNer assigns way too much "future value" of the benefits of attending the more expensive school (dream school => dream residency => dream income).
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Well I am in the same boat since my IS school has a 40k COA, so that is the best I could have possible done besides sucking up to TX. 😳
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atomi said:
It was intentional. I was referencing a common stereotype about wealth/doctors to make a point....I guess sarcasm doesn't convey well through text. I was simply using Mercedes and nice houses to depict wealth. And no, those things aren't the end-game but you'd be surprised how many people still think of doctors as stuffy, rich conservatives who drive around in their luxury cars and malignantly charge patients for their right to healthcare.
I was merely stating that the "rich doctor" no longer really exists and that we will continue to see physicians salaries fall judging by the state of things.
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Amen to that.
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I have been casually studying this issue for awhile, and while a lot of the hard data has been elusive, I have discovered some interesting things.
For several decades before 1968, most physicians had comfortable incomes that were well above average, but were by no means extravagantly wealthy. It was a simpler time in terms of medical technology, and most people afforded their own office visits while carrying hospitalization insurance. Physicians actually gave out a significant amount of charity care, and this contributed to the respect the profession garnered.
The so-called Golden Age started, ironically, with the inception of Medicare. With access to an enormous and virtually unregulated new stream of revenue, providers went nuts and billed great fortunes. Also, the Vietnam war led a great deal of young doctors into research as a method to prevent deployment. Virtually all of the expensive technology we use today is rooted in that period.
The end began in 1983, when the free-for-all billing system was effectively ended. Since that time salaries and working conditions have fluctuated, but overall trended down.
I reckon the point of all this is that while we should be mindful of our income, we are likely not outside historical norms. If we compare ourselves to the Golden Age then sure, there is going to be disappointment, but that's an unrealistic comparison.
Also, despite our self perceived greatness, it's pretty easy to come off like a bunch of money hungry pricks. Since our jobs and incomes rely on public relations, we should be mindful of that, too.
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I probably would not pick EVMS over UVA in that example for that price differential (isn't that, in fact, the IS tuition diff for those schools?), but I might pick VCU over UVa for the same tuition savings. I would want to compare total costs of attending (rents, need for a car, etc.), before deciding.
If I am applying instate to any of those school pairs, the total cost for either school would be relatively low compared to an OOS public or a private school. So an additional $32k over 4 years tacked on to an already low IS tuition is not going to break my back. It is the $32k or more PER YEAR separating schools that I find untenable and difficult to justify under any cost/benefit analysis.
I may be singing a different tune next year at this time, so we will see.
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"Well gosh, I guess I became a doctor because, ever since I was a little boy, I just wanted to help people. I dont
tell this story very often, but, I remember when I was seven years old, one time I found a bird that had fallen out of its nest. And so, I picked him up, and I brought him home, and I made him a house out of an empty shoebox, and Oh my God! - I became a doctor for the same four reasons everybody does: Chicks, money, power, and chicks. But, since HMOs have made it virtually impossible to make any real money, which directly affects the number of chicks who come sniffing around and dont ask me what tree theyre barkin up, cause theyre sure as hell not pissin on mine. And as far as power goes, well, here I am during my free time letting some thirteen-year-old psychology fellow who couldnt cut it in real medicine ask me questions about my personal life. So, heres the inside scoop, there, pumpkin: Why dont you go ahead and tell me all about power."
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Why is the common wisdom that medicine has "a low ceiling"?
Most of the time, the highest paid people in any industry got there one of two ways.
1. They rose up the ladder inside a hierarchy to a high level managing others, rather than doing the work themselves.
2. They saved up some of their money from one career, and invested it into a small business, usually one that they run. Through hard work and considerable luck, they grow the small business until it generates large profits. The most successful small businesses do something new or innovative.
It kind of seems like physicians have a major leg up for both #1 and #2. Hospitals, large insurance corporations, and large physician's groups all have hierarchies. Physicians do sometimes give up treating patients, and fight to climb the corporate ladder instead. I'm sure it's much more difficult to succeed than it is to simply treat patients and bill for it, but there are multi-million dollar jobs at the top of the heap. The M.D. (especially if combined with an MBA) is also probably a slightly better degree than if you merely had an MBA like many management candidates.
As for #2 : again, physicians have a double advantage, there. The more disposable income one has, the better the chances of starting up a successful business. Banks are more likely to lend you funds, you have more capital to invest, ect. Also, if you open up a clinic providing some kind of medical service to the cash paying population, there are lots of ways that costs can be reduced and customer service improved compared to existing clinics.
Don't get me wrong, it's still incredibly difficult to become wealthy in America, but it's hard for anyone who isn't already rich. I don't see how physicians have worse chances than anyone else, though, and it most respects it seems like their odds are better.
Most of the time, the highest paid people in any industry got there one of two ways.
1. They rose up the ladder inside a hierarchy to a high level managing others, rather than doing the work themselves.
2. They saved up some of their money from one career, and invested it into a small business, usually one that they run. Through hard work and considerable luck, they grow the small business until it generates large profits. The most successful small businesses do something new or innovative.
It kind of seems like physicians have a major leg up for both #1 and #2. Hospitals, large insurance corporations, and large physician's groups all have hierarchies. Physicians do sometimes give up treating patients, and fight to climb the corporate ladder instead. I'm sure it's much more difficult to succeed than it is to simply treat patients and bill for it, but there are multi-million dollar jobs at the top of the heap. The M.D. (especially if combined with an MBA) is also probably a slightly better degree than if you merely had an MBA like many management candidates.
As for #2 : again, physicians have a double advantage, there. The more disposable income one has, the better the chances of starting up a successful business. Banks are more likely to lend you funds, you have more capital to invest, ect. Also, if you open up a clinic providing some kind of medical service to the cash paying population, there are lots of ways that costs can be reduced and customer service improved compared to existing clinics.
Don't get me wrong, it's still incredibly difficult to become wealthy in America, but it's hard for anyone who isn't already rich. I don't see how physicians have worse chances than anyone else, though, and it most respects it seems like their odds are better.
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There are 2 things I would like to point out.
1--Physicians prior to 1983 did not have to deal with anywhere near the amount of legal bull**** that physicians have to now. It significantly complicates the field and costs a huge amount of money in the form of preventative medicine.
2--The amount of money being injected into healthcare increases, but physician salaries decrease. The people soaking up the difference and giving us the shaft are the profit-oriented middlemen (ie insurance). This, to me, is unacceptable since they do not provide a service (pooling everybodys money together and then deciding what their treatment should be with no medical background is not a service) and, again, make the field much more complicated then it used to be.
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<sigh>
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This here,say whatever you want,when you peel away all the layers of bureacracy, politics,policy, legal mumbo jumbo, is at the very crux of the problem. And I think everyone knows it but they dont want to admit it for fear of disrupting a very very very large and powerful industry.
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You forgot that they are at a permanent advantage thanks to an extremely liberal interpretation of antitrust laws.
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Then why has noone proposed a way to fix this? I guess what I am saying is, every other night or so I get on SDN for 15-20 mins and see (usually) intelligent people in legion united that this is unacceptable.
What can we do to fix it? This is directed for residents and attendies... now that you have seen this, and hated it, what do you recommend? Perhaps if we stop complaining and start proposing ideas, we can move towards a more productive end.
What can we do to fix it? This is directed for residents and attendies... now that you have seen this, and hated it, what do you recommend? Perhaps if we stop complaining and start proposing ideas, we can move towards a more productive end.
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There have been ideas thrown around, but none of them are politically possible. One is a doctor union that could actually gain a foothold in congress and subsequently have a say in how healthcare changes, but antitrust laws nix that. Until then, whatever ideas you come up with will be ignored unless they are beneficial to insurance as well and they take up your cause for you. $$-->lobbying-->law, thats how the majority of democracy in the US works.
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we have to have political courage and persistence just like what obama said. I know you guys hate him. Just keep on pushing bill after bill and working the bills until it passes. It wont happen over night but certainly policy change has to happen to "get rid of the middleman". there are 1500 -2000 insurance companies operating in the usa. DO you think they are going to wither away without a serious fight?
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I'm sure everyone knows, but I'll point out it again ILLEGAL. Not demeaning your comment, just pointing it for maybe those who don't know it is.
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Why is a union "ILLEGAL"?
As I understand it, doctors who are running independent practices from one another cannot unionize because each practice is considered a separate corporate entity. But, if they combine resources into a single large physicians "group", that group can bargain as a unit because it is organized as a single corporation.
Once enough groups merged together, factions of physicians within the resulting corporation could unionize.
But in any case, I'm pretty sure a physician mega-group with hundreds of doctors in it could be arranged to have most of the benefits of private practice. Your "salary" could be primarily determined by the earnings of the practice you work for, and all physicians in the group could be shareholders, with outside entities prohibited from purchasing shares. The group could give you hire/fire authority over your subordinates (staff), and charge expenses for your practice against your salary (discouraging leeching off the group).
I'm not a business major or law major, but it seems like this could work. It could probably combine the advantages of private practice with more market power. Overhead would be higher due to having to pay another layer of management, but maybe it would be possible to save money by sharing resources between physicians. Perhaps the group could have a single office of billing specialists which would consist of an organized team of folks who's job is to harass insurance companies for payment all day long. The office could use automation, such as automatic tools to fill in insurance forms, a robo-dialer to call insurance companies, and so forth. Basically fighting fire with fire.
That's terrible, actually. 30% of the healthcare money spent is supposedly paying paper pushers (versus 10% for doctors). And it's easy to see why.
As I understand it, doctors who are running independent practices from one another cannot unionize because each practice is considered a separate corporate entity. But, if they combine resources into a single large physicians "group", that group can bargain as a unit because it is organized as a single corporation.
Once enough groups merged together, factions of physicians within the resulting corporation could unionize.
But in any case, I'm pretty sure a physician mega-group with hundreds of doctors in it could be arranged to have most of the benefits of private practice. Your "salary" could be primarily determined by the earnings of the practice you work for, and all physicians in the group could be shareholders, with outside entities prohibited from purchasing shares. The group could give you hire/fire authority over your subordinates (staff), and charge expenses for your practice against your salary (discouraging leeching off the group).
I'm not a business major or law major, but it seems like this could work. It could probably combine the advantages of private practice with more market power. Overhead would be higher due to having to pay another layer of management, but maybe it would be possible to save money by sharing resources between physicians. Perhaps the group could have a single office of billing specialists which would consist of an organized team of folks who's job is to harass insurance companies for payment all day long. The office could use automation, such as automatic tools to fill in insurance forms, a robo-dialer to call insurance companies, and so forth. Basically fighting fire with fire.
That's terrible, actually. 30% of the healthcare money spent is supposedly paying paper pushers (versus 10% for doctors). And it's easy to see why.
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I have to find it, but that was discussed in a previous thread. Give me some time and I'll find it....I probably should have done that before I opened my big mouth!
Here we go! It wasn't on here but this should explain more, like other have talked about already, I shouldn't say it "illegal" altogether; however going about it is tricky. Some of the things most unions tackle a union with physicians will have some trouble accomplishing, so in a sense some of the actions could be illegal. Check this out:
Physician News
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Not everyone here hates Obama. I voted for him... now I'm just hoping he's as lucky as he is smart.
I have seen this "middlemen" thing myself. My mother is an attorney currently at a medical insurance liason company. This company is a HUGE "middleman", and provides no care or substancial advantage other than its precedent. My mother and I have had several conversations about this situation, and she and I both agree that it would be best if these companies did not exist. In fact, she seems to be under the impression that if her company and those like it closed tonight, with relatively little change in current practice, nothing significant would be lost and a range of billing would be saved that is quite a lot depending on the case.
So I am biased. Both as a future physician and after talking to my mother, I really do think this needs to change. But that is not enough.
I want to know how. What do you all RECOMMEND we do? What sort of group associations ARE legal? What would be most effective? Are their other bodies who have faced the same trials?
We have to change our complaining to planning or we will have a peanut gallery view of the end of our profession and the decline of healthcare.
So let's think... HOW?
I have seen this "middlemen" thing myself. My mother is an attorney currently at a medical insurance liason company. This company is a HUGE "middleman", and provides no care or substancial advantage other than its precedent. My mother and I have had several conversations about this situation, and she and I both agree that it would be best if these companies did not exist. In fact, she seems to be under the impression that if her company and those like it closed tonight, with relatively little change in current practice, nothing significant would be lost and a range of billing would be saved that is quite a lot depending on the case.
So I am biased. Both as a future physician and after talking to my mother, I really do think this needs to change. But that is not enough.
I want to know how. What do you all RECOMMEND we do? What sort of group associations ARE legal? What would be most effective? Are their other bodies who have faced the same trials?
We have to change our complaining to planning or we will have a peanut gallery view of the end of our profession and the decline of healthcare.
So let's think... HOW?
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If physicians do unionize, I believe its the REICO laws that preven this, it has to be done very carefully.
As has been stated in earlier in the thread people have the stereotype of the golf playin rich doctor. While if you look at your other unions theyre more the blue collar worker fighting for rights. Going on strike and the like would not look good. Basically we would need the creation of a political action committee, and it would need to be well funded and do some great lobbying.
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It's quite simple. Physician income is dictated by reimbursements, which are set by a totally different industry (insurance). You can say "unionize" all you want, but the bottom line is that if you can only charge X for an office visit and Y for a procedure, there is a finite number of those things that can be done in a 12 hour (or however long you are willing to work) day. Which is the definition of a ceiling. In law we didn't have this -- if I decided my time was worth $250/hour and a client was willing to pay it, then that's what I (well, actually my firm) got.
As for investing, that's always available if you have disposable income, but with a ceiling you end up with less disposable income than many others, so you are starting from a worse position there too. And with doctor's hours you have less time to research good investments, so you are usually at the mercy of mutual funds or CFAs. And other fields have a faster track access toward private investments (where the real money is). How many IPOs does the typical cardiologist get invited into by his patients? Certainly not as many as business lawyers or investment bankers do by their clients.
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I feel for you and hope you know what you are doing.
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I don't think there's such a thing as REICO. You might mean RICO, (covering esp racketeering and other white collar and "mob" criminal activity), and it's doubtful that would apply here.
While there are legal impediments to unionizing, the main issue is that doctors are not similarly situated. Is a well paid spine surgeon really going to stop work and picket because a PCP is getting shafted? Doubtful.
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That is a whopping amount of debt. Have you run it through a payment calculator to get a feeling for the level of repayment you face? Off hand, it is going to be very high...something north of $3,000 per month I would guess.
Do you only have one acceptance, or are you choosing the higher cost school of 2 more acceptances? Just curious if this is your only shot...
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Aren't the insurance companies guilty of that?
When a couple of large insurers in an area say "here's out patient pool, if you want access, these are the rates we'll pay" that sounds an awful lot like use of market power to set prices. And, as long as doctors are individuals, they can get singled out easily by these sharks and end up working for whatever the RVU gods degree that they are to be paid.
If the doctors pool up into a group "well, if you want our doctor pool to cover your patient pool, you should pony up the dough" it's more balanced.
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He's not smart, he's educated. Big difference. Smart people do smart things which, vis-a-vis the economy, foreign policy and anything else you care to name, he is not, repeat not, doing. So if you voted for him because he's "smart," well, shame on you. Every president since I can remember has been college educated, usually in the Ivy League. President Bush had an MBA. President Obama has a Law Degree. Big Deal.
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Howso?
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ROFL. Maybe to silliest post I've read on SDN in a long time. As most career changers from other high net worth professions can tell you, we will never catch up to where we would have been had we stayed put. Taking a decade to change degrees when you could be earning a very lucrative salary over that same decade is financially crazy. But some of us put a premium on doing what we want to do over what earns us the most. But I think you have to understand that nontrads are probably the only people on here who you can totally believe aren't doing it for the money, because they already had the money, and never will catch up to their previous trajectory. Thanks for the laugh, though.
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Compared to the prior president, yes, he's smart. And yes, I think a law degree beats an MBA in terms of "smarts" because an MBA is meant to hone existing skills whereas law, like medicine is designed to give you a skillset. So if you didn't have an existing skillset, an MBA is throwing bad money after good. And based on our last president's grasp of basic concepts like vocabulary and his multiple failed businesses before he went into government, I think it's fair to say the MBA was wasted on him.
