Bernie Sanders announces he is running for President

[Stagg737]

Shouldn't corporations and private med schools be chomping at the bit to create more spots?

In case you were unaware, they are doing this now. In my city alone there are 4 residency programs being opened by private corporations (mostly HCA) in the next 3 years. So yep, they are. Likely because some have realized they can basically treat residents as MLPs and make bank off of them.

Honestly, what I'm more concerned about is convincing you of the folly of considering government involvement in medical education "something necessary but not desirable." I keep wondering why many shy away from it when the rest of the first world has already embraced it. Surely you have read about the history of medical school and the history of residency training in the United States, especially in the early 20th century. National standardization of admissions criteria, curriculum, and USMLE did wonders for the the quality of medical care and its practitioners. Granted, the Flexner report was independent and the changes were implemented under the auspices of the AAMC/LCMC and not the govt, but it demonstrates the power of how a centralized body can effect massive change for the better. Unfortunately, this national standardization didn't trickle down to individual state medical boards, and physicians who desire geographic mobility have to go through an expensive nightmare every time they move or do out of state locums.

Don't disagree with this, but this is looking at our medical education system through rose-colored glasses and ignoring many of the problems which have been created by that central system. Which I'll admit are rampant through most fields of higher education. I'll also point out that there's a difference between implementing policies to create acceptable standards of care and getting financially involved in the process. The former I have few problems with, the latter is a different story.

CMS/govt similarly, for all its problems, has been a boon to medical education for the last 30 years. We have a problem nowadays with number of applicants vs. residency spots

Actually we don't. If we were to stop approving fed loans to Caribbean medical schools we'd have a few thousand residency positions available every year. 37,100 total applicants for 33,100 total positions. 5,000 IMG applicants, and 7,000 FMG applicants. So roughly 25,000 US grads for 33,000 positions. So problem with total applicants? Sure, but we could easily place all US grads if we wanted to and that deficit in positions to total applicants has been stable at ~4,000 for the past several years.

The game you're playing where you think it's reasonable to go on a rant that essentially implied that you've won the private practice/cash pay/no medicare lottery due to the practice nature of psychiatry and then chide me for making a reasonable assumption about your presumable lack of interest in charity care has gotten rather tiring.

And you making crappy assumptions (about several things) is also getting tiring.

Do you have any idea how ridiculous it sounds saying that "as an intern" that you are bringing in > 100k/yr? You doing an H&P and then presenting it to your senior or attending for final approval does not constitute you bringing in that money. If you had an unrestricted medical license, board certification, malpractice insurance, the ability to treat the most complex patients independently, and the ability to bill an insurance company, then yes, you could say that you bring in >100k / yr.

At my hospital I see the patient, present to my attending, write the notes, enter the encounter titles, enter billing codes and diagnoses, and sign the notes. Literally the only thing my attendings do are listen to me present the patient, tweak my plan when then feel it's necessary (which is about 25% of the time for me at this point), and sign the note. The only extra thing they do on our unit is write an admission note which usually consists of a list of diagnoses, a brief treatment list, and an addendum saying "I agree with what is written in X note by Dr. Stagg." So from the hospital's perspective I'm largely functioning as a supervised mid-level. Since I'm at an academic program the attendings do have teaching points after we present and we have mini-didactic sessions daily and have them available to ask questions. So I'm mostly functioning independently with supervision at my program with availability for teaching points when I have questions.

I low-balled my previous calculations and probably half of those progress notes are 99233s and admits are 99223s. I also didn't include my overnight call or weekend call income. So realistically my work probably generates closer to $180k/yr for the hospital/program. Obviously that's supervised, but so are midlevels in my state so I guess you don't count their work as bringing in income either?

Just for shiggles, I calculated how much I brought in the hospital last week. My work during the week was billed for $3,465.65 and my call day was an additional 1,066.26 according to medicare billing schedules and last week was a typical week for me. So my weekly schedule would generate $180,213.80/yr and if I have 20 weekend call days per year (a little low) that's another $21,325.20 for a total of $201,539. This doesn't include any patients I see in the ED who don't get admitted (we bill for ED consults) or inpatient consults off unit (which we cover on call). So that ~$200k is a low-ball number. There are 3 residents (interns and second years) working under 1 supervising attending on this unit, so if everyone is like me (which they are) then that's ~$600k generated by us. So if our attending made $300k (which he doesn't) and you subtract that from the cost we bring in since that's what it costs to supervise us, then we're still each bringing in about $100k/yr for the hospital. So actually, I can probably say I'm bringing in $100k/yr in addition to that which is covering my supervision for the hospital in exchange for being paid roughly half that.

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[Stagg737]

I’m a supporter of single payer healthcare because, to be honest with you, I don’t want the reason for me to continue working full time in my 50s and beyond to be that healthcare is too expensive and I need to wait until I’m eligible for Medicare to cut back or retire.

The bottom line is this, the government has become a tool by which the corporations and rich have continued to concentrate power and wealth. We don’t have a free market. As a result, the middle class in America has suffered. You need a very expensive college degree to even have a shot at covering not only living expenses, but saving for things like retirement and health surprises. Upward social mobility essentially doesn’t exist and many children are worse off than their parents are despite working harder with more education. At some point something has to give.

The opinions on this board, while valuable, don’t mean much in the grand scheme. We all make more than enough money to live comfortably. The majority of Americans support these ideas (including the Republican voters if you talk to them away from the Fox propaganda machine). The majority of Americans are asking for a hand with these big expenses...education and healthcare. It does not seem all that unreasonable for the well off to chip in a bit more for the benefit of our fellow citizens. That ideal is written directly into our Constitution by the founding fathers. It’s not Communism, it’s just good citizenry. Who knows, free up some of people’s capital from the worries of things like healthcare and student debt and you might unlock more young people creativity to create new businesses and a more vibrant economy.

I don't disagree with this, especially the point about college being prohibitively expensive even though a college degree is basically the new HS diploma in terms of necessary education level. I used to work in fast food and during my interview I was actually asked if I had a college degree for a delivery position, which was insane to me. It's not really realistic, but I'd ideally like to decrease the threshhold for degree requirement for many jobs. There's no reason an entry level sales position should require a college degree, especially when a company has 4-6 weeks of training before starting. The college degree requirement just requires 4 more years of expensive education which many people will either not use in their future careers or use peripherally in order to obtain a job which will allow them to pay off debt in a few decades if living modestly. The education bubble has to pop sooner or later, and it's not going to be pretty when it does.

As for healthcare I'm not opposed to some form of safety net in the system, but single-payer would be disastrous. There's only 2 or 3 true single payer systems in the world and I don't particularly want to emulate any of them.

 

[DirtDocMD]

Since the beginning of man’s existence, most have had to “work” (hunting/gathering/farming) until they died, to provide themselves food/housing/“healthcare”. For some to think that we ought to go to “single payer”, simply so they don’t have to work past their early 50’s, seems ridiculous. Try saving up some money, or putting money away in an HSA for 20 years to help cover insurance costs.

This sounds like the “job lock” crap Pelosi was talking about 10 years ago. You think ANYBODY is gonna work if they can get all this stuff at the age of 50, or earlier?? Ever taken a look at the country of Greece?? Not everyone can make pottery or write poetry. Somebody’s got to clean toilets, dig ditches, or provide healthcare.....

 

[nimbus]

In case you were unaware, they are doing this now. In my city alone there are 4 residency programs being opened by private corporations (mostly HCA) in the next 3 years. So yep, they are. Likely because some have realized they can basically treat residents as MLPs and make bank off of them.



Don't disagree with this, but this is looking at our medical education system through rose-colored glasses and ignoring many of the problems which have been created by that central system. Which I'll admit are rampant through most fields of higher education. I'll also point out that there's a difference between implementing policies to create acceptable standards of care and getting financially involved in the process. The former I have few problems with, the latter is a different story.



Actually we don't. If we were to stop approving fed loans to Caribbean medical schools we'd have a few thousand residency positions available every year. 37,100 total applicants for 33,100 total positions. 5,000 IMG applicants, and 7,000 FMG applicants. So roughly 25,000 US grads for 33,000 positions. So problem with total applicants? Sure, but we could easily place all US grads if we wanted to and that deficit in positions to total applicants has been stable at ~4,000 for the past several years.



And you making crappy assumptions (about several things) is also getting tiring.



At my hospital I see the patient, present to my attending, write the notes, enter the encounter titles, enter billing codes and diagnoses, and sign the notes. Literally the only thing my attendings do are listen to me present the patient, tweak my plan when then feel it's necessary (which is about 25% of the time for me at this point), and sign the note. The only extra thing they do on our unit is write an admission note which usually consists of a list of diagnoses, a brief treatment list, and an addendum saying "I agree with what is written in X note by Dr. Stagg." So from the hospital's perspective I'm largely functioning as a supervised mid-level. Since I'm at an academic program the attendings do have teaching points after we present and we have mini-didactic sessions daily and have them available to ask questions. So I'm mostly functioning independently with supervision at my program with availability for teaching points when I have questions.

I low-balled my previous calculations and probably half of those progress notes are 99233s and admits are 99223s. I also didn't include my overnight call or weekend call income. So realistically my work probably generates closer to $180k/yr for the hospital/program. Obviously that's supervised, but so are midlevels in my state so I guess you don't count their work as bringing in income either?

Just for shiggles, I calculated how much I brought in the hospital last week. My work during the week was billed for $3,465.65 and my call day was an additional 1,066.26 according to medicare billing schedules and last week was a typical week for me. So my weekly schedule would generate $180,213.80/yr and if I have 20 weekend call days per year (a little low) that's another $21,325.20 for a total of $201,539. This doesn't include any patients I see in the ED who don't get admitted (we bill for ED consults) or inpatient consults off unit (which we cover on call). So that ~$200k is a low-ball number. There are 3 residents (interns and second years) working under 1 supervising attending on this unit, so if everyone is like me (which they are) then that's ~$600k generated by us. So if our attending made $300k (which he doesn't) and you subtract that from the cost we bring in since that's what it costs to supervise us, then we're still each bringing in about $100k/yr for the hospital. So actually, I can probably say I'm bringing in $100k/yr in addition to that which is covering my supervision for the hospital in exchange for being paid roughly half that.

Your entire post is based on the incorrect assumption that a half-trained resident can go out there and collect market rates for their labor. If that were the case, people wouldn’t need to complete residency. The reality is that if a resident doesn’t complete residency, they are essentially unemployable.

Also those hospitals aren’t opening a residency because they are a profit center. They create them because they know they will need PCPs to feed patients into their own health systems.

Finally, an experienced hospitalist can probably do the work of that entire team by his or her self. I work in a quasi academic hospital with both teaching and nonteaching hospitalists services. The nonteaching services carry the same patient loads. Many of the surgeons prefer to have their patients admitted through the nonteaching service because the service they provide is consistently excellent and predictable. They know the score. Experience breeds efficiency. Teaching is noble and necessary but it is not an efficient process.

 

[Stagg737]

Your entire post is based on the incorrect assumption that a half-trained resident can go out there and collect market rates for their labor. If that were the case, people wouldn’t need to complete residency. The reality is that if a resident doesn’t complete residency, they are essentially unemployable.

Also those hospitals aren’t opening a residency because they are a profit center. They create them because they know they will need PCPs to feed patients into their own health systems.

Finally, an experienced hospitalist can probably do the work of that entire team by his or her self. I work in a quasi academic hospital with both teaching and nonteaching hospitalists services. The nonteaching services carry the same patient loads. Many of the surgeons prefer to have their patients admitted through the nonteaching service because the service they provide is consistently excellent and predictable. They know the score. Experience breeds efficiency. Teaching is noble and necessary but it is not an efficient process.

I don't disagree with the bottom two lines, or the point about collecting market rates. The point about being unemployable as a resident other than residency is irrelevant when discussing whether residents bring profits into their hospitals. Additionally I could go out and get my full license in 4 months and practice with full scope moonlighting or with locums. In fact I plan to do so with a private psych hospital in my area if I'm able to gain program approval for moonlighting. So not completely correct there either.

I disagree with middle sentence though. If they're only opening residencies because they'll need PCPs to feed patients into their own systems why are they opening specialty fields (2 of the programs opening in my city are surgical fields, so not really primary care). I get your point, I think that believing residents once their in their 3rd or 4th years won't bring profits in (especially FM programs which have outpt clinics attached to the hospital) is incorrect.

 

[vector2]

In case you were unaware, they are doing this now. In my city alone there are 4 residency programs being opened by private corporations (mostly HCA) in the next 3 years. So yep, they are. Likely because some have realized they can basically treat residents as MLPs and make bank off of them.

Uh, man, I'm the one who just corrected you in the last exchange about how CMS isn't the only game in town when it comes to funding residencies.

Don't disagree with this, but this is looking at our medical education system through rose-colored glasses and ignoring many of the problems which have been created by that central system. Which I'll admit are rampant through most fields of higher education. I'll also point out that there's a difference between implementing policies to create acceptable standards of care and getting financially involved in the process. The former I have few problems with, the latter is a different story.

Actually we don't. If we were to stop approving fed loans to Caribbean medical schools we'd have a few thousand residency positions available every year. 37,100 total applicants for 33,100 total positions. 5,000 IMG applicants, and 7,000 FMG applicants. So roughly 25,000 US grads for 33,000 positions. So problem with total applicants? Sure, but we could easily place all US grads if we wanted to and that deficit in positions to total applicants has been stable at ~4,000 for the past several years.

For all the problems with a centralized system, I don't know why you automatically assume the counterfactual that a fragmented, private system would be better at medical education. But again, you still haven't addressed the point as to why private corporations haven't stepped up in a big way to start residency programs (instead of just a scattered few here and there) when nothing has been stopping them from doing so for the past 30 years. Neither you nor me have any reason to believe they would step in if your goal of removing govt financial involvement in medical education ever came to fruition.

Excellent point about Caribbean and FMG, but every professional organization out there estimates that there is a pending physician shortage given the aging population. Also, I wonder how many Carib and FMGs are American citizens who were qualified for medical school based on grades/MCAT but there just weren't enough spots. I would prefer we had enough residency spots for every American who was qualified, preferably through CMS if necessary.

At my hospital I see the patient, present to my attending, write the notes, enter the encounter titles, enter billing codes and diagnoses, and sign the notes. Literally the only thing my attendings do are listen to me present the patient, tweak my plan when then feel it's necessary (which is about 25% of the time for me at this point), and sign the note. The only extra thing they do on our unit is write an admission note which usually consists of a list of diagnoses, a brief treatment list, and an addendum saying "I agree with what is written in X note by Dr. Stagg." So from the hospital's perspective I'm largely functioning as a supervised mid-level. Since I'm at an academic program the attendings do have teaching points after we present and we have mini-didactic sessions daily and have them available to ask questions. So I'm mostly functioning independently with supervision at my program with availability for teaching points when I have questions.

I low-balled my previous calculations and probably half of those progress notes are 99233s and admits are 99223s. I also didn't include my overnight call or weekend call income. So realistically my work probably generates closer to $180k/yr for the hospital/program. Obviously that's supervised, but so are midlevels in my state so I guess you don't count their work as bringing in income either?

Just for shiggles, I calculated how much I brought in the hospital last week. My work during the week was billed for $3,465.65 and my call day was an additional 1,066.26 according to medicare billing schedules and last week was a typical week for me. So my weekly schedule would generate $180,213.80/yr and if I have 20 weekend call days per year (a little low) that's another $21,325.20 for a total of $201,539. This doesn't include any patients I see in the ED who don't get admitted (we bill for ED consults) or inpatient consults off unit (which we cover on call). So that ~$200k is a low-ball number. There are 3 residents (interns and second years) working under 1 supervising attending on this unit, so if everyone is like me (which they are) then that's ~$600k generated by us. So if our attending made $300k (which he doesn't) and you subtract that from the cost we bring in since that's what it costs to supervise us, then we're still each bringing in about $100k/yr for the hospital. So actually, I can probably say I'm bringing in $100k/yr in addition to that which is covering my supervision for the hospital in exchange for being paid roughly half that.

Cool story, man. I wonder if your attendings would view your work through the same lens if you shared your thoughts with them. Granted I'm no psych expert, but it's interesting to me that a February intern in any specialty would have such a big ego and talk so flippantly about doing admits and high level prog notes and getting his plans tweaked "only" 25% of the time and about how independent he is already. Like, have you even taken your first in training exam that isn't a garbage, practice throwaway one that only interns take? Honestly, those few paragraphs you wrote just now about how valuable you are comprise probably one of the best arguments I've seen against allowing residents to bill.

Psychiatry or not, you have not been doing this long enough to even be capable of any honest self-assessment of your final ability as a physician. As the saying goes, you just don't know what you don't know. I know it's hard to grasp because all interns feel like they're doing a lot of work day in and day out, but let me repeat it so there's no misunderstanding: you are not directly bringing in money because you are not billing the payer for your services. Furthermore, you are operating under your attending's license when s/he signs the notes and s/he is assuming the risk in regard to liability and malpractice. Also, in all likelihood, one attending or one attending + one midlevel could likely do all the work an entire teaching team does on most inpatient services, and likely do it faster and more efficiently.

Staff mid-levels are not trainees and they are credentialed, have their own malpractice, and are billing in whatever fashion (supervised vs unsupervised) the law, their licenses and hospital credentialing allows. As great as you make yourself sound right at this moment, if you were to suddenly leave residency, your contribution to psychiatry would be zero because you would not be allowed to practice psychiatry even with all the tremendous experience you've gotten doing this job for a whopping 7 months. As long as you are billing under someone else's license, stop patting yourself on the back and counting the beans.

 

[nimbus]

Additionally I could go out and get my full license in 4 months and practice with full scope moonlighting or with locums. In fact I plan to do so with a private psych hospital in my area if I'm able to gain program approval for moonlighting. So not completely correct there either.

Sounds like a good option and no big deal. I don’t know why we get desperate posts on SDN from people who are about to be fired/not renewed from their residency.

 

[Stagg737]

Uh, man, I'm the one who just corrected you in the last exchange about how CMS isn't the only game in town when it comes to funding residencies.

Yea, yea. I was using hyperbole before. The private sector funding residencies is just picking up steam over the last 2-3 years and is a relatively new phenomenon with the modern system.

I don't know why you automatically assume the counterfactual that a fragmented, private system would be better at medical education.

Point to where I said that. I didn't. More ridiculous assumptions. Seriously, you have a gift.

your goal of removing govt financial involvement in medical education ever came to fruition.

Again, not something I said, although this assumption actually makes sense. I don't have a goal of removing gov financial involvement, I don't like that the funding comes from the same bucket as medicare/caid, but I fully acknowledge the problems with trying to fund it through the private sector. I honestly do not know what the best solution for this would be, but I feel like there are better options available.

you still haven't addressed the point as to why private corporations haven't stepped up in a big way to start residency programs (instead of just a scattered few here and there) when nothing has been stopping them from doing so for the past 30 years.

I clearly don't know exact reasons, however it would obviously be tied to their ability to profit/margin of profits. What the difference is now vs. then idk but I'm sure it's related to some policy change. Like how they recently made med student notes billable...

Like, have you even taken your first in training exam that isn't a garbage, practice throwaway one that only interns take?

Yep, took PRITE in October. Scored at ~60th percentile nationally for all psychiatry residents (not sure if it included fellows, but also includes combined residents like med/psych) according to my breakdown and much better than that compared to interns. ITE exam seems like a very poor prognosticator for clinical ability in psych though as large portions were neuro and genetics and far less actual clinical psych than I expected. I was disappointed with the exam.

Granted I'm no psych expert, but it's interesting to me that a February intern in any specialty would have such a big ego and talk so flippantly about doing admits and high level prog notes and getting his plans tweaked "only" 25% of the time and about how independent he is already.

It's relatively common in psych for residents, even interns, to work very independently once they have their feet under them. I'm not attempting to sound flippant at all nor am I trying to diminish the role my attendings play in any way as they're obviously far more important, knowledgeable, and essential to my education than I can express. Where I'm at, the residents have a lot of freedom to treat our patients with our own plans so long as we can justify them and our attendings play more of an educational role than babysitting us. If it sounded like I was knocking my attendings' roles in my education or what they do, that's not what I was trying to do at all.

Honestly, those few paragraphs you wrote just now about how valuable you are comprise probably one of the best arguments I've seen against allowing residents to bill.

How so?

Psychiatry or not, you have not been doing this long enough to even be capable of any honest self-assessment of your final ability as a physician. As the saying goes, you just don't know what you don't know. I know it's hard to grasp because all interns feel like they're doing a lot of work day in and day out, but let me repeat it so there's no misunderstanding: you are not directly bringing in money because you are not billing the payer for your services. Furthermore, you are operating under your attending's license when s/he signs the notes and s/he is assuming the risk in regard to liability and malpractice. Also, in all likelihood, one attending or one attending + one midlevel could likely do all the work an entire teaching team does on most inpatient services, and likely do it faster and more efficiently.

Completely agree minus the part about the mid-level given the ones I've worked with or seen plans of. They're terrifying (at least in psych).

Staff mid-levels are not trainees and they are credentialed, have their own malpractice, and are billing in whatever fashion (supervised vs unsupervised) the law, their licenses and hospital credentialing allows. As great as you make yourself sound right at this moment, if you were to suddenly leave residency, your contribution to psychiatry would be zero because you would not be allowed to practice psychiatry even with all the tremendous experience you've gotten doing this job for a whopping 7 months. As long as you are billing under someone else's license, stop patting yourself on the back and counting the beans.

Legally, yea, but that's not really relevant to any of the points I was previously making.

Sounds like a good option and no big deal. I don’t know why we get desperate posts on SDN from people who are about to be fired/not renewed from their residency.

Eh, if I shared the full details of the position you'd probably be thinking otherwise. It's a pretty specific situation and I wouldn't be concerned about losing my license given the job. As I said, I would only pursue something like this after being approved by my program and would ensure they fully understood what this job would entail as it's a bit different. Still, my point was simply that it could be done while you were saying it couldn't. This is also highly variable depending on the field. If one can open up their own PP their employability doesn't matter, only whether they can legally practice and be reimbursed.

 

[deleted480308]

I’m a supporter of single payer healthcare because, to be honest with you, I don’t want the reason for me to continue working full time in my 50s and beyond to be that healthcare is too expensive and I need to wait until I’m eligible for Medicare to cut back or retire.

The bottom line is this, the government has become a tool by which the corporations and rich have continued to concentrate power and wealth. We don’t have a free market. As a result, the middle class in America has suffered. You need a very expensive college degree to even have a shot at covering not only living expenses, but saving for things like retirement and health surprises. Upward social mobility essentially doesn’t exist and many children are worse off than their parents are despite working harder with more education. At some point something has to give.

The opinions on this board, while valuable, don’t mean much in the grand scheme. We all make more than enough money to live comfortably. The majority of Americans support these ideas (including the Republican voters if you talk to them away from the Fox propaganda machine). The majority of Americans are asking for a hand with these big expenses...education and healthcare. It does not seem all that unreasonable for the well off to chip in a bit more for the benefit of our fellow citizens. That ideal is written directly into our Constitution by the founding fathers. It’s not Communism, it’s just good citizenry. Who knows, free up some of people’s capital from the worries of things like healthcare and student debt and you might unlock more young people creativity to create new businesses and a more vibrant economy.

It’s govt that has allowed the huge expansion of cost in those areas. They literally could not have happened without govt making it so

And there is a ton of income mobility. We’ve went through that multiple times in the spf forum

I agree with you that the masses want “free” stuff

 

[VA Hopeful Dr]

I'm still for national social security even if I think FICA taxes should be progressively structured. Just like I'm for federal income tax that's progressively structured and a national health program that can at least provide basic medical care, catastrophic care, and access to required surgeries. Just because I'm not for rash, blanket changes to the programs does not mean I'm not for the programs at all. Breaking these programs up into smaller geographies is ineffective as you can see from what's happened to state administered medicaid. Rich states do OK, poor states get killed. Put the money in the biggest pool possible and then target it where it's needed. Economies of scale can't be beat in many regards.

My concern with this is that it won't play out this way. Who decides what is a required surgery or basic medical care? I could get behind a very bare bones universal coverage plan if I thought it would stay that way. But it won't, because it almost never does. And I get why. In my field, some of the newest and most expensive diabetes drugs actually are the best. They have better outcomes. Should those be denied to people with diabetes? Fiscally, yes. Ethically, probably not.

 

[VA Hopeful Dr]

I’m a supporter of single payer healthcare because, to be honest with you, I don’t want the reason for me to continue working full time in my 50s and beyond to be that healthcare is too expensive and I need to wait until I’m eligible for Medicare to cut back or retire.

The bottom line is this, the government has become a tool by which the corporations and rich have continued to concentrate power and wealth. We don’t have a free market. As a result, the middle class in America has suffered. You need a very expensive college degree to even have a shot at covering not only living expenses, but saving for things like retirement and health surprises. Upward social mobility essentially doesn’t exist and many children are worse off than their parents are despite working harder with more education. At some point something has to give.

The opinions on this board, while valuable, don’t mean much in the grand scheme. We all make more than enough money to live comfortably. The majority of Americans support these ideas (including the Republican voters if you talk to them away from the Fox propaganda machine). The majority of Americans are asking for a hand with these big expenses...education and healthcare. It does not seem all that unreasonable for the well off to chip in a bit more for the benefit of our fellow citizens. That ideal is written directly into our Constitution by the founding fathers. It’s not Communism, it’s just good citizenry. Who knows, free up some of people’s capital from the worries of things like healthcare and student debt and you might unlock more young people creativity to create new businesses and a more vibrant economy.

Part of this is the stupid idea that everyone needs to go to college. They don't. When I had my own practice I did a lot of networking. The folks working blue collar jobs were doing quite well, especially as many started around age 20.

You want to make college affordable again, cap student loan amounts. Colleges charge more because they can get away with it. When I graduated college in 2005, my tuition was 18k. For the 2015 school year, it was 42k. I can promise you that the education is not 2.3X better.

 

[VA Hopeful Dr]

Sounds like a good option and no big deal. I don’t know why we get desperate posts on SDN from people who are about to be fired/not renewed from their residency.

Not all states allow this. Plus it does limit you to less reputable urgent cares, prison med, and off-hours moonlighting for the most part. I got my full licence 3 months into my 2nd year and could have quit and found paid work then and there. But as a BC FP, my opportunities are probably 1000X greater having finished.

 

[deleted171991]

We don't need free college. We need a K-12 system that's way more than extended babysitting while the parents are at work.

We need world-class federally-financed quality K-12 education (which includes REAL science), not the joke we have in many poor areas and redneck states. THAT's equality of opportunity, not free college. As long as we don't fix the school system, college will remain just a semi-useless extension of high school, especially when majoring in "liberal arts" and other useless BS.

We don't need more than 20-30% of the population to go to college; we need more vocational schools, not colleges. We have too many colleges as it is.

 

[vector2]

Yea, yea. I was using hyperbole before. The private sector funding residencies is just picking up steam over the last 2-3 years and is a relatively new phenomenon with the modern system.


Again, not something I said, although this assumption actually makes sense. I don't have a goal of removing gov financial involvement, I don't like that the funding comes from the same bucket as medicare/caid, but I fully acknowledge the problems with trying to fund it through the private sector. I honestly do not know what the best solution for this would be, but I feel like there are better options available.


I clearly don't know exact reasons, however it would obviously be tied to their ability to profit/margin of profits. What the difference is now vs. then idk but I'm sure it's related to some policy change. Like how they recently made med student notes billable...

Exactly, it begs the question of why the private sector did not step in to fund more private residencies when they were free to do so and the market would've allowed it? Are they just not that profitable? Are they only doing some now because there is some niche need which serves a corporate purpose? My hypothesis is that a large amount of residency funding is not lucrative, and keeping medical education unbiased by having a funding source that does not have a profit motive should be of the utmost priority. Look at what has happened with NP schools and CRNA schools. A ton of fly by night diploma mills that are extremely lucrative have popped up and now are literally endangering patient safety because their graduates are so poorly educated and trained. I see no reason why private medical schools (esp many of the new, lower tier DO schools) wouldn't go out of their way to start funding more lower tier residency slots just so that they can attract more poorly qualified medical students who are willing to pay cash cause they know they have a better chance now at a residency slot.

Yep, took PRITE in October. Scored at ~60th percentile nationally for all psychiatry residents (not sure if it included fellows, but also includes combined residents like med/psych) according to my breakdown and much better than that compared to interns. ITE exam seems like a very poor prognosticator for clinical ability in psych though as large portions were neuro and genetics and far less actual clinical psych than I expected. I was disappointed with the exam.

It's relatively common in psych for residents, even interns, to work very independently once they have their feet under them. I'm not attempting to sound flippant at all nor am I trying to diminish the role my attendings play in any way as they're obviously far more important, knowledgeable, and essential to my education than I can express. Where I'm at, the residents have a lot of freedom to treat our patients with our own plans so long as we can justify them and our attendings play more of an educational role than babysitting us. If it sounded like I was knocking my attendings' roles in my education or what they do, that's not what I was trying to do at all.

How so?

Again, I don't know that much about psychiatry training, but what I do know is that the DSM is a massive tome, the journals are dense, and your training program is 4 years long. If you're telling me you have this kind of independence this early on, then why is your program not 3 years long like IM, FM, peds, or many EM residencies?

I remain very cautious and think your description is good argument of why residents shouldn't bill because your self-assessment still seems very egotistical and arrogant to me for someone who is still an intern, and I'm sure there are many other trainees in various other specialties who share your opinions. I have a high degree of caution because in my field, seconds matter and arrogant residents kill people. 100 times out of 100, I would prefer a resident who exhibits very little of the Dunning-Kruger effect, i.e. one who appropriately doubts themselves, frequently calls me about updates and questions etc, as opposed to one who is very confident all the time. I very much dislike working with junior residents who after 1-1.5 years of anesthesia training think they are able to independently perform most anesthetics without attending oversight. If psychiatry is like anesthesia in that major, disastrous complications are still relatively rare, then it is easy to fall into other cognitive biases like the gambler's fallacy where you think, "well, my last 50 pts I treated all did fine and my attending was barely involved so I'm sure the next 50 will be the same."

Legally, yea, but that's not really relevant to any of the points I was previously making.

"Legally" isn't relevant to the point you're making? You legally couldn't practice psychiatry if you left residency right this second, so it is relevant to the context of how you judge your own autonomy and how much money you think you are currently bringing into the hospital. The fully licensed mid-level can leave at any time and go be productive somewhere else. You can't.

 

[vector2]

Point to where I said that. I didn't. More ridiculous assumptions. Seriously, you have a gift.

JFC, you are the king of pedantry.

Let me give you an example of what you're doing:

-----------------
You: Hmm, I don't really prefer reddiwhip because canned whipped cream is a little too sweet

Me: Oh, I guess you must prefer eating the fresh kind because you can control the sugar

You: HAHA! YOU FOOL AND YOUR ASSUMPTIONS! I NEVER LITERALLY SAID "I DON'T EAT REDDIWHIP." WHY WOULD YOU EVER THINK THAT? IN FACT I'M SPRAYING A WHOLE CAN INTO MY MOUTH AS WE SPEAK AND TYPING WITH ONE HAND!
-----------------

This is called arguing in bad faith. I'm able to pry out of you a bunch of wishy washy statements about what you sorta like and don't like vis a vis nationalized or socialized programs but you never really present a foundational position. Perhaps you haven't fully fleshed out your position yet. In either case, it makes it impossible to have any sort of productive discussion because you take whichever side seems more convenient at any given moment regardless of whether you're maintaining any internal consistency throughout the discussion.

 

[BLADEMDA]

I’m a supporter of single payer healthcare because, to be honest with you, I don’t want the reason for me to continue working full time in my 50s and beyond to be that healthcare is too expensive and I need to wait until I’m eligible for Medicare to cut back or retire.

The bottom line is this, the government has become a tool by which the corporations and rich have continued to concentrate power and wealth. We don’t have a free market. As a result, the middle class in America has suffered. You need a very expensive college degree to even have a shot at covering not only living expenses, but saving for things like retirement and health surprises. Upward social mobility essentially doesn’t exist and many children are worse off than their parents are despite working harder with more education. At some point something has to give.

The opinions on this board, while valuable, don’t mean much in the grand scheme. We all make more than enough money to live comfortably. The majority of Americans support these ideas (including the Republican voters if you talk to them away from the Fox propaganda machine). The majority of Americans are asking for a hand with these big expenses...education and healthcare. It does not seem all that unreasonable for the well off to chip in a bit more for the benefit of our fellow citizens. That ideal is written directly into our Constitution by the founding fathers. It’s not Communism, it’s just good citizenry. Who knows, free up some of people’s capital from the worries of things like healthcare and student debt and you might unlock more young people creativity to create new businesses and a more vibrant economy.

We can't afford Medicare for all in the USA. If we adopt such a program the defense budget will need to be slashed.
Taxes will need to be raised significantly. Many Citizens pay nothing for healthcare or next to nothing. The middle class will be taxed very heavily for these programs.

I see the Dems offering a "buy-in" to Medicare for those over 50. That's the likely next step to the update of the ACA/Obamacare. I also see OAC and the Dems figuring out a way to pressure all states into Medicaid expansion.

There isn't enough money in the coffers for the other free stuff. The USA govt. paying for college won't happen in 2020/2021. Maybe, reduced community college costs for those in poverty?

We, as citizens of the USA, first have an obligation to fund the obligations/entitlements on the books before adding more unfunded freebies. This means taxes are going up to just maintain current SS obligations and Medicare funding.

We can't afford more tax cuts or more social programs. We need to act like responsible adults who care about their kids and grandkids futures.

 

[d9sccr]

I love that while advocating for government takeover of college tuition we’re just glossing over the fact that government intervention played a key role if not the pivotal role in the escalating costs of attendance.

As I stated in an earlier post, there’s nothing the federal government doesn’t get involved in that doesn’t result in increased cost and decreased efficiency. The two biggest expenditures for most people in the US also have some of the most government intervention.

 

[d9sccr]

We can't afford Medicare for all in the USA. If we adopt such a program the defense budget will need to be slashed.
Taxes will need to be raised significantly. Many Citizens pay nothing for healthcare or next to nothing. The middle class will be taxed very heavily for these programs.

I see the Dems offering a "buy-in" to Medicare for those over 50. That's the likely next step to the update of the ACA/Obamacare. I also see OAC and the Dems figuring out a way to pressure all states into Medicaid expansion.

There isn't enough money in the coffers for the other free stuff. The USA govt. paying for college won't happen in 2020/2021. Maybe, reduced community college costs for those in poverty?

We, as citizens of the USA, first have an obligation to fund the obligations/entitlements on the books before adding more unfunded freebies. This means taxes are going up to just maintain current SS obligations and Medicare funding.

We can't afford more tax cuts or more social programs. We need to act like responsible adults who care about their kids and grandkids futures.

I wish that were true, but I don’t see spending being reigned in anytime soon. The new consensus seems to be “federal debt doesn’t matter”. Both sides are only increasing costs for differing reasons. At least the republicans have the benefit of growing the economy with it.

There’s a new movement called “The Convention of States” who’s goal in part is to rein in federal spending as well as limiting term limits and making congress live by the laws they’re intent on passing. Seems like something of a long shot but maybe the best shot for citizens to have some actual say in the cluster that is currently D.C.

 

[Stagg737]

Exactly, it begs the question of why the private sector did not step in to fund more private residencies when they were free to do so and the market would've allowed it? Are they just not that profitable? Are they only doing some now because there is some niche need which serves a corporate purpose? My hypothesis is that a large amount of residency funding is not lucrative, and keeping medical education unbiased by having a funding source that does not have a profit motive should be of the utmost priority. Look at what has happened with NP schools and CRNA schools. A ton of fly by night diploma mills that are extremely lucrative have popped up and now are literally endangering patient safety because their graduates are so poorly educated and trained. I see no reason why private medical schools (esp many of the new, lower tier DO schools) wouldn't go out of their way to start funding more lower tier residency slots just so that they can attract more poorly qualified medical students who are willing to pay cash cause they know they have a better chance now at a residency slot.

That all sounds reasonable and share some of the thoughts against why private corporations are probably not the best option for the entire system to move to. As I said, my major qualm with the current system is that I don't like residency funding is coming from the same source as medicare/caid, though I'm not sure what the better funding source would be. One idea I like is funding coming from the state with the promise that residents will remain in state for X years after residency as attendings to ensure the states are getting the right bang for their buck. Many states do this with med school tuition stipends already. Additionally, those states could mandate that residents work in underserved areas for a year or two to ensure patients in need receive healthcare. Wouldn't be that hard to add a clause about that to resident contracts.

Again, I don't know that much about psychiatry training, but what I do know is that the DSM is a massive tome, the journals are dense, and your training program is 4 years long. If you're telling me you have this kind of independence this early on, then why is your program not 3 years long like IM, FM, peds, or many EM residencies?

There have been many pushes to shorten psychiatry in the past. Reasons it hasn't been shortened are many fold. One being that the ACGME requires 12 consecutive months of outpatient clinics to gain experience with continuity of care with outpatients. Our intern year requires us to have at least 2 months of IM and 2 months of neuro, but most programs have significantly more medicine (ours does) during intern year than that. Additionally, there are a lot of possible sub-fields of psych and most programs have a significant amount of electives built in. This is also useful as it allows for 2 year CAP fellowships to be fast-tracked so that one of those years is rolled into residency making the training for CAP a total of 5 years instead of 6 (important because all other psych fellowships are only 1 year and there is a massive CAP shortage). If we wanted to cut out medicine rotations and decrease the amount of dedicated outpatient months to 9 or 6 months you certainly could shorten it to 3 years. However, I don't like that idea because general psychiatrists also commonly treat the full age range of patients from 4-5 year olds to 95 year olds and those on the ends of the age spectrum not only require different dosages or even meds, they have unique sets of diagnoses. So having significant experience working with those populations is important (neither of which I would feel comfortable treating without immediate supervision at this point).

I remain very cautious and think your description is good argument of why residents shouldn't bill because your self-assessment still seems very egotistical and arrogant to me for someone who is still an intern, and I'm sure there are many other trainees in various other specialties who share your opinions. I have a high degree of caution because in my field, seconds matter and arrogant residents kill people. 100 times out of 100, I would prefer a resident who exhibits very little of the Dunning-Kruger effect, i.e. one who appropriately doubts themselves, frequently calls me about updates and questions etc, as opposed to one who is very confident all the time. I very much dislike working with junior residents who after 1-1.5 years of anesthesia training think they are able to independently perform most anesthetics without attending oversight. If psychiatry is like anesthesia in that major, disastrous complications are still relatively rare, then it is easy to fall into other cognitive biases like the gambler's fallacy where you think, "well, my last 50 pts I treated all did fine and my attending was barely involved so I'm sure the next 50 will be the same."

Psychiatry is very different from anesthesia in that sense. It's exceedingly rare when seconds matter in terms of keeping a patient alive and when that is true it's typically because of a behavioral issue on the unit and nothing related to the actual clinical care of the patient. Most of the time when someone is admitted inpatient we could literally let them hang out for days, sometimes weeks, and they will still be fine. Additionally many medication reactions which have to be addressed don't need to be addressed in seconds or even minutes. Additionally, from talking to residents at numerous other programs both on the interview trail and just people I know at other programs, interns having high levels of independence with treatment plans with attendings only making major changes when necessary is pretty normal for this field. So very different from your field. I don't presume to be anywhere near as knowledgeable as my attendings and I certainly still question every decision I make before making them. I've just gotten very good feedback from my attendings thus far in regards to those decisions and am confident enough that I can handle the basic stuff adequately (though not necessarily optimally). I fully recognize the issue of gamblers fallacy and the fact that there is much I don't know, which is why I sactively seek out my attendings with questions. Additionally, I did a pretty excessive number of psych rotations during med school with most being sub-I's (6 total with 4 sub-I's), so I'm slightly ahead of the curve in terms of experience and carrying my own patient load. I'm not sure why I'm really justifying this to you, but I can assure you that I am well-aware of my evals have said in regards to my current level of functioning.

Also, I should clarify that the following statement was probably poorly worded:

At my hospital I see the patient, present to my attending, write the notes, enter the encounter titles, enter billing codes and diagnoses, and sign the notes. Literally the only thing my attendings do are listen to me present the patient, tweak my plan when then feel it's necessary (which is about 25% of the time for me at this point), and sign the note.

I was not implying that this was all my attendings did. I meant that is their primary involvement with the patients I carry (other than supervision and final say in diagnosis and treatment plan obviously). They also have other duties during the day which they perform unrelated to my patients and working with residents allows them to oversee those patients while still being able to perform their other duties. Was not trying to imply that this is all they are doing at their jobs, just that's what they are doing with our specific patients. That's also another way in which we are operating in a similar capacity to mid-levels.

"Legally" isn't relevant to the point you're making? You legally couldn't practice psychiatry if you left residency right this second, so it is relevant to the context of how you judge your own autonomy and how much money you think you are currently bringing into the hospital. The fully licensed mid-level can leave at any time and go be productive somewhere else. You can't.

My point had nothing to do with being able to leave and be productive somewhere else, it had to do with the financial value I bring to the current institution which is why being able to legally practice somewhere else was irrelevant to that point. Though if you want to make the legal argument and say that's the standard we should be using, I'll point you back to my previous argument that in 4-5 months I will legally be allowed to go moonlight or take locums positions and work independently. Also, in the state I currently live in one is only required to pass Step 3 and 1 year of PGY training to be able to practice independently. So in this state I could leave residency in 4-5 months and legally opened shop if I wanted to. To be clear so no assumptions are made, I will not be doing that for obvious reasons.

In regards to your posts about assumptions, you've made some very bad ones. Assuming that someone doesn't care about charity because they don't want to accept Medicare is a pretty huge jump. Assuming that because I don't like that funding comes from CMS means I automatically think the private sector is the only option is a pretty huge jump.

I won't continue discussing the aspects of my residency or employability further since I think we've derailed the thread enough. I'm fine with continuing to discuss residency funding as that at least seems to peripherally relate to Bernie and views on healthcare funding.

 

[vector2]

That all sounds reasonable and share some of the thoughts against why private corporations are probably not the best option for the entire system to move to. As I said, my major qualm with the current system is that I don't like residency funding is coming from the same source as medicare/caid, though I'm not sure what the better funding source would be. One idea I like is funding coming from the state with the promise that residents will remain in state for X years after residency as attendings to ensure the states are getting the right bang for their buck. Many states do this with med school tuition stipends already. Additionally, those states could mandate that residents work in underserved areas for a year or two to ensure patients in need receive healthcare. Wouldn't be that hard to add a clause about that to resident contracts.

The issue of states funding residencies is tangentially related to what I was discussing before in regard to how medicaid (in contrast to medicare) has been a disaster in many places primarily because it is 1/2 state-administered. Wealthier states likes Virginia and Connecticut have no problem with making sure medicaid is accessible, poorer states like Alabama and Mississippi have their budgets hit much harder and have many more shortfalls and coverage gaps. It's a double whammy because the people of poorer states like AL and MS are by far unhealthier than those in richer ones. Actually, it's a triple whammy because Southern conservative states also mostly didn't accept the ACA medicaid expansion and now have much larger coverage gaps (pts make too much for medicaid, not enough for insurance) than neighboring states.

My guess is that this phenomenon would carry over to residency training as well. Richer states would be flush with spots, poorer states and their citizens would likely suffer from lack of physicians who train there and stay there to practice.

There have been many pushes to shorten psychiatry in the past. Reasons it hasn't been shortened are many fold. One being that the ACGME requires 12 consecutive months of outpatient clinics to gain experience with continuity of care with outpatients. Our intern year requires us to have at least 2 months of IM and 2 months of neuro, but most programs have significantly more medicine (ours does) during intern year than that. Additionally, there are a lot of possible sub-fields of psych and most programs have a significant amount of electives built in. This is also useful as it allows for 2 year CAP fellowships to be fast-tracked so that one of those years is rolled into residency making the training for CAP a total of 5 years instead of 6 (important because all other psych fellowships are only 1 year and there is a massive CAP shortage). If we wanted to cut out medicine rotations and decrease the amount of dedicated outpatient months to 9 or 6 months you certainly could shorten it to 3 years. However, I don't like that idea because general psychiatrists also commonly treat the full age range of patients from 4-5 year olds to 95 year olds and those on the ends of the age spectrum not only require different dosages or even meds, they have unique sets of diagnoses. So having significant experience working with those populations is important (neither of which I would feel comfortable treating without immediate supervision at this point).



Psychiatry is very different from anesthesia in that sense. It's exceedingly rare when seconds matter in terms of keeping a patient alive and when that is true it's typically because of a behavioral issue on the unit and nothing related to the actual clinical care of the patient. Most of the time when someone is admitted inpatient we could literally let them hang out for days, sometimes weeks, and they will still be fine. Additionally many medication reactions which have to be addressed don't need to be addressed in seconds or even minutes. Additionally, from talking to residents at numerous other programs both on the interview trail and just people I know at other programs, interns having high levels of independence with treatment plans with attendings only making major changes when necessary is pretty normal for this field. So very different from your field. I don't presume to be anywhere near as knowledgeable as my attendings and I certainly still question every decision I make before making them. I've just gotten very good feedback from my attendings thus far in regards to those decisions and am confident enough that I can handle the basic stuff adequately (though not necessarily optimally). I fully recognize the issue of gamblers fallacy and the fact that there is much I don't know, which is why I sactively seek out my attendings with questions. Additionally, I did a pretty excessive number of psych rotations during med school with most being sub-I's (6 total with 4 sub-I's), so I'm slightly ahead of the curve in terms of experience and carrying my own patient load. I'm not sure why I'm really justifying this to you, but I can assure you that I am well-aware of my evals have said in regards to my current level of functioning.

Also, I should clarify that the following statement was probably poorly worded:


I was not implying that this was all my attendings did. I meant that is their primary involvement with the patients I carry (other than supervision and final say in diagnosis and treatment plan obviously). They also have other duties during the day which they perform unrelated to my patients and working with residents allows them to oversee those patients while still being able to perform their other duties. Was not trying to imply that this is all they are doing at their jobs, just that's what they are doing with our specific patients. That's also another way in which we are operating in a similar capacity to mid-levels.



My point had nothing to do with being able to leave and be productive somewhere else, it had to do with the financial value I bring to the current institution which is why being able to legally practice somewhere else was irrelevant to that point. Though if you want to make the legal argument and say that's the standard we should be using, I'll point you back to my previous argument that in 4-5 months I will legally be allowed to go moonlight or take locums positions and work independently. Also, in the state I currently live in one is only required to pass Step 3 and 1 year of PGY training to be able to practice independently. So in this state I could leave residency in 4-5 months and legally opened shop if I wanted to. To be clear so no assumptions are made, I will not be doing that for obvious reasons.

Interesting synopsis of your training, thanks for sharing. I am glad that you are able to recognize some of your limitations even though psych appears to have greater autonomy sooner than most specialties. I want to clarify that I am not saying that you do not bring any value to the practice. My main point is that say you are responsible as an intern for $180k worth of CPT codes filed, your value to the hospital is still significantly less than that. No matter your degree of independence, the total amount of your value (even though you billed that much) was not $180k because as I said before, you are not privileged or licensed to practice psychiatry independently, you still had to be supervised and did not perform 100% of the assessment and plan solo, you are not capable of dealing with all the unforeseen emergencies or strange complexities solo, and you are not considering what attending level malpractice costs. Not to mention, presumably a solo attending or attending + MLP could likely do all the work of the a resident team faster/more efficiently.

But to get back to the main topic at end, aka federal funding of residencies and any overarching policy of allowing residents to bill and thus reduce the number of federal dollars required, I think this most recent line of discussion is more evidence for why coming up with a comprehensive resident billing policy is for all intents and purposes impossible. We've gone back and forth with 5000 words about the independence/billing intricacies of one resident in one specialty (psych) who is at one particular PGY level (1). We haven't even talked about what the variation is like nationally if one were to consider all US psychiatry interns. Can you even imagine the infeasibility of trying to come up with an appropriate billing scheme for 150,000 residents at various PGY levels across 120 different specialties and subspecialties?

In regards to your posts about assumptions, you've made some very bad ones. Assuming that someone doesn't care about charity because they don't want to accept Medicare is a pretty huge jump. Assuming that because I don't like that funding comes from CMS means I automatically think the private sector is the only option is a pretty huge jump.

Well, I guess that's your opinion. Please feel free to be more direct in what you actually believe and don't believe vis a vis a policy level and I'm sure we can avoid any future misunderstanding.

 

[medschoolzombie]

The “road to hell is paved with good intentions.” Does anyone REALLY think, that even under the most PERFECT of circumstances, that there’s not going to ALWAYS be a certain percentage of the populace (10-20% ????) that is going to be “disadvantaged” or “poor”?? Perhaps it’s due to mental illness? Maybe drug abuse? Lack of education or the mental ability to be adequately educated? Maybe just pure “laziness”??

Are we going to drag down the entire country, and put everyone into a “one size fits all” system of healthcare/education/high taxation, with overly complex and expensive schemes, merely in hopes of reaching the unattainable goal of 100% “prosperity” and “good health”??? Perhaps consider acknowledging that a prosperous ECONOMY (lots of jobs, reasonable taxes, deregulation) would allow us to take care of “most” of these ills? Rather than choking taxpayers/industry/etc to death, a strong ECONOMY could work just as well, without killing folks’ freedom/independence/work ethic in the process.

Remember when churches and charities used to help folks and build hospitals, and could do so, because they were flush with cash from successful American workers? The same applies to the Govt’s tax “coffers” if employment is high with good jobs. Do you take a “few” of the goose’s “golden eggs”, or do you take so many, that she just gives up, gets depressed, and stops laying???

Until we completely get rid of capitalism, a certain percentage of the population will always be poor/disadvantaged. That’s just the nature of the system. What we’re trying to do now is keep the ‘good’ parts of a capitalist system while adding more socialist elements and expecting it to trump the negative effects of capitalism.

To be fair though, if churches and the like really wanted to find hospitals, help the poor etc, they could. Churches are some of the wealthiest organizations in the country. In a lot of those mega churches, it’s leaders get paid millions, yet claim they’re a nonprofit

We don't need free college. We need a K-12 system that's way more than extended babysitting while the parents are at work.

We need world-class federally-financed quality K-12 education (which includes REAL science), not the joke we have in many poor areas and redneck states. THAT's equality of opportunity, not free college. As long as we don't fix the school system, college will remain just a semi-useless extension of high school, especially when majoring in "liberal arts" and other useless BS.

We don't need more than 20-30% of the population to go to college; we need more vocational schools, not colleges. We have too many colleges as it is.

This reads as: we need to get the rural parts of America urbanized which I agree with. You’ll notice that a lot of those issues happen in poorer states with less urbanized areas, with state govts that heavily subsidize coal lords and those type of industries

 

[Stagg737]

The issue of states funding residencies is tangentially related to what I was discussing before in regard to how medicaid (in contrast to medicare) has been a disaster in many places primarily because it is 1/2 state-administered. Wealthier states likes Virginia and Connecticut have no problem with making sure medicaid is accessible, poorer states like Alabama and Mississippi have their budgets hit much harder and have many more shortfalls and coverage gaps. It's a double whammy because the people of poorer states like AL and MS are by far unhealthier than those in richer ones. Actually, it's a triple whammy because Southern conservative states also mostly didn't accept the ACA medicaid expansion and now have much larger coverage gaps (pts make too much for medicaid, not enough for insurance) than neighboring states.

My guess is that this phenomenon would carry over to residency training as well. Richer states would be flush with spots, poorer states and their citizens would likely suffer from lack of physicians who train there and stay there to practice.

I can see how richer states would benefit more from such a system, but there are also holes with the current one anyway even after expansion of medicaid. I know a few people who ended up falling in the coverage gap in my home state (which had significant medicaid expansion) including myself. The kicker was that when I was 22 I purchased my own insurance, then the ACA kicked in, then I went on my parents because prices went up (and my plan disappeared), and after I turned 26 the rates for a similar plan to mine had skyrocketed. Anecdotal, but from personal experience and experience of several friends even with expansion we got completely screwed. So not something unique to those conservative states, but I guess maybe worse for them. Idk, the more conservative state I'm in now is doing far better than the very liberal one I grew up in.

My bigger question would be which model would allow rural and severely underserved urban areas to receive better access to care though? I think with the state funded plan it gives the option of basically hand-cuffing people to do some care for more rural areas as state funding can be reallocated based on which programs' contracts create clauses to provide those services. Not something that can really be done so easily with funding coming from the national level. Additionally the potential argument that those spots wouldn't attract as many applicants is somewhat moot because as you pointed out there are many more total applicants that positions when including international applicants.

But to get back to the main topic at end, aka federal funding of residencies and any overarching policy of allowing residents to bill and thus reduce the number of federal dollars required, I think this most recent line of discussion is more evidence for why coming up with a comprehensive resident billing policy is for all intents and purposes impossible. We've gone back and forth with 5000 words about the independence/billing intricacies of one resident in one specialty (psych) who is at one particular PGY level (1). We haven't even talked about what the variation is like nationally if one were to consider all US psychiatry interns. Can you even imagine the infeasibility of trying to come up with an appropriate billing scheme for 150,000 residents at various PGY levels across 120 different specialties and subspecialties?

I cannot, which is largely why I think a system in which the income is simply based on residents billing for their services is so flawed. I do not prefer to go back to the dark days of legitimate residency where the residents actually lived in the hospital and were compensated almost nothing (and in some cases legitimately nothing in terms of salary). However, I also feel like you could implement a model for resident billing that would make sense. Such as lowering the amount of the subsidy to programs which residents are given but allowing residents to bill and keep X% of their production. This way could potentially decrease the amount of subsidy needed to be contributed by the public, residents could bill and be encouraged to learn the reimbursement system and efficiency more, residents could have greater control over their earnings, and hospitals could collect for residents billing. Not sure how well that would work across all specialties, but would decrease the CMS funding being used since attendings are billing and hospitals gain revenue based off our work anyway.

I also don't find it that much less feasible than the cluster**** of a billing scheme used in the US today anyway (and this is coming from someone who used to work in healthcare administration before med school).

Well, I guess that's your opinion. Please feel free to be more direct in what you actually believe and don't believe vis a vis a policy level and I'm sure we can avoid any future misunderstanding.

I'll try to when able, but as you alluded to earlier I don't have solid ideas for what I think would actually work for many aspects of the system as it is. I'm pretty good at picking apart systems/plans and finding flaws with them and coming up with patchwork solutions are oftentimes simple but just serve to create an even more convoluted system than was started with. So when it comes to major overhauls and plans, I don't share many of those ideas. Mostly because if I can pick my own ideas apart myself then I don't think it's a great plan and probably not worth discussing.

 

[deleted162650]

Until we completely get rid of capitalism, a certain percentage of the population will always be poor/disadvantaged.

You’re right. Then we can all be poor and disadvantaged.

 

[deleted480308]

Until we completely get rid of capitalism, a certain percentage of the population will always be poor/disadvantaged. That’s just the nature of the system. What we’re trying to do now is keep the ‘good’ parts of a capitalist system while adding more socialist elements and expecting it to trump the negative effects of capitalism.

To be fair though, if churches and the like really wanted to find hospitals, help the poor etc, they could. Churches are some of the wealthiest organizations in the country. In a lot of those mega churches, it’s leaders get paid millions, yet claim they’re a nonprofit



This reads as: we need to get the rural parts of America urbanized which I agree with. You’ll notice that a lot of those issues happen in poorer states with less urbanized areas, with state govts that heavily subsidize coal lords and those type of industries

Religious groups do a ton of charity

 

[Stagg737]

We don't need free college. We need a K-12 system that's way more than extended babysitting while the parents are at work.

We need world-class federally-financed quality K-12 education (which includes REAL science), not the joke we have in many poor areas and redneck states. THAT's equality of opportunity, not free college. As long as we don't fix the school system, college will remain just a semi-useless extension of high school, especially when majoring in "liberal arts" and other useless BS.

We don't need more than 20-30% of the population to go to college; we need more vocational schools, not colleges. We have too many colleges as it is.

I agree with everything here except the bolded. I went to a liberal arts college for UG and the whole premise of that degree is not the subject matter, it's to teach an individual to think critically about various situations from multiple perspectives. My favorite college class ever was called science and pseudoscience; the whole point of it was to break down illogical thought processes and fallacies and understand why those ways of thinking permeated through our society and even with scientists. We studied UFOs and aliens, homeopathy, mythology, paranormal phenonena, etc. The subject matter wasn't the point, the thought process was. Being able to utilize that kind of thought process is essential and in my science courses it helped me understand how to breakdown research papers and find the shortcomings and true strong points better.

The problem with liberal arts colleges and degrees comes when the focus is on the material itself and not the thought process, which I feel is becoming more and more pervasive in our society as a whole. Having a degree in philosophy is pretty useless today if you actually want to become a philosopher, but the thought process can give you a leg up in almost any field you enter. I do agree that we have too many of these types of schools though and I also believe that we should be starting to teach these concepts in high school. I said this before that college is the new high school, just a lot more expensive.

 

[deleted171991]

I agree with everything here except the bolded. I went to a liberal arts college for UG and the whole premise of that degree is not the subject matter, it's to teach an individual to think critically about various situations from multiple perspectives. My favorite college class ever was called science and pseudoscience; the whole point of it was to break down illogical thought processes and fallacies and understand why those ways of thinking permeated through our society and even with scientists. We studied UFOs and aliens, homeopathy, mythology, paranormal phenonena, etc. The subject matter wasn't the point, the thought process was. Being able to utilize that kind of thought process is essential and in my science courses it helped me understand how to breakdown research papers and find the shortcomings and true strong points better.

The problem with liberal arts colleges and degrees comes when the focus is on the material itself and not the thought process, which I feel is becoming more and more pervasive in our society as a whole. Having a degree in philosophy is pretty useless today if you actually want to become a philosopher, but the thought process can give you a leg up in almost any field you enter. I do agree that we have too many of these types of schools though and I also believe that we should be starting to teach these concepts in high school. I said this before that college is the new high school, just a lot more expensive.

Be my guest to study UFOs and aliens, homeopathy etc. just not on public money. A (free) college should prepare an individual for the real world, not the Matrix.

Nobody pays you nowadays just to think; they pay you to both know and think; hence a BS in BS is worthless, a BS in a STEM field is not.

Btw, I was never formally taught how to analyze research papers. I had a great (and free) K-12 education, with outstanding science teachers. THAT's where I was taught to think (in general). Then I went to a 6-year medical school (for free), without wasting time and money on a lot of useless college stuff. Then I learned how to analyze research papers on my own, and saved another $100K in the process.

 

[Stagg737]

Be my guest to study UFOs and aliens, homeopathy etc. just not on public money. A (free) college should prepare an individual for the real world, not the Matrix.

Nobody pays you nowadays just to think; they pay you to both know and think; hence a BS in BS is worthless, a BS in a STEM field is not.

Btw, I was never formally taught how to analyze research papers. I had a great (and free) K-12 education, with outstanding science teachers. THAT's where I was taught to think (in general). Then I went to a 6-year medical school (for free), without wasting time and money on a lot of useless college stuff. Then I learned how to analyze research papers on my own, and saved another $100K in the process.

Disagree that such a degree would not prepare an individual for the real world. Simply because there are values to learning how to approach problems, especially recognizing flaws or holes in our own thought processes, that most (perhaps all) individuals will not find on their own. Disagree that no one is paid to just think, plenty of people in media, writing, politics, etc who are paid to do nothing other than share their thoughts effectively. Even disregarding that, learning how to utilize thought processes appropriately can make you more effective at what you do regardless of field. It's why most med school admissions boards value individuals who get degrees outside of biology and chemistry, because they're not robots that just learn facts and algorithms and regurgitate them.

Can an individual do that on their own? Yes. Does it also help to be able to show that shiny piece of paper that says you can do it? Absolutely.

Again though, I agree with your previous point that there are too many colleges and that oftentimes liberal arts colleges aren't actually accomplishing what I stated above, but rather indoctrinating their students to think in a specific way that actually discourages critical thinking. In those cases I 100% agree those degrees are a waste of everyone's time and resources.

 

[GravelRider]

We can't afford Medicare for all in the USA. If we adopt such a program the defense budget will need to be slashed.
Taxes will need to be raised significantly. Many Citizens pay nothing for healthcare or next to nothing. The middle class will be taxed very heavily for these programs.

I see the Dems offering a "buy-in" to Medicare for those over 50. That's the likely next step to the update of the ACA/Obamacare. I also see OAC and the Dems figuring out a way to pressure all states into Medicaid expansion.

There isn't enough money in the coffers for the other free stuff. The USA govt. paying for college won't happen in 2020/2021. Maybe, reduced community college costs for those in poverty?

We, as citizens of the USA, first have an obligation to fund the obligations/entitlements on the books before adding more unfunded freebies. This means taxes are going up to just maintain current SS obligations and Medicare funding.

We can't afford more tax cuts or more social programs. We need to act like responsible adults who care about their kids and grandkids futures.

Bernie Sanders’ platform is neither the right answer in its pure form nor will it ever be brought into law because of a branch of government called Congress. Every politician should go into this knowing that they will have to compromise on some areas because we have a large and diverse country. However, Bernie Sanders is focusing on issues that matter to a lot of Americans, not just the well off. I’m willing to hear a legitimate proposal from the Republicans to address things like $1.5 trillion in student debt or how to make healthcare affordable...things that matter to the middle class. Instead any Republican agenda involves fear-based politics...whether that’s fear of the government seizing your guns and property or fear of “the others,” whether that be immigrants or shemales. We have been doing it this way for decades now and all that has happened is a shrinking middle class and enormous wealth disparity aided by the government. I would love for a Republican to put forward some ideas on how to address these issues, but instead it always comes back to immigrants. I don’t blame them because it works to get their base motivated, and the Democrats keep taking that bait. The only candidate who has steered safely away from the fear-issues and focused on things that really matter is Bernie Sanders, which is why I think he has a more legitimate shot in the general election than any other Democrat.

Our current President has based his entire agenda on building a silly wall, a more enormous waste of taxpayer money does not exist.

 

[VA Hopeful Dr]

Bernie Sanders’ platform is neither the right answer in its pure form nor will it ever be brought into law because of a branch of government called Congress. Every politician should go into this knowing that they will have to compromise on some areas because we have a large and diverse country. However, Bernie Sanders is focusing on issues that matter to a lot of Americans, not just the well off. I’m willing to hear a legitimate proposal from the Republicans to address things like $1.5 trillion in student debt or how to make healthcare affordable...things that matter to the middle class. Instead any Republican agenda involves fear-based politics...whether that’s fear of the government seizing your guns and property or fear of “the others,” whether that be immigrants or shemales. We have been doing it this way for decades now and all that has happened is a shrinking middle class and enormous wealth disparity aided by the government. I would love for a Republican to put forward some ideas on how to address these issues, but instead it always comes back to immigrants. I don’t blame them because it works to get their base motivated, and the Democrats keep taking that bait. The only candidate who has steered safely away from the fear-issues and focused on things that really matter is Bernie Sanders, which is why I think he has a more legitimate shot in the general election than any other Democrat.

Our current President has based his entire agenda on building a silly wall, a more enormous waste of taxpayer money does not exist.

Shrinking middle class you say?

Yes, the US middle class is shrinking, but it's because Americans are moving up. And no, Americans are not struggling to afford a home. - AEI

 

[deleted480308]

Bernie Sanders’ platform is neither the right answer in its pure form nor will it ever be brought into law because of a branch of government called Congress. Every politician should go into this knowing that they will have to compromise on some areas because we have a large and diverse country. However, Bernie Sanders is focusing on issues that matter to a lot of Americans, not just the well off. I’m willing to hear a legitimate proposal from the Republicans to address things like $1.5 trillion in student debt or how to make healthcare affordable...things that matter to the middle class. Instead any Republican agenda involves fear-based politics...whether that’s fear of the government seizing your guns and property or fear of “the others,” whether that be immigrants or shemales. We have been doing it this way for decades now and all that has happened is a shrinking middle class and enormous wealth disparity aided by the government. I would love for a Republican to put forward some ideas on how to address these issues, but instead it always comes back to immigrants. I don’t blame them because it works to get their base motivated, and the Democrats keep taking that bait. The only candidate who has steered safely away from the fear-issues and focused on things that really matter is Bernie Sanders, which is why I think he has a more legitimate shot in the general election than any other Democrat.

Our current President has based his entire agenda on building a silly wall, a more enormous waste of taxpayer money does not exist.

The way to stop student loan debt problems is to stop backing it via govt and make loans dischargeable in bankruptcy.

To be clear this absolutely drastically reduce availability of loans to degrees that don’t demonstrate clear ability to generate an income later and that is a good thing

 

[BLADEMDA]

FYI, the majority of CRNAs are considered upper income:

 

[vector2]

I can see how richer states would benefit more from such a system, but there are also holes with the current one anyway even after expansion of medicaid. I know a few people who ended up falling in the coverage gap in my home state (which had significant medicaid expansion) including myself. The kicker was that when I was 22 I purchased my own insurance, then the ACA kicked in, then I went on my parents because prices went up (and my plan disappeared), and after I turned 26 the rates for a similar plan to mine had skyrocketed. Anecdotal, but from personal experience and experience of several friends even with expansion we got completely screwed. So not something unique to those conservative states, but I guess maybe worse for them. Idk, the more conservative state I'm in now is doing far better than the very liberal one I grew up in.

My bigger question would be which model would allow rural and severely underserved urban areas to receive better access to care though? I think with the state funded plan it gives the option of basically hand-cuffing people to do some care for more rural areas as state funding can be reallocated based on which programs' contracts create clauses to provide those services. Not something that can really be done so easily with funding coming from the national level. Additionally the potential argument that those spots wouldn't attract as many applicants is somewhat moot because as you pointed out there are many more total applicants that positions when including international applicants.

No doubt you had a terrible experience, and the gaps still exist everywhere regardless of medicaid expansion which is why the ACA isn't super popular with the far left, either. Anecdotally, we will be able to find people who fell into the dreaded gap in both medicaid expansion and non-expansion states. However, if we look at the data (and again, why I harp that larger policy initiatives is where you get your bang for the buck), the uninsured rate in expansion states was 9.1% in 2017 whereas it was 15.9% in non-expansion states.

Your bigger question of which model would allow for better rural and underserved access is answered better by first talking about having everyone insured (preferably with a policy that reimburses at a good rate), and then moving on to the question of targeting how residency training is funded. It does no good to handcuff providers to a geographic region if the populace there still remains uninsured. However, putting aside the question of insured %, I think you will still run into the same issue where poorer states will still require a federal subsidy to create a "hand-cuff" rule for their medical trainees (refer above to the infographic of the states that receive more from the federal govt than they contribute in taxes).

I cannot, which is largely why I think a system in which the income is simply based on residents billing for their services is so flawed. I do not prefer to go back to the dark days of legitimate residency where the residents actually lived in the hospital and were compensated almost nothing (and in some cases legitimately nothing in terms of salary). However, I also feel like you could implement a model for resident billing that would make sense. Such as lowering the amount of the subsidy to programs which residents are given but allowing residents to bill and keep X% of their production. This way could potentially decrease the amount of subsidy needed to be contributed by the public, residents could bill and be encouraged to learn the reimbursement system and efficiency more, residents could have greater control over their earnings, and hospitals could collect for residents billing. Not sure how well that would work across all specialties, but would decrease the CMS funding being used since attendings are billing and hospitals gain revenue based off our work anyway.

I also don't find it that much less feasible than the cluster**** of a billing scheme used in the US today anyway (and this is coming from someone who used to work in healthcare administration before med school).

No doubt that we currently have a clusterf*ck billing scheme as it stands, but it's much easier to handwave a statement like or merely propose a thought-experiment like "I also feel like you could implement a model for resident billing that would make sense" than to actually even start the legwork of making a policy like that a reality. Don't get me wrong, I would've loved to have billed and made >100k as a PGY 4 anesthesia resident, but until I see some kind of proposal on paper that specifically addresses the question of handling tens of thousands of residents across multiple PGY and multiple specialties, it remains a pipedream to me and we should be working to make existing resident funding sources better.

I'll try to when able, but as you alluded to earlier I don't have solid ideas for what I think would actually work for many aspects of the system as it is. I'm pretty good at picking apart systems/plans and finding flaws with them and coming up with patchwork solutions are oftentimes simple but just serve to create an even more convoluted system than was started with. So when it comes to major overhauls and plans, I don't share many of those ideas. Mostly because if I can pick my own ideas apart myself then I don't think it's a great plan and probably not worth discussing.

Indeed, it's also much easier for me to pick apart the implementation of current systems than try to propose a coherent alternative.

 

[jw3600]

Somehow and Sociopolitical Forum topic has made it over to the Anesthesiology Forum......if @Arch Guillotti did his thing I wouldn't miss it

Is this you implying this thread is off topic and should be moved/closed? I don’t understand this kind of complaint. Why don’t you simply not open the thread?

 

[XWing5000]

Little off topic, but how will free college education impact people from joining the military for the GI. Bill?