Dear AMA, I quit!

[austinap]

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http://www.huffingtonpost.com/dr-chris-mccoy/dear-ama-i-quit_b_214318.html

 

[Perrotfish]

This has not been the case with the creation of public police forces in the second half of the 1800's (private security companies still exist), we have a robust system of public and private colleges existing the same market, and bookstores still sell books despite the presence of public libraries. A mix of public and private enterprises in the market is a truly American solution to ensuring equal access, as well as competition to drive quality improvement

For me, this was the key piece of double-think in the article. The author is trying to make it sound like we have a 50/50 mix of competent public and private options in all markets. What we really have is a system where all the rich people all go private and the middle class and poor people are basically all forced into the public option. While this is better than nothing for the truely poor, it is extremely grating for the middle class who, if they were taxed a bit less, might have been able to afford the private option that the rich currently enjoy.

What I find most annoying about Obama's health care proposal is not the wealth redistribution (honestly I think that's reasonable) but rather that he's so clearly setting it up so that his family will never have to participate in the government run health care option. In 10 years when his children are sick they will take a day off from their private schools, drive from their gated communities guarded by private security, and will drive to their doctor who will see them immediatlely because they have private helath insurance. I am sure if his children need a book to read while they recover they will also certainly buy a new one at Barnes and Noble. Meanwhile working middle class citizens will find that there isn't enough in the budget to pay for both public and private insurance (just as there isn't enough to pay for public and private schools) and will get stuck with whatever third world looking disaster our government cobbles together, even though before they were capable of paying for private insurance in what is (if you're insured) probably the best health care system in the world. This just seems too much like when he magnanamously killed the district of Columbia's school voucher program, and then refused to send his children to the same public schools.

If we are going to have public health care, and I think we should, I believe there are 2 reasonable options:

1) Go the Canada/UK route and force everyone to use a nationalized public system.

or

2) Healthcare vouchers for private insurance.

I'm surprised no one seems to be suggesting option 2, since it was such a major Republican talking point for education, but I'd be fine with either. What I really DON'T want is yet another government system where the people forcing it on me 'for my own good' refuse to participate themselves.

 

[Excelsius]

...What we really have is a system where all the rich people all go private and the middle class and poor people are basically all forced into the public option. ...

I agree. If this is not implemented properly, we are going to have a two-tier healthcare in America. The best and smartest doctors will not accept insurance and will work only for the rich. The leftovers will be left to the public. One thing that is not clear is how highly specialized doctors, like Orthos, will do in this market. There aren't that many of them anyway and if any large percentage goes completely private, I don't know who is going to be left to cover for the universal healthcare patients. I am not really against the general concept, but I am against having it affect the doctor salaries in any significant way. I have read at some places where economists argue that it is not the doctor salaries that drive up the healthcare costs. It is important to implement cuts that are high yield, such as system wide changes that will affect the overhead and changes in laws that will put in an end to unnecessary triple tests for the fear of litigation. This will affect the malpractice insurance as well.

Here is an interesting article about what might happen if this plan backfires: Japan Doctors Say New Health Funding Won't End Death-by-Delay

Japan's plan to spend an extra $1.4 billion on hospital doctors won't alleviate the shortage of staff causing treatment delays and fatalities, doctors said.
...
The low pay and long shifts have left hospitals short-staffed nationwide, resulting in a case in August when a woman with labor complications lost her baby after she was refused treatment at 10 hospitals that said no doctors were available.
...
In 2006, 667 women in labor were turned away by more than three hospitals because of a lack of doctors, government records show.
...
More patients are seeking hospital care as Japan's society ages. Older patients have greater medical needs to treat heart disease, stroke, dementia and other chronic conditions, leaving fewer resources for emergencies such as heart attack and obstructed labor.
...
The Asahi said it contacted all 205 emergency centers in Japan and received response from 187. One hospital in Hokkaido had to close its emergency room because all the doctors quit, the newspaper said.

​

Universal healthcare can hardly work if it is not done properly. In UK, were things are more or less ok, the doctor salaries were significantly increased in 2005 and in some cases the doctors there make more than in the US. Also keep in mind that when you look at European or Canadian salaries the overhead and the malpractice insurance is nowhere near as high as in the USA.

 

[austinap]

For me, this was the key piece of double-think in the article. The author is trying to make it sound like we have a 50/50 mix of competent public and private options in all markets. What we really have is a system where all the rich people all go private and the middle class and poor people are basically all forced into the public option. While this is better than nothing for the truely poor, it is extremely grating for the middle class who, if they were taxed a bit less, might have been able to afford the private option that the rich currently enjoy.

What I find most annoying about Obama's health care proposal is not the wealth redistribution (honestly I think that's reasonable) but rather that he's so clearly setting it up so that his family will never have to participate in the government run health care option. In 10 years when his children are sick they will take a day off from their private schools, drive from their gated communities guarded by private security, and will drive to their doctor who will see them immediatlely because they have private helath insurance. I am sure if his children need a book to read while they recover they will also certainly buy a new one at Barnes and Noble. Meanwhile working middle class citizens will find that there isn't enough in the budget to pay for both public and private insurance (just as there isn't enough to pay for public and private schools) and will get stuck with whatever third world looking disaster our government cobbles together, even though before they were capable of paying for private insurance in what is (if you're insured) probably the best health care system in the world. This just seems too much like when he magnanamously killed the district of Columbia's school voucher program, and then refused to send his children to the same public schools.

If we are going to have public health care, and I think we should, I believe there are 2 reasonable options:

1) Go the Canada/UK route and force everyone to use a nationalized public system.

or

2) Healthcare vouchers for private insurance.

I'm surprised no one seems to be suggesting option 2, since it was such a major Republican talking point for education, but I'd be fine with either. What I really DON'T want is yet another government system where the people forcing it on me 'for my own good' refuse to participate themselves.

I agree with most of what you say in the top half of your post, but that seems to be mostly a rant against the way our government / country is set up. The same could be said of almost any example where government representatives are voting in place of the public - typically, they vote for or against things that they will never have to actually deal with, or they can vote themselves out of any situation they want to. What other job gets to vote on their own pay raises?

However, I don't think that was the main point of this article. I thought there were two major points. The first is that the AMA is being disingenuous with its criticisms of public health care plans. While there are certainly a lot of valid arguments against any of these sorts of plans, the AMA comes across as only concerned about physician's salaries and not about the state of medicine in this country. To me, the AMA is supposed to represent a sort of quality control system for medicine in this country, allowing doctors to have a collective voice. More and more, the organization comes across as just being a labor union for doctors.

The second point I take away is this - there is now a huge driving force for some massive improvement in health care in this country. The statistics are horrifying - we pay 35% more than any comparable European country per capita, yet we have the worst scores on all of the benchmarks - average life span, infant mortality rate, you name it. Whether or not doctors are OK with that (I think they shouldn't be, but that's a different discussion) doesn't really matter, the point is that the public isn't ok with it. If doctors aren't willing to play a part in fixing things, they're going to get screwed. By not helping bring about a demanded change, physicians are going to lose any voice they might have had in the change that inevitably will come. It shouldn't be impossible to come up with a system that works reasonably well for all parties.

 

[Secondary Gain]

I've never understood what's so evil about having an organization that defends the interests of physicians. Every other interest group has an organization to defend its own interests (AHA, PHARMA, ABA); physicians should as well. People like Dr. McCoy seem to think in black and white - we are either money grubbing profiteers or we are altruistic "good doctors". In reality most of us are somewhere in between, just like our patients: we want to be paid a comfortable salary in exchange for a lifetime of hard work. If we stick together and defend our interests in the coming healthcare reform we might be able to preserve that for ourselves.

I'm not saying I support everything that this AMA says and does, but I'm sure not opposed to the CONCEPT of an AMA.

 

[Perrotfish]

However, I don't think that was the main point of this article. I thought there were two major points. The first is that the AMA is being disingenuous with its criticisms of public health care plans. While there are certainly a lot of valid arguments against any of these sorts of plans, the AMA comes across as only concerned about physician's salaries and not about the state of medicine in this country. To me, the AMA is supposed to represent a sort of quality control system for medicine in this country, allowing doctors to have a collective voice. More and more, the organization comes across as just being a labor union for doctors.

What I think, and what I think the AMA is trying to emphasize, is that quality and quanitity of physicians is directly related to the quality of physician reimbursement. If When national medical organizations have 'alturistically' given up physican salaries (as in Germany, Israel, and Japan) there was a short term drop in costs followed by a significant and accelerating decline in patient care as physicians either formed unions and began to strike (Germany, Israel) or left the profession in droves (Japan).

To me, the biggest thing that the AMA needs to communicate is that there is no magic trick that the other nations are using to keep their health care costs down: they all just decided not to pay someone involved with health care. I might have be the hospitals (Japan and Canada), it miight have been the doctors (Japan and Germany), and in almost all cases they stopped paying the insurance companies and the pharm companies. What we have seen in other countries is that this isn't a long term solution, it's just trading your future health care quality for a short term present gain. Farther down the line the doctors start quitting, the hospitals start shutting down, and the pharm innovations moves at the sluggish pace of academia because there's no financial incentive for private industry to put out new drugs (right now almost all of their profit is in the US market).

The second point I take away is this - there is now a huge driving force for some massive improvement in health care in this country. The statistics are horrifying - we pay 35% more than any comparable European country per capita, yet we have the worst scores on all of the benchmarks - average life span, infant mortality rate, you name it. Whether or not doctors are OK with that (I think they shouldn't be, but that's a different discussion) doesn't really matter, the point is that the public isn't ok with it. If doctors aren't willing to play a part in fixing things, they're going to get screwed. By not helping bring about a demanded change, physicians are going to lose any voice they might have had in the change that inevitably will come. It shouldn't be impossible to come up with a system that works reasonably well for all parties.

See, what I think physicians need to work on communicating, is that the reason that out public has a terrible health care system on average is due to outliers at the low end. All of our various statistics (infant mortality, life span, whatever) is including a significant percentage of the population that is completely uninsured and reliant on emergency rooms for the sum total of their care. What physicians need to communicate to the public is that, for the 80% of the public that actually HAS health insurance, they have access to the best health care system in the world.

This health care package is largely being sold as "100% of the nation getting health care vs. 80% of the nation having health care". What we actually have, and need to communicate to the public, is 80% of the nation having the best quality health care in the world vs. 100% of the nation having the quality of health care that you would expect from the United States Government.

BTW if you want to see what happens when hard working individuals are exposed to government run health care, go read through the military medicine forum.

 

[austinap]

I've never understood what's so evil about having an organization that defends the interests of physicians. Every other interest group has an organization to defend its own interests (AHA, PHARMA, ABA); physicians should as well. People like Dr. McCoy seem to think in black and white - we are either money grubbing profiteers or we are altruistic "good doctors". In reality most of us are somewhere in between, just like our patients: we want to be paid a comfortable salary in exchange for a lifetime of hard work. If we stick together and defend our interests in the coming healthcare reform we might be able to preserve that for ourselves.

I'm not saying I support everything that this AMA says and does, but I'm sure not opposed to the CONCEPT of an AMA.

I don't disagree with the idea of having a sort of union for doctors, but then call it what it is. From the AMA's website, their mission statement is:

"Mission:
To promote the art and science of medicine and the betterment of public health."

That's a big part of what I see as the problem. I don't think that doctors should get a pittance for their work, quite the contrary. However, I think we should be honest about that, and I don't see the statements "doctors should make a reasonable wage" and "the public deserves a reasonable standard of medical care" to be opposing viewpoints.

 

[austinap]

This health care package is largely being sold as "100% of the nation getting health care vs. 80% of the nation having health care". What we actually have, and need to communicate to the public, is 80% of the nation having the best quality health care in the world vs. 100% of the nation having the quality of health care that you would expect from the United States Government.

BTW if you want to see what happens when hard working individuals are exposed to government run health care, go read through the military medicine forum. It's not pretty.

That's a very good point, but it still neglects the fact that we're paying significantly more for that healthcare than European nations, and only 80% of us are getting it.

I guess my point with posting that article isn't that this is the plan that should be approved. I don't necessarily think that. What I think is that we have a significant problem, and from the public perspective right now, the AMA is standing in the way of solutions. Given their mission statement and the huge stake that physicians have in the future of medicine in this country, it seems to me that the AMA should be the one initiating the discussion rather than defending everything we have. Resisting public demand is only going to make the public respect our field less than it currently does. Nobody wins in that situation.

 

[Secondary Gain]

I don't disagree with the idea of having a sort of union for doctors, but then call it what it is. From the AMA's website, their mission statement is:

"Mission:
To promote the art and science of medicine and the betterment of public health."

That's a big part of what I see as the problem. I don't think that doctors should get a pittance for their work, quite the contrary. However, I think we should be honest about that, and I don't see the statements "doctors should make a reasonable wage" and "the public deserves a reasonable standard of medical care" to be opposing viewpoints.

Fair enough. I'm in full agreement.

 

[Perrotfish]

What I think is that we have a significant problem, and from the public perspective right now, the AMA is standing in the way of solutions. Given their mission statement and the huge stake that physicians have in the future of medicine in this country, it seems to me that the AMA should be the one initiating the discussion rather than defending everything we have. Resisting public demand is only going to make the public respect our field less than it currently does.

I'm guessing that you didn't grow up in the DC area? Honestly when the public starts demanding something, especially something complicated and expensive that it doesn't really understand, the main job of lobbies is to try to stonewall until the public has time to think about what they're asking for and realizes the various downsides to their requests. Then a saner conversation can take place between people who have actually taken the time to understand the logistics of the issue. The public won't repect us less because of the AMA. They have no idea who the AMA is, and at this point they have only the vaguest idea what this new health care plan entails (everythings going to be 'free' now). When the lobbies fail and the government is allowed to rush ideas into existance based on public 'demand' you get banner successes like the war in Iraq and the department of Homeland Security.

Now that doesn't mean I'm not in favor of putting forward another idea (as I suggested, health care vouchers for lower income families), but the first the job of all health care lobbies needs to be to stand united againt the first wave of idiocy. After that a serious conversation can take place beteen public health officials, doctors, and economists about the future of American health care and the people can really think about the various options we have.

 

[Lukkie]

Identity revealed!

Gut Shot's real name is Chris McCoy

 

[glypha1104]

The public won't repect us less because of the AMA. They have no idea who the AMA is, and at this point they have only the vaguest idea what this new health care plan entails (everythings going to be 'free' now). When the lobbies fail and the government is allowed to rush ideas into existance based on public 'demand' you get banner successes like the war in Iraq and the department of Homeland Security.

I constantly see remarks in the comment sections of health policy articles such as, "The AMA limits the number of med school seats." From what I understand, the AMA is essentially a lobbying group for physicians; it doesn't control medical school seats, funding for residencies, or any thing else relating to the whole process of training physicians.

But for the sake of arguemnt, let's say they did have direct control over these matters. You still need hospitals, basic science professors, clinical professor, facilities, and a whole host of other very expensive investments, that AMA still wouldn't have control of.

 

[austinap]

I'm guessing that you didn't grow up in the DC area? Honestly when the public starts demanding something, especially something complicated and expensive that it doesn't really understand, the main job of lobbies is to try to stonewall until the public has time to think about what they're asking for and realizes the various downsides to their requests. Then a saner conversation can take place between people who have actually taken the time to understand the logistics of the issue. The public won't repect us less because of the AMA. They have no idea who the AMA is, and at this point they have only the vaguest idea what this new health care plan entails (everythings going to be 'free' now). When the lobbies fail and the government is allowed to rush ideas into existance based on public 'demand' you get banner successes like the war in Iraq and the department of Homeland Security.

Now that doesn't mean I'm not in favor of putting forward another idea (as I suggested, health care vouchers for lower income families), but the first the job of all health care lobbies needs to be to stand united againt the first wave of idiocy. After that a serious conversation can take place beteen public health officials, doctors, and economists about the future of American health care and the people can really think about the various options we have.

Sure, we shouldn't be jumping to any rash conclusions or attempted solutions. However, you make it sound as though this is some completely new problem that nobody saw coming. This problem has been here for quite some time now, and it has only been getting worse. We're only hearing about potential changes now because of a change in administrations and because public frustration is reaching new highs.

Also, I disagree with your analysis of how the public views the AMA. You seem to take the popular sentiment 'the public is stupid' to a literal level. While I think it's true that the majority of the public is completely illiterate in national / world politics, those people tend to be politically inactive.

There is a very large part of the population, however, that isn't completely ignorant - they'll read the occasional paper, watch a few news shows, that sort of thing. Most of those people have heard of the AMA, and from the AMAs statements, they see the organization as being opposed to actually improving health care. They may be stupid in that they won't take an in-depth look as to why doctors may be justified high wages, the real problems that any potential solution may have, and they certainly don't know the history of the AMA, etc. However, to assume they're universally stupid is dangerous and unproductive.

 

[Gut Shot]

Identity revealed!

Gut Shot's real name is Chris McCoy

Awwww.

I don't see the statements "doctors should make a reasonable wage" and "the public deserves a reasonable standard of medical care" to be opposing viewpoints.

QFT.

 

[glypha1104]

Quote from the AMA wikipedia article, "The AMA's mission claims to promote the art and science of medicine for the betterment of the public health, to advance the interests of physicians and their patients, to promote public health, to lobby for legislation favorable to physicians and patients, and to raise money for medical education. However it has consitantly opposed universal health care in the United States leaving many to die as as a consequence."

 

[Perrotfish]

Sure, we shouldn't be jumping to any rash conclusions or attempted solutions. However, you make it sound as though this is some completely new problem that nobody saw coming. This problem has been here for quite some time now, and it has only been getting worse. We're only hearing about potential changes now because of a change in administrations and because public frustration is reaching new highs.

This is a key point. Has the problem really been getting worse? One of the key points that advocates of health care reform harp on is that we are in a crisis, a downward spiral, or something of the sort. Really what we have is the only system that's NOT in crisis. It might not be a good system, but it has the advantage of not getting any worse. Japan and Germany are hemoraging doctors, everyone else is closing hospitals, and our healthcare system is stable and even gradually improving.

The reason we're hearing about this now is that public frustration IN GENERAL is reaching new heights, which should not be confused with the public's frustration specifically with the health care industry. The last election the public stood up and demanded their jobs back, demanded an end to the Iraq war, demanded a return to responsibility. The person who they associated with that just happened to want health care reform, which is something that his party has wanted for decades longer than anyone has been 'demanding' it, and which has basically never been a winning issue for them. This time, though, the guy is popular enough that he might get the reform pushed through.

Now that doesn't mean people don't know what they want. They know exactly what they want. They want health care for free. That's been the overall trend of the polls I've seen: people overwhelmingly support any question phrased in such a way to make it seem like the government health care will be chaper, and are overwhelmingly opposed when the question makes it clear that the benifits will be cost neutral or even cost them money. Are you satisfied with your current healthcare? YES Do you think you pay too much for your current healthcare? YES. Would you like free government healthcare? YES. Would you be willing to pay any taxes at all for government healthcare? NO. I really think when you have an honest debate about what the 80% of the population that is insured is willing to give up to cover the 20% of the population without insurance, they're willing to give up nothing. No change in benifits, no increase in their taxes. So the entire debate has been based on the idea that somehow our government is going to reverse over 200 years of historical trends and do something so much better than private industry that we can insure everyone without giving up anything. Good luck with that.

Also, I disagree with your analysis of how the public views the AMA. You seem to take the popular sentiment 'the public is stupid' to a literal level. While I think it's true that the majority of the public is completely illiterate in national / world politics, those people tend to be politically inactive.

There is a very large part of the population, however, that isn't completely ignorant - they'll read the occasional paper, watch a few news shows, that sort of thing. Most of those people have heard of the AMA, and from the AMAs statements, they see the organization as being opposed to actually improving health care. They may be stupid in that they won't take an in-depth look as to why doctors may be justified high wages, the real problems that any potential solution may have, and they certainly don't know the history of the AMA, etc. However, to assume they're universally stupid is dangerous and unproductive.

People are way, way more ignorant than you think they are. 3/4th of registered voters can actually name the vice president. That's a long way from an understanding of who the AMA is, and associating them with physicians' roles in health care reform.

 

[austinap]

I should have been more careful with my words, you're right: by most standards we haven't gotten much worse. We also haven't gotten much better.


Sure, you can poll tons of people and they'll all say that they want more for less. That isn't anything new. And once again, I'm not arguing that the proposed government insurance plan is _the_ solution that we should implement. I'm saying that there are severe problems with our medical system, they're not going away, and the AMA doesn't seem to be doing anything proactive. As a nation as a whole, we pay more for less than European nations. Our infant mortality rates are nearly three times as high as the current world best (Singapore), and globally we rank ~45th by this marker (CIA factbook). We rank 30th in average life expectancy, with Canada, Japan, and most European countries beating us. Yet for this amazing system, we pay as much as twice as much per capita as the countries that are beating us. Over 15% of our country's GDP goes to healthcare, and that is predicted to increase. I'm not sure what part of you thinks that this is acceptable.


By outright objecting to any proposals yet failing to suggest changes of their own, the AMA seems to be saying that they want to keep things the way they are. I'm not OK with that. If the AMA truely wants to stand by their mission statement, they should be the ones leading the discussion. The solution doesn't have to be "pay doctors significantly less," but it likely will be if physicians don't step up and suggest other reasonable options.

 

[circulus vitios]

The public wants free health care? Fine, let them have it. They'll be the ones suffering. Enjoy your multiple hour wait times in the ER. Enjoy multiple day wait for MRIs. Enjoy the health care rationing. Enjoy the non-coverage of experimental procedures. Enjoy the overall lower quality of care. Enjoy sub-par physicians when medicine is no longer an attractive profession due to lower reimbursements. So long and thanks for the memories, capitalism.

 

[Col Kurtz]

The public wants free health care? Fine, let them have it. They'll be the ones suffering. Enjoy your multiple hour wait times in the ER. Enjoy multiple day wait for MRIs. Enjoy the health care rationing. Enjoy the non-coverage of experimental procedures. Enjoy the overall lower quality of care. Enjoy sub-par physicians when medicine is no longer an attractive profession due to lower reimbursements. So long and thanks for the memories, capitalism.

Every time I've been to the ER, there has been multi-hour waits. When I worked in an ICU and chatted with ER staff the biggest complaint of patients was the wait time.

You're correct that low wages wouldn't attract the best and brightest (evidence: the public school system), but insanely high wages attract people who are chasing the money. There is a happy medium somewhere that would work, unfortunately no one knows what that income level is.

By the way, ONE aspect of the economy being socialized does not destroy capitalism. And by the way the free market is not a panacea.

The AMA should defend doctor's interests, but not at the expense of the public. And they should also function a bit as the public face of the profession, which means they also cannot appear to only defend the interests of health care professionals.

 

[Col Kurtz]

If we are going to have public health care, and I think we should, I believe there are 2 reasonable options:

1) Go the Canada/UK route and force everyone to use a nationalized public system.

or

2) Healthcare vouchers for private insurance.

I'm surprised no one seems to be suggesting option 2, since it was such a major Republican talking point for education, but I'd be fine with either. What I really DON'T want is yet another government system where the people forcing it on me 'for my own good' refuse to participate themselves.

I am also surprised that some sort of voucher for private insurance has not gained more traction. It seems like it would be feasible politically and logistically. It also does not suffer from one of the major problems with school vouchers--there aren't enough private school slots. There may not be enough hospitals either, but the problem wouldn't be in the same ballpark if done with health insurance. Of course it doesn't solve the problem of private insurers deciding compensation for physicians or how those physicians decide on a course of treatment. If it does, I'd love for someone to enlighten me on that

 

[platon20]

I hope Chris McCoy and the rest of you on this board realize that the new plan Obama is proposing currently has a MANDATE for doctors to participate. You knew that right?

Basically the stipulation is that if you take Medicare you HAVE to participate in the new program too. I bet Chris McCoy didnt know that, and most of you probably didnt know that either. With that step, doctors will become DE JURE indentured servants by law. No other profession does this. There is no law which says that firefighters have to work for a certain city, or that teachers have to work at only public schools. Doctors would be subject to a legal mandate that is a modern form of indentured servitude.

I'm all for a public health program to drive the private insurance industry out of business. But doctors should have a CHOICE of who they want to work for, and its absurd that we are contemplating taking that right away from doctors nationwide.

 

[Longshanks]

The public wants free health care? Fine, let them have it. They'll be the ones suffering. Enjoy your multiple hour wait times in the ER. Enjoy multiple day wait for MRIs. Enjoy the health care rationing. Enjoy the non-coverage of experimental procedures. Enjoy the overall lower quality of care. Enjoy sub-par physicians when medicine is no longer an attractive profession due to lower reimbursements. So long and thanks for the memories, capitalism.

Wait, aren't you describing the current health care environment in the US?

 

[Dr Gerrard]

Austinap: Those are interesting statistics, but I do not think we can just compare countries based on these numbers. The US also has a significantly higher obesity rate compared to many European nations, and that is something that is not the fault of physicians. The American public also has to take a part of that blame, which should not fall solely on American health care.

Platon: I did not know that fact. So are you saying that all docs would have to accept this plan? Are all doctors required to take Medicare/Medicaid? If the latter is not true, than it seems as though all doctors would not have to participate either.

 

[austinap]

Austinap: Those are interesting statistics, but I do not think we can just compare countries based on these numbers. The US also has a significantly higher obesity rate compared to many European nations, and that is something that is not the fault of physicians. The American public also has to take a part of that blame, which should not fall solely on American health care.

Sure, there are always differences, but that is one of the closest comparisons that we have. Again, I'm not saying that this is physicians' faults either, but rather a problem with the system as a whole. I'm sure obesity does play a role in where our numbers fall globally, but I highly doubt that you could explain all of that due to obesity. The higher cost, maybe. The average life expectancy, probably. The infant mortality? I'd be surprised if you could pull that one off.

 

[Gut Shot]

I hope Chris McCoy and the rest of you on this board realize that the new plan Obama is proposing currently has a MANDATE for doctors to participate. You knew that right?

Funny, I thought Obama was in the White House. These proposals are written in Congress. You knew that right?

While Obama has been a proponent of a public option, he has been deliberately short on details. It's going to be very difficult to pass one at all, much a version with mandatory physician participation, but that's how negotiation/compromise works. Right now I'm betting that a co-op system is the most politically viable option.

 

[Dr Gerrard]

Yeah, the infant mortality rate is one that definitely correlates more to health care quality than the other two.

 

[sunset823]

I'm actually impressed by the insightfulness of this thread, who knew that pre-meds/med students had the time or proclivity to involve themselves in such tangential things to their careers as the politics of health reform? 🙄

Here is my two cents: the health care system is not going to be easily fixed - I really wish that we could all start from scratch, but we can't, and there is a lot more than just hospitals and physician compensation involved. I, for one, can only look at myself affording the enormous cost of medical school because I am not in it for the money, and I know that with my sound financial discipline I can pay my loans relatively quickly and live comfortably on a salary of 100-125k. Unfortunately, this is not the case for everyone. Some people I know who wanted to do medicine (and were smart enough) cannot because of its cost, even for in-state public schools.

Then there is the fact that a lot of doctors, especially in high-risk fields (OB-GYN comes to mind) are so afraid of lawsuits that they order completely unnecessary tests. You can only blame the doctors to a small extent in these situations, it is a structural problem encompassing the legal and political systems, as well as medical.

These are systemic issues, and just cutting Medicare payments, and possibly lowering salaries, without addressing the cost of medical education, or the overuse of expensive treatments, or the litigious nature of US society, is just going to turn away more potential doctors away from the profession at a time when even more will be needed (for an increased patient pool due to wider insurance coverage).

My fear is that in the hurry to get a reform off the table and signed into law, larger structural problems that lead to high health care costs will not be addressed, and only make the situation worse. It sometimes makes me wonder that when some 'hostile nations' are willing to be at the table on certain foreign policy issues, that US doctors are unwilling to be a part of a discussion that will affect them for better or worse. For some it may be ignorance of the issues involved due to lack of sufficient training in non-science issues very pertinent to medicine, for others (ie the AMA), it is just obsolete ideologies that have no place in our current, rapidly degrading system.

 

[Cardiac]

You're correct that low wages wouldn't attract the best and brightest (evidence: the public school system), but insanely high wages attract people who are chasing the money. There is a happy medium somewhere that would work, unfortunately no one knows what that income level is.

By the way, ONE aspect of the economy being socialized does not destroy capitalism. And by the way the free market is not a panacea.

If you've read the Heart of Darkness, it's a bit ironic to see someone named "Kurtz" saying this.

What is the hesitation to allowing medicine to have high wages? Why would you ever think that insanely high wages would be bad for the quality of physicians? Yes, it is possible that more people would come to medicine because of the money, but yes, it is also true that these people would be far better qualified than many of those who would be our doctors otherwise. Possibly they are less altruistic, but they are likely harder workers and would perform better in the long term. From their perspective, they are motivated by the dual forces of money and medicine (probably in that order). No matter the sources of this motivation, if the total is greater than those motivated purely by medicine, the money-lovers will be pushed to work harder and perform better, thus increasing the quality of care.


One of the ways that this argument fails is in producing primary care physicians. If doctors are more motivated by money, they will usually choose to specialize instead of going into primary care. Herein, we need to make a distinction between primary care doctors and specialists in terms of medical education. As it currently stands, FPs have ~15K hrs of training and NPs have ~3000, however the day-to-day care that a FP and a NP give are approximately equal, except when unique cases arise. If we were to create some sort of middle ground school between medical and NP schools and then place these graduates in primary care positions, we could partially alleviate the shortage of PCPs. This shift though would have to be tied to a "promotion" of actual family practitioners and other primary care Doctors to a semi-specialist role, where they would see only the most unique cases and would otherwise supervise the group of NPs. Thus, medical school would function more as a school for specialists and less as a school for primary care physicians, as it really should.

 

[student1799]

Now that doesn't mean people don't know what they want. They know exactly what they want. They want health care for free.

Agree 100%. The American public has been conditioned by politicians into believing that they can get something for nothing, and health care is no exception. Just as with education and other government services, we want the best of everything--but don't even THINK of raising our taxes to pay for it. Anything but that.

It is time in this country for a truly honest debate about what kind of health care system we want, how much it will cost, and who is going to pay for it, and how. Given the public's reluctance to tax itself enough to pay for truly adequate care for all (which would indeed be very costly), we could well end up with a private/public dual system like the UK. But remember, the UK NHS was starved of funding for a generation, and ended up delivering Third-World-quality health care until funding was increased in the late 1990's.

What I think, and what I think the AMA is trying to emphasize, is that quality and quanitity of physicians is directly related to the quality of physician reimbursement. If When national medical organizations have 'alturistically' given up physican salaries (as in Germany, Israel, and Japan) there was a short term drop in costs followed by a significant and accelerating decline in patient care as physicians either formed unions and began to strike (Germany, Israel) or left the profession in droves (Japan).

[...]there is no magic trick that the other nations are using to keep their health care costs down: they all just decided not to pay someone involved with health care. I might have be the hospitals (Japan and Canada), it miight have been the doctors (Japan and Germany), and in almost all cases they stopped paying the insurance companies and the pharm companies. What we have seen in other countries is that this isn't a long term solution, it's just trading your future health care quality for a short term present gain. Farther down the line the doctors start quitting, the hospitals start shutting down, and the pharm innovations moves at the sluggish pace of academia because there's no financial incentive for private industry to put out new drugs (right now almost all of their profit is in the US market).

This is also completely true. I worked for many years as a health care investment specialist on Wall Street, and became very familiar with the economics of health care in different European countries. In Italy, for example, the government hasn't approved a new drug WITH REIMBURSEMENT for years, so patients have to pay for the latest therapies out of their own pockets. Public hospitals in France had to wait more than 10 years for implantable defibrillators for heart-attack survivors, when there was very strong evidence from clinical studies that they sharply reduced mortality in these patients. In the UK, patients with many hard-to-treat cancers (notably renal cancer) can't get the breakthrough drugs that might help them, because the NHS has denied reimbursement on a national basis. They must appeal to their local health care authorities for reimbursement out of discretionary funds, and there are widespread regional disparities in whether these requests are granted (Manchester may pay for a certain drug, but Southampton won't). This has caused UK cancer patients to dub the system the "postcode lottery," because your chances of survival may depend more on your postcode [zipcode] than anything else.

And, as Perrotfish says, when doctors don't get paid enough for their work, they leave the system. In the UK, for example, NHS reimbursement rates for dentists are considered inadequate, and many have left the public system, resulting in 1-year-plus waits for patients in many urban areas to get dental care.


I think Dr. McCoy's blind altruism feeds right into the schizophrenic attitude of the American public: they want doctors to have the world's best education and training, which costs them an extraordinary amount of money and effort to obtain, but somehow it is wrong for them to make the kind of salaries that would compensate them for that huge investment. I'd bet that when Dr. McCoy went to med school, he didn't graduate with $200K in debt, and the loans he did take out probably had a much lower rate of interest than today's 6.8%.

How can the public expect people to enter the medical profession if stagnant salaries will make it difficult for doctors to pay for their educations, buy houses and send their own children to college? No one has proposed a real solution to this problem.

 

[atomi]

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[Col Kurtz]

If you've read the Heart of Darkness, it's a bit ironic to see someone named "Kurtz" saying this.

What is the hesitation to allowing medicine to have high wages? Why would you ever think that insanely high wages would be bad for the quality of physicians? Yes, it is possible that more people would come to medicine because of the money, but yes, it is also true that these people would be far better qualified than many of those who would be our doctors otherwise. Possibly they are less altruistic, but they are likely harder workers and would perform better in the long term. From their perspective, they are motivated by the dual forces of money and medicine (probably in that order). No matter the sources of this motivation, if the total is greater than those motivated purely by medicine, the money-lovers will be pushed to work harder and perform better, thus increasing the quality of care.

I encourage you to read "Things Fall Apart." I have no problem with my name being ironic. Perhaps you should think why that may be. Do you actually glorify this despicable character with that statement?

So you think those chasing the money are "harder" workers? Hmm. Let's think this through. Someone who loves their job will work harder than someone who loves the paycheck. Have you ever worked in a restaurant? The slow times, ie when the floorstaff makes little money has the effect of making everyone a little less concientious about their job. I live in a very seasonal economy and during the summer when it's slow waiters tend to be lazier and less attuned to the demands of the job. Another example: professional athletes who are their for the money tend to work hard only in contract years. This phenomenon is fairly common, particularly in the NFL. Who works the hardest among NFL players? Players like P Manning, T Brady, and Andre Johnson. And those players are consistently good. Those players also have cut their own salaries to help the time. Why? Because they love the game. Bringing this back to medicine, the number of premeds on this board who talk about why should doctors have to pay for the fat unhealthy people's healthcare are like the players who only play hard in contract years.

Also, doctors who came for the money are more likely to be supremely unhappy with the total immersion the profession requires. Don't you think that whould show up in their work? Besides that why do you think Adcoms focus so much on the question of why medicine? The reason people who want to make a lot of money go into medicine is because the AVERAGE salary is higher than pretty much any other profession. The other careers that pay out a lot--law and business--require years of hard work with no guarantee. In both of those instances, you have to be somewhat lucky to make high end money. While medicine requires similar hard work as far as med school and residency, you come out of those things making good money and can make partner in 3-4 years at most practices. Try making partner at a law firm in three years.

How about some evidence for your statements above?

One of the ways that this argument fails is in producing primary care physicians. If doctors are more motivated by money, they will usually choose to specialize instead of going into primary care. Herein, we need to make a distinction between primary care doctors and specialists in terms of medical education. As it currently stands, FPs have ~15K hrs of training and NPs have ~3000, however the day-to-day care that a FP and a NP give are approximately equal, except when unique cases arise. If we were to create some sort of middle ground school between medical and NP schools and then place these graduates in primary care positions, we could partially alleviate the shortage of PCPs. This shift though would have to be tied to a "promotion" of actual family practitioners and other primary care Doctors to a semi-specialist role, where they would see only the most unique cases and would otherwise supervise the group of NPs. Thus, medical school would function more as a school for specialists and less as a school for primary care physicians, as it really should.

Actually this proves my point. If more people were going to med school for altruistic reasons, there would not be a PCP shortage. Why? PCP positions pay less as you pointed out. What are the most competitive residencies? I don't think it is a coincidence that the most competitive are the highest paying specialties. Now I admit that much of this has to do with debt, nor do i think every doctor is only in it for the money, but your reasoning jsut does not hold up.

And before you respond take the the time to read some other posts of mine. I think doctors should be paid well, but I suspect that trimming the salaries a bit, especially for the highest paid specialties might change that. If you didn't notice, I took the middle ground on this--I don't think salaries are unjustified, but lower salaries will not destroy the profession as many on SDN seem to think.

 

[atomi]

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[Gut Shot]

What a socialist hack. Who is he to demand that the entire profession sacrifice their lives for their patients in every way possible?

Strawman. Here is what he actually said:

As a physician, I advocate first for what is best for my patients and believe that as a physician, as long as I continue to maintain the trust and integrity of the profession, I will earn the respect of my community. The appropriate financial compensation for my endeavors will follow in kind.

Perhaps you can explain to me how advocating for the patient's best interest is tantamount to complete professional sacrifice?

With regard to competiton, the cornerstone of capitalism, he has this to say:

That was 50 years ago ... and none of that has come to pass. And yet this year, the AMA argues that a public health insurance plan will destroy the private insurance market. I challenge the AMA leadership to cite a single example of an industry where involvement by the government has lead to the elimination of private enterprise. This has not been the case with the creation of public police forces in the second half of the 1800's (private security companies still exist), we have a robust system of public and private colleges existing the same market, and bookstores still sell books despite the presence of public libraries. A mix of public and private enterprises in the market is a truly American solution to ensuring equal access, as well as competition to drive quality improvement. In fact, the creation of the public health insurance option will *increase* competition, as demonstrated by the AMA's own studies showing that 94% of health insurance markets only have 1 or 2 providers in the market.

As you can now see, Dr. McCoy is neither arguing for total sacrifice nor ablating competition.

You know, it's really nice outside of Ayn Rand's colon. Perhaps you should pull your head out once in a while.

 

[Col Kurtz]

You fundamentally misunderstand what altruism is and why some will demand it of you. I.e., they intend to use your own good virtues against you to instill a sense of guilt so that you will voluntarily agree to your own enslavement. That is altruism in the sense you mean it. And that is a good thing?

Giving something you have worked hard to produce away in return for nothing to those who not only do not deserve it, but demand it unconditionally and without appreciation is not altruism, it is evil.

Hello, God Complex. Maybe your name should be Kurtz. Thank you for telling me what I mean. Oh wait, no. Altruism means you give of yourself regardless of the reward. You know who the best teachers are? The ones who could have done other things that are more financially rewarding, but sacrificed riches to do something they saw as worthwhile that pays less. And no, I am not using my virtues against you, you do that yourself. And no, it is not enslavement, go do a different job, you're not in any way required to go into medicine sir. I am not driven out of guilt, I am driven by humanity.

By the way, I was not trying to make you feel guilty at all, perhaps that is your conscience. There are other professions that pay well that don't require you to have a conscience, go do that if you're offended by altruism. I am not trying to rub it in your face, I have no problem with people trying to get their piece of the pie. But I do have a problem with it the profession requires more than the desire to make money--good doctors require compassion and your post indicates that you do not possess that quality. I am not judging you as a person, I am just wondering whether medicine is right for you.

And by the way, since i didn't explain it above. The god complex comment comes from this: "...those who don't deserve it." Just a question, are you religious? Because every religion I know of reserves that right to God. Ones that do not are called cults.

Keep building the straw men please, this is just too easy.

 

[Col Kurtz]

You know, it's really nice outside of Ayn Rand's colon. Perhaps you should pull your head out once in a while.

Now that is funny. But ya know maybe they should hear a quote from Rand herself. “You must be the kind of man who can get things done. But to get things done, you must love the doing, not the secondary consequences.”

Hmm...I detest her philosophy, but this seems right on. To those who are going into medicine for money, please take this to heart and change your career track. There are those of us who want to do it to contribute to the world, not our bank statements.

 

[atomi]

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[atomi]

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[atomi]

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[Cardiac]

I encourage you to read "Things Fall Apart." I have no problem with my name being ironic. Perhaps you should think why that may be. Do you actually glorify this despicable character with that statement?

Agreed. I enjoyed Things Fall Apart and I'm glad we both see the irony. I only mentioned it because most people associate Kurtz with "Apocalypse Now" instead of the book. I wasn't calling you out.

So you think those chasing the money are "harder" workers? Hmm. Let's think this through. Someone who loves their job will work harder than someone who loves the paycheck. Have you ever worked in a restaurant? The slow times, ie when the floorstaff makes little money has the effect of making everyone a little less concientious about their job. I live in a very seasonal economy and during the summer when it's slow waiters tend to be lazier and less attuned to the demands of the job. Another example: professional athletes who are their for the money tend to work hard only in contract years. This phenomenon is fairly common, particularly in the NFL. Who works the hardest among NFL players? Players like P Manning, T Brady, and Andre Johnson. And those players are consistently good. Those players also have cut their own salaries to help the time. Why? Because they love the game. Bringing this back to medicine, the number of premeds on this board who talk about why should doctors have to pay for the fat unhealthy people's healthcare are like the players who only play hard in contract years.

Also, doctors who came for the money are more likely to be supremely unhappy with the total immersion the profession requires. Don't you think that would show up in their work? Besides that why do you think Adcoms focus so much on the question of why medicine? The reason people who want to make a lot of money go into medicine is because the AVERAGE salary is higher than pretty much any other profession. The other careers that pay out a lot--law and business--require years of hard work with no guarantee. In both of those instances, you have to be somewhat lucky to make high end money. While medicine requires similar hard work as far as med school and residency, you come out of those things making good money and can make partner in 3-4 years at most practices. Try making partner at a law firm in three years.

I never said that those chasing money are harder workers, just that money was an additional incentive. If, as you recommend, you read my past posts, you'll see plenty of arguments for why high physician pay is good, but I'll explain again here. If you add the incentive of money to the incentive of medicine (composed of altruism, service, societal respecet, etc. that comes with being a doctor), you increase the total incentive to go into the field. Some people value money more, some value the other things more, but however it stacks up, if there is more total incentive to be in the field there will be more competition to enter it. Thus, with more competition for medical school from more total incentive, you will have better doctors in the long run.

If, as you say, a doctor ends up not in love with his work, one of three things will happen. Either, he will do less work and earn less money, continue to do the work because the love of money is enough for him, or figure out a way to change the work so that he likes it again. If the first situation is true or his work suffers, he will get less money and then another doctor will come in, see the opportunity, and take the patients and money that he neglected to keep up. Either way, the system (competition) is a self-correcting one: if the doctor finds that the burdens of the job outweighs the incentives, something will change, but if the incentives are high this will happen rarely and will be quickly fixed.

Going to your examples, when I worked in a restaurant, if somebody was being lazy and not working hard, they either made less money in tips or were fired. The incentive of making more money (and not getting fired) will outweigh the desire to slack off or you will find another job. If service suffers from time to time, this is usually because of a lack of competition for the jobs. Next, the example of NFL players is a bit of a stretch and can't be applied to the market as a whole. Yes, some players in the top 2% of wage earners will sacrifice for a team to win a championship (which notably is not an altruistic sacrifice, but a self-serving one), but when do the mid- or low-salaried players do this? Entire teams don't take a pay cut to win a championship, nor would the entirety of NFL Players, if the pay off was just to raise the level of play a bit (which is actually backwards - it would diminish it). It's a bit hard then to stretch this argument to saying that all doctors should take a cut to raise the level of care.

If more people were going to med school for altruistic reasons, there would not be a PCP shortage. Why? PCP positions pay less as you pointed out. What are the most competitive residencies? I don't think it is a coincidence that the most competitive are the highest paying specialties. Now I admit that much of this has to do with debt, nor do i think every doctor is only in it for the money, but your reasoning just does not hold up.

And before you respond take the the time to read some other posts of mine. I think doctors should be paid well, but I suspect that trimming the salaries a bit, especially for the highest paid specialties might change that. If you didn't notice, I took the middle ground on this--I don't think salaries are unjustified, but lower salaries will not destroy the profession as many on SDN seem to think.

If more people went into medicine for altruistic reasons, the quality of care would decrease. There simply isn't enough altruism for it to outweigh money, and without the incentive of economic gain, altruism alone isn't going to raise the incentives enough that the most qualified and smartest go into this field over any other field. Again, I contend that if we want to keep the field of medicine strong, we need the best and brightest people in it. If this means transitioning some primary care positions to others, then let's do it. If we have higher quality care overall and higher quality physicians overseeing the primary caregivers (be they NPs or others), the quality of our primary care will increase (or stay the same at worst) while the quality of our specialty care will go through the roof. (again, see my old posts or pm me if the incentives part of this doesn't make sense)

 

[atomi]

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[Col Kurtz]

It is clear that you just don't get it. Sacrificing your life to 'humanity' does not make you noble. And at what point did I indicate that I felt guilty? I believe in giving to those who are completely helpless and to a reasonable extent (for example, my favorite charity is toys for tots - children have no means of providing for themselves and it is unlikely the toys I donate will be misappropriated). I believe in giving to those who need help and to those whose virtues I respect. I do not believe in giving to those who demand it by compulsion, because that undermines the entire point of a gift. A gift is worthless to those who do not value it. Give a bum 20 bucks and he won't care (try it if you don't believe me). Give your best friend who just got laid off a loan to keep him from losing his house, and see how he reacts.

By your own words, if you ever work for even a single cent of profit in your career, you are a hypocrite. There will ALWAYS be somebody out there more needy of that cent than yourself (this is why socialism doesn't work btw).

One of the problems I have with religion is that they all attempt to take away man's judgement: i.e., it is not right for us to think about what is right and what is wrong, who is good and who is bad, leave that up to God.

And waht does make you noble exactly? And I never said you should sacrifice your whole life. I think I am pursuing medicine for the right reasons, but I also know I will enjoy the financial security it can provide. Again, I have typed so many times in these threads now that I think physicians should have a high salary--they sacrifice a lot. But keeping salaries high at the expense of the health of others is wrong, expecially when viewed through the lens of a compassionate profession. Now, I also suspect that there are things that should be done that will save more money than cutting salaries, and those should be done first. But if there still isn't enough money, then salaries should drop but only to a certain extent. It requires balance.

Interesting that you used the word hypocrite because I didn't. You missed the point. There are other ways to make money if you do not want to help people. But as a physician it should not your right to say you won't treat someone because of whatever reason. Your job is to treat the people who need it. And no, making a dime off of your profession does not make you a hypocrite. But you saying that some people do not "deserve health care," IS mutually exclusive with humanistic concerns. So yes, I do get it.

Toys for tots is great, but lumping everyone who does not have access to care as undeserving reveals a lot in my opinion. Notice one other thing about my post, I managed to not call you evil. I don't think you are, but I also don't think it is your place to decide who gets treated and who does not. And by your interpretation does that mean that people in jail do not deserve health care? Especially when viewed in the light that those in prison do get health care, while there are law abiding citizens who do not.

 

[womp]

Here is an interesting article about what might happen if this plan backfires: Japan Doctors Say New Health Funding Won't End Death-by-Delay.

Good article. I've heard a lot of Single-payer proponents champion Japan as a model for health care, with its low costs and long lifespans. Well here is the other side:

Trauma doctor Hisashi Matsumoto said he gets $6 an hour, or less than the average minimum wage, for a 16-hour night shift.

Convenience store attendants receive more on an hourly basis than some doctors working extended shifts in hospitals, said Kobayashi, the former head of the emergency center at Teikyo University Hospital.

``Doctors feel it's their mission to save lives,'' Kobayashi said. ``Are they getting paid for what they sacrifice? No.''

Rejection of patients is sometimes unavoidable, Aruga said in an interview on Jan. 24. His hospital recently had to decline to accept a coronary patient because it was already treating four people with heart conditions and had two others waiting, he said.

``The funding won't help,'' said Kunio Kobayashi, a doctor who headed the emergency center at Tokyo's Teikyo University Hospital until he switched to teaching paramedics in 2005. Increases in medical reimbursements don't reach hospital doctors because the medical centers are losing money, he said.

``The additional payments to hospitals will benefit management not doctors,'' said Tohru Aruga, a doctor and vice director of Showa University Hospital in Tokyo.

 

[Col Kurtz]

You misunderstand the meaning of that which you quoted. The meaning is that you cannot just love money, that you must also love work. There is nothing wrong with loving work because it produces money. In fact, that is proper. Money just does not magically appear because you love it. Loving money and hating work are mutually exclusive and illogical (A is non-A in Rand speak). That is the point of your quote.

With that in mind, your conclusion doesn't make any sense.

That's not true, many people ahte their jobs, but do it because the money is good. I admit, I am no expert on Objectivism, but there are doctors who don't like their work and stay in because they like the money. I don't think it is wrong to love work because of the money per se, but i do question whether the quality of their work suffers.

 

[Col Kurtz]

Agreed. I enjoyed Things Fall Apart and I'm glad we both see the irony. I only mentioned it because most people associate Kurtz with "Apocalypse Now" instead of the book. I wasn't calling you out.



I never said that those chasing money are harder workers, just that money was an additional incentive. If, as you recommend, you read my past posts, you'll see plenty of arguments for why high physician pay is good, but I'll explain again here. If you add the incentive of money to the incentive of medicine (composed of altruism, service, societal respecet, etc. that comes with being a doctor), you increase the total incentive to go into the field. Some people value money more, some value the other things more, but however it stacks up, if there is more total incentive to be in the field there will be more competition to enter it. Thus, with more competition for medical school from more total incentive, you will have better doctors in the long run.

If, as you say, a doctor ends up not in love with his work, one of three things will happen. Either, he will do less work and earn less money, continue to do the work because the love of money is enough for him, or figure out a way to change the work so that he likes it again. If the first situation is true or his work suffers, he will get less money and then another doctor will come in, see the opportunity, and take the patients and money that he neglected to keep up. Either way, the system (competition) is a self-correcting one: if the doctor finds that the burdens of the job outweighs the incentives, something will change, but if the incentives are high this will happen rarely and will be quickly fixed.

Going to your examples, when I worked in a restaurant, if somebody was being lazy and not working hard, they either made less money in tips or were fired. The incentive of making more money (and not getting fired) will outweigh the desire to slack off or you will find another job. If service suffers from time to time, this is usually because of a lack of competition for the jobs. Next, the example of NFL players is a bit of a stretch and can't be applied to the market as a whole. Yes, some players in the top 2% of wage earners will sacrifice for a team to win a championship (which notably is not an altruistic sacrifice, but a self-serving one), but when do the mid- or low-salaried players do this? Entire teams don't take a pay cut to win a championship, nor would the entirety of NFL Players, if the pay off was just to raise the level of play a bit (which is actually backwards - it would diminish it). It's a bit hard then to stretch this argument to saying that all doctors should take a cut to raise the level of care.



If more people went into medicine for altruistic reasons, the quality of care would decrease. There simply isn't enough altruism for it to outweigh money, and without the incentive of economic gain, altruism alone isn't going to raise the incentives enough that the most qualified and smartest go into this field over any other field. Again, I contend that if we want to keep the field of medicine strong, we need the best and brightest people in it. If this means transitioning some primary care positions to others, then let's do it. If we have higher quality care overall and higher quality physicians overseeing the primary caregivers (be they NPs or others), the quality of our primary care will increase (or stay the same at worst) while the quality of our specialty care will go through the roof. (again, see my old posts or pm me if the incentives part of this doesn't make sense)

I agree that salaries should be high. ANd I think it does function as a bit of quality control. But there are plenty of successful med students and doctors who didn't perform all that well in school. But they worked as hard as they could and got their way into med school and became fantastic doctors. But by measurements such as MCAT and grades, they would be far from the common conception of "best and brightest."

Ultimately I think you and I agree more than we disagree. I don't think doctors should make 80k a year. But why is it that people who make 300k a year refuse to allow their taxes to be raised a little if it is for the public good? Nor do I think it requires 300k to lure the best and brightest. Plenty of our best and brightest young people go to law school, and don't chase it for money. IT doesn't make them less of an attorney. Why do you think that is? Because they are not chasing the money. Ditto with things like social work, etc. Those people aren't inherently dumber, they just made a choice.

No matter what way you cut it, 150k-200k are good salaries and is plenty of an incentive to lure the best and brightest. But if they went higher, you'd get more people in med school who would have gone into corporate law or investment banking simply because there is more of a guarantee of a high salary in medicine than in those professions. Again, there should be balance here.

 

[Cardiac]

Again, I have typed so many times in these threads now that I think physicians should have a high salary--they sacrifice a lot. But keeping salaries high at the expense of the health of others is wrong, expecially when viewed through the lens of a compassionate profession. Now, I also suspect that there are things that should be done that will save more money than cutting salaries, and those should be done first. But if there still isn't enough money, then salaries should drop but only to a certain extent. It requires balance.

Absolutely. With salaries at ~10% of the healthcare costs, we should be focusing on cutting costs elsewhere. Now let's just remove the insurers from the equation and go to an entirely direct-pay (subscription) system and we've got it taken care of...

 

[Cardiac]

I agree that salaries should be high. ANd I think it does function as a bit of quality control. But there are plenty of successful med students and doctors who didn't perform all that well in school. But they worked as hard as they could and got their way into med school and became fantastic doctors. But by measurements such as MCAT and grades, they would be far from the common conception of "best and brightest."

Ultimately I think you and I agree more than we disagree. I don't think doctors should make 80k a year. But why is it that people who make 300k a year refuse to allow their taxes to be raised a little if it is for the public good? Nor do I think it requires 300k to lure the best and brightest. Plenty of our best and brightest young people go to law school, and don't chase it for money. IT doesn't make them less of an attorney. Why do you think that is? Because they are not chasing the money. Ditto with things like social work, etc. Those people aren't inherently dumber, they just made a choice.

No matter what way you cut it, 150k-200k are good salaries and is plenty of an incentive to lure the best and brightest. But if they went higher, you'd get more people in med school who would have gone into corporate law or investment banking simply because there is more of a guarantee of a high salary in medicine than in those professions. Again, there should be balance here.

Haha, yeah we do agree for the most part, just maybe not about where the correct salary range is. Your example of the person with decent grades excelling in med school is spot on, and I'll talk about it for a second. Here is an example of a person for whom all the incentives that go along with being a doctor are enough to drive him to work hard and excel. In this sense, he may not have demonstrated it at first, but he is, in fact, one of those "best and brightest" Unfortunately, purely these incentives are not enough for everyone, which is why it's important to have high physician pay (that, and the super high costs of education). Thus, with both the incentives of salary and altruism/doctorness, medicine will attract even more of the top students.

I know you're not one of them, but I can't stand those guys who rant about the need to reduce doctor pay, saying money plays no part of a "good doctor's" desire to go into medicine.

 

[womp]

And waht does make you noble exactly? And I never said you should sacrifice your whole life. I think I am pursuing medicine for the right reasons, but I also know I will enjoy the financial security it can provide.

You do realize you are free-riding off the battles of others (that "financial security" you will be enjoying) while simultaneously bashing those physicians who bought you that financial security? What happens when that financial security disappears as it has in Japan?

 

[Col Kurtz]

I haven't seen anyone post this yet. I am sure there will be a rebuttal posted by someone. Remember that the plan introduced in Congress was written by Congress, not Obama. Having said that the more public support for him, the more likely he will deliver a plan that everyone, including physicians and conservatives can get behind.

http://www.huffingtonpost.com/2009/06/15/obama-takes-up-public-hea_n_215736.html

 

[Gut Shot]

No, it's not a strawman. I know exactly what his words intended, even if he didn't admit it.

So you have to extract what you perceive to be his intentions in spite of his actual words. Essentially you are (mis)characterizing his statement in order to attack something which isn't necessarily there. That, my friend, pretty much defines a strawman.

He is demanding that the entire profession sacrifice their labor at the benefit of all patients, deserving or not, for compensation less than a free market would bear. I don't know how this could be much more clear cut.

No, he is rejecting the notion that our profession is better off if we willfully divorce our own self interest from that of our patients. Ultimately the two are inexorably linked, and to ignore that relationship is short sighted and foolish. While you may never agree fully with this sentiment, perhaps you will have a better understanding of it in a few years.

, profit is the cornerstone of capitalism, not competition. Competition is a secondary effect of profit.

I disagree. Profit is the goal, but competition is the way.

Sound familiar?

It does, but that may be because the dog just farted. It was a wet one, too.

 

[Col Kurtz]

You do realize you are free-riding off the battles of others (that "financial security" you will be enjoying) while simultaneously bashing those physicians who bought you that financial security? What happens when that financial security disappears as it has in Japan?

Oh really, so I go through teh same med school, same residency, yet I am free riding. This is the dumbest thing I have ever heard. That is NOT a free ride, and no I am not bashing those who want to make money, I do too. But demanding that you make excessive money is greed. And that financial security won't disappear--you appear to only listen to propaganda. I suggest you read my last response to cardiac. I also suggest you stop listening to whomever you're listening to for your political news. I guess i have to type this again for the second time in ten minutes--I THINK DOCTOR'S SHOULD HAVE HIGH SALARIES, BUT NOT AT THE EXPENSE OF THE PUBLIC GOOD. THEY ARE NOT MUTUALLY EXCLUSIVE.