If I ruled the world...

[ForeignBody]

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Medical schools used to have a cutoff age for new students of 30. They used to not give any sort of accomodation to people with learning or other disabilities. Both those standards make a lot of sense. I am suggesting that those two rules be rolled back into place.

Nearly every doctor out there is in a position where a serious error is fatal to the patient. That's sort of where the line has been drawn between MD/DOs and other professionals. Each new doctor trained costs society something, not only in dollars and the time of existing doctors, but also in additional mistakes inevitably made when you put n00bs in charge. The 'perfect doctor' for society would be someone who never aged, so that he or she needed to be trained only once. Hence, training older people or people with a disease that significantly shortens life expectancy is a horrible decision.

I graduate in like 3 months and your idealism makes me laugh.

 

[colbgw02]

There are some ridiculous thoughts getting tossed around on this thread.

First of all, it is pure vanity to think that we can prospectively deny all disabled persons a chance at a medical degree because society can't afford to invest those resources. All it takes is one cancer patient who is impassioned enough about their illness to find a cure to make it worthwhile to have trained that individual.

Second of all, some folks are saying we should shorten undergraduate training. Some of that I understand; most of it I do not. Sure, a well-trained and motivated highschool graduate could probably dive right into basic science medical training, but that doesn't mean he or she should. My undergraduate education made me a more rounded individual, which - in turn - has made me a better doctor. I still maintain that the single most important undergraduate class I took to prepare me for medical school was philosophy.

It sounds like some folks want to turn physicians into all-breathing, all-consuming scientific automatons who can quote double-blind, prospective clinical trial results from rote memory in their sleep. Not the right answer, IMHO.

 

[KluverB]

...Nearly every doctor out there is in a position where a serious error is fatal to the patient....

The same can be said of many other professions... pharmacists, engineers, architects, construction workers, pilots, bus drivers, etc. Does that mean everyone should choose their career straight out of highschool and stay in it?

 

[OTD]

I have to laugh at all these people who what to decrease the amount of pay for physicians like that would somehow "help" healthcare.

People, all physicians income combined make up LESS THAN 10% of healthcare expendatures.

Physicians earn every penny, and many are severely underpaid.

 

[Nick Name]

Yes, but at least everyone is being measured against the same ruler,...

But using a ruler to measure something that ought to be measured in joules is a mistake. Using a measure relevant to medicine is not the same tasks relevant to surgery, or OB.

Granting admission to medical school solely on country of origin is another mistake. Spots ought to go for the most qualified - and denying just one highly qualified FMG a spot for a less qualified AMG could result in the deaths of a great many people , which is far too great a cost to accept. Your less qualified children should be rejected for the more highly qualified FMG

 

[dragonfly99]

2 things I would do to make medical education better (which would produce better physicians)

1) somehow stop the crazy inflation of tuition (undergrad and grad/professional schools)
2) reward med school faculty for teaching and mentoring, rather than just for RVU's billed and research grants and publications obtained

 

[dragonfly99]

nick name is right about the fixed costs of medicine also. A lot of the cost of medical care is overhead, the costs of administration/medical billing, and costs of defensive medicine (i.e extra labs/imaging ordered on the off change the patient has something you've missed and your needing to cover your a--). Physician salaries do factor in, but not to the extent that you would think. Docs here in the US in many fields make a comparable amount to those in other countries, especially if you correct for the greater hours we work and for the cost of paying student loans back and the fact that we are in training longer (at least than some other countries).

Physicians' salaries really aren't set mostly by supply and demand, either...they are pretty much determined by how much a doc can bill, minus his overhead. That's in the private world, I mean. How much a doc can bill depends on what the insurance companies will pay for a particular service (since the vast majority of docs don't run cash practices and the vast majority of patients don't pay directly for their care), and how many patients/day he/she can treat. So one can increase income a little by working more, but one doesn't really set one's own level of compensation.

 

[Squiggy]

I have to laugh at all these people who what to decrease the amount of pay for physicians like that would somehow "help" healthcare.

People, all physicians income combined make up LESS THAN 10% of healthcare expendatures.

Physicians earn every penny, and many are severely underpaid.

Physicians (specialists at least) are way overpaid. In no other career can you make so much with complete job security and not have to innovate, demonstrate business skills, or out-compete your peers (once you become an attending). Many specialties (the American College of Dermatology is a good example) artificially restrict their supply by restricting training in order to inflate their earning potential. Each medical specialty is pretty much it's own little monopoly. The same can be seen with dentists as they have been producing a dearth of dentists compared to a few decades ago, lowering supply while demand has increased, which in addition to the rise of cosmetic dentistry has allowed their real incomes to increase.

Managed care and insurance is basically presenting another monopolistic force to compete against the medical profession's monopolies and declining reimbursements are simply a means of reducing physician incomes to the levels they should be. If anything, the medical profession should resemble what they have in the UK or Belgium where they are essentially very well compensated govt. workers and students graduate earlier and with minimal debt. Doctors should not be paid as well as C-suite executives simply for being highly trained technicians. However, they should not be subjected to such a high risk of malpractice/tort that they do in this country, which leads to CYA medicine and further drives up costs.

As a consumer, anything that decreases the cost of healthcare will help. It's access to care I'm worried about and not having top-notch care is fine with me. I think we should move to universal healthcare with the ultimate goal of a single-payer system like the UK.

 

[OTD]

Physicians (specialists at least) are way overpaid. In no other career can you make so much with complete job security and not have to innovate, demonstrate business skills, or out-compete your peers (once you become an attending)........... Doctors should not be paid as well as C-suite executives simply for being highly trained technicians. However, they should not be subjected to such a high risk of malpractice/tort that they do in this country, which leads to CYA medicine and further drives up costs.

As a consumer, anything that decreases the cost of healthcare will help. It's access to care I'm worried about and not having top-notch care is fine with me. I think we should move to universal healthcare with the ultimate goal of a single-payer system like the UK.

LMBO

So says the premed with no idea the amount of work, intelligence, responsibility, and moral fiber needed to be a good physician. Calculate it by the hour, then you might be suprised to learn that auto workers make more per hour than a great many docs.

Doctors most definately are NOT over paid.

Don't even get started on the "single payer" thing. Picture the entire US healthcare system as inefficient as the VA system, except nation wide. Now private hospitals pick up the slack daily for the VA, they send them out, have full bed and can't admit patients daily. Who would take up the slack for the entire US population?

 

[BlondeDocteur]

I like PeepshowJohnny's plan, because the only redundancy I see in the current system is in some of the first year basic sciences-- I know my medical school, and many others, are moving to make 1st and 2nd year 1.5 yrs long instead, and teach organ systems physiology and pathophys simultaneously.

I have been placed in the position, many many many times, of explaining to an inquiring foreigner why American medical training is on a postgraduate model, instead of an undergraduate one, and what the possible advantages could be. I agree that while teenagers are bright enough to pass the sciences, they are for the most part in no way ready for the emotional depth being a physician requires. They need to see and experience life, take courses that cause them to think instead of memorize, to formulate their moral, philosophical, religious and political opinions-- to become, in short, adults. So I do not agree that 6 year post-high school MD programs should be at all the way to go-- and I know that the most incredibly gifted, talented, inspiring doctors I've worked with have been Julliard-trained strings players, ethicists, theologians, architects, historians, financial players, etc. I love the flexibility of the American medical system that permit people with talents extending beyond a facility for memorizing the different sorts of intravesicular transport or whatever other crap we all regurgiated in basic science/ premed classes to become doctors.

 

[genericderm8]

I love children. So naive. So idealistic. So filled with hope.

By the way, if you're going to criticize a field, you should get your facts straight.

The American Academy of Dermatology (there is no ACOD genius) has done research on what the impact would be in terms of increasing residency positions. The limited spots indicates that if all graduating residents were to work fulltime in MEDICAL dermatology, patient demand would be met. There's no need to increase the # of spots. It's not something that was mandated willy-nilly. Hospital and government funding also play a role.

Physicians (specialists at least) are way overpaid. In no other career can you make so much with complete job security and not have to innovate, demonstrate business skills, or out-compete your peers (once you become an attending). Many specialties (the American College of Dermatology is a good example) artificially restrict their supply by restricting training in order to inflate their earning potential. Each medical specialty is pretty much it's own little monopoly. The same can be seen with dentists as they have been producing a dearth of dentists compared to a few decades ago, lowering supply while demand has increased, which in addition to the rise of cosmetic dentistry has allowed their real incomes to increase.

Managed care and insurance is basically presenting another monopolistic force to compete against the medical profession's monopolies and declining reimbursements are simply a means of reducing physician incomes to the levels they should be. If anything, the medical profession should resemble what they have in the UK or Belgium where they are essentially very well compensated govt. workers and students graduate earlier and with minimal debt. Doctors should not be paid as well as C-suite executives simply for being highly trained technicians. However, they should not be subjected to such a high risk of malpractice/tort that they do in this country, which leads to CYA medicine and further drives up costs.

As a consumer, anything that decreases the cost of healthcare will help. It's access to care I'm worried about and not having top-notch care is fine with me. I think we should move to universal healthcare with the ultimate goal of a single-payer system like the UK.

 

[PeepshowJohnny]

I like PeepshowJohnny's plan, because the only redundancy I see in the current system is in some of the first year basic sciences-- I know my medical school, and many others, are moving to make 1st and 2nd year 1.5 yrs long instead, and teach organ systems physiology and pathophys simultaneously.

I have been placed in the position, many many many times, of explaining to an inquiring foreigner why American medical training is on a postgraduate model, instead of an undergraduate one, and what the possible advantages could be. I agree that while teenagers are bright enough to pass the sciences, they are for the most part in no way ready for the emotional depth being a physician requires. They need to see and experience life, take courses that cause them to think instead of memorize, to formulate their moral, philosophical, religious and political opinions-- to become, in short, adults. So I do not agree that 6 year post-high school MD programs should be at all the way to go-- and I know that the most incredibly gifted, talented, inspiring doctors I've worked with have been Julliard-trained strings players, ethicists, theologians, architects, historians, financial players, etc. I love the flexibility of the American medical system that permit people with talents extending beyond a facility for memorizing the different sorts of intravesicular transport or whatever other crap we all regurgiated in basic science/ premed classes to become doctors.

Thanks, BD. I set up my "dream system" to shave off time but still leave the undergraduate experience (mostly) intact. I am very proud that I took classes in mythology, history, philosophy, and film in undergraduate. As I look back at my class now at the end of medical school, I think it is valuable tha we have students who have had undergraduate education in business, in the arts, in theology, in political science, in history etc. because we need people with that interest and perspective as young doctors.

And I hate to come down as well on some posting in here, but unless you're an 3rd or 4th year medical student or resident I don't think you have enough perspective yet to comment. I know you mean well, but you need more time to see the big picture.

 

[Habeed]

The American Academy of Dermatology (there is no ACOD genius) has done research on what the impact would be in terms of increasing residency positions. The limited spots indicates that if all graduating residents were to work fulltime in MEDICAL dermatology, patient demand would be met. There's no need to increase the # of spots.

Now, common sense, just from reading that statement, says that there is not enough spots. The way the AAD is "phrasing" it sounds like pure self-interest. There should be enough spots to provide care at the actual productivity of graduating dermatologists. So, if half of graduates consistently decide to work part time, creating a shortage, then more spots should be opened up. (for instance, statistically women physicians work fewer hours than men over their lifetimes, but the seat quotas are based assuming equal productivity) Same if half of graduates started doing cosmetic procedures most of the time.

This would be like the equivalent organization for plastics surgeons saying "100 graduates a year is enough to do all medical reconstructive surgery...we don't need any more spots. It's not "our" fault that there is a huge shortage and patients are forced to pay the existing surgeons $1000/hour"

How else could you interpret that statement?

p.s. to the other posters above, I agree that my 'ideas' are idealistic, and that more likely than not, my views on the matter will change dramatically in 4 years. I was just trying to 'dream up' what I thought was a better system than the one we have now, as per the title of the thread.

 

[bananamed]

I guess the best and brightest are no longer headed towards medicine. If this is the caliber of pre-meds coming up to medicine.

Let me repeat it since some of you have are a bit slow. There is no such thing as the ACOD. It's called the AAD.

I agree with the AAD's policies. We have enough dermatologists. Many choose to work part-time or go off into cosmetics. There's no need to oversaturate our field to allow for more inferior applicants.

Now, common sense, just from reading that statement, says that there is not enough spots. The way the ACOD is "phrasing" it sounds like pure self-interest. There should be enough spots to provide care at the actual productivity of graduating dermatologists. So, if half of graduates consistently decide to work part time, creating a shortage, then more spots should be opened up. (for instance, statistically women physicians work fewer hours than men over their lifetimes, but the seat quotas are based assuming equal productivity) Same if half of graduates started doing cosmetic procedures most of the time.

This would be like the equivalent organization for plastics surgeons saying "100 graduates a year is enough to do all medical reconstructive surgery...we don't need any more spots. It's not "our" fault that there is a huge shortage and patients are forced to pay the existing surgeons $1000/hour"

How else could you interpret that statement?

p.s. to the other posters above, I agree that my 'ideas' are idealistic, and that more likely than not, my views on the matter will change dramatically in 4 years. I was just trying to 'dream up' what I thought was a better system than the one we have now, as per the title of the thread.

 

[Squiggy]

If there isn't a shortage of dermatologists, there is definitely a shortage of medical derm care. If the AAD doesn't allow more dermatologists to be produced, then the govt. should lower reimbursements to lifestyle specialties like derm, encouraging insurers to follow suit, so that specialists increase their hours and meed society's demands. Also, if more physicians (ie. PCPs) dabbled in cash-based cosmetics there would be more price competition which would put pressure on derms and maybe plastic surgeons to commit more to the medicine they trained for.

 

[Habeed]

Squiggly : that won't work. Economics 101 says that if you lower the price paid for a good, you lower supply. Meaning the existing dermatologists would work fewer hours if you lowered reimbursements, long term.

Second, bananamed is a *******.

1. He claims that we have enough dermatologists when right now, everyone (himself included) acknowledges we do have a shortage. He uses the creative reasoning of "if all the dermatologists we have now magically started working full time at just derm, we would have enough"....ignoring the reality. That would be like hiring 10 women for a job and saying "we have enough employees, so long as no one takes time off for kids". Or ten men, and golf, same thing.
2. He claims that opening more seats would allow for "inferior applicants". Uh, news flash : any U.S. allopathic graduate who can do internal med can do derm. It's not that friggin hard relative to other specialties, and is probably a ton easier than surgery. Only reason you need ridiculous numbers to get derm is because everyone wants it.

 

[Squiggy]

Decreasing reimbursements has worked for primary care. Now PCPs, unless they work in a really large group practice or something work really long hours, increasing supply because they won't make a good living if they didn't.

The problem with derm is that if govt. and private insurance reimbursed crap, they can do lots of cash-based stuff on the side. If derm paid so poorly that you couldn't make a lot of money working part-time and the alternatives were shut out, I bet derms would increase the hours they worked just like PCPs, OB/Gyns, etc.

 

[BlondeDocteur]

Habeed, friend, it's screamingly obvious that

a) you were a re-applicant to medical school and had to do an SMP to get in;
b) you very recently landed an allopathic acceptance and have your nose stuck in whatever part of the atmosphere nimbus clouds populate;
c) you think all of the people who got spots ahead of you in no way deserved them.

There's nothing wrong with A, but B and C are problematic, and a thick envelope doesn't immediately convey complex knowledge of the demands, pressures, and sucessess of doctoring. You're free to express your opinions, but it's rather obvious that your attempts at reforming the system are entirely colored by your own frustrating experience with medical admissions. Just accept that most of us strongly disagree with you, and are reasoning rather than venting our collective spleens.

 

[Habeed]

Habeed, friend, it's screamingly obvious that

a) you were a re-applicant to medical school and had to do an SMP to get in;

Nope.

As for the rest of it : I guess no one here read macroeconomics 101...

 

[PeepshowJohnny]

Decreasing reimbursements has worked for primary care. Now PCPs, unless they work in a really large group practice or something work really long hours, increasing supply because they won't make a good living if they didn't.

The problem with derm is that if govt. and private insurance reimbursed crap, they can do lots of cash-based stuff on the side. If derm paid so poorly that you couldn't make a lot of money working part-time and the alternatives were shut out, I bet derms would increase the hours they worked just like PCPs, OB/Gyns, etc.

What the hell are you talking about? Decreasing reimbursement has led more and more PCP's to A) Retire B) try to convince other medical students not to go into primary care and C) Encouraged people to set up boutique practices that cater to a smaller number of wealthier patients.

And how is cutting dermatologist reimbursement going to discourage them from doing more cash based stuff. You say it's going to be "Shut out"...How? By encouraging primary care people to do them as you alluded to before? The kind of people who have the money to blow it on out of pocket treatments and procedures are going to make up their own minds, and I think most of them are going to pick the dermatologist.

This is madness!

 

[rockit]

Janette : just because something sounds unpopular to granola eating hippies doesn't mean it is a good idea.

If you have most cancers, statistically, you are not going to live long enough to pay pack the resources sunk into medical training.

The same goes if you are old.

If a candidate has dyslexia or ADD so severe they need special accomodation, exactly why should they be given charge of living patients?

Finally, almost all medical schools receive massive funding from local and state governments. Ultimately, that means tax dollars paid by American citizens. I want any kids that I have who want higher education to not have to 'compete' for slots with foreigners who aren't Americans.

I had cancer during med school you m-f'er. School that I managed to attend without getting a master's degree. So by your scale, I deserve to be admitted 8 times before you get a sniff at a spot.

 

[bananamed]

So which one is it Senator?

You say you don't want inferior people in medicine?

And then turn around and say it's okay for inferior residents in dermatology?

Can't have it both ways dimwit.

Squiggly : that won't work. Economics 101 says that if you lower the price paid for a good, you lower supply. Meaning the existing dermatologists would work fewer hours if you lowered reimbursements, long term.

Second, bananamed is a *******.

1. He claims that we have enough dermatologists when right now, everyone (himself included) acknowledges we do have a shortage. He uses the creative reasoning of "if all the dermatologists we have now magically started working full time at just derm, we would have enough"....ignoring the reality. That would be like hiring 10 women for a job and saying "we have enough employees, so long as no one takes time off for kids". Or ten men, and golf, same thing.
2. He claims that opening more seats would allow for "inferior applicants". Uh, news flash : any U.S. allopathic graduate who can do internal med can do derm. It's not that friggin hard relative to other specialties, and is probably a ton easier than surgery. Only reason you need ridiculous numbers to get derm is because everyone wants it.

 

[bananamed]

I had cancer during med school you m-f'er. School that I managed to attend without getting a master's degree. So by your scale, I deserve to be admitted 8 times before you get a sniff at a spot.

1. Definitely.

2. Habeed is a *****. I wouldn't worry. Obnoxious people who overrate their own ability (master's degree huh? I didn't need one of those either) tend to be cut down early. And if not, there's always 3rd year.

3. Hope your health is fine.

 

[Winged Scapula]

Users are asked to keep the conversation civil.

Please note that insulting other members is a violation of the SDN Terms of Service agreement.

 

[yumita]

I think that medical school, as well as higher education, should be highly subsidized by the gov't, with strict standardized criteria for admission, and strict standards for quality across the board. Most students would then attend schools close or closer to home and that would also cut costs. In exchange for an almost free education you are required to perform social service for a certain number of years in primary care after graduation. Similar to the FQHC but there would be more of them and a structured system of supervision and continuing education. Perhaps everyone would be able to complete a primary care specialty during these years, and receive a resident-like salary. This would vastly increase the availability of primary care physicians in underserved communities both because of those who are doing their service years, and because of all those who would realize that they enjoy their primary care gigs and why do another residency if it;s not necesary? Many countries have this type of arrangement and it works quite well.

 

[rockit]

Sorry about that, I get a little touchy when talking about it.

And my health is different, but I no longer have cancer. So all in all, I'm ok.

 

[bananamed]

Sorry about that, I get a little touchy when talking about it.

And my health is different, but I no longer have cancer. So all in all, I'm ok.

No worries, I think I was the one being reprimanded for potty mouth. Glad to hear you're ok.

 

[Habeed]

rockit : sorry for bringing up a touchy point. And, I can't imagine the cold, helpless feeling that you must have felt when you found you had cancer.

But I'm not changing my position. When you HAD cancer, your life expectancy was cut. What if there were a 20% chance that you did not survive 5 years? That means that there is a 20% chance that you wouldn't finish med school & internship...from a med school's point of view, that would be like taking someone with a 22 MCAT and a 3.0. Someone with numbers that low probably has a 20% chance of not finishing as well.

That's what I am getting at...if I ruled the world, decisions would be based on known facts, not things that sound good but are dumb.

 

[dragonfly99]

Habeed, the world is not black and white. The med school admissions process is not perfect. I too had to try 2x to get into med school, despite definitely having the numbers and volunteer work, etc. that one would think would get someone into a medical school. I don't think that banning cancer patients and anybody over 30 would make things more perfect...as is, I think that things like general health/fitness to practice medicine and sometimes the age of applicants does come into play. I would rather have an excellent 30 year old applicant in med school, vs. a marginal 22 year old (academically marginal or one who I am not sure has a clear concept of working in a medical setting, and has never had a real job, etc.). I think adcoms do their best to admit qualified students, but they are human and sometimes they will screw up no matter what system you design. I too have concerns about the very oldest med students (like over 40) but I think for every rule we make, there would be an exception to it and then we'd wish we hadn't made the rule...

If we only took 18 or 20 year olds into med school, I would not be a physician today. Some folks don't realize what their calling is until some time during college, or even later. Also, nobody here has mentioned that taking folks straight from high school would likely depress the number of quality URM applicants even more...many URM grew up in less affluent circumstances and are more likely than the average caucasian applicant to have attended a public school. Some are pretty good (like the one I attended) but we all know that some just aren't that great and don't have a lot of resources. I feel like starting med school at age 18 would lead to a further gentrification of medicine where doctor's kids and any kids of affluent families will be filling up the med school classes.

It is interesting to discuss these ideas, though. I am all for having multiple pathways to enter med school...some people do know at age 18 that this is what they want to do. We do have several 6-7 year med schools, and/or early guaranteed acceptance programs (numerous ones @various universities) so I don't feel like we need radical changes there.

One can argue there are way too few dermatologists - my dad has psoriasis and lives in a town of 35k people and there only seems to be one dermatologist in town, and it takes months to get an appointment. I think we'd probably be safe making a few more dermatologists...I think derm, though, is an extreme example of the physician supply problem. We could use a few more docs across all specialties, and this is being addressed by increasing med school sizes. Mainly, though, we have a physician distribution problem...plenty in most large cities, not enough everywhere else. We need to address this in a multifactorial way, including making it more attractive to work in nonurban areas. As is, it's more difficult in terms of harder work, and less support from specialists and technically advanced hospitals and imaging centers, etc. You can force docs on visas to work in these rural areas for a while, but some will leave when their term of service is over. We need to recruit more students from nonurban (or nonsuburban) areas, but also just make working conditions better in areas outside of cities, and be creative with recruiting, etc. to get docs out of the cities.

To squiggy, the person who said that decreasing primary care salaries has had the desired effect of making the docs work more and thus fixed the supply problem:
That is completely false. Downward pressure on reimbursements has caused some docs to work more, for a while, but it has also caused a lot of docs to quit doing primary care and either quit medicine altogether, lose their practice/business and be forced to become employed physicians (which will ultimately not likely save the health care system any money), start doing cosmetic procedures in place of primary care (like some family docs are doing). Probably most importantly, the crappy working conditions in primary care (and I'm not just talking about money) have driven many/most med students away from the primary care fields. In primary care, one is faced with a mountain of paperwork, hassles from insurance companies like prior authorizations, etc. as well as often a lack of respect from patients and sometimes from other health care providers. Also, one has to deal with drug seeking/addicted patients and other patients that no specialist wants to choose to deal with, so they turf the patients back to primary care doc. Primary care docs spend a lot of unpaid time filling out paperwork like family/medical leave act for sick patients' relatives, forms to get the patient a power wheel chair, etc.

If one looks at physician salaries, they were higher relative to the general population in the 1970's/80's than they are now, so the escalating costs of medical care in recent years really can't be due primarily to physician salaries...it would be neat and easy explanation if that were true, but it isn't really. Physician and nurse salaries, etc. do factor in to health care costs but there are many, many other factors. I think that redistributing some of the money in the health care system toward primary care would help us as a society, but that money has to come from somewhere. You could get a little by redirecting from the specialists to the primary care docs, but I think that looking at other areas like administrative costs, insurance company profits, home health costs, durable medical goods, etc. are likely more important.

Lastly, please, let's do keep this thread respectful and not resort to personal attacks, guys...

 

[Squiggy]

That's why I think we should move to a single payer system like the NHS or Canada. PCP's in Canada are earning more for their time than PCP's here while specialists here are still vastly overpaid compared to specialists in all other developed countries. Moving to a single payer system would be disastrous for the insurance industry but we'd basically be killing off the middleman. And moving towards a single-payer system wouldn't crush physician incomes either. NHS docs can make 100k pounds a year which is pretty much $200k here. You could just restructure reimbursements (simple in a govt-controled single-payer system) to physicians so that earnings from working full-time hover between an inflation adjusted $160k to $320k with exceptions for the specialities that require the most training or have the toughest jobs (i.e. surgery not derm). At the same time, the govt. could take measures to induce malpractice/tort reform.

Another thing the govt. could do is allow graduates to pay tuition for GME and bypass quotas set by individual specialties' boards. Not only will this correct any physician shortages, but you would truely be letting the free market decide physician incomes as prices will adjust (based on reimbursements) to the markets of different specialists. The AAD may say that demand is being met, but what they say doesn't mean crap unless they have empirical proof. Obviously they'd say there's enough derms: their bottom line is at stake. You don't need to be an exceptionally bright med student to be a derm. My PCP basically takes up all the derm work where I live. Maybe for something like surgery and it's subspecialties you do. A group like the AAD is operating just like a union monopoly; they're no better for society than an entity like west coast longshoremen.

But the best quick-fix for giving primary care a boost would be to cut reimbursements to specialties (ROAD) in order to fund reimbursement increases to primary care (and maybe ob/gyn and GS as well). Hopefully something like that gets done while Obama's in office if not anything else.

 

[dragonfly99]

I don't have super strong opinions about socialized medicine/single payer vs. not, but I don't think anyone should assume it will be a panacea.

Canada, for example, has about a 12 month waiting period to get a CABG for unstable angina, and the rate of death while waiting for the operation is much higher than here in the US. The socialized medical systems don't really reward one person for working harder than another, and don't really reward things like speed and efficiency. That's the counterpoint to the oft-quoted infant mortality rate difference between our country and others.

There are no perfect systems and we just have to realize that...whether single payer benefits are > single payer system's detrimental aspects I think is in the eye of the beholder.

 

[KluverB]

I think that medical school, as well as higher education, should be highly subsidized by the gov't... In exchange for an almost free education you are required to perform social service for a certain number of years in primary care after graduation... This would vastly increase the availability of primary care physicians in underserved communities both because of those who are doing their service years, and because of all those who would realize that they enjoy their primary care gigs and why do another residency if it;s not necesary? Many countries have this type of arrangement and it works quite well.

Many countries do have these types of arrangements, but you're kidding yourself to think that physicians in those countries like these "return-of-service" arrangements. They are simply forced into it. If given the choice they end up specializing, OR moving to the US.

Then again, in most of these countries there is indeed a slight (or not so slight) oversupply of doctors. It's fairly easy when education is free (or next to free; ie. paid for by taxpayers). Also, payscales post-training are a lot lower. It's nice to not have any loans to pay back. However, there is an old adage that states that you get what you pay for. If something becomes worth less, it will also become less competitive. Medicine is not the romantic career it used to be. It's a service industry. Why would anyone want to do primary care for peanuts is beyond me. You really have to enjoy you work, all the paper work, the hours, the potential for lawsuits (see other thread), the malingerers, etc. I suppose if doctors made less money they would become targets of lawsuits much less often. Who would want to sue if they weren't going to get anything out of the system? That could be an advantage.

That's why I think we should move to a single payer system like the NHS or Canada. PCP's in Canada are earning more for their time than PCP's here while specialists here are still vastly overpaid compared to specialists in all other developed countries.... NHS docs can make 100k pounds a year which is pretty much $200k here. ...

Specialists in Canada make a lot more than PCPs, as well. Canada, however has it's own problems, as eluded to elsewhere.

100k pounds is a lot, esp. when you have no loans to pay back. However, also isn't entirely a single payer system... Like the rest of Europe it allows for a two-tiered system... Cash is king, for everything else there is the NHS. 🙂

The system here is rigged. The class divide is just to vast, getting wider, and in no danger of going away anytime soon.

 

[SocialistMD]

I can't find the thread because it was probably over 5 years ago or so when it existed, but we had this discussion a long time ago and I agree with BlondeDocteur about some sort of work experience time off prior to entering medical school. I worked a full-time job all through college (which, under some of the plans suggested here, would have made it impossible for me to double-major or dedicate the study-time needed for the first year courses I would be taking in my final year of college), but even that was not enough "work experience" to qualify for what was truly eye-opening. I took a year off and worked as a pharmacy technician in a neonatal ICU. It wasn't the clinical experience (of which there was some, as the neonatologists all knew I was going to medical school the following year and allowed me to attend rounds and work on their research projects in my spare time), but rather the life experience I gained from that year that made me into a (I feel) much more well-rounded and mature person; a person who didn't care if my classmates had previously had cancer or were over 30 or were from another country or had a handicap/learning disability or anything else the is not 22 and fresh out of college.

Most of my class had at least one year out of college where they actually did something, be it work at a bank and play a lot of softball or as an ED nurse or a chemist at his dad's dairy or an Army Ranger, that had nothing to do with school or grades or competition. And, by the way, that list of people doesn't only include some of the junior AOAers in my class (as was the guy in my class who was hearing impaired), but each one of them is a truly great physician to whom I would go if I had a disease treated by his/her respective specialty because they have a perspective on medicine and life that I don't think they would have had they gone straight to medical school right out of college. There is a lot to be said for life experience, as less than 5% of the US population is a physician, but nearly 100% of us have to live in the real world (whether we choose to acknowledge it or not), and to know what that is like can help us make a family cry one less tear, convince a patient to take one more lap around the floor, etc...

 

[Excelsius]

Some of you guys sound like you'd like to destroy medicine. The physician shortage is the reason why doctors have high salaries, in part. If we fixed that problem, we'd have a massive drop in compensation. Lower compensation > people of lower caliber flocking to medicine, less competent doctors and poorer outcomes.

...

Interesting. I just brought up this very point in another thread. Can you please explain what makes you think that this is true? I think that you and others who think alike are wrong. First, there is a LOT of demand for doctors. The shortage is even becoming dangerous with the geriatric population now filling up with baby boomers. Second, as you know, we have capitalism. You can't try to artificially control competition and get away with that. Think. Why do you think chiros, doctor nurses, and CRNAs keep popping up left an right? How do you think DOs came to exist? They are all there to fill in the void created by this senseless, artificial inflation. AMA does not = de Beers where they are artificially regulating the prices of diamonds. At least those guys are businessmen. What does your average premed-->medstudent-->resident-->doctor know about business and economics? Judging by the situation the doctors are in right now, not much. Average salaries have either been stagnant or eroding. My proposal is to start an organization that will prevent these people from making any decisions about the rest of us. It's a disaster that can't continue.

To the person talking about foreigners as if they are inferior: the majority of US grad students are immigrants. They are there due to their hard work. Instead of trying to prevent them from getting degrees thereby crashing the US economy, you'd be better off to think about ways to encourage American students to be more involved in the sciences and be more competitive. You should probably start by overhauling the entire educational system.

 

[BlondeDocteur]

I think that you and others who think alike are wrong.

Charming way of putting it.

Second, as you know, we have capitalism. You can't try to artificially control competition and get away with that.

The professions exist by erecting barriers to entry around themselves by means of training and licensure. Some say this is precisely a euphemism for controlling competition. And yes, you can get away with it quite well.

Think.

OK.

Why do you think chiros, doctor nurses, and CRNAs keep popping up left an right?

Precisely because the aforementioned boundaries are not particularly strong or well-policed. Or, in the other view, to fill critical shortages and to reward experience with the same perks as education.

How do you think DOs came to exist? They are all there to fill in the void created by this senseless, artificial inflation.

This is emphatically NOT how osteopathy began. In the late nineteenth century there was a great deal about medicine that was not particularly evidence-based, and differing philosophies of healing were circulating. Osteopathy had as good of results, if not better, than many contemporary allopathic therapies (caustic drugs, mercury, doping everyone up with laudanum, etc). The fact that the two now teach a near-identical curriculum reflects less a triumph of one paradigm over another rather than a convergence of the two towards empiric, scientific medicine.

Regardless, "senseless artificial inflation" does not create voids.

What does your average premed-->medstudent-->resident-->doctor know about business and economics? Judging by the situation the doctors are in right now, not much. Average salaries have either been stagnant or eroding.

You might remember that the invisible hand corrects disparities. Perhaps average salaries were artifically high earlier? Regardless, this is a very poor index of the average state of business savvy amongst doctors.

My proposal is to start an organization that will prevent these people from making any decisions about the rest of us.

So... a medical Gestapo, squelching the average doctor with his biology degree and 1-2 courses in econ from speaking out about poplicy matters related to the profession? Locking the AMA in an iron fist? What exactly would this do, and how would preventing other people from making decisions leads to the decisions you want made, made?

To the person talking about foreigners as if they are inferior: the majority of US grad students are immigrants. They are there due to their hard work. Instead of trying to prevent them from getting degrees thereby crashing the US economy...

Foreign graduate students earning PhDs in chemistry and computer science do not, in any way, crash the US economy.

If I remember correctly you're currently 19 or so, taking general requirements at a community college. While all posters are welcome (after all, this is the residency forum and I'm a medical student) it would behoove you to speak a little less authoritatively on subjects of which you have absolutely no firsthand knowledge.

 

[Excelsius]

Charming way of putting it.

The professions exist by erecting barriers to entry around themselves by means of training and licensure. Some say this is precisely a euphemism for controlling competition. And yes, you can get away with it quite well.

OK.

Precisely because the aforementioned boundaries are not particularly strong or well-policed. Or, in the other view, to fill critical shortages and to reward experience with the same perks as education.

This is emphatically NOT how osteopathy began. In the late nineteenth century there was a great deal about medicine that was not particularly evidence-based, and differing philosophies of healing were circulating. Osteopathy had as good of results, if not better, than many contemporary allopathic therapies (caustic drugs, mercury, doping everyone up with laudanum, etc). The fact that the two now teach a near-identical curriculum reflects less a triumph of one paradigm over another rather than a convergence of the two towards empiric, scientific medicine.

Regardless, "senseless artificial inflation" does not create voids.

You might remember that the invisible hand corrects disparities. Perhaps average salaries were artifically high earlier? Regardless, this is a very poor index of the average state of business savvy amongst doctors.

So... a medical Gestapo, squelching the average doctor with his biology degree and 1-2 courses in econ from speaking out about poplicy matters related to the profession? Locking the AMA in an iron fist? What exactly would this do, and how would preventing other people from making decisions leads to the decisions you want made, made?

Foreign graduate students earning PhDs in chemistry and computer science do not, in any way, crash the US economy.

If I remember correctly you're currently 19 or so, taking general requirements at a community college. While all posters are welcome (after all, this is the residency forum and I'm a medical student) it would behoove you to speak a little less authoritatively on subjects of which you have absolutely no firsthand knowledge.

You definitely must be confusing me with someone else. I haven't been 19 or in a CC in a while. I am a non-trad student and I have worked in three different fields, including several years in the corporate America. So in a way, I have more experience in work and economics than the large number of residents who did not work much, if at all, before they started med school. I also don't know the reason you mentioned the CC, but I have been through four different institutions, including a year at a top school, if that's supposed to mean more than the CC...

You also misunderstood my comments about immigrants. What I meant was that if you suddenly STOP all these immigrant from getting a higher education, which I think the poster was suggesting, it would impact the US economy very negatively. America is strong because we import some of the smartest people around the world. We deal with this issue regularly in one of my jobs in law.

Ok. I think we realize the same thing, but we choose to interpret it differently. You are saying that the existence of professionals like CRNAs is because AMA is weak. I am agreeing with you, but I am also taking it further and saying that AMA cannot do much about it because when there is extreme shortage in something in a capitalistic system, it is almost a guarantee that something else will appear to fill in the void. That's how all these fields came to exist, and they are directly competing with doctors. With their numbers rising, the salaries of doctors will be affected more significantly. AMA has not been serving doctors well since over the years things have only been getting worse. Public relations is virtually non-existent. Maybe that's why when I tried to do a short survey of some patients, most of them rated their chiropractors and nutritionists higher than they rated their doctors, even those patients who are wealthy. A new organization would not be a Gestapo, but it should set up some general guidelines for doctor's conduct and police those doctors who would do nothing but harm the field with their views. You are right, non of us in here are economists, but I have seen no evidence whatsoever that artificially decreasing the number of doctors (to a point) actually translates to higher salaries. The new organization would have to employ some of the brightest lawyers and economists to find out what is the best path to take and exactly how much artificial decrease in supply is safe. If you do it too much, not only the salaries are not going to be kept safe since others start to substitute doctors, but you have the basic authority of doctors erode when a nurse claims he can do the same that an anesthesiologist can do. That might create a snowball effect.

I hope you understand that my proposal is there to benefit doctors and patients. AMA as an organization is pretty powerless and it has no value. I don't know why it still exists and exactly what is its function. The number one issue right now is to halt the insurance company's encroachment on doctor-patient relationship. AMA isn't doing much, if anything. I think doctors are not united and that's why nothing can be achieved. And having an efficient organization with large number of doctor participants is not the same as unionizing. Don't forget that if doctors want power, they must have a great relationship with the public. Why? Because public=constituents=power. Have you ever seen a politician blatantly telling something to the public that the public might not like? Any doctor organization should approach the public as if it is a political organization. The only way for doctors to regain power is to go through Washington with force, and you can't go through Washington when most of the constituents dislike doctors.

I am willing to hear as to what your proposal is for the solution and exactly what about my plan is wrong. This very same thing is being discussed in this thread, where the OP is an older attending - much more knowledgeable about the problems than most of us. He actually has tried to change the system, unsuccessfully.

 

[Doowai]

Having gone through something like cancer can make someone a better physician by creating empathy, a more sincere and believable bedside manner which helps a patient feel the importance of obtaining proper care, being a more driven physician to help overcome bureacracy etc which stands in the way of patients obtaining care, etc

 

[Squiggy]

I've always wanted to make a new medical profession (to add on to MD/DO), using some wacky supplementary technique/ideology like OMM as a marketing tool. We'd have the same educational/training system as either of the two professions. However, our specialist boards would not have training quotas and if we can't secure funding, we'd allow graduates to pay tuition to fund residencies.

The major challenges the profession would face would be fending off litigation from the AMA/AOA, having attendings help to set up residencies, and then building up rapport with the govt. and insurers to order to secure payers.

Like the DO's we'd pump graduates into primary care first and later spread into the specialties.

We'll cause the physician shortage to abate and we'll be breaking the oligopoly medical professionals hold. With increased supply, both the government and insurers could cut their reimbursements.

Of course, this profession may not be neccessary as DNPs could do this job. If they can fortify their position as PCPs and make their educational/training model reflexive of physicians, I doubt the govt. or insurers/HMOs would resist their expansion into the specialties.

 

[kingalls]

Great idea - I'm in. Can we call our new field, based on some 'wacky supplementary technique like OMM' ..."Chiropractic"?

 

[Squiggy]

We won't be using OMM as our wacky technique. Maybe something like acupuncture that may or may not work but won't harm patients even if it doesn't work. A placebo of sorts.

The main idea is that the profession will be practicing real medicine. The OMM-like thing will just be a marketing ploy that distinguishes us from allopathic/osteopathic medicine. We'll cannabalize MD/DO primary care attendings first to acquire comparable training, proliferating as we have new attendings traing more graduates and so on. Once we gain public recognition and have a good piece of the primary care market share we'll move on to the specialties.

Kingalls- When you're a rads attending we'll pay you to be our preceptor/residency training person.

 

[yumita]

Are you stuck in the 80's? Acupuncture is as effective, or more so, than western medicine in the treatment of a long list of health problems. That is, if you can believe those hippies at NIH and the WHO...

 

[SouthernSurgeon]

The program I am in isn't medical school. It is just a creative way to waste a year for a chance to get into med school (which I didn't need, thank god)

So piecing together your various claims on this thread, you're in an SMP but you don't "need" to be? Well then you're just wasting a bunch of time and/or money...

 

[exPCM]

The best change in residency would be to stop the current system where the Medicare GME funding is given directly to the hospitals at ~100+ K per slot average nationally (IME AND DME).
Here is an old table for the years 2001 - 2005 shown with the 2001 data first : http://www.graham-center.org/online...s.Par.0001.File.tmp/dt-teaching-hospitals.pdf
When looking at the total amount that a hospital is receiving per resident you have to add the DME and IME payments to the hospital and then divide by the total number of residents at the hospital. Unfortunately this is not done in the above table but you can figure it out on your own.

I would change the system to where 100K+ per year of funding was given to each resident and that the residents could then negotiate with residency programs for the best deal (in terms of much of the money they would pay to the program and how much the resident could keep, work hours, benefits, quality of training, grounds for termination, etc.)

Here is great article rom 1996 which discusses the issues which led to President Clinton capping residency spots due to hospitals using residents as cash cows.
http://content.healthaffairs.org/cgi/reprint/15/2/250.pdf
" Graduate medical education in this country is a heavily subsidized enterprise. The GME "market" is not a "free market" in any classical sense but rather a publicly supported work-study program, with tax dollars enhancing the already significant labor value of residents. Hospitals have responded to these incentives as one might expect, by increasing the number of residency positions by 25 percent since 1988. One can argue that Medicare GME funding is good policy or bad policy, but it is hard to make the case that it is not a very "hands-on" federal policy that provides major financial incentives to U.S. teaching hospitals. As such, it is expensive,
influential, and a fair subject for public scrutiny and modification."
Here are some GME funding primers: http://www.amsa.org/pdf/Medicare_GME.pdf and
www.aadprt.org/training/GME/GME_Financing_Summary.rtf

 

[Substance]

If I ruled the world, I'd have Flordia renamed "Bonerland" because it kind of looks like a boner.

Thuh end.

 

[KluverB]

Are you stuck in the 80's? Acupuncture is as effective, or more so, than western medicine in the treatment of a long list of health problems. That is, if you can believe those hippies at NIH and the WHO...

Not sure where you're getting your data. Acupuncture is as at best as effective, or more so, as non-procedural placebo.

 

[yumita]

Not sure where you're getting your data. Acupuncture is as at best as effective, or more so, as non-procedural placebo.

????

 

[yumita]

Not sure where you're getting your data. Acupuncture is as at best as effective, or more so, as non-procedural placebo.

http://news.bbc.co.uk/1/hi/health/4111047.stm

http://www.ncbi.nlm.nih.gov/pubmed/17875198

http://www.who.int/medicinedocs/en/d/Js4926e/

 

[NotAProgDirector]

http://news.bbc.co.uk/1/hi/health/4111047.stm

http://www.ncbi.nlm.nih.gov/pubmed/17875198

http://www.who.int/medicinedocs/en/d/Js4926e/

The first link references a single Annals article from 2004.

Of note, there are two more recent Annals articles:

This one describes another RCT. This one is a meta-analysis. Both show that acupuncture was no better than placebo.

The second article is a study comprising 30 patients, and no sham acupuncture was performed, so it is impossible to separate placebo effect from real benefit.

The third is simply a list of many small studies, many of which are poorly done.

My bottom line: There is no convincing evidence that acupuncture is effective. This does not mean that it's ineffective, simply that it has never been convincingly proven effective. This is due to 1) a large placebo effect, 2) difficulties with blinding, 3) small study sizes, 4) short followups, and 5) lack of uniformity of the intervention (i.e. not everyone performs acupuncture in the same way.

Just to be fair, if you change "acupuncture" to "SSRI", you get a similarly true statement. SSRI's are the new placebo.

 

[pdp2001]

first two years of med school should be finished while in undergrad, everyone should have to take a NBME shelf exama as finals. get rid of the stupid MCAT (what a waste of money). you're only qualifying exam for med school should be your step 1 score. first year of med school should be rotations, second year should pretty much be an intern med/surg year.

haven't quite figured out where applying for residency should go since that takes a ridiculous amount of time and money. also, i seem to have axed the only good part of med school which is fourth year...

 

[Substance]

If I ruled the world:

1. We'd go back to the rotating year. After medical school graduation, an intern does a general rotating year. Once this year is complete, a resident can practice as a general practitioner.


2. Should said resident feel, at any particular point in his future, that he is more interested in another specialty, that resident is free to apply to the match to pursue said goal, knowing full well they will be making a resident's salary.


3. The match is open to ANYONE who has completed the general rotating year, for as many attempts at the match as desired.


4. The salary for a general practitioner will be $250,000. After 5 years in practice, it will increase to $350,000. Furthermore, any specialist will make $400,000. I believe these are respectable figures. If there's 900 billion for the bailout, there's enough to pay physicians these values.


5. Eliminate the vernacular term and specialty of "family medicine". It is not a specialty. General medicine is not a specialty. It is general medical knowledge that any physician should be able to apply. Unfortunately, our current educational and medical climate does not see this point. If every physician does not have the ability to manage usual medical situations that one would encounter in a clinic, however mundane, I fail to see the point of medical school in the first place.