Lawsuit Alleges Practicing Physicians Block New Residency Program

[Obnoxious Dad]

I agree that you're paid based on the markets value of you. That is why physicians want to prevent flooding the field and driving their wages down. If people were waiting a year to see the doctor because the US was cranking out 10 doctor a year and the average salary of a US doctor was 10 million a year I would agree with you. Right now supply and demand is set up to where the salary of physicians is closer to what most physicians think is fair for their work and education.

Why don't we focus on the responsibilities that fall on the patient? If they don't want to wait to see a specialist they can make an appointment somewhere else and travel there. If you move to the middle of nowhere you should expect to have to travel to see doctors. Why should the market get flooded and ruined so that people aren't responsible for their choices in life?

The salary that physicians think is "fair" is perfectly irrelevant. Crazy baseball fans thought that Jordan Zimmerman's salary of $24 million per year was "fair" in spite of the fact that Zimmerman didn't do anything for it other than remain on the disabled list.

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[deleted1100659]

The salary that physicians think is "fair" is perfectly irrelevant. Crazy baseball fans thought that Jordan Zimmerman's salary of $24 million per year was "fair" in spite of the fact that Zimmerman didn't do anything for it other than remain on the disabled list.

You have yet to say what a fair salary would be for physicians

 

[Obnoxious Dad]

Well that is the one thing I agree with you about; the the cost of medical school is absurd and is one of the reasons we have to have a good salary, otherwise we would be in debt for the rest of our lives. But its not a barrier to entry; federal loans are widely accessible and few people who want to be a doctor give up on that idea because of the cost, they just go into massive debt like half of the attendings on SDN.

If anything, DO schools over recruit. The attrition at a fair number of DO schools is much higher then you know. In my class out of 150 around 25 people couldnt survive how rigorous it was and had to leave/be dismissed, and they left with a sizeable loan burden. If anything DO schools are often too generous.

We need to be if anything, more rigorous with who gets accepted. Medical school is no joke, its quite hard, and it only gets harder after that. If you don't make it you end up with six figure debt and nothing to show for it. Thats a huge a price to pay for a dream that didnt pan out. Not as many people are as qualified as you think.

From an economic perspective, not a legal perspective, the price of tuition is in fact an entry barrier.

The attrition problem at medical schools stems from the idiotic admissions process and not the applicant pool. Medical schools recruit bon vivants and social justice warriors rather than scientists and then the faculty is aghast that some students can't hack the science. If you look at the DO thread concerning GPA and MCAT statistics, you will see that the GPAs among matriculating DO students are almost as high as the GPAs among MD students but the average MCAT scores are abysmal. Furthermore, at both MD and DO schools physical science majors actually have GPAs that are the same as other matriculants but the MCAT scores of physical science majors are higher.

 

[Obnoxious Dad]

You have yet to say what a fair salary would be for physicians

The salary that's fair is measured in the same way that everybody else's salary is measured i.e. whatever clears the market.

 

[deleted1100659]

From an economic perspective, not a legal perspective, the price of tuition is in fact an entry barrier.

The attrition problem at medical schools stems from the idiotic admissions process and not the applicant pool. Medical schools recruit bon vivants and social justice warriors rather than scientists and then the faculty is aghast that some students can't hack the science. If you look at the DO thread concerning GPA and MCAT statistics, you will see that the GPAs among matriculating DO students are almost as high as the GPAs among MD students but the average MCAT scores are abysmal. Furthermore, at both MD and DO schools physical science majors actually have GPAs that are the same as other matriculants but the MCAT scores of physical science majors are higher.

But how is it a barrier to entry? I financed my entire medical school education through loans, I had 1,000 in savings when I started. I also financed my own college through working/scholarships. I dont understand how it prevents people from entering. I didnt have money when i started. My parents didnt pay for any of it.

The second part is school dependent. The newer DO schools have significantly lower matriculant GPAs.

 

[nimbus]

The salary that's fair is measured in the same way that everybody else's salary is measured i.e. whatever clears the market.

Glad that’s settled.


So back to the original topic. If I’m a private practice orthopedist who can do a total knee replacement in 50 minutes, can do 6/day, be done by 3pm, and clear $1mil/year, what is the incentive for me to start teaching residents, do them in 2 1/2hrs, cut my own productivity, and have them set up shop across the street when they finish?

 

[Obnoxious Dad]

Glad that’s settled.


So back to the original topic, if I’m a private practice orthopedist who can do a total knee replacement in 50 minutes, can do 6/day, be done by 3pm, and clear $1mil/year, what is the incentive for me to start teaching residents, do them in 2 1/2hrs, cut my own productivity, and have them set up shop across the street when they finish?

Did you get trained or did you just buy a manual? Training residents is a choice that physicians make because they enjoy teaching and want to be a part of academic medicine. Apparently, you don't feel the same way and that's just fine. However, if HCA wants to start a residency program and can find the board certified physicians to train residents, that's HCA's business.

 

[Neopolymath]

Glad that’s settled.


So back to the original topic, if I’m a private practice orthopedist who can do a total knee replacement in 50 minutes, can do 6/day, be done by 3pm, and clear $1mil/year, what is the incentive for me to start teaching residents, do them in 2 1/2hrs, cut my own productivity, and have them set up shop across the street when they finish?

I would love for Obnoxious Dad and Co to have their job outsourced and keep up this line of thinking. Ah, yeah, I forgot that only doctors are expected to do this job for free as a calling. Hell, we should pay for the privilege of being a doctor.

 

[Obnoxious Dad]

But how is it a barrier to entry? I financed my entire medical school education through loans, I had 1,000 in savings when I started. I also financed my own college through working/scholarships. I dont understand how it prevents people from entering. I didnt have money when i started. My parents didnt pay for any of it.

The second part is school dependent. The newer DO schools have significantly lower matriculant GPAs.

Let me help you out.

Britannica Money

barriers to entry, in economics, obstacles that make it difficult for a firm to enter a given market. They may arise naturally because of the characteristics of the market, or they may be artificially imposed by firms already operating in the market or by the government. Natural barriers to entry

www.britannica.com

"barriers to entry, in economics, obstacles that make it difficult for a firm to enter a given market. They may arise naturally because of the characteristics of the market, or they may be artificially imposed by firms already operating in the market or by the government.

Natural barriers to entry usually occur in monopolistic markets where the cost of entry to the market may be too high for new firms for various reasons, including because costs for established firms are lower than they would be for new entrants, because buyers prefer the products of established firms to those of potential entrants, or because the industry is such that new entrants would have to command a substantial share of the market before they could operate profitably. Because they are effectively shielded from competition, established firms in monopolistic markets are able to charge higher prices. That fact is one of the main reasons why governments regulate monopolistic industries such as utilities, airlines, and insurance, among others.

Artificial barriers to entry may arise when firms in a certain market engage in practices that make it more difficult for other firms to enter. For example, established firms may participate in predatory pricing by deliberately lowering their prices to prevent new entrants from making a profit. Artificial barriers also arise when a certain industry is protected by government regulations, licenses, or patents."

 

[nimbus]

Did you get trained or did you just buy a manual? Training residents is a choice that physicians make because they enjoy teaching and want to be a part of academic medicine. Apparently, you don't feel the same way and that's just fine. However, if HCA wants to start a residency program and can find the board certified physicians to train residents, that's HCA's business.

I watched a few YouTube videos

Tbh some people like to teach and some don’t and not everybody is a good teacher. Teaching should be a choice. OrthoSC made their choice. No big deal. HCA should recruit others to be professors of orthopedic surgery. Good luck to them.

 

[nimbus]

Let me help you out.

Britannica Money

barriers to entry, in economics, obstacles that make it difficult for a firm to enter a given market. They may arise naturally because of the characteristics of the market, or they may be artificially imposed by firms already operating in the market or by the government. Natural barriers to entry

www.britannica.com

"barriers to entry, in economics, obstacles that make it difficult for a firm to enter a given market. They may arise naturally because of the characteristics of the market, or they may be artificially imposed by firms already operating in the market or by the government.

Natural barriers to entry usually occur in monopolistic markets where the cost of entry to the market may be too high for new firms for various reasons, including because costs for established firms are lower than they would be for new entrants, because buyers prefer the products of established firms to those of potential entrants, or because the industry is such that new entrants would have to command a substantial share of the market before they could operate profitably. Because they are effectively shielded from competition, established firms in monopolistic markets are able to charge higher prices. That fact is one of the main reasons why governments regulate monopolistic industries such as utilities, airlines, and insurance, among others.

Artificial barriers to entry may arise when firms in a certain market engage in practices that make it more difficult for other firms to enter. For example, established firms may participate in predatory pricing by deliberately lowering their prices to prevent new entrants from making a profit. Artificial barriers also arise when a certain industry is protected by government regulations, licenses, or patents."

Moats are the American way. Warren Buffett talks about this all the time and he’s become a folk hero.

 

[DOVinciRobot]

Did you get trained or did you just buy a manual? Training residents is a choice that physicians make because they enjoy teaching and want to be a part of academic medicine. Apparently, you don't feel the same way and that's just fine. However, if HCA wants to start a residency program and can find the board certified physicians to train residents, that's HCA's business.

That’s not what HCA did in this scenario. It would appear they tried to stiff arm the private group they are contracted with at that location to be faculty for said program and said private group said no and now HCA is pissy about it. Unless it’s already explicitly in their group contract it’s delusional to believe these private orthopods are somehow obligated to help HCA develop a program.

HCA wants nothing more than their own employed physicians they can control. Which is fine, but they don’t get to force private physicians to train their replacements.

 

[nimbus]

The bashing of HCA in some of the posts here is just a red herring. The physicians in the article aren’t taking a stand on the basis of HCA’s “terrible business model” or past legal liabilities. They’re explicitly taking a stand because they don’t want competitors. In other words, they want to continue to artificially limit patients’ options for their own financial gain. There’s no reason at all to think that they would be supportive of a potential residency program that were started by, say, a non-profit. They simply don’t want more orthopedic surgeons around to treat patients.

Regarding the topic of salaries: The artificially high salaries of American physicians are merely a symptom of a more serious underlying problem: the monopolization of healthcare services. And the physicians who are fighting for continued monopolization in order to keep their salaries artificially high (e.g., the physicians in the article) are contributing to this problem. Nobody here is saying that physician salaries in and of themselves are a “top 10” problem.

Do you see similar bashing of Cleveland Clinic, Mayo, MD Anderson here? There’s a reason why HCA and Tenet are regularly bashed.

 

[deleted1100659]

Let me help you out.

Britannica Money

barriers to entry, in economics, obstacles that make it difficult for a firm to enter a given market. They may arise naturally because of the characteristics of the market, or they may be artificially imposed by firms already operating in the market or by the government. Natural barriers to entry

www.britannica.com

"barriers to entry, in economics, obstacles that make it difficult for a firm to enter a given market. They may arise naturally because of the characteristics of the market, or they may be artificially imposed by firms already operating in the market or by the government.

Natural barriers to entry usually occur in monopolistic markets where the cost of entry to the market may be too high for new firms for various reasons, including because costs for established firms are lower than they would be for new entrants, because buyers prefer the products of established firms to those of potential entrants, or because the industry is such that new entrants would have to command a substantial share of the market before they could operate profitably. Because they are effectively shielded from competition, established firms in monopolistic markets are able to charge higher prices. That fact is one of the main reasons why governments regulate monopolistic industries such as utilities, airlines, and insurance, among others.

Artificial barriers to entry may arise when firms in a certain market engage in practices that make it more difficult for other firms to enter. For example, established firms may participate in predatory pricing by deliberately lowering their prices to prevent new entrants from making a profit. Artificial barriers also arise when a certain industry is protected by government regulations, licenses, or patents."

I mean all you did was spew out definitions for me,,,,not what I asked at all. I didnt ask for the definition. I asked how the financial aspect was a barrier considering im proof that your theory doesnt hold up.

The money aspect didnt make it significantly harder to enter medical school, it just made it significantly harder to pay back the loans from medical school, and when people such as yourself advocate for lower physician salaries, it makes it even harder to become debt free.

If youre not willing to work hard to get into medical school, then you probably dont have the work ethic to survive it/be a good doctor.

 

[ACSurgeon]

On why it’s ignorant to heavily implying that lower SES folks are not as smart as affluent folks or why it’s ignorant to say it doesn’t matter if lower SES populations aren’t represented in medicine despite that meaning minorities will disproportionately be less represented?

This is a complex question.

Are people from lower SES genetically less smart? No.

Has the environment of lower SES folks limited their intellectual growth and academic abilities? Probably. I thought that’s the entire premise of the discussion, that rich people having access to tutors and resources gives them a leg up. This doesn’t start in the premed phase. It starts as soon as your born. That’s what my wife wants me to believe anyways and why she makes me spend so much for the kids pre-school education. Getting into and through medical school requires an academic foundation and a level of discipline that is nurtured more in educated and affluent families. I say this based on my limited experience with my own extended family and seeing the academic accomplishments of my cousins with educated parents compared to those whose parents weren’t college educated.

Regarding having low SES represented in medicine. I understand this to a limited extent. I don’t know that you can expect the average low SES child to grow up and get into and through medical school because of the factors above. They have inferior public schools in the inner city compared to rich suburbs let alone compare to expensive private schools. Am I missing something here? So then med schools try to make up for this by taking people from different racial backgrounds. Again my limited experience is that many people who take advantage of these opportunities are kids of a minority background with better financial means that the average person in a low SES class. Maybe they share a race and thus they are “disadvantaged socially” (in quotes because I don’t mean to be disrespectful and I don’t know if there is a more PC way to convey this, and because I agree that biases exist), but I’m not sure that these students represent the average person from their racial group.

 

[Matthew9Thirtyfive]

This is a complex question.

Are people from lower SES genetically less smart? No.

Has the environment of lower SES folks limited their intellectual growth and academic abilities? Probably. I thought that’s the entire premise of the discussion, that rich people having access to tutors and resources gives them a leg up. This doesn’t start in the premed phase. It starts as soon as your born. That’s what my wife wants me to believe anyways and why she makes me spend so much for the kids pre-school education. Getting into and through medical school requires an academic foundation and a level of discipline that is nurtured more in educated and affluent families. I say this based on my limited experience with my own extended family and seeing the academic accomplishments of my cousins with educated parents compared to those whose parents weren’t college educated.

Doing better on the MCAT doesn’t necessarily mean you are smarter. That should be pretty obvious. Two people of equal intellect who take the MCAT are likely to get drastically different scores if one has access to tutors and prep classes with nothing to do but study, and the other one has to study between work and school.

The solution to systemic issues creating inequity in education is not to say that lower SES folks won’t have the means, so tough **** if they can’t make it. The solution is to fix it (which is in itself a complex issue).

Regarding having low SES represented in medicine. I understand this to a limited extent. I don’t know that you can expect the average low SES child to grow up and get into and through medical school because of the factors above. They have inferior public schools in the inner city compared to rich suburbs let alone compare to expensive private schools. Am I missing something here? So then med schools try to make up for this by taking people from different racial backgrounds. Again my limited experience is that many people who take advantage of these opportunities are kids of a minority background with better financial means that the average person in a low SES class. Maybe they share a race and thus they are “disadvantaged socially” (in quotes because I don’t mean to be disrespectful and I don’t know if there is a more PC way to convey this, and because I agree that biases exist), but I’m not sure that these students represent the average person from their racial group.

Med schools trying to take people from different racial backgrounds is approaching the problem from the wrong end, but because it’s easier than actually fixing the problem so that these kids don’t grow up being forced through a ****ty school system and set up for a much more difficult path to the same place, that’s all that’s done.

 

[ACSurgeon]

Doing better on the MCAT doesn’t necessarily mean you are smarter. That should be pretty obvious. Two people of equal intellect who take the MCAT are likely to get drastically different scores if one has access to tutors and prep classes with nothing to do but study, and the other one has to study between work and school.

The solution to systemic issues creating inequity in education is not to say that lower SES folks won’t have the means, so tough **** if they can’t make it. The solution is to fix it (which is in itself a complex issue).

Med schools trying to take people from different racial backgrounds is approaching the problem from the wrong end, but because it’s easier than actually fixing the problem so that these kids don’t grow up being forced through a ****ty school system and set up for a much more difficult path to the same place, that’s all that’s done.

I agree with you. And as far as I know med schools try to factor in life circumstances rather than just look at numbers, and many med school essays try to ask about that. I’m not at all involved in any admission process as a community physician, so not speaking as an admissions authority.

I think people of lower SES have their intellectual growth limited by their circumstances. So, it’s hard to say if they have equal intellect as adults when they had limited opportunities for growth their entire childhood. I don’t know how to account for that from the admissions end, because you need some objective way to know the student can handle the rigors of med school so GPA/MCAT will have to be part of the process.

I don’t think med schools have the ability to fix this problem. This is a societal problem overall, and we need better public schools and opportunities for people early in life. I don’t believe you can make up for this easily later in life at the pre-med phase. So, I agree there’s a problem but it’s not with our medical profession, it’s with our government and society overall.

 

[Matthew9Thirtyfive]

I don’t think med schools have the ability to fix this problem. This is a societal problem overall, and we need better public schools and opportunities for people early in life. I don’t believe you can make up for this easily later in life at the pre-med phase. So, I agree there’s a problem but it’s not with our medical profession, it’s with our government and society overall.

Totally agree.

 

[nimbus]

Doing better on the MCAT doesn’t necessarily mean you are smarter. That should be pretty obvious. Two people of equal intellect who take the MCAT are likely to get drastically different scores if one has access to tutors and prep classes with nothing to do but study, and the other one has to study between work and school.

The solution to systemic issues creating inequity in education is not to say that lower SES folks won’t have the means, so tough **** if they can’t make it. The solution is to fix it (which is in itself a complex issue).

Med schools trying to take people from different racial backgrounds is approaching the problem from the wrong end, but because it’s easier than actually fixing the problem so that these kids don’t grow up being forced through a ****ty school system and set up for a much more difficult path to the same place, that’s all that’s done.

Some people are savants at standardized tests. They tend to have very high IQs.

 

[Matthew9Thirtyfive]

Some people are savants at standardized tests. They tend to have very high IQs.

That doesn’t really change anything I said.

 

[dnyal]

Of course a pre med would say that.

Yeah, if it weren't for the fact that I already have a foreign medical degree and practiced medicine in my native, middle-income country for many years for 3.5x the minimum wage there (and no, it doesn't even adjust for cost of living: I wasn't able to live on my own or even afford a car). I definitely didn't go into medicine (and not going at it again!) for the money, but hey, that's just me.

 

[nimbus]

Not full. They accept people below median stats and favors legacies too. Multiple leaderships can be achieved very easily by knowing the right people which is easy for them. Same thing for multiple papers, research/academia suffer badly from nepotism too. The real winners are those who got into such schools without that privilege or advantage

Some legacies with below median stats may have been admitted but there were probably even higher numbers of URM admitted with below median stats. The SFFA v Harvard revealed that both were true in the case of Harvard undergrad admissions. This came at a cost to ORMs.

 

[Lawpy]

Some legacies with below median stats may have been admitted but were probably even higher numbers of URM admitted with below median stats. The SFFA v Harvard revealed that both were true in the case of Harvard undergrad admissions. This came at a cost to ORMs.

I actually don’t think that’s true but if it happens in some schools, i count that as a huge win. I think legacy admissions should be permanently banned and removed completely because their only value is to stroke the egos of wealthy medical education leaders by pleasing the donors and getting more money for the schools. Getting more minorities and lower (and frankly middle) SES people into medicine is a massive net gain for medicine

 

[nimbus]

I actually don’t think that’s true but if it happens in some schools, i count that as a huge win. I think legacy admissions should be permanently banned and removed completely because their only value is to stroke the egos of wealthy medical education leaders by pleasing the donors and getting more money for the schools. Getting more minorities and lower (and frankly middle) SES people into medicine is a massive net gain for medicine

I agree. Go MIT and Caltech!

I’d love to see the median stats broken down by race, SES, and legacy status at HMS but it would probably require another lawsuit for such data to be released.

 

[deleted1100659]

I agree. Go MIT and Caltech!

I’d love to see the median stats broken down by race, SES, and legacy status at HMS but it would probably require another lawsuit for such data to be released.

median mcat scores by race are public data as well as gpa, legacy status isnt though. I dont think the legacy status is a huge deal at most schools though

 

[nimbus]

Yeah, if it weren't for the fact that I already have a foreign medical degree and practiced medicine in my native, middle-income country for many years for 3.5x the minimum wage there (and no, it doesn't even adjust for cost of living: I wasn't able to live on my own or even afford a car). I definitely didn't go into medicine (and not going at it again!) for the money, but hey, that's just me.

For many years? Are you sure?

I skipped senior year of high school, went straight through undergrad/med school/residency and didn’t finish until I was 29.

I am not 35, but I am 31 and became a sophomore after last Spring. I am married and my spouse works full time (no children), so he is able to support me. I don't work because I am taking like 15 credits per semester (a few less over the summers to keep me from getting burnt out) while involved in clubs and volunteering, on top of family responsibilities and house chores. So, I supplement our income with student loans (my savings were gone in the first year).

It is doable. My husband is very supportive and that truly gives me motivation.

 

[nimbus]

median mcat scores by race are public data as well as gpa, legacy status isnt though. I dont think the legacy status is a huge deal at most schools though

Link?

 

[deleted1100659]

2023 FACTS: Applicants and Matriculants Data

These FACTS tables present data on U.S. medical school applicants and matriculants.

www.aamc.org

looks like for AA average percentile is around 65th for matriculants, cucasian 85th percentile, and asian even higher. This is for USMD not DO.

 

[nimbus]

2023 FACTS: Applicants and Matriculants Data

These FACTS tables present data on U.S. medical school applicants and matriculants.

www.aamc.org

looks like for AA average percentile is around 65th for matriculants, cucasian 85th percentile, and asian even higher. This is for USMD not DO.

Thanks. Would love to see school specific data. Here’s Harvard undergrad FWIW. It’s funny the average rejected Asian applicant
has higher scores than the average accepted applicant in most other groups. And despite having the highest average scores in the applicant pool, Asians had a lower overall acceptance rate than any other group.

Asian-American Harvard Admits Earned Highest Average SAT Score of Any Racial Group From 1995 to 2013 | News | The Harvard Crimson

Over an 18-year period stretching from 1995 to 2013, Asian-American students admitted to Harvard scored higher on the SAT than did their peer admits from other racial groups, according to data released in the admissions trial.

www.thecrimson.com

 

[Spine MD]

I'm a native of SC and still live here.

I'm going by size of hospital (Grand Strand is significantly smaller than MUSC and Prisma Upstate and Midlands, the places that have Ortho already).

Catchment area, I use MSA as a rough measure. Columbia, Charleston, and Greenville are all significantly larger by that measure.

Look, we don’t need more orthos per se and especially not via HCA. But let’s discuss facts and not gestalt: MB’s MSA is 2nd fastest growing in the country. MSA of 500K and growing.

 

[VA Hopeful Dr]

Look, we don’t need more orthos per se and especially not via HCA. But let’s discuss facts and not gestalt: MB’s MSA is 2nd fastest growing in the country. MSA of 500K and growing.

None of what I posted was gestalt, both of those measures were hard numbers.

 

[Spine MD]

None of what I posted was gestalt, both of those measures were hard numbers.

Agree, it's also true that the cities/MSA you mentioned are larger still.

 

[nimbus]

What makes you think that "the vast majority of medical school faculty don't do ANY volunteer work or community service?" I mean, your interviewer is almost certainly volunteering their time to interview you...and many physicians who teach on clinical rotations or give occasional pre-clinical lectures at medical schools are volunteering to do so. Also most medical school and residency faculty are often asked to be on hospital committees and advisory councils, again for free. There are also plenty who do medical missions, take on pro bono work/cases, and so on, not to mention that they're working probably 60-80 hours a week providing direct patient care...

I’ve been practicing over 30 years and volunteering for 20 yrs. In my experience, the vast majority of practicing doctors don’t volunteer. There are always excuses, kids, family obligations, etc, etc. I’m just pointing out the hypocrisy. In my training program, there were a few who volunteered but it was less than 20% in a clinical setting. Committee meetings are just a fact of life in modern medical practice. They are not community service.

 

[ChordaEpiphany]

Not sure how this thread went from "greedy physicians" to full on "affirmative action dumpster fire debate" in the span of a few days, but getting back to the original point, I never see the most compelling financial arguments for why physician compensation is as high as it is in the states. I only ever see morality and hard work arguments, which mean squat.

1) The reimbursement market is artificially low. It's absurd to expect physicians to compete with free market labor supply in a market that artificially limits demand/reimbursement via regulation. If you want to know what true free market healthcare would look like, look at law. Poor people just get garbage legal counseling (or none at all), and rich people are willing to pay out the nose for something valuable to them. In a free market we'd train far more physicians and providers. Top physicians would be charging FAR more for their services, they'd cater exclusively to the upper class, and they'd spend far more time per patient. Then there would be a massive range of providers of all levels who cater to the other classes at different price points. The lower class would get, at best, palliative care. I'm not saying it should be this way, but if you're asking for free market conditions...

2) Physicians in the states are paid at a similar income percentile compared to European countries. Salaries in Europe in ALL professions are peanuts compared to the US, even in the middle class. A top 1% income in the UK is ~£175K ($230K). A top 1% income in the US is ~$360K. According to this study (if you adjust for currency/inflation), attendings in the UK are making ~$240K (much of that from private/locum work) while attendings in the US are making ~$320K. Meanwhile, attendings in the US are saddled with more debt and shorter careers.

3) Opportunity cost brings physician salaries down 30-40% from the "raw" number. If you actually consider net present value, or if you run a financial simulation, the length of training and loans associated with medical school bring US physician incomes down ~30-40% compared to other college-educated career tracks. You may make ~$300K, but in order to catch up on lost savings (and missed compounded interest) and pay down debt, you effectively make closer to $200K if you're comparing to a "normal" career, even with extra education like a masters.

So for @Osminog who is so offended by "monopolization" of healthcare service, I'd urge you to look at regulation that has actually monopolized the way we are reimbursed for medical care.

For @7331poas, who is offended by "cartel" behavior by physicians, I'd urge you to think about why you are arguing in favor of free market principles only when it harms physicians' bottom line, but not when it would benefit them. I think we have to acknowledge that healthcare is one of those sectors of the economy that doesn't work perfectly on a free market. That means someone is basically artificially deciding what physicians are paid (and those people work for CMS to set rates, which dictate rates for private insurance as well). This makes @ACSurgeon's point (below) even more salient.

How do you define “market value” for physicians?

Why does an investment banker make as much as they do? Why is that their “market value”

Why do hospital administrators make what they make?

When someone sacrifices their 20’s and 30’s to train in a pressure cooker environment with little room for error or breaks and finally learn a skill set they can work with to heal humans, what do you think is a fair price for the sacrifice and for their unique skill?

A physician bills 2-3 million dollars worth a year and gets paid a small fraction of that. If employed, the physician earns his/her employer a ton more more in the way of labs, imaging studies, having patients staying in the hospital, procedure/OR fees and much more. So I ask again, how do you define market value?

 

[Proudfather94]

Not sure how this thread went from "greedy physicians" to full on "affirmative action dumpster fire debate" in the span of a few days, but getting back to the original point, I never see the most compelling financial arguments for why physician compensation is as high as it is in the states. I only ever see morality and hard work arguments, which mean squat.

1) The reimbursement market is artificially low. It's absurd to expect physicians to compete with free market labor supply in a market that artificially limits demand/reimbursement via regulation. If you want to know what true free market healthcare would look like, look at law. Poor people just get garbage legal counseling (or none at all), and rich people are willing to pay out the nose for something valuable to them. In a free market we'd train far more physicians and providers. Top physicians would be charging FAR more for their services, they'd cater exclusively to the upper class, and they'd spend far more time per patient. Then there would be a massive range of providers of all levels who cater to the other classes at different price points. The lower class would get, at best, palliative care. I'm not saying it should be this way, but if you're asking for free market conditions...

2) Physicians in the states are paid at a similar income percentile compared to European countries. Salaries in Europe in ALL professions are peanuts compared to the US, even in the middle class. A top 1% income in the UK is ~£175K ($230K). A top 1% income in the US is ~$360K. According to this study (if you adjust for currency/inflation), attendings in the UK are making ~$240K (much of that from private/locum work) while attendings in the US are making ~$320K. Meanwhile, attendings in the US are saddled with more debt and shorter careers.

3) Opportunity cost brings physician salaries down 30-40% from the "raw" number. If you actually consider net present value, or if you run a financial simulation, the length of training and loans associated with medical school bring US physician incomes down ~30-40% compared to other college-educated career tracks. You may make ~$300K, but in order to catch up on lost savings (and missed compounded interest) and pay down debt, you effectively make closer to $200K if you're comparing to a "normal" career, even with extra education like a masters.

So for @Osminog who is so offended by "monopolization" of healthcare service, I'd urge you to look at regulation that has actually monopolized the way we are reimbursed for medical care.

For @7331poas, who is offended by "cartel" behavior by physicians, I'd urge you to think about why you are arguing in favor of free market principles only when it harms physicians' bottom line, but not when it would benefit them. I think we have to acknowledge that healthcare is one of those sectors of the economy that doesn't work perfectly on a free market. That means someone is basically artificially deciding what physicians are paid (and those people work for CMS to set rates, which dictate rates for private insurance as well). This makes @ACSurgeon's point (below) even more salient.

Unfortunately I feel that our health care system is starting to head that way with insurance companies and the government slashing how much they pay physicians every year. Experienced private practice physicians can demand cash payments and redirect pts with low money or crappy insurance to new physicians. This would increase the risk of things being misdiagnosed or missed and when the new doctor gets enough experience they can switch to cash only as well and continue the cycle.

 

[ChordaEpiphany]

Unfortunately I feel that our health care system is starting to head that way with insurance companies and the government slashing how much they pay physicians every year. Experienced private practice physicians can demand cash payments and redirect pts with low money or crappy insurance to new physicians. This would increase the risk of things being misdiagnosed or missed and when the new doctor gets enough experience they can switch to cash only as well and continue the cycle.

I don't think it's heading that way at all. As long as a large amount of the market is funded through socialized or subsidized and highly regulated insurance, you can't support the market for healthcare through direct cash payments on a large scale. Many of the wealthier people are 65+, and they're on Medicare which pays less for healthcare than it even costs to provide. Medicare also serves as a fantastic bargaining tool for private insurance.

So basically the government says, "By law we provide tax-funded insurance to about 50% of the total market, including the demographic who would be your best paying customers. We know most of you can't stay afloat without this market segment, so we negotiated this horrendous rate of reimbursement." Then the private insurance says, "Well if Medicare is paying X, I'm not paying much more than that, and you really need me because Medicare is ripping you off already."

Overall, this is actually a great deal for both CMS and for private insurance. They are paying far less than a classic market rate for medical services. Then they skim off the top and charge consumers what they are actually willing to pay for high quality medical care (which is still less than what 65+ year olds would be willing to pay if they weren't on Medicare). So the existence of Medicare basically eliminates any possibility of a system like law in medicine or of widespread concierge medicine.

I'm not saying Medicare is bad. I'm saying Medicare is a massive departure from the free market. If you are going to define the "market value" of a physician, it's pretty obvious that our current system does not capture that value in pure revenue and profits. Many people would be willing to pay a lot more for high quality healthcare in a free market, and not many more people would be willing to put in physician work-ethic/training years to get there. Therefore, claiming that physicians are forming "cartels" is misguided at best and exploitative at worst. Expecting physicians to sit back calmly and experience full-on free market supply of labor while accepting a completely rigged reimbursement system is a hell of a take. For those who espouse these views, it shows an enormous level of entitlement towards others' hard work.

 

[deleted1100659]

Lets throw out a crazy hypothetical situation here. Lets say , I dunno, a pandemic hits due to a relatively unknown virus at the time. Everyone else gets to quarantine and stay home. Physicians dont share in that luxury. How much value does that provide, this insurance policy, knowing that when things go south doctors are still working at hospitals?

Most people who fund their own medical school will be well over 300k in debt at around 6 percent daily compounding interest. The interest on my medical school debt is well over 1k a month. I lose 1/3 of my salary to uncle sam each year, not to mention being a doctor in itself there is often all these hidden expenses. How many people would realistically put themselves through intense training/potential hell for at least 12 years to come out with a salary of 100k a year, when there is a plethora of jobs that would easily pay that and require significantly less training? I suspect mankind does not have that amount of altruism/stupidity.

When there is a physician shortage in many areas, and a psychiatrist shortage in most, lowering the pay seems counterintuitive to fixing the problem. Maybe the really self righteous people on here would be willing to work 100 hours a week for free to set an example for me while simultaneously filling in healthcare needs.

 

[Proudfather94]

I don't think it's heading that way at all. As long as a large amount of the market is funded through socialized or subsidized and highly regulated insurance, you can't support the market for healthcare through direct cash payments on a large scale. Many of the wealthier people are 65+, and they're on Medicare which pays less for healthcare than it even costs to provide. Medicare also serves as a fantastic bargaining tool for private insurance.

So basically the government says, "By law we provide tax-funded insurance to about 50% of the total market, including the demographic who would be your best paying customers. We know most of you can't stay afloat without this market segment, so we negotiated this horrendous rate of reimbursement." Then the private insurance says, "Well if Medicare is paying X, I'm not paying much more than that, and you really need me because Medicare is ripping you off already."

Overall, this is actually a great deal for both CMS and for private insurance. They are paying far less than a classic market rate for medical services. Then they skim off the top and charge consumers what they are actually willing to pay for high quality medical care (which is still less than what 65+ year olds would be willing to pay if they weren't on Medicare). So the existence of Medicare basically eliminates any possibility of a system like law in medicine or of widespread concierge medicine.

I'm not saying Medicare is bad. I'm saying Medicare is a massive departure from the free market. If you are going to define the "market value" of a physician, it's pretty obvious that our current system does not capture that value in pure revenue and profits. Many people would be willing to pay a lot more for high quality healthcare in a free market, and not many more people would be willing to put in physician work-ethic/training years to get there. Therefore, claiming that physicians are forming "cartels" is misguided at best and exploitative at worst. Expecting physicians to sit back calmly and experience full-on free market supply of labor while accepting a completely rigged reimbursement system is a hell of a take. For those who espouse these views, it shows an enormous level of entitlement towards others' hard work.

What can physicians do to stop or slow the cuts?

 

[Dr G Oogle]

What can physicians do to stop or slow the cuts?

We can all collectively “retire” for a week and show everyone what a world without doctors would be like.

 

[Proudfather94]

We can all collectively “retire” for a week and show everyone what a world without doctors would be like.

Would there be a way to do it that wouldn't effect pts in a negative way? I just feel that if things keep going the way they are these pts are going to get screwed with not being able to find a physician who will take them and it isn't even their fault.

 

[deleted1100659]

Would there be a way to do it that wouldn't effect pts in a negative way? I just feel that if things keep going the way they are these pts are going to get screwed with not being able to find a physician who will take them and it isn't even their fault.

Its illegal for physicians to go on collective strike is my understanding, but I think that poster was being more facetious.

We need more awareness geared towards the public of what we do, and how we get to the point of where we are. Perhaps that would also help in regards to people playing doctor themselves via google. Exposing the ridiculous tutition costs/expenses of medical school, and calling people out for it/holding them responsible. I know this would never happen. but schools with ridiculous price tags, id love to see a boycott of them. See what happens when the dean doesnt get that 700k paycheck for sitting on his butt all year.

We need to work together as physicians and advocate for change, putting aside political differences and focusing on the big picture. I think many physicians have become complacent, and we hope some white knight politician or doctor will swoop in and make it better but that will never happen.

 

[Matthew9Thirtyfive]

Its illegal for physicians to go on collective strike is my understanding, but I think that poster was being more facetious.

We need more awareness geared towards the public of what we do, and how we get to the point of where we are. Perhaps that would also help in regards to people playing doctor themselves via google. Exposing the ridiculous tutition costs/expenses of medical school, and calling people out for it/holding them responsible. I know this would never happen. but schools with ridiculous price tags, id love to see a boycott of them. See what happens when the dean doesnt get that 700k paycheck for sitting on his butt all year.

We need to work together as physicians and advocate for change, putting aside political differences and focusing on the big picture. I think many physicians have become complacent, and we hope some white knight politician or doctor will swoop in and make it better but that will never happen.

As long as people chase prestige, that kind of boycott will never happen. There are plenty of people who will gladly pay half a million dollars to say they went to HMS.

 

[7331poas]

We can all collectively “retire” for a week and show everyone what a world without doctors would be like.

Janitors can say the same...

 

[ChordaEpiphany]

What can physicians do to stop or slow the cuts?

Something we can all do is work on reforming the medical training pipeline. This can be done internally and does not require justifying to rent-seeking admins or legislators why doctors require high compensation. So many people are reaching into your pockets before you even start making this "super high" salary that is under so much fire, and those people are physicians, usually physicians who are groveling to administrators for scraps (or just blindly following prestige).

Starting to save a decade later can literally halve the amount of money you earn. Combined with loans, our own leadership has effectively given us all 30% pay cuts just in expectations of longer training time.

Over the past 10-20 years a few key changes have occurred in the training pipeline.

1) Medical school tuition. It has risen far beyond the cost of inflation.

2) Gap years and research years. Adcoms, residencies, and fellowships have started to value "gap years." This has created a CV arms race that pushed the average age to start medical school up by ~2 years. People looking to match competitive specialties are now taking research years regularly, and tons of residencies are incorporating non-clinical research years, even for people who aim to do no research in practice.

3) Additional clinical training. Additional fellowship training is encouraged or required for many jobs, again pointing to a CV arms race that delays your earning years. This does not increase pay compared to older physicians who perform the same tasks, but qualified through experience instead of formal education.

Below I used a FIRE calculator to compare the net worth of a physician who went to med school under conditions common in the 80s and 90s (no gap years, no research years, residency with no fellowship, $100K in loans) vs. a student today, who takes 2 gap years after college, accumulates $350K in loans, takes an extra research, and takes on additional fellowship training after residency to get a job. All of it is adjusted for inflation, of course, and both of these physicians is extremely financially savvy, saving 30% of take home pay as an attending ($350K) and 10% as a resident ($55K).

This amounts to a 35% pay cut over the course of your career. Now I know many of you will defend gap years, research years, etc... But go ahead and look into the careers of current boomer physicians (even those in high places). Why do these people who insist that you must do all this training not have that training themselves? How come in 1984 you could go to medical school with nothing but a GPA and MCAT score and match into ortho with nothing but decent grades, but today you need a laundry list of accomplishments, full time jobs, and extra years for research?

Medical students and residents today are getting robbed on both ends. It's not sustainable, and it doesn't serve a true purpose. 84% of us will go on to be community physicians. Even among academic physicians, most will do vast majority clinical work. As an MD/PhD, I am all for research experiences for clinicians, but I don't see why this can't be done concurrently with medical training or integrated more gracefully with research rotations.

For people like @7331poas, changes to these practices would serve the community quite well also, because it would expand the practicing physician workforce. This is something we should all be able to get behind.

 

[7331poas]

snip

Yeah but did you account for how much money we all made on GME calls?

 

[Proudfather94]

Something we can all do is work on reforming the medical training pipeline. This can be done internally and does not require justifying to rent-seeking admins or legislators why doctors require high compensation. So many people are reaching into your pockets before you even start making this "super high" salary that is under so much fire, and those people are physicians, usually physicians who are groveling to administrators for scraps (or just blindly following prestige).

Starting to save a decade later can literally halve the amount of money you earn. Combined with loans, our own leadership has effectively given us all 30% pay cuts just in expectations of longer training time.

Over the past 10-20 years a few key changes have occurred in the training pipeline.

1) Medical school tuition. It has risen far beyond the cost of inflation.

2) Gap years and research years. Adcoms, residencies, and fellowships have started to value "gap years." This has created a CV arms race that pushed the average age to start medical school up by ~2 years. People looking to match competitive specialties are now taking research years regularly, and tons of residencies are incorporating non-clinical research years, even for people who aim to do no research in practice.

3) Additional clinical training. Additional fellowship training is encouraged or required for many jobs, again pointing to a CV arms race that delays your earning years. This does not increase pay compared to older physicians who perform the same tasks, but qualified through experience instead of formal education.

Below I used a FIRE calculator to compare the net worth of a physician who went to med school under conditions common in the 80s and 90s (no gap years, no research years, residency with no fellowship, $100K in loans) vs. a student today, who takes 2 gap years after college, accumulates $350K in loans, takes an extra research, and takes on additional fellowship training after residency to get a job. All of it is adjusted for inflation, of course, and both of these physicians is extremely financially savvy, saving 30% of take home pay as an attending ($350K) and 10% as a resident ($55K).

View attachment 346939

This amounts to a 35% pay cut over the course of your career. Now I know many of you will defend gap years, research years, etc... But go ahead and look into the careers of current boomer physicians (even those in high places). Why do these people who insist that you must do all this training not have that training themselves? How come in 1984 you could go to medical school with nothing but a GPA and MCAT score and match into ortho with nothing but decent grades, but today you need a laundry list of accomplishments, full time jobs, and extra years for research?

Medical students and residents today are getting robbed on both ends. It's not sustainable, and it doesn't serve a true purpose. 84% of us will go on to be community physicians. Even among academic physicians, most will do vast majority clinical work. As an MD/PhD, I am all for research experiences for clinicians, but I don't see why this can't be done concurrently with medical training or integrated more gracefully with research rotations.

For people like @7331poas, changes to these practices would serve the community quite well also, because it would expand the practicing physician workforce. This is something we should all be able to get behind.

With the oversupply of premeds begging to get in I don't think tuition is going to change. It seems like every field has the same issue of having those at the top who squeeze every ounce of money and productivity from those beneath them and creates a market to where you are either at the top getting a ton of undeserved wealth or are at the bottom busting your butt and wondering why you can't live like your parents or grandparents did at your age even though you are following in their footsteps.

 

[Dr G Oogle]

Would there be a way to do it that wouldn't effect pts in a negative way? I just feel that if things keep going the way they are these pts are going to get screwed with not being able to find a physician who will take them and it isn't even their fault.

No, there is no way to do it with having bad patient outcomes, so only a day of “no doctors” would showcase the societal value we provide. In most cases of doctor strikes the critically Ill and infirm remain in the care of physicians, but all non-emergent care (most care in the US) comes to a complete halt. I doubt the same could be said about janitors as my friend @7331poas postulates. Not to state that janitorial work is demeaning or not worthy of respect, but most of us can mop our own floors and pick up our own trash. Most of us can’t take out our own appendix or treat our own cradiac disease. There have been plenty of editorials written on the ethics of doctors to strike, and the public, corporate overlords, etc like to use the ethics argument. But what most of the editorials conclude is that it would be unethical for the ability to strike to not be given to doctors. Sometimes drastic means are needed to see reason.

 

[ChordaEpiphany]

No, there is no way to do it with having bad patient outcomes, so only a day of “no doctors” would showcase the societal value we provide. In most cases of doctor strikes the critically Ill and infirm remain in the care of physicians, but all non-emergent care (most care in the US) comes to a complete halt. I doubt the same could be said about janitors as my friend @7331poas postulates. Not to state that janitorial work is demeaning or not worthy of respect, but most of us can mop our own floors and pick up our own trash. Most of us can’t take out our own appendix or treat our own cradiac disease. There have been plenty of editorials written on the ethics of doctors to strike, and the public, corporate overlords, etc like to use the ethics argument. But what most of the editorials conclude is that it would be unethical for the ability to strike to not be given to doctors. Sometimes drastic means are needed to see reason.

Agreed. We lost janitors in my research building for 6 months over the pandemic. Yes, floors got a little dirtier, but life went on. We appointed someone in the lab to take the trash out to the dumpster at the end of each day, and we convinced someone from facilities to give us a key to the closet where supplies were kept. It was inconvenient, but no one died, which is why janitors are allowed to strike.

The idea behind a strike is, "We don't work, we don't get paid, but neither does the employer, and in the long term it should result in better working conditions and better pay." Why not have a system where doctors can work, but anything they order can't be billed? This would have to extend to billing ancillary services as well, of course, but it would have a major impact and allow doctors to negotiate. Feels like something you could easily work into a bill. You don't even have to get everything, just fracture the billing cycle enough to be disruptive to the hospital bottom line. Maybe that's what the AMA should work on instead of creating a code of ethics that says doctors can't strike...

 

[Dr G Oogle]

Agreed. We lost janitors in my research building for 6 months over the pandemic. Yes, floors got a little dirtier, but life went on. We appointed someone in the lab to take the trash out to the dumpster at the end of each day, and we convinced someone from facilities to give us a key to the closet where supplies were kept. It was inconvenient, but no one died, which is why janitors are allowed to strike.

The idea behind a strike is, "We don't work, we don't get paid, but neither does the employer, and in the long term it should result in better working conditions and better pay." Why not have a system where doctors can work, but anything they order can't be billed? This would have to extend to billing ancillary services as well, of course, but it would have a major impact and allow doctors to negotiate. Feels like something you could easily work into a bill. You don't even have to get everything, just fracture the billing cycle enough to be disruptive to the hospital bottom line. Maybe that's what the AMA should work on instead of creating a code of ethics that says doctors can't strike...

Not billing or disrupting the billing demonstrates value to the employer but not to society. Only cancelling all elective (I.e anything not immediately life threatening including cancer care, non emergent cardiac procedures, and various QOL and preventive care) even for a day would clearly demonstrate value of doctors to society. Even the idea of this is so abhorrent to most people that it is enough to illustrate what value society doctors provide. Nobody would care if bankers, corporate people etc would walk off the job, teachers and nurses strikes are painful but there are ways to deal with them; look no further than current nursing shortages, painful but manageable. But if docs walk off it’s an unmitigated disaster.

I very much believe health care is a right, but the rights of the deliverers of health care especially the ones who go into steep debt and give up their 20s and often chunk of their 30s is no less important.

 

[ChordaEpiphany]

With the oversupply of premeds begging to get in I don't think tuition is going to change. It seems like every field has the same issue of having those at the top who squeeze every ounce of money and productivity from those beneath them and creates a market to where you are either at the top getting a ton of undeserved wealth or are at the bottom busting your butt and wondering why you can't live like your parents or grandparents did at your age even though you are following in their footsteps.

There were tons of pre-meds pounding down the door when boomers were applying too, but their loans were 1/4 the size of ours (adjusting for inflation). It was never about the demand for medical school. The greatest/silent generations just had a lot more class. There has always been an incentive for raising tuition costs, and it could easily go higher.

Tuition isn't even the main issue though. It actually has a relatively low effect overall. My problem with high tuition is mostly that it discourages entry into primary care. If you cut tuition in half today so that most med schools were ~$30K/year, you'd still take ~$60K in loans each year. In fact, here's how everything from $60K tuition to free tuition + stipend affects your earnings.

Eliminating tuition entirely actually only results in a 14% bump in career wealth. Eliminating the extra years along the pipeline while keeping tuition completely stable results in an additional 36%. The CV arms race and all these extra expected years is actually costing us more than pay cuts or tuition.

Again, I'd be fine with extra years if I felt they truly served a valuable purpose for our education. Instead they seem to be methods for filling high-skill positions with low-pay individuals, making some C-suite hospital administrator and/or medical school dean very happy.

To get back to the original post, physicians guarding their turf in this way is actually fine. We don't need tons and tons of trainees, but administrators and others who profit off of med students and residents would love to see an explosion of this cheap and abundant labor.