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What you're proposing would require making every physician in this country a government employee. Who in their right mind would want to do that for life?
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What you're proposing would require making every physician in this country a government employee. Who in their right mind would want to do that for life?
I agree. Who said physicians shouldn't be well paid? And who said that the cost of medical education shouldn't be at least partially subsidized?
That said, how do we get from the SDN "it's a privilege, you are entitled to nothing" mantra to the above?
~Concierge~ Which, now, even hospitals systems are starting to adopt (so you won't have as much control, but you cut out a large part of the middlemen)
Also, a large part of NHS' financial troubles is all the non-medical middle-managers. A gov't system doesn't cut down on meddling
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You mean as opposed to all the ways physicians are currently constrained by private sector pressures that influence and create a tight circle around what you can and can't do? People seem to just get hysterical at any mention of "the government."
Not necessarily. private entities can exist alongside public ones and the public ones can be local, not just federal. The point is that everyone has access to care. The single, federal NHS-style option is one of many
Going into the profession is a privilege. The amount of time/energy/effort + the fact that other people's lives hang in your judgement is why physicians do deserve adequate compensation. By virtue, I guess that in it's own way is a right. Look at any field that has that sort of stress in it. Their compensation will be high.
Also, I'm not sure how much subsidizing the cost of medical education will help. As has been pointed out before, there's no such thing as a free lunch. Subsidizing medical education costs means that somewhere down the line, something else will cave. Whether that's the amount of faculty, infrastructure, ect. That is yet to be seen.
Well, if you think **** is bad now, just look at the military health system.
It won't get better by going down the government control route.
Listen, I think physicians should make a lot of money (and I also think students have devoted 4-5 years to getting in med school and have hit or exceeded some competitive targets should get a seat in med school). I wonder if the backlash here is more about money or more about control. And if it's the latter, you're going to feel controlled in substantial ways whether everyone has healthcare as a right or not.
The bleeding of arrogance and indignance does disturb me. We've got 20-somethings who are very smart also presuming they've inherited wisdom (because most certainly haven't earned it). That's another "biological" fact. 50 year olds tend to have a bit more wisdom to mix with their intellects than 20-25 year olds.
I'm sure it's a bit of both, but can you blame physicians for it? The general public/politicians don't have to worry about practicing or applying the changes the government makes and so to them it's all "theory" that what they're doing/lobbying is for the better good. But as we've seen with EMR, and ACA, a theory is not always practical. I think this is where a lot of resentment of ACA/politicians/insurance companies come from on the physician sideof things. Despite the large outcry, no real effort has been made to make healthcare better utilizing physicians opinions. There's a reason why every physician who has practiced in the 80's and 90's have advised young aspiring physicians to select an alternative path from medicine. The common phrase being "medicine isn't what it used to be, it's a ****show"
Yes, there are many problems with the private sector, but private systems do at least have to be responsive to their employees concerns. I work in a lab at a major academic hospital. Our health insurance is subsidized and tiered according to your salary, so I pay $22/month for my health insurance plan. I get 30 paid days off/yr. And plenty of other benefits. The private sector does have to worry more about pleasing their employees, or they will walk. They create incentives to keep people around. Basically they have control, but they can only push too far and they work to mitigate the negatives controllers that are tied to gov't enforced medicaid/medicare measures (eg. creating methods in which physicians can offload paperwork in order to have more time with patients). Not to mention, before the past decade of gov't measure, private practice was a more viable option
And it is a mix of money and control. Many gov't systems (like where we are headed) set guidelines for treatment, such that physicians are limited in their ability to make clinical decisions and then efficiency measures (which come from private sector and gov't forces) cause physicians to see too many patients.
http://www.nytimes.com/2016/01/10/business/doctors-unionize-to-resist-the-medical-machine.html?_r=0 This was actually an interesting case where hospitalists unionized to keep more control over how many patients they see in a day, which they chose over getting an increased salary
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For the record, I believe physicians should have more autonomy, great pay AND everyone should be able to receive healthcare.
My father, a gen surgeon AND a Republican-conversative, who practiced during the good ol' days, believed that single payer was inevitable (and desirable).
As for the 30 days of leave, that's bundled leave, correct? Sounds good in the private company brochure, but that includes personal and sick time bundled with vacation time. I've worked for private vendors. They have total control over you and it's not easy to walk either. Delve deeper into the private sector taking over the medical and mental health services in prisons and jails in this country. Ask correction officers, police officers, etc if they would prefer to be privatized.
Ok
As I said before, there is a whole lot more overlap than not. We're talking about slightly non-overlapping bell curves here. Also, nowhere did I say men are more intelligent than women. They have their own strengths and weaknesses, in aggregate, but when looking at measures of "overall intelligence" (say IQ) there really is no statistically significant difference the two. A "wash" in other words.
What? I said nothing about race. The IQ race gap is a very different topic. That conversation has very little to do with genetics. And stop with the implications that I think "white men" are some kind of superior breed.
Genetics are the interaction of genes and the environment, you cannot separate the two -- it is 100% genetic and 100% environmental. A better question is, "how much of the phenotypic variance of a given trait can be explained by environment/genetics?"
I think if you take a step back, you may realize that there is nothing frightening about what I'm saying.
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First off, I could go cash only, as I said before- I know plenty of people that do so, in everything from primary care to psych to pain. They provide less expensive care to their clients while also making more money simply by cutting the overhead that is inherent in collecting insurance (billing/coding/compliance/EMR). You also sell short that I do intend to help people- 10% of my panel will be charity care, because that's the right thing to do, and all care I provide in retirement will be free of charge (assuming, of course, I ever get to retire should we end up with a nightmarish government system similar to the VA).
And the people who want universal health care do not want physicians to be more in-control. They want evidence based medicine, which, as anyone here who's actually practiced can tell you, is far less "evidence based" than one would be led to believe, and far more about controlling the autonomy of providers and reigning them in. They want a quantifiable, fixed system that operates on protocols and cheap drugs, rather than the best personalized care with the best interventions possible. Look at the NHS to see what they want- people being denied cancer care because it's too expensive, transplants being denied based on completely arbitrary parameters for "the greater good," life-saving medications being unavailable- you think that wouldn't happen here? This isn't just about money, this is very much about maintaining the physician-patient relationship, physician autonomy, and patient choice. Money is in the mix, certainly, but it is far from the only (or even the biggest) issue.
As to this being about control, a lot of us were drawn to medicine because it afforded us a greater deal of control over our careers than we would otherwise be afforded (while sacrificing control in some other aspects). Physicians have historically been very independent. We weren't employees, we weren't cogs in a machine, we were small business owners, our own bosses, and free to operate our practices and conduct our treatments as we saw fit. We're not some sheep that are looking for direction, we got in this to lead others and to be in control of our own careers and futures. If I wanted to be a part of some overly burdensome corporate or government hierarchy, I'd have been a police officer or a middle manager. You're telling me, "you should just fold over and be a part of the system." I'm saying, **** that, I'm going to fight to make things better, in whatever way I can.
And I'm hardly a neocon loooool, the members of the SPF would probably spit their coffee straight into their keyboards if they'd seen you lob that one at me. I'm a fiscally conservative, socially liberal type, typical amongst physicians and medical students.
http://www.dailymail.co.uk/health/a...e-banned-routine-ops-deemed-fat.html#comments
The US is in a unique situation where we can see the problems with our system and we can see the problems in other healthcare systems. I wish people would stop and think in order to devise a system that addresses our issues without walking right into other blatant problems
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Let me also say that it kind of grinds my gears that @Nietzschelover is not, and does not plan to be, a physician, and yet he feels perfectly fine setting the standards, ethics, and requirements of our profession, without having to live up to those standards, ethics, or requirements himself, nor having to go through the sacrifices we have gone through to do what we do. While that doesn't invalidate your argument, it really goes to show how many liberals are fine with directing how others conduct their lives, while risking little to nothing themselves.
Doubly so if they're already working within an oppressive system- teachers, nurses, and the like have unions that were very supportive of physicians being forced into a single payer system in which they'd become subordinates just like the union members, and can't see the problem with taking a previously autonomous profession and shoving it into a subjugated bureaucratic nightmare because they've been dealing with the same thing for years. Rather than fix their own house, they choose to make their neighbor's house a mess like theirs.
Doubly so if they're already working within an oppressive system- teachers, nurses, and the like have unions that were very supportive of physicians being forced into a single payer system in which they'd become subordinates just like the union members, and can't see the problem with taking a previously autonomous profession and shoving it into a subjugated bureaucratic nightmare because they've been dealing with the same thing for years. Rather than fix their own house, they choose to make their neighbor's house a mess like theirs.
First of all, I think you are romanticizing the good 'ol days just a bit.
Secondly, I already told I am all for you making excellent money and having autonomy (to the extent that is possible aside from private vs public), and I don't think those things have to conflict with everyone receiving health care.
Third, you are preaching to the choir with me on "evidence-based." Permit me a moment of hyperbole...."evidence-based" is one of great hoaxes perpetrated on the American people. It didn't necessarily start with "the government." I was first introduced to it in the world of sex offender treatment. Evidence-based became joined with cognitive therapy = major cost savings. They back "evidence-based" by doing meta-analyses on every cognitive-therapy based study to prove a tautology. Now evidence-based gets used as a catch-phrase in virtually every industry. It is hardly just a function of a more government involved healthcare industry. Are the roots of "managed care" in the government or private insurance companies?
You are acting like I live in a different universe or that I practice in a different world that you are going to practice in. I can assure you that is not the case. I do practice in the healthcare field (mental health) where these issues are just as relevant and in some respects far more dire. I also grew up with a conservative physician and have those very close to me on the same journey as yourself. You've got better places (and targets) to grind your gears.
Managed care was put forward by insurance corporations and lauded by politicians. It fell apart rapidly, however, as employees that were a part of managed care organizations were extremely unhappy with provider choices, limited treatment, etc. This is why the HMO revolution kind of collapsed- we had a free market, and people/employers were willing to pay more to avoid managed care entirely. While managed care still exists in some capacity (it's huge in states like California but practically nonexistent in New England), it didn't really work for patients, so it was largely abandoned in much of the country.
Not sure why you took a shot at liberals in your post in that specific context. Think about all of the male conservatives who fight tooth and nail to eliminate women's reproductive rights. Obviously, none of those men will ever get pregnant.
Do you see many conservatives pushing for a universal health care system?
Conservatives have their problems on social issues, but I see this as a fiscal issue, and one that liberals are exclusively invested in advancing at all costs. As a fiscally conservative, socially liberal individual, I have serious problems with both parties, but this is one that I exclusively lay my hate on the liberals in regard to.
I live in New England. The impact of managed care is alive and well. Harvard Pilgrim, Tufts, BC/BS, etc, etc.
Prior to Obama and ACA, I was a senior figure in a small private mental health company. Every year the company had to pay much more to keep providing a company portion of individual health insurance costs. The rates were going up at a completely unsustainable rate, and prevented employees form getting raises and better benefits for the sole reason that the company was stretched beyond its resources just to continue a 60/40 split on the costs of health insurance. There is a knee-jerk reaction to blame "the government" that really doesn't jive with reality.
BTW, @Mad Jack, you think getting a Ph.D. doesn't involve any sacrifices? Took me 11 years (post-undergrad) to get that, and for my troubles I've made half or less than half of what a psychiatrist makes for the past 25+ years.
My point was that liberals aren't the only ones guilty of telling others how to conduct their lives, while risking little to nothing themselves. In your post, you made it seem as if this practice is solely a liberal thing. Or perhaps I took your words out of context. And if I did, I apologize.
A Ph.D. is certainly a different level of sacrifice than medical school and residency, both financially and time-wise. Most of the people I know in Ph.D. programs aren't suffering like a resident suffers, I'll tell you that much, and they're almost exclusively on stipends that not only pay for their education but give them money to live off of to boot.
The Boston metro area is largely the exception in New England, and accounts for the bulk of Mass' managed care penetration rate:
Location HMO Penetration Rate
Connecticut 7.4%
Maine 10.7%
Massachusetts 36.1%
New Hampshire 20.4%
Rhode Island 22.1%
Vermont 3.9%
That HMO enrollment is so low shows pretty clearly that it is an undesirable system that most patients and employers find unfavorable.
As to fast-growing rates, that is certainly undeniable. I'm actually not against the ACA, as it has helped maintain a private system that can keep rates down a touch. But I am against single-payer or centralized health care as a matter of principle.
This debate aside, I have tremendous respect for anyone who possesses the discipline to get a Ph.D.
Liberals are more prone to do so, what with the everything from the PC movement that seeks to stifle free speech to their attempts to tear down second amendment rights to their wanting to prop up a single-payer healthcare system that will reign in physician and patient autonomy.
Conservatives do have the abortion issue, but liberals have far, far more impositions of what they view to be society's "greater good" at the cost of the individual's rights and freedom.
I do as well- it's something to be respected, and the intellectual capacity for getting a Ph.D. is something to be admired. It is generally a different sort of sacrifice than the physician makes, however, both financially and emotionally, so I view them as very apples to oranges comparisons in that regard.
Two problems:
1. A single entity shouldn't be determining prices. This is a monopoly and is completely antithetical to efficiency. We need competition to keep prices down.
2. I'm a little confused what difference it makes calling something a right when physicians are under absolutely no obligation to uphold the rights of patients. If a physician can deny treating someone who "has a right to healthcare" then what exactly does that right benefit? How is it different from what we have now? How do you guarantee that "there is an affordable and accessible option for every citizen" if physicians don't have to provide the service if they don't want to?
Efforts must be made to promote competition and eliminate oligopoly. The bane to successful free markets is excessive government regulation - the less the government plays a role, the better.
Ah, so as long as I don't deem something "medically necessary" I don't have to provide the service? Sounds promising and not susceptible to corruption at all!
People will always die from preventable illnesses - there simply isn't enough money to do what you're asking. How is this not sticking?
Wrong. Everyone always conflates "access to care" with "quality of care" - the two are inversely related. America has great quality while reduced access, while socialized countries like Britain and Scandinavia have greater access with reduced quality. Do you enjoy ridiculously long wait lists? Do you enjoy not having any control in your healthcare decisions? If so, socialism is for you.
The true meaning of having a "right to healthcare" would mean physicians are under an obligation to provide that service. If physicians don't have a choice in whether or not they should provide the service, then they are slaves. It doesn't matter how much money they get paid, it doesn't matter if the treatment goes against their own morals - they have to treat because it's mandatory.
What you're suggesting in this hypothetical "everyone has a right to healthcare but no doc is required to treat" makes absolutely no sense.
I would never attempt to downgrade what physicians go through to become physicians. Why would I be here at all if I wasn't interested in what physicians go through?
That said, it's true that I didn't go into a lot of debt. BUT, I had to live with a bunch of roommates during my early years, made 9K as a substance abuse counselor while still taking classes, progressed to crap studio apartments for several years, and made about 11.5K a year in four years of training at Saint Elizabeth's Hospital in Wash, DC (you know, the place where Hinckley lives). First real job post-Ph.D. and after top-tier training including a chief residency? 30K. Then 46K. Then 15+ years in the 60-80K range.
You're talking about insurance that has the specific term HMO in its name. I include PPOs and all plans except for full indemnity plans that cost a fortune. I technically don't have a HMO but I now have to get a PCP referral to see any specialist.
PPOs are far more variable in benefits than traditional managed care plans- I've got Cigna, and I've got a great choice of providers, out of network rates are reasonable, and I don't need to see a primary care physician before seeing a specialist.
As to your sacrifice- I'll owe more in debt than you probably made in your first 8 years out in practice, if not more. I will owe $31.2k in interest alone per year, sacrificed a job in healthcare that made me 70k (plus overtime, could easily clear 100k if I were working 52 hours a week) per year, all to spend 7-11 years of 60-80 hours of work per week after the first four years to make an amount that nets $7.2k per year after just paying the interest on my loans (or I can let them grow even bigger!), and not paying for my medical license and other expenses (several thousand dollars per year!). Now, why do I say I wouldn't do this job for less than 200k? In my state, that nets me $116,872.25 after all is said and done. On an extended repayment plan (25 years), that nets me $82318.49 after taxes. To start a career at almost 40 (I'm a nontraditional). With almost no retirement savings (most of that went to getting me into medical school). And that's before professional fees, malpractice, etc etc. Financially, even at this pay, I'd have been better off staying in my prior career. So you can see why I'd be upset with people saying, "oh, you can get by just fine on 120k per year (which, after all of the loans and everything else, would net me a whopping 39k per year post-taxes and loans, literally less than I made after taxes in my old job). I worked hard for this, and I sacrificed enough. The public wants what I paid to learn? They'd better pay me right the **** back, and well.
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I currently bring in $2k/month post-tax. When I finish residency at 35, if I want to pay my debt off in 10 yrs, I will need to pay $12-13K/month. That means I would need to make at least $310K in order to only have that $2K/month to live on from 35-45. If I want to pay it off in 25yrs, I will need to pay $5K/yr and make $150K/yr to be able to have that $2K/month to live on. (This is all using NY salaries, which has higher taxes. There is a 0% chance I will be practicing in my home state in the future)
Honestly, getting a MD right now is a huge financial risk. So I think while getting a PhD in your time was more financially sucky, nowadays, not having to take such a tremendous financial gamble is a huge benefit of PhDs
(As an aside: I know dozens of people who will have a lot more debt than I will. And there will probably be a good 20,000 physicians graduating in the next 5yrs with my debt load or more. We should probably focus on maybe not having this whole system collapse, which would screw up the economy)
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Unrelated to this discussion but...
If you think an MD is a bigger risk than a PhD right now then you are seriously drinking some strong kool-aid
OP: Keep your head down and stay off the radar.
The tallest blade of grass is the first one cut.
The tallest blade of grass is the first one cut.
You certainly blew through my "sacrifice" pretty quick lol. I've supervised psychiatrists who make double and almost triple what I make even now.
I can be empathetic with your sacrifices and efforts, your journey to be a physician, and your frustrations about debt and desired salary levels AND STILL support healthcare for everyone and/or single payer. And I can support the latter while still believing you personally should make more than 200K a year. I have no desire to see physicians make less money. And I'd rather see that happen by limiting how and when lawyers can go after docs, controlling malpractice rates, etc than excluding those that can't pay from receiving health care.
Maybe I live in a different world, but my BA bio friends who do not want to move on in academia are at pharm companies making $80K. And I work in a pharm-related lab in a program that is geared towards people wanting to go into industry. They are getting good job offers and finding good opportunities. Going into academia is not a good idea right now, but industry is doing okay. I'm running the risk of never being able to get out of debt/travel/have children/retire/making significantly less than NPs or PAs or any other career that I could have chosen/being financially trapped in a career until I pay off my loans, whereas a PhD is just taking a chance on wasting some time or starting out in a lower paying job.
That's insane. "We" should do something about it. This is part of why I'm surprised when I get so much pushback about the "it's privilege" nonsense whenever I challenge the hoops perfectly strong applicants are made to jump through and are painted as inadequate in some way when they don't hit or exceed every new and ever increasing hurdle beyond GPA/MCAT and more than decent ECs. Getting in shouldn't be like a lottery and no one shouldn't be going 200-300K in debt for the honor of being a physician.
In terms of Ph.D.s.....Most will never make the money that physicians make, and not even close.
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Well, at least you've got great insurance! My point is that whether the term HMO applies technically or not, the environment at large is still a "managed care" framework. And the way things were going pre-Obama most people would have to pay nearly half their salary to maintain higher-end insurance allowing greater freedom in terms of hospital choices, specialists without referrals, etc.
But you're neglecting that if such a system would be passed, it would be controlled by, you guessed it, Congress. You honestly believe a bunch of fiscal conservatives are going to be down with giving doctors piles of government money to physicians? Right now, they've got the excuse of "Medicare has to compete with the private market or they'll stop taking Medicare patients." Put our lives in their hands, and they'll cut, cut, cut. Not only that, but a centralized system would likely take to paying hospitals and organizations, which would then pay us what they deemed "appropriate" compensation. If you know anything about hospital administration, and I'm sure you do, you would know that they pay employees as little as possible so they can skim as much money for management and the hospital as they can. If there are no alternatives because everyone's under the same system and there's no competition, you can sure as hell bet they'll cut, cut, cut.
Oh, and as to the golden days you'd referred to previously- I wasn't referring to the past. I know people who currently accept cash-only and do very well, actually making more than they made when accepting insurance with far more time with their patients and less hassle.
I agree with you that we can provide health care to everyone and keep physician salaries reasonable, but that's because you and I both know the sacrifices and investment it takes to become a physician. The problem is that people are going to push for a single-payer system that reduces physicians salaries. As long as physicians are making high salaries, people are going to be upset. Then businesses and administrators will keep the focus (of the gov't and general public) on physician salaries in order to keep the focus off them. Physicians, as always, won't stand up for their own interests and we'll end up with a crappy system. That's why I'm more in favor of fixing medicaid/medicare with physician involvement and capping drug prices than transitioning completely to a gov't system.
And we are past the point of $200-300K, hahaha. My state school would be $320K. Then the gov't puts some nice clauses in our loan contracts that allows them to change our repayment terms if they want to down the road.
I don't know if I'm more or less cynical than you (and others). I think the insurance industry has had as much of a role in depressing physician income (and because of all of the money that is lost because of lawyers) as the government. I think most people want physicians to make good money. I think most have some general idea of the difficulty that goes into becoming a physician and I think most appreciate the level of skill that physicians possess. Given the sacrifices that you and a few others have described quite well, I think the public and "the government" understand that physicians would not continue and/or pursue the field without the prospect of very good compensation. What if single player meant you made more money? Would you still be opposed on political grounds?
As to your lower wages, you chose your field knowing that going in. You chose the career that had the right mix of what pays, what you're good at, and what you can stand doing. If you wanted more money, the physician route was always on the table, and you could've taken on the debt and went down that path. For whatever reason, you chose not to. Your current salary is not a "sacrifice," it was a choice, in the same manner that someone choosing to become a high school teacher instead of a physician is not a sacrifice, but a choice.
Well, this has become a rather interesting **** flinging contest!
If you have an industry-geared PhD from a brand-name institution then you have opportunities in industry. For basic science PhDs though, the type that are interested in biomedical research? Drugs or die.
It would depend on the structure of the system. If physicians could not opt out of it, I would remain firmly opposed on ethical grounds, not political ones. I'm actually not opposed to any system that:
1) does not cause an absurd increase in tax rates for those that utilize the system
2) allows patients and physicians to opt out if they so choose, and to not pay taxes for the system if they choose to opt out
Those will never, ever happen though, because the government will no doubt want to sap cash from everyone they can, and force as many people into the system as possible, just as they did with Medicare's absurd restriction that you MUST accept medicare or else you lose your social security benefits. Wtf kind of absurdity is that...
Also I have no faith in the public to give a **** about anyone that makes more money than them, nor in politicians to not use literally every line item of the budget as a political football. Our democracy is dysfunctional, therefore all things that that democracy holds sway over have a serious potential to suffer.
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You don't like to give much in these discussions, huh? I wasn't just talking about the money (in terms of salaries). 11 years, my friend, barely scraping by and not living the high life. And I would have accumulated significant debt if my father had not been a physician 😉.
But if you are going to argue on the basis you do so above, your also made a choice, and choice knowing the debt you would incur and all the rest.
BTW, I only shared all that because you said I was grinding your gears, which was grinding my gears.
I don't know if I posted this before, but you might appreciate it. It's a quote from a KevinMD article about the need for physicians to unionize and I love it: "I have faith that intelligent and educated people understand by now that the sole difference between progressive and conservative agendas is a personal preference to have your serfdom managed either through a government intermediary, or directly by the business overlords."
Based on what I've seen from our gov't and how people in the general public continue to talk about how greedy doctors are and how they are always golfing (people cannot let go of stereotypes even though those days are long gone for new doctors), I don't think they will care if physicians take a huge pay cut. I veer more towards having the gov't put some regulations on the business overlords and the overlords being the one's we directly deal with. I think that leaves more options and leaves more of an opportunity to negotiate our position. In a gov't system it is more, take it or leave and you are just stuck with the crap.
Interesting. I've never in my 50+ years heard anyone complain about physicians golfing. The physicians I knew back in the day played tennis FWIW.
The public (as a whole) wants great doctors. They want their loved ones to receive the best of the best. I think the majority of folks are willing for physicians to make good money to ensure that they and those close to them receive exceptional care.
I made an informed decision with the debt and income factored in.
Now, I'll have invested 4 years of undergrad (really 6, I took my time, but I'll simplify it for the average undergrad student), 4 years of medical school, 3 years of residency, and 3 years of fellowship, along with $1,000,000 of debt and lost wages (excluding the amount undergrad cost me and the amount I'm losing from not being able to invest, which would substantially balloon the figure). 14 years and $1,000,000 is an investment I want to at least break even on lol.
