I keep hearing that back in the 70s-80s was the "golden age of medicine", that doctors were paid really well and lived really well, but now medicine "is not worth it". What exactly happened?
So what happened?
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The big bad NP's done came and stole our jobs
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Exploding bureaucratic demands, Managed Care (insurance companies interfering with doctors' decisions), business/management theory being rammed down the throats of health care institutions without any solid rationale, skyrocketing costs of medical malpractice settlements (and therefore insurance), sub-sub-specialization eroding the status of generalist practice, encroachment of other health professionals on traditional doctor turf (further eroding the status of doctors, especially generalists), dominance and corruption of the profession by industry, ever-increasingly complexity of care with an outdated and broken payment system...for starters.
That said, there was never a Golden Age of anything, anywhere, anytime.
That said, there was never a Golden Age of anything, anywhere, anytime.
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Yeah but you hear that about almost every traditional profession.
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70s-80s were the golden age of most professions. If you spend time around Wall Street folks they'd say the same thing. Other industry that would really be different now is tech...
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My basic understanding is that medicine has always been business oriented, but lately even more so. What used to be a fairly autonomous field is now heavily regulated.
Corporate oversight demanding increased profit at the expense of time spent with pts , Insurance becoming heavily involved in more than coverage and often impacting the course of treatment (in order for X to be covered, insurance demands you try A, B and C before covering treatment X) are a couple of examples. Obviously this can be helpful in terms of scaling treatment options slowly, but often physicians know the pt will need treatment X eventually, so jumping through these hoops becomes unnecessary, time consuming and often, annoying) Just based off a couple conversations I've had.
Corporate oversight demanding increased profit at the expense of time spent with pts , Insurance becoming heavily involved in more than coverage and often impacting the course of treatment (in order for X to be covered, insurance demands you try A, B and C before covering treatment X) are a couple of examples. Obviously this can be helpful in terms of scaling treatment options slowly, but often physicians know the pt will need treatment X eventually, so jumping through these hoops becomes unnecessary, time consuming and often, annoying) Just based off a couple conversations I've had.
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Well done, beat me to it lol
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You forgot about the astronomical rise in tuition and student debt.
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I read an account from Leon Unger, MD (Illinois Medical Journal 1976) that also referred to the 'golden age of medicine" and according to him, it was circa 1915.
I think it is all relative. I also think the high debt load and having to play to the whims of insurance corporations are making things painful.
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Build the wall
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Even in the 90's and early 2000's doctors had a lavish life. My dad was a psychiatrist and many of our family vacations at amazing resorts were at the expense of Eli Lilly lol. But come mid 2000s and forward, he was usually just wine and dined at local 4-5 star restaurants in our home town.
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I think it takes a very vapid perspective to look at your career and say that the 80s were the golden age of medicine. We were failing to even understand cancer let alone treat it and we were watching hundreds of thousands die of AIDS. The sheer failure of medicine in the 80s drove an enormous shift within medicine. We began to realize that we need to talk about ethics, change course towards molecular biology, and reevaluate the role of physicians as public health figures that could potentially influence communities.
But that's my perspective. I would have hated to be a doctor in the 80s.
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Can't wait to watch where this goes...
On a side note the whole topic was already told by the Boss:
C
cellsaver
Physicians got greedy in the 1960s, practiced fraudulent billing, President LBJ ushered in socialized medicine to defeat "the war on poverty", President Richard Nixon signed the HMO Act of 1973 to introduce HMOs.... and the rest is HERSTORY/HISTORY
BOHICA
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It wasn't the golden age for treatment, but in terms of physician lifestyle and compensation it was. I mean, medicine still isn't bad now (kind of hard to complain about a salary that starts at 200k), but it certainly isn't the cash cow it used to be where a doc could finish med with 40k in debt at a 3% interest rate and then be in the top 1% of earners straight out of residency. Those days are gone, and they're not coming back.
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sounds like doctors were entitled back then. Didn't do a whole lot of things that great, but still thought they deserved to be rich as hell.
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Press-ganey scores and RVU pressures
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Or maybe the compensation system was set up in a way that allowed them to make a lot of money. nothing to do with entitlement.
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First, I agree with others that you have to be a little cautious about buying too much into the "Golden Age" dogma with regards to any profession. A retired pathologist who started practicing in the 1960s once told me that when he declared his pre-med intents, his family internist told him, "Don't do it! They just passed this thing called Medicare not too long ago. It's going to completely ruin medicine. Complete socialism."
Now one could argue that where we are at now is in fact the long, drawn out conclusion of the internist's warnings. But as you can see, the 20-30 years following this internist's warning--and the vast majority of the pathologist's career--were in the supposed "Golden Age of Medicine."
Personally, I witnessed a similar "Golden Age" caution from my father, who was a commercial airline pilot, with Pan Am for much of his career--until they went out of business. Most pilots from his era (starting in the 60s and 70s) will agree that the Golden Age was back then and that the 80s marked the beginning of the end of the airline industry. Having seen my dad's work schedule, autonomy, and general annoyances associated with the job increase--along with pay decrease for younger pilots--as he progressed through his career, it does seem to me from the outside looking in that there may be some truth to their claims. But I also know many young pilots who are in the profession and still love the job, even if they do sometimes complain about the pay when starting out, the lack of security with any given airline, and onerous security requirements.
Overall, the airlines used to be flush with cash, security was minimal, and they competed on service and convenient routes--not on price. So whereas there used to be an expectation that you would stay at the same airline your whole career, make a ton of money upon retirement, enjoy free travel for you and your spouse until death, stay at 5-star hotels when on trips, and get great catered food in the cockpit...things are now different. Pay is much less when adjusted for inflation, bargain hotels aren't uncommon for domestic flights, free travel is a bogus fringe benefit since almost all flights are near 100% full, and meal service doesn't even exist in most flights. And of course there's no more waltzing through the airport in five minutes, leaving the cockpit door open the whole flight, inviting kids up to the cockpit to check things out. Now you have to barricade yourself in for fear of a cockpit invasion.
One could certainly say medicine has had similar changes since the 60s. Nearly every specialty is having to justify their worth. Patients expect much more autonomy and won't immediately acquiesce to authority as in decades past--some might say justifiably so. Insurance companies and Medicare nickle and dime physicians left and right, always looking for a way to deny payment or bargain down a price. Brief notes and dictation have gone the way of physicians spending hours on a daily basis typing notes optimized for billing and bureaucratic compliance. Med school tuition and resulting debt has increased many times greater than inflation--and the increase in physician salaries.
The screws have been tightened on many fronts. As others have correctly mentioned, this has been a common theme among many industries in the United States over the last half-century. Could it be just the obvious conclusion of a country that went from being flush with cash and the only major functioning democracy post-WWII--now with increased competition from around the world, increased debt, and an increasingly old, sick, and non-working (i.e. longer retirement period) population? Medicare was never intended to support people several decades of their lives, and employers are increasingly unable to pay for a medical system that is filled with expensive technology and pharmacology. Things were a lot different when a CT scan was considered high-tech and the most expensive drug was an antibiotic.
Patients are living longer and becoming much sicker, but we're still offering aggressive care all the way to the end of one's life. And with new chemotherapy agents, robotic surgery, and everything else available, patients and their families are demanding these therapies. The question is who will pay for them?
As some have suggested on here, so-called mid-level providers are part of the equation, but I don't know that they're a driver of the decline of the "Golden Age" as much as a symptom. Physician training is long and expensive, and the resultant commiserate compensation is expensive. I think it's more an issue of more people living longer and demanding top-notch care, but there just isn't any sustainable way to pay for it all. I'm not sure we can expect that every single patient in the country--regardless of their employment status, ability to pay, etc.--can go in for a half-hour visit with a primary care medical doctor every year. Obviously, the trend has already moved away from that reality except for those willing to pay for it out of their own pockets.
Regardless of all of the above, I would suggest that for those still in the pre-med or medical training phases, I still think becoming a physician is a great career choice in the United States...if you want to be a physician. I would never recommend it solely for financial security, "getting rich," or for prestige or status. It will still provide the first, sometimes the last...but "getting rich" by way of practicing medicine is increasingly difficult--if it ever way easy. And if your primary goal is making the most money possible, you will be miserable through all of the many years of training learning about medicine, physiology pathology, and treating patients--and not actually making any money.
I always say that I see absolutely nothing wrong with smart, talented students expecting to make a good, upper-middle class income from a career in medicine. After all, most would have been fully capable of going into similarly paying jobs in law, business, engineering, and other fields. But at some base level, you actually have to enjoy learning about the science and practice of medicine. And with the exception of a few medical specialties (e.g. pathology, radiology), you need to enjoy working with patients.
Finally, to address concerns about whether or not a mid-level degree would be a better bet, I think this is a very personal question that everyone must answer for themselves. If you desire a much shorter training period, less debt (in general), and less responsibilities and a more traditional and flexible working schedule after training (i.e. easier to get a 40-hour, regular schedule than the usual 50-60 hours per week most physicians work)...then perhaps looking into becoming a physician assistant, nurse practitioner, nurse anesthetist, anesthesiology assistant, perfusionist, etc. is for you. But if you know that you will absolutely not be satisfied unless you have the broadest, most in-depth, and most comprehensive understanding of human physiology and pathology--encompassing all fields of medicine and not just your area of expertise--then think twice before ruling out becoming a physician.
To sum it up, maybe the "Golden Age of Medicine" is over. But for the right person, it's still a good time to be a physician. You just have to have the right expectations about what you're getting into. I think most of my colleagues just getting into practice in the last few years never had many of the expectations that many retiring docs bemoan the loss of. So is the field different? Definitely. Is it worse? Not necessarily. Most younger docs are also going to be far less likely to work 60-80 hours per week with virtually no time off throughout their entire practicing career.
Good luck!
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Dr. Google came along.
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This:
Plus doctors "weren't that great" because a lot of medical technology and diagnostics were terrible in the 70's and 80's compared to now. MRI's and CT's were being used for the first time medically in the 70's. PCR wasn't invented until the 80's. Not to mention all of the new treatments that have come out in the past 20-30 years. Whenever there's a new cutting edge treatment or procedure, it's going to be expensive as hell. Also, from what I've been told at that time less people were reliant on Medicare/caid (which has reimbursement so bad that some hospitals which rely heavily on those patients for income have actually closed down) and insurance companies reimbursed better. It's not about entitlement, I'd guess it's more to do with the medical system not being a total nightmare for physicians back then like it is today.
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I think it's actually bizarre to think of the fact that so much of what we know as instrumental to medicine today only really was successfully implemented and worked through while we were in grade school.
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Yeah, I'll take the average near-retirement community vascular surgeon to do my emergent open AAA over a fellowship-trained vascular surgeon 5 years into practice any day. Now an EVAR is another story...and of course I hope to never have an emergent open AAA! But you get the idea.
One common theme of modern-day physician burnout is decreased autonomy and hourly pay combined with increased bureaucracy and administrative tasks. Increased consolidation in the insurance industry, coupled with increased vertical integration with hospitals--all with a backdrop of increased government regulation and red tape (some justified, some less so)--is likely the biggest culprit of increased physician dissatisfaction in my opinion. But I could be wrong, and there are definitely other factors at play. At the end of the day, money is tighter across the board, and there seem to be more and more people trying to defend their piece of the pie.
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I happen to think most of what being a great doctor is, has nothing to do with technology. In fact, I would argue that time spent face to face with a patient, with the right skills and knowledge, is irreplaceable. I would argue that everything that has "gotten in between" the doctor and the patient, has eroded the therapeutic alliance, without which we are nothing. Nothing.
If doctors got to spend more time with their patients back in the day, then I would say that was the Golden Age. When by some miracle of chance I can spend all the time I want talking to a patient educating, and I'm not at all struggling to checkbox something with a computer mouse in a rush, hell, even if none of it sticks, than that was the Golden Appointment right there.
Doctor in Latin means Teacher. When we actually get to live up to that title, rather than pay lip service to it, then that's medicine.
The rest of it is a lot of half-assing and going through the motions, but thankfully we can often just click enough tests to dx, nevermind that none of the Rxs and stock AVS instructions stick. Virtual reality according to the EHR can supplant real reality, can act as "treatment." Enough health outcomes can be affected this way that we say it suffices.
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I'd rather be a scorned technician than a kind harbinger of death.
But sure, you bring up many very valid points. Medicine needs to emphasize the patient-doctor relationship significantly more. But I would also hate to be a doctor in an era where I felt useless too. On the topic, was there ever a statistical analysis of hopelessness within doctors of the past? I mean it's one thing when you tried all you can to cure someone's cancer, but when you knew that many of your geriatric patients were on the death march, that must be depressing.
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As any good doc would say, it's all about managing expectations.
Prognosticating, whether's it's by EBM or by "feelz", is in our blood. I imagine how they felt was guided by what they thought they could reasonably achieve, just as it is now. It's not like we've eliminated dealing with uncertainty, bad outcomes, medical futility, and bad or fatal prognoses.
This gets into, how does a physician measure the quality of his work? Hence the goal has always been to maximize knowledge and control over factors for which one can control, and to learn to make peace with/control those you cannot. Sounds a lot like the serenity prayer/drive to research.
Incidentally, I just wrote a long post about being a kind harbinger of death more than a scorned technician (general IM, over say, general surgery??)
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And I agree with the bolded, but it's undeniable that improvements in medical technology have allowed us to make diagnoses earlier, identify problems which we never would have found until autopsy, and save literally millions of lives (at least for a while).
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Was it a very different experience for the passengers too? I think the majority of my childhood was post-9/11, so I've grown up with a deep dislike of airports and planes. The whole ordeal is just a massive PITA.
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Yep, night and day. I was born in 1979, so I remember some childhood flights when things were still different. Flights were often 70% full--not always packed to the gills. Free meal service always. More legroom. Nice flight attendants and gate workers. More direct flights, less hub-and-spoke. Security was a minor inconvenience--not an hour-long affair.
To be fair, overall flights were more expensive in the 60-85 time period in real dollars. They got cheap in the 90s. But ever since 9/11 and the fuel price hikes of the 2000s, they raised fares again. Now fuel prices are back down, but fares are still frequently expensive. And what deals do exist are sold on complicated, algorithm-driven, online sites in which you get a different fare quote every few minutes and nobody pays the same price.
There's a reason fractional jet ownership became a huge business in the 2000s. Nobody likes flying commercial anymore, and those who can afford to avoid it do just that.
Are we headed down the same path with health care? Concierge service is analogous to a private jet, while everyone else goes wherever their insurance company or ACA provider tells them? I guess only time will tell...
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maybe it just stands out to me, that there are many many times, where for all that, it really comes down to a patient and their conversation with a physician. We take for granted that people will just go along with all this stuff, and most of the time, yes, they do.
It's when you get resistance, communication fails, or the patient refuses and you have to win them over, that you realize someone's life isn't hinging on the availability of lasix, stress echo, blood transfusion, vitamin K injection, it's all hinging on your interaction with them. The way the conversation goes, and how good you are at connecting with them, understanding them on an emotional level, AND how to teach them some advanced shyte without being over their head or seeming condescending, and parrying their questions and responses which you don't always see coming or know how to handle, and knowing THAT'S the difference that makes the difference. This is life or death. The conversation, not the technology.
You're actually trying to talk them into a gamble. They do it your way, and things go well. Easy. But you are also talking them into things that end up being mistakes, for which they suffer. And you round on them each day to talk about how they listened to you and it didn't go well. Thankfully, they are often more forgiving than you feel you deserve.
hell, even coming back to your damn clinic or not just leaving the damn hospital isn't something you can take for granted.
You'll start to realize all the docs have about the same access to the same stuff. And a difference that makes a difference with knowledge makes a difference, sure. But there's a lot in place about quality assurance and tests, that the knowledge base is similar.
Basically, none of that stuff is jack**** without YOU. That application from a knowledge standpoint is a bit of experience, style, and yeah, art. The rest of it is you selling it to the patient. You might not appreciate it until it slows your roll, but you are doing that from the first handshake.
That's what you'll be working on constantly. Thought, application, and interaction. The tools change but it is the interaction of physician and patient that is key.
Studies are backing up that technology blah blha blha has advanced but outcomes aren't greatly improved. Studies showing whether it's snake oil or a cure for cancer in a pill, none of it can do a damn thing because patients aren't taking their meds. They're not getting follow up on their tests. Why? Besides money/time, most of them express that they don't really understand why it's important. Most of a patient's health care happens outside the walls of a hospital or clinic. So how are YOU going to use the tools you have, the high tech stuff, to affect what they do at home?
I'd rather my patient die of a disease I couldn't diagnose or cure because we don't have the tools, than die just because I didn't have time to explain them to him and save his life. A patient dies with a cure in his hand he didn't understand how to take when it was my job to explain it to him.
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