Specializing & Salaries

[panvard92]

Okay, so after med school you need to choose a residency to go into...and say you choose neuro (or cardio or blah), so if you want to specalize in like child neuro or something would you technically get paid more since you're putting in more years?

Or is it possible to be paid even less after specializing?

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[DrYoda]

Okay, so after med school you need to choose a residency to go into...and say you choose neuro (or cardio or blah), so if you want to specalize in like child neuro or something would you technically get paid more since you're putting in more years?

Or is it possible to be paid even less after specializing?

Reimbursment isn't based on years of residency.

In some cases it works that way (a cardiology fellowship gives one significantly more earning power than just an internal medicine residency). But for some it doesn't ( an infectious disease fellowship doesn't give you much more earning power even though it takes an extra couple years).

Generally pediatric anything makes less than the equivalent adult speciality.

 

[Algophiliac]

It is absolutely possible to get paid less even after spending more years in training. Child neuro is ironically a great example of a specialty that pays less than its counterpart, adult neurology. There are even more examples of specialties that get paid less...hell, even MD/PhD or academic medicine training usually ends up paying much less than just straight up private practice in a rural area.

But honestly, it makes no sense to argue over salary amounts when as an MD, you're going to have enough money to make a living, no matter what specialty you choose. The line between sensible and greedy is not that thin, so don't cross it.

 

[BigRedBeta]

Actually the two best cases in which more training ends up with less salary are radiology and anesthesia compared to their pediatric subspecialties. You can come out and make bank directly out of those specialties but throw in a year or two of pediatric fellowship in those fields and your earning power is cut significantly...

This is compared to pediatrics where, although pediatric specialists make less than their adult counterparts, peds subspecialties make more money than generalist pediatricians, so more training does increase your salary...

 

[penguin24]

Generally, the more time you spend training, the more you make. But since medicine is a business, w/ politics, negotiations w/ ins companies, etc, there are some specialties where you will train for a long time and make less than somebody else who trained less just b/c of the way that particular specialty is set up. The classic example is Peds, which pay less across the board (ex: peds cardio pays less than reg cardio, peds GI less than reg GI).

The other irony is that academic positions are harder to get than private practice, but pay less.

Also, specialties that involve more procedures (GI/Cardio) pay more that others that involve less (Neuro/Endocrine)

So, there's lots of factors that go into salaries, and the length of training is just one of them.

 

[oldbearprofessor]

This is compared to pediatrics where, although pediatric specialists make less than their adult counterparts, peds subspecialties make more money than generalist pediatricians, so more training does increase your salary...

This is not true for all pediatric subspecialties. In general, neonatology, pedi cardiology, pedi EM and a few others will clearly make more on the average than general pedi. Others, including pedi ID, pedi endo, and pedi rheum will have a tough time significantly exceeding general pedi as they are almost exclusively academic and have no procedures. Taking into account the 3 years of lost salary and one has to be dedicated to the fields to do them. Of course, that IS the best reason to do them.

 

[Pepipanda]

Why is it that the pediatric versions of specialties pay less?

 

[Rendar5]

I don't know. Perhaps it's that kids aren't as sick so less needs to be done for them usually.

If you are in high school, it's not going to be all that useful to take a look at how much different specialties make. By the time you're actually out of college, out of med school, out of residency, everything could easily go topsy turvy. Who knows what's gonna happen to how insurance works, how doctors bill, how often ppl actually pay, co-pay structure in the next 10 years.

 

[135892]

... The line between sensible and greedy is not that thin, so don't cross it.

What is wrong with greed? Greed is a primary motivator for many, and it is a damn good one (as long as you stay within the legal bounds of course)

 

[dragonfly99]

"Greed is Good!",
says Gordon Gecko

Seriously, time in training doesn't have much to do with salary. For example, a geriatrician would do 4-5 years of a residency+fellowship, but will make < half what an orthopedist or radiologist with 5 years of residency would make. How much money you make depends on how much the gov't and insurance companies are willing to pay you for certain patient care activities. Procedures or surgeries like orthopedic surgeries pay a lot more than "thinking and medication adjusting" activities such as an internist or geriatric specialist would do. I'm not sure why pediatrics gets reimbursed less than internal med, for example...probably it is because peds tends to be more outpatient focused with well child checkups, etc. vs. internal medicine where we see more hospital patients and also have to send our patients for more tests and medical procedures, and/or they have more stuff wrong with them so we bill for taking care of multiple medical disorders (i.e. management of diabetes and HTN).

 

[Algophiliac]

What is wrong with greed? Greed is a primary motivator for many, and it is a damn good one (as long as you stay within the legal bounds of course)

There are a lot of things wrong with it, imo. If you're just doing a job for the money, well...surely I don't need to explain how that just isn't right. It's just like annoying little pre-meds grubbing for higher and higher grades, because guess what? They only study for the pretty little numbers and don't give a damn about the subject. And if everyone thought the way you do, we'd end up with no pediatric neurologists. Some people just love to do what they love to do, money regardless. I don't want to be involved with people who only want the rewards from life, because I've been around enough of them to see how boring and pathetic they are. Sorry to sound so...blunt. It's a bit of an old wound for me.

Don't confuse ambition with greed. Ambition, within legal limits, is damn good.

 

[135892]

There are a lot of things wrong with it, imo. If you're just doing a job for the money, well...surely I don't need to explain how that just isn't right. It's just like annoying little pre-meds grubbing for higher and higher grades, because guess what? They only study for the pretty little numbers and don't give a damn about the subject. And if everyone thought the way you do, we'd end up with no pediatric neurologists. Some people just love to do what they love to do, money regardless. I don't want to be involved with people who only want the rewards from life, because I've been around enough of them to see how boring and pathetic they are. Sorry to sound so...blunt. It's a bit of an old wound for me.

Don't confuse ambition with greed. Ambition, within legal limits, is damn good.

I could argue your points, but I have a question: Why do you think medicine is so competitive? Is it because you get to "help" people directly? Well there are plenty of jobs where you can do this (social work, nursing, etc...). Is it for the love of science? Well, why is grad school not so competitive? Is it for some other noble reason? I highly doubt it. Why are derm and plastic surgery the most competitive residencies? Is there something "wrong" with all these people? Are these people all bad doctors? Have they ruined the field of medicine?

Although, with the direction healthcare in this country is heading, I think more and more people will start to enter medicine for the "right" reasons.

 

[Algophiliac]

I could argue your points, but I have a question: Why do you think medicine is so competitive? Is it because you get to "help" people directly? Well there are plenty of jobs where you can do this (social work, nursing, etc...). Is it for the love of science? Well, why is grad school not so competitive? Is it for some other noble reason? I highly doubt it. Why are derm and plastic surgery the most competitive residencies? Is there something "wrong" with all these people? Are these people all bad doctors? Have they ruined the field of medicine?

Although, with the direction healthcare in this country is heading, I think more and more people will start to enter medicine for the "right" reasons.

I hope so. Ironically, part of the reason I don't want to do medicine is the insanely high compensation. Not because I hate money or anything, but because I hate the kind of people money attracts. Of course, luckily enough, most of these people can't walk the walk.

Yes, it's about helping people directly and having the autonomy, prestige, and respect (all earned over time, of course) that will get people to do what you say without question. If someone is dying, I want to be the one who gives the orders and thinks on his feet to save the person's life, not the mindless individual simply obeying orders. My reasons are not noble, really. They are exactly what I want, but as you notice, money has nothing to do with it.

They have not ruined the field of medicine (at least, this cannot be proven) nor are they bad people, but I simply dislike them for their lack of passion and dedication to something aside from the absolutely pointless rewards. To think that a physician would leave his or her job as soon as the salaries fall is appalling. To think that a physician would turn away a patient simply because the patient must resort to Medicare is appalling. How do you justify this to yourself, I wonder, hmm?

 

[NonTradMed]

Why is it that the pediatric versions of specialties pay less?

I spoke with a couple of doctors, including one pediatric surgeon on this very topic. They both said that the pediatric patient base has the highest percentage of medicaid patients. Medicaid, in general, is poorly funded and reimbursement is not enough to cover expenses for many doctors. Medicare reimbursement is "ok" while private insurance typically pays the best (although I guess that can depend on the type of insurance you have too).

So anyone dealing with kids will have a higher chance of seeing medicaid patients than adults doctors. That's one subject I think is always missed when talking about health care reform. People assume that because someone is 'covered', either by government or otherwise, they have access to health care. Actually, that's not always true. If a person have only a poorly funded health program, many doctors will not take them because reimbursement is so poor. Children who are covered by medicaid may have health coverage, but that doesn't mean they have ready access to care.

 

[0Complications]

I could argue your points, but I have a question: Why do you think medicine is so competitive? Is it because you get to "help" people directly? Well there are plenty of jobs where you can do this (social work, nursing, etc...). Is it for the love of science? Well, why is grad school not so competitive? Is it for some other noble reason? I highly doubt it. Why are derm and plastic surgery the most competitive residencies? Is there something "wrong" with all these people? Are these people all bad doctors? Have they ruined the field of medicine?

Although, with the direction healthcare in this country is heading, I think more and more people will start to enter medicine for the "right" reasons.

You'll know the answer to this one as soon as you spend a few days in a professional lab. As a people person I would rather be set on fire than stuck in a lab all day.

As an aside, it's not about the money for everyone. I gave up a field that would pay me at least 2x what I'll ever make as a doctor with fewer hours, but it was not stimulating for me. Science is amazing, and while I am going into medicine to treat patients I would say the other half of the reason is a love for the sciences. Don't undervalue you're personal happiness. Your parents weren't lying to you when they said, "Money can't buy you happiness."

Not everyone goes in for the right reasons, but I believe that many still do and will continue to do so.

 

[niranjan162]

I hope so. Ironically, part of the reason I don't want to do medicine is the insanely high compensation. Not because I hate money or anything, but because I hate the kind of people money attracts. Of course, luckily enough, most of these people can't walk the walk.

Yes, it's about helping people directly and having the autonomy, prestige, and respect (all earned over time, of course) that will get people to do what you say without question. If someone is dying, I want to be the one who gives the orders and thinks on his feet to save the person's life, not the mindless individual simply obeying orders. My reasons are not noble, really. They are exactly what I want, but as you notice, money has nothing to do with it.

They have not ruined the field of medicine (at least, this cannot be proven) nor are they bad people, but I simply dislike them for their lack of passion and dedication to something aside from the absolutely pointless rewards. To think that a physician would leave his or her job as soon as the salaries fall is appalling. To think that a physician would turn away a patient simply because the patient must resort to Medicare is appalling. How do you justify this to yourself, I wonder, hmm?

Sounds like your in for disappointment. Autonomy of physicians is less and less; you bickering with insurance companies however is on the up. People dont respect doctors anymore. Whatever prestige medicine has will dwindle away a reimbursements go down it becomes less competitive and mid levels keep expanding.

 

[Terpskins99]

I hope so. Ironically, part of the reason I don't want to do medicine is the insanely high compensation. Not because I hate money or anything, but because I hate the kind of people money attracts. Of course, luckily enough, most of these people can't walk the walk.

Yes, it's about helping people directly and having the autonomy, prestige, and respect (all earned over time, of course) that will get people to do what you say without question. If someone is dying, I want to be the one who gives the orders and thinks on his feet to save the person's life, not the mindless individual simply obeying orders. My reasons are not noble, really. They are exactly what I want, but as you notice, money has nothing to do with it.

They have not ruined the field of medicine (at least, this cannot be proven) nor are they bad people, but I simply dislike them for their lack of passion and dedication to something aside from the absolutely pointless rewards. To think that a physician would leave his or her job as soon as the salaries fall is appalling. To think that a physician would turn away a patient simply because the patient must resort to Medicare is appalling. How do you justify this to yourself, I wonder, hmm?

I think its a little bit presumptuous of you to assume that physicians can't be good at what they do, enjoy what they're doing and still desire high compensation for their work.

I'm curious. What are your opinions of OB/GYN's that move their practice to another state because the local malpractice insurance have premiums exceeding their total salary? Or how about those GYN's that have abandoned OB practice altogether? Do you consider that appalling as well?

I also find it curious that you consider any health care provider not titled doctor as being nothing more than a "mindless individual simply obeying orders".

And what makes a desire for prestige and the ability to boss others around (i.e. power) so much more noble than money? Both are equally materialistic, if you ask me.

 

[Algophiliac]

I think its a little bit presumptuous of you to assume that physicians can't be good at what they do, enjoy what they're doing and still desire high compensation for their work.

I am not saying physicians should accept minimal compensation for their work, rather that a thread bickering over differences between two large salaries is silly. Are you telling me everyone would go into plastics, surgery, and derm if they had the scores for it and money/lifestyle would be the leading, if not sole, motivations? Am I really the only person who sees something wrong with this?

I'm curious. What are your opinions of OB/GYN's that move their practice to another state because the local malpractice insurance have premiums exceeding their total salary? Or how about those GYN's that have abandoned OB practice altogether? Do you consider that appalling as well?

That is a bit extreme--obviously if they're not making any money at all they need to move. This is in the sensible category. Maybe I should define greedy:

Excessively desirous of acquiring or possessing, especially wishing to possess more than what one needs or deserves.

I also find it curious that you consider any health care provider not titled doctor as being nothing more than a "mindless individual simply obeying orders".

Not usually, no. I am speaking of emergency situations and difficult cases. But perhaps I am wrong on this count and simply have not shadowed enough to have a decent frame of reference.

And what makes a desire for prestige and the ability to boss others around (i.e. power) so much more noble than money? Both are equally materialistic, if you ask me.

I never said it was noble. It isn't, but it's a positive source of motivation. There will never be an instance of "desiring power" that could cause a physician to turn away patients or order useless tests or see so many patients in one day that neither patient gets adequate attention. Again, I am not against money. Hell, I love money, who doesn't?

niranjan162, midlevels on the rise is probably not fine with anyone but the midlevels, but the other factors do not bother me too much. What I would really hate is if standards were changed to involve cookbook medicine.

 

[Terpskins99]

I am not saying physicians should accept minimal compensation for their work, rather that a thread bickering over differences between two large salaries is silly. Are you telling me everyone would go into plastics, surgery, and derm if they had the scores for it and money/lifestyle would be the leading, if not sole, motivations? Am I really the only person who sees something wrong with this?

First, don't confuse a thread started by high schoolers and assume the same line of reasoning extends to medical students/residents.

Money/lifestyle is rarely (if ever) the SOLE motivation for pursuing a specialty. (Btw, surgery is hardly a lifestyle specialty.) Apparently you believe that a genuine interest in a field is and should be necessary for them to succeed in that field. I think interest helps, but the bottom line is you have to be competent at what you do.

That is a bit extreme--obviously if they're not making any money at all they need to move. This is in the sensible category. Maybe I should define greedy:

Excessively desirous of acquiring or possessing, especially wishing to possess more than what one needs or deserves.

Then what delineates "sensible" versus "excessive"? Who gets to draw that line?

I never said it was noble. It isn't, but it's a positive source of motivation. There will never be an instance of "desiring power" that could cause a physician to turn away patients or order useless tests or see so many patients in one day that neither patient gets adequate attention.

Again, what makes desiring power = a positive source of motivation? This is the same problem I have with you deciding how much money should be enough. Its entirely subjective. Btw, with regard to power-seekers (i.e. control-freaks)... many doctors have issues with arrogance and that OFTEN leads to harm to a patient.

niranjan162, midlevels on the rise is probably not fine with anyone but the midlevels, but the other factors do not bother me too much. What I would really hate is if standards were changed to involve cookbook medicine.

To be honest, I'm not crazy about midlevels taking over as PCP either. But with the way things have been progressing over the years, I think its almost inevitable. For the record, I do think midlevels can take over most PCP responsibilities as long as they have a very firm understanding of what their limits are and when they need to refer patients to a specialist.

 

[ballerina86]

dude you guys are in high school! who cares!

 

[Algophiliac]

Money/lifestyle is rarely (if ever) the SOLE motivation for pursuing a specialty. (Btw, surgery is hardly a lifestyle specialty.) Apparently you believe that a genuine interest in a field is and should be necessary for them to succeed in that field. I think interest helps, but the bottom line is you have to be competent at what you do.

I suppose I based that assertion mainly on myself, as I hardly do anything I dislike. For me, boredom is the enemy of good, and genuine interest and passion basically define success. Maybe some people can dedicate at least a third of their lives to something they dislike merely to spend the rewards on the other two-thirds, but to me, this sounds silly. I want a job I love so much, coming home feels like a chore. And I wish more people could think this way. I've worked on something as simple as group projects in various high school classes...and there is a HUGE difference between the people who care and really love the project versus the people who are simply aiming to scrape by with a high A. I never ever ever want to end up with the latter. And I really don't think most doctors would fall under that category, or at least, not from what I've seen.

Then what delineates "sensible" versus "excessive"? Who gets to draw that line?

You have a good point here. Unfortunately, everyone has to draw that line for themselves and apparently some people have a heavy dislike for drawing lines.

Again, what makes desiring power = a positive source of motivation? This is the same problem I have with you deciding how much money should be enough. Its entirely subjective. Btw, with regard to power-seekers (i.e. control-freaks)... many doctors have issues with arrogance and that OFTEN leads to harm to a patient.

Power is not always about arrogance, nor does having control over a situation necessarily have to make a person feel entitled to listen to his opinions and his opinions only. If I see someone dying on the street, I don't want to feel powerless to help him. This does not mean that the minute I have said power to help him, I'm going to strut around in a crown and tights to show off how amazing I am. I really wasn't referring to the corruption possible with the accumulation of power.

To be honest, I'm not crazy about midlevels taking over as PCP either. But with the way things have been progressing over the years, I think its almost inevitable. For the record, I do think midlevels can take over most PCP responsibilities as long as they have a very firm understanding of what their limits are and when they need to refer patients to a specialist.

Hmmm, interesting. Does this basically spell death row for FP and IM?

 

[135892]

I suppose I based that assertion mainly on myself, as I hardly do anything I dislike. For me, boredom is the enemy of good, and genuine interest and passion basically define success. Maybe some people can dedicate at least a third of their lives to something they dislike merely to spend the rewards on the other two-thirds, but to me, this sounds silly. I want a job I love so much, coming home feels like a chore. And I wish more people could think this way. I've worked on something as simple as group projects in various high school classes...and there is a HUGE difference between the people who care and really love the project versus the people who are simply aiming to scrape by with a high A. I never ever ever want to end up with the latter. And I really don't think most doctors would fall under that category, or at least, not from what I've seen.

This is a great attitude to have . Hopefully you won't get jaded as (unfortunately) many do.

 

[ToldYouSo]

Wow Algophiliac your attitude is definitely amazing... It is something alot of ppl should realize also.

 

[tennisball80]

I spoke with a couple of doctors, including one pediatric surgeon on this very topic. They both said that the pediatric patient base has the highest percentage of medicaid patients. Medicaid, in general, is poorly funded and reimbursement is not enough to cover expenses for many doctors. Medicare reimbursement is "ok" while private insurance typically pays the best (although I guess that can depend on the type of insurance you have too).

So anyone dealing with kids will have a higher chance of seeing medicaid patients than adults doctors. That's one subject I think is always missed when talking about health care reform. People assume that because someone is 'covered', either by government or otherwise, they have access to health care. Actually, that's not always true. If a person have only a poorly funded health program, many doctors will not take them because reimbursement is so poor. Children who are covered by medicaid may have health coverage, but that doesn't mean they have ready access to care.

Interesting. They government can make a law stating that doctors must accept every single patient. Then, these doctors who are not willing to accept Medicaid will have to accept poor patients.

 

[NonTradMed]

Interesting. They government can make a law stating that doctors must accept every single patient. Then, these doctors who are not willing to accept Medicaid will have to accept poor patients.

Now, why would anyone want to advocate such a foolish law? Medicaid typically don't cover the cost of the patient visit. If a patient visit costs $10, and medicaid pays $5, why should the doctor be forced to take in the medicaid patient? Shouldn't the doctor's first obligation be to his own clinic? To make sure he can pay for his nurses and staff and to support his own family? Where in the medical curriculum does it say doctors must *pay* to work?

And anyways, as physicians in private practice, the government cannot dictate who private docs can or cannot treat, especially if the payment is not enough to cover expenses. In essence, it would amount to involuntary labor since it requires the physician to eat the cost of the nonpaying patient.


Furthermore, if a doctor sees too many poor reimbursements, they, like any business, would go bankrupt, closing their clinic and no one would get health care. Remember that everyone costs and someone has to pay. Doctors do not have an infinite amount of cash to spread to their medicaid patients. If more money is going out (due to poor reimbursement), then there is no money to pay the staff and the physician.

It's one thing for doctors in county hospitals to see any and all patients that walk through the door because they take no liability of the hospital/clinic's bottom line and they are paid regardless of their clientele. It's quite another matter for private practice physicians who have to support themselves, to take on the liability of their own clinic but none of the autonomy and decision making.

Anyway, it just boggles the mind that anyone would think forcing doctors to take any patient is a good solution in today's health care problems.

 

[niranjan162]

I suppose I based that assertion mainly on myself, as I hardly do anything I dislike. For me, boredom is the enemy of good, and genuine interest and passion basically define success. Maybe some people can dedicate at least a third of their lives to something they dislike merely to spend the rewards on the other two-thirds, but to me, this sounds silly. I want a job I love so much, coming home feels like a chore. And I wish more people could think this way. I've worked on something as simple as group projects in various high school classes...and there is a HUGE difference between the people who care and really love the project versus the people who are simply aiming to scrape by with a high A. I never ever ever want to end up with the latter. And I really don't think most doctors would fall under that category, or at least, not from what I've seen.

Just go look around the forums, everyone is brimming up to the eyeballs with idealism. Most of us start out this way. I wonder what happens between now and then that makes people, as you say, aim to scrape by.

Im sure everyone would love a job that they love but that simply isnt the reality for everyone. I dont think its quite as easy as you paint it. I dont enjoy going to work, but im gonna get up tomorrow and do it.

I think as with any job there will be things you like and dont like. However I think after 40 years of doing something it tends to become a job just like any other.

Especially the way medicine is going it might not be as great as it once was to be a physician. I think Primary care can be saved, but its gonna take alot of political clout, etc. The older generation of physicians are done, its up to those taking their place to stand up for medicine.

 

[tennisball80]

Now, why would anyone want to advocate such a foolish law? Medicaid typically don't cover the cost of the patient visit. If a patient visit costs $10, and medicaid pays $5, why should the doctor be forced to take in the medicaid patient? Shouldn't the doctor's first obligation be to his own clinic? To make sure he can pay for his nurses and staff and to support his own family? Where in the medical curriculum does it say doctors must *pay* to work?

And anyways, as physicians in private practice, the government cannot dictate who private docs can or cannot treat, especially if the payment is not enough to cover expenses. In essence, it would amount to involuntary labor since it requires the physician to eat the cost of the nonpaying patient.


Furthermore, if a doctor sees too many poor reimbursements, they, like any business, would go bankrupt, closing their clinic and no one would get health care. Remember that everyone costs and someone has to pay. Doctors do not have an infinite amount of cash to spread to their medicaid patients. If more money is going out (due to poor reimbursement), then there is no money to pay the staff and the physician.

Why would anyone think it's a feasible plan to force physicians to work for free? And would would be an incentive for a pediatrician to stay in practice if she knows that she may not make any money depending on who walks in the door that day?

It's one thing for doctors in county hospitals to see any and all patients that walk through the door because they take no liability of the hospital/clinic's bottom line and they are paid regardless of their clientele. It's quite another matter for private practice physicians who have to support themselves, to take on the liability of their own clinic but none of the autonomy and decision making.

Anyway, it just boggles the mind that anyone would think forcing doctors to take any patient is a good solution in today's health care problems.

I understand your concerns. However, a similar law exists in my home country. Let's see what's happening.

My home country, Japan, has a law stating every physician is mandatory to take any patients regardless of financial ability. Even an illegal immigrant comes to a clinic, the physician must take the patient.

Government has a national price regulation on how much a single procedure doctors can charge. If a doctor charges more than what says on a hand-book, the book deserves a big fine.

Since every procedure at any clinics or hospitals are the same price, we can choose the good university hospitals instead of seeing a GP. We can see any specialists without a referral letter from a GP. If you feel a back pain, we can walk into an orthopedic surgeon's office without the GP's referral. And the orthopedic surgeon is mandatory to take patients.

50% of Japanese hospitals are in financial difficulties. I have seen a few hospitals lay off every year. But still, we still have the law to protect against patients, according to Japanese Medical Association.

The Japanese system is too beneficial for the patients but not for the physicians.

Some Interesting Quotes.

...Japan's universal health insurance system is a system based on the obligatory membership of all people in Japan in a health insurance system under which the government guarantees that all members can receive appropriate and low-cost health care, whenever and wherever in Japan they may be.... In order to fulfill its mission, the JMA proposes health policies based on the perspective of the patient.

Message from President

The mission of medical science and health care is to cure diseases, to maintain and promote the health of the people; and based on an awareness of the importance of this mission, the physician should serve society with a basic love for humanity.....

5. The physician should respect the spirit of public service that characterizes health care, contribute to the development of society while abiding by legal standards and establishing legal order.

6. The physician will not engage in medical activities for profit-making motives.

Principles of Medical Ethnics - Japanese Medical Association

 

[NonTradMed]

I understand your concerns. However, a similar law exists in my home country. Let's see what's happening.

My home country, Japan, has a law stating every physician is mandatory to take any patients regardless of financial ability. Even an illegal immigrant comes to a clinic, the physician must take the patient.

Government has a national price regulation on how much a single procedure doctors can charge. If a doctor charges more than what says on a hand-book, the book deserves a big fine.

Since every procedure at any clinics or hospitals are the same price, we can choose the good university hospitals instead of seeing a GP. We can see any specialists without a referral letter from a GP. If you feel a back pain, we can walk into an orthopedic surgeon's office without the GP's referral. And the orthopedic surgeon is mandatory to take patients.

50% of Japanese hospitals are in financial difficulties. I have seen a few hospitals lay off every year. But still, we still have the law to protect against patients, according to Japanese Medical Association.

The Japanese system is too beneficial for the patients but not for the physicians.

I'm not sure what you are arguing for. The very fact that half of Japanese hospitals are experiencing financial difficulties seems to indicate that your solution would not help the US situation. In fact, it sounds very wasteful since it does not encourage efficiency and it allows patients to choose expensive procedures bypassing physicians altogether. Primary care doctors are there to tell you that you don't need to have surgery when a simple pill could work. If a patient decides otherwise, why have a doctor available? Tt seems a waste of resources.

The US system is probably not any better than the Japanese. You'd really be exchanging one set of headaches for another. I guess I'd like to see a system where people are allowed some autonomy to choose doctors but still allow for efficiency. Shortchanging doctors seems a poor way to get about it.

 

[tennisball80]

I'm not sure what you are arguing for.

Hmmm.. what ? I didn't try to argue with any of your opinion. I am just providing information here and hopefully to gain some new insights through a discussion.

 

[tennisball80]

I'm not sure what you are arguing for. The very fact that half of Japanese hospitals are experiencing financial difficulties seems to indicate that your solution would not help the US situation. In fact, it sounds very wasteful since it does not encourage efficiency and it allows patients to choose expensive procedures bypassing physicians altogether. Primary care doctors are there to tell you that you don't need to have surgery when a simple pill could work. If a patient decides otherwise, why have a doctor available? Tt seems a waste of resources.

The US system is probably not any better than the Japanese. You'd really be exchanging one set of headaches for another. I guess I'd like to see a system where people are allowed some autonomy to choose doctors but still allow for efficiency. Shortchanging doctors seems a poor way to get about it.

No. The current Japanese system is not a solution for U.S.

How bout a national price regulation on the U.S current system to determine every procedure but to set the price HIGH enough so doctors can make $$$ ?

Wait but Canada is like this. The doctors in Canada makes a lot $$$ comparing to the Japanese ones. But there are too long waiting lists in Canada.

Don't know what to do about health care.. There is not single perfect system.

 

[Terpskins99]

I suppose I based that assertion mainly on myself, as I hardly do anything I dislike. For me, boredom is the enemy of good, and genuine interest and passion basically define success. Maybe some people can dedicate at least a third of their lives to something they dislike merely to spend the rewards on the other two-thirds, but to me, this sounds silly. I want a job I love so much, coming home feels like a chore. And I wish more people could think this way. I've worked on something as simple as group projects in various high school classes...and there is a HUGE difference between the people who care and really love the project versus the people who are simply aiming to scrape by with a high A. I never ever ever want to end up with the latter. And I really don't think most doctors would fall under that category, or at least, not from what I've seen.

I appreciate your idealism. I really do. But I hope you understand that a high school group project is hardly equivalent to a career in medicine. You screw up a high school project, the worse thing that happens is you get a poor grade. Things get a bit more complicated when the stakes involve another person's life. At that point, competency becomes everything. If money and lifestyle is what is involved in bringing out the best of the best in specialty candidates... so be it.

I don't care if my surgeon is only in it for the money, as long as he's one of the best at performing the operation. Desire for money (or fear of losing it) is the one quantifiable measure of motivation for any doctor to be at the top of their game. That extends to all healthcare in the US. And I believe thats the reason why the US continues to lead the world in terms of developing the most advanced and effective treatment for disease.

Hmmm, interesting. Does this basically spell death row for FP and IM?

For family medicine, I think so. At least eventually. IM will always stay popular, as long as you still have to go through IM to get to cardiology/gi/hemeonc... etc. Its hardly a secret that family medicine is among the least popular specialties that medical students pursue. They continue to get paid less and less money, and just my opinion... the job they do most of the time doesn't require a medical degree. After 3 months of family medicine rotations, I'd estimate that at least 90% of what FM docs do on a daily basis could be handled with reasonable competency by a CRNP or a PA. I'd say the one thing that a FM doctor seem to do more effectively than CRNP/PA's is screen patients a little better for legitimate emergencies and send fewer of their patients to the ER (heheh, this based upon my time rotating at an ER). CRNP's and PA's are very trigger happy with any patient who walks in complaining of chest pain.

 

[Law2Doc]

...
I'm curious. What are your opinions of OB/GYN's that move their practice to another state because the local malpractice insurance have premiums exceeding their total salary? Or how about those GYN's that have abandoned OB practice altogether? Do you consider that appalling as well?
...

The situation is greatly exaggerated. OBGYNs have threatened to relocate or get out of the business since at least the early 80s. It's 20+ years later and they are still singing the same song, but the field still exists and they really haven't moved en mass to other states or abandoned practices to any significant degree. What we have seen is their fees/reimbursements increased a bit to keep pace with the increase in premiums such that fields like OBGYN are much more highly compensated than FP or Peds. And their complaints have definitely become more high profile over the years -- with president Bush saying a few years back what a shame it was that "[t]oo many OB/GYNs aren't able to practice their ... their love, with women all across the country."

But saying that medmal premiums exceeded total salary and other similar claims are hugely exaggerated, and designed to get sympathy, but not really convey the actual situation. They get sued more than most, have harder cases to defend, and pay more medmal than other fields, no doubt. But they in turn earn more than FP and Peds, the other primary care fields they are considered most comparable to.

 

[Terpskins99]

The situation is greatly exaggerated. OBGYNs have threatened to relocate or get out of the business since at least the early 80s. It's 20+ years later and they are still singing the same song, but the field still exists and they really haven't moved en mass to other states or abandoned practices to any significant degree. What we have seen is their fees/reimbursements increased a bit to keep pace with the increase in premiums such that fields like OBGYN are much more highly compensated than FP or Peds. And their complaints have definitely become more high profile over the years -- with president Bush saying a few years back what a shame it was that "[t]oo many OB/GYNs aren't able to practice their ... their love, with women all across the country."

But saying that medmal premiums exceeded total salary and other similar claims are hugely exaggerated, and designed to get sympathy, but not really convey the actual situation. They get sued more than most, have harder cases to defend, and pay more medmal than other fields, no doubt. But they in turn earn more than FP and Peds, the other primary care fields they are considered most comparable to.

[Note: Medical Malpractice Premium is the annual money physicians (or hospitals pay for physicians) to insurance companies to protect from bankruptcy in case of a patient suing for malpractice]

Here's the Top-10 list of the worst states :

1. Florida (>$270,000 in Dade County - Year 2004)
2. Nevada
3. Michigan
4. District of Columbia
5. Ohio
6. Massachusetts
7. West Virginia
8. Connecticut
9. Illinois (>$230,000 in Cook County - Year 2004)
10. New York

source: http://mdsalaries.blogspot.com/2007/10/states-with-highest-lowest-malpractice.html

...as of April 2006, seventy-six percent of all obstetricians /gynecologists have been sued at least once, 57 percent have been sued twice, and nearly 42 percent have been sued three times or more. Ob-Gyn has consistently ranked as a specialty with the highest Malpractice Insurance Premiums , i.e. the money you pay each year to protect yourself financially in case you are sued by patients. The AMA website puts this is averaging to about $35,000/- per year, but take note that the variations are huge country-wide. For example, the Ob-Gyn docs in Cook county in Illinois State paid an average of $138,484 during 2006 in premiums alone (One of the reasons why Illinois is losing its physicians) . Compare this with national averages of $8000/- per year for Family Practice and $9000/- pre year for Internal Medicine...

source: http://mdsalaries.blogspot.com/2005/10/obstetrician-gynecologist-salaries.html

Malpractice insurance premiums vary widely from state to state. Florida is the highest-premium state, with an average 2004 premium of more than $195,000, followed by Nevada, Michigan, the District of Columbia, Ohio, Massachusetts, West Virginia, Connecticut, Illinois and New York.

The 10 lowest-premium states are Oklahoma, at about $17,000 on average, and Nebraska, South Dakota, Minnesota, Indiana, Idaho, North Dakota, Wisconsin, Arkansas and South Carolina.

Many areas of the country, especially around major metropolitan areas, are experiencing large increases in the average costs of premiums. Between 2003 and 2004, Dade County in Florida, which includes the city of Miami, went from $249,000 to $277,000, an increase of about 11 percent.

In that same period, Cook County in Illinois, which includes Chicago , jumped about 67 percent from $138,000 to more than $230,000. Wayne County in Michigan , which includes Detroit, went up 18 percent, from almost $164,000 to nearly $194,000.

source: http://www.med.umich.edu/opm/newspage/2005/obgyn.htm

 

[Algophiliac]

I appreciate your idealism. I really do. But I hope you understand that a high school group project is hardly equivalent to a career in medicine. You screw up a high school project, the worse thing that happens is you get a poor grade. Things get a bit more complicated when the stakes involve another person's life. At that point, competency becomes everything. If money and lifestyle is what is involved in bringing out the best of the best in specialty candidates... so be it.

I suppose I simply cannot understand how money and lifestyle can bring out the best in specialty candidates, but we'll just have to agree to disagree on that point. Perhaps they really like whatever they're buying with that money. I am aware that I'm hardly a typical example anyway, so I shouldn't be using myself as a measure of how the system should function. If it works, it works. And I wouldn't mind such doctors treating me as much as I would mind having to work with them as colleagues day in and day out. But again, I don't see that mindest in doctors. Yes, they may be partially in it for the money, but from what I've seen, very few if any would leave if salaries began dropping.

For family medicine, I think so. At least eventually. IM will always stay popular, as long as you still have to go through IM to get to cardiology/gi/hemeonc... etc. Its hardly a secret that family medicine is among the least popular specialties that medical students pursue. They continue to get paid less and less money, and just my opinion... the job they do most of the time doesn't require a medical degree. After 3 months of family medicine rotations, I'd estimate that at least 90% of what FM docs do on a daily basis could be handled with reasonable competency by a CRNP or a PA. I'd say the one thing that a FM doctor seem to do more effectively than CRNP/PA's is screen patients a little better for legitimate emergencies and send fewer of their patients to the ER (heheh, this based upon my time rotating at an ER). CRNP's and PA's are very trigger happy with any patient who walks in complaining of chest pain.

So we can basically say goodbye to General IM? If medical school was never really necessary for these specialties, it's a wonder they lasted this long. Thanks for the insight!

Law2Doc, I think you have a great point about medicine as a specialty in general. There is often talk about stagnant salaries not keeping up with inflation, rising medical school costs, and large malpractice premiums, but nothing seems to affect the influx of medical school applications each year! Apprently we have not yet reached a breaking point.

 

[Terpskins99]

I suppose I simply cannot understand how money and lifestyle can bring out the best in specialty candidates, but we'll just have to agree to disagree on that point. Perhaps they really like whatever they're buying with that money. I am aware that I'm hardly a typical example anyway, so I shouldn't be using myself as a measure of how the system should function. If it works, it works. And I wouldn't mind such doctors treating me as much as I would mind having to work with them as colleagues day in and day out. But again, I don't see that mindest in doctors. Yes, they may be partially in it for the money, but from what I've seen, very few if any would leave if salaries began dropping.

Money and lifestyle attract the strongest medical students. Or rather, only the strongest medical students end up in that field. Its that simple.

So we can basically say goodbye to General IM? If medical school was never really necessary for these specialties, it's a wonder they lasted this long. Thanks for the insight!

Well, yes to what I think you're trying to say: which is for outpatient general practitioners. Most internists and hospitalists (which is what a "general IM"-doctor is) still take care of patients in a hospital setting, and that will always require a medical doctor to oversee.

But for running a primary care outpatient clinic to handle routine checkups and screening? Yes, I think this work can and eventually will be taken over by CRNP's and PA's. Should they take over? No. But I think its almost inevitable. Each year, fewer and fewer med students/residents are interested in going into primary care. The main reason for that? Money.

 

[coffeebythelake]

What is wrong with greed? Greed is a primary motivator for many, and it is a damn good one (as long as you stay within the legal bounds of course)

if greed is the prime motivator, you'll be sorely disappointed with the reality of medicine.

 

[CScull]

I suppose I based that assertion mainly on myself, as I hardly do anything I dislike. For me, boredom is the enemy of good, and genuine interest and passion basically define success. Maybe some people can dedicate at least a third of their lives to something they dislike merely to spend the rewards on the other two-thirds, but to me, this sounds silly. I want a job I love so much, coming home feels like a chore. And I wish more people could think this way. I've worked on something as simple as group projects in various high school classes...and there is a HUGE difference between the people who care and really love the project versus the people who are simply aiming to scrape by with a high A. I never ever ever want to end up with the latter. And I really don't think most doctors would fall under that category, or at least, not from what I've seen.

If everyone had your passion for medicine then we wouldn't need to have this conversation. Unfortunately that's not the way it is though... everyone always has their own reasons for choosing this field. There will be people who don't make it who are going at it for the "right" reasons, and some people who do make it for the "wrong" ones. And sometimes the doctors who we say work for the "wrong" reasons make better doctors than those who are working for the "right" reasons. The only thing we can do is make sure we don't fall into the category of those who are aspiring health careers for the "wrong" reasons.

 

[Algophiliac]

Money and lifestyle attract the strongest medical students. Or rather, only the strongest medical students end up in that field. Its that simple.

Not necessarily. What about academic medicine, MD/PhD, or other routes that very strong students take despite the pay cut? I may be idealistic (although honestly, I'm a pessimist), but you're not really divulging the whole truth. Only the strongest medical students end up in those fields because the fields are competitive, and this is possibly due to lack of spots, in addition to great pay and excellent lifestyle. So, while I agree that money and stability of income do play some part in some students' specialty choices, I don't think this is the whole story at all.

Well, yes to what I think you're trying to say: which is for outpatient general practitioners. Most internists and hospitalists (which is what a "general IM"-doctor is) still take care of patients in a hospital setting, and that will always require a medical doctor to oversee.

But for running a primary care outpatient clinic to handle routine checkups and screening? Yes, I think this work can and eventually will be taken over by CRNP's and PA's. Should they take over? No. But I think its almost inevitable. Each year, fewer and fewer med students/residents are interested in going into primary care. The main reason for that? Money.

Ohhh, I see! I did not think that a medical doctor might still be necessary to oversee procedures in a hospital setting, so thanks for pointing that out.

I think the reasoning might be more in the realm of longER (too obvious? ) hours than other specialties that get paid more, and the fact that most choose to specialize, which may or may not be for the sake of earning more money.

Haha, CScull, I'll always be the one taking the pay cuts to save the universe one complaining patient at a time!

 

[Terpskins99]

Not necessarily. What about academic medicine, MD/PhD, or other routes that very strong students take despite the pay cut? I may be idealistic (although honestly, I'm a pessimist), but you're not really divulging the whole truth. Only the strongest medical students end up in those fields because the fields are competitive, and this is possibly due to lack of spots, in addition to great pay and excellent lifestyle. So, while I agree that money and stability of income do play some part in some students' specialty choices, I don't think this is the whole story at all.

The whole truth? And what would that be? I am not saying that money and lifestyle are the only reasons one person chooses a specialty (or a career in medicine, for that matter). Only that money and lifestyle are a BIG reason and what most would consider an IMPORTANT reason. I just don't see why you have such a problem with that... outside of the fact that it perhaps creates additional competition for you to get in at some point.

Ohhh, I see! I did not think that a medical doctor might still be necessary to oversee procedures in a hospital setting, so thanks for pointing that out.

It would be a very bad idea to allow physician assistants and nurses to take over all the duties of an inpatient medicine service.