When did Doctors become helpless against BC and GME?

[Staphylococcus Aureus]

I know of doctors that have only done a transitional year that see patients cash only, and obviously that was much more common in the past. I believe even into the 80s (could be wrong on this) any doc could do EM, now you basically have no chance if you're not board certified in EM. If you don't pay massive sums to become BC and continually pay to be re-certified it has a serious effect on your employment opportunities. There's also the dynamic of unsubsidized loans ballooning while you make pennies, while in the past your intern year could pay off your entire debt.

When did this happen and why do doctors have so little power in the training process? And before the quality of training and "standard of care" argument rushes in, the standard to practice independently is essentially non-existent now that NPs have full prescription rights. So why is it that midlevels can hop from psych to EM to derm on a whim, while med students kill themselves (sometimes literally) trying to match into a specialty that they will determine the confines of their career?

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[ACSurgeon]

I know of doctors that have only done a transitional year that see patients cash only, and obviously that was much more common in the past. I believe even into the 80s (could be wrong on this) any doc could do EM, now you basically have no chance if you're not board certified in EM. If you don't pay massive sums to become BC and continually pay to be re-certified it has a serious effect on your employment opportunities. There's also the dynamic of unsubsidized loans ballooning while you make pennies, while in the past your intern year could pay off your entire debt.

When did this happen and why do doctors have so little power in the training process? And before the quality of training and "standard of care" argument rushes in, the standard to practice independently is essentially non-existent now that NPs have full prescription rights. So why is it that midlevels can hop from psych to EM to derm on a whim, while med students kill themselves (sometimes literally) trying to match into a specialty that they will determine the confines of their career?

They system overall has become much more stringent, for better and for worse.

If you were sick, and went to an ER, would you want a non-trained Doctor taking care of you or your family? I've seen ERs with ER doctors and those without. The level of troubleshooting and patient care is very different.

Same argument can be made for going to see a GP vs. family medicine trained person.

Just because the NPs are doing it doesn't make it right.

Of course all that said, the governing bodies have become ridiculous, and some degree of reform would be amazing (although unlikely).

 

[Staphylococcus Aureus]

They system overall has become much more stringent, for better and for worse.

If you were sick, and went to an ER, would you want a non-trained Doctor taking care of you or your family? I've seen ERs with ER doctors and those without. The level of troubleshooting and patient care is very different.

Same argument can be made for going to see a GP vs. family medicine trained person.

Just because the NPs are doing it doesn't make it right.

Of course all that said, the governing bodies have become ridiculous, and some degree of reform would be amazing (although unlikely).

To be clear I'm interested in this as a discussion and hopes of improvement, I'm not against GME in any form. Just seems that the standards and requirements to practice, especially in primary care, have become so rigid while every other profession has let their standards go flaccid.

 

[SurfingDoctor]

I'm confused as to what you are asking. Are you asking why physicians have to undergo graduate level medical training board certified in a particular specialty which mid-level practitioners don't? If physician didn't undergo training and prove competency, how would their training and attainment of knowledge be different than a mid-level practitioner? It is that difference that gives physicians a leg up.

Now, being board certified doesn't automatically mean one is a good physician or even a competent physician, and the money going into and retaining board-certification is ridiculous (that is a different discussion), but it's the best peer-reviewed metric we have.

 

[Osteoth]

I know of doctors that have only done a transitional year that see patients cash only, and obviously that was much more common in the past. I believe even into the 80s (could be wrong on this) any doc could do EM, now you basically have no chance if you're not board certified in EM. If you don't pay massive sums to become BC and continually pay to be re-certified it has a serious effect on your employment opportunities. There's also the dynamic of unsubsidized loans ballooning while you make pennies, while in the past your intern year could pay off your entire debt.

When did this happen and why do doctors have so little power in the training process? And before the quality of training and "standard of care" argument rushes in, the standard to practice independently is essentially non-existent now that NPs have full prescription rights. So why is it that midlevels can hop from psych to EM to derm on a whim, while med students kill themselves (sometimes literally) trying to match into a specialty that they will determine the confines of their career?

Really interesting question. I had never thought about it like that.

But to the point, from what I understand talking to midlevels (PA, NP), the more specialized the training, the higher in-demand the skills and the higher the pay. The same is similar in the MD world, where in rural communities they still have FP/IM doctors staffing their EDs due to lack of supply of docs.

I'm confused as to what you are asking. Are you asking why physicians have to undergo graduate level medical training board certified in a particular specialty which mid-level practitioners don't? If physician didn't undergo training and prove competency, how would their training and attainment of knowledge be different than a mid-level practitioner? It is that difference that gives physicians a leg up.

Now, being board certified doesn't automatically mean one is a good physician or even a competent physician, and the money going into and retaining board-certification is ridiculous (that is a different discussion), but it's the best peer-reviewed metric we have.

I think the question is most applicable to generalized fields (FP, IM, EM) and why can't one residency be said to be applicable to all three of those fields. Obviously the answer is more training = better proficiency = better outcomes etc. But the corollary being drawn between our independent midlevel friends who are not constrained by the same system is valid.

 

[Staphylococcus Aureus]

There should certainly be residences, it just seems like the system leaves doctors helpless to play the game exactly how the rules are laid out. Take neonatology for example, definitely GME is needed for this, but it's a inflexible path of 3 years peds of patients 0-18, then 3 years neo (2 of which are often research) then if you don't board certify and you can't get a hospital job, then to keep that job is endless hoops and money to stay certified. I guess my question was why does it seem doctors and students have no power in their own profession, but a number of explanations come to mind.

 

[Brorthopedic]

I think it's because we're too busy doing other things to stand up for ourselves. Throughout med school we're taught to "roll with the punches" and this sort of mentality is dangerous. We let small changes happen and these things add up overtime, convoluting the system.

 

[SurfingDoctor]

There should certainly be residences, it just seems like the system leaves doctors helpless to play the game exactly how the rules are laid out. Take neonatology for example, definitely GME is needed for this, but it's a inflexible path of 3 years peds of patients 0-18, then 3 years neo (2 of which are often research) then if you don't board certify and you can't get a hospital job, then to keep that job is endless hoops and money to stay certified. I guess my question was why does it seem doctors and students have no power in their own profession, but a number of explanations come to mind.

Well, if one is unable to obtain board certification because they can't meet the peer-reviewed standards, I'm not sure that is the systems fault. Typically they give a lot of leeway from a timing standpoint to make sure one is board-eligible. I don't know what it is for all specialties, but for pediatrics, an individual has 7 years to become certified, if they can't, they have to have 6 months of ACGME-accredit supervision and then are eligible for another 7 years. That is a long time to give someone to meet the standards of practice. That being said, there are jobs available for non-board certified people. One could set up their own business for instance. Certainly options will be more limited, but it's not like one has to give up practicing as long as they don't have other professional demerits.

As for you other points, yep, board-certification is a money suck, but it the grand scheme of things $2K to $3K every ten years is really not cost prohibitive, especially if one is a neonatalogist. Speaking to the duration of training, I think most residency training (at least for pediatrics, which is what I'm familiar with) is about right. You need to see enough of everything to at least be semi-competent when you encounter the one offs. As for fellowship training, yes, it is unnecessary to fellowship training to be as long as it is in pediatrics. This is mostly because of the scholarly requirements set forth by the board. The reasons go back a ways, but the idea was that subspecialists were not competent at critically reviewing scientific data and not pushing the field forward, thus they required trainees to complete a project to learn those skills. While I think the intent was good, the reality didn't work out that way. Though it is subspecialty dependent, many fellows don't have any intent in doing scientific work for their careers and mandating them to obtain those skills seems like a misguided goal. Additionally, for those who do want to do scholarly work longterm, the research experience is woefully inadequate. So were left with kinda half a-s attempt to make people learn a skill which is unnecessary for some and inadequate for others. There has been talk of going back to the 1.5 to 2 year system, but it hasn't gained much traction... yet.

To speak to your question though, there are physicians who have the power in determining all of this. As I mentioned, it is peer-reviewed and determined. The medical accreditation boards are comprised of physicians. The physicians who want to get involved, do. The physicians who don't, don't. You can join medical associations, medical boards, etc. and help guide things as you see fit. However, you also have to realize that others may hold a completely different opinion and thus there will always be compromise. It doesn't mean things can't change, but it will always be slow. That being said, if you don't like the way things are, but choose to voice your concerns from the sidelines, I guarantee your voice won't be heard.

 

[omn]

I know of doctors that have only done a transitional year that see patients cash only, and obviously that was much more common in the past. I believe even into the 80s (could be wrong on this) any doc could do EM, now you basically have no chance if you're not board certified in EM. If you don't pay massive sums to become BC and continually pay to be re-certified it has a serious effect on your employment opportunities. There's also the dynamic of unsubsidized loans ballooning while you make pennies, while in the past your intern year could pay off your entire debt.

When did this happen and why do doctors have so little power in the training process? And before the quality of training and "standard of care" argument rushes in, the standard to practice independently is essentially non-existent now that NPs have full prescription rights. So why is it that midlevels can hop from psych to EM to derm on a whim, while med students kill themselves (sometimes literally) trying to match into a specialty that they will determine the confines of their career?

Insightful, Intelligent, and Important .. but wouldn't surprise me if on SDN your post was reported for being "inaccurate"...

 

[neusu]

Follow the money. Hospitals/attendings at training programs benefit in two ways by maintaining the current status quo. 1) The federal government pays the salary of trainees 2) By creating an increased cost of entry to the marketplace, your relative monopoly on the service you provide is ensured. They utilize vehicles like JCAHO and insurance reimbursement to prohibit entry via granting privileges and reimbursement, respectively. The former grants "accreditation" to hospitals while the latter pays the bills. Any more, board certification has become a de facto seal of approval to practice. In some way, the licensing boards have become irrelevant, because with a license you can not do much in modern medicine. Still, one could open a private office, assess patients, do minor procedures, order labs,and write prescriptions that will be filled at pharmacies. The reason most do not is several fold. Building a practice independently is difficult, and while many do even after residency, moonlighting helps supplement income. Likewise, admitting privileges for internists, and more so for , are useful for continuity of care; though any more most internists do either office based or hospital based medicine. Further, portability of a practice is limited, and far more difficult without board accreditation. Finally, school administration at medical schools are naive, or perhaps pushing a prerogative of doing residency, and fail to explain the nuances of post medical school life as a medical doctor.

In sum, there is nothing stopping you from doing a TY, obtaining a full medical license through your state and accepting cash to see patients. You will never be granted privileges, nor be able to enroll in billing through insurance, however, because you are not board eligible.

 

[Osteoth]

Well, if one is unable to obtain board certification because they can't meet the peer-reviewed standards, I'm not sure that is the systems fault. Typically they give a lot of leeway from a timing standpoint to make sure one is board-eligible. I don't know what it is for all specialties, but for pediatrics, an individual has 7 years to become certified, if they can't, they have to have 6 months of ACGME-accredit supervision and then are eligible for another 7 years. That is a long time to give someone to meet the standards of practice. That being said, there are jobs available for non-board certified people. One could set up their own business for instance. Certainly options will be more limited, but it's not like one has to give up practicing as long as they don't have other professional demerits.

As for you other points, yep, board-certification is a money suck, but it the grand scheme of things $2K to $3K every ten years is really not cost prohibitive, especially if one is a neonatalogist. Speaking to the duration of training, I think most residency training (at least for pediatrics, which is what I'm familiar with) is about right. You need to see enough of everything to at least be semi-competent when you encounter the one offs. As for fellowship training, yes, it is unnecessary to fellowship training to be as long as it is in pediatrics. This is mostly because of the scholarly requirements set forth by the board. The reasons go back a ways, but the idea was that subspecialists were not competent at critically reviewing scientific data and not pushing the field forward, thus they required trainees to complete a project to learn those skills. While I think the intent was good, the reality didn't work out that way. Though it is subspecialty dependent, many fellows don't have any intent in doing scientific work for their careers and mandating them to obtain those skills seems like a misguided goal. Additionally, for those who do want to do scholarly work longterm, the research experience is woefully inadequate. So were left with kinda half a-s attempt to make people learn a skill which is unnecessary for some and inadequate for others. There has been talk of going back to the 1.5 to 2 year system, but it hasn't gained much traction... yet.

To speak to your question though, there are physicians who have the power in determining all of this. As I mentioned, it is peer-reviewed and determined. The medical accreditation boards are comprised of physicians. The physicians who want to get involved, do. The physicians who don't, don't. You can join medical associations, medical boards, etc. and help guide things as you see fit. However, you also have to realize that others may hold a completely different opinion and thus there will always be compromise. It doesn't mean things can't change, but it will always be slow. That being said, if you don't like the way things are, but choose to voice your concerns from the sidelines, I guarantee your voice won't be heard.

Obviously I don't think anyone is arguing that stringency and minimum-competencies should be highly standardized to ensure maximum patient care, but I think the issue that a lot of younger professionals have is that things are going in the wrong direction.

What I mean is that while there is increasing specialization across all fields, causing more and more competition in each niche, but many of the advantages that once came with those sacrifices in terms of additional training seem to be going away too.

Honestly, I find it very hard to imagine if I was interested in family medicine why I wouldn't become a NP instead. The $30,000/year salary difference is easily matched by the lack of additional training, stress, licensing, and responsibility is takes to become a physician.

Responsibility and competition seem to be going up in the House of God, but compensation, respect, authority, and autonomy all seem to be going down.

Obviously all of us have made the choice we did for reasons, but it is still difficult for many of us early in our careers to see that many of the benefits our older colleagues enjoyed, and some of the reasons we joined the field, are blowing away with the wind.

 

[W19]

Honestly, I find it very hard to imagine if I was interested in family medicine why I wouldn't become a NP instead. The $30,000/year salary difference is easily matched by the lack of additional training, stress, licensing, and responsibility is takes to become a physician.

Responsibility and competition seem to be going up in the House of God, but compensation, respect, authority, and autonomy all seem to be going down.

Obviously all of us have made the choice we did for reasons, but it is still difficult for many of us early in our careers to see that many of the benefits our older colleagues enjoyed, and some of the reasons we joined the field, are blowing away with the wind.

I think it's a lot higher than that (~100k/year), but FM doc spends 11 years in school as opposed to 6... And opportunity cost also is the most important thing to consider.

 

[VA Hopeful Dr]

I think it's a lot higher than that (~100k/year), but FM doc spends 11 years in school as opposed to 6... And opportunity cost also is the most important thing to consider.

It should be more than 100k/year. Average FNP salary is right at 100k. As a family doctor, making over 200k isn't actually all that hard. Heck I'm starting a job in 3 months with 4 day weeks, 8-4:30 with an hour for lunch making 220k. If I add in 2 urgent care shifts per month on the Mondays that I don't work, we're up to 250k/year. That's every other Monday off (it would be 280k if I did urgent care every Monday), no weekends, no nights, no holidays, no setting foot in the hospital ever.

Beyond that, its easier to find a job as an FP than an NP - lots of places don't hire midlevels but I've yet to come across a family medicine job that was only taking midlevels.

Yes, you do give up some opportunity cost for training but when you're done you have easily the best job market in the country. I'm in SC. There are currently 40 FM jobs scattered through every part of the state (likely more, but I'm not going to look past the AAFP job listings). Literally. Pick any spot, draw a circle 30 miles around and you'll have a job available.

 

[Staphylococcus Aureus]

if I was interested in family medicine why I wouldn't become a NP instead. The $30,000/year salary difference is easily matched by the lack of additional training, stress, licensing, and responsibility is takes to become a physician.

Exactly, it's not a simple number of 11 vs 5-6 training years, the paths to almost the same license are completely different in terms of amount of stress, standards, and scrutiny. Idk how much the online NP programs are but I doubt they're 300K debt like medicine. The "look on the bright side" mentality when comparing the salary difference is mute because of this.

 

[Staphylococcus Aureus]

Insurance hasn't been brought up, but it's certainly one of the many factors to why physicians have lost autonomy in their own craft.

 

[oncology2020]

I'm confused as to what you are asking. Are you asking why physicians have to undergo graduate level medical training board certified in a particular specialty which mid-level practitioners don't? If physician didn't undergo training and prove competency, how would their training and attainment of knowledge be different than a mid-level practitioner? It is that difference that gives physicians a leg up.

I hate this logic. The difference between physicians and midlevels should be attained in medical school and through our 4 extremely difficult licensing exams. Otherwise what is the purpose of having one of the most strenuous medical doctorates and licensing exams in the world when that degree is useless without further training and jumping through even more hoops just to get board certified. It makes sense in other nations where the medical degree is traditionally an undergraduate degree (MBBS stands Bacher of Medicine and Bachler of Surgery) and this is also why it's traditionally called GRADUATE medical education (GME) because the medical degree has traditionally been an undergraduate degree. They need to cut down on the 4 years of premed and do it like other nations do and make medicine 4-5 years and focus on actual on job training. In the US, our medical education and post graduate training is a total scam, all done in the name of "patient care." Without being board certified your MD means absolutely nothing which is a shame.

 

[Staphylococcus Aureus]

Anyone else feel boxed in and chained despite being the apex of medicine? Doctors have lost hold the reins of their own profession. Be it school administrators, insurance companies, hospital CEOs, patient satisfaction surveys, why do we get pushed around by non-doctors that know nothing about medicine?

Contrast this with lawyers (not the best analogy as they have a different set of problems), they are still the masters of their profession. Only lawyers can practice law, judges and most law makers went to law school, they can switch areas of practice at will, if they have a boss it is always another lawyer, their compensation is usually not dictated by a non-lawyer, the list goes on.

 

[anbuitachi]

That's why doctors stand no chance

 

[VA Hopeful Dr]

I hate this logic. The difference between physicians and midlevels should be attained in medical school and through our 4 extremely difficult licensing exams. Otherwise what is the purpose of having one of the most strenuous medical doctorates and licensing exams in the world when that degree is useless without further training and jumping through even more hoops just to get board certified. It makes sense in other nations where the medical degree is traditionally an undergraduate degree (MBBS stands Bacher of Medicine and Bachler of Surgery) and this is also why it's traditionally called GRADUATE medical education (GME) because the medical degree has traditionally been an undergraduate degree. They need to cut down on the 4 years of premed and do it like other nations do and make medicine 4-5 years and focus on actual on job training. In the US, our medical education and post graduate training is a total scam, all done in the name of "patient care." Without being board certified your MD means absolutely nothing which is a shame.

Except the total years are about the same. Let's take the UK. Med school is 6 years after high school. After med school it takes 5 years to become a GP. Total post high school commitment: 11 years. In America undergrad is 4 years, med school is 4 years, residency is 3 years. Total time: 12 years. Sure, let's change our whole system around with who knows what unforeseen adverse events to save 1 year. That's a good idea.

 

[bashwell]

Anyone else feel boxed in and chained despite being the apex of medicine? Doctors have lost hold the reins of their own profession. Be it school administrators, insurance companies, hospital CEOs, patient satisfaction surveys, why do we get pushed around by non-doctors that know nothing about medicine?

Contrast this with lawyers (not the best analogy as they have a different set of problems), they are still the masters of their profession. Only lawyers can practice law, judges and most law makers went to law school, they can switch areas of practice at will, if they have a boss it is always another lawyer, their compensation is usually not dictated by a non-lawyer, the list goes on.

They can also sue anyone and everyone they don't think is being cool to them.

 

[bashwell]

Except the total years are about the same. Let's take the UK. Med school is 6 years after high school. After med school it takes 5 years to become a GP. Total post high school commitment: 11 years. In America undergrad is 4 years, med school is 4 years, residency is 3 years. Total time: 12 years. Sure, let's change our whole system around with who knows what unforeseen adverse events to save 1 year. That's a good idea.

Although some UK med schools are 5 years, I believe. Not that that changes your main point at all.

Also, lots of UK doctors (especially junior doctors) are trying to escape the NHS, which seems to be spiraling downards (e.g., people can Google all the doctor strikes that have been happening as well as how many doctors are moving to places like Australia and NZ from the UK each year).

 

[SurfingDoctor]

I hate this logic. The difference between physicians and midlevels should be attained in medical school and through our 4 extremely difficult licensing exams. Otherwise what is the purpose of having one of the most strenuous medical doctorates and licensing exams in the world when that degree is useless without further training and jumping through even more hoops just to get board certified. It makes sense in other nations where the medical degree is traditionally an undergraduate degree (MBBS stands Bacher of Medicine and Bachler of Surgery) and this is also why it's traditionally called GRADUATE medical education (GME) because the medical degree has traditionally been an undergraduate degree. They need to cut down on the 4 years of premed and do it like other nations do and make medicine 4-5 years and focus on actual on job training. In the US, our medical education and post graduate training is a total scam, all done in the name of "patient care." Without being board certified your MD means absolutely nothing which is a shame.

I guess I'm confused, you hate what logic? That interns aren't performing CABGs or managing complex ICU patients independently out of medical school? Or that undergrad is too long? Sure, I guess they could cut down undergrad by 2 years. I'm not sure that would make a lot of difference. A couple less years of loans would be good.

 

[SurfingDoctor]

Obviously I don't think anyone is arguing that stringency and minimum-competencies should be highly standardized to ensure maximum patient care, but I think the issue that a lot of younger professionals have is that things are going in the wrong direction.

What I mean is that while there is increasing specialization across all fields, causing more and more competition in each niche, but many of the advantages that once came with those sacrifices in terms of additional training seem to be going away too.

Honestly, I find it very hard to imagine if I was interested in family medicine why I wouldn't become a NP instead. The $30,000/year salary difference is easily matched by the lack of additional training, stress, licensing, and responsibility is takes to become a physician.

Responsibility and competition seem to be going up in the House of God, but compensation, respect, authority, and autonomy all seem to be going down.

Obviously all of us have made the choice we did for reasons, but it is still difficult for many of us early in our careers to see that many of the benefits our older colleagues enjoyed, and some of the reasons we joined the field, are blowing away with the wind.

Like I mentioned before, board committees, credential committees, the ACGME etc. are all made up of physicians who set the competency requirements. If you don't like the current system now, get on a committee and become an advocate.

 

[W19]

I have been saying that med school in the US should be: 2-3 years prereq, 3-year med school and 2+ years residency...

 

[VA Hopeful Dr]

I have been saying that med school in the US should be: 2-3 years prereq, 3-year med school and 2+ years residency...

No thanks

 

[Stagg737]

Anyone else feel boxed in and chained despite being the apex of medicine? Doctors have lost hold the reins of their own profession. Be it school administrators, insurance companies, hospital CEOs, patient satisfaction surveys, why do we get pushed around by non-doctors that know nothing about medicine?

Contrast this with lawyers (not the best analogy as they have a different set of problems), they are still the masters of their profession. Only lawyers can practice law, judges and most law makers went to law school, they can switch areas of practice at will, if they have a boss it is always another lawyer, their compensation is usually not dictated by a non-lawyer, the list goes on.

Because most doctors don't care enough about the financial and business aspect of medicine to have a clue about it beyond the basics. There are plenty of ways to make more as a doc in the lower paying fields (cash only practice, DPC, locums, etc). Heck most new docs don't have a clue about what they're actually worth and accept low-ball offers without even making a counter-offer. Just go look in the attending/residency forums and you'll see plenty of people asking if the offer they got is good (most of the time the answer is no).

As for the second part, physicians can switch areas of practice within their specialties. Take a few seminars or at most do an extra year of fellowship and you can start doing new procedures or switch fields. If we're talking about switching fields though, I think there's a good reason it's not an easy thing to do as once physicians start down one path they dump a lot of relevant info from other fields. Personally, I don't want they guy seeing me in the ER to be some guy that spent 20 years in surgery and decided it was time for something new a year ago.

I have been saying that med school in the US should be: 2-3 years prereq, 3-year med school and 2+ years residency...

So basically an NP degree with a 2 year residency...sounds promising...

 

[cellsaver]

Insurance hasn't been brought up, but it's certainly one of the many factors to why physicians have lost autonomy in their own craft.

Det. Lester Freamon: You follow drugs, you get drug addicts and drug dealers. But you start to follow the money, and you don't know where the **** it's gonna take you. "The Wire: Game Day (#1.9)" (2002)​

Insurance/Third Party Payers are like a harlot in bed with the federal government thanks to the HMO Act of 1973. Thus the answer to your question is "1973". The legislation was authored by Senator Ted Kennedy (MA), passed by the US Congress and signed into law by President Richard M. Nixon. Watergate is chump change compared to the HMO Act.

Any business professional knows that if they want to do well in their markets, they must understand how they will get paid. Apple and Google don't bring their products and services to free for a reason. While physicians scream and holler about their income (when is enough enough?), the Feds and 3rd Party Payers are having a grand old time.

Third party payers and the Feds have this pony primed. Has the Federal government ever relinquished control of an entity once they had their firm grasp on it just because? Ever? Has a profitable industry ever abandoned their business schema while making kahbillions of dollars? Ever?

Physicians and those in training don't stand a chance in Hades until they become well acquainted with their business environment. The US healthcare industry accounts for almost 20% of the USA GDP. Think about that.

Start here:

Health Maintenance Organization Act of 1973​

and

Dorsey, J. L. (1975). The Health Maintenance Organization Act of 1973 (P.L. 93-222) and Prepaid Group Practice Plans. Medical Care, 13(1), 1-9.

“Prior to passage of this Act, Federal health care legislation was directed at purchase of health care services (Medicare and Medicaid), at planning for the allocation and distribution of health care services (Comprehensive Health Planning Act and Regional Medical Programs), or at improving the availability of facilities and manpower resources (Hill Burton and Health Manpower Acts).The Medicare bill stated specifically that the legislation would not interfere with the existing delivery system; the HMO Act is designed to stimulate the development of an alternative organizational structure for health services delivery.”​

It isn't pretty but essentially the Feds took over this gravy train in 1973, to answer your question. Physicians will be screaming BOHICA forever more ala Edgar Alan Poe's Raven until they break out of this business model, one that isn't really all that old.

Become well versed with the current medical business model as a physician since it is how you will get paid. Then offer your competing business model. It will work. If you build it they will come.

 

[Staphylococcus Aureus]

Det. Lester Freamon: You follow drugs, you get drug addicts and drug dealers. But you start to follow the money, and you don't know where the **** it's gonna take you. "The Wire: Game Day (#1.9)" (2002)​

Insurance/Third Party Payers are like a harlot in bed with the federal government thanks to the HMO Act of 1973. Thus the answer to your question is "1973". The legislation was authored by Senator Ted Kennedy (MA), passed by the US Congress and signed into law by President Richard M. Nixon. Watergate is chump change compared to the HMO Act.

Any business professional knows that if they want to do well in their markets, they must understand how they will get paid. Apple and Google don't bring their products and services to free for a reason. While physicians scream and holler about their income (when is enough enough?), the Feds and 3rd Party Payers are having a grand old time.

Third party payers and the Feds have this pony primed. Has the Federal government ever relinquished control of an entity once they had their firm grasp on it just because? Ever? Has a profitable industry ever abandoned their business schema while making kahbillions of dollars? Ever?

Physicians and those in training don't stand a chance in Hades until they become well acquainted with their business environment. The US healthcare industry accounts for almost 20% of the USA GDP. Think about that.

Start here:

Health Maintenance Organization Act of 1973​

and

Dorsey, J. L. (1975). The Health Maintenance Organization Act of 1973 (P.L. 93-222) and Prepaid Group Practice Plans. Medical Care, 13(1), 1-9.

“Prior to passage of this Act, Federal health care legislation was directed at purchase of health care services (Medicare and Medicaid), at planning for the allocation and distribution of health care services (Comprehensive Health Planning Act and Regional Medical Programs), or at improving the availability of facilities and manpower resources (Hill Burton and Health Manpower Acts).The Medicare bill stated specifically that the legislation would not interfere with the existing delivery system; the HMO Act is designed to stimulate the development of an alternative organizational structure for health services delivery.”​

It isn't pretty but essentially the Feds took over this gravy train in 1973, to answer your question. Physicians will be screaming BOHICA forever more ala Edgar Alan Poe's Raven until they break out of this business model, one that isn't really all that old.

Become well versed with the current medical business model as a physician since it is how you will get paid. Then offer your competing business model. It will work. If you build it they will come.

Excellent post, I hope you're some MD/MBA gunning for change.

 

[W19]

So basically an NP degree with a 2 year residency...sounds promising...

I am pretty sure Music, Art Appreciation and a repeat of American National Government classes in undergrad will make you a good M.D./D.O. . 4th year med school is mostly a waste as evidenced by some schools are transitioning to 3-year curriculum now. 3rd year IM/FM residents in places I did clerkship are functioning independently with almost ZERO attending input...

 

[Stagg737]

I am pretty sure Music, Art Appreciation and a repeat of American National Government classes in undergrad will make you a good M.D./D.O. . 4th year med school is mostly a waste as evidenced by some schools are transitioning to 3-year curriculum now. 3rd year IM/FM residents in places I did clerkship are functioning independently with almost ZERO attending input...

2-3 years of undergrad I'm fine with. I honestly don't know who all these people are that think 4th year is a waste, but I think they're either exaggerating or just did a terrible job setting up their rotations. I've set my 4th year up so that I'll be on rotations to specifically check out certain aspects of the field I hope to enter (inpatient vs. outpatient, 3 separate sub-specialties, and rotations in other fields which complement what I'm going into), so I plan on learning as much as possible before starting residency. I'll give you that the end of 4th year (after the match) may be a waste for many people, saying 4th year is a complete waste is an exaggeration (I'd also be curious to know how many schools are actually transitioning from 4 year to 3 year curriculums, as I've never heard of this).

I also don't know where you've been that 3rd year residents felt like they were ready to practice independently because I've never heard a 3rd year say "I'm totally ready to be on my own!" You're also completely ignoring literally every other field that does more than 3 years of residency. You really think surgical residents are ready to practice independently as 3rd years? Or that fellowship tracks should only be 2 years? If so, you might as well just give midlevels independent practice rights and say screw it with medicine as a whole.

 

[anbuitachi]

Its not even so much the training. It's the type of individuals accepted to each program. Medicine is highly regulated with very limited spots. Most people in medicine (regardless of what you think) is much smarter than average population of IQ 100. Nursing is far less regulated and a lot of not so bright people are able to get accepted. I feel like a lot of nurses wouldn't even be able to get thru medical training, they'd be on the weed out list. That's why there are very good NPs, and god awful NPs, and it's scary if all of them become equivalent to doctors. I wouldn't mind it as much if their selection is as rigorous as ours but they go thru a bit less training..

And I think there should be more combined Bachelor/MD programs, condensced into 6 years or so. If you know you want to be a doctor, you can save a lot of time by 'majoring' in medicine. I dont think most of college classes make you a better doctor anyway.

 

[W19]

2-3 years of undergrad I'm fine with. I honestly don't know who all these people are that think 4th year is a waste, but I think they're either exaggerating or just did a terrible job setting up their rotations. I've set my 4th year up so that I'll be on rotations to specifically check out certain aspects of the field I hope to enter (inpatient vs. outpatient, 3 separate sub-specialties, and rotations in other fields which complement what I'm going into), so I plan on learning as much as possible before starting residency. I'll give you that the end of 4th year (after the match) may be a waste for many people, saying 4th year is a complete waste is an exaggeration (I'd also be curious to know how many schools are actually transitioning from 4 year to 3 year curriculums, as I've never heard of this).

I also don't know where you've been that 3rd year residents felt like they were ready to practice independently because I've never heard a 3rd year say "I'm totally ready to be on my own!" You're also completely ignoring literally every other field that does more than 3 years of residency. You really think surgical residents are ready to practice independently as 3rd years? Or that fellowship tracks should only be 2 years? If so, you might as well just give midlevels independent practice rights and say screw it with medicine as a whole.

2+ years residency (you neglect the plus)... I rotated in IM/FM with 3rd year residents and saw them practically do everything with very little attending input... 3 years med school can be 18 months of preclinical and 18 months clerkship so people can have a 3-4 months to rotate in subspecialties if they desire...

 

[Stagg737]

Its not even so much the training. It's the type of individuals accepted to each program. Medicine is highly regulated with very limited spots. Most people in medicine (regardless of what you think) is much smarter than average population of IQ 100. Nursing is far less regulated and a lot of not so bright people are able to get accepted. I feel like a lot of nurses wouldn't even be able to get thru medical training, they'd be on the weed out list. That's why there are very good NPs, and god awful NPs, and it's scary if all of them become equivalent to doctors. I wouldn't mind it as much if their selection is as rigorous as ours but they go thru a bit less training..

And I think there should be more combined Bachelor/MD programs, condensced into 6 years or so. If you know you want to be a doctor, you can save a lot of time by 'majoring' in medicine. I dont think most of college classes make you a better doctor anyway.

There are a few 6 year programs already and there are plenty of problems with them. The most notable to me is that they have ridiculous attrition rates (over 20%) compared to the average US med school (around 5%). Also, if you have a 6 year program you'd have to figure out how you'd accept non-trads and how they'd integrate into the curriculum, as someone who is applying to med school after being in the work force isn't going to want to take 6 years of med school instead of 4...

2+ years residency (you neglect the plus)... I rotated in IM/FM with 3rd year residents and saw them practically do everything with very little attending input... 3 years med school can be 18 months of preclinical and 18 months clerkship so people can have a 3-4 months to rotate in subspecialties if they desire...

By 3rd year they should be doing most things on their own, but the point of those extra years is that there is supervision so that when they screw up someone else can catch the mistake. As for med school, my preclinical years were awful enough as a 2 year curriculum, there's no way in hell I'd want to try and condense it down even more (especially second year). The best argument I've heard is that you don't need 4 years of undergrad before med school, which I agree with. For those who want a shorter path, there are 6 year programs. However, I also know there are plenty of problems with those programs as well (higher attrition rates, lower board scores, etc).

 

[anbuitachi]

There are a few 6 year programs already and there are plenty of problems with them. The most notable to me is that they have ridiculous attrition rates (over 20%) compared to the average US med school (around 5%). Also, if you have a 6 year program you'd have to figure out how you'd accept non-trads and how they'd integrate into the curriculum, as someone who is applying to med school after being in the work force isn't going to want to take 6 years of med school instead of 4...



By 3rd year they should be doing most things on their own, but the point of those extra years is that there is supervision so that when they screw up someone else can catch the mistake. As for med school, my preclinical years were awful enough as a 2 year curriculum, there's no way in hell I'd want to try and condense it down even more (especially second year). The best argument I've heard is that you don't need 4 years of undergrad before med school, which I agree with. For those who want a shorter path, there are 6 year programs. However, I also know there are plenty of problems with those programs as well (higher attrition rates, lower board scores, etc).

I dont mean replace, I just mean increase . There are only a few 6 yr programs.

 

[Shams al Deen]

If we made premed 2 years and medical school 3 years, would the incoming interns be any less prepared for residency? I would argue no.

Medical school would be most efficient with 1 year (max 1.5 years) for pre-clerkship, then 1.5-2 years for clerkships. There is absolutely no need to spend 2 full years on step 1, it's pointless.

But residency is where you learn the trade. If we start cutting years off that, then I think patient care will actually start to suffer.

 

[Osteoth]

Like I mentioned before, board committees, credential committees, the ACGME etc. are all made up of physicians who set the competency requirements. If you don't like the current system now, get on a committee and become an advocate.

I don't mean to say that the standards we have set are bad, quite the opposite I think they are fine.

The question I more mean to pose is this: At what point do people stop being attracted to medicine? Of course it is one of the most noble and worthwhile crafts out there, but with the erosion of so many previous areas of strength, when does medicine get to the point where the best and brightest shake their heads and do something else?

It seems like that is the natural extension of the downward slope we find ourselves on.

Det. Lester Freamon: You follow drugs, you get drug addicts and drug dealers. But you start to follow the money, and you don't know where the **** it's gonna take you. "The Wire: Game Day (#1.9)" (2002)​

Insurance/Third Party Payers are like a harlot in bed with the federal government thanks to the HMO Act of 1973. Thus the answer to your question is "1973". The legislation was authored by Senator Ted Kennedy (MA), passed by the US Congress and signed into law by President Richard M. Nixon. Watergate is chump change compared to the HMO Act.

Any business professional knows that if they want to do well in their markets, they must understand how they will get paid. Apple and Google don't bring their products and services to free for a reason. While physicians scream and holler about their income (when is enough enough?), the Feds and 3rd Party Payers are having a grand old time.

Third party payers and the Feds have this pony primed. Has the Federal government ever relinquished control of an entity once they had their firm grasp on it just because? Ever? Has a profitable industry ever abandoned their business schema while making kahbillions of dollars? Ever?

Physicians and those in training don't stand a chance in Hades until they become well acquainted with their business environment. The US healthcare industry accounts for almost 20% of the USA GDP. Think about that.

Start here:

Health Maintenance Organization Act of 1973​

and

Dorsey, J. L. (1975). The Health Maintenance Organization Act of 1973 (P.L. 93-222) and Prepaid Group Practice Plans. Medical Care, 13(1), 1-9.

“Prior to passage of this Act, Federal health care legislation was directed at purchase of health care services (Medicare and Medicaid), at planning for the allocation and distribution of health care services (Comprehensive Health Planning Act and Regional Medical Programs), or at improving the availability of facilities and manpower resources (Hill Burton and Health Manpower Acts).The Medicare bill stated specifically that the legislation would not interfere with the existing delivery system; the HMO Act is designed to stimulate the development of an alternative organizational structure for health services delivery.”​

It isn't pretty but essentially the Feds took over this gravy train in 1973, to answer your question. Physicians will be screaming BOHICA forever more ala Edgar Alan Poe's Raven until they break out of this business model, one that isn't really all that old.

Become well versed with the current medical business model as a physician since it is how you will get paid. Then offer your competing business model. It will work. If you build it they will come.

Could use a primer if you want to write one up.

 

[Osteoth]

I think it's a lot higher than that (~100k/year), but FM doc spends 11 years in school as opposed to 6... And opportunity cost also is the most important thing to consider.

Regardless, with the time-value of money and all that the point is the difference is slim given compounding etc etc.

 

[Goro]

I just learned yesterday that the med school at UCD has a 3-year program designed to get people into Primary Care. So part of your solution seems to have been put into operation. I do wonder what they have cut out.

I worry about the maturity issue of a twenty-year-old starting medical school though in the other part of your solution

If we made premed 2 years and medical school 3 years, would the incoming interns be any less prepared for residency? I would argue no.

Medical school would be most efficient with 1 year (max 1.5 years) for pre-clerkship, then 1.5-2 years for clerkships. There is absolutely no need to spend 2 full years on step 1, it's pointless.

But residency is where you learn the trade. If we start cutting years off that, then I think patient care will actually start to suffer.

 

[cellsaver]

I don't mean to say that the standards we have set are bad, quite the opposite I think they are fine.

consider the outcomes. the data is everywhere:

Stories Doctors Tell
JAMA. 2017;318(2):124-125. doi:10.1001/jama.2017.5518
Excerpts on SDN here

Mistreated: Why We Think We're Getting Good Health Care—and Why We're Usually Wrong - Dr Robert Pearl MD.

Dr. Robert Pearl, MD, is CEO Kaiser Permanente Medical Group of Kaiser Permanente, Yale SOM graduate, Stanford professor and he has come out swinging at the broken 'system' in his book "Mistreated".​

There are many others who have published numerous books and articles written by physicians competent in their own realms.

Could use a primer if you want to write one up.

I provided a few links already. it is incumbent upon physicians to become familiar with their business environment otherwise they get what they put into it

 

[SurfingDoctor]

I just learned yesterday that the med school at UCD has a 3-year program designed to get people into Primary Care. So part of your solution seems to have been put into operation. I do wonder what they have cut out.

I worry about the maturity issue of a twenty-year-old starting medical school though in the other part of your solution

I remember a medical student who went to a 6 year combine undergrad/medical school who was rotating in the clinic when I was resident. Though they were only 4 years behind me in training, the maturity distance seemed much greater.

 

[Osteoth]

My medical school started a joint undergrad/MD admissions program. I interviewed some of the first candidates as an M4. My god.

I mean Jesus they're 18 years old...

 

[W19]

The chair (woman) of the NBME does not even have a medical degree. Pretty sure she understands all the intricacies of med ed..

NBME Executive Board | NBME

 

[Tenk]

I'm gonna pick apart your example of EM because I am ABEM certified and have worked under/alongside both ABEM certified and uncertified and grandfathered physicians.

It is ****ing night and day.

I cannot believe how some of these non board certified doctors practice emergency medicine. Their workups make no damn sense, they sit on sick patients doing no critical interventions, they miss obvious cardiac cases, and they basically do a terrible job of practicing emergency medicine. Granted our field is new and we have only been around for several decades, the difference between a board certified EM physician and a non board certified is night and day.

There are always a few exceptions to this rule and I have met many physicians that practice EM who are not board certified that I would let take care of myself or my family but unfortunately these are rare compared to the vast number I would never let touch me.

The fees are minimal. This is not really important.

We are currently in a large war in multiple specialties against MOC (maintenance of certification) exams that actually is looking somewhat promising so if you are interested, go look into that. Personally I don't really care because I actually enjoy studying sometimes and this forces me to do it.

Midlevels in the ED function largely like an urgent care provider. Most don't even have the training or experience to see anything above a level 3 and a lot of them will just stick to level 4s and 5s.

Again all of this is EM related but hopefully it gives you some insight into why we have boards. It's literally so that people do not die. Like literally: day and night, life and death. I **** you not.

 

[Status Sciaticus]

I'm gonna pick apart your example of EM because I am ABEM certified and have worked under/alongside both ABEM certified and uncertified and grandfathered physicians.

It is ****ing night and day.

I cannot believe how some of these non board certified doctors practice emergency medicine. Their workups make no damn sense, they sit on sick patients doing no critical interventions, they miss obvious cardiac cases, and they basically do a terrible job of practicing emergency medicine. Granted our field is new and we have only been around for several decades, the difference between a board certified EM physician and a non board certified is night and day.

There are always a few exceptions to this rule and I have met many physicians that practice EM who are not board certified that I would let take care of myself or my family but unfortunately these are rare compared to the vast number I would never let touch me.

The fees are minimal. This is not really important.

We are currently in a large war in multiple specialties against MOC (maintenance of certification) exams that actually is looking somewhat promising so if you are interested, go look into that. Personally I don't really care because I actually enjoy studying sometimes and this forces me to do it.

Midlevels in the ED function largely like an urgent care provider. Most don't even have the training or experience to see anything above a level 3 and a lot of them will just stick to level 4s and 5s.

Again all of this is EM related but hopefully it gives you some insight into why we have boards. It's literally so that people do not die. Like literally: day and night, life and death. I **** you not.

Regarding this topic, the issue is not that multiple specialties are against the IDEA of learning; we do this with required CMEs. The problem with MOCs is the cost, inflexibility, and the fact that its not relevant to clinical practice. It doesnt improve patient care or outcomes. If youve been certified once, theres no need to do it again and again. There is no data to support that board certification produces better doctors.
A point to note, the issue is with the lack of transparency. Why is it so expensive to take one test? Where is the money going? It comes across as a money making scam, because thats what it is.
Since you brought up ABEM, is there a reason why Dr. Nora, the President and CEO, is making roughly 1,000,000 a year and why the ABEM has nearly ~40,000,000 in reserves?

 

[cellsaver]

A point to note, the issue is with the lack of transparency. Why is it so expensive to take one test? Where is the money going? It comes across as a money making scam, because thats what it is.
Since you brought up ABEM, is there a reason why Dr. Nora, the President and CEO, is making roughly 1,000,000 a year and why the ABEM has nearly ~40,000,000 in reserves?

You're only scratching the surface. Keep going.

The reason why the "medical system is broken" is because of the damage each of the stakeholders are contributing to the damage: physicians, patients, hospitals, government, third party payers, industry, accrediting bodies, etc just to list a few. With medicine accounting to close to 20% of GDP, it is naive to think any of the parties (never mind all of the parties) are going to relinquish their revenue flow precisely from the "medical system" that they have broken. They want their money first and foremost. The poor outcomes are someone else's fault.

The CEO of the "health system" at my state university earns approximately $1M/year. We all know it. It is published yearly in the local newspaper. The medical school is a palace: beautiful structures, amazing design, reminds me of the Taj Mahal. The hospital is "state of the art", nothing but the best that state money can buy, while the outcomes....meh. The accrediting bodies pontificate on what should be done, how the system can be improved, how to have a more "caring" system, <insert ad nauseam ad infinitum platitudes>, all the while having an army of CPAs and spread sheets monitoring their fiscal statements with their own CEOs making more money than the GP in rural America.

As long as stakeholders are making money, none of them are going to turn off the spigot and walk away in the interest of repairing the system. Not going to happen.

 

[Tenk]

Regarding this topic, the issue is not that multiple specialties are against the IDEA of learning; we do this with required CMEs. The problem with MOCs is the cost, inflexibility, and the fact that its not relevant to clinical practice. It doesnt improve patient care or outcomes. If youve been certified once, theres no need to do it again and again. There is no data to support that board certification produces better doctors.
A point to note, the issue is with the lack of transparency. Why is it so expensive to take one test? Where is the money going? It comes across as a money making scam, because thats what it is.
Since you brought up ABEM, is there a reason why Dr. Nora, the President and CEO, is making roughly 1,000,000 a year and why the ABEM has nearly ~40,000,000 in reserves?

Like I said, I don't give a damn one way or the other. I just happen to like destroying tests sometimes so it doesn't bother me to take one occasionally. Also, my job covers the costs so I don't pay a dime. Shrug. I'm not promoting or condoning it.

 

[Stagg737]

If we made premed 2 years and medical school 3 years, would the incoming interns be any less prepared for residency? I would argue no.

Medical school would be most efficient with 1 year (max 1.5 years) for pre-clerkship, then 1.5-2 years for clerkships. There is absolutely no need to spend 2 full years on step 1, it's pointless.

But residency is where you learn the trade. If we start cutting years off that, then I think patient care will actually start to suffer.

Are you saying that we only need 1 year of study to pass step 1 or that only 1 year of study is required to legitimately learn that material? There's a very big difference between the two, and I don't think 1 year is adequate for the vast majority of people to legitimately learn that volume of material. If you're arguing the former, we may as well just throw away Step 1 and pre-clinical education altogether and cut straight to rotations, in which case we might as well just call ourselves DNPs.

I mean Jesus they're 18 years old...

That's the point. People are here arguing that the typical 18 y.o. is mature enough to handle med school in a healthy way, which is the complete opposite of what my (and I'm guessing most people's) experiences have been.

 

[cellsaver]

People are here arguing that the typical 18 y.o. is mature enough to handle med school in a healthy way, which is the complete opposite of what my (and I'm guessing most people's) experiences have been.

MCAT, Step Scores and technical skills are entry level requirements. Today's 20 something's are yesterdays adolescents. Emotional Intelligence should be used as a rigorous metric if not more so

Emotional intelligence in medicine: a systematic review through the context of the ACGME competencies. - PubMed - NCBI​

Higher EI was reported to positively contribute to the doctor-patient relationship (three studies), increased empathy (five studies), teamwork and communication skills (six studies), and stress management, organisational commitment and leadership (three studies).​

Popularized by Dr Daniel Goldman in the 1990s with his classic book, EI was first coined by Dr John Mayer of UNH and Dr Peter Salovey of Yale.

"From a scientific (rather than a popular) standpoint, emotional intelligence is the ability to accurately perceive your own and others’ emotions; to understand the signals that emotions send about relationships; and to manage your own and others’ emotions." Dr John Mayer​

 

[Osteoth]

That's the point. People are here arguing that the typical 18 y.o. is mature enough to handle med school in a healthy way, which is the complete opposite of what my (and I'm guessing most people's) experiences have been.

To be fair I'm in my late 20s and I often times feel as though I'm not mature enough to handle med school in a healthy way. Regardless of age/experience your training years are going to be a difficult and often traumatic experience IMO.

 

[anbuitachi]

To be fair I'm in my late 20s and I often times feel as though I'm not mature enough to handle med school in a healthy way. Regardless of age/experience your training years are going to be a difficult and often traumatic experience IMO.

Doing it helps. People in other countries often start med school at 18 cause they don't need to do regular college first. If they can do it no reason we can't. Their doctors turn out fine