Why practice medicine in the U.S.

[Anathema]

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A friend of mine was looking into practicing medicine in another country b/c they felt too restricted with what they can do in the U.S. (pay per patient system, shorter appointment times, more emphasis on prescribing drugs than recommending lifestyle choices). They're also not a big fan of how doctors end up in a large amount of debt and end up focusing on the financial and business aspects of medicine rather than purely thinking about the patients.

I gave my viewpoints, but it didn't seem to make them budge. What are reasons why everyone here still thinks practicing medicine in the U.S. is a good cause?

 

[osprey099]

No matter how good pre-meds/med students/residents/doctors try to disguise it, a ranking of the REAL motivations for medicine end up being more-or-less looking like this:

1. $ + job security; there is 0 other reasonably attainable jobs in the US that offer a better combination of $ + job security.
2. satisfaction from treating patients
3. prestige
4. can't see themselves doing anything else

 

[Anathema]

No matter how good pre-meds/med students/residents/doctors try to disguise it, a ranking of the REAL motivations for medicine end up being more-or-less looking like this:

1. $ + job security; there is 0 other reasonably attainable jobs in the US that offer a better combination of $ + job security.
2. satisfaction from treating patients
3. prestige
4. can't see themselves doing anything else

I mentioned 1 and 2 with them, but it didn't seem like a good enough reason. This person is all about altruism and hates whenever I bring up point 1. Of course nobody likes to screw a patient over due to financial reasons (lower reimbursements and that crap), but I'm not really sure the current system is going to be fixed in the next couple of years.

 

[osprey099]

I mentioned 1 and 2 with them, but it didn't seem like a good enough reason. This person is all about altruism and hates whenever I bring up point 1. Of course nobody likes to screw a patient over due to financial reasons (lower reimbursements and that crap), but I'm not really sure the current system is going to be fixed in the next couple of years.

We have a procedure-based system instead of a quality-based system. That is the root cause of why the US spends 3x more $ on healthcare than the #2 country that spends the most $ but we are only tied with like Tanzania or some other random country for quality. However, if you try to correct the current system, like what Obamacare is trying to do, all you're going to do is have more medical students wanting to specialize and sub-specialize instead of going into peds, psych, EM, or IM. And nurses and PAs would start replacing/working alongside PCPs as the demand for PCPs increase -> PCPs feel discouraged knowing that they're essentially replaceable b/c people with a "lesser" education can get their job. This will only result in medical school students to want to specialize more but if residency spots for those specialities don't increase, then you're going to have a problem..

 

[Awesome Sauceome]

A friend of mine was looking into practicing medicine in another country b/c they felt too restricted with what they can do in the U.S. (pay per patient system, shorter appointment times, more emphasis on prescribing drugs than recommending lifestyle choices). They're also not a big fan of how doctors end up in a large amount of debt and end up focusing on the financial and business aspects of medicine rather than purely thinking about the patients.

I gave my viewpoints, but it didn't seem to make them budge. What are reasons why everyone here still thinks practicing medicine in the U.S. is a good cause?

I have relatively limited view, mostly from working as a medical assistant and shadowing a few docs in a few different types of environments and I think a lot of what you said is extremely variable. I think the emphasis on prescribing drugs instead of lifestyle changes absolutely depends on the doctor. I have met many who are happy to just push the pills and see more critical patients. Contrarily I have seen some that will end up basically arguing with patients on why they do not need those pills or certain treatments etc. So that is a person by person basis.

The rest of that is really on a environmental basis. I have spent time with some docs who hire 5 medical assistants for every 1 doctor. As you can imagine this can create a situation where they have their MA/CNA/RN spend more time with the patient, therefore they spend less time with the patient themselves. This leads to shorter appointment times, and because they now essentially have 4 or 5 more "mouths to feed" (their MA/CNA/RN's) they really can start focusing too hard on the business side. They essentially HAVE to see more patients in a shorter amount of time in order to keep feeding the "beast" that is their business. It is a pretty vicious cycle actually... it is kind of sad. They essentially have to work the way that you described otherwise their business could go under/ they will not make money that they are happy with.

On the flip side to this I have spent time in an orthopedic surgeons office where there are 5 docs and 5-10 administrative types that schedule appointments and such and thats it. The docs there do EVERYTHING themselves. I have talked to them a lot about this and they said basically they end up not having to work as much because they do not have to pay anyone else to do the work that they could do quicker and more effectively. They get to spend more time with the patients because they are doing the entire workup of the patient and doing all of the treatment stuff (cleaning wounds, putting casts on etc.), so there is an extremely low overhead that they have to overcompensate for by seeing more patients in a shorter period of time. However, they have remarked that this is sort of an "old school" method to running a practice. But it works really well for all of them. They do extremely well and stay pretty busy. They have a couple days a week they they only do surgery and a couple days a week that are only in their office. It works great. One of the surgeons only worked like 35-40 hours a week because of the fact that the 5 docs share the load and because they do not have a bunch of nurses and stuff to pay for.

But take this with a little grain of salt since a) its not a hospital setting, mostly private offices/surgical centers. I am not sure as to the complexity of hospital settings and b) I have never seen medicine practiced outside of the country so I have not personally seen any benefits of it. The general gist is, a lot of docs can mold their practices the way that they want to- from the business side of the practice to the medical part of the practice. So if your friend is interested in running a shop where he/she does not want to prescribe as many pills, see less patients and spend more time with them. It is possible. People can work as little or as much as they want (depending on if they are in private practice and HOW they run their practice). They do not necessarily need to leave the country to practice medicine as certain way...

 

[Flashfan]

If someone wants to make a big difference, get a scholarship to pay for school, work in a rural environment, or get a job with the commissioned Public Health Service or work for IHS. There are plenty of opportunities to work for the common good. A doctor that I know sacrifices money for the chance to work with HIV+ patients and doing health education work. Why go to another country when there is a pathway here?

Yes, there is work with groups like Doctors Without Borders, but that has disadvantages too.

 

[circulus vitios]

Tell your friend to think his plan through. Other countries aren't so quick to sell their own citizens out. I imagine there are significant barriers for foreigners with respect to residency and practice rights.

 

[Anathema]

That was a nice response Awesome Sauceome. I definitely agree where things vary on a person to person basis. I've personally had good experiences with doctors that didn't seem rushed with me. Most of these experience also happened in a hospital setting rather than in a practice.

I guess the disenfranchising moment comes from all the med students or doctors that will have to work in a hospital setting until they feel comfortable opening or joining a practice (if ever). You have to have some altruism in this job, and do people ever feel they're not doing enough for their patients when they're being forced to meet the business aspects of medicine? How do you discriminate between uncaring doctors versus doctors that are being forced to spend less time with their patients?

 

[Awesome Sauceome]

And just as a side note and continuation from your message. I know it is becoming increasingly common for docs to open up a group businesses. Heck personally I have not seen a successful business that is not run by at least 2-3 docs. People do not want to deal with the constant on-call and stuff if you are the sole doc owning a business anymore. So with that said, there is ABSOLUTELY place for docs who work in the hospital setting, but just as equally there is absolutely a place for docs who team up with a few other docs and open up shop where they like. I am not sure how much of it is a comfort thing (running a business) as much as it is enjoying hospital vs. private medicine.

As for your second statement about altruism. I have seen it more of an issue with docs who want to practice a certain way, but insurance crap (especially medicare) essentially forces them to practice another way. I have seen the frustration that this can cause. I have yet to meet a doc who is like "well I would do this thing that is better, but this less effective thing pays more money." What I have ended up seeing however is docs who charge for a crap ton of tiny little things they they know will neither hurt nor help the patient (but the patient does not know any better), so that they can bill it. Those 20$ iontophoresis patches add up to $100,000 a year if you put one on every patient that comes in with pain (which is every single one haha).

Here is also what I have seen: There is a patient that NEEDS something but cant afford it (I am talking like dying or is in extreme pain etc.). I have NEVER seen a doc turn that person away. The doc will usually do it pro bono. I have even heard of neurosurgeons performing surgeries for free if the person did not have insurance and would die otherwise. So again its sort of on a personal level. If a doc feels a moral obligation to treat effectively, they tend to do that for their patients, but obviously they cant hand out free stuff to every single patient. But as you are alluding to, be prepared to find SOME docs who are freaking sneaky when it comes to billing codes. They would charge for the air a patient is breathing if they could- deeming it "pure doctor air."

 

[mehc012]

Honestly, one of my biggest issues with going to med school is that it somewhat condemns me to live in the US from then on. I mean, there are ways around it, but medicine seems less conducive to moving to a different country than most other jobs. Part of me wants to say $#^% it, go to med school in Ireland or something, and move there. But since I've never actually BEEN to Ireland, that seems a bit overly-spontaneous!

 

[notbobtrustme]

Going to another country and practicing is extremely difficult unless the place is a ****hole. There are multiple exams to pass, language barriers, and additional training requirements. Remember, in many of the European countries, it is essentially impossible for foreign-trained doctors to practice medicine. And if you do practice, chances are you'll be a resident forever (which isn't that bad of a gig since hours are capped at 40ish).

The US is unique in the ease of foreigners to practice here.

 

[Awesome Sauceome]

Honestly, one of my biggest issues with going to med school is that it somewhat condemns me to live in the US from then on. I mean, there are ways around it, but medicine seems less conducive to moving to a different country than most other jobs. Part of me wants to say $#^% it, go to med school in Ireland or something, and move there. But since I've never actually BEEN to Ireland, that seems a bit overly-spontaneous!

I have heard this is especially true for DOs unfortunately. Like overall I believe there are less countries willing to accept DO's as physicians (Asian countries in particular come to mind). And as someone above noted, doctors without borders, while very honorable, for sure seems like it comes with some baggage and hassles...

 

[KnuxNole]

Trying to change lifestyles is hard everywhere, not only the US. Sure in the us fit healthy people are the minority, but there are still plenty of people making positive changes that are fueled by physicians. It's definitely very hard, but it's gonna be hard wherever you travel to.

 

[mehc012]

Trying to change lifestyles is hard everywhere, not only the US. Sure in the us fit healthy people are the minority, but there are still plenty of people making positive changes that are fueled by physicians. It's definitely very hard, but it's gonna be hard wherever you travel to.

Unless I totally missed the point in a prior post, I think that was directed at mine?
At any rate, I didn't mention a lifestyle change, and I don't really want one...but it does bother me that medicine pretty much ties you to one country.

Going to another country and practicing is extremely difficult unless the place is a ****hole. There are multiple exams to pass, language barriers, and additional training requirements. Remember, in many of the European countries, it is essentially impossible for foreign-trained doctors to practice medicine. And if you do practice, chances are you'll be a resident forever (which isn't that bad of a gig since hours are capped at 40ish).

Yeah, I know...that's what bothers me!

 

[KnuxNole]

I meant to the OP, talking about their friend listing one of the reasons why working in the US would be undesirable

 

[hamsawx]

This conversation has been great. Thanks for the input!

 

[Awesome Sauceome]

When I started down this path I was sort of disillusioned because I thought every single person that I wanted to treat better be dying or something. When you first set your eyes on medicine a lot of people have the "hero" complex. This is noble and great and super and all of that. But realistically I dont think it is necessary for one to travel to other countries to provide true help to people. Not only are there some very sick people even in good communities throughout this country, there are certainly a great deal of very sick people in poor communities too. I think if one's heart is so inclined to search for these types of areas where they feel they can do "the most good," or be a hero, I think there are plenty of places throughout this nation that are desperate for well taught doctors with a good heart. I also think that if one's heart is so inclined to go to other countries and do the same thing, I think if you put your mind to it, that is possible as well, just be aware of some of the stipulations which have been mentioned before. I think only a handful of countries truly have their doors swinging wide open for docs from anywhere to come help. But realistically you will probably run in to a lot of the same thing that you see here.... sick people...

 

[SunsFun]

You can still practice in a less developed country. They will be more open to have a physician trained in America practice there. European counties will most likely not be too happy about it though.

 

[Awesome Sauceome]

Something that I have been curious about but honestly dont know much about is, how is Britain? Like would they be more likely to swap docs than most EU countries?

 

[Anathema]

When I started down this path I was sort of disillusioned because I thought every single person that I wanted to treat better be dying or something. When you first set your eyes on medicine a lot of people have the "hero" complex. This is noble and great and super and all of that. But realistically I dont think it is necessary for one to travel to other countries to provide true help to people. Not only are there some very sick people even in good communities throughout this country, there are certainly a great deal of very sick people in poor communities too. I think if one's heart is so inclined to search for these types of areas where they feel they can do "the most good," or be a hero, I think there are plenty of places throughout this nation that are desperate for well taught doctors with a good heart. I also think that if one's heart is so inclined to go to other countries and do the same thing, I think if you put your mind to it, that is possible as well, just be aware of some of the stipulations which have been mentioned before. I think only a handful of countries truly have their doors swinging wide open for docs from anywhere to come help. But realistically you will probably run in to a lot of the same thing that you see here.... sick people...

I think my friend definitely is facing a hero complex. I have no idea what practicing healthcare would be like in another country in terms of business restrictions. To be honest, it seems like my friend is overwhelmed with how healthcare works in the U.S. (insurance companies, physician restrictions and emphasis on western medicine). In their ideal medical setting they would be able to pursue this whole hero complex by having hour long appointments with patients, prescribing less medicine and looking to other less invasive procedures that may leave traditional western medicine practices. It's kind of sad to see someone become so detached from medicine in the U.S. especially since it's their first year in an M.D. school and they're already having these feelings. Like others have mentioned, I think it would be hard for my friend's criteria to be met easily unless they really do go to a really undesirable location where help is needed.

 

[Awesome Sauceome]

Something that I have been curious about but honestly dont know much about is, how is Britain? Like would they be more likely to swap docs than most EU countries?

Not that I would really consider going EU or GB... I like American whiskey far too much heh...

 

[Awesome Sauceome]

I think my friend definitely is facing a hero complex. I have no idea what practicing healthcare would be like in another country in terms of business restrictions. To be honest, it seems like my friend is overwhelmed with how healthcare works in the U.S. (insurance companies, physician restrictions and emphasis on western medicine). In their ideal medical setting they would be able to pursue this whole hero complex by having hour long appointments with patients, prescribing less medicine and looking to other less invasive procedures that may leave traditional western medicine practices. It's kind of sad to see someone become so detached from medicine in the U.S. especially since it's their first year in an M.D. school and they're already having these feelings. Like others have mentioned, I think it would be hard for my friend's criteria to be met easily unless they really do go to a really undesirable location where help is needed.

I can understand it... disillusioned is really the best word for it. Not that I have started med school, but working in a couple different practices. It can be discouraging seeing how things sometimes run. The first time the docs in these various practices had a sit down with me and discussed business, my eyes were really opened to some of the incredible good they are doing, but also some of the incredibly annoying, frustrating, wasteful, and out-of-your-control parts that come with practicing medicine in America. I can understand the frustration your friend is feeling, but I think it is best to really encourage your friend to not a make solid opinions until he/she is out of med school (though I guess thats a solid opinion I just made there haha). Because your viewpoint on medicinal business while in med school I think is much different than when you are a resident and much different than when you are an attending/ own your own practice. I have watched friends go through the entire process and each step of the way seems to add different pros and cons to American medicine. At some points they seem burnt out and frustrated, at other points they love what they do and they admire the way the system is. Realistically the only time it really matters is when you are an attending/own your own practice- at which point you can make a lot of the decisions yourself and really be more in control of the approach that you take to business with regards to medical practice. Until that point you are along for the ride: in med school, paying money to learn about medicine, in residency being payed by the hospital which is being funded by medicare etc., its not really until you are on the other side that I think there is a really clear vision for the direction you can go. It is not until then that you are making money solely patient by patient.

 

[Awesome Sauceome]

Also I think a lot of people are overwhelmed by the system as it is now, no matter where they are. The ACA is really throwing people for a loop. I dont think it will really be until maybe this time next year that people will really be able to make strong judgements towards the new system. Not until it either rocks everyones world and works beter than ever, or bombs miserably heh

 

[kyamh]

As someone who has immigrated to a country once already, I don't see why anyone would choose to bounce around the world unless they had to or it was their life's ambition to live in a bunch of countries. I would much rather travel and visit the world. Immigration and assimilation into another country is tough on your existing relationships, stressful, and expensive. Your friend can practice medicine in another country if that is where they would like to make their life, but I don't see why you would uproot yourself entirely on a philosophical whim.

 

[mehc012]

I just don't particularly like the US. I think the 2-party system leads to completely unnecessary political strife, and our legislative body is currently a joke. I have very little respect for my country and I would love the flexibility to be able to move elsewhere. Now, I don't love it enough to actually change my career choice over it, but it does make me sad when I consider it.

 

[Awesome Sauceome]

I just don't particularly like the US. I think the 2-party system leads to completely unnecessary political strife, and our legislative body is currently a joke. I have very little respect for my country and I would love the flexibility to be able to move elsewhere. Now, I don't love it enough to actually change my career choice over it, but it does make me sad when I consider it.

Heh yea... dont we all. The people will be drowning while the politicians will be on their life raft still fighting over how the ship sunk. Best to just keep working hard and hope for the best...

 

[Anathema]

I just don't particularly like the US. I think the 2-party system leads to completely unnecessary political strife, and our legislative body is currently a joke. I have very little respect for my country and I would love the flexibility to be able to move elsewhere. Now, I don't love it enough to actually change my career choice over it, but it does make me sad when I consider it.

Similar belief my friend has (doesn't like govt subsidizing junk food, Monsanto backing, political decisions blah blah blah). I've got gripes with the U.S., but the benefits of living here outweigh the positives. Sure, I could go to France (I think they have one of the highest rated healthcare systems), but I sure as hell won't. I'll admit I feel a little put on the spot when people ask me why I like this country.

 

[Awesome Sauceome]

Similar belief my friend has (doesn't like govt subsidizing junk food, Monsanto backing, political decisions blah blah blah). I've got gripes with the U.S., but the benefits of living here outweigh the positives. Sure, I could go to France (I think they have one of the highest rated healthcare systems), but I sure as hell won't. I'll admit I feel a little put on the spot when people ask me why I like this country.

I do think it is important to remember that in the long run we are actually still a new country who is figuring stuff out (compared to many EU countries that have been around 3x or 4x as long as us. And with most civilizations, things sort of wax and wane. Times of trial bring about times of prosperity. 50 years ago we were enjoying capitalist prosperity after WWII. 50 years from now we could be a lot better or a lot worse than we are now. A lot can and will change over time.

 

[SunsFun]

I just don't particularly like the US. I think the 2-party system leads to completely unnecessary political strife, and our legislative body is currently a joke. I have very little respect for my country and I would love the flexibility to be able to move elsewhere. Now, I don't love it enough to actually change my career choice over it, but it does make me sad when I consider it.

I honestly think we are missing the simplest things out when we only look at the bigger picture. I like living in the US but the life here is so individualistic and confined to work for the sake of work that people miss out on the simplest pleasures. In most areas there is no public places to hang out, you are stuck living miles away in a suburban house and the only place you visit on the regular is your work. Having an opportunity to earn a good living definitely trumps the problems if we compare the US to most third world counties but other things come into play when the US is compared to EU. Surprisingly having the biggest house and the coolest car on the block doesn't actually make people happy and quite often does just the opposite.

 

[mehc012]

Similar belief my friend has (doesn't like govt subsidizing junk food, Monsanto backing, political decisions blah blah blah). I've got gripes with the U.S., but the benefits of living here outweigh the positives. Sure, I could go to France (I think they have one of the highest rated healthcare systems), but I sure as hell won't. I'll admit I feel a little put on the spot when people ask me why I like this country.

For me it's not the specific decisions that we make, but rather the actual setup of the political process. I honestly think that many of the decisions we make are inconsequential; even the taxes which were so heavily debated last election were both fairly moderate plans, historically speaking...but I think that our current system lends itself to polarization. It promotes an Us vs Them mentality and actually eliminates any incentive for voters to bother educating themselves on political issues, because a) extreme gerrymandering has rendered legislators subject to the whims of the extremes b) third parties are not a viable possibility. The first issue paralyzes our legislature and inflates the impact of the extreme minorities, while the second issue means that, rather than choosing between multiple platforms with different combinations of ideas, most voters have a few key issues which they cannot/will not vote against (for me, it's social issues)...which means their vote is predetermined and they then sit there rationalizing the rest of the platform to themselves because they're going to vote for it anyway. So, for me, since I cannot ethically support one of the political parties' social views, there is absolutely no political reason to educate myself on economic policy. My uncle shares most of my social views, but he is in a different stage of his life and votes based primarily on economics...whenever we discuss the issues, we end up agreeing on everything we say, but voting in complete opposition....but the longer we do this, the more our non-hot-button issues shift towards the parties we have aligned ourselves with.

 

[Awesome Sauceome]

So sort of off topic. Does anyone know how US docs (MD and DOs) are viewed in Canada and Australia? Like would an american doc be able to work in one of those countries no problem? It is obviously known that it is more challenging for Canadian residents to attend an american medical school (much stiffer requirements). So does the american medical education system see itself as better than the Canadian system? And therefore would Americans have no problem moving to one of those countries to practice?

 

[mehc012]

So sort of off topic. Does anyone know how US docs (MD and DOs) are viewed in Canada and Australia? Like would an american doc be able to work in one of those countries no problem? It is obviously known that it is more challenging for Canadian residents to attend an american medical school (much stiffer requirements). So does the american medical education system see itself as better than the Canadian system? And therefore would Americans have no problem moving to one of those countries to practice?

Hmm...good question, but remember that just cuz the US thinks that we're the bomb doesn't mean the rest of the world agrees. Most first world countries seem to see their own education system as the best source of their doctors. I'd be surprised if Canadian docs didn't have preference in Canada, with all foreign grads at a disadvantage...including US. I highly doubt you would just have 'no problem'. To Google!

 

[mehc012]

According to Wikipedia on the Canadian match process:

The R-1 Main Residency Match is open to final year medical students in all 17 Canadian medical schools, as well as prior-year graduates from Canada and the U.S. who meet basic eligibility criteria. The R-1 match is also open to international medical graduates from recognized international medical schools who also meet eligibility requirements.

The R-1 match is offered in two iterations. To be eligible in the first iteration, graduates must not have had prior postgraduate training in Canada or the United States. The second iteration is for applicants who were not matched in the first iteration, as well as applicants who have had previous Canadian/U.S. postgraduate training (at recognized institutions) and who wish to apply for an R-1 position in Canada.

On the other hand (and yes, I know it's only Reader's Digest...so sue me. Or Google it yourself): http://www.readersdigest.ca/health/healthy-living/why-canada-shutting-out-doctors
Not sure about US attendings who want to move, though...*more Google*

 

[Awesome Sauceome]

A sad and interesting article that sort of goes back to some of the concerns in the OP
http://www.nejm.org/doi/full/10.1056/NEJMp1312793