14 ms·

How Being a Doctor Became the Most Miserable Profession

119 points by vwinsyee 12y ago

rayiner 12y ago
Suicide rates are about 17.7 per 100,000 for men and 4.5 per 100,000 for women, and 11.3 overall. There are about 535,000 male physicians in the U.S., and 234,000 female physicians, and 66,000 of unreported gender. So the expected number of suicides would be 113 rather than 300.
- deleted 12y ago
  [deleted]
- josephschmoe 12y ago
  I like you. Isn't suicide also extremely rare among adults with more than a bachelor's?
- curtis 12y ago
  I don't have a citation handy, but it's my understanding that doctors attempt suicide at a rate less than the general population but when they do make a suicide attempt they are more likely to succeed.
josephschmoe 12y ago
You'll find this is happening in many industries. Despite that it lowers productivity and increases costs. The problem is that management is filled with perverse incentives. It looks good on the books to have fewer employees - until you realize you have highly trained specialists spending hours per week working on paperwork or rushing their actual job and increasing long-term costs.
tdees40 12y ago
The biggest problem is just the AMA. They limit the number of doctors in America, so there are just too few. This drives up the salaries for the few doctors who live the tell the tale (but certainly don't want to go into primary care, when other more lucrative jobs are on offer), and drives up the hours for everyone. Making it easier to become a doctor would improve things immediately (especially given the recent research that makes it clear that nurse practitioners do just fine).
- deleted 12y ago
  [deleted]
  - selmnoo 12y ago
    > To pay this off in 10 years, the monthly payment would be on the order of $3400. Once employed, hospitals agree on some arrangement in which they help pay sometimes up to as much as 50% of their loans (HRSA alone pays $170k in loan repayment to primary care docs for 5 years of service in a shortage area). And I don't know what kind of doctors you guys have been hanging out with, but most make way more than $300k after only a handful of years of experience. > It's not unheard of for some medical students to have loan debt exceeding $300k. True, but as it turns out, most doctors are sons and daughters of rich folks (at least that's what sister tells me, who's doing her residency now). So those loan debt episodes are being paid by mommies and daddies, and it's rather rare for these doctors to ever feel the pangs of financial pain in their time.
    - dfc 12y ago
      > True, but as it turns out, most doctors are sons and daughters of rich folks > (at least that's what sister tells me, who's doing her residency now). Lets pretend that anecdata is useful and assume that it is generalizable to the entire population of med students. Do you think the prevalence of rich kids is alarming? Possibly an indication that something needs to change in the financing of healthcare or healthcare education? ADDENDUM Feel free to ignore this: (obviously you are morally bound to respond to the above;) The way you speak about being the sons and daughters of rich kids seems to indicate that you and your sister feel separate from that group. Did you come from an affluent family?
      - deleted 12y ago
        [deleted]
      - selmnoo 12y ago
        Yes, clearly it is a problem that only the rich are able to have the resources to get ahead. But this is a much bigger problem than who's able to become a doctor and who's not, it has to do (imo) with the greater issues of society, like new parents being unable to provide high quality preschool education, mom and dad still working when kids are teenagers and need attention and guidance, and so on. I'm a fan of quasi-socialistic, progressive-taxing to ensure everyone gets the resources. I'm from a brown immigrant family. Brown/Asian immigrants seem to be exceptions everywhere, in that they're usually poor starting out and still persevere and make it through medical schools and whatever else. My family now is doing quite okay, but is probably still below the average residency student's family. The way it looks to me (anecdata), the average residency student's family has a household income of 1mil+. My family's household income is barely 200k, so make of that what you will.
GFK_of_xmaspast 12y ago
Friendly warning, the article quotes Malcolm Gladwell uncritically.
- aaronem 12y ago
  True, but amazingly enough this is one of the two times per day when Gladwell's stopped clock happens to coincide with the actual time.
deleted 12y ago
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- aaronem 12y ago
  > If doctors have the final say on all matters, they don't have a patient - they have a subject. "Extremist language" indeed, and true only in cases where the doctor can forbid the patient from going to another doctor.
  - deleted 12y ago
    [deleted]
- baddox 12y ago
  > If doctors have the final say on all matters, they don't have a patient - they have a subject. In a competitive market of doctors, profit motive will tend to cause doctors to meet the demands of patients.
  - avoutthere 12y ago
    Unfortunately, the culture in the U.S. is taking us in exactly the opposite direction from medical competition.
rdmcfee 12y ago
There's no evidence that the profession causes doctors to commit suicide. It's not a stretch to hypothesize that people accepted to medical schools are self selecting for perfectionism and bipolar disorders.
jseliger 12y ago
Also relevant: I wrote "Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school" (http://jseliger.wordpress.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school/ http://jseliger.wordpress.com/2012/10/20/why-you-should-beco...) based on watching the experience of my fiancée and her friends and peers. EDIT: In the essay I describe why it can become so hard to leave medicine after one has invested more than a year or two in med school because of student loans; that may help explain the suicide issue: people who feel trapped may in turn feel like death is the only way out. A surprisingly large number of doctors hit residency and realize they don't want to become doctors. In most professions that's not a tremendous problem, but in medicine the only way to pay back $100 – $250K in graduate student loans is by becoming a doctor.
- erikcw 12y ago
  A similar phenomenon is at work with law students. Granted law school is shorter than an MD program at only 3 years -- but can still result in $150k of student loan debt.
  - karmajunkie 12y ago
    This is true of almost all terminal degrees today. Higher education is such a corrupt industry, feeding those at the top of the pyramid by making promises to prospective students they are fully aware are unrealistic.
- DanBC 12y ago
  Another explanation of the suicide rate: doctors have access to means and methods of completing suicide. They are also aware of techniques that make completed suicide more or less likely.
- cylinder 12y ago
  With Pay As You Earn a debtor won't pay more than 10% of AGI to federal student loans. Note that's AGI, not gross income, meaning you can contribute to retirement and not have it counted. Loans aren't as big of a constraint on career options as people make them out to be. Debtors are also willfully ignorant of these sorts of options and choose to instead destroy their lives paying debts that don't need to be paid. To be clear, it's a huge problem, and we shouldn't have this sort of debt loads on those who want to educate themselves. It also weakens the broader economy and drives up professional services costs. But to say people are killing themselves because of student loans is a mistake.
al2o3cr 12y ago
For fun, reread this article with "doctor" universally replaced by "teacher", and note the similarities. Then note that the doctor is probably taking home 4-5x the cash. There's also this: http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-shortage-go-unheeded/ http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-sh...
- Dan_Nguyen 12y ago
  After 1.5x-2x the schooling, 3x-5x the apprenticeship period, and around 6x the debt.
eldavido 12y ago
This is completely a story of industry structure and bad incentives, and how people react to them. Currently, in the United States, we believe all of the following things: (1) Human physicians, are the only qualified parties to diagnose, treat, and/or recommend courses of action related to health (not nurses, physician's assistants, computer programs, etc.), (2) everyone has a fundamental right to healthcare, (3) health professionals must undergo expensive, lengthy, difficult courses of study and training, and (4) we reimburse for procedures, not pay for outcomes. Given these incentives, it's not hard to see why doctors are some of the most overworked, stressed-out, and generally miserable professionals out there. They're at the nexus of a crushing conflict between keeping people healthy, a management system that demands more revenue (and remember that revenue=procedures, because we reimburse for procedures, so the only way to increase "productivity" is to do more, faster, with fewer breaks and longer shifts), and a legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study. I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. I believe this outcome is inevitable, but will take a decade or more to surface, because it requires major shifts in how doctors and insurance companies think about billing, greater human trust in computers and recommendation systems, and a collective realization that the current state of healthcare is untenable.
- clarkmoody 12y ago
  > give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles I agree completely, but you forgot to add under what we believe: (5) "government has the solution for everything." At least that's what it feels like lately. The cynic in me says that the healthcare industry will continue to get worse for some time before it gets better, if ever. We may see complete nationalization because the government must swoop in and "save us" from the monster it has helped to create through misguided regulation.
  - cwal37 12y ago
    In countries with socialized healthcare systems, costs are much lower, as is the overall amount spent on healthcare. Americans actually display stunning recalcitrance towards this fact, and as a result we have an incredibly polarized debate which has led to a bastardized and amalgamated system comprised of several other, and often conflicting, constructs.
rdmcfee 12y ago
In Canada our GPs are paid approximately $31 for a regular visit. They pay their overhead out of this $31 and still typically keep 65-70% of their billings. It's amazing that the billing costs in the US are a factor of magnitude higher.
- adventured 12y ago
  I wonder how salaries for nurses and doctors compare in the US vs Canada. Do you happen to have any data on that (or know of a good government source for it in Canada)? I know that compared to much of first world Europe, our nurses and doctors often make two to four times as much as their counter parts there. Wonder if that's true compared to Canada as well.
  - rdmcfee 12y ago
    In my province of BC, all payments from the Medical Service Plan (MSP is our public insurance system which costs Canadians a maximum of $65/mo or as little as $0 for low income individuals) publishes all annual payments to physicians: http://www.health.gov.bc.ca/msp/legislation/pdf/bluebook2012.pdf http://www.health.gov.bc.ca/msp/legislation/pdf/bluebook2012... The average for Family Doctors is around $240,000 CAD and for specialists is about $430,000. Average registered nurse salary in BC is about $61,000 CAD.
  - PeterisP 12y ago
    If you take away the need to pay back six-figure student loans and tens of thousands each year for malpractice insurance - then much more of that money stays in the doctors pocket. Doctors in Europe live quite well, and don't have as ridiculous workhours as the numerous USA examples listed, or the suicide problem.
    - rdmcfee 12y ago
      Tuition at UBC med is $16,000 per year and many students qualify for up to $100,000 in bursaries. After 4 years of academics there is a paid residency. It's not a huge salary (~$50k) but enough to avoid going into debt.
SapphireSun 12y ago
I don't get why overworked personnel aren't regarded as a dire safety issue. There's a reason the FAA restricted the number of hours commercial pilots are allowed to fly per week without rest. http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot-fatigue-mandatory-rest-new-faa-rules/4304417/ http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot... I met a resident the other day, and they routinely get four hours of sleep or less and worked for shifts that are insanely long that are basically dictated by patient demand. Why not just hire more doctors, maybe lower salaries by increasing supply, and give them a healthier lifestyle? Maybe medical school prices would go down with additional scale.
- hga 12y ago
  One solid reason is the same reason sleep deprivation is used in basic training. Most doctors, will, at some point in their life, have to make life and death decisions when they're operating far from 100% ... or at least that was true back in the days when they'd take calls at any hour of the day (as late as the '70s). Less dire, they have office hours they must keep unless they're really sick, and they certainly won't be at 100% every day. So this is useful training, albeit at a cost. Although if they make a mistake that kills a patient during residency and learn they can't deal with the consequences of that, I suppose the earlier the better. They can of course move to less life and death specialties.
  - SapphireSun 12y ago
    I get that deprivation training can be helpful, but to be deprived nearly 100% of the time in a safety critical, fast paced environment? That's crazy. These guys aren't special forces (who I assume have in-field careers similar to pro-sports players), they're normal people trying to work at this for many decades. If your goal is to reduce medical errors, create systems that don't depend on a single person's fluctuating energy level (e.g. have two doctors responsible for each patient, keep patient loads low enough that they can deal, automate as much as possible with computer systems (e.g. billing), and delegate to e.g. PAs for mundane diagnoses). Exhausted people make mistakes, can't work or think as quickly, are less creative, and are generally less happy. All the technology in the world won't help you if the key decision makers screw up at the wrong time. After all, coffee does exist for those times when your natural energy level won't do it for you. ;)
analog31 12y ago
I'll bet that the half of doctors who want out of the profession, are the ones who are exploited by the other half. Naturally the profession wants us to see doctors as selfless workers saving our lives, not as rentiers who are ruining us.
thefreeman 12y ago
And now that Medicare payments will be tied to patient satisfaction—this problem will get worse. That just sounds crazy. Can you imagine if your car insurance had to pay less if you complained about your mechanic? Not to mention that medicare is for the elderly who tend to have a lot to complain about anyway. Can I pay my taxes based on my satisfaction with the government?
tokenadult 12y ago
A comment here mentioned the absolute number of physicians in the United States, so I did some Googling and found a convenient website showing the number of physicians per 10,000 population in different countries. (The primary source for these data is studies by the World Health Organization, but the WHO website is not quite as user-friendly.) Note that in some countries the level of training and clinical experience to become a physician is much higher than in other countries. http://kff.org/global-indicator/physicians/ http://kff.org/global-indicator/physicians/
joshlegs 12y ago
> In fact, physicians are so bummed out that 9 out of 10 doctors would discourage anyone from entering the profession. OP missed a perfect headline opportunity: "9 out of 10 doctors recommend not becoming a doctor." But seriously, we wonder what's wrong with healthcare. I seriously believe it's because of the lawsuit-happy nature of patients nowadays. Yeah, something could go wrong during your surgery, or your diagnosis for that matter. But that's an inherent risk in having something wrong with you that you need checked out.
- alayne 12y ago
  I've read that malpractice insurance is a few thousand dollars a year and the premiums have been going down.
  - coned88 12y ago
    depends where you live. a doctor in nyc could pay $30K/yr while one in kansas $2k/yr
- eldavido 12y ago
  Anecdotally, nonpayment is a much bigger problem than lawsuits. I remember listening to the CEO of Carle, a large Central Illinois healthcare chain, talking about this, and saying that "we expect to collect 60 cents of every dollar we bill". It's a revenue optimization problem -- the goal is to collect the most revenue overall. Set prices too high and people/insurance goes elsewhere, too low and you leave money on the table the org could use to cross-subsidize non-payers.
  - ryanburk 12y ago
    > "We expect to collect 60 cents of every dollar we bill" you have to be careful with that statement since it can be a clever way of talking about what insurance agrees to pay with the chain versus the "retail" rate the doctors charge. my father is a general practitioner and I was always amazed when he started saying about 25 years ago that he wouldn't let me become a GP if I had gone into medicine. and this article covers all of his concerns well. malpractice is a big part of the issue and it varies state to state. for example, in pennsylvania malpractice insurance is amazingly expensive. and people sue all the time, which is sad unless it is gross incompetence, since every doctor I've met is trying their best.
cassowary37 12y ago
A consideration of the economics would suggest that any doc who trained in the last two decades isn't in it for the money - the ROI on an MD is far less than most other advanced degrees. If we wanted to be wealthy, with the grades and letters required to get into med school in the US, most of us could readily have chosen other professions. (Heck, some even walk away from startups, believe it or not). My impression as someone in practice for more than a decade, who cares for a large number of docs, and has run a large clinic: It's really not the reimbursement. It's the combination of dealing with payers determined to deny treatment, massive requirements in terms of documentation and ongoing accreditation, and - in particular - constant pressure to spend less time with more patients. Then, we read posts like these which buy into conspiracy theories about how we're out to poison patients with expensive medications to line our pockets. The time problem in particular afflicts primary care docs the most, but even the surgeons complain about it. As far as ACA and its impact, there's no question it's a hack (and not a good one) - most economists not on the far right agree single payer would be optimal - but under the political circumstances, it was probably the best we could get. Regardless, we'll move to a system where the majority of care isn't delivered by docs. Then we'll complain about it. But, it will be more cost-effective.
DatBear 12y ago
Funny that the article links to http://www.dailymail.co.uk/news/article-2600319/Medicare-database-reveals-paid-doctors.html http://www.dailymail.co.uk/news/article-2600319/Medicare-dat... which references the top paid doctors by medicare... I read an article last week saying that this data would be misinterpreted, as a lot of the "top paid" doctors actually are just like whole departments using the lead physician's billing code, and they don't actually get any of that money - and here we are.
sizzle 12y ago
did this article "borrow" from the air talk segment this afternoon on the radio: http://www.scpr.org/programs/airtalk/2014/04/15/6508/ http://www.scpr.org/programs/airtalk/2014/04/15/6508/
rflrob 12y ago
"Just processing the insurance forms costs $58 for every patient encounter, according to Dr. Stephen Schimpff, an internist and former CEO of University of Maryland Medical Center who is writing a book about the crisis in primary care." I'm curious how the arithmetic on that works out. The median pay for medical assistants is $14.12/hour [1], which means that assuming the assistant is handling the insurance form, that works out to just over 4 hours per patient encounter. There might be some fixed costs (filing space, for instance, is not free), and some costs associated with communicating with the insurance company, but it's really not obvious to me how any of those can add up to $58/visit. [1] http://www.bls.gov/ooh/healthcare/medical-assistants.htm http://www.bls.gov/ooh/healthcare/medical-assistants.htm
- deleted 12y ago
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- dunmalg 12y ago
  Cost of employing someone is more than just their hourly rate * hours worked. For example, at one job where I was paid $26/hr, my time was billed at $48/hr--- and this was for a government agency internally billing itself, so there was no profit margin involved, just the cumulative cost of wages, benefits, and associated overhead.
deleted 12y ago
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deleted 12y ago
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119 points by vwinsyee 12y ago

Suicide rates are about 17.7 per 100,000 for men and 4.5 per 100,000 for women, and 11.3 overall. There are about 535,000 male physicians in the U.S., and 234,000 female physicians, and 66,000 of unreported gender. So the expected number of suicides would be 113 rather than 300.

deleted 12y ago
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josephschmoe 12y ago
I like you. Isn't suicide also extremely rare among adults with more than a bachelor's?
curtis 12y ago
I don't have a citation handy, but it's my understanding that doctors attempt suicide at a rate less than the general population but when they do make a suicide attempt they are more likely to succeed.

josephschmoe 12y ago

You'll find this is happening in many industries. Despite that it lowers productivity and increases costs. The problem is that management is filled with perverse incentives. It looks good on the books to have fewer employees - until you realize you have highly trained specialists spending hours per week working on paperwork or rushing their actual job and increasing long-term costs.

tdees40 12y ago

The biggest problem is just the AMA. They limit the number of doctors in America, so there are just too few. This drives up the salaries for the few doctors who live the tell the tale (but certainly don't want to go into primary care, when other more lucrative jobs are on offer), and drives up the hours for everyone. Making it easier to become a doctor would improve things immediately (especially given the recent research that makes it clear that nurse practitioners do just fine).

deleted 12y ago
[deleted]
- selmnoo 12y ago
  > To pay this off in 10 years, the monthly payment would be on the order of $3400. Once employed, hospitals agree on some arrangement in which they help pay sometimes up to as much as 50% of their loans (HRSA alone pays $170k in loan repayment to primary care docs for 5 years of service in a shortage area). And I don't know what kind of doctors you guys have been hanging out with, but most make way more than $300k after only a handful of years of experience. > It's not unheard of for some medical students to have loan debt exceeding $300k. True, but as it turns out, most doctors are sons and daughters of rich folks (at least that's what sister tells me, who's doing her residency now). So those loan debt episodes are being paid by mommies and daddies, and it's rather rare for these doctors to ever feel the pangs of financial pain in their time.
  - dfc 12y ago
    > True, but as it turns out, most doctors are sons and daughters of rich folks > (at least that's what sister tells me, who's doing her residency now). Lets pretend that anecdata is useful and assume that it is generalizable to the entire population of med students. Do you think the prevalence of rich kids is alarming? Possibly an indication that something needs to change in the financing of healthcare or healthcare education? ADDENDUM Feel free to ignore this: (obviously you are morally bound to respond to the above;) The way you speak about being the sons and daughters of rich kids seems to indicate that you and your sister feel separate from that group. Did you come from an affluent family?
    - deleted 12y ago
      [deleted]
    - selmnoo 12y ago
      Yes, clearly it is a problem that only the rich are able to have the resources to get ahead. But this is a much bigger problem than who's able to become a doctor and who's not, it has to do (imo) with the greater issues of society, like new parents being unable to provide high quality preschool education, mom and dad still working when kids are teenagers and need attention and guidance, and so on. I'm a fan of quasi-socialistic, progressive-taxing to ensure everyone gets the resources. I'm from a brown immigrant family. Brown/Asian immigrants seem to be exceptions everywhere, in that they're usually poor starting out and still persevere and make it through medical schools and whatever else. My family now is doing quite okay, but is probably still below the average residency student's family. The way it looks to me (anecdata), the average residency student's family has a household income of 1mil+. My family's household income is barely 200k, so make of that what you will.

GFK_of_xmaspast 12y ago

Friendly warning, the article quotes Malcolm Gladwell uncritically.

aaronem 12y ago
True, but amazingly enough this is one of the two times per day when Gladwell's stopped clock happens to coincide with the actual time.

deleted 12y ago

[deleted]

aaronem 12y ago
> If doctors have the final say on all matters, they don't have a patient - they have a subject. "Extremist language" indeed, and true only in cases where the doctor can forbid the patient from going to another doctor.
- deleted 12y ago
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baddox 12y ago
> If doctors have the final say on all matters, they don't have a patient - they have a subject. In a competitive market of doctors, profit motive will tend to cause doctors to meet the demands of patients.
- avoutthere 12y ago
  Unfortunately, the culture in the U.S. is taking us in exactly the opposite direction from medical competition.

rdmcfee 12y ago

There's no evidence that the profession causes doctors to commit suicide. It's not a stretch to hypothesize that people accepted to medical schools are self selecting for perfectionism and bipolar disorders.

jseliger 12y ago

Also relevant: I wrote "Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school" (http://jseliger.wordpress.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school/ http://jseliger.wordpress.com/2012/10/20/why-you-should-beco...) based on watching the experience of my fiancée and her friends and peers. EDIT: In the essay I describe why it can become so hard to leave medicine after one has invested more than a year or two in med school because of student loans; that may help explain the suicide issue: people who feel trapped may in turn feel like death is the only way out. A surprisingly large number of doctors hit residency and realize they don't want to become doctors. In most professions that's not a tremendous problem, but in medicine the only way to pay back $100 – $250K in graduate student loans is by becoming a doctor.

erikcw 12y ago
A similar phenomenon is at work with law students. Granted law school is shorter than an MD program at only 3 years -- but can still result in $150k of student loan debt.
- karmajunkie 12y ago
  This is true of almost all terminal degrees today. Higher education is such a corrupt industry, feeding those at the top of the pyramid by making promises to prospective students they are fully aware are unrealistic.
DanBC 12y ago
Another explanation of the suicide rate: doctors have access to means and methods of completing suicide. They are also aware of techniques that make completed suicide more or less likely.
cylinder 12y ago
With Pay As You Earn a debtor won't pay more than 10% of AGI to federal student loans. Note that's AGI, not gross income, meaning you can contribute to retirement and not have it counted. Loans aren't as big of a constraint on career options as people make them out to be. Debtors are also willfully ignorant of these sorts of options and choose to instead destroy their lives paying debts that don't need to be paid. To be clear, it's a huge problem, and we shouldn't have this sort of debt loads on those who want to educate themselves. It also weakens the broader economy and drives up professional services costs. But to say people are killing themselves because of student loans is a mistake.

al2o3cr 12y ago

For fun, reread this article with "doctor" universally replaced by "teacher", and note the similarities. Then note that the doctor is probably taking home 4-5x the cash. There's also this: http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-shortage-go-unheeded/ http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-sh...

Dan_Nguyen 12y ago
After 1.5x-2x the schooling, 3x-5x the apprenticeship period, and around 6x the debt.

eldavido 12y ago

This is completely a story of industry structure and bad incentives, and how people react to them. Currently, in the United States, we believe all of the following things: (1) Human physicians, are the only qualified parties to diagnose, treat, and/or recommend courses of action related to health (not nurses, physician's assistants, computer programs, etc.), (2) everyone has a fundamental right to healthcare, (3) health professionals must undergo expensive, lengthy, difficult courses of study and training, and (4) we reimburse for procedures, not pay for outcomes. Given these incentives, it's not hard to see why doctors are some of the most overworked, stressed-out, and generally miserable professionals out there. They're at the nexus of a crushing conflict between keeping people healthy, a management system that demands more revenue (and remember that revenue=procedures, because we reimburse for procedures, so the only way to increase "productivity" is to do more, faster, with fewer breaks and longer shifts), and a legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study. I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. I believe this outcome is inevitable, but will take a decade or more to surface, because it requires major shifts in how doctors and insurance companies think about billing, greater human trust in computers and recommendation systems, and a collective realization that the current state of healthcare is untenable.

clarkmoody 12y ago
> give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles I agree completely, but you forgot to add under what we believe: (5) "government has the solution for everything." At least that's what it feels like lately. The cynic in me says that the healthcare industry will continue to get worse for some time before it gets better, if ever. We may see complete nationalization because the government must swoop in and "save us" from the monster it has helped to create through misguided regulation.
- cwal37 12y ago
  In countries with socialized healthcare systems, costs are much lower, as is the overall amount spent on healthcare. Americans actually display stunning recalcitrance towards this fact, and as a result we have an incredibly polarized debate which has led to a bastardized and amalgamated system comprised of several other, and often conflicting, constructs.

rdmcfee 12y ago

In Canada our GPs are paid approximately $31 for a regular visit. They pay their overhead out of this $31 and still typically keep 65-70% of their billings. It's amazing that the billing costs in the US are a factor of magnitude higher.

adventured 12y ago
I wonder how salaries for nurses and doctors compare in the US vs Canada. Do you happen to have any data on that (or know of a good government source for it in Canada)? I know that compared to much of first world Europe, our nurses and doctors often make two to four times as much as their counter parts there. Wonder if that's true compared to Canada as well.
- rdmcfee 12y ago
  In my province of BC, all payments from the Medical Service Plan (MSP is our public insurance system which costs Canadians a maximum of $65/mo or as little as $0 for low income individuals) publishes all annual payments to physicians: http://www.health.gov.bc.ca/msp/legislation/pdf/bluebook2012.pdf http://www.health.gov.bc.ca/msp/legislation/pdf/bluebook2012... The average for Family Doctors is around $240,000 CAD and for specialists is about $430,000. Average registered nurse salary in BC is about $61,000 CAD.
- PeterisP 12y ago
  If you take away the need to pay back six-figure student loans and tens of thousands each year for malpractice insurance - then much more of that money stays in the doctors pocket. Doctors in Europe live quite well, and don't have as ridiculous workhours as the numerous USA examples listed, or the suicide problem.
  - rdmcfee 12y ago
    Tuition at UBC med is $16,000 per year and many students qualify for up to $100,000 in bursaries. After 4 years of academics there is a paid residency. It's not a huge salary (~$50k) but enough to avoid going into debt.

SapphireSun 12y ago

I don't get why overworked personnel aren't regarded as a dire safety issue. There's a reason the FAA restricted the number of hours commercial pilots are allowed to fly per week without rest. http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot-fatigue-mandatory-rest-new-faa-rules/4304417/ http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot... I met a resident the other day, and they routinely get four hours of sleep or less and worked for shifts that are insanely long that are basically dictated by patient demand. Why not just hire more doctors, maybe lower salaries by increasing supply, and give them a healthier lifestyle? Maybe medical school prices would go down with additional scale.

hga 12y ago
One solid reason is the same reason sleep deprivation is used in basic training. Most doctors, will, at some point in their life, have to make life and death decisions when they're operating far from 100% ... or at least that was true back in the days when they'd take calls at any hour of the day (as late as the '70s). Less dire, they have office hours they must keep unless they're really sick, and they certainly won't be at 100% every day. So this is useful training, albeit at a cost. Although if they make a mistake that kills a patient during residency and learn they can't deal with the consequences of that, I suppose the earlier the better. They can of course move to less life and death specialties.
- SapphireSun 12y ago
  I get that deprivation training can be helpful, but to be deprived nearly 100% of the time in a safety critical, fast paced environment? That's crazy. These guys aren't special forces (who I assume have in-field careers similar to pro-sports players), they're normal people trying to work at this for many decades. If your goal is to reduce medical errors, create systems that don't depend on a single person's fluctuating energy level (e.g. have two doctors responsible for each patient, keep patient loads low enough that they can deal, automate as much as possible with computer systems (e.g. billing), and delegate to e.g. PAs for mundane diagnoses). Exhausted people make mistakes, can't work or think as quickly, are less creative, and are generally less happy. All the technology in the world won't help you if the key decision makers screw up at the wrong time. After all, coffee does exist for those times when your natural energy level won't do it for you. ;)

analog31 12y ago

I'll bet that the half of doctors who want out of the profession, are the ones who are exploited by the other half. Naturally the profession wants us to see doctors as selfless workers saving our lives, not as rentiers who are ruining us.

thefreeman 12y ago

And now that Medicare payments will be tied to patient satisfaction—this problem will get worse. That just sounds crazy. Can you imagine if your car insurance had to pay less if you complained about your mechanic? Not to mention that medicare is for the elderly who tend to have a lot to complain about anyway. Can I pay my taxes based on my satisfaction with the government?

tokenadult 12y ago

A comment here mentioned the absolute number of physicians in the United States, so I did some Googling and found a convenient website showing the number of physicians per 10,000 population in different countries. (The primary source for these data is studies by the World Health Organization, but the WHO website is not quite as user-friendly.) Note that in some countries the level of training and clinical experience to become a physician is much higher than in other countries. http://kff.org/global-indicator/physicians/ http://kff.org/global-indicator/physicians/

joshlegs 12y ago

> In fact, physicians are so bummed out that 9 out of 10 doctors would discourage anyone from entering the profession. OP missed a perfect headline opportunity: "9 out of 10 doctors recommend not becoming a doctor." But seriously, we wonder what's wrong with healthcare. I seriously believe it's because of the lawsuit-happy nature of patients nowadays. Yeah, something could go wrong during your surgery, or your diagnosis for that matter. But that's an inherent risk in having something wrong with you that you need checked out.

alayne 12y ago
I've read that malpractice insurance is a few thousand dollars a year and the premiums have been going down.
- coned88 12y ago
  depends where you live. a doctor in nyc could pay $30K/yr while one in kansas $2k/yr
eldavido 12y ago
Anecdotally, nonpayment is a much bigger problem than lawsuits. I remember listening to the CEO of Carle, a large Central Illinois healthcare chain, talking about this, and saying that "we expect to collect 60 cents of every dollar we bill". It's a revenue optimization problem -- the goal is to collect the most revenue overall. Set prices too high and people/insurance goes elsewhere, too low and you leave money on the table the org could use to cross-subsidize non-payers.
- ryanburk 12y ago
  > "We expect to collect 60 cents of every dollar we bill" you have to be careful with that statement since it can be a clever way of talking about what insurance agrees to pay with the chain versus the "retail" rate the doctors charge. my father is a general practitioner and I was always amazed when he started saying about 25 years ago that he wouldn't let me become a GP if I had gone into medicine. and this article covers all of his concerns well. malpractice is a big part of the issue and it varies state to state. for example, in pennsylvania malpractice insurance is amazingly expensive. and people sue all the time, which is sad unless it is gross incompetence, since every doctor I've met is trying their best.

cassowary37 12y ago

A consideration of the economics would suggest that any doc who trained in the last two decades isn't in it for the money - the ROI on an MD is far less than most other advanced degrees. If we wanted to be wealthy, with the grades and letters required to get into med school in the US, most of us could readily have chosen other professions. (Heck, some even walk away from startups, believe it or not). My impression as someone in practice for more than a decade, who cares for a large number of docs, and has run a large clinic: It's really not the reimbursement. It's the combination of dealing with payers determined to deny treatment, massive requirements in terms of documentation and ongoing accreditation, and - in particular - constant pressure to spend less time with more patients. Then, we read posts like these which buy into conspiracy theories about how we're out to poison patients with expensive medications to line our pockets. The time problem in particular afflicts primary care docs the most, but even the surgeons complain about it. As far as ACA and its impact, there's no question it's a hack (and not a good one) - most economists not on the far right agree single payer would be optimal - but under the political circumstances, it was probably the best we could get. Regardless, we'll move to a system where the majority of care isn't delivered by docs. Then we'll complain about it. But, it will be more cost-effective.

DatBear 12y ago

Funny that the article links to http://www.dailymail.co.uk/news/article-2600319/Medicare-database-reveals-paid-doctors.html http://www.dailymail.co.uk/news/article-2600319/Medicare-dat... which references the top paid doctors by medicare... I read an article last week saying that this data would be misinterpreted, as a lot of the "top paid" doctors actually are just like whole departments using the lead physician's billing code, and they don't actually get any of that money - and here we are.

sizzle 12y ago

did this article "borrow" from the air talk segment this afternoon on the radio: http://www.scpr.org/programs/airtalk/2014/04/15/6508/ http://www.scpr.org/programs/airtalk/2014/04/15/6508/

rflrob 12y ago

"Just processing the insurance forms costs $58 for every patient encounter, according to Dr. Stephen Schimpff, an internist and former CEO of University of Maryland Medical Center who is writing a book about the crisis in primary care." I'm curious how the arithmetic on that works out. The median pay for medical assistants is $14.12/hour [1], which means that assuming the assistant is handling the insurance form, that works out to just over 4 hours per patient encounter. There might be some fixed costs (filing space, for instance, is not free), and some costs associated with communicating with the insurance company, but it's really not obvious to me how any of those can add up to $58/visit. [1] http://www.bls.gov/ooh/healthcare/medical-assistants.htm http://www.bls.gov/ooh/healthcare/medical-assistants.htm

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dunmalg 12y ago
Cost of employing someone is more than just their hourly rate * hours worked. For example, at one job where I was paid $26/hr, my time was billed at $48/hr--- and this was for a government agency internally billing itself, so there was no profit margin involved, just the cumulative cost of wages, benefits, and associated overhead.

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