Our waiting times for getting healthcare are an international embarrassment.
Our healthcare costs are also an international embarrassment.
Comparing the US to Canada is silly since we share many common foundations that has caused our healthcare crisis.
We need many more physicians. Then the laws of supply an demand will lower the cost and open up better access.
Our healthcare costs are also an international embarrassment.
Comparing the US to Canada is silly since we share many common foundations that has caused our healthcare crisis.
We need many more physicians. Then the laws of supply an demand will lower the cost and open up better access.
3
Our very poor international rankings on health of women and children in theis country are the result of the laws that govern the delivery of health care, note health care, not medical care.
"We could fix that by ... increasing our willingness to use midlevel practitioners through changes in regulations or licensing. None of these approaches are easy, and all would most likely require governments to act."
As noted by Lauren, "Mid-level providers ... typically take more time with patients, which ... can lead to better results in some patients."
"We could fix that by ... increasing our willingness to use midlevel practitioners through changes in regulations or licensing. None of these approaches are easy, and all would most likely require governments to act."
As noted by Lauren, "Mid-level providers ... typically take more time with patients, which ... can lead to better results in some patients."
2
DOM: this is unfortunately a grossly wrong assumption that mid-levels are better at patient outcomes because they take more time with the patients... this is a mindless propaganda by the mid-levels and their professional societies like the ANCC.
20
Sorry-
Lauren is not a midlevel provider, but a medical student. Which basically means that she knows nothing about how healthcare works yet.
When she is finished her residency and practicing for a few years, then her opinion may actually carry some weight. But again, no one should be quoting her as if she knows what she is talking about.
Lauren is not a midlevel provider, but a medical student. Which basically means that she knows nothing about how healthcare works yet.
When she is finished her residency and practicing for a few years, then her opinion may actually carry some weight. But again, no one should be quoting her as if she knows what she is talking about.
8
Sorry, but no.
The Institute of Medicine report recommends increasing the number of training slots for doctors by restructuring the system. This works because cutting one specialty slot residency slot can pay for 2-3 rural PCP residency slots.
Technology and drugs has yet to replace a carefully taken history and physical exam. Telemedicine is a stop-gap for people who wouldn't have access to a doctor any other way, not a viable option to replace a local physician. A more efficient and compatible EMR system could probably save time by making it easier to share records, that that is decades away. EMR systems also reduce doctor's efficiency as much as 20%, so you have to take that into consideration.
Mid-level providers are already highly-utilized, but the still need a physician's supervision in nearly all states. Adding more of them is going to hit a point of diminishing returns. They also typically take more time with patients, which diminishes their efficiency, although the extra time can lead to better results in some patients.
Inefficiency does reduce access to care, that's ture. Insurance companies, EMRs and uneven distribution of doctors are prime culprits. Sometimes, though, not having enough doctors creates its own inefficiencies. The U.S. has a high demand for specialits because many PCPs no longer have enough time to diagnose and so punt patients to specialists.
The Institute of Medicine report recommends increasing the number of training slots for doctors by restructuring the system. This works because cutting one specialty slot residency slot can pay for 2-3 rural PCP residency slots.
Technology and drugs has yet to replace a carefully taken history and physical exam. Telemedicine is a stop-gap for people who wouldn't have access to a doctor any other way, not a viable option to replace a local physician. A more efficient and compatible EMR system could probably save time by making it easier to share records, that that is decades away. EMR systems also reduce doctor's efficiency as much as 20%, so you have to take that into consideration.
Mid-level providers are already highly-utilized, but the still need a physician's supervision in nearly all states. Adding more of them is going to hit a point of diminishing returns. They also typically take more time with patients, which diminishes their efficiency, although the extra time can lead to better results in some patients.
Inefficiency does reduce access to care, that's ture. Insurance companies, EMRs and uneven distribution of doctors are prime culprits. Sometimes, though, not having enough doctors creates its own inefficiencies. The U.S. has a high demand for specialits because many PCPs no longer have enough time to diagnose and so punt patients to specialists.
4
How should the system go about matching emergency care to underserved counties? Robert Wood Johnson, County Health Rankings? Dr. J. Runge's model? Lou Lomabardo's model? Pressure from insurance companies?
Then there is political resistance to "Obamacare". What happens with the new president and a strengthened partisan Congress? Require the jurisdiction to fund the emergency care? Or require the people who use the emergency care to fund the service? People living in the jurisdiction don't have the money to pay for ambulances, EMTs, trauma rooms. People who need the service die, so there voice is silenced.
I am curious as to why so many MDs are running for elective office. Dean, Bera, Frist... Then I read starting salaries of $52,000 per year. Wow!!!
Then there is political resistance to "Obamacare". What happens with the new president and a strengthened partisan Congress? Require the jurisdiction to fund the emergency care? Or require the people who use the emergency care to fund the service? People living in the jurisdiction don't have the money to pay for ambulances, EMTs, trauma rooms. People who need the service die, so there voice is silenced.
I am curious as to why so many MDs are running for elective office. Dean, Bera, Frist... Then I read starting salaries of $52,000 per year. Wow!!!
1
And astoundingly self serving piece of research from the physicians at at the Institute of medicine. This editorial fails to mention that physicians have insisted the laws be written so that all of these "para professionals" have to kick up part of their fees to "supervising" physicians. This plan may improve services but it will also maintain an economically inefficient system that profits physicians and beggars everyone else.
3
We do have the military-sponsored Health Professions Scholarship Program (HPSP). It is just not very popular because it requires to serve for some years in the military
HPSP pays full tuition, supplies, and fees for any accredited U.S. or Puerto Rican medical school, as well as a monthly stipend of $2,088 for 10 and a half months and a second lieutenant's salary—roughly double the stipend—for the other six weeks.
"If the school requires it to attend, then the scholarship will pay for it," says Dillon, an HPSP recipient in 1985.
Eric Ness, whose studies at UVA are funded by the Air Force, says it's "a very generous deal," though HPSP comes with strings attached. He needs to apply for an Air Force residency after medical school, and he owes the Air Force three years of service to repay the three years of his scholarship.
Dillon, who never expected he'd practice medicine in the Army two decades ago, says the commitment is a good trade. The Army is "very family friendly," and all service members get 30 days of paid vacation per year, he says. "It provides the balance that many young professionals desire in their lives."
http://www.usnews.com/education/best-graduate-schools/top-medical-school...
HPSP pays full tuition, supplies, and fees for any accredited U.S. or Puerto Rican medical school, as well as a monthly stipend of $2,088 for 10 and a half months and a second lieutenant's salary—roughly double the stipend—for the other six weeks.
"If the school requires it to attend, then the scholarship will pay for it," says Dillon, an HPSP recipient in 1985.
Eric Ness, whose studies at UVA are funded by the Air Force, says it's "a very generous deal," though HPSP comes with strings attached. He needs to apply for an Air Force residency after medical school, and he owes the Air Force three years of service to repay the three years of his scholarship.
Dillon, who never expected he'd practice medicine in the Army two decades ago, says the commitment is a good trade. The Army is "very family friendly," and all service members get 30 days of paid vacation per year, he says. "It provides the balance that many young professionals desire in their lives."
http://www.usnews.com/education/best-graduate-schools/top-medical-school...
3
I'm a med school student who started as an Army Medic. My school has lots of HPSP students. It is a great deal of your want to be a career military doctor, but less so if you have other career goals.
It's hard to get specialty residencies, and you will get less experience and training than in a civilian residency. You also have to sign up before your clinical years, so I wouldn't recommend it unless you are sure you want to be in primary care. Your population will be limited. You will make less money out of residency and have less choice in your assignment. You will be an officer in the military, which is both a privilege and a burden. However, carrerist nurses and PAs will outrank you, so be prepared for them to be in command positions above you.
HPSP is a great program to make the military a competitive option for people who already want to serve. But joining just to avoid debt is likely to be a mistake.
Many programs to in the VA, IHS, military and underserved areas will pay back up to $120k in loans once you have finished residency. This is probably a better option for most people.
It's hard to get specialty residencies, and you will get less experience and training than in a civilian residency. You also have to sign up before your clinical years, so I wouldn't recommend it unless you are sure you want to be in primary care. Your population will be limited. You will make less money out of residency and have less choice in your assignment. You will be an officer in the military, which is both a privilege and a burden. However, carrerist nurses and PAs will outrank you, so be prepared for them to be in command positions above you.
HPSP is a great program to make the military a competitive option for people who already want to serve. But joining just to avoid debt is likely to be a mistake.
Many programs to in the VA, IHS, military and underserved areas will pay back up to $120k in loans once you have finished residency. This is probably a better option for most people.
5
Most other countries allow pharmacists to prescribe. Eliminates a lot of doctor visits for minor issues. That alone could improve the system (and miles traveled!) dramatically.
1
Allow pharmacists to prescribe?? That is insanity. Would the pharmacist perform the history and physical exam?? A pharmacist should become a doctor if he wishes to prescribe medications!!
11
Where tuition costs are a concern, medical school can be funded by joining the armed forces. The physician does have to practice in the military for a few years after graduation, but that helps get experience.
2
It's academic now since no doubt one of the first things Trump's administration and Republican-dominated Congress will do is dismantle Obamacare. Suddenly we won't need so many doctors after all.
Some of the other solutions, such as greater reliance on nurse practitioners and telemedicine will be instituted by private health insurance companies, as is already happening.
Some of the other solutions, such as greater reliance on nurse practitioners and telemedicine will be instituted by private health insurance companies, as is already happening.
Again, the focus is on physician shortages and how this can be fixed with NPs or PAs. That is all well and good, however, none of the aforementioned will be the person delivering day-to0day care at a bedside of a hospital or nursing facility. That person would be an RN. The ACA failed to include funding for basic nursing education while the shortage of about 250K nurses that has persisted since my graduation in 1978 is expected to grow to 500K to 1 million jobs that cannot be filled as my generation starts to retire. The ANA and current nursing education programs at universities are no help- they keep making changes that end up disappointing prospective nursing students to seek other career paths. My advice: get healthy, stay healthy and do all possible to avoid needing in-patient care in the future as there will llikely not be anyone around to answer that call bell...
5
Some newer medical schools recruit specifically to produce primary care docs to work in underserved, mainly rural areas in MI. The is one down the road on a campus I teach at, once in a while.
It remains to be seen whether those graduates, a: actually choose to specialize in primary care, and b: dedicate their lives to caring for disgruntled, minimally educated patients who will gripe that their doctors are too well paid, and that health insurance costs too much.
Not unlike most citizen/patients who are oblivious to the facts U.S. healthcare costs so much because: 1) ALL hospitals are money-making monopolies, 2) pharmaceutical companies are no different, and 3) that their young primary care doc owes more money for her training than what both their and their neighbor's family farms are worth.
It remains to be seen whether those graduates, a: actually choose to specialize in primary care, and b: dedicate their lives to caring for disgruntled, minimally educated patients who will gripe that their doctors are too well paid, and that health insurance costs too much.
Not unlike most citizen/patients who are oblivious to the facts U.S. healthcare costs so much because: 1) ALL hospitals are money-making monopolies, 2) pharmaceutical companies are no different, and 3) that their young primary care doc owes more money for her training than what both their and their neighbor's family farms are worth.
3
There are not enough physicians in primary care to cover all the patients who can afford primary care under the ACA. This is on top of the deliberate control of the number of physicians that has been instituted by the profession for many decades. Anyone with any knowledge of physicians and health care providers in the U.S. understands that the United States has a system which limits the supply of physicians to assure strong enough demand to enable physicians to earn much higher than average incomes. The seats offered in medical schools do not provide enough medical students to serve the demands of the system enabling students educated abroad to find residencies and to gain the educations required for licenses and board certifications. Physicians who have practiced in other countries may not practice in the United States, they must find residencies in U.S. institutions and be educated in these before applying for licenses and board certifications. The costs of medical schools are so high in the U.S. that practices in primary care will enable repayment only over many years.
2
Doctors are no longer utilized for their specialized skill set in the US.
Corporations (insurance companies, hospitals, large multi specialty groups) and their administrators are creating work that doctors MUST do, rather than allowing them to treat patients and manage their health and disease.
The "shortage" exists because doctors today spend more time typing (in electronic medical records) and less time talking to patients than their own secretaries. Improved efficiency requires techs for getting insurance approval (more procedures require me to speak to a "doctor" at insurance company than ever before because initial approval refused) and "note"/documentation techs. There is a need for PAs and NPs too as part of a clinical team with physicians, rather than instead of physicians.
I went to medical school because I wanted to care for other people, I loved science and I wanted to use my brain. I was fortunate to have opportunities to pursue other more lucrative careers. I chose medicine. Now I hesitate to encourage others to pursue this field. One can help others in science in many other careers without being spoken down to by people half as educated and half as hard working.
Corporations (insurance companies, hospitals, large multi specialty groups) and their administrators are creating work that doctors MUST do, rather than allowing them to treat patients and manage their health and disease.
The "shortage" exists because doctors today spend more time typing (in electronic medical records) and less time talking to patients than their own secretaries. Improved efficiency requires techs for getting insurance approval (more procedures require me to speak to a "doctor" at insurance company than ever before because initial approval refused) and "note"/documentation techs. There is a need for PAs and NPs too as part of a clinical team with physicians, rather than instead of physicians.
I went to medical school because I wanted to care for other people, I loved science and I wanted to use my brain. I was fortunate to have opportunities to pursue other more lucrative careers. I chose medicine. Now I hesitate to encourage others to pursue this field. One can help others in science in many other careers without being spoken down to by people half as educated and half as hard working.
15
I don't think nurse practioners and physician assistants are qualified to be primary care providers. If you have diabetes, a heart condition, or other chronic health problems, you need to have doctor. Don't medical school and residencies count for anything? I see how the others can fill in gaps. But as your sole primary care provider, which is what people in rural areas increasing have even if they are chronically and seriously ill, it's a terrible idea.
4
Yes, nurse practioners and physician assistants are qualified to manage chronic conditions such as diabetes. In fact they are often better able to do so than physicians since their training emphasizes patient education, management of symptoms, and watching for signs of complications, and they typically spend more time with the patient than MD's are able to. Much of the management of chronic disease centers around trying to persuade patients to change lifestyle factors, explaining how and when to take medication, tweaking dosages and delivery methods, and dealing with the patient's psychological state. Nurses are far better trained for such interpersonal interaction than MD's. They don't replace MD's but they supplement what the physicians do.
5
Many people who complete the MD do not practice full time for very long , if at all. The individual bears the cost of medical training and is forced to think in terms of ROI. If we adopted the military model of having people pay for their education by committing to years of service , we could reduce the number of people bailing on medicine and increase the focus on practicing medicine rather than making money. It would also attract a better class of doctors .
1
Your first sentence is incorrect, unless you use a very expansive definition of "many." I do not have time to pursue references this morning; too busy in my office.
The rest is right on, IMO. Full disclosure: after 40+ years, I am cutting back, but I do not consider that bailing.
The rest is right on, IMO. Full disclosure: after 40+ years, I am cutting back, but I do not consider that bailing.
4
Define "full time." In medicine it's not 40 hours a week. It's more like 60-80 hours per week.
5
These "experts" always seem to come to the same conclusion in these opinion pieces- that we need more NPs and PAs. As a primary care physician, I have to fix their serious mistakes frequently. They order the wrong tests, interpret results incorrectly. They just don't have adequate training. If you want to risk substandard medicine, go ahead. For a cold they are fine. That was the original purpose before they started to creep forward with their expansion of scope of practice. But many, after their minimal training, move into specialties and work for specialists. So if you're expecting to get more primary care by promoting the "mid levels" you're just plain wrong. Also, they make almost as much as I do when you consider how short was their training vs how many years I gave to learn my profession (I gave years to working 80 hours a week for a nominal minimum wage) and they come out ahead with minimal debt and immediate earnings.
21
It starts with the lack of standards with the basic 1st step of students who cannot write, and are not capable of basic math. Also, the willingness of too many health care administrators who are attorneys or have MBAs or were politicians who failed to win their election or carried the banner for the winner and think they can be administrators in a demanding health care profession which requires much more knowledge than they could ever comprehend. It's complicated, and people deserve better than what is happening in the health care field.
6
Where I am, midlevels have taken over a lot of the rural primary care and ED visits-one physician may "supervise" half a dozen PA's in a 50 mile radius and most small hospitals have only a PA/NP in the ER, no physicians available. I suppose it's better than no health care at all, but just barely. It is a DAILY occurence to see patient care that would qualify as malpractice if done by a physician-lethal drug interactions, prescribing wrong antibiotics for the given diagnosis (and getting the diagnosis wrong too), failing to refer lung cancer for 6 months, not being to perform emergency procedures competently, and on and on. Sometimes I feel like I spend half my time explaining to patients why everything their previous "provider" told them is wrong.
I think midlevels have a place. The problem is that they are being touted as "as good as a doctor but cheaper" and that is extremely foolish. By the time I finished training, I had done roughly 3000 clinical hours in med school and 15,000 hours of training in residency, while a fresh grad PA has perhaps 600-700 hours of training total. That's an enormous experience gap. If you don't think that training and experience means anything, by all means go to see a midlevel. Just don't complain when you don't get what you won't pay for.
I think midlevels have a place. The problem is that they are being touted as "as good as a doctor but cheaper" and that is extremely foolish. By the time I finished training, I had done roughly 3000 clinical hours in med school and 15,000 hours of training in residency, while a fresh grad PA has perhaps 600-700 hours of training total. That's an enormous experience gap. If you don't think that training and experience means anything, by all means go to see a midlevel. Just don't complain when you don't get what you won't pay for.
14
I don't see the value of a primary care doctor. Research consistently shows that annual exams and screenings deliver little value, yet primary docs sometimes sound like used car salesmen as they push for more and more tests. Internal medicine docs are useless when it comes to musculoskeletal issues. Theoretically they would coordinate care but that doesn't seem to be compensated and few have time to do a thorough job. I've known people who love their PCPs but when faced with illness or injury, the PCP was too busy doing routine exams and sent them to urgent care centers or the ER.
1
It take s 10,000 hours of practice to master a field.
Nurse Practitioners and Physician Assistants have around 600 hours of clinical training before they are eligible to be licensed.
Physicians have over 7000 hours of clinical training before they are eligible to be licensed. (Most physician have at least 18000 hours of clinical experience before they leave training and actually start practicing.)
Who do you want taking care of your loved one?
The shortage in Primary Care is because insurance companies - including Medicare - only pay Primary Care Physicians enough to spend THREE MINUTES with each patient. (Any businessman will tell you that's not viable.)
The Government runs the VA and they can't do that right.
Oh - and Nurses practice Nursing NOT Medicine, (The two fields are completely different.)
Nurse Practitioners and Physician Assistants have around 600 hours of clinical training before they are eligible to be licensed.
Physicians have over 7000 hours of clinical training before they are eligible to be licensed. (Most physician have at least 18000 hours of clinical experience before they leave training and actually start practicing.)
Who do you want taking care of your loved one?
The shortage in Primary Care is because insurance companies - including Medicare - only pay Primary Care Physicians enough to spend THREE MINUTES with each patient. (Any businessman will tell you that's not viable.)
The Government runs the VA and they can't do that right.
Oh - and Nurses practice Nursing NOT Medicine, (The two fields are completely different.)
13
We let nurses prescribe drugs but not Pharm D's. Which profession do you think has a greater knowledge of medicinal chemistry? Let doctors diagnose and let trained pharmacists prescribe.
5
It takes about 11 years to train a primary care doctor. Including 4 years each of college and medical school and 3 years of residency. It is impossible for medical schools to train enough of them to fulfill the predicted shortage the time spent on basic sciences in college and medical school is streamlined to only what is necessary. The science courses could be combined into a primary care track. Two years of college and two of medical school, should be able to prepare a student for residency—which should be done in community health centers with just short rotations in the hospital.
Most primary care doctors no longer treat patients in the hospital or in nursing homes and much of their pre-residency training is unnecessary for primary care.
A good primary care doctor could be turned out in 6 or 7 years instead of the traditional 11. Until that happens or more likely, concurrent with it nurse practitioners and physician assistants will enter and permanently remain as co-partners with physicians in the primary care workforce. Their presence will greatly alleviate the stress and burnout that most primary care doctors are experiencing. Nurse practitioners already are independently licensed to practice within the limits of their training in at least 20 states.
It is likely that the primary care provider of the future will be a hybrid that combines the qualities of a physician, a nurse practitioner, and a physician assistant.
Most primary care doctors no longer treat patients in the hospital or in nursing homes and much of their pre-residency training is unnecessary for primary care.
A good primary care doctor could be turned out in 6 or 7 years instead of the traditional 11. Until that happens or more likely, concurrent with it nurse practitioners and physician assistants will enter and permanently remain as co-partners with physicians in the primary care workforce. Their presence will greatly alleviate the stress and burnout that most primary care doctors are experiencing. Nurse practitioners already are independently licensed to practice within the limits of their training in at least 20 states.
It is likely that the primary care provider of the future will be a hybrid that combines the qualities of a physician, a nurse practitioner, and a physician assistant.
1
The most accessible and well trained, but underutilized health provider is the pharmacist. Pharmacists are more readily available in rural areas.
8
The pharmacists role is to fill prescriptions. I don't see how they can be any more "utilized."
One thing is for sure- there is absolutely NO role for pharmacists to be prescribing medications or treating patients in any way.
One thing is for sure- there is absolutely NO role for pharmacists to be prescribing medications or treating patients in any way.
4
Blame it on the individual specialities that determine the number of residency slots per year. Let's look at Pathology: There are way too many trained pathologists for the available positions. More pathologists are trained than are needed because the academics like to use residents to do the 'scut' work. The hospitals gain by having cheap labor and by profiting from the government assistance accrued for every resident trained. The resident makes $55,000 but the hospital receives >$100,000 per resident.
2
Here is the supply projection for the state of New York for pathology through 2030;
Pathology
1,716 ( current)
1,286 (2030)
-25%
-1.19%
So this seems to move opposite of your assertion. I have never met a US trained pathologist who was looking for work.
Pathology
1,716 ( current)
1,286 (2030)
-25%
-1.19%
So this seems to move opposite of your assertion. I have never met a US trained pathologist who was looking for work.
2
As Dr. Carroll pointed out there is no easy fix. However as a foreign trained and european board certified specialist, I still have to take all the united states medical licensing exams and go through residency and fellow ship a second time. I am not saying that we should allow anyone to come to the U.S. and practice without any supervision. But as a highly qualified physician who writes exam questions as a member of the European Respiratory Society exam committee for the yearly european pulmonary board exam I question the current practice that discourages well qualified doctors to even consider to come here. However I doubt that this practice will ever change without political pressure and will.
3
So you think that you should be able to come here and practice medicine without taking any of the US licensing exams?? Based on the fact that you say you are a "highly qualified physician who writes exam questions as a member of the European Respiratory Society exam committee??"
Talk about a sense of entitlement. You are licensed in your home country. Why don't you stay there? I wouldn't expect to go to your country and be able to work as a doctor.
I think that foreign doctors who wish to come here to practice should have more hurdles to clear, not fewer. If you aren't happy with the system here, why don't you go back to your home country and practice??
Talk about a sense of entitlement. You are licensed in your home country. Why don't you stay there? I wouldn't expect to go to your country and be able to work as a doctor.
I think that foreign doctors who wish to come here to practice should have more hurdles to clear, not fewer. If you aren't happy with the system here, why don't you go back to your home country and practice??
6
Well I am not complaining that there is doctor shortage in the US. Or am I? Also I am not complaining that there is an overpriced low quality healthcare system in place, right? Also as mentioned I have not had any professional (or financial) incentive to come here. But I sure hope for you that you go vote today to express your political view.
3
Not all countries are equal in their medical training. Without the standardized licensing exams, there would be too many charlatans in practice. Whether you like the American Healthcare system of delivery or not, our physicians are among the best trained in the world. It is the most highly competitive field in the U.S. The average medical school receives 10,000 applicants per year for approximately 150 spots. Ours is among the brightest and the best. No compromising that!!
5
I appreciated Aaron Carroll’s evidence-based analysis of the medical system in the U.S., and the reasonable conclusion that the system is more inefficient than understaffed, in large part due its failure to take advantage of the excellent care provided by so-called ‘midlevel practitioners’, like Nurse Practitioners. May I also suggest that part of the problem is in the label, ’midlevel’? My ‘midlevel’ partner is a nurse practitioner who went through 4 years of undergraduate and 5 years of graduate study, earning degrees at Yale and NYU. She has over 16 years of clinical experience in primary care, and carried a caseload of 500 patients while working part-time in a leadership role at a clinic in New York City. I doubt any one of her patients thought of her as anything less than a highly qualified medical professional devoted to keeping them well. Not sure the term ‘midlevel’ really fits.
5
Lynn-
The term "midlevel" DOES fit because that's what your partner is. It doesn't matter that her degrees are from Yale/NYU etc or how much "training" she had.
She is a nurse- a midlevel provider. She should stay within her realm of nursing. If she wants to practice medicine in the role of a physician, she should go to medical school and become a doctor.
End of story.
The term "midlevel" DOES fit because that's what your partner is. It doesn't matter that her degrees are from Yale/NYU etc or how much "training" she had.
She is a nurse- a midlevel provider. She should stay within her realm of nursing. If she wants to practice medicine in the role of a physician, she should go to medical school and become a doctor.
End of story.
23
If an institute affiliated with physicians that does a study that casts doubt on there being a doctor shortage, that study should be viewed with some skepticism, if only because part of what enables many physicians to make $500,000 a year or more, is a shortage of physicians. If the number of physicians were increased in a meaningful way such that the supply/demand curve were shifted, the natural effect would be reduced costs (assuming everything else stayed the same). Yes, I know physicians and clinics have many fixed costs, but imagine a world where doctors had to fight for business more than they do now. For once, true skill and results would start to matter.
2
Outside of extreme situations , how does a patient determine true skill and results? Also, I think the spectre of potential unemployment for doctors would lessen the quality of applicants to medical school. Finally, the annual income of $500,000 you mention is far away from what most doctors, including specialists, actually make these days.
3
I think we should highly subsidize medical education so that physicians can graduate without debt. I believe that many doctors use their debt to justify their outrageous fees. They should not have the debt (and they should not charge as much as they do.)
4
MSL-
You fail to understand that there is a complete disconnect between the "outrageous fees" that the doctors charge and what they actually get paid.
A doctor can charge $1MM for a procedure but if it is done thru insurance, he will only get reimbursed what the insurance company pays.
You fail to understand that there is a complete disconnect between the "outrageous fees" that the doctors charge and what they actually get paid.
A doctor can charge $1MM for a procedure but if it is done thru insurance, he will only get reimbursed what the insurance company pays.
11
And the insurance company executive takes home millions in pay and bonuses.
14
Seriously look at the actual EOBs.
My baby daughter had a hernia surgery. The professional fee (the money that MD actually doing it got) was less than it took to get a plumber out to my house to fix a leaky pipe. No lie. The surgery was OVERALL expensive but that was mostly the fee to the hospital- the doctor got only a couple hundred dollars out of a $10000 bill paid.
My baby daughter had a hernia surgery. The professional fee (the money that MD actually doing it got) was less than it took to get a plumber out to my house to fix a leaky pipe. No lie. The surgery was OVERALL expensive but that was mostly the fee to the hospital- the doctor got only a couple hundred dollars out of a $10000 bill paid.
12
No easy solutions. I am a PA. I know my colleagues and also NPs are providing care and have been for close to 50 years. We are not an experiment, we are a proven way to deliver health/medical care. We need to remove barriers, insurance and legislative that prevent PAs and NPs from doing what they were educated to do; take care of people who need care. "MIDLEVEL PRACTITIONERS" is a phrase not used by with the PA or NP professions. The author should know this. We are highly educated clinicians. I have been able to write prescriptions in my state for 40 years. There is nothing MIDLEVEL about the care I give. And who, dare I ask is lower level?
Dave
Dave
10
I don't believe that "midlevel practitioner" is meant to be pejorative. It's a reference to your level of training, education, and certification. There is no "lower level." Now that many places have decided to refer to most health-care workers as "providers," there is a need for this distinction. There are many fine physician assistants and nurse practitioners, but they are not physicians.
2
I keep losing doctors - not because there is a shortage, but because they have stopped taking insurance or (the new trend) offer "concierge" services only. One former doctor is now charging $1,200 per year just to be allowed to be his patient (doesn't include any visits). My mother's doctors will only write her prescriptions for 3 months at a time, insisting on an office visit for each renewal. That practice makes it harder for patients who really need to see a doctor to get an appointment. Yes, medical school is expensive and insurance doesn't reimburse the doctors enough - so they are driven to these schemes to get more money - but I don't think more physicians will solve the problem.
4
"We could fix that by increasing the number of physicians, either by training more or allowing more to immigrate into the country."
This thinking just galls me. Rob Peter to pay Paul. The same thinking has caused many physicians and nurses to immigrate from countries that have their own shortages - think the Indonesian nations, the Philippines, and the Balken area. What right do we have as a nation to take other countries resources to solve our problem, especially when we really have the money and resources to fix it if we really want to? I am not alone in this concern, it has been debated for over 30 years.
Once here these individuals also encounter a very difficult path to licensing. Many must repeat much or all of their training - which means that they are unable to perform what they are trained to do without utilizing the same system that is causing the shortage here. More debt, specialization, and use of our resources - as well as language barriers. So please, do not be disingenuous in regard to the above logic.
This thinking just galls me. Rob Peter to pay Paul. The same thinking has caused many physicians and nurses to immigrate from countries that have their own shortages - think the Indonesian nations, the Philippines, and the Balken area. What right do we have as a nation to take other countries resources to solve our problem, especially when we really have the money and resources to fix it if we really want to? I am not alone in this concern, it has been debated for over 30 years.
Once here these individuals also encounter a very difficult path to licensing. Many must repeat much or all of their training - which means that they are unable to perform what they are trained to do without utilizing the same system that is causing the shortage here. More debt, specialization, and use of our resources - as well as language barriers. So please, do not be disingenuous in regard to the above logic.
5
Despite the high cost to students, medical school is still subsidized. I would have no problem supporting programs that pay off medical student debt in return for 5-year commitments to work in rural areas as GPs. Consider it another form of 'residency training.' I'd also like to see more done to encourage retired physicians to act as mentors. They may not be willing or able to serve regular shifts as locums but their insights on patients could be valuable to young doctors who are relying on their mobile phone apps to look up symptoms and make diagnoses.
2
That already exists; it is called Public Service Loan Forgiveness (PSLF). The main problems with PSLF which the article indirectly alluded to is that, generally speaking, picking a specialty is more lucrative than primary care PSLF, and that there is little incentive for physicians to spread out geographically. I am a specialist physician living in the capital of a mainly rural state, and it is routine for patients to travel 2-3 hours each way for an appointment.
2
I'm a family doctor and have practiced clinical, hospital, and emergency medicine in each of rural Georgia, metropolitan Seattle, and LA's outskirts.
I believe that there is a physician shortage because physicians are not being recruited and trained appropriately. Physicians need to be invested in areas of shortage. If you are not invested then no amount of money will convince you to stay.
In the US, the costs of high-acuity care are paid for with dollars charged in low-acuity care. Fix that and you will have answered this problem. Most NPs and PAs are trained to be great adjuncts and poor substitutes for physicians; to ask physicians to supervise them is ask them to become experts then to require them to be managers.
I believe that there is a physician shortage because physicians are not being recruited and trained appropriately. Physicians need to be invested in areas of shortage. If you are not invested then no amount of money will convince you to stay.
In the US, the costs of high-acuity care are paid for with dollars charged in low-acuity care. Fix that and you will have answered this problem. Most NPs and PAs are trained to be great adjuncts and poor substitutes for physicians; to ask physicians to supervise them is ask them to become experts then to require them to be managers.
4
Can we stop using the term "mid-level practitioners"? It demeans the high-quality care that nurse practitioners and physician assistants provide. Continued use of this term contributes to an inability to really assess access to high-quality care. If we only look at access to physicians, we are unable to see where gaps occur, especially as nurse practitioners are more likely to work in underserved populations and to provide necessary primary care than physicians. Additionally, it is confusing and undermines patient confidence and provider-patient relationships. It is well beyond time for this outdate term to be retired.
6
NPs and PAs ARE midlevel providers. That is the extent of their training. They constantly are fighting to get more rights and privileges.
They should remain in their current role of being supervised mid-level providers. If you want to be a doctor, go to medical school.
They should remain in their current role of being supervised mid-level providers. If you want to be a doctor, go to medical school.
19
The AMA shoots itself in the foot when it fights the use of midlevel providers. Physicians don't want to practice in underserved (read poor and rural) communities where nurses have historically provided the only health care services.
1
The fact that you believe that:
"Physicians don't want to practice in underserved (read poor and rural) communities where nurses have historically provided the only health care services."
Is in no way relevant to your other statement:
"The AMA shoots itself in the foot when it fights the use of midlevel providers"
Your comment adds zero value to this discussion
"Physicians don't want to practice in underserved (read poor and rural) communities where nurses have historically provided the only health care services."
Is in no way relevant to your other statement:
"The AMA shoots itself in the foot when it fights the use of midlevel providers"
Your comment adds zero value to this discussion
3
Mid levels don't want to practice in rural areas either. Many want to "specialize" in dermatology or surgery and work in urban areas. This idea that mid-level somehow want to work in underserved and rural areas is a farce propagated by those attempting to gain more independent practice rights for mid levels. Bottom line, Hospitals like to employ mid levels because they are cheaper than physicians. They are cheaper upfront however they cost the system more in the end. Many do not have the clinical experience to appropriately diagnose and end up over prescribing medications and giving referrals. None of the physician mid-level comparison studies take these down stream costs into effect.
11
Not only that, the hospital administrators will tell you to your face that using midlevel providers to care for more complicated cases is "good enough care" and is mandated by their effort to save dollars. That's an insult to everyone all the way around.
I enjoyed this article and found it thought-provoking. Specialty care is what makes American medicine great. people travel from all over the world to see specialists in the United States,. They don't travel to see primary care doctors. So I agree that there are NOT too many specialists in the US. The author talks about more nurse practitioners and physician assistants taking primary duties. A word of caution: the training is not the same. The problem is that medical students choosing to enter primary care face this type of thinking: Are they just at the same level as NPs and PAs? Really? Or should they do something special and unique that is theirs to own? It isn't a choice based solely on money. And many NPs and PAs specialize by the way. PAs who work in orthopedic doctor offices and operate with them is very common! So not all PAs and NPs automatically become primary care providers. many specialize for the same reasons medical students do- to have an area of focus and expertise that is theirs.
7
Some have suggested that primary care physicians could function as team leaders, overseeing groups of NPs/PAs who do the bulk of the hands-on work. In this way the MD could still see some primary care patients--probably the more diagnostically challenging ones--while also carving out a niche as a primary care leader. Leading teams of healthcare professionals is a desirable skill as we continue to move toward team-based care.
2
I agree with you. Good point.
This is exactly the agenda of mid-level providers. That they will see the easy patients, leaving the difficult & complex patients to the physician, yet the physician will continue to be liable and responsible for ALL the patients.
That's the goal of the militant NPs and PAs in a nutshell.
That's the goal of the militant NPs and PAs in a nutshell.
13
Let those in favor of national healthcare (me) speak honestly. National healthcare means all doctors work for the government. Hospitals will no longer compete for patients and malpractice lawsuit will be prohibited. As it is phased in medical schools will become tuition free but doctors will also work where the government determines they are needed, at least for set period of years.
9
Our system doesn't work quite like you describe, but it's very good. And the fact that there aren't competing insurance companies trying to shift responsibility off to each other or to the government makes for an amazing difference in emergencies. Recently a man fainted and fell in a local store. Store staff kept him lying down until a nearby clinic could send a doctor over, who arrived just before the ambulance. The doctor and paramedicals checked him over, helped him up and the ambulance drove him over to our hospital to give him a thorough check. When the hubbub was over, I offered to write a witness report, as I'd seen the man fall. "Why?" I was asked - "who would need a report?" "To give to your insurance company in case of a lawsuit." "Who's going to sue? We all have the same insurance." Wow.
5
One of the reasons for a high ratio of specialists to generalists in American medicine is that the prices doctors charge are not set in a market in which price is determined by supply and demand. They are set by a committee of the American Medical Association that is controlled by surgeons, radiologists, and other specialists who do procedures.
3
Where did you get this idea?
3
It's not an idea, Spencer, it is a fact. You can read about it in a book called Fixing Medical Prices.
3
As a physician I agree the issue is complex. I have worked both in and out of the hospital in large and small cities and there is no easy solution. I was in private practice in Kentucky and made less than $100,000/yr. I found I could have more personal freedom and make three times as much working only in the hospital setting. I was able to pay off my medical school debts after several years. But, money isn't everything and I miss the deep patient doctor relationships I don't have anymore.
I think the larger issue is something this article touched on, our population is aging. In the US the number of people over the age of 65 is 46.2 million (2014) or 14.5 percent of our population. In the year 2060 this number is expected to reach 98 million. We are living longer but not always better. We utilize a huge amount of resources at the very end of our life. Other countries do not share this same pattern. We seem to want to avoid death at all costs. I experience this daily. We consume billions of dollars and tie up thousands of doctors in and out of clinics and hospitals trying to stay alive. We wouldn't need as many physicians if the demand for complex medical care at the end of our lives was not so great. I think the most profound issue facing healthcare is not the lack of doctors but the defiance of our citizens to acknowledge their own mortality. If we could face this issue, healthcare consumption would drop and quality of life improve.
I think the larger issue is something this article touched on, our population is aging. In the US the number of people over the age of 65 is 46.2 million (2014) or 14.5 percent of our population. In the year 2060 this number is expected to reach 98 million. We are living longer but not always better. We utilize a huge amount of resources at the very end of our life. Other countries do not share this same pattern. We seem to want to avoid death at all costs. I experience this daily. We consume billions of dollars and tie up thousands of doctors in and out of clinics and hospitals trying to stay alive. We wouldn't need as many physicians if the demand for complex medical care at the end of our lives was not so great. I think the most profound issue facing healthcare is not the lack of doctors but the defiance of our citizens to acknowledge their own mortality. If we could face this issue, healthcare consumption would drop and quality of life improve.
49
When you calculate how much doctors earn, are you comparing it to what they would be earning if they:
Went to work after high school and invested much of their money in index funds or real estate without running up their debt and having it compound;
Earned an A. A. and . . .
A B.A, M.S., MBA, . . .
Those years of school then residency and borrowing money before the big income should be calculated into their money earning, not just what they make as a pediatric heart surgeon or . . .
Went to work after high school and invested much of their money in index funds or real estate without running up their debt and having it compound;
Earned an A. A. and . . .
A B.A, M.S., MBA, . . .
Those years of school then residency and borrowing money before the big income should be calculated into their money earning, not just what they make as a pediatric heart surgeon or . . .
11
Just think what they could make if they played in the NBA.
4
I would probably need to be a bit taller than 5'2" and probably male to boot...
3
Yes, if you had the money that med school costs, in one hunk, and invested it, you might wind up better off than most primary care docs. But most 22-year olds don't have access to that much cash. If you went into a specialty netting $400-5o0k a year, you could catch up fairly soon. See, it all depends.
2
A chief tenet of PA education is to master the art of the old fashioned physical exam. They are trained as generalists. They must listen to the patient and strive to recognize interconnectedness of various symptoms. The intense medical education they receive is heavily augmented by the attentive training of their physician colleagues, especially the early phase of their careers. PAs must re-certify as generalists although they can become certified in a number of specialties as well. PAs log ample CME credits through conferences, etc., as do physicians. To become a certified PA, one must first graduate from an accredited US program. Therefore, utilizing PAs will spare the US from further participating in the "brain drain" by which physicians are lured from their homelands which may be in dire need of physicians, and furthermore, their governments have invested heavily in their education in hopes of helping their own citizens. This foreign recruiting practice is greatly discouraged by the WHO, and the richer nations (i.e., USA) are supposed to compensate the poorer nations from which the doctors have been lured. Sometimes, language barriers (i.e., colloquialisms) can pose problems for the doctor/patient relationship, and this has been heavily addressed in England. PAs are seeking to reclaim the title of the inception of their profession, physician associate, since this title resonates more accurately their training and scope of practice.
3
Every other developed nation realized long ago that medical care does not fit into our standard free market capitalist system. Despite acknowledging that our medical system is not really working we persist in trying to fit a square peg into a round hole. Until we stop thinking that solutions that work for commodity production work in medical care we will always come up short.
30
I find it mildly offensive that the author will include links to his own blog.
Furthermore, I find it offensive that he would then cite articles that are completely useless. One of them was published in a Nursing Journal utilizing questionable research data. It used a meta analysis of previously available data. Such data included- self reported data, poorly designed studies that met the inclusion criteria, and studies of clinically less significant indicators of patient outcomes.
Its obvious that the studies were not just poorly designed but even after cherry picking were inaccurate
Furthermore, I find it offensive that he would then cite articles that are completely useless. One of them was published in a Nursing Journal utilizing questionable research data. It used a meta analysis of previously available data. Such data included- self reported data, poorly designed studies that met the inclusion criteria, and studies of clinically less significant indicators of patient outcomes.
Its obvious that the studies were not just poorly designed but even after cherry picking were inaccurate
7
The problem has been worsening for decades, and it's not a doctor shortage, rather an oversupply of sickness.
7
I would the NYT to produce a graphic explaining where each healthcare dollar is spent - hospitals, doctors, mid levels, nursing, drugs, medical devices, administration etc.
Keep splitting the the money into smaller and smaller sub groups. I would like to see how my use of healthcare compares to the rest of the country, maybe even state-by-state. It would also be interesting to see if over time the relative allocation of money has moved to different parts of the healthcare spectrum.
People complain about increasing insurance premiums, but have no idea what they are spent on.
Keep splitting the the money into smaller and smaller sub groups. I would like to see how my use of healthcare compares to the rest of the country, maybe even state-by-state. It would also be interesting to see if over time the relative allocation of money has moved to different parts of the healthcare spectrum.
People complain about increasing insurance premiums, but have no idea what they are spent on.
9
Yet another stealth promotional for non-equivalent physician extenders as substitutes for real doctors. You get what you pay for.
26
@Lennie (right behind you) -Your statement suggests that PAs and Nurse Practitioners are never adequate and should be dismissed. That thinking is part of the problem. These trained professionals can indeed perform much routine care very well. I have seen a PA as the allergist for a number of years - all he does, all the MD ever did, was look up my nose, listen to my chest, and write a prescription. Likewise, I saw an NP when I had a swollen foot. She asked some questions, examined the foot, and ordered an x-ray.
I have a bachelors degree in nursing and worked for a number of years in critical care. Even at that level of training, nurses become adept at listening to lungs and assessing patients in a variety of ways. Nurses, not MDs, are alone with critically ill patients in ICUs for hours on end - it is the nurses who recognize a variety of signs re problems, evaluate the patient's progress, and call the MD as necessary. With the additional training of a Practitioner (often a specialty, always a Master's degree), NPs can provide a wide variety of routine care knowing when to refer a patient to a collaborating physician (or when to consult him/her further). Your "you get what you pay for" attitude is one of the beliefs that drives up healthcare costs without increasing benefit.
I have a bachelors degree in nursing and worked for a number of years in critical care. Even at that level of training, nurses become adept at listening to lungs and assessing patients in a variety of ways. Nurses, not MDs, are alone with critically ill patients in ICUs for hours on end - it is the nurses who recognize a variety of signs re problems, evaluate the patient's progress, and call the MD as necessary. With the additional training of a Practitioner (often a specialty, always a Master's degree), NPs can provide a wide variety of routine care knowing when to refer a patient to a collaborating physician (or when to consult him/her further). Your "you get what you pay for" attitude is one of the beliefs that drives up healthcare costs without increasing benefit.
25
Very misleading statements here. Nurses are not the only ones who spent hours with patients. The physicians just have a much larger number of patients to care for.
Mid levels are increasing overall costs by their overprescribing, overdiagnosing or misdiagnosing and essentially become another stop in the referral chain.
Mid levels are increasing overall costs by their overprescribing, overdiagnosing or misdiagnosing and essentially become another stop in the referral chain.
7
Nurses practice Nursing and have a Nursing License.
They do not practice Medicine.
Different Disciplines. Different Profession.
And BTW, Why are you not proud to be a Nurse?
They do not practice Medicine.
Different Disciplines. Different Profession.
And BTW, Why are you not proud to be a Nurse?
1
Who's the "we" that is going to be fixing the issue? Medicare? Medicare Advantage? Medicaid? Private insurers? Patients themselves? We have several different systems operating and no doubt the solution will be different for each. For people who can afford concierge service, they will get that. For those who have platinum or gold health care plans maybe there will be a push to pay doctors more, while those who are restricted to narrow networks will likely find themselves facing longer waits or shorter visits, especially if more people come into the system, and as for Medicaid, well who knows. Our system is not content merely to put PCPs at a disadvantage relative to specialists, but to reward them differently depending on what type of patients they serve and how much bargaining power the hospital they may be affiliated with has.
If we increasingly segment both the insured population and the providers into smaller groups, doesn't that suggest that there will be no one solution for all? And isn't that the point?
If we increasingly segment both the insured population and the providers into smaller groups, doesn't that suggest that there will be no one solution for all? And isn't that the point?
3
A private organization, made up entirely of physicians, the ACGME is responsible for determining the number of doctors we produce in any given year. This body, an outgrowth of the American Medical Association is answerable only to itself and is responsible for the accreditation of almost every medical school in the United States.
So how come the physician who wrote this article about a physician shortage never mentions it.
He is right about needing government intervention though. The government should snatch this organization's authority away on day one because of the appalling conflict of interest obvious in allowing a council of physicians, in this case a doctor's union, to decide how many physicians this country needs. That decision should be part of public policy making.
So how come the physician who wrote this article about a physician shortage never mentions it.
He is right about needing government intervention though. The government should snatch this organization's authority away on day one because of the appalling conflict of interest obvious in allowing a council of physicians, in this case a doctor's union, to decide how many physicians this country needs. That decision should be part of public policy making.
11
The only profession that needs its authority "snatched" is the ABA.
6
Don't forget the need for more residency programs, also run by ACGME. Funding is outdated and cobbled together for these critical training years. Finally, people are shocked when they hear my debt is about $24,000/$300,000 interest earned while in med school, when it is impossible to be paying back loans.
One issue not mentioned is that licensure for docs is state by state. I have talked with physicians in my family who tell me that there is a substantial burden to getting relicensed in a new state. This makes it difficult for docs to move to areas where they are needed. Because many training facilities are in cities in the northeast, mid-atlantic, and west coast, and because docs get licensed during training, they may not be willing or able to undergo the process needed to get licensed in a state where there is a shortage of docs. This would support, in my mind, the need for a federal licensure that would allow more mobility of medical resources.
24
The last article I read was on why Republicans have abandoned cities to the Democrats, and rural areas are all Republican. The article before that on why education makes people vote Democratic; the Republican party is willing to abandon both facts and reason. The article before that on how Republicans have abandoned welcoming immigrants (who used to be the source of doctors for underserved areas.)
And we wonder why doctors don't choose to go to rural areas. Doctors who are immigrants (who used to be a primary resource for underserved areas) can't go to rural areas, where demagoguery has whipped up a frenzy of racial and immigrant hatred. No longer is it comfortable, or even respectable, to be the most educated person in town. Urban and rural, educated and uneducated, are two new class divides that no one talks about. It really isn't the money. Why on earth would a doctor be willing to raise, or try to educate, children in a town full of "Trump" signs?
And we wonder why doctors don't choose to go to rural areas. Doctors who are immigrants (who used to be a primary resource for underserved areas) can't go to rural areas, where demagoguery has whipped up a frenzy of racial and immigrant hatred. No longer is it comfortable, or even respectable, to be the most educated person in town. Urban and rural, educated and uneducated, are two new class divides that no one talks about. It really isn't the money. Why on earth would a doctor be willing to raise, or try to educate, children in a town full of "Trump" signs?
64
Strangers willingly move to cities where they can readily establish personal networks among others with similar interests. People are not so ready to move to rural communities that seem closed and insular to those without family ties and friendships that go back to childhood. One way to get doctors to work in rural areas would be to have a recruitment and training program to attract bright young people from those areas and to help pay for their medical education.
4
Does it ever occur to anyone that the Association of American Medical Colleges just might have a stake in projecting a "doctor shortage." How about doctors who threaten to stop seeing patients with Medicare - can they really afford to do that? What about the alarmists who say 10,000 new beneficiaries are added to Medicare every single day and don't mention the 7,000 that drop out of Medicare every single day?
5
Medicare covers 80% of a providers costs so need volume in order to make this work. In addition, under ACA, providers have to have an annual "Risk Adjustment" visit with every patient attributed to them. These visits take approximately 1 hour for approximately the same reimbursement as a wellness visit which takes only 15-20 minutes. PCP's schedule patients every 15 minutes thus, it takes longer to see Medicare patients then ever before which is also affecting the ability to service the growing numbers of Medicare eligible patients..
3
Roughly speaking, about half of all medical spending is Medicare-related. If a provider can afford, and is willing, to drop any patient as they turn 65, it proves the incentives have little to do with the patient's health.
rd415 - you're separating PCP's and providers that see Medicare patients? I think that's a false separation.
I suspect most PCP's handle a mixed caseload of wellness physicals (30-60 minutes), follow-ups on chronics (15 minutes), acute care (who knows, leave some space in the schedule). Unless you're talking about EMR, I don't believe "it takes longer to see Medicare patients than ever before."
rd415 - you're separating PCP's and providers that see Medicare patients? I think that's a false separation.
I suspect most PCP's handle a mixed caseload of wellness physicals (30-60 minutes), follow-ups on chronics (15 minutes), acute care (who knows, leave some space in the schedule). Unless you're talking about EMR, I don't believe "it takes longer to see Medicare patients than ever before."
1
I can't understand how any physician (except maybe psychiatrists) can "afford" to drop Medicare patients. Aren't the sickest people 65 years old and older? Where will the physicians who opt out find patients when HRC offers Medicare to the 55-64 year olds?
Doctors don’t take an oath of poverty, if the want ads in the New England Journal of Medicine are any indication.
1
My wife and I feel very fortunate to be covered by Virginia Mason with the same Doctor for a number of years. JGAIA
1
I guess my question is why don't we just let the market figure this out? Why do we need some government planners to sit around and determine if we have the right amount of physicians? We don't do that for any other profession. If there are people capable of getting through medical school who are willing to pay full freight at a medical school and they're currently being turned down then I would say we're in a shortage condition. It is the government's job to make sure that that condition is alleviated. Even if the practice of medicine were NPV-negative (an absurd thought in this day and age) it wouldn't be the only career that could make that claim and the government should not be engaging in protectionism to guarantee a return on someone's investment in schooling and training time.
2
The "market?" When you go into the health care market it's not like going into a grocery store because you're hungry and decide to buy apples instead of oranges because apples are cheaper. Your going to be pretty confident the apple will solve the hunger problem. But lets say you go into the health care market because your head aches and you choose the 10 cent aspirin instead of the $50,000 brain surgery? How confident will you be about your purchase solving the problem? In the health care market your choices can have very serious life or death consequences. In most cases when we go into the health care market we don't have a clue about what we need to buy. Health care is a "restrictive monopoly" in this country and for good reason. Without government involvement we'd be buying a lot of "snake oil."
6
"Without government involvement we'd be buying a lot of 'snake oil.'"
And bankrupting the back-up systems of acute and emergency care when the snake oil failed. After wasting oodles of cash on the snake oil in the first place.
As physician I welcome the minority of patients who are able and willing to make wise choices, and I honor those choices. The other folks I try to educate and help as best I can.
And bankrupting the back-up systems of acute and emergency care when the snake oil failed. After wasting oodles of cash on the snake oil in the first place.
As physician I welcome the minority of patients who are able and willing to make wise choices, and I honor those choices. The other folks I try to educate and help as best I can.
2
Dr. Carroll, I think you left out a really important component of this issue, namely the hospitals who train the specialists because they make money for the hospitals. Procedures make money for the hospitals, while people, like endocrinologists and GPs who could help keep people out of hospitals, lose money for them. Here is an article from several years ago, which I heard about first hand from an endocrinologist who was a participant
http://www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/11diabetes.html
"With much optimism, Beth Israel Medical Center in Manhattan opened its new diabetes center in March 1999. .At four hospitals across the city, they set up centers that ...would be boot camps for diabetics, who struggle daily to reduce the sugar levels in their blood. The centers would teach them to check those levels, count calories and exercise with discipline, while undergoing prolonged monitoring by teams of specialists.
But seven years later, even as the number of New Yorkers with Type 2 diabetes has nearly doubled, three of the four centers, including Beth Israel's, have closed.
They did not shut down because they had failed their patients. They closed because they had failed to make money.
This shows the limits of a market based healthcare economy. Companies do not strive to become more efficient in order to reduce their profits.
http://www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/11diabetes.html
"With much optimism, Beth Israel Medical Center in Manhattan opened its new diabetes center in March 1999. .At four hospitals across the city, they set up centers that ...would be boot camps for diabetics, who struggle daily to reduce the sugar levels in their blood. The centers would teach them to check those levels, count calories and exercise with discipline, while undergoing prolonged monitoring by teams of specialists.
But seven years later, even as the number of New Yorkers with Type 2 diabetes has nearly doubled, three of the four centers, including Beth Israel's, have closed.
They did not shut down because they had failed their patients. They closed because they had failed to make money.
This shows the limits of a market based healthcare economy. Companies do not strive to become more efficient in order to reduce their profits.
37
If there are more doctors per 1000 people in Sweden or Germany, do these doctors make more or less than American doctors? And are their prospects for doing extremely well financially greater or less than in this country?
Doctors get to save lives and improve the quality of life for others, so their jobs are worth doing and rewarding on their own, aside from the money. Doctors who want to serve others will also want a decent standard of living for their families, but once that is assured they can practice their healing arts and not think much about money. They may be happier and more satisfied that way. So a competitive capitalist system must work to change that orientation and get them to view their education as an investment that will pay off for them in the future rather than a preparation to serve their fellow man. Making them go into debt to finance their education forces them to view their education in investment terms. Making them do paperwork and record what they are doing to get paid lessens the satisfaction they get from helping people and orients them towards managing and playing the system and entrepreneurship and running a small business rather than healing.
Idealism and service compete with medicine as a business for the souls of doctors. Our economic system regards idealistic doctors as threats to its values, and has found many ways to blunt this threat by encouraging, rewarding, and forcing doctors to bow down to business thinking.
Doctors get to save lives and improve the quality of life for others, so their jobs are worth doing and rewarding on their own, aside from the money. Doctors who want to serve others will also want a decent standard of living for their families, but once that is assured they can practice their healing arts and not think much about money. They may be happier and more satisfied that way. So a competitive capitalist system must work to change that orientation and get them to view their education as an investment that will pay off for them in the future rather than a preparation to serve their fellow man. Making them go into debt to finance their education forces them to view their education in investment terms. Making them do paperwork and record what they are doing to get paid lessens the satisfaction they get from helping people and orients them towards managing and playing the system and entrepreneurship and running a small business rather than healing.
Idealism and service compete with medicine as a business for the souls of doctors. Our economic system regards idealistic doctors as threats to its values, and has found many ways to blunt this threat by encouraging, rewarding, and forcing doctors to bow down to business thinking.
8
"We rely too heavily on physicians and not enough on mid level practitioners?"
I spent a night at the ER room at Metropolitan Hospital in Manhattan with excruciating pain. It took 3 hours to be seen by a doctor (Mexican) for like 10 seconds.It was the end of his shift and then it took another 3 hours until a new doctor (Indian) saw me, again for 10-15 seconds when I largely self-diagnosed. They delegated ALL the possible patient work. There was zero bed talk and no bed manner. When I complained they spent two psychiatrists who spend much more time with me than the actual doctor. They let me go in the morning with the same pain, no diagnosis and no treatment. I felt as if I were in a third world country not in Manhattan, USA!
I spent a night at the ER room at Metropolitan Hospital in Manhattan with excruciating pain. It took 3 hours to be seen by a doctor (Mexican) for like 10 seconds.It was the end of his shift and then it took another 3 hours until a new doctor (Indian) saw me, again for 10-15 seconds when I largely self-diagnosed. They delegated ALL the possible patient work. There was zero bed talk and no bed manner. When I complained they spent two psychiatrists who spend much more time with me than the actual doctor. They let me go in the morning with the same pain, no diagnosis and no treatment. I felt as if I were in a third world country not in Manhattan, USA!
12
Your comments belie racism btw. America is a multicultural city. The ethnicity of the MDs is irrelevant.
2
Mpg - perhaps the ER physicians had accents that were hard to understand? Also, the bedside manner of a doctor trained in an authoritarian way, or under time constraints in an ER, can be somewhat different from the more collaborative approach some GPs have.
When you find the Dr rushed and get little direct communication it can increase anxiety, too. And anxiety can be recognized differently according to cultural background. The few foreign doctors I have seen have taken my questions as a challenge to their diagnosis rather than my attempt to understand. I think this is not unusual and I'm sure there are exceptions. So, I didn't take that comment as being racist, although I can see how it may be interpreted that way.
When you find the Dr rushed and get little direct communication it can increase anxiety, too. And anxiety can be recognized differently according to cultural background. The few foreign doctors I have seen have taken my questions as a challenge to their diagnosis rather than my attempt to understand. I think this is not unusual and I'm sure there are exceptions. So, I didn't take that comment as being racist, although I can see how it may be interpreted that way.
1
Patients are getting more complicated, so we should have those with less medical training providing primary care? This results in multiple specialists and over-testing and over-medicating, which exacerbates the complexity and cost of care. Expecting mid-level providers to manage the recommendations and medications of many specialists, who most likely pay attention to naught but their own field, is not the answer. Make primary care more attractive to physicians, instead of treating it as a dumping ground, as many specialists do.
20
I've wondered if rather than charging painfully high tuition for medical school followed by increasing stipends each year for residency and specialty fellowship training--which have the effect of driving new docs toward specialties and subspecialties--we made medical school more affordable, paid stipends only for primary care residencies, and charged tuition for specialty and subspecialty residency training. New docs could afford to do primary care in that case, and only people passionate about a specialty would need to go into debt to obtain that training. This method doesn't answer the geographic distribution problem, but student loan payments help. That's how I got to Maine, and I was grateful to have the money. There would have to be a discussion about what constitutes primary care, but Family Practice, Pediatrics, Psychiatry, General Surgery and OB-Gyn would make sense.
19
What a horrifically dumb idea that completely missed the problem presented.
As has been noted, the number and distribution issue of specialists is even greater and more acute then that of primary care physicians. We can cover a great deal of primary care deficits with mid levels (PA, NP, CRNA) at 1/3 the costs, but it takes 10-15 years and $500k-750k to educate and train a surgeon or gynecologist, the role of which can't be lateralled to mid level.
As has been noted, the number and distribution issue of specialists is even greater and more acute then that of primary care physicians. We can cover a great deal of primary care deficits with mid levels (PA, NP, CRNA) at 1/3 the costs, but it takes 10-15 years and $500k-750k to educate and train a surgeon or gynecologist, the role of which can't be lateralled to mid level.
3
We are lead to believe that there are as many people wanting to be health providers as are needed and that each provide the same values, quality and receive the same satisfaction. While the number of patients who taxpayers fund is believed to be equal; while we all know this isn't true.
So what are physicians who are able to retire after 35 years doing today to plan for their future and is taking earlier than usual retirement or adjusting their patients loads or type of practice increase shortages?
Whens the last time you've talked to your care givers about what insurance they take before you decide your Medicare plans? Does yours accept new patients, and ER visits decrease? As cancer and other conditions decrease and we fund billions to "cure" even "orphan" diseases will we need more or less oncologists? rheumatologist? and as they workload decreases will they just retire, change specialties, or "go back to the future" and become general practitioners for less money and experience that "newly minted ones or NP's?
If or when we "cure" all diseases will we have to retrain doctors as we do coalminers?
I recall when Malaria, TB and Polio killed many here and still do globally, but are basically eliminated here now, perhaps they would make great farmers, when they run out of doctor work? Shortages can become overages in almost everything in todays World!
So what are physicians who are able to retire after 35 years doing today to plan for their future and is taking earlier than usual retirement or adjusting their patients loads or type of practice increase shortages?
Whens the last time you've talked to your care givers about what insurance they take before you decide your Medicare plans? Does yours accept new patients, and ER visits decrease? As cancer and other conditions decrease and we fund billions to "cure" even "orphan" diseases will we need more or less oncologists? rheumatologist? and as they workload decreases will they just retire, change specialties, or "go back to the future" and become general practitioners for less money and experience that "newly minted ones or NP's?
If or when we "cure" all diseases will we have to retrain doctors as we do coalminers?
I recall when Malaria, TB and Polio killed many here and still do globally, but are basically eliminated here now, perhaps they would make great farmers, when they run out of doctor work? Shortages can become overages in almost everything in todays World!
1
Let's improve this situation with technology, not more nurse practitioners and physician assistants in place of doctors.
The web enables us to partner, one on one, with a primary care doctor who has a limited number of patients. That doctor can act as a quarterback. A care coordinator. A first-line of defense and care for when we are ill. That doctor can really know us and all of our medical history. A long-term, personal relationship for overall health and wellness.
And, that doctor can be augmented by the current in-person system that we have, with all of its conveniences and innefficiences. Urgent care on just about every corner (with a random doctor). 15 minute doctor appointments. Time wasted in the waiting room, exam room. Little follow up. A health insurance system that makes it really hard for primary care doctors to thrive and provide great care.
Online anytime with the same doctor. In-person when you need it with a random doctor. This is achievable today without massive reform, and would provide better care for most Americans.
Disclaimer: my company SteadyMD offers concierge primary care online.
The web enables us to partner, one on one, with a primary care doctor who has a limited number of patients. That doctor can act as a quarterback. A care coordinator. A first-line of defense and care for when we are ill. That doctor can really know us and all of our medical history. A long-term, personal relationship for overall health and wellness.
And, that doctor can be augmented by the current in-person system that we have, with all of its conveniences and innefficiences. Urgent care on just about every corner (with a random doctor). 15 minute doctor appointments. Time wasted in the waiting room, exam room. Little follow up. A health insurance system that makes it really hard for primary care doctors to thrive and provide great care.
Online anytime with the same doctor. In-person when you need it with a random doctor. This is achievable today without massive reform, and would provide better care for most Americans.
Disclaimer: my company SteadyMD offers concierge primary care online.
4
I grew up in New York - central New York State - a rural area. I didn't know it as a child, but the small medical building which housed a GP downstairs, and dentist, up, was put up with federal funds. One ob-gyn that my mother saw was an immigrant who came in an some special program, which deposited him in a non-urban areas, to the gratitude of the local population - maybe not what he expected but, overall, there was mutual gain. Up there now, there is widespread use of PAs both because of the preference of younger physicians for urban centers, and to save money.
It would not be difficult to create a program to attract younger Drs. to practice in underserved areas if there were write-offs of some or all debt, and targeted immigration policies.
It would not be difficult to create a program to attract younger Drs. to practice in underserved areas if there were write-offs of some or all debt, and targeted immigration policies.
24
There is a program called the National Health Service Corps that does exactly that. It has been around for decades. It is not enough of an enticement, we must do more.
1
My experience is that neither PA or NAs are physicians, they simply lack the training and experience. The solution might be that for at least five years they work under the supervision of a physician. That would be very similar to Residents in a teaching hospital, they would perform the initial intake History and Phyical, current medical condition, etc. The PA or NA would present the case to the training physician. The patient has the protection of a knowledgeable physician (my hope is that the physician is truly knowledgeable and a good teacher).
16
Yes, PAs and NPs are not physicians, but to make a blanket statement that they lack the training and experience to deliver medical care at the level and standard of physician care is simply not true. The average PA training program is 26 months in length at the graduate level. It includes 2000 hours of clinical training rotating through all the specialties.
PAs already work in health care teams lead by physicians and surgeons, and numerous studies have confirmed that PAs delivery care, in many settings, indistinguishable from physicians. While I can only speak for PAs, I know from 35 years of clinical and surgical practice, that PAs are the solution to the problem described in this article Take my own experience for example.
I currently practice on a plastic and reconstructive surgery service at a community hospital, staffing all aspects of surgery including an ICU level burn unit. The surgeon with whom I work with also covers a county hospital. I'm on the ground rounding, doing consults in the ED and on the floor, handling admissions and discharges, Preparing patients for surgery and seeing them in followup after their procedure. We do over 700 procedures at our hospital annually. The surgeon could not possible cover this service without a team approach to our practice, and heavy reliance on the PA staff. I make him more efficient, and keep him at the "table" doing what he loves best, surgery.
PAs are the solution to the problem.
PAs already work in health care teams lead by physicians and surgeons, and numerous studies have confirmed that PAs delivery care, in many settings, indistinguishable from physicians. While I can only speak for PAs, I know from 35 years of clinical and surgical practice, that PAs are the solution to the problem described in this article Take my own experience for example.
I currently practice on a plastic and reconstructive surgery service at a community hospital, staffing all aspects of surgery including an ICU level burn unit. The surgeon with whom I work with also covers a county hospital. I'm on the ground rounding, doing consults in the ED and on the floor, handling admissions and discharges, Preparing patients for surgery and seeing them in followup after their procedure. We do over 700 procedures at our hospital annually. The surgeon could not possible cover this service without a team approach to our practice, and heavy reliance on the PA staff. I make him more efficient, and keep him at the "table" doing what he loves best, surgery.
PAs are the solution to the problem.
16
Residents usually have four years after college graduation, Fellows have an additional year or two. So 26 months is not on that level but PAs could have another five years of training but they could never replace a competent physician.
5
But competent, trained and experience PAs do replace physicians in nearly every health care setting, and with outcomes and quality measures that are indistinguishable from their physician partners. I realize that I am not a physician. I am no replacement nor equal for my board certified plastic and reconstructive surgeon business partner. However, together, we are greater than the sum of the parts.
That is the whole point. There are no physicians to take my place on the team. My absence would create *tremendous* barriers to specialty care that would result in delayed or nonexistent care, and adversely affect our community.
I am highly specialized as a PA. I have worked ICU level burns, and plastic and reconstructive, craniofacial, and hand surgery for seven years. Thousands of complex procedures and critical burns. Who would you rather have at the table and in the ICU with a loved one? Me? or a "competent" family practice physician? You can't support the statement that a physician is *always* better than a PA. It depends on many factors.
I don't want to replace a physician. I want to be an effective component of the health care team that functions with every member practicing at the top of their license, and with respect for the training and experience of each member. I'm doing that now. I want to serve my community and its' health care needs first and foremost.
That is the whole point. There are no physicians to take my place on the team. My absence would create *tremendous* barriers to specialty care that would result in delayed or nonexistent care, and adversely affect our community.
I am highly specialized as a PA. I have worked ICU level burns, and plastic and reconstructive, craniofacial, and hand surgery for seven years. Thousands of complex procedures and critical burns. Who would you rather have at the table and in the ICU with a loved one? Me? or a "competent" family practice physician? You can't support the statement that a physician is *always* better than a PA. It depends on many factors.
I don't want to replace a physician. I want to be an effective component of the health care team that functions with every member practicing at the top of their license, and with respect for the training and experience of each member. I'm doing that now. I want to serve my community and its' health care needs first and foremost.
21
Classifying those not physicians as mid-level practitioners is insulting!
While my Medicare dollars help to provide paid residencies for medical students after graduation, nurses and physicians don't have that luxury despite the fact that their indebtedness can be almost the same or equal of physicians. Lacking a supportive residency program after graduation from a nursing or PA school, it is much harder for these providers to hone their skills with learned supervision. Thus, physicians keep knocking these able practitioners for their lack of hours of training.
Providing paid internships/residencies for those that will be 'generalists' is a better way to solve the problem.
Chronic care isn't sexy and exciting but it is true caring.
While my Medicare dollars help to provide paid residencies for medical students after graduation, nurses and physicians don't have that luxury despite the fact that their indebtedness can be almost the same or equal of physicians. Lacking a supportive residency program after graduation from a nursing or PA school, it is much harder for these providers to hone their skills with learned supervision. Thus, physicians keep knocking these able practitioners for their lack of hours of training.
Providing paid internships/residencies for those that will be 'generalists' is a better way to solve the problem.
Chronic care isn't sexy and exciting but it is true caring.
12
Sue-
It's not "insulting". It's an accurate term for what they are.
It's not "insulting". It's an accurate term for what they are.
16
No, it is insulting. Just as it would be insulting if we were to start referring to LVNs or paramedics as "low-level" providers given that they train for fewer years than an RN. Healthcare and patients are not helped by imposing rigid hierarchies on everything. It is factually true to say that one type of clinician, e.g. MD/DO, has more training than an NP/PA. But we don't need resort to insulting monikers to point that out. Otherwise, by the same logic, specialist MDs could claim to be "higher-level" clinicians than "mid-level" primary care MDs, simply because they are in training longer. Please refer to us as non-physician providers (NPPs), as Medicare does.
1
No caligirl, it is not insulting. PAs and NPs are midlevel providers who are fighting to be independent providers.
They should remain as midlevels due to their training which pales in comparison to a physician's training.
They should remain as midlevels due to their training which pales in comparison to a physician's training.
5
The ACA does NOT provide adequately for graduate
Medical education. The loss of autonomy for providers will stifle progress. The lack of access to new research is unaddressed. Only the patients can remedy the crisis.
Medical education. The loss of autonomy for providers will stifle progress. The lack of access to new research is unaddressed. Only the patients can remedy the crisis.
2
How about something like a medical service corp. The government pays your tuition, and you owe 2 years of your time. I'm 70 so I grew up with the draft and served in the Navy medical corps, so some sort of national service does not seem oppressive; and hey, your schooling is free. I do not see how you will convince students who grew up in the northeast to practice in Nebraska, but after working there some may like it and stay. Nurse practitioners should also be used as gatekeepers to the system, I agree we do not need more generalists. And can we please rationalize how we pay for this monstrosity we have created, far too much money is wasted in administrative costs.
I am a retired physician, but I remember these same problems when I was in medical school. Doctors are burning out, we need to find a better way.
I am a retired physician, but I remember these same problems when I was in medical school. Doctors are burning out, we need to find a better way.
42
I've long thought the medical service corp a good idea; both docs and underserved areas benefit.
22
RG maybe you forgot that Medicare already pays for 90% of doctor training. Are you suggesting that the government also pay for medical school?
1
This already has existed for decades, it is called the National Health Service Corps: http://www.nhsc.hrsa.gov/
Clearly this is not enough and we need to do more/implement different strategies.
Clearly this is not enough and we need to do more/implement different strategies.
Looks like the doctors union (aka the AMA) has been very successful in restricting the number of doctors it allows medical schools to graduate.
5
Did you read the article? The major stumbling block is not medical school graduates, but a limitation on the number of residency spots placed by- you guessed it- Congress. Number of medical colleges and graduates has been increasing rapidly over the past decade, but the number of residencies to train them has not. Without residency training, an MD as a degree is nearly worthless, as you cannot be licensed to practice medicine AT ALL anywhere in the U.S. without at least an intern year, and no insurance will pay you (and so you won't have a job) without completing some sort of residency. So you may have more MDs, but lots who cannot actually practice medicine! So if you are looking for blame, go write your congressperson or senator and tell them to fund graduate medical education expansion through Medicare.
52
Do you not think the AMA has the ear of congress? I mean you're right about the residency slots - they've been set at the same level since 1997. And those are controlled by congress. It's a lot easier for a special interest to kill bills in congress than it is to prevent some random university from building a medical school. In any case maybe you successfully countered a detail of David's post but his overall point stands - the number of people allowed to enter this profession is severely restricted.
2
Durham, the government (Congress) has no "limitation" on the number of residency spots. If you, your hospital, city or state wants pay for more residency "spots" then go ahead and do it. Congress won't stop you.
4
Looks like the Doctors union (aka the AMA) has been successfully in restricting the number of Doctors they will allow medical schools to graduate.
3
Some years back the AMA decided we had too many doctors and limited the amount of new doctors graduated from medical schools.It is definitely greed from the medical establishment causing this shortage.
11
This is a total fantasy. The AMA has no say in how many students a med school takes.
14
Agree with hddvt.
1
The ACGME makes that decision ( indirectly, by accrediting medical schools) and the AMA is part of this organization, so Lazarus is absolutely correct.
We have what is in essence a physicians union, deciding how many physicians we need. This has caused havoc and needs to stop. This decision should always have been part of public policy
We have what is in essence a physicians union, deciding how many physicians we need. This has caused havoc and needs to stop. This decision should always have been part of public policy
2
What about the option of a government supported general medical practice education, in exchange for a two (or more) year commitment to civil service general medical practice wherever needed? Aren't some medical institutions are already doing that sort of thing, in return for a commitment to work at *their* hospitals? For some, that might be a viable option to enter the field, rather than being saddled with hundreds of thousands of debt right out the door.
17
Have agreed with this idea for a long time.
5
This would be welcomed by prospective doctors who were interested in healing people rather than making a good living, and such prospective doctors would damage medicine's prospects as a growing and profitable industry. If caring for patients is made unpleasant by paperwork and pressures for increased productivity, doctors will try to escape this situation by moving into managing practices instead of practicing, or by serving the affluent who can afford to pay for customized care.
3
This is called the national health service corps
As long as we have a fragmented, dysfunctional health care financing system, which the Affordable Care Act only perpetuates, the medical industry is going to take care of its own interests first - whatever the market will bear.
If we had a single public purchaser of health care - a single payer system - our public stewards would demand greater value for patients. We would have better allocation of our resources along with more appropriate pricing - goals that other nations have shown can make access universal while gaining better control over global expenditures.
The traditional Medicare program has been more effective than the private insurers in bringing us greater value, but it has no control over four-fifths of our national health care spending. If we improved Medicare and then expanded it to cover everyone, we could greatly improve value, including correcting the deficiencies that Dr. Carroll describes.
If we had a single public purchaser of health care - a single payer system - our public stewards would demand greater value for patients. We would have better allocation of our resources along with more appropriate pricing - goals that other nations have shown can make access universal while gaining better control over global expenditures.
The traditional Medicare program has been more effective than the private insurers in bringing us greater value, but it has no control over four-fifths of our national health care spending. If we improved Medicare and then expanded it to cover everyone, we could greatly improve value, including correcting the deficiencies that Dr. Carroll describes.
27
While mentioned, the issue of student debt was not given the importance it deserves in selecting the type of career a student selects. a person who graduates college at 21 is 30 after medical school and 5 years of residency and fellowship and owes hundreds of thousands of dollars in student debt. This is forced to influence career choice.
Another point, not mentioned, is society's level of respect for each of the medical specialties. Society does not show respect for generalists like it does for neurosurgeons or cardiologists. Physicians who do procedures are more respected than physicians whose practice is cognitive services without procedures. And the procedure-doing doctors get financial rewards much higher than those of the cognitive service physicians.
Until our society addresses the issues of student debt and gives recognition through respect and income to the medical services we say we want and need, these two drivers of medical student specialization will remain.
Another point, not mentioned, is society's level of respect for each of the medical specialties. Society does not show respect for generalists like it does for neurosurgeons or cardiologists. Physicians who do procedures are more respected than physicians whose practice is cognitive services without procedures. And the procedure-doing doctors get financial rewards much higher than those of the cognitive service physicians.
Until our society addresses the issues of student debt and gives recognition through respect and income to the medical services we say we want and need, these two drivers of medical student specialization will remain.
40
MMR, it's hard for the general public to sympathize with physicians who incur debt while going to medical school and training. The average income for new active physicians is in excess of $200,00 a year.
John, those numbers skew high due to outliers. Your average pediatrician or family doc won't even see anything like those numbers even towards the end of their careers. Yes, you will have the odd neurosurgeon skewing the numbers high offset by 9 pediatrician making nowhere near that number. You are taking an numerical average and thinking it is more like a median.
5
Where ? Could I move there?And what is it 5 years later ? 210K or 190K ?
2
In evaluating the "shortage" question, Prof. Carroll might have presented information about relative wages: where do U.S. physicians stand in the distribution of incomes in the U.S., and where do physicians in other OECD countries stand in the range of incomes in their regions? (Some interpretation would be required also.)
7
The New York times investigated this question back in 2009,
http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-othe...
And according to their analysis
"According to this model, the 2007 report says, “The U.S. position above the trendline indicates that specialists are paid approximately $50,000 more than would be predicted by the high U.S. GDP. General practitioners are paid roughly $30,000 more than the U.S. GDP would predict, and nurses are paid $8,000 more.”
http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-othe...
And according to their analysis
"According to this model, the 2007 report says, “The U.S. position above the trendline indicates that specialists are paid approximately $50,000 more than would be predicted by the high U.S. GDP. General practitioners are paid roughly $30,000 more than the U.S. GDP would predict, and nurses are paid $8,000 more.”
They sort of covered that a few years back. To no one's surprise the US is overpaying.
http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-othe...
http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-othe...
Bill, that analysis is very flawed. It does not take two very important factors in play for physician pay which are not issues in any of those other countries. First of all, in almost the entire rest of the world, physician training is low cost or free. Here in the U.S, as noted in this article, physicians are racking up on average six figure debts, with interest and with low salaries unable to repay them, before they even start in practice. Doctors in Europe don't go into practice in their 30s with $180,000 in debt already they have to repay. Also, malpractice premiums are astronomically higher in this country than in any of the others. Renumeration needs to take that into account as well. If you want to pay U.S. doctors like doctors elsewhere in the world, fine- but to get people to be able to afford it, you're going to need to make their college and medical school low cost or free as well as switch to some sort of no-fault payment system for bad medical outcomes.
6
There is no indication of the number of mid-level practitioners in the other comparable nations. Also, saying the US is less efficient with tech in medicine seems bizarre. What other industries is the US lag in tech?
We have all seen many times when physician groups have worked dutifully to keep US physician shortages very high. Clearly for self interested greed. You have not convinced me you are any different.