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Doctors Do it in Debt
January 24, 2013 5:25 AM   Subscribe

American physicians do not make as much money as you think...
posted by Renoroc (87 comments total) 18 users marked this as a favorite

 
In an era of skyrocketing healthcare costs, an increasing need for healthcare services and diminishing resources – Americans need to be cognizant of whom they exploit.

Or maybe higher education is insanely expensive?
posted by Huck500 at 5:36 AM on January 24, 2013 [30 favorites]


The man seems to be unclear about what the word "make" means.
posted by NotMyselfRightNow at 5:43 AM on January 24, 2013 [8 favorites]


First sentence:

Physicians spend about 40,000 hours training and over $300,000 on their education, yet the amount of money they earn per hour is only a few dollars more than a high school teacher.

I'm gonna go out on a limb here and guess that this computation is based on the hours that a high school teacher spends in class. They should have used college professors -- by that standard, I only work 6 hours a week, so imagine how much richer than a doctor I must be!
posted by escabeche at 5:45 AM on January 24, 2013 [37 favorites]


That's some pretty fuzzy math. For instance, his first assumption is that the average student loan debt for a BS degree is $100,000 (which drives a substantial portion of the debt load since that debt accumulates interest charges the longest). However, the actual figures who average student loan debt for 4 year college students is actually $28,000. His numbers appear similarly exaggerated across the board to me.
posted by Lame_username at 5:47 AM on January 24, 2013 [4 favorites]


I'm pretty sure the standard free-market response to any other group of workers bemoaning their low pay and high education debt is "No one forced you to go into that field and take-on debt" or "You should have saved more money to pay for school".
posted by Thorzdad at 5:49 AM on January 24, 2013 [8 favorites]


This is just asinine. This guy is literally taking the most extreme examples imaginable at either end of the spectrum and stretching the truth as far as possible.

You can't use self-reported work hours from surveys of physicians and compare them with an assumption of 40 hours / week (and no supplemental work) for teachers. You can't assume that an average teacher will have a good pension after they retire (and that they will live to 80). You especially can't do that while pretending doctors won't have any form of post-retirement income available to them by virtue of having enough annual income to better invest for retirement.

Well, actually you can, but then you're just gonna look like a whiny asshole who denigrates teachers when you should be making a much more relevant point about the cost of higher education for everyone, as Huck500 pointed out.
posted by graphnerd at 5:50 AM on January 24, 2013 [38 favorites]


Huck500's point is a lot stronger than the article. With the cost of med school so high, not only does it force up the cost of healthcare, but it drives more doctors to higher paid specialties, giving us fewer GPs. I'm prefectly fine with doctors making a lot of money; but it needs to be easier for people to become doctors so we can have smaller practices and preventative medicine again.

The other thing we could take a look at is malpractice reform. (It's the only good Republican idea of the last quarter century.) If this was addressed, malpractice insurance would be less burdensome, allowing for lower medical costs (ideally).
posted by spaltavian at 5:50 AM on January 24, 2013 [8 favorites]


Most medical doctors are not working as scientists, but they are all required to spend a substantial portion of their education in science-oriented (rather than technically-oriented) subjects. The notion that there are no shortcuts is kind of silly, when one considers that in many countries in the developed world medical education starts directly after high school. There is no absolute need for a 4-year university degree before medical training even begins. Graduate school makes sense for the smaller portion of medical doctors who want to do research or join university faculties. Training all of our doctors this way is a waste of time and money, and drives up prices across the board thanks to debt loads.

How about we look into why it costs so damned much to attend medical school, and try to drive those prices down. My thought is that a national health care system wouldn't work without nationalizing medical schools anyway.
posted by 1adam12 at 5:52 AM on January 24, 2013 [24 favorites]


I get the feeling the article author set out to get the doctors numbers as low as possible and the teachers as high.

For instance, it seems a little unfair to count the hours doctors are reporting working, but then glossing over the hours that teachers work overtime because doctors also read medical related material at home.

I've never known a teacher that doesn't take a substantial amount of real, 'needs to be done or you're going to end up fired' work home, yet the article just counts them all as nice 40 hour weeks, upping the hours to 50/wk and the net hourly wage falls to $24.82

Perhaps the bigger question is, why should a teacher be paid less then a doctor?
posted by Static Vagabond at 5:52 AM on January 24, 2013 [8 favorites]


The author isn't wrong, just glosses over areas and does some odd math. It's not an appealing path to be a generalist. When specialists (ex. cardiologists, radiologists, surgeons) can pull double or more of what a general practice/internist makes, I can't imagine who would want to stay as a generalist.
posted by kensch at 5:53 AM on January 24, 2013 [2 favorites]


It's an old blog entry (the only blog entry in the entire blog as far as I can see) written by a doctor who is selling a book about the U.S. medical education system (with a convenient link to the book on Amazon).
posted by pracowity at 5:55 AM on January 24, 2013 [6 favorites]


Yea, the article brings up a point that my uncle once raised to me when there was a news segment on TV about how public/primary school teacher's pay is low compared to other jobs. Basically he was of the opinion that you never hear it mentioned that, while their salary may be low compared to other jobs, they often have summers off, the potential opportunity for extra tasks to marginally increase their pay (one of my instructors drove a bus for example and made extra wages for doing so, or coaching or what not), but (and this is the part that he emphasized) they were always going to have the same off days/work hours (or nearly so for the latter) as their own children. This is in stark contrast to the life my father, grandfather, and uncle lived as they worked in a skilled industrial, albiet unionized, setting and would often have 'outages', planned or not, that required them to work nights or 80 hour weeks or work at another location for months at a time or to be called/paged in at any given hour of the night and, quite literally, forced to come to work.

My dad... he worked hard.* That's not to say that teachers don't but they aren't going to get a phone call at 3am the night before the family vacation saying "We need you to come in. Can you?" and dad asking if they've already went through the entire call-in list hoping they had someone else who wanted the overtime hours so that we didn't lose a day out of our yearly trip to see out of state family.

The article compares teachers to physicians to get their hourly numbers and that's what brought all this to mind, so sorry for the rant. I just wonder how the numbers would look if the author compared physician hourly wage to careers that don't include ~10 week summer vacation and all major holidays off. And it also bears mentioning that teachers aren't like janitors or even my family that has worked in industrial settings, teachers don't necessarily keep their work at work, they may be (read:are) doing work/grading at home. Lord knows MrsEld is doing her fair share of that as she grades undergrads papers in the lab section she's TA-ing.

*Please, I understand teachers are an important and often shat upon role in our society. This comment is really not meant to belittle their salary/job deficiencies. It's an observation that has to be taken as a part of the discussion but shouldn't be used as a justification for the crappy way teachers are all to often treated.
posted by RolandOfEld at 5:56 AM on January 24, 2013 [3 favorites]


The other thing we could take a look at is malpractice reform. (It's the only good Republican idea of the last quarter century.) If this was addressed, malpractice insurance would be less burdensome, allowing for lower medical costs (ideally).

Do you have any good links or suggestions to where I could read up on this? I'm genuinely curious, because when I hear "malpractice reform", I can't help but think of "tort reform", and then immediately write it off as bullshit. Maybe I should reconsider?
posted by graphnerd at 6:00 AM on January 24, 2013 [1 favorite]


while their salary may be low compared to other jobs, they often have summers off, the potential opportunity for extra tasks to marginally increase their pay (one of my instructors drove a bus for example and made extra wages for doing so, or coaching or what not), but (and this is the part that he emphasized) they were always going to have the same off days/work hours (or nearly so for the latter) as their own children.

From my understanding this is emphatically not the case. Teachers work tremendously long hours because teaching isn't about showing up at school and going home, there's a lot of lesson planning and extracurricular work involved as well. The teachers I know were also busy all summer, whether from training courses, teaching summer school, or taking other jobs. I mean, I'm not sure how it's a benefit that you could take a second job in the summer if you have to take a second job in the summer in order to support yourself.
posted by schroedinger at 6:01 AM on January 24, 2013 [13 favorites]


Psst, graphnerd: Previously. (Re malpractice costs among other topics)
posted by ActionPopulated at 6:02 AM on January 24, 2013 [1 favorite]


I suppose if the best educated and traditionally highly compensated professions in an industry that is consuming enough GDP to cause political squeals about it consuming more than 100% of GDP(o' hopeless future!) are getting a stiff rogering from this brave new unfair world, then us coal mining ordinarys might as well line up to be shoved into the protein vats today.

And malpractice reform doesn't lower malpractice insurance rates.
posted by dglynn at 6:02 AM on January 24, 2013 [3 favorites]


In the US you have to do a 4 year Bachelor BEFORE you start Studying Medicine? Thats just crazy!

In Australia Medicine is long but you don't have to do a Bachelor Degree beforehand.
posted by mary8nne at 6:03 AM on January 24, 2013 [3 favorites]


but (and this is the part that he emphasized) they were always going to have the same off days/work hours (or nearly so for the latter) as their own children.

My kids are off school tomorrow. The teachers are doing some sort of catch-up or professional development day. The teachers were working over Winter Break as well. They'll be working in June after the kids are gone, and in August to get ready to meet them at the door.

Old Army joke: What's the hardest job in the Army? Mine. What's the easiest job in the Army? Yours. The weird thing is, it works no matter who I'm talking to. Everybody's job is always easier than mine, because I have no idea what they really do.
posted by Etrigan at 6:04 AM on January 24, 2013 [33 favorites]


I noticed that he assumed that the BA's would be paid for mostly by loans. However, many (if not most) of the pre-med students I've met have various merit, minority and needs-based scholarships.
posted by oddman at 6:05 AM on January 24, 2013


I'm just tired of the argument "well I get paid a lot because my school was expensive and my job is hard."

I know a lot of people who can say that that get paid less than $50,000 a year (plus or without benefits), which for wealth is really what matters - how much a worker can actually bring in per year. Hourly compensation is a ridiculous model for any comparison of salaried vocations. If you make twice as much as me and work twice as many hours, you still make twice as much money as I do, so don't tell me we're paid the same.
posted by illovich at 6:05 AM on January 24, 2013 [8 favorites]


Fuzzy math and quasi-denigration of teachers aside, I think he makes a point that alot of kids don't realize: That being a doctor is not an easy ticket to never have financial worries, and it's alot more than counting the number of zeroes after your 10 years of training.

There's a whole industry, from banks to medical schools, to licensing bodies that thrives off of pricing EVERYTHING, textbooks, licensing exams, equipment, based on the assumption that you'll be making the big bucks later.

Just this week, in Canada, is the beginning of the "match interviews" where fourth year medical students go to respective schools to interview for their residencies. People spend two weeks flying from vancouver, to newfoundland, back to manitoba, then ontario, going to 15-20 interviews and I've heard people spending 20-30000$ on flights and accomodations alone. Its just implicit that, since they are going to be the future 1% or whatever that its pennies.

Which is fine, if you're going to be an interventional cardiologist or a plastic surgeon or do Lasik MD. But that doesn't make a good health care system.
posted by cacofonie at 6:06 AM on January 24, 2013 [6 favorites]


graphnerd: "The other thing we could take a look at is malpractice reform. (It's the only good Republican idea of the last quarter century.) If this was addressed, malpractice insurance would be less burdensome, allowing for lower medical costs (ideally).

Do you have any good links or suggestions to where I could read up on this? I'm genuinely curious, because when I hear "malpractice reform", I can't help but think of "tort reform", and then immediately write it off as bullshit. Maybe I should reconsider?
"

We had this discussion a while back. I seem to recall that despite what some people claim, malpractice costs aren't really that burdensome for a business. Another number that sticks in my brain is something like 1000 malpractice judgments in the state of California per year (no source) - which isn't bad at all. Just a convenient strawman.

Even if malpractice were ten times as much, it still would pale next to the cost of overhead - a doctor's office has something like 6 office workers doing medical billing per doctor. All that overhead, just to code and bill the insurance companies, and then all that overhead on the insurance side, trying to deny claims...
posted by notsnot at 6:06 AM on January 24, 2013 [6 favorites]


I mean, I'm not sure how it's a benefit that you could take a second job in the summer if you have to take a second job in the summer in order to support yourself.

Right, the salary should be able to be lived upon without this being necessary. There are plenty of examples that can go either way, I knew teachers in high school (not rich Alabama if that matters) who didn't need to do what you're saying to stay off food stamps over the summer, but yes, I agree with what you're saying.

The teachers are doing some sort of catch-up or professional development day. The teachers were working over Winter Break as well. They'll be working in June after the kids are gone, and in August to get ready to meet them at the door.

I know there are workdays, I'm really not belittling it. I'm just saying that, from his point of view which I don't see as completely invalid, how many Christmas mornings have the teachers at your school missed because they were at workdays? I remember multiple times dad couldn't make it. That's a perk for one career path and a downside for another. That's all I'm saying.
posted by RolandOfEld at 6:08 AM on January 24, 2013


This has been making the rounds among my med school classmates. While I'm obviously sympathetic to the argument and will be paying off my anticipated $300,000 loan debt well into my forties, Dr. Brown provides some misleading information about the availability of loan repayment programs. Even if a physician can't be placed by the military, even if they don't want to go serve out in Indian Country, or at a VA hospital or public health clinic, or out in the private sector, there's still the Public Service Loan Forgiveness program, in which anyone working for a decade at any of these places: "federal, state, or local government agency, entity, or [501(c)(3)] organization or a non-profit...[or] emergency management, public safety, public health services, public education..." gets their loans cancelled after making 120 on-time monthly payments.

As a practical example, let's say that I earn $47,000/yr during residency and make income-based repayments for those three years, then take a job as a family med doc in a FQHC with a salary of about $100,000/yr (starting salary for 0602 GS-13) and continue to make income-based payments on my loans for the following 7 years. All told, I'll pay back about $160,000 of my $300,000 loans before the 120-payment plan kicks in and erases all the remaining debt. Not such a bad deal after all. Hell, if all goes according to plan, I'll be able to retire by the time I'm 68 or so.

But more importantly, I think there's a *reason* why this guy conveniently glosses over the service-based repayment programs: they're tied to some of the lowest-paid physician jobs in the country, and many of my colleagues feel that the work is below them. They don't like that generalists aren't highly-respected in the field. They don't like managing chronic conditions. And they don't like the "puny" salaries. This last part is the important part-- while I don't have any good data to back me up on this, I suspect that none of my colleagues have thought critically about exactly how much money they will need in life to achieve their personal goals, so they make ridiculous off-the-cuff estimates and use those to guide their decisions when it comes time to apply for residency. This leads to a nation of supersubspecialist doctors who have an aversion to service and more money than they know what to do with.
posted by The White Hat at 6:09 AM on January 24, 2013 [22 favorites]


You can't use self-reported work hours from surveys of physicians and compare them with an assumption of 40 hours / week (and no supplemental work) for teachers.

I'll go ahead and make the stronger statement:

When you assume that teachers work 40 hours a week, and that teachers don't work during summer and "break" periods, and that teachers' educations cease at a BA, that makes you what is technically known as an "asshole."
posted by ROU_Xenophobe at 6:15 AM on January 24, 2013 [38 favorites]


That's a lot of writing. The author could have just said, by your early to mid 30s, a trained cardiologist or surgeon will make 300k-400k/yr, with more in more difficult subspecialties and less in more general fields, with adjustments for competition and overhead of your practice, but will almost certainly put you in the top 5% of wage earners and in many cases the top 1%. And there is zero risk of layoffs or extended periods of unemployment.

Certainly when reading things like this, it is helpful to remember the mantra "someone's biggest problem is their biggest problem" in order to have empathy for the writer, but their problems are things along the lines of not making as much money as they expected to make, having to deal with compliance paperwork, seeing their friends who went into finance making more money, etc. The idea that people who have regular jobs face much greater challenges to their economic security, earning power, and personal health doesn't even occur to them, because they have no idea how that works.
posted by deanc at 6:17 AM on January 24, 2013 [13 favorites]


I'm just saying that, from his point of view which I don't see as completely invalid, how many Christmas mornings have the teachers at your school missed because they were at workdays? I remember multiple times dad couldn't make it.

This manages to be both goalpost-moving and cherry-picking, you realize. In one exchange, you went from "they were always going to have the same off days" (your/your uncle's emphasis) to "how many Christmas mornings". You narrowed your comparison from approximately 185 days (the average in the U.S. is 180 days per year in school) to one. More accurately, rather than moving the goalpost, that's insisting the kicker has to hit the inside half of the left upright.
posted by Etrigan at 6:17 AM on January 24, 2013 [4 favorites]


I would love to see the same arguments made with greater honesty and I have a feeling some of the writer's points will be valid - even if not the overall one that a physician makes as much as an average high school teacher.
He chooses California which has one of the highest state income taxes.
As noted before, he chooses a specialty that is not among the most highly paying.
He kerjiggers the numbers for how many hours teachers and physicians work.
He seems to think that doctors' conferences are work and not a perq.

I would submit as proof - look at the houses doctors live in and then compare them to the houses teachers live in.
posted by dances_with_sneetches at 6:23 AM on January 24, 2013 [16 favorites]


I'm a physician and I agree with pretty much all of the criticisms voiced in this thread. If you ever catch me whining about how much I make feel free to call me out on it.
posted by TedW at 6:31 AM on January 24, 2013 [10 favorites]


If you're going into medicine, please please please do yourself a favor and find a specialty you like and can get into. GPs work ridiculous hours for comparatively little pay. Yes, there need to be GPs, but unless getting up at 5a and getting home from the office around 9p sounds like a pretty great workday (I know two GPs and that's how both of them live), find something with better hours or it'll eat your life and you'll make less than you might otherwise.

Both of the GPs I know are transitioning out of it (one to aesthetics, one to some private practicewhose details I forget).
posted by Pope Guilty at 6:32 AM on January 24, 2013


I think part of his point, dances_with_sneetches, is that going into medicine used to be extraordinarily profitable and stable until the last decade or so, and that while doctors used to be able to live quite well, that is changing. That was due to a lot of different things, but one of the most significant changes has been the slashes in reimbursement to doctors for doing their job of keeping healthy people healthy, and they are then forced to medicate or diagnosis healthy people as sick in order to make rent.

Then you have the secondary problem of tuition and loans. Currently my federal loans are for 200k at 8.5 %, which is ludicrous. Then you have a mandatory period of up to ten years as a resident/fellow where you are earning just enough money to live on (my cousin in Puerto Rico only made 23k his first year of residency) while the interest piles on, higher every year. So the 200k turns into 500k. Things weren't as bad a decade ago when tuition was cheaper and federal loans were 2-3%. Which they should have remained at given the repayment rate is something like 98%

Sure there's loan forgiveness programs but there's no guarantee they will still be around when I complete their requirements, or that Sallie Mae will somehow lose one of the payments and negate the whole thing due to their standard incompetence.

I lost a lot of faith in the Obama administration when they attempted to reform student loans but kept Sallie Mae on as their loan processor, and my interest stayed pegged at 8.5. Maybe it was because I don't generally have enough free time to pay attention to politics, but it was at that point I realized it was all a show, the same people are still running things.

Obligatory infographic comparing the mafia to Sallie Mae
.
posted by hobo gitano de queretaro at 6:33 AM on January 24, 2013 [8 favorites]


conveniently glosses over the service-based repayment programs: they're tied to some of the lowest-paid physician jobs in the country, and many of my colleagues feel that the work is below them

That's not it. It is that the benefit of joining these repayment programs is low compared with simply specializing in a high-compensating field. Sure, you can get your loans paid off by doing primary care in an undeserved region. But you can also pay off your loans by going into orthopedic surgery, which has the benefit of leaving you with a lot more money left over after your loans are paid off. Do the math.

These sorts of incentives to work in an underserved area ARE very valuable to foreign-educated doctors for whom the opportunity to practice in the USA is worth a huge amount in additional lifetime earnings, so THEY are willing to do it. For most everyone else, unless you have a particular passion for primary care, it doesn't make any sense.
posted by deanc at 6:35 AM on January 24, 2013


This manages to be both goalpost-moving and cherry-picking

Right, I'm saying teachers should make poverty wages and have fewer off days. As you state but fail to delineate from my own (probably my fault), that was the opinion of the relative, mine isn't exactly in line but I see where outsiders can have that logic, denying that or calling it unfair isn't going to get anywhere when you're talking about the perception of teacher's job which leads (in the most convoluted way possible) to their salary. Also denying that there are perks along with the rubbish that comes with a teaching job makes it a frustrating task to say "Hey, let's look at this from all angles."

Anyway, I said all that once or twice above and it was discarded or unclear so I'll let the discussion go back to the whole "Physicians have it so bad a comparison to teachers is justified."
posted by RolandOfEld at 6:40 AM on January 24, 2013


When I meet a doctor raising their children in a 1 or 2 bedroom apartment, or unable to afford a car, I'll start worrying about them.

I've been really pissed off by some MDs complaining about how "little" they make. One went on and on about how she was really only paid $1 or $2 an hour during her residency, until her husband pointed out that was her hourly rate in addition to her yearly salary. Sure, residents don't make much, but between her salary and his (he had maybe $50k/year), they were still able to afford to buy a house before they were 30, maintain 2 cars and do multiple overseas vacations per year. They felt poor because they knew people in the top 5% of incomes, but they were already living a very middle class lifestyle. They are now the richest people I know under 50, and finally realizing that their "money problems" are really more an issue of "spending problems".
posted by jb at 6:43 AM on January 24, 2013 [7 favorites]


If we could turn this thread into pitchfork waving about Sallie Mae that'd be great kthnks.
posted by Potomac Avenue at 6:44 AM on January 24, 2013 [1 favorite]


With the cost of med school so high, not only does it force up the cost of healthcare, but it drives more doctors to higher paid specialties, giving us fewer GPs. I'm prefectly fine with doctors making a lot of money; but it needs to be easier for people to become doctors so we can have smaller practices and preventative medicine again.

Don't we already do that, except we call them nurse practitioners and physician assistants?
posted by ROU_Xenophobe at 6:44 AM on January 24, 2013 [5 favorites]


being a doctor is not an easy ticket to never have financial worries,

But that is simply a fact of human nature: everyone has financial worries. The act of having more money simply gives you a greater number of things to worry about. You won't "feel" less worried, and "money doesn't make you happy" will always apply. But a lot of financial concerns grappled with on a regular basis by a system administrator or HR administrator don't exist for people in medicine.

What is striking is, honestly, how non-monetary the concerns of doctors are, in the same way that teachers' complaints are frequently not about money. The concerns are about lack of professional autonomy, a workload that has a larger and larger component that is not about their "core duties", etc. It gets couched a lot in issues about money, but to a large degree it is about their professional class expectations.
posted by deanc at 6:47 AM on January 24, 2013 [2 favorites]


I make $16.25 per hour and never complain despite living in one of the most expensive cities in the world. Please go eat a huge butt.
posted by Mooseli at 6:55 AM on January 24, 2013 [13 favorites]


I'm afraid I don't have much sympathy for the doctor. Sure, it costs a lot to be educated as a doctor, and it's a lot of work. But the system is set up to let them rake in mega cash later on.
Case in point, last year, I scheduled my annual physical with my GP. At one point, that one physical was going to require SEVEN separate visits, to either my doctor or the lab (this is illegal where I live, by the way). She would have been able to charge for every single visit, since they were all separate, and this is for a routine thing that should have taken one visit. She eventually cut the visits to three, after an article in the local paper appeared decrying the practice of multiple visits for a single issue.
posted by LN at 6:55 AM on January 24, 2013 [1 favorite]


my wife, the teacher, got up at 6 am yesterday, was at her school by 7 am, she left school 9 hours later, came home, sat down and started grading papers. She took 20 off to eat dinner, went back to grading and planning, she came to bed at midnight and got up this morning a half hour earlier than usual to meet with some struggling students. This is her normal day. 40 hours per week? bullshit!

Let me add that her district, next year, will be cutting her pay by 20% and increasing, by about 15% the amount she needs to contribute to her health care benefits and retirement.
posted by HuronBob at 6:58 AM on January 24, 2013 [10 favorites]


All I know about teachers is that they would often die earlier than other professions, due to the stress of teaching (this has been reduced since early retirement became more common).
posted by jb at 6:59 AM on January 24, 2013


Modern medical science has proven that people have an infinite capacity for feeling sorry for themselves.
posted by miyabo at 7:01 AM on January 24, 2013 [2 favorites]


I was in school for much longer than a MD to get my PhD and my career prospects aren't as good, especially seeing that a lot of research jobs are getting outsourced, and tenure track jobs are made out of unobtanium.
posted by koolkat at 7:07 AM on January 24, 2013 [4 favorites]


Nice chart. Now lets see you do it for a Physics PhD, or an elementary school teacher, or pretty much anything that requires obtaining a college degree today. That chart should be plastered on the first page of the admissions form for prospective students.

"This is you. This is a big hole. Wouldn't you prefer to be a journeyman electrician or plumber?"
posted by Xyanthilous P. Harrierstick at 7:09 AM on January 24, 2013 [6 favorites]


I'd be the first to agree that the US system for training physicians is deeply flawed at every level (and further note that this is precisely why professions like nurse practitioners and physician assistants are burgeoning). The article though just seems... whiny, for all the reasons everyone here has pointed out. Even with massive debt, most physicians can in no way be considered poor.

The article also leaves out part of the picture as well. While maybe not every poor beleaguered GP has the chance, there are numerous opportunities for physicians to supplement their income. Maybe I'm biased by sitting on my institutions conflict of interest committee, but I see physicians making thousands in fees for speaking/consulting on work they're already doing or products they're already using, earning early retirement level royalties/licensing fees from inventions whose development was supported by federal grants, or earning money on the side from start-ups (also supported by federal grants). And that's just from the small selection I see as a result of them conducting research.

So yeah, I have sympathy for prospective docs having to run a gauntlet through a broken system, but those article is less than convincing.
posted by Panjandrum at 7:18 AM on January 24, 2013 [1 favorite]


Whiny or not.

There is *nothing* good about what the modern health insurance industry has done to health care. Weep for the Doctors, Weep for the Patients. The Shareholders are doing okay though.
posted by DigDoug at 7:20 AM on January 24, 2013 [2 favorites]


Teachers have had unions, and unions that have been willing to haul the mail, for decades. Doctors - no unions to speak of. This is my shocked face. :|

(Not really.)
posted by newdaddy at 7:21 AM on January 24, 2013


Rarely is the question asked: Is our doctors earning?
posted by blue_beetle at 7:23 AM on January 24, 2013 [8 favorites]


graphnerd: "You can't assume that an average teacher will have a good pension after they retire (and that they will live to 80). You especially can't do that while pretending doctors won't have any form of post-retirement income available to them by virtue of having enough annual income to better invest for retirement. "

What are you talking about? A defined-benefit pension such as most teachers/firefighters/police officers get is a huge benefit, and should absolutely be accounted for when you are figuring total compensation.

I have a buddy who is a surgeon at Kaiser. He may retire after 30 years of practice with a yearly pension of 50% of his annual pay. He makes less working for Kaiser than he might make in private practice, but that defined-benefit pension adds substantially to his total compensation. In essence, it's an annuity.
posted by etherist at 7:23 AM on January 24, 2013


If you're going into medicine, please please please do yourself a favor and find a specialty you like and can get into. GPs work ridiculous hours for comparatively little pay. Yes, there need to be GPs, but unless getting up at 5a and getting home from the office around 9p sounds like a pretty great workday (I know two GPs and that's how both of them live), find something with better hours or it'll eat your life and you'll make less than you might otherwise.

This is one of those "individual choices, systemic failure" things, isn't it? Sounds like a case of the perverse incentives.
posted by the man of twists and turns at 7:26 AM on January 24, 2013 [1 favorite]


To be honest I only skimmed the article. Many comments are saying the figures are a little high. Even if this is the case the cost and time involved to be a doctor are still high, which has led many med students to pursue careers in surgery in order to make more money. Surgeons are absolutely necessary but this has led to a shortage of general practitioners. A single payer system would help to alleviate some of these problems. The education costs wouldn't have to necessarily come down. As with many teachers, the loans could be forgiven after a number of years of service. The doctors would not have to dedicate as much time and energy into billing and collection. Being that they would be government employees, the legal standard for negligence would be raised. This would get rid of doctors paying for malpractice insurance.

On another note, it not as easy as many people think to file and win (or settle favorably) a malpractice case. In order to do so one would would need another doctor to assert that there was malpractice. Most doctors would not be willing to tarnish there reputation to back up a frivolous claim. It still might be difficult to find a doctor to back up the claim if the malpractice is not absolutely clear. Insurance companies also defend these cases vigorously and are very successful in doing so.
posted by blairsyprofane at 7:39 AM on January 24, 2013 [1 favorite]


etherist: Maybe graphnerd was talking about the fact that there have been some news hits in the last few years about how several teacher's pension plans have went bust, see promised benefits decrease, or been cut out from under them by the state for various sundry reasons. I won't post any links but it seems like I've heard of a few and googling for 'teachers lose pension' didn't come up dry.

I guess you could say that pension cuts or removal, through no fault of the employee, is just as likely for your doctor friend as it is for teachers. Maybe it is and the teacher's stuff just makes the news more, I really don't know but maybe that explains what graphnerd was getting at.
posted by RolandOfEld at 7:39 AM on January 24, 2013


Breathe deeply ...
posted by Kabanos at 7:39 AM on January 24, 2013


You can't assume that an average teacher will have a good pension after they retire (and that they will live to 80). You especially can't do that while pretending doctors won't have any form of post-retirement income available to them by virtue of having enough annual income to better invest for retirement.

What are you talking about? A defined-benefit pension such as most teachers/firefighters/police officers get is a huge benefit, and should absolutely be accounted for when you are figuring total compensation.


Before you make this assumption, you have to find out how many teachers actually end up receiving the pension. For instance, the 50 percent retirement pay for U.S. military service members is a great perk -- for the 17 percent who make it to 20 years and are therefore eligible. For the other 83 percent who don't cross that magical line, the pension is worth precisely zero.
posted by Etrigan at 7:42 AM on January 24, 2013 [1 favorite]


they're tied to some of the lowest-paid physician jobs in the country, and many of my colleagues feel that the work is below them

That's not it. It is that the benefit of joining these repayment programs is low compared with simply specializing in a high-compensating field. Sure, you can get your loans paid off by doing primary care in an undeserved region. But you can also pay off your loans by going into orthopedic surgery, which has the benefit of leaving you with a lot more money left over after your loans are paid off. Do the math.


Indeed. A specialist's lifetime earnings can be between $1–3 million more than a GP's.
posted by Kabanos at 7:58 AM on January 24, 2013 [1 favorite]


but (and this is the part that he emphasized) they were always going to have the same off days/work hours (or nearly so for the latter) as their own children.

You have obviously never spent a lot of time with a competent teacher. Unless they're only using canned lesson plans, putting little to no effort into tailoring them to their students, and have TAs to do all their grading, these "days off" you speak of are when teachers get their grunt work done.

Sure, my dad got summers off. But except for the occasional road trip, he spent every day of those summers reworking his lesson plans for the next year, writing textbooks for courses that didn't have any good materials available, going to educational conferences, and the like.

During the school year, I'm sure he did enjoy all those public holidays - because that meant he could do his grading during the day instead of spending 3-4 hours on it after dinner almost every night, since all his free time during the day was spent doing impromptu tutoring sessions with confused students.

And the real kicker is that my first job out of college paid better than his current salary, and he's been at the school's salary cap for years.

You don't go into teaching for love of money or vacation. At best, teaching could be considered a 25% telecommute position. But 3 months off? Ha.
posted by chundo at 8:01 AM on January 24, 2013 [3 favorites]


A defined-benefit pension such as most teachers/firefighters/police officers get is a huge benefit, and should absolutely be accounted for when you are figuring total compensation.

Are you talking about the pension plans that went unfunded by cities without any repercussion, leaving the teachers without their money? Or the the pension funds that were raided by politicians looking to shore-up budget shortfalls, again leaving the teachers without funds? Or, maybe, you're referring to the pensions that were unilaterally converted to 401Ks by union-busting legislators?
posted by Thorzdad at 8:25 AM on January 24, 2013 [3 favorites]


Even if we were to accept that malpractice insurance rates are really the most important factor in how expensive health care is, malpractice/tort reform really doesn't do much to help there.

Most people who file malpractice suits do so because they have medical bills they can't pay. The quickest and most effective way to keep medical malpractice insurance premiums low is sensible, accessible universal health care.
posted by asperity at 8:27 AM on January 24, 2013 [2 favorites]


Believe it or not, the amount of money reaching a physician’s personal bank account per hour worked is only a few dollars more than that of a high school teacher.

Can you see my skepticism over the internets? As they say, figures always lie and liars always figure.
posted by caddis at 8:28 AM on January 24, 2013 [1 favorite]


This report suggests the following lifetime earnings:

Elementary and middle school teachers: $1.7–2.1 million.
Postsecondary teachers with doctoral degrees: $2.8 million.
Physicians and Surgeons: $6.1 million.

I think that more than makes up for the additional debt burden of doctors.
posted by Kabanos at 8:31 AM on January 24, 2013 [8 favorites]


Yeah, why medical school requires a B.A. in the sciences in the USA is not 100% clear to me. Taking people directly from high school as in the UK would eliminate a ton of debt for future doctors and would get them into their careers four years sooner on top of that. As a side benefit, it would cut way down on the number of disaffected premeds universities would have to force to pretend to care about science.
posted by en forme de poire at 8:31 AM on January 24, 2013 [2 favorites]


Yeah, why medical school requires a B.A. in the sciences in the USA is not 100% clear to me

It didn't always. You could get the science prereqs done in 2 years and then go to med school, adding up to about the same time as it takes if you go directly from high school. But with increased competition, you have people with a BSc or a MSc competing with someone who has taken 20 university courses and it's not hard to guess who will be accepted. It's the same kind of creep as "jobs that used to require a high school degree now needing a university one, jobs that required a bachelor's now requiring a master's".

Incidentally, there are a few places here that take you into a premed/prelaw program 1 year after HS (US equivalent, anyways) with 1 year of prereqs only, and the students there are generally poorer students in that program, because they have less experience, are less sure of what they want, etc. There are some upsides to taking a bit longer to get into medicine.
posted by jeather at 8:45 AM on January 24, 2013


that doesn't make a good health care system

My girlfriend is going to be going to med school, and as far as I can tell nothing about the way things are handled in the US makes a good health care system. Aside from the absolute asininity of the insurance system and the already-addressed and rather nonsensical requirement of an undergrad degree, med school itself doesn't even make much sense. Why is it a four-year program? Both my father (an MD) and her father (an MD) say that they don't even remember and have never used a good 75% of what they learned in med school. It's a grueling program for what amounts to no good reason at all, when what should probably happen is a one-year general program to expose you to the various types of medicine that are done, followed by a more extended specialist training/residency at a teaching hospital somewhere that does what you want to do well.
posted by adamdschneider at 8:48 AM on January 24, 2013 [1 favorite]


Thorzdad:
"Are you talking about the pension plans that went unfunded by cities without any repercussion, leaving the teachers without their money? Or the the pension funds that were raided by politicians looking to shore-up budget shortfalls, again leaving the teachers without funds? Or, maybe, you're referring to the pensions that were unilaterally converted to 401Ks by union-busting legislators?"

While there is a public pension crisis in the US for just the reasons you describe, how many teachers have been shafted out of a pension because the money wasn't there? Very few. Sure, it could still happen in the next several years, as cities start to declare bankruptcy.
posted by etherist at 9:18 AM on January 24, 2013


Kabanos & Pope Guilty: "That's not it. It is that the benefit of joining these repayment programs is low compared with simply specializing in a high-compensating field. Sure, you can get your loans paid off by doing primary care in an undeserved region. But you can also pay off your loans by going into orthopedic surgery, which has the benefit of leaving you with a lot more money left over after your loans are paid off. Do the math.

Indeed. A specialist's lifetime earnings can be between $1–3 million more than a GP's.
"

Right. I'm aware of the numbers. My point is that my colleagues are not, and that their failure to think economically, not only about how much money they are going to make but also how much money they're going to need, results in their choosing supersubspecialties instead of primary care positions-- that their unfounded fear of financial struggle causes them to make decisions that needlessly boost income.

This is all perpetuated by articles like this and incomplete financial aid seminars that focus on getting students to understand the amount of debt they're incurring without also helping them realistically estimate living expenses (house, kids, car, college savings account, retirement planning). In order to make good, rational decisions, that information has to be made explicit. I can't speak for all med schools, but I can tell you that mine does not do a very good job of training people to understand all that.
posted by The White Hat at 9:22 AM on January 24, 2013 [2 favorites]


Yeah, why medical school requires a B.A. in the sciences in the USA is not 100% clear to me. Taking people directly from high school as in the UK would eliminate a ton of debt for future doctors and would get them into their careers four years sooner on top of that. As a side benefit, it would cut way down on the number of disaffected premeds universities would have to force to pretend to care about science.

On the flip side of that equation is that I have had an NHS doctor practically leap behind his desk because he was afraid he would catch shingles from me and he didn't even know that it was a second stage chicken pox infection when I tried to talk to him about it. Fortunately his computer system could tell him what to prescribe. My NHS experiences while 'free' in a tax supported sense were almost universally poor in a way that my experience of Canadian healthcare was not.

UK medical training is also criticized by other EU members such as France and Germany who have been seeking legislative means to declare the degrees non-equivalent like the US does to third world degrees.
posted by srboisvert at 9:27 AM on January 24, 2013 [2 favorites]


There are some legit complaints here, even if he fudges the numbers almost as badly as the "poor" University of Chicago prof. a couple years back.

One of the things that we can do is reset the income tax brackets — we haven't adapted them for inflation. Adding more brackets and pegging them higher would be both more progressive and start to deal with some of the tax distortions that folks like this complain about.

Another thing we can do is to accredit more medical programs. One of the reasons why the costs have skyrocketed is that the finite number of medical programs have no real incentive to charge less, and the applicant pool far outstrips the amount of slots. I don't recall off the top of my head who the accrediting body is for med school (AMA?), but I do know that they haven't kept pace with the population increase in terms of number of doctors graduated.

Something else that may be worth pursuing is taking some pages from the Cuban training model, where doctors from any state school (which, in Cuba, is all of them) are assigned for at least a year to wherever the state needs them most, i.e. generally lower income areas. That, combined with the emphasis on preventative care, does cut health care costs substantially throughout the system. Give doctors a modest stipend and cut a significant amount off their debt for doing it (and don't just send them to the Res), and you could make this a requirement for doctors from all state programs.
posted by klangklangston at 10:13 AM on January 24, 2013 [1 favorite]


Who are all these people who can afford to retire at 65?
posted by Obscure Reference at 10:14 AM on January 24, 2013 [1 favorite]


srboisvert, I don't contest your experiences (and that is pretty lol/sad-worthy right there, jesus) - but is the overall standard of care in the UK appreciably lower than in, say, the USA? I haven't found anything to support that so far.

French medical school seems like a way longer road but also unbelievably cheap, which would certainly be another route forward - sadly also one that may be unlikely to gain traction stateside. (Not that up-ending med school requirements would be much more likely, of course.)
posted by en forme de poire at 10:14 AM on January 24, 2013


Why should calculus have anything to do with what med school you get into? Again according to the two doctor fathers, it has fuck all to do with being a doctor. Just more gatekeeping.
posted by adamdschneider at 10:17 AM on January 24, 2013 [1 favorite]


The stereotype of premeds who are grade-grubbing grinds without any intellectual interest in their required coursework is just that, a stereotype. There is some truth to the idea that to be successful in applying to and completing med school, and then transitioning to a successful medical career, pre-med have to have a mix of hard and soft skills, prioritize a number of different activities, and work quite hard. If that annoys you because doctors enjoy high status but can't exist solely in the realm of intellectual pursuits, nobody cares.

This article is a bit whiny, but at the end of the day doctors have a great deal of control over how they practice and are generally quite well-compensated. The people that are really hurt by the current structure of medical education and the debt it entails are the poor and those with chronic, complex illnesses. Patients with a complex picture deserve a fully-trained primary care physician who specializes in "complex care", which requires more training than even the best PAs and NPs can provide. Primary care is a mix of routine preventitive care, simple to complex diagnostic work, and balancing multiple priorities in a way that best serves the patient in the current health system. This is the kind of work that intuitively appeals to a great number of our best and brightest students but is not adequately rewarded even with loan repayment programs that are available.
posted by fraxil at 10:21 AM on January 24, 2013


The stereotype of premeds who are grade-grubbing grinds without any intellectual interest in their required coursework is just that, a stereotype.

Wait, have you not met them? I've met lots of those people. They aren't, as a whole, the ones who end up getting into med school, but they actually exist. (You don't notice the other ones so much because they aren't irritating assholes.)
posted by jeather at 10:25 AM on January 24, 2013 [1 favorite]


When will Watson become board certified as an internist/GP? With the advances in robot surgery and telepresence how long before health care becomes automated? Doctoring can go back to what is best suited for providing assurance by ritual. The human body is afflicted by thousands of ailments that have specific causes unfortunately there are a limited number of symptoms that are unique to any specific illness. Much of medical practice is playing the odds that the body is a self regulating biological system capable of "curing" itself of a large number of the ailments that humans seek relief from. The most cliched doctor's advice is often the right one... 'Take 2 aspirin and call me in the morning'. Time is the best healer. What people often need is a dose of feel good mixed with distraction the typical Haitian Voodoo ceremony fits the bill nicely.
posted by pdxpogo at 10:29 AM on January 24, 2013


Why should calculus have anything to do with what med school you get into? Again according to the two doctor fathers, it has fuck all to do with being a doctor. Just more gatekeeping.

It's because no one going anywhere near scientific classes should do so without understanding calculus. It is a staple of college level science work. It is true that outside of radiation oncology, doctors don't use math in their day-to-day work, but it is a necessary foundational work. You always need to understand something at one or two levels deeper than you actually use it. When was the last time an academic computer scientist used the "mechanics" units of his Physics classes from undergrad? Probably not anytime recently.

That said, in an earlier era, surgeons were not physicians in the traditional sense-- they were the plumbers of the body, and required less background training. But since we have merged surgical training into the rest of the physician, they learn a lot more than they strictly "need" in their day to day lives.
posted by deanc at 10:38 AM on January 24, 2013 [2 favorites]


The stereotype of premeds who are grade-grubbing grinds without any intellectual interest in their required coursework is just that, a stereotype.

I dated a premed in college for a year plus, lived with a different one for two years, was friends with a lot of their premed friends, etc. Not all of the premeds that I knew were grade-grubbing grinds without any intellectual interest in their coursework...but most of them sure were.
posted by Kwine at 10:47 AM on January 24, 2013


Etherist:

More than anything I was objecting to the bullshit back-of-the-envelope pull-numbers-from-thin-air aspect of it all. Assuming that average teachers will retire at 65 and live to 80, on the one hand and ignoring retirement accounts typical of high income earners on the other.
posted by graphnerd at 11:53 AM on January 24, 2013


"The stereotype of premeds who are grade-grubbing grinds without any intellectual interest in their required coursework is just that, a stereotype"

Heh, god love 'em, but having a girlfriend who has graded pre-med (and med and pharm) students for nigh on six years now, it certainly describes enough of them to use it to describe all of them. (Now, sampling bias, sure, as the ones that my girlfriend deals with when they come to complain about her grades are by definition the grubbers, but there are enough and they're petty and self-centered enough, that I don't feel too bad about recognizing the med students who don't do this as the exceptions.)
posted by klangklangston at 12:11 PM on January 24, 2013


One reason to make doctors take calculus is so that they don't waste time reinventing Calculus II techniques.
posted by Elementary Penguin at 12:26 PM on January 24, 2013 [8 favorites]


The problem is not so much that the stereotype defines every pre-med - I know several people who were pre-med and also honestly engaged with the work they were doing in college - but that the ones who do fit the stereotype have an outsize and negative effect on the culture of the department. And I mean, it makes sense: for future doctors, your entire earning potential for the rest of your life hinges in large part on how many As you get in undergrad (not true for life scientists), so of course that's what at least some people are going to optimize for. It's also true that no practicing doctor really needs a command of e.g., organic chemistry -- what, are you going to go into the back and rotovap something for me? -- so you can imagine why the focus is on getting through it rather than understanding it. Some profs have actually tried to create new curricula which are more rigorous and harshly graded in order to select out people who are optimizing for GPA, but it's of course an imperfect solution, especially compared to having a separate medical track, and only one that can be implemented at colleges with a lot of resources. Plus there's the eternal Impressiveness Treadmill. (Anyway, bigger problems of course exist in medicine, science, and education, but I think it's still worth a small amount of complaining about. And OK, now I'm done.)
posted by en forme de poire at 1:03 PM on January 24, 2013


One reason to make doctors take calculus is so that they don't waste time reinventing Calculus II techniques.

But...this person is a doctor. In America? So, probably they were forced to take Calculus? So...I guess it didn't do any good.
posted by adamdschneider at 1:18 PM on January 24, 2013


You can definitely make it to med school without taking integral calc.
posted by en forme de poire at 3:45 PM on January 24, 2013


Also while that paper is funny as hell, I should point out that the author is not actually a doctor.
posted by en forme de poire at 3:47 PM on January 24, 2013


Has the process for training doctors remained consistent with our current understanding of skills attainment and subject mastery? It seems like we are still following the basic outline developed in an era before computer simulations and when we had a very different understanding of pedagogy. It is possible that this has resulted in a system that is inefficient and results in a significant shortage if trained workers. Furthermore as the field continues to specialize, I wonder if the current notion that all become MD's or OD's before going onto specialized training is still effective.
posted by humanfont at 4:42 PM on January 24, 2013


What is it with those two letters M and D that seems to create this tremendous sense of entitlement? Many in other professions spend a lot of time and accrue a lot of debt during their studies, and make similar sacrifices to be highly trained professionals. Still, this type of diatribe seems to come so often from M.D.s. Personally, I have an advanced degree in science because I enjoy it. While I'm well enough compensated, I'm not going to complain about how my salary is not meeting expectations. Sheesh.

And don't get me started about teaching premeds chemistry.


posted by Otherwise at 6:33 PM on January 24, 2013 [1 favorite]


en forme de poire Also while that paper is funny as hell, I should point out that the author is not actually a doctor.

Although it was not written by a doctor, it was almost certainly reviewed by doctors before being accepted, which is kind of worse, actually.
posted by yeolcoatl at 7:40 PM on January 24, 2013


srboisvert, I don't contest your experiences (and that is pretty lol/sad-worthy right there, jesus) - but is the overall standard of care in the UK appreciably lower than in, say, the USA? I haven't found anything to support that so far.


I looked into it whilst in the UK and the health outcomes are not significantly different from Canada. My theory is that the NHS has smart systems that make up for not-necessarily-so-smart front line care and that problematic cases are quickly referred to knowledgeable specialists. Also they have pretty much full drug coverage. Canada does not. So maybe people are more effectively treated once diagnosed with something amenable to drug therapies.

Having just today gotten my first invoice for covered medical care in the U.S. I can only use my favourite adopted UK term: gobsmacked. Medical History, Birth Control and flu shot - $ 300. Cost in the UK? Zero. Cost in Canada: $7.
posted by srboisvert at 10:32 PM on January 24, 2013 [3 favorites]


It's also true that no practicing doctor really needs a command of e.g., organic chemistry -- what, are you going to go into the back and rotovap something for me?

I disagree with this idea; you may be able to practice medicine without using organic chemistry, but you are definitely a better physician if you know a little bit about it. Even a basic understanding of structure-activity relationships of drugs is very useful. Knowing which local anesthetics are esters and which are amides is important if a pt. is allergic to one class. Knowing that the neuromuscular blocking drug cis-atracurium undergoes Hoffman elimination in the body is important if you are choosing a drug for a patient with liver or kidney disease. Drugs such as esmolol that undergo ester hydrolysis are useful when you need a very short acting drug. (Also, being able to rotovap something means you are lab tech, not necessarily a chemist.)

The same is true of other disciplines. Heart murmurs and wheezing are both due to turbulent flow and some knowledge of the physics involved give you a better understanding of what is going on. Knowing that the transducers used to measure blood pressure are really strain gauges that are configured as one arm of a Wheatstone bridge is useful in knowing how your physiologic monitors work and when their readings may be in error. I could go on, but you get my drift.

Furthermore, a knowledge of humanities is important for the physician to be a well-rounded person who is able to communicate effectively with a wide variety of people. So to me, a four year undergraduate education makes sense for physicians.
posted by TedW at 6:07 AM on January 25, 2013 [4 favorites]


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