Med students who wake up this morning will learn....

March 15, 2006 9:49 PM

Today,about 17,000 American medical students and almost as many foreign trained doctors learn what types of doctors they will be. Yes, it’s Match Day. Ok, while most people probably could care less about this post, it presents an intriguing look into the forces (i.e. how the ratio between specialists and generalists arises and to note: more specialists equals more procedures and costlier health care) that shape American health care today. And, it represents the strange culmination of years of study (at least 8+ years after high school) that many students take just to leave it up to a strange algorithm that is under a anti-trust lawsuit as they wake up one day in March and learn where they will be spending the next (at least) three years of their life. Also, if you see a recent graduate of an "ADORE+P" residency -- Anesthesiology, Dermatology, Orthopedics/Optho, Radiology, ENT/Emergency Room medicine (plus, of course, Plastic surgery) -- (the professions that work great hours and make the most money) -- congratulate her or him on being the best (statistically) of the crop.
posted by narebuc (33 comments total)

A general practitioner will make abiut 100,000 a year. An internal medicine "specialist" will make around 240,000 a year. Get-a-long little doggie! Susie needs to see a "specialist!" Get her well real quick. All the more reason to move out of the God GOP forsaken Midwest.
posted by The Jesse Helms at 9:59 PM on March 15, 2006

Two people I know just finished their residencies and are starting their dermatology practices. I knew they were special and that I was somewhat jealous of their success, but I didn't realize how inferior I should feel in their presence. I guess its a good thing I'm an idiot and don't pick up on those kind of things.

No, really I'm just happy for them. And anyone who makes it through med school all the crap they put med students through has my respect.
posted by djeo at 9:59 PM on March 15, 2006

Gee, isn't nice that somebody has conspired to limit the number of medical students to about a constant 17,400 over the last 15 years even while the population of the US has grown considerably?

Nothing like mandating scarcity to avoid competition and drive up prices.
posted by MonkeySaltedNuts at 10:56 PM on March 15, 2006

do you mean to tell me that what kind of doctor you become is a random thing?

i didn't know that ...

i don't even know what to think about that ... i'm not even sure i believe it

it's whacked ...
posted by pyramid termite at 11:29 PM on March 15, 2006

MSN, indeed. The AMA is a cabal akin to OPEC
posted by AllesKlar at 11:31 PM on March 15, 2006

Well -- like I sort of said though -- the US lets in about 10,000 more foreign trained doctors (who have to pass the same tests as American grads) so its a bigger amount than 17000 -- but, yes, it's a limited amount.

And, trust me, fewer doctors equals cheaper health care. More cooks can easily mess up the stew here.
posted by narebuc at 11:38 PM on March 15, 2006

Oh -- and the AMA is almost completely powerless -- maybe 50% of doctors are members and they are losing more and more people a year.

The "doctor glut" is something that deserves greater attention in the national media -- and it's one reason the AMA is powerless. Physician salaries have been stangant (or fallen) for about 20 years mostly because of "lowest bidder" doctors who'll listen to what HMOs tell them to do.
posted by narebuc at 11:42 PM on March 15, 2006

pyramid termite: medical students apply to match within certain programs. if you want to be a radiologist, you'd only apply to radiology programs, for example.
posted by dvdgee at 11:43 PM on March 15, 2006

Wow, fascinating post narebuc.

I am astonished that there's a "control" system on who and how many get to be what in the med profession.

But somebody clarify something for me... so you can't be a doctor in the US without going through the match?
posted by HiveMind at 11:56 PM on March 15, 2006

And, trust me,

Why? Facts please. This goes against what I've heard and read.
posted by raysmj at 12:21 AM on March 16, 2006

MeFi: And, trust me, fewer doctors equals cheaper health care.

I repeat it: #narebuc:And, trust me, fewer doctors equals cheaper health care.

I would love to read your rationalization of this since it goes against what is taught in high school economics classes.

A current rationalization of "doctors have to make big bucks" is that medical school is sooo expensive that new doctors have to pay off a big debt load. But why is medical school expensive? Because the teachers say they are fancy doctors that could make $2,000,000 in private practice so they want an equivalent salary. And of course med schools only accept students that buy into this "pay a lot, get a lot" paradigm.

If this ideological pustule could be burst then maybe there would be more doctors who were more concerned about health than money grubbing.
posted by MonkeySaltedNuts at 12:44 AM on March 16, 2006

MonkeySaltedNuts, I don't think your analysis can be correct, because in Australia a medical degree costs very little more than an arts degree ($40,000AU for 6 years compared to $15000AU for 3 years in arts) and doctors are still very highly paid. This implies that the doctors are in fact valuable, and are not simply deluding everyone.

Here is a reasonably straightforward outline of relative costs of degrees (scroll down to the table) - and all this is paid upfront by the government for most students, who then pay it back through the tax system.
posted by jacalata at 2:02 AM on March 16, 2006

A current rationalization of "doctors have to make big bucks" is that medical school is sooo expensive that new doctors have to pay off a big debt load.

I don't think that's the case at all. Doctors earn high salaries because they perform a highly specialized service that requires a lot of education, training, and experience. And seeing as how they're in short supply, their services remain in high demand. Your statement is analogous to saying college graduates earn higher salaries simply because college is expensive which isn't true. Back to doctors, even if medical school was made cheaper for the same 17,000+ students, I don't think it would significantly impact their salaries. Their salaries are correlated with the value of services, not the cost of education.

Because the teachers say they are fancy doctors that could make $2,000,000 in private practice so they want an equivalent salary.

Why should the salaries of medical school instructors differ from their real-world counterparts any more than graduate school instructors differ from industry employees? Medical school instructors are current and former doctors and academics with significant years of experience. I see no reason why they should trade that in for say, a high school teacher's salary simply because they want to teach instead of practice medicine. We don't bemoan the salaries of graduate school professors - they've earned their teaching salaries and then some cuz they could certainly be making more by working in industry. Similarly, medical school instructors could be making a lot more money in private practice but they've chosen to take the lower salary in order to teach. I wouldn't trust my health to any doctor whose instructors were paid $30,000/yr simply in the interest of "health."
posted by junesix at 3:02 AM on March 16, 2006

#jacalata: I don't think your analysis can be correct, because in Australia a medical degree costs very little

Jeez, I can't believe that you are arguing that the cost of a degree in Australia (which has socialized medicine) shows that medical education is inexpensive in the US.

The AMA says [in the US] In 2005, the median amount of that debt was more than $120,000. And this is just the median. If you want to go to a good med school and train in a high paying specialiaty then you might have to pay many times this "base cost".
posted by MonkeySaltedNuts at 3:26 AM on March 16, 2006

Damn you, narebuc. I had a Match Day FPP all planned for today, too. I'll be with my wife at school at 1pm when the envelopes are opened. I'm all a-twitter.
posted by Plutor at 4:00 AM on March 16, 2006

Their salaries are correlated with the value of services, not the cost of education.

Yes, but there is oftentimes a correlation between the cost of education and value of the education, if value is determined by potential earning power.
posted by mrmojoflying at 4:41 AM on March 16, 2006

A general practitioner will make abiut 100,000 a year. An internal medicine "specialist" will make around 240,000 a year. Get-a-long little doggie! Susie needs to see a "specialist!" Get her well real quick. All the more reason to move out of the God GOP forsaken Midwest.

Yes, but you will note that the Internal Medicine doctor finished her residency and is board eligible, if not board certified. GPs finished a year of residency (some specialists do up to 8 with fellowships) and are not seen fit, by their peers, to take their qualifying board's exam.

I do know where I am going.
posted by jmgorman at 5:00 AM on March 16, 2006

I once read some memoirist doctor recalling that before the second war, med students were advised to marry rich women because there was no money in medicine. (Quaint in so many ways, that.)

I wonder if the money lure now makes for better medicine or not. Anyone ever look into this? (Leaving technical advances out of the equation, of course, which I suppose is impossible.)
posted by IndigoJones at 5:01 AM on March 16, 2006

As a doctor, I can clarify a few issues:

1. You cannot be a doctor in the US without going through the match (with a very few exceptions for desperate programs)
2. Salaries have been stagnant, in fact of the ADORE-P someone mentioned, ER physicians, opthalmologists and ENT surgeons don't really make a lot of money any more. Surgical and medical subspecialists (heart surgeons, cardiologists etc) make more money than these.
3. The compensation per hour for someone who's trained that many years (11 years post-high school for me) and works that many hours (>60/week) and has to put up with so much crap is ridiculous. This is why children of doctors now rarely go into medicine (unlike a few decades ago).
posted by lowgfr at 5:57 AM on March 16, 2006

I'm in the same boat as Plutor - The wife and I are getting her envelope today. Jesus fucking christ.
posted by sohcahtoa at 6:02 AM on March 16, 2006

MonkeySaltedNuts, I didn't make any point about how much it costs to go to med school in the US. You argued that high med school fees in the US is the cause of high salaries for medical practitioners. I gave the counter example of a place with low med school fees where graduates still receive high salaries, thus showing that fees cannot be the sole cause of the high salaries.
Jeez!
posted by jacalata at 6:11 AM on March 16, 2006

One of the neat (or is it crazy) things is the similarities between the Match program for doctors, and sorority rush. I'm having trouble finding specific info on sororities, but basically, each girl picks her top three sororities, and then everyone (or most) people that applied get assigned to a house.

Apparently students have tried stopping this process in the past with a class action suit "contending that the match violates antitrust laws by denying students opportunities to negotiate the terms of employment."
posted by inigo2 at 6:47 AM on March 16, 2006

If the hmo's are making doctors work 60 hours a week for low pay, then shouldn't they use the AMA as a trade union to organize against hmo's from working them so much?

In general, if there's such a caseload for doctors that they are working too much, why wouldn't more doctors be needed? that seems terribly obvious. (it's also a caseload based on who is able to pay, so the real demand for treatment is going to be bigger)

It's also obvious that working such long hours can make you a jerk, because at least that's the case with my primary care physican. 'bedside manner' or 'not treating the patient like a lab rat' is evidently not on those med tests.

As for the fees that doctors make, in economics it's called Tournament Theory, and it's as brutal as the name implies. I think this theory is more relevant than marginal productivity in high stakes positions, like executives and the limited slots for doctors.
posted by eustatic at 7:11 AM on March 16, 2006

As a relatively low paid fellow, now in my 5th year of training after graduation from medical school, I have to add my $0.01 (because I can't afford to put in my $0.02):

1. Physician salaries represent a surprisingly small amount of the overall healthcare budget and are not the only force driving health care inflation. Drug costs are rising much, much faster than phyisican salaries. In fact, administrative costs, which represent over 30% of the health care budget (New England Journal of Medicine 349(8):768-776, 2003) are almost as large a part of the US health care budget as physician salaries.

2. Physician salaries, overall, have been flat to lower when you factor in inflation. Remember that insurance companies often peg reimbursement to the Medicare payment schedule, and that the goverment has included physician salary reductions every year for the past several years, and bugets these reductions in over the next few years. Physician groups have been somewhat successful in slowing these cuts, but they certainly haven't received any gains over the rate of inflation. Oh, and don't forget that while insurance companies can force physicians to accept lower reimbursement rates by threatening to not put them on their panels, physicians cannot work together to negotiate increases in rates becuase of current anti-trust laws.

3. In addition to the cost of medical school, you also need to factor in lost opportunity cost. Remember that residents are paid, on average, somewhere in the $30-40,000/year rage for 80 hours of work per week for the 3-5 years of their residency. Subspecialty trainees (fellows) are paid somewhat more, but not much. I live in Boston, work well over 60-70 hours/week, and am reimbursed a hearty $54,000/year. Now I understand that I am still in training and could've easily chosen a different job, but this is what I want to do with my life. The flip side is that I'm 38 years old, a board-certified pediatrician, and, won't finish my training until I'm 40. Plus, residencies don't come with retirement benefits. The long and short of it is that physicians start out life (unless they're wealthy going in), in a deep hole. If you want quality people to come into medicine (and last I checked, we're rationale economic beings just like the lawyers and stockbrokers of the world), you have to compensate them. And trust me, the average salary for physicians is miniscule compared to CEOs, NBA players, reality TV show hosts, congressmen on the take, real-estate developers, etc. My fellow pediatric oncologists are getting $120K to start out of fellowship and they're grateful. Of course, we can't slam dunk, take bribes from Jack Abramoff or raid corporate coffers. We just treat childhood cancer.

4. My wife is a nurse anesthetist who went to school for 2 years after her undergraduate/nursing degrees, works 40 hours a week, has a 401K and pension, gets 8 weeks of vacation, is mostly insulated form lawsuits, and makes over twice my salary. Now, what were you saying about physician salaries being high?
posted by scblackman at 7:25 AM on March 16, 2006 [1 favorite]

There is some more information about the match here, including a list of specialites that don't participate in the match. There are also permutations of the match , most notably the couples match. There are a number of ways to get around going throught the match; the most common is to switch from one specialty to another in mid-year. Also some programs do not fill all of their approved posittion for a variety of reasons (for example, they may be in the middle of changing leadership and not have the time to educate a full load of residents) and when they are ready to expand later on they will often take residents who want to start earlier than the standard July 1 start date. In any event, the match is the way the vast majority of programs select most of their residents, but is definitely not the only game in town (and the exceptions are not limited to a very few exceptions for desperate programs).
posted by TedW at 7:45 AM on March 16, 2006

The thing that I find interesting about doctors is, as scblackman so clearly demonstrates, it seems as though you have to be roughly 240% sure that you want to be a doctor for the rest of your life when you decide to go to med school. There are people who can get through law school, work a couple of years, then start a new path. Not so with medical school. When you sign up, you're signing up for 15, 20 years at least.

I guess it's good that "the system" weeds out people who aren't entirely sure they want to be doctors, but it also seems like it would/could fester all types of bitterness. The current economy is about flexibility - people changing jobs all the time. I don't know of any profession where that is less true than medicine.
posted by billysumday at 7:50 AM on March 16, 2006

Also, to clarify for some of the non-medical people reading this, there are a number of different organizations that control medical practice in this country. First of all, in order to practice as a physician, you must first obtain a license from the state medical board where you wish to practice. The requirements vary from state to state; for example, some states require a year of internship before you can practice, while others only require a degree from an accredited medical school. This license gives you the legal right to practice any kind of medicine you want, from taking vital signs to open-heart surgery. The limiting factor in keeping just anyone who went to medical school from calling themselves a heart surgeon is that hospitals won't grant privileges and malpractice carriers won't insure just anybody. In order to get other than the most basic hospital privileges you must go through residency training (the subject of the post). Residency programs are set up by the individual specialties (who are represented mainly by the American Board of Medical Specialties, although there are much smaller competing organizations out there). It is at the specialty level that decisions are made that limit the number of training positions available. And yes, the specialties do try to limit the number of trainees in order to both maintain the quality of the training and preserve the income of those already in practice. These residencies are then accredited by the Accreditation Council For Graduate Medical Education, which maintains training standards and tells each program the maximum number of residents they may accept each year (although as mentioned in my earlier post, programs may choose to accept fewer). The ACGME and individual specialties work closely to determine the requirements for accreditation. The final step is board certification, which is administered by the individual specialty boards (the ABA in my case) which work closely with the professional society for each specialty (the ASA for me). This typically consists of a written and often oral exam given upon successful completion of a residency. Some physicians skip this step as the exams are expensive, given only once or twice a year, and often difficult, but as credentialing committees in hospitals get more strict this is becoming less and less an option. There are similar requirements for D.O.s, and foreign medical graduates have an exam of their own to pass before they can be accepted into an internship which is required of all foreign medical graduates in this country (no matter how far they went in their careers elsewhere). As you can see, the match is only one of many non-government organizations controlling medical education in this country. The same is true of other aspects of health care, such as hospital accreditation. Sorry this got so long, but it really is a complex system and I think few people who have not been through it really understand how all the parts fit together.
posted by TedW at 8:20 AM on March 16, 2006 [1 favorite]

So there really isn't a Harry Potter-like sorting hat thing on Match Day?
posted by dr_dank at 9:00 AM on March 16, 2006

If there are less doctors (or even not enough), more people die waiting to get treatment. Hence the total cost is lower. Cruel but true.
posted by kika at 10:35 AM on March 16, 2006

sohcahtoa & Plutor - so? Good news?
posted by raedyn at 7:15 AM on March 17, 2006

Definitely good news here: Boston Medical Center.
posted by Plutor at 9:23 AM on March 17, 2006

We're very pleased to be moving to the Bronx.
posted by sohcahtoa at 11:13 AM on March 17, 2006

Congrats to you and your significant others.
posted by raedyn at 11:23 AM on March 17, 2006