Both of my parents are doctors. In high school I had real thoughts of going into medicine. They strongly discouraged me towards going into that field. In college I was pushed towards a MD/PhD program by my lab's PI. I thought about graduating at 28-30 and decided against it.
Jr year I interned at Amazon after that experience I knew I made the right decision. It is a really, really hard sell for this current generation to do another 5 years of school with residency and then specialization when you can quickly make 100k+ at a tech company. All of my friends who went into medical school are working hours like 6am-6pm or 8pm-8am. They get like two days off every two weeks. I think there are a bunch of possible solutions but the easiest one is making 5 year medical programs (2 years undergrad, 3 graduate) more common in the US.
My father was a MD and he discouraged me as well of pursuing that path.
My friends who are now doctors make much more money that I do, they are more respected, they don't have to deal with some annoying hierarchy, and their job is meaningful. As for working hours, it really depends on the speciality, and the hours they chose to work. I know some dermatologists who work 4 days a week for instance.
In the end, I don't regret that I chose a different path as I loved maths and programming and I did some interesting things as well. But nowadays I feel just like a worthless pawn, developing crappy programs, who is starting to suffer from age discrimination...
It isn't just the time and money side. I personally feel the solution is that most of the time we don't really need a doctor. How many appointments at a primary care are for colds/flu?
We have to switch to largely seeing mid-level providers like PAs or RNs and maybe push even lower. The doctors can be there for the tough cases and to consult and monitor. It is already starting to happen and is one way we can reduce the cost of health care.
I have 2 friends in their 40s who are primary care physicians at Kaiser (one in Bay Area, one in Sacramento). Both have dropped down to 60% time (3 days per week), explaining that 60% time is actually 40 hours. In the last few years Kaiser has added both EHR work and e-medicine work without reducing the number of appointment slots. So, it's about 7 hours per day of appointments and then catching up on all of the deferred paperwork and emails.
But overtime I think doctors will earn more than software engineers. Also doctors are more valued the more senior they are, while software engineers not as much, need to move to management, ageism, etc.
I ran into the oncologist that took care of someone close to me in a social setting and we ended up talking for awhile. We were talking about getting ready for the holidays, etc and she expressed a fairly significant guilt about being absent for so many things. That's no wa to live.
It struck me as very sad, as I've heard similar things from other physicians.
On the other hand, a friend of mine is a dermatologist who works three 8-hour days for week and makes 200k+, one yeah after residency. In the end I still prefer doing what I'm doing, but it's not an obviously bad choice.
Meanwhile my dad is an ophthalmologist and at the age of 66 he is talking about how he wants to keep working full time until 70 and then half time after that. Some people are just made for the lifestyle of a physician I guess...
I’m still not sure why most US medical schools want an undergraduate degree. I see lots of people trying to go pre-med doing research in the lab when we should really just cut out the middleman and have medachool admit straight out of high school or the military [in the USA not sure how other countries work]. This would really reduce the amount of time wasted of people that don’t want to go into research. Right now you can go to school for 4+2(MS degree) and make just as much [total comp] as a GP at FAANG+MSFT and get much, much better working hours.
Ideally we would increase the amount of Medicare residencies too. Then everyone could get a residencie and we would also be able to import MD from around the world.
I find this is a common refrain with any profession that regularly has to deal with insurance. I've seen it in medical, home repair and even long standing family auto shops.
The more layers get forced in between the people providing a service and the people receiving the service, the worse things seem to get.
But the flip side to tech is also ageism, which is a serious issue.
Maybe things will get better down the road, 20-30 years from now; But as it is now, a lot of the good paying companies will be very hesitant in hiring you once you're old enough.
It's not that tough of a sell when you consider that many/most medical students are math-phobic and would most likely be unable to obtain a high-paying SWE gig in lieu of becoming a doctor.
There is a significant difference between the skillset that produces a medical student (work ethic and drive) and a SWE (analytical reasoning).
Please lobby the AMA to not artificially limit the supply of doctors by creating regulations around residency. I personally know of many people with MDs from India who don't work here as physicians because they could not get a residency 'slot' in the Bay Area where their family lives.
Relevant thread with links on StackExchange: https://skeptics.stackexchange.com/questions/4561/does-the-a...
The AMA isn't limiting the supply of doctors. The actual limit is in the number of residency program slots funded by the US Federal government. If you actually want to increase the supply of doctors then lobby Congress for higher residency funding.
to be fair, there are very few residency spots in the bay area in any specialty anyway. My wife went through the residency match program last year and the bay area programs are ultra competitive because it is a desireable place to live. Adding more residency slots is a good idea, but they're going to be spread across the US.
People underestimate how much of a problem is... There are so many qualified MDs who are underutilized or unable to go into the residency that they'd be most productive in simply because the supply of programs is kept artificially low
My wife just graduated medical school and started residency.
The burn-out affected both of us and we're just starting to get over it.
* Med school is a freaking grind. She was either at class, at rotations, or studying. Pretty much 80+ hours/week for 4 years.
* We had to move a lot, which has limited my social life. Ended up spending a lot of time just "working" while she'd study in the evenings.
* Major life impacting tests nearly every year. Low scores or failures on a single exam can kill any career aspirations.
* Insane debt load. We're looking at total payback costs around $310k. That was with no undergrad debt and my job paying for all living expenses. If you don't become an attending, you're fucked financially.
* Not enough residency spots for the number of medical schools. Less than 80% of candidates matched into a residency spot. Follow on matching is very low.
* That's right, pretty much 1 in 5 doctors will not go on to practice medicine because they cannot get a residency position.
* Residency salaries are complete shit. It's not unheard of for residents to have to take out loans to payback loans during residency.
* Resident have absolutely no leverage. They are literally slaves to the program they're "matched" to. Program director changes, hospital gets bought out, peers are insufferable - sucks to be you, you're stuck until you graduate.
* Financially being a doctor doesn't make any sense. Everyone looks at doctor's salaries, but completely forgets about the 8 to 10 years doctors (a) make nothing (b) pay for education (c) make pennies. Even with the "doctor salaries", it will take my wife well into our 50's to be financially ahead had simply pursued a career in her STEM field. There's a lot of life that can be live in 30 years that a "big house and a fancy car" doesn't make up for.
* Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives.
I could rant for hours about all of the bullshit my wife went through (and, lesser myself).
If you're thinking of becoming a doctor, do yourself a favor and do something else.
If you really want to work in medicine, becoming an NP or PA is a looking like an increasingly attractive route.
I was interested in medicine in high school. I was able to shadow a few physicians and talk about career options. At the time I was shocked that most of the physicians I talked to said they would take a different career path if they could do it over again.
The common theme was that they felt it used to be a respected profession but now they’re broadly just cogs in a healthcare system that given them little freedom for professional discretion and lots of paperwork.
I would like to see the data sliced by employed vs independent physicians.
Independents (a majority of physicians) need to deal with all the billing and insurance headaches that now come with the industry, and have to deal with setting up their own EHR to deal with it.
Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient.
Would be good to see if there is a correlation there.
>Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient.
"Employed" physicians no longer deal with patients, they are called customers. Helps to keep customers happy and physicians focused on the profit motive.
It seems like the days of the independent physician are drawing to a close. Many independent practices have become physician groups which in turn have been bought by hospitals. (Perhaps specialists are still largely independent, but general outpatient medicine seems to have become largely corporate.)
Many physicians I know have a boss, and have to meet metrics about how many patients they see ever year in order to get their incentive bonus. Physicians who work for hospitals are viewed as "loss leaders", and find their appointment times squeezed to twenty, fifteen, or even twelve minutes per patient. (The idea is that for every n visits, a patient will be referred to a profitable service provided by the hospital.)
I know it's only anecdotal but my brother in law is a doctor at a large hospital (employed physician) and he sees patients 9-5 but he's at the hospital from 7am-8pm doing prep, research and patient notes. That also doesn't count the nights/weekends when he's on call for the ER (usually takes calls from home but occasionally has to go in too). He basically only sees his kids on the weekend.
I worked similar hours for a few years while coding and I expect he will (but hope he doesn't) burn out eventually. It's obviously not sustainable.
I realize from the comments here that I wasn't as clear as I intended. I conflated "employed" with "employed in an integrated system with a health plan." Having an integrated insurance plan run by the provider in theory aligns incentives to keep patients healthy rather than fight over billing.
Strangely, this "report" is a set of slides. It would have been useful if there was more information about how the Medscape authors conducted this study. On slide 28, it says the sampling size was "15,181 physicians across 29+ specialties met the screening criteria and completed the survey". What was the screening criteria and how many physicians did Medscape initially reach out?
I'm sure this isn't the case for every doctor, but what I've observed is that scale seems to be killing everything. When you have 10 minutes with a patient, have no long-term relationship, ship them off to a specialist that has even less context of their overall health, and ultimately just prescribe them meds to treat a symptom, that person does not get healthier. Over thousands of patients that starts to challenge any sense of moral obligation you originally had when entering the field. Then you become disillusioned and burn out.
The irony is the part about everyone becoming less healthy. That creates more demand for medical services. Rinse, repeat. We truly have the worst system imaginable in the US. It evolved over time. It's nobody's fault. It's everybody's fault. It needs to be burned down and rebuilt. It seemed like we had a chance with the ACA but it was pretty clear early on that it wouldn't fix the root causes and it hasn't.
There’s a few doctors in my city who charge a $50 a month fee for a 30-39 year old and you can call and see them whenever. Insurance doesn’t cover it at all. I’d also imagine if you tried to really abuse the relationship and show up constantly for no reason the doctor might fire you. I feel like it’d encourage a relationship of respect both ways.
I interviewed a couple of them and one talked to me for an hour about health and diet and exercise, just a friendly chat to see if I wanted to use him. He said he was getting ready to retire from medicine after years of ER work when his doctor friend encouraged him to try direct primary care. It was so different than the regular medical system, cutting out all the middle men.
Physician practices get absorbed by large national corporations and patient care gets reduced to metrics that administrators can tweak to extract more revenue and profit. The benefits get paid to administrators as bonuses, while physicians see their salaries stagnate.
The corporitization of physician practices is destroying the profession.
I've been working in the field (software side) for a while and it is a little bit complicated. Some medical procedures absolutely require constant practice to maintain a very high level of quality and safety. Others don't. If you grow the number of residents by 10x, the total number of cases won't follow and you can end up with a more dangerous situation overall as every physician will be less qualified by virtue of practising less. That varies by specialty.
There is also the money. Sure you can train 10-100x physicians, but total compensation won't grow as fast, and so you should see lower overall wages (supply and demand). But it's still more complicated than that, because some people choose not to undergo X or Y procedure for various reasons, insurers don't cover or whatever. So even if you could train enough doctors to fulfil the whole population's needs, that doesn't mean you will have: 1. enough equipment, material, operating rooms, etc to do the procedures 2. enough supporting staff, and on and on.
The most common reason I hear from MDs against training much more doctors is the first one I gave you: less practice means a more dangerous practice.
My own opinion is relatively simple. Medical schools should stop screening applicants as much and let students join freely.
Medical schools are all about getting well-rounded individuals who did extra-curriculars etc. They usually view it as a good thing that you have life experiences outside of medicine, like working or studying an entirely different subject. However it works one-way: you can't (generally) just go to med school, learn the subject matter and then move on to another field, enriching _that_ one with your experience. I have come to believe that if we are to see any improvement, med school will have to open up just like every other discipline. The current system of stressing out students for a few years before even being allowed in the classroom is, IMO, partly responsible for the job dissatisfaction that you see.
Now freeing up med school admissions does not mean allowing everybody to _practice_ medicine. Prospective students would actually get a chance to learn the material for a few years before having to interview for internships. So instead of filtering _before_ med school and forcing a huge sunk cost psychological barrier to students, you can let the students figure out by themselves if they actually enjoy the subject matter. It's not a perfect solution but I am quite certain that society as a whole would benefit. It is entirely unfair that medical knowledge (not practice) is restricted to a lucky few.
That's a complicated question. Let's say you're working on a software project that's running late. Does that indicate you should through more software developers at it?
The problem with medicine is that you have a culture of perfectionism in a field where random bad shit naturally happens all the time, and there's a great amount of human suffering. On top of that, perfectionism helps a lot, in the short run, even though it may be toxic in the long run.
What is the baseline of burnout for all mid-career professionals? I'm a mid-career guy and most of my friends/peers are a little burnt out no matter what they are doing. Balancing any serious career with kids on one side and aging parents on the other is tough.
Anecdotal but my gen prac warned me on this 10 years ago, that obgyns were being driven out by high malpractice insurance. He suspected this would ultimately lead to consolidation of doctors under health organizations to limit personal liability.
Sure enough you have conglomerate health services corporations absorbing small practices, cheaper prices for consumers with added bureaucratic noise & volume thresholds for practitioners.
There are a lot of misconceptions and misinformation coming out in this thread. I'm going to try and shed some light on them. (HN says my post is too big, so I'll have to split up a bit).
There are four major groups of physicians:
-Residents. These are the folks that just completed medical school, and are doing four-plus years of training in a hospital setting to become independently practicing physicians. In year one they are called interns. By year three or four they have various amounts of independence: in internal medicine, family medicine, etc. they are basically practicing as full physicians, with some light supervision (the heavy supervision is years one and two). They are one of the hospitals most valuable employees: taking into account supervision costs, they are producing about 80-90% of the revenue of a "real" physician, for less than 1/4 the cost. These are the guys who work 80+ hours per week without exception, do all the scut, etc. These are not "mid career physicians". This is where "old physicians had to go through it, so young physicians have to go through it."
--Resident Training: the AMA has been pushing to expand resident training spots for years. The funding is part of Medicare legislation, and no one has been willing to back expanding medicare spending in the name of training physicians. I know the AMA has been backing this because I've attended the Region 7 and national meetings where the resolution to push for it has been passed, repeatedly. Literally, hit DDG and enter "AMA restricted residency training funding" and your entire page of results is the opposite. They may have done so more than a generation ago, but... let's move onto things that were done by, and affect, people not currently retired, eh?
-Hospitalists. These guys have completed their residency training, and elected to work for a hospital, doing in-hospital medicine. Their specialty is "hospital medicine." They have no private clinic, no private patients, and are paid a salary by the hospital. Whether this is an integrated system like Kaiser, or ... every other hospital in the market, they're very common. Their practice patterns are heavily dictated by the hospital, which is heavily dictated by the Centers for Medicare/Medicaid Services and the major insurers. Their work is increasingly focused strictly on documentation, since documentation is the way that CMS and insurers (a) find excuses to refuse reimbursement, and (b) the way that CMS and insurers outsource collection of "quality" information, by forcing docs to structure their input in very discrete ways. These physicians don't have to deal with billing directly, but they are constantly being pulled into trainings for the ways documentation requirements are constantly evolving, the ways in which payors want them order tests and in what order, etc. They constantly get phone calls from "helpful billing people" raking them over the coals whenever there's a mistake. THe hospital keeps running tallies and reports on doctors' mistakes in this arena, aiming for public pillorying and, ultimately, withheld wages. (Docs don't generally get bonuses, they get withheld wages - except for high-revenue services like procedures, where they may get a bonus for very high productivity.) These are "mid career physicians." They tend to work an official 10-12 hour day, ten days on, ten days off. In reality, due to documentation requirements, and the fact that they get more patients than anyone could ever see and document in 10-12 hours, they tend to work 14+.
-Private Practice. These guys completed their residency and either opened their own private practice (almost no one can do that these days, with the complexity of the documentation and EMRs required by CMS and insurers, and attendant overhead costs) or have become employed by such a practice with the medium-term goal of buying in as a partner. They are likewise having their arms heavily twisted by insurers and CMS, without any sort of leverage to fight back and negotiate better terms. These guys are going out of business left and right. These are "mid career physicians." Hours worked here are highly variable, depending on the specific practice pattern, number of employees and partners, etc.
-"Private Practice." Because of the complexities and overhead that are now required to stay open, many practices... can't. They sell to a local hospital - often at cost - and become hospital employees. The hospital offers solid salaries for the first couple of years, and then drives them out, replacing them with younger employees. Many of the "private practices" you go to are thus actually practices run by the hospital, with an employee acting as the physician. These are "mid career physicians." These tend to work 9-5 with one evening hour a week, or none. The spread of this is why no one can find a doctor to see in the evenings anymore.
Key to Understanding Medical Reimbursement:
This is not a free market. It is fee for service. You get a patient visit, it is coded as a particular service (usually a Level 3 Evaluation & Management), and a fixed amount of reimbursed, assuming you meet various documentation requirements. If you do not, the amount is decreased or denied altogether. Private insurers peg their fee schedules to CMS, so CMS - directly or indirectly - drives all physician reimbursement. If you own a geographic area (such as part of a sweeping hospital network), that network will negotiate better reimbursement (e.g., "112% of Medicare"), but that is not passed along to employee physicians. Total revenue for a physician is amount of work-time per year divided by time-per-average-service, times reimbursement-per-average-service.
That's it; that's your cap.
Thus, most services patients want are strictly cost centers. The sort of things that other businesses compete on - e.g., ambiance, good front desk staff - are problematic for physicians, because you can't pass that along to patients in moderately higher prices. The only way you can compete on service, and be free to set your prices accordingly, is to refuse all insurance and only take cash patients. There are vanishingly few such patients, largely due to a cultural expectation that insurance = healthcare. Actually paying cash for a primary care physician, at least, isn't that expensive, but since that doesn't cover all of your other healthcare costs, who can afford to pay that extra premium? Only upper-middle-class and up.
While I was having a vasectomy late last year I had a conversation with the doctor performing the surgery. It started with a quip about "It's not your first time, right?" or something to that effect, and went into the general process of developing new techniques which he claims is non-existent in the US right now, what with liability and the threat of malpractice squashing any incentive for innovation.
He gave a specific Urological example of a technique that was developed at MIT and took 6 hours, impractical for all purposes. European doctors have since come over and trained US doctors on a means of the same outcome that takes 1 hour.
My first thought was that the stagnancy of the field would contribute to burnout, but thinking about it more, I think just living under the imminent threat of malpractice lawsuits is probably enough.
Mandated electronic medical records is the problem, not some constrained supply of doctors. (Not the concept of electronic records, but the implementation. Scanned paper records probably would have been fine. Epic and competing software solutions are not.) It means the same supply of doctors has less time for the same (or increased) demand.
Forcing doctors into a workflow dictated by software is what's causing 12 hour days to turn into 16-18 hour days, with no additional pay, and no reduced hours to compensate.
Also results in doctors focusing on the computer instead of the patient.
You didn't see burnout levels increase until electronic charts were forced.
Stuff like this make me question how those in the medical field can put up with this stuff. All that hard work, all that debt, all that lost time, and for what? Meanwhile there's a bunch of people in a handful of cities who make comparable if not greater salaries for writing software to freaking deliver ads to sell people shit they don't need (I'm exaggerating a little). And all while living a much more comfortable life! Time ain't free.
I cannot find the studies now, but I have seen multiple times numbers to the effect that medical interventions/treatments are responsible for 10% of health outcomes. The remaining 90% is determined by diet, exercise, and genetics.
Genetics is out of everyone's control. But the fact that 1/6 of the American economy is focused on that 10% is mind blowing.
The best ways to improve your health are to eat less, eat better, and exercise more.
I have seen this happen as a chronically ill patient for the past 30 years. There is a wave of poorly understood chronic illness and doctors are powerless to treat it. It must be exhausting to tell so many people that there is nothing they can do. I say this with 100% sincerity. It must be a nightmare to work so hard without the reward and satisfaction of significantly improving people's lives.
I think specialization is making labor markets more exploitative.
If the market expects you to do things that aren't worth the wage, but you spend a decade and half a million dollars on training and switching to something comparable would take a ton more time and money, well, then you probably won't switch careers. And if too few people switch then there's little market pressure to adapt.
[+] [-] xzel|6 years ago|reply
Jr year I interned at Amazon after that experience I knew I made the right decision. It is a really, really hard sell for this current generation to do another 5 years of school with residency and then specialization when you can quickly make 100k+ at a tech company. All of my friends who went into medical school are working hours like 6am-6pm or 8pm-8am. They get like two days off every two weeks. I think there are a bunch of possible solutions but the easiest one is making 5 year medical programs (2 years undergrad, 3 graduate) more common in the US.
[+] [-] yodsanklai|6 years ago|reply
My friends who are now doctors make much more money that I do, they are more respected, they don't have to deal with some annoying hierarchy, and their job is meaningful. As for working hours, it really depends on the speciality, and the hours they chose to work. I know some dermatologists who work 4 days a week for instance.
In the end, I don't regret that I chose a different path as I loved maths and programming and I did some interesting things as well. But nowadays I feel just like a worthless pawn, developing crappy programs, who is starting to suffer from age discrimination...
[+] [-] snarf21|6 years ago|reply
We have to switch to largely seeing mid-level providers like PAs or RNs and maybe push even lower. The doctors can be there for the tough cases and to consult and monitor. It is already starting to happen and is one way we can reduce the cost of health care.
[+] [-] pkaye|6 years ago|reply
[+] [-] hardtke|6 years ago|reply
[+] [-] christiansakai|6 years ago|reply
[+] [-] Spooky23|6 years ago|reply
It struck me as very sad, as I've heard similar things from other physicians.
[+] [-] scarmig|6 years ago|reply
[+] [-] ls612|6 years ago|reply
[+] [-] rayhendricks|6 years ago|reply
Ideally we would increase the amount of Medicare residencies too. Then everyone could get a residencie and we would also be able to import MD from around the world.
[+] [-] brightball|6 years ago|reply
The more layers get forced in between the people providing a service and the people receiving the service, the worse things seem to get.
[+] [-] TrackerFF|6 years ago|reply
Maybe things will get better down the road, 20-30 years from now; But as it is now, a lot of the good paying companies will be very hesitant in hiring you once you're old enough.
[+] [-] mbbutler|6 years ago|reply
There is a significant difference between the skillset that produces a medical student (work ethic and drive) and a SWE (analytical reasoning).
[+] [-] univalent|6 years ago|reply
[+] [-] nradov|6 years ago|reply
https://www.ama-assn.org/press-center/press-releases/ama-fun...
[+] [-] tmh79|6 years ago|reply
[+] [-] neonate|6 years ago|reply
[+] [-] codekansas|6 years ago|reply
[+] [-] SkyPuncher|6 years ago|reply
The burn-out affected both of us and we're just starting to get over it.
* Med school is a freaking grind. She was either at class, at rotations, or studying. Pretty much 80+ hours/week for 4 years.
* We had to move a lot, which has limited my social life. Ended up spending a lot of time just "working" while she'd study in the evenings.
* Major life impacting tests nearly every year. Low scores or failures on a single exam can kill any career aspirations.
* Insane debt load. We're looking at total payback costs around $310k. That was with no undergrad debt and my job paying for all living expenses. If you don't become an attending, you're fucked financially.
* Not enough residency spots for the number of medical schools. Less than 80% of candidates matched into a residency spot. Follow on matching is very low.
* That's right, pretty much 1 in 5 doctors will not go on to practice medicine because they cannot get a residency position.
* Residency salaries are complete shit. It's not unheard of for residents to have to take out loans to payback loans during residency.
* Resident have absolutely no leverage. They are literally slaves to the program they're "matched" to. Program director changes, hospital gets bought out, peers are insufferable - sucks to be you, you're stuck until you graduate.
* Financially being a doctor doesn't make any sense. Everyone looks at doctor's salaries, but completely forgets about the 8 to 10 years doctors (a) make nothing (b) pay for education (c) make pennies. Even with the "doctor salaries", it will take my wife well into our 50's to be financially ahead had simply pursued a career in her STEM field. There's a lot of life that can be live in 30 years that a "big house and a fancy car" doesn't make up for.
* Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives.
I could rant for hours about all of the bullshit my wife went through (and, lesser myself). If you're thinking of becoming a doctor, do yourself a favor and do something else.
If you really want to work in medicine, becoming an NP or PA is a looking like an increasingly attractive route.
[+] [-] code4tee|6 years ago|reply
The common theme was that they felt it used to be a respected profession but now they’re broadly just cogs in a healthcare system that given them little freedom for professional discretion and lots of paperwork.
I ultimately didn’t pursue medicine.
[+] [-] chkaloon|6 years ago|reply
Independents (a majority of physicians) need to deal with all the billing and insurance headaches that now come with the industry, and have to deal with setting up their own EHR to deal with it.
Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient.
Would be good to see if there is a correlation there.
[+] [-] ses1984|6 years ago|reply
"Employed" physicians no longer deal with patients, they are called customers. Helps to keep customers happy and physicians focused on the profit motive.
[+] [-] jt2190|6 years ago|reply
Is this still true?
It seems like the days of the independent physician are drawing to a close. Many independent practices have become physician groups which in turn have been bought by hospitals. (Perhaps specialists are still largely independent, but general outpatient medicine seems to have become largely corporate.)
Many physicians I know have a boss, and have to meet metrics about how many patients they see ever year in order to get their incentive bonus. Physicians who work for hospitals are viewed as "loss leaders", and find their appointment times squeezed to twenty, fifteen, or even twelve minutes per patient. (The idea is that for every n visits, a patient will be referred to a profitable service provided by the hospital.)
[+] [-] SkyPuncher|6 years ago|reply
Independents likely have it easier as their EMR are less complex and they have fewer people to coordinate with.
EMRs in general have little to do with patient care. They are glorified billing systems.
[+] [-] bonestamp2|6 years ago|reply
I know it's only anecdotal but my brother in law is a doctor at a large hospital (employed physician) and he sees patients 9-5 but he's at the hospital from 7am-8pm doing prep, research and patient notes. That also doesn't count the nights/weekends when he's on call for the ER (usually takes calls from home but occasionally has to go in too). He basically only sees his kids on the weekend.
I worked similar hours for a few years while coding and I expect he will (but hope he doesn't) burn out eventually. It's obviously not sustainable.
[+] [-] pasttense01|6 years ago|reply
[+] [-] chkaloon|6 years ago|reply
[+] [-] hhs|6 years ago|reply
Strangely, this "report" is a set of slides. It would have been useful if there was more information about how the Medscape authors conducted this study. On slide 28, it says the sampling size was "15,181 physicians across 29+ specialties met the screening criteria and completed the survey". What was the screening criteria and how many physicians did Medscape initially reach out?
I wish the WSJ asked these types of questions.
[+] [-] drewr|6 years ago|reply
The irony is the part about everyone becoming less healthy. That creates more demand for medical services. Rinse, repeat. We truly have the worst system imaginable in the US. It evolved over time. It's nobody's fault. It's everybody's fault. It needs to be burned down and rebuilt. It seemed like we had a chance with the ACA but it was pretty clear early on that it wouldn't fix the root causes and it hasn't.
[+] [-] wincy|6 years ago|reply
I interviewed a couple of them and one talked to me for an hour about health and diet and exercise, just a friendly chat to see if I wanted to use him. He said he was getting ready to retire from medicine after years of ER work when his doctor friend encouraged him to try direct primary care. It was so different than the regular medical system, cutting out all the middle men.
[+] [-] assblaster|6 years ago|reply
The corporitization of physician practices is destroying the profession.
[+] [-] yayajacky|6 years ago|reply
[+] [-] dantheman|6 years ago|reply
We need to open up the medical profession to competition and allow the # of doctors to meet the demand.
[+] [-] tpfour|6 years ago|reply
There is also the money. Sure you can train 10-100x physicians, but total compensation won't grow as fast, and so you should see lower overall wages (supply and demand). But it's still more complicated than that, because some people choose not to undergo X or Y procedure for various reasons, insurers don't cover or whatever. So even if you could train enough doctors to fulfil the whole population's needs, that doesn't mean you will have: 1. enough equipment, material, operating rooms, etc to do the procedures 2. enough supporting staff, and on and on.
The most common reason I hear from MDs against training much more doctors is the first one I gave you: less practice means a more dangerous practice.
My own opinion is relatively simple. Medical schools should stop screening applicants as much and let students join freely.
Medical schools are all about getting well-rounded individuals who did extra-curriculars etc. They usually view it as a good thing that you have life experiences outside of medicine, like working or studying an entirely different subject. However it works one-way: you can't (generally) just go to med school, learn the subject matter and then move on to another field, enriching _that_ one with your experience. I have come to believe that if we are to see any improvement, med school will have to open up just like every other discipline. The current system of stressing out students for a few years before even being allowed in the classroom is, IMO, partly responsible for the job dissatisfaction that you see.
Now freeing up med school admissions does not mean allowing everybody to _practice_ medicine. Prospective students would actually get a chance to learn the material for a few years before having to interview for internships. So instead of filtering _before_ med school and forcing a huge sunk cost psychological barrier to students, you can let the students figure out by themselves if they actually enjoy the subject matter. It's not a perfect solution but I am quite certain that society as a whole would benefit. It is entirely unfair that medical knowledge (not practice) is restricted to a lucky few.
[+] [-] jseliger|6 years ago|reply
But, from what I understand, the number of residencies is the big choke point.
[+] [-] nerdponx|6 years ago|reply
[+] [-] DiabloD3|6 years ago|reply
[+] [-] SkyPuncher|6 years ago|reply
Less than 80% of candidates match into a residency. That means 1 in 5 doctors are blocked from practicing.
[+] [-] frenchyatwork|6 years ago|reply
The problem with medicine is that you have a culture of perfectionism in a field where random bad shit naturally happens all the time, and there's a great amount of human suffering. On top of that, perfectionism helps a lot, in the short run, even though it may be toxic in the long run.
[+] [-] jshaqaw|6 years ago|reply
[+] [-] Psyladine|6 years ago|reply
Sure enough you have conglomerate health services corporations absorbing small practices, cheaper prices for consumers with added bureaucratic noise & volume thresholds for practitioners.
[+] [-] husarcik|6 years ago|reply
[+] [-] ZhuanXia|6 years ago|reply
[+] [-] arkades|6 years ago|reply
There are four major groups of physicians:
-Residents. These are the folks that just completed medical school, and are doing four-plus years of training in a hospital setting to become independently practicing physicians. In year one they are called interns. By year three or four they have various amounts of independence: in internal medicine, family medicine, etc. they are basically practicing as full physicians, with some light supervision (the heavy supervision is years one and two). They are one of the hospitals most valuable employees: taking into account supervision costs, they are producing about 80-90% of the revenue of a "real" physician, for less than 1/4 the cost. These are the guys who work 80+ hours per week without exception, do all the scut, etc. These are not "mid career physicians". This is where "old physicians had to go through it, so young physicians have to go through it."
--Resident Training: the AMA has been pushing to expand resident training spots for years. The funding is part of Medicare legislation, and no one has been willing to back expanding medicare spending in the name of training physicians. I know the AMA has been backing this because I've attended the Region 7 and national meetings where the resolution to push for it has been passed, repeatedly. Literally, hit DDG and enter "AMA restricted residency training funding" and your entire page of results is the opposite. They may have done so more than a generation ago, but... let's move onto things that were done by, and affect, people not currently retired, eh?
-Hospitalists. These guys have completed their residency training, and elected to work for a hospital, doing in-hospital medicine. Their specialty is "hospital medicine." They have no private clinic, no private patients, and are paid a salary by the hospital. Whether this is an integrated system like Kaiser, or ... every other hospital in the market, they're very common. Their practice patterns are heavily dictated by the hospital, which is heavily dictated by the Centers for Medicare/Medicaid Services and the major insurers. Their work is increasingly focused strictly on documentation, since documentation is the way that CMS and insurers (a) find excuses to refuse reimbursement, and (b) the way that CMS and insurers outsource collection of "quality" information, by forcing docs to structure their input in very discrete ways. These physicians don't have to deal with billing directly, but they are constantly being pulled into trainings for the ways documentation requirements are constantly evolving, the ways in which payors want them order tests and in what order, etc. They constantly get phone calls from "helpful billing people" raking them over the coals whenever there's a mistake. THe hospital keeps running tallies and reports on doctors' mistakes in this arena, aiming for public pillorying and, ultimately, withheld wages. (Docs don't generally get bonuses, they get withheld wages - except for high-revenue services like procedures, where they may get a bonus for very high productivity.) These are "mid career physicians." They tend to work an official 10-12 hour day, ten days on, ten days off. In reality, due to documentation requirements, and the fact that they get more patients than anyone could ever see and document in 10-12 hours, they tend to work 14+.
-Private Practice. These guys completed their residency and either opened their own private practice (almost no one can do that these days, with the complexity of the documentation and EMRs required by CMS and insurers, and attendant overhead costs) or have become employed by such a practice with the medium-term goal of buying in as a partner. They are likewise having their arms heavily twisted by insurers and CMS, without any sort of leverage to fight back and negotiate better terms. These guys are going out of business left and right. These are "mid career physicians." Hours worked here are highly variable, depending on the specific practice pattern, number of employees and partners, etc.
-"Private Practice." Because of the complexities and overhead that are now required to stay open, many practices... can't. They sell to a local hospital - often at cost - and become hospital employees. The hospital offers solid salaries for the first couple of years, and then drives them out, replacing them with younger employees. Many of the "private practices" you go to are thus actually practices run by the hospital, with an employee acting as the physician. These are "mid career physicians." These tend to work 9-5 with one evening hour a week, or none. The spread of this is why no one can find a doctor to see in the evenings anymore.
Key to Understanding Medical Reimbursement:
This is not a free market. It is fee for service. You get a patient visit, it is coded as a particular service (usually a Level 3 Evaluation & Management), and a fixed amount of reimbursed, assuming you meet various documentation requirements. If you do not, the amount is decreased or denied altogether. Private insurers peg their fee schedules to CMS, so CMS - directly or indirectly - drives all physician reimbursement. If you own a geographic area (such as part of a sweeping hospital network), that network will negotiate better reimbursement (e.g., "112% of Medicare"), but that is not passed along to employee physicians. Total revenue for a physician is amount of work-time per year divided by time-per-average-service, times reimbursement-per-average-service.
That's it; that's your cap.
Thus, most services patients want are strictly cost centers. The sort of things that other businesses compete on - e.g., ambiance, good front desk staff - are problematic for physicians, because you can't pass that along to patients in moderately higher prices. The only way you can compete on service, and be free to set your prices accordingly, is to refuse all insurance and only take cash patients. There are vanishingly few such patients, largely due to a cultural expectation that insurance = healthcare. Actually paying cash for a primary care physician, at least, isn't that expensive, but since that doesn't cover all of your other healthcare costs, who can afford to pay that extra premium? Only upper-middle-class and up.
[+] [-] trey-jones|6 years ago|reply
He gave a specific Urological example of a technique that was developed at MIT and took 6 hours, impractical for all purposes. European doctors have since come over and trained US doctors on a means of the same outcome that takes 1 hour.
My first thought was that the stagnancy of the field would contribute to burnout, but thinking about it more, I think just living under the imminent threat of malpractice lawsuits is probably enough.
[+] [-] beerandt|6 years ago|reply
Forcing doctors into a workflow dictated by software is what's causing 12 hour days to turn into 16-18 hour days, with no additional pay, and no reduced hours to compensate.
Also results in doctors focusing on the computer instead of the patient.
You didn't see burnout levels increase until electronic charts were forced.
[+] [-] Ghjklov|6 years ago|reply
[+] [-] jackcosgrove|6 years ago|reply
Genetics is out of everyone's control. But the fact that 1/6 of the American economy is focused on that 10% is mind blowing.
The best ways to improve your health are to eat less, eat better, and exercise more.
[+] [-] wavepruner|6 years ago|reply
[+] [-] 6gvONxR4sf7o|6 years ago|reply
If the market expects you to do things that aren't worth the wage, but you spend a decade and half a million dollars on training and switching to something comparable would take a ton more time and money, well, then you probably won't switch careers. And if too few people switch then there's little market pressure to adapt.