Below, an excerpt from an article in the most recent (December 23 ) New England Journal of Medicine titled “Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List, by Howard Brody, M.D., Ph.D. ” (At the end of the excerpt, I offer my commentary. )
“Early in 2009, members of major health care–related industries such as insurance companies, pharmaceutical manufacturers, medical device makers, and hospitals all agreed to forgo some future profits to show support for the Obama administration’s health care reform efforts. Skeptics have questioned the value of these promises, regarding at least some of them as more cosmetic than substantive. Nonetheless, these industries made a gesture and scored some public-relations points.
“The medical profession’s reaction has been quite different. Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians’ income would not be negatively affected by reform.
“It is appropriate to question the ethics of organized medicine’s public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the “special interests” affected by health care reform, justify demanding protection from revenue losses? . . .
“the myth that physicians are innocent bystanders merely watching health care costs zoom out of control cannot be sustained. What we now know about regional variation in costs within the United States suggests that nearly one third of health care costs could be saved without depriving any patient of beneficial care, if physicians in higher-cost regions ordered tests and treatments in a pattern similar to that followed by physicians in lower-cost regions.. . .
“ Physicians should recognize that the high cost of future medical care is one of the main stumbling blocks to the passage of health care reform legislation that would extend insurance coverage to most Americans who now lack it . . .
“In my view, organized medicine must reverse its current approach to the political negotiations over health care reform. I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty’s “Top Five” list. The panels should include members with special expertise in clinical epidemiology, biostatistics, health policy, and evidence-based appraisal. The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit. Examples of items that could easily end up on such lists include arthroscopic surgery for knee osteoarthritis and many common uses of computed tomographic scans, which not only add to costs but also expose patients to the risks of radiation.4,5
“Having once agreed on the Top Five list, each specialty society should come up with an implementation plan for educating its members as quickly as possible to discourage the use of the listed tests or treatments for specified categories of patients. . . .
“Some societies will be tempted to bluff their way through the Top Five exercise, deliberately omitting cost-cutting measures that would particularly affect members’ revenue streams. Societies could display their professional seriousness by submitting their lists for review and comment to several societies in other specialties.
“Some would object that considerably more comparative-effectiveness research is needed before such lists can be compiled and implementation strategies developed. And indeed, today we have no idea how to implement a practical plan that would recapture the roughly 30% of health care expenditures estimated to be wasted on nonbeneficial measures. I would guess, however, that if we were trying to save that entire sum of money, we would be proposing “Top Twenty” or “Top Fifty” lists for many specialties, not just the Top Five. I suggest that no matter how desirable more research is, we know enough today to make at least a down payment on medicine’s cost-cutting effort. As good citizens and patients’ advocates, we should begin where we can.
“A Top Five list also has the advantage that if we restrict ourselves to the most egregious causes of waste, we can demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply “rationing” health care, regardless of the benefit, for cost-cutting purposes. As we inched closer to the entire 30% savings, we would inevitably face increasingly controversial treatment cutbacks — cases in which a substantial minority of experts believed a treatment provided real benefits for many populations. Such controversies should be postponed until the evidence is clearer and a more acceptable national structure for adjudicating such debates is in place.
“Another objection might come from primary care specialties. Given the serious shortage of primary care physicians in the United States, due partly to the income gap between that field and others, shouldn’t societies of primary care physicians get a pass on the Top Five list? Although I’m sensitive to the urgent need for increasing the primary care workforce, I would argue that all physicians have ethical responsibilities. Showing that we are ready to stand alongside all other specialties in examining our own practices in light of the best scientific evidence is an important aspect of professional integrity and should not be avoided by any specialty.
“Finally, the best rebuttal to the antireform argument that all efforts to control medical costs amount to the “government getting between you and your doctor” is to have physicians, not “government,” take the lead in identifying the waste to be eliminated. Mark Twain said, “Always do right. This will gratify some people and astonish the rest.”
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My take: First, let me say that I consider the sums that Pharma, device-makers and hospitals have agreed to give up are relatively small when compared to what needs to be done. Many drugs and devices are hugely over-priced; many hospitals are extraordinarily wasteful. In the past ten years, private insurers have done little to rein in costs.
That said, Brody makes a good point: “Where are the doctors?”
If we are going to make our bloated health care system affordable, virtually everyone will have to give up something. There is no one villain in our dysfunctional system. All of us (including patients) are complicit. Just like members of a dysfunctional family, we are accustomed to things being done in a certain, counter-productive way.
I do agree that primary care physicians, geriatricians, palliative care specialists, pediatricians, psychologists, and others who practice “cognitive medicine” (listening to and talking to patients) are underpaid. But in order to stay afloat, many find themselves becoming more entrepreneurial in ways that may be hurting patients—and probably aren’t helping them.
For example, sometimes it’s more economical for a primary care physician to simply refer the patient to a specialist, and move on to the next customer, spending no more than 8 to 10 minutes with each. In some of these cases, the family practitioner gives up the chance to use what he knows about a patient he has been seeing for a numbers of years. If he asked questions, really listened, and explored the problem , perhaps he would arrive at a better diagnosis. He might be able to detect and treat the illness himself. At the very least, he could make a better referral. Too often, a primary care physician recommends a patient to a specialist who runs some tests—and refers her to another specialist. The patient may wind up seeing three or four specialists before ever getting a diagnosis that leads to effective treatment.
So I agree that primary care doctors and others in this group should come up with their own list of the 5 most wasteful practices.
At the same time, I think we should boost the incomes of doctors who practice cognitive care by paying them significantly more for the time they spend explaining risks and benefits to patients, answering phone calls and e-mails, advising families on how to care for patients at home, talking to patients about how to participate in their own care, and most importantly, counseling, consoling and caring for their patients. Net, net, these physicians should see their incomes climb so that they don’t feel the need to find other ways to boost the bottom line.
What I like most about Brody’s idea is that it asks specialties to begin to put their own houses in order.
There is a limit to what we can accomplish through legislation. Physicians know, better than anyone else (except, perhaps, nurses), where the waste is in their own specialty. I think of how anesthesiologists reduced patient risk by examining their own practices, and figuring out how to make their patients far safer. (The number of lawsuits fell dramatically.)
While we wait for health care reform to become a reality, three or four years from now, physicians should seize the opportunity to lead reform.
I’m a family doc. I’ll be happy come up with the list and live by it as soon as society increases my salary by 50%. Deal?
j smith–
I’m afraid that the post wasn’t entirely clear. Thiis is not about what woldl be best for you. This is about what would be best for your patients.
Going forward, physicians are likely to be paid more for better outcomes, as part of “bundled payments” to doctors and hospitals.
Doctors who are good at working with other doctors and hospitals to provide better, safer and more efficient care for patients will do well. Doctors who have been hiking their incomes on volume (by “doing more” whether or not it will improve outcomes,), will probably see their incomes drop.
But let’s address your concens regarding your income. .
Mecicare now has proposed raising primary care fees by 4% next year (Jan 1, 2010). Privae insuerers generally follow Medicare’s lead on fee increases .
Reform legislation calls for lifting pay for primary care by 5% to 10% when reform rolls out. (10% if you are practicing in an areas where this ia shortage of primary care docs.)
Between now and then, I woudl expect another one or two 4% increases.
Compounded, this could mean an incrase of 16% to
22% over the next three years.
Today, aveage salary for a primary care doc in the U.s in the mddle of his career is around $150,000 to $160,000.
Do you need 50% more– $225,00 to $240,000 in order to live comfortably? (That’s assuming you are single. If you live with someone who also works, your joint income would be much higher.)
I live in Manhattan where I know many people who live very comofortably on less than $200,000, joint income (including yours truly).
I understand that some people feel that they need to earn much more than that to live well.
If that’s the case, they shouldn’t have gone into medicine.
By 1990, it was clear that medicine was no longer one of the most lucrative careers. Any bright young person could earn far more–with much less effort and education– by going into the financial world.
As a society, we just cannot afford to over-pay some physicians because they made a bad career decision.
I’m an internist…
Lets start with basics.
How about stop screening mammograms in women in their 40’s with no risk factors and no symptoms..
Oops thats right…society doesn’t really care about best evidence..
Maybe the doctors are showing up….and no one wants to listen.
Maggie,
Some of the problem with your argument is that some reasonable salary is needed to attract people to an occupation that requires 8 years of training at considerable expense followed by 3-9 years of residency. If you cut salaries too drastically, then you will certainly get less qualified candidates to enter medicine (unless you want all your doctors to come from Pakistan and India where the educational costs are considerably less). You may create some of the same problems that are currently affecting primary care in some of these specialty areas if you reduce salaries below a level that accounts for all this extensive training.
One could consider other alternatives, however, to cut training time and cost. Many European countries do not require 4 year of undergraduate training to enter medical school for instance. Who has decided that this requirement should be foisted on people training for medical careers? Is it justified to subject students to potentially an extra 50-100 grand of cost and 2-4 extra years of lost income while they attend undergraduate education programs? Has no one looked to see if this can be accomplished more economically, thus reducing the heavy debt burden and time committment devoted to such a carrer?
One suspects that one part of this cost equation that has been ignored is that of educating physicians, and educational institutions have shown no desire to become more efficient since most benefit from having students complete this four years of undergraduate training (most medical schools are attached to larger universities offering these four year programs).
Look at the fact that nurse practitioners can be licensed to prescribe medications after only 6 years of training and that nurse anesthesists can make more than primary care docs after the same 6 years of training. Many medical schools have 6 year programs that are very sought after by high school graduates who have a clear desire to become a physician, but have not expanded these programs.
Cut the cost of time and training and you take away one of the major resons that specialists claim for their reequired high compensation.
Secondly, I would hope our goverment takes into account the cost to physicians practices as they dictate the details of this coming health reform. Goverments are good at passing unfunded mandates, and as they pass on more beuracratic burdens, they reduce the pleasure of practicing medicine and decrease the amount of compensation that physicians can make.
I know this avoids your argument that physicians should put their patients needs above their personal needs, but physicians do not exist in a vacuum; they have families that depend upon them and children that need to attend college (with usually no financial assistance in their income category forthcoming). And other institutions that add to the economic burden of what are considered physician cost need to be held accountable as well. Continue to make medicine less appealing as a profession with micromangement and reductions in salary and I fear you will not like the results.
I work as one of those primary care physicians, and am very content with my current income level, but I could very easily lower my costs if I wasn’t paying exorbitant levels of malpractice insurance and having to spend a large part of my income jumping through insurance company hoops to get paid. Over the course of my career, my net income after expenses has gone from 60% of gross collections down to 40%. And now the payers want me to jump through more hoops in terms of measuring quality and buying expensive (and unproven) information systems. Yes, some physician specialties are overpaid, but to suggest an across the board approach of cost reductions is too simplistic an approach to a much more complicated problem.
Keith & Jordan–
Keith–
Neither I nor Dr. Brody are talking about an across the board cut in physicians’ salaries–or even in specialists’ salaries.
As I have written many times before, that would be a crude solution. We need to make cuts with a scalpel, not an axe.
Dr. Brody is suggesting that physicians wield the scalpel–in their own specialty by trying to begin to eliminate wasteful services. Many physicians have told me that they know where the waste is in their own area of expertise.
As for the requirement that doctors receive an undergraduate education . . .
When U.S. students graduate from high school, even many bright students can barely write. Their analytic abilities are limited. Many know little history, less literature.
In Europe, students undergo a much more rigorous education before going to college–as they do in Canada.
(My son has taught undergraduates at Cornell, where he had a number of Canadian students. My daughter attended McGill in Montreal. Both there impressed by how well-educated Canadians are by the time they enter college: they can write; they are relatively well-read; they can make an analytic argument.
They go to school for 13 years before going to college (high school is 5 years instead of 4) and the curriculum is much more demanding.
At McGill the curriuculum is also more demanding that at a U.S. university like Yale or Harvard.
As an undergraduate majoring in English, my daughter was required to take 4 semesters that covered the history of English literature from Beowful to Virginia Woolf. The major also required two additional seminars in pre-18th century literature. Like all undergraduates, she had to take science and history and a foreign language (Or pass a foreign language exam.) She was constantly writing: one semester she wrote 17 papers. Gradiing was hard.)
When she graduated she began teaching in NYC’s version of “Teach for America.” There were a number of Ivy League graduates in the program with her. It was then that she fully realized what a good education she got at McGill.
The notion of letting U.S. students go directly to medical school, without having the opportunity to learn something about the world . . .
As it is, some of the best medical schools are realizing that they need more pre-meds with a rich background in the humanities.
As for “bureaucratic burdens” most reformers are urging physicians to join large accountable care organizations where they have relatively few bureaucratic burdens. They are on salary, and someone else deals with insurance companies, billing, etc.
Finally, these days a great many jobs require college and a post-graduate degree that typically takes 5 years
These Ph.D’s are never as physicially strenuous as medical education, but often are intellectually just as demanding and stressful (especially when you know that your chances of landing a job when your finish are less than 50%).
As for the notion that the quality of people entering medical school will decline if they know that they are likley to earn “only” $250,000 to $300,000 a year rather than the $400,000 to $600,000 that many specialists earn, mid-career, today . . .
All I can say is that students entering med school over the past 15 years did not have as high expectations regarding income as those who entered med school in the 1980s. Yet I would say that the quality of applicats has, if anything, risen.
“Making money” is no longer one of the two or three top reasons for going to med school–by the 1990s, it was clear that there are much, much easier ways to make a high income.
Finally, as I have said before, I favor more scholarships and loan forgiveness programs for med students, in part to attract students coming from different backgrounds, in part so that students don’t emerge from school with large debts.
The Senate bill, by the way, has greatly increased funding for med students.
Jordan–
If you go back and read the posts Naomi and I wrote about mammograms, you’ll see that breast cancer is one of the most sensitive subjects among the general public.
For all sorts of psycho-sexual reasons, men as well as women are horrified by breast cancer. The breast represnts maternity, beauty–the though that it could be linked to death is just very upsetting for many people. And for decades, we have been telling women that if they just have annual mammograms, they’ll be “safe.”
By contrast, if orthopods got together and drew up guidelines regarding knee surgery and osteoarthritis, I doubt you would hear a huge outcry.
Some back surgeons have become much more conservative about back surgery, warning patients that there is a very good chance that it will do absolutely no good.
Again, you don’t read newspaper stories about back surgeons “rationing.”
Pediatricians have become much better about prescribing antibiotics for ear-aches. (I’m not a pediatrician, but I’ve been told by pediatricians that in the U.S. we too often give the child an antibiotic when what he needs is a painkiller. Perhaps we need guidelines here.)
Particularly if the decisions are coming from within the specialty, most Americans will accept the notion of specialists drawing up guidelines.
Three related perspectives on this issue.
1. I attended college for four years, medical school for four, followed by a year of internship and two years of residency in internal medicine. My subsequent career included a variety of clinical responsibilities (none in private practice), but has mostly been spent in biomedical research, to the point where my children claimed that M.D. stood for “mouse doctor”. I never earned what my fellow M.D.s earned as practitioners, but I’ve had a comfortable quality of life. I never envied them, because I assumed that I might have earned far more than they if I had become a corporate CEO or a Wall Street investment banker. I still think they and I went into medicine with the knowledge that we were sacrificing earning power for the sake of some other objective. That appeal has not vanished.
2. At the same time, it seems to me that the non-financial gratifications of medicine have been diminished over time by the encroachment of changes that have rendered medicine more impersonal – technology, paperwork, and fragmentation of effort – all of which distract from physician-patient interactions and the rewards of seeing one’s efforts culminate in observable benefit to a living human who sought help. More and more, that person is likely to be somewhere else in the system when the good work is finished. It’s therefore understandable why income has become a larger component of the reward system. To reverse this trend will require attempts, I believe, to reduce both the administrative burdens and the fragmentation. The proposed reforms will perhaps accomplish some of this – by more standardized insurance forms, increased exploitation of information technology, and integrated patient care via accountable care organizations, “medical homes”, etc. – but how successful these attempt will be remains to be seen.
3. Finally, the infusion of 30 million more insured individuals into the system will aggravate the problem of excessive tests and treatments on a per person basis, because many of these individuals will now seek medical help that they had previously found unaffordable. In that sense, the ultimate goal of achieving an actual reduction in total healthcare services for the population as a whole will need to be subordinated to the more immediate problem of preventing the total from expanding so rapidly as to overwhelm the system. For that reason alone, it will be imperative to achieve the efficiencies described in the NEJM article. At some point, we can begin to shrink the system, but if we are adding 30 million more consumers, we must first make sure we’re not causing it to explode.
Primum non nocere.
I’m seeing 30 patients today in my full time internal medicine practice. It’s not the end of the day yet, but I’m going to guess that about a third of these visits could have been handled over the phone (and if skype were possible, a few more could have been handled that way). But, I don’t get paid for phone calls.
Annual physicals with labs for healthy people are unnecessary–but they pay more than does seeing the elderly slightly confused woman on a bunch of meds. I would much rather spend my time with people who need it, but, you could go bankrupt that way. Even if I accept a smaller salary, I still have support staff who are trying to get by.
I have about 15 years left in me before I retire. In that time, I don’t expect to see things change to the point where what I do is valued more highly. Sadly, I just hope things don’t get worse.
Yes, I’m sure I order tests and make referrals that are unnecessary. Not deliberately IMO. Probably the most expensive thing I do is order following imaging (MRIs, etc) at the behest of the radiologist who finds some incidental blip on the original study that has nothing to do with the patient’s real problem. And, if asked, yes, I will refer a patient back for the annual checkup with the cardiologist for his benign murmur, so that he can get the annual, unnecessary echo and stress test. And, in terms of the big picture, even that’s not as expensive as say some of the big, unnecessary ortho procedures that get paid for.
Well, enough ranting. Ten more to go.
Thank you for this post that discusses the elephant in the room that we all seem to often ignore.
The health care problem = too much cost per citizen.
I like the idea but I need to understand it better. I ask the following: some docs are expected by their health system to keep the volume up and if they don’t, they will be suffer. How does the suggestion of top 5 address that issue?
I heard once that a hospital administrator told a doc, “Well if you cant do than many of X, then you have to do more of Y.” The equation of X vs Y was directly related to medicare reimbursement for the two procedures and had nothing to do with need.
The doc stood by his principal, said no to a defacto quota system and was flatlined in his career, disrespected by his peers, and had his income cut in comparison to his peers.
How do we address the systematic issue, not just the doc issue where one tree standing simply gets cut down?
Better question, what entity acually rewards pay for more medicine? How many docs are paid directly by insurers and how many are paid by an intervening entity like a hospital or practice plan or whatever?
Indeed, where does an administrator get nicked in the proposed changes to pay for procedure vs pay for outcome?
I largely agree with these points. I think for primary care providers it will require more soul-searching than for proceduralists; to me it’s easier to set up appropriate guidelines for who will benefit from a cardiac catheterization or knee surgery than it is to decide which people who have recurrent dizziness need further imaging and a neurology referral and which need observation only, but maybe I feel that way because I’m a primary care provider. I would put on our top 5: annual “physicals,” annual lab tests in most patients, antibiotics for bronchitis, referrals to specialists when unnecessary, PSA testing (the urologists certainly wouldn’t agree with that). But as is pointed out by Jordan, the minute we try to bring rationality to the discussion we are accused of caring only about money and not about patients.
Along that line, I also think that although we as physicians need to advocate for ourselves for better working conditions, we need to keep our concerns about our incomes out of the public debate. I’m very frustrated with physicians who lump in better salaries for themselves along with things that are truly beneficial for patients. Although some make an argument that well-paid doctors will take better care of their patients, the truth is that there are plenty of people happy to work in a job where they are in the top 1% of the income bracket regardless of their specialty. The disparity between cognitive specialists and proceduralists is problematic, but should not be the only thing lawmakers hear about from doctors.
When I have spoken with my legislative representatives, I have heard multiple times that they don’t often see physicians whose primary concern is their patients’ access to care. They hear over and over again about reimbursement and paperwork. Although those are important things, we have really lost our way if that’s what we’re known for in Congress. That puts us on the same level as the insurance and pharmaceutical industries.
Let’s start thinking about how to help patients better. If things are better for them, things will be better for most of us; the exception will be proceduralists who provide unnecessary treatments.
Maggie,
With all due respect, this post seems to suggest we should all come up with 5 thngs we do in our individual specialties that have limited or no proven benefit. If indeed this was followed through on, then we would all essentially be committing ourselves to reduced income. And as you point out, there may be some areas where the list can be extended to more than 5. Does that mean that these areas continue to waste health care dollars on those extra items that are worthless just by virtue of having so many worthless endeavors to begin with? That is what makes this suggestion so arbitrary, although I understand that the author is saying physicians need to be involved in identifyng the areas of waste and redundency. It needs a more comprensive solution than this.
The USPHTFS has nicely laid out the clinical evidence for many of the procedures and tests done in medicine having graded many of them as to the evidence supporting their clinical effectiveness. Why not simply start with their analysis, beginning with those items that cost health consumers the most in dollar amounts and start working down the list? This is why comparitive effectiveness research was, in my mind, so essential to health care cost containment!
The other side of the coin also needs to be addressed as well, which is what about the things that are clearly proven and cost effective, but insurance fails to adequately compensate? Do we providers get to state the items we feel would be best to compensate physician for that presently do not get paid for?
As concerns my other suggestion regarding trimming year of education,while not all high school students are prepared for medical school right off the bat, there are clearly many bright kids that are focused and mature enough to enter medical training after 2 years of college. I would propose that students have the option of applying to medical school after 2 years of liberal arts education if they so choose, and if they have the credentials and maturity to begin. Medical training is so long and rigorous it is better to learn the skills you need early on and have a longer term to begin earning a living and repaying educational debt.
Your argument about how well students are prepared in European countries says alot about our educational system. If true, we do not invest enough on pre- secondary education only to have to spend an enormous amount on post- secondary education to catch back up. Not a wise use of our resources, since this post secondary debt is one of the excuses for specialists demanding higher wages once they finnish their education, and medical students selecting medical specialties once they graduate. At any rate, to assume all students are ill prepared coming out of high school for a medical education ignores the fact that the Europeans seem to do it and have better medical outcomes than we do in this country. Are we an inferior race?
You completely ignored my statement about physician overhead costs as well. What does it say that there have been such dramatic tilts in what physicians used to take home as pay vs the overhead expense? Many of these expenses have been foisted upon MDs and have driven up the costs of health care. I am not allowed to practice medicine (or it is damn hard) unless I have malpractice insurance. I have to tolerate the insurance middle man who does all he can to delay payment for legitimate services, thus playing a very expensive game that drives up overhead for pracitices. How about legislation regulating the health care process that would give physicians relief from these practices in exchange for reductions in fees? And how come no attempt to deal with tort reform?
By the way, you failed to mention that all those other entities who gave up funds got something in return. The hospitals got 30 million more insured patients they don’t have to take care of for free. The drug companies got the donut hole filled for pharmaceuticals and the goverment does not get to negotiate the costs of the drugs. Medical device makers had no cost constraints placed on their supposed tax, so what is to keep them from just adding it to what they charge for these devices? I don’t recall any offer to doctors of a similar exchange. The only promise I am aware of is a promise to fix the SGR and it remains a promise unfulfilled.
Maggie, It is not about what I need. It is about what medical students want(or think they want.) It is about supply and demand for physician labor.
Please see Dr. Mark Ebell’s short JAMA article. Fill rates for residencies are highly correlated with starting salaries. That’s the reality that must be faced. It’s the money, Maggie. Docs might say it’s not, but it is. You can exhort us to be self-sacrificing until you are blue in the face, and we will smile and nod and agree with you to your face, but, at bottom, it’s not going to happen.
How much money is enough? Well, that’s an individual matter. You and I really have no say in this matter. It is up to the individual medical students who are making their specialty decision.
The solution lies not in jawboning. As I am sure you know well, the solution lies with structuring incentives so that doctors can increase or at least maintain their own incomes while simultaneously decreasing overall health care costs. That’s the way ahead. The ball is in society’s court.
I get the feeling that M.Ds’ in many blogs are unhappy and rant. PCPs feel so overwhelmed with their loads of paperwork and significant part of their work is undervalued. Sadly, the efficient PCP who can handle the arrythmia, heart failure, inject joints, lance a abscess is penalised in current system. I recently met a great primary care doc who is a great clinician, handles mutiple conditions appropriately and seldom needs consults. How can our system reward such people? It will be extermely difficult to address such things. My dad trained 3 decades ago, he is an anaesthesiologist but handled rashes, bronchtis, dislocated shoulder and several other medical issues with great ease. The current medical training had become too narrow and referrals have become a knee jerk reaction. In fact it should be the internist who should train a little longer since they have to handle a wide array of issues. This would in turn cut the number of specialists needed.
Maggie,
I understand your arguments about breast cancer screening being different but I think you are wrong in assuming that there will not be an outcry when we as physicians use evidence based medicine. Here are five examples of things I do as an internist that limit uneccesary spending and I believe improve patient care:
1)I generally don’t prescribe antibiotics for run of the mill pharyngitis,sinusitis, bronchitis
2)I discuss PSA tetsing with my patients and have cut down 50 percent ont he number of PSA’s I have ordered over the last year
3)I do not suggest screening colonoscopies in otherwise normal risk patients after the age of 76
4) I do not do screening ekg’s or urinalysis on asymptomatic low risk patients
5) I limit the number of ct scans and stress tests I order based on need as opposed to patient preference
And what do I get for this…Angry patients who generally self refer themselves to a specialist and end up getting antibiotics, colonoscopies, ekgs, and cat scans anyway.
The truth is that evidence is great as long as it is someone else. The public thinks differently when they are dealing with their own medical problems.
Also specialty societies have historically been one of the main purveyors of self serving, evidence lacking, expensive guidelines (radiologists will suggest mammograms, urologists will suggest PSA’s, cardiologists will suggest stress tests!). I think it is naive to let the specialty societies lead the way.
The USPSTF or similar bodies are our best chance. And remember although PCP’s are not without flaw…we are the only ones who don’t financially benefit from increased testing and consulting.
J Smith is right on the compensation issue. Until primary care docs are well paid relative to their peers, I’m not sure the US will see the shift it needs in medical students choosing primary care. To deny this reality, that medical students like everyone else are concerned about their incomes and lifestyles, is a non-starter.
I agree that moralizing from on high does not help the situation. Nor does it change the facts on the ground. I posted on this specific issue a week or so ago, but the post and Maggie’s response seem to have disappeared from the Blog… Otherwise, I’d point everyone to it.
Maggie, can you please re-post those postings? They were in the comment section of your Dec 20, 2009 post: Glass Half-Empty, Glass Half-Full, part 3–Older Americans at Risk.
To Jordan: I would add that, unfortunately, PCPs do benefit (albeit indirectly) from increased testing and consults, in that they can see more patients in less time, thus increasing the revenue stream to pay the overhead. This isn’t only because they sometimes feel they can spend less time with a patient if they’re referring or testing; they also don’t have to spend 5 minutes per patient explaining why they don’t need a consult or test. I have certainly done some referrals merely for “patient preference,” and though I hate to do it, I know that they will simply find someone else who will if I don’t, creating even more over-utilization.
To JSmith: although many people will always follow the money, there are plenty of people who are interested in primary care but choose something else, either because of loans or lifestyle/job satisfaction (or both). If we made primary care less of a treadmill and offered all primary care physicians complete loan repayment in exchange for service we might see more students who are interested.
SharonMD,
You make a common error by failing to recognize that, in primary care, money and lifestyle are two sides of the same coin. Suppose you’re a grunt family doc working 55 hours per week and making 150k. A lot of us have been there or are there at present. Not much joy on that particular treadmill. Now suppose Dr. Grunt’s income is doubled. Now you have choices. You can continue to abuse yourself but enjoy more crass consumer items (or pay for your children’s education at a private university, which at 150k is out of your price range), or you can work half as much, thereby getting off the treadmill to a great extent, and still afford send your kids to State. A much better situation indeed. “Well, young med student, you can have that life if you wish it, but not if you go into primary care.”
Don’t buy the loan repayment claptrap. Medical students know arithmetic. They know that 150k-200k in loan repayment is peanuts compared with the income that generalists forgo. It’s the money, Dr. Sharon.
Looks like cardiology Society is suing HHS Sebelius for the cuts in reimbursement for nuclear stress and Echo studies. Most private cardiologists own these equip and many asymptomatic patients are subjected to these tests, I wonder how you can get societies to come forward with sensible comments if some socities are behaving this way.
As a former high school math teacher (very briefly many years ago) at a girls Catholic high school, I can tell you that trying to teach Algebra to a 15 year old girl who is not interested is a waste of time for both the teacher and student.
Most European countries don’t maintain the same fiction that we do in the US – that all students are capable of going to college. As far as I know, in most European countries kids are segregated based on tests into those that are thought capable of going to the University and those that are not. The latter group are funneled into trade schools, not into academic programs.
My politically incorrect solution to the 15 year old girl who has no interest in learning is that she should be Norplanted and allowed to go out into the work force. After a couple of years of flipping burgers (or some other dead end job) she should be allowed to come back to school and learn things that will help her get a better job.
As for Keith Sarpolis’ suggestion that College and Med School could be cut to 6 years, I think it is perfectly valid. There were in fact programs like that in the US in the 70s. One of my partners went to one. He is not noticeably more stupid, uncultured or otherwise “not up to snuff” than other docs I work with. He may not be as smart as a Canadian, but being from Buffalo, he does at least like that most intellectual sport favored by our Northern neighbors – hockey 🙂
responses are fascinating in that they seek ways to add complexity of a very simple suggestion — each specialty should focus on a list of things done now that could be eliminated and help contain costs. somehow this becomes a broad discussion about medical education, relative incomes of different types of physicians and suddenly requires annual Jackson Hole conferences to set an agenda. this is typical of the entire broader debate where simple and helpful suggestions that could be implemented reasonably quickly, albeit not painlessly, morph into gigantic long-term projects that require years of study before the first results become visible.
“they seek ways to add complexity (to) a very simple suggestion …. that could be implemented reasonably quickly”
Ah yes, simple solutions that could be implemented quickly – I love them. Reminds me of the fable about the mice that want to put a bell on the neck of the cat – a simple solution that could be implemented quickly. Until one little mouse asks who is the mouse that will put the bell on the cat’s neck.
Fred & Sharon & RAy, Jim, Lurker, Jordan, Ed, FP, Keith, Concerned FP . . .
Rred & Sharon & Ray–
Thank you each very much for your insightful comments.
I hope others will read them.
What you say is true–and valuable.
I could repeat what you said here, but I would rather send readers to your comments above so that they can read them in full. (Please note: Sharon MD & Ray have made than one comment.. . All are well worth reading. )
Sharon ,Ray and Fred– again, thank you, Happy New Year, and please co tinue to share your insights with HealthBeat readrse. I appreciate you all.
Jim– I agree, adn thank you for speakingout.
My post was meant to be a post about unncessary procedures, not a post about doctors’ incomes.
As you point out, somehow, it ballooned into a thread about doctors’ incomes, in many cases ignoring questions about wasteful treatments.
As you say, the NEJM article was suggesting a fairly simple solution. It certainly wouldn’t work in all specialties, but even if three specialties did it well, that would be three steps forward.
I’m disappointed that so many readers shifted from what matters for patients (overtreatment) to what matters most for some doctors (income)
Lurker–.
Thanks very much for your candor.
I am sorry–it sounds as if you are one of many primary care physicians doing the best they can for patients in a broken system.
But your patients are lucky to have a doctor who is aware of the problems–rather than a smug physician who is totally clueless.
Because you are self-conscious about what is happening, when push comes to shove, and your decision really matters for the patient, my guess it that you do what is in the patient’s best interest.
Ed-
Most doctors in this country work solo or in small practices. They don’t work for a “system.”
Doctors who are urged to “do more” by the system they work for are, in most cases, working in for-profit hospitals–as well some non-profit hospitals (that have become very much like for-profit hospitals.)
Healthcare is more expensive in some parts of the South, in part because there are so many for-profit hospitals and doctor-owned surgical centers in the South. (Especially Louisiana & Texas)
In non-profit systems like Kaiser, Geisinger, Intermountain, etc. doctors are not encouraged to run more tests, do more procedures. . .
Medicare is working on ways to pay hospitals less when they don’t deliver value for health care dollars.
Keith–
First, thanks for asking some intelligent and , important questions and disagreeing with me without lashing out.
This is the sort of comment that makes me feel good about HeathBeat’s audience.
I agree that simply starting with the Preventive Services Task Force’s grading of the most important and least useful services would be very helpful.
The Senate bill actually does this: there is no cost-sharing (no co-pays and deductibles don’t apply) for preventive care that the Preventive Services Task Force grades as “A” or “B.”
I like the NEJM article that I excerpt in this post because it suggests that physicians can join in this effort of deciding which procedures (within their specialities) are done too often, with little benefit to patients.
My guess is that some specialty societies would do this, and do it pretty well. Others wouldn’t. But the ones that did would be making a real contribution to evidence-based care, much as the anesthesiologists made a real contribution to patient safety.
Yes, I definitely think that specialty societies should also name treatments and procedures that are underpaid.
My guess is that most of these would have to do with spending more time listening to patients, counseling them, explaining options, risks and benfits to patients.
I definitely think that we should pay doctors more for talking to patients on the phone and responding to e-mails that need a response.
On college education for pre-meds. I taught undergraduates English lit at Yale for 11 years. I can’t think of any of my students (and I had wonderful students who I liked very much and still remember) who were ready to go to med school at age 19.
My own wonderful children, who are now in their 20s, would not have been qualified to go to med schools when they were 19.
And they are very bright, were raised in a rich, loving environment (I’m their mother, after all! ) And they spent much time with my ex-husband who is an extremely devoted father, very intelligent, well-read, etc. etc. )
Undergraduate education gives American kids a chance to begin to grow up (and I stress “begin.”)
My son has been teachign udndergraduates for the last 5 years– he agrees, so this is not just a generational thing on my part. .
I also deeply believe that doctors need the deep background that comes with reading great novels, philosphy, history, anthropology, psychology etc. for four years. I realize that many pre-meds dont’ take these courses.
But med schools are becoming more savvy about the profession needing studdents who have a deep background int the “humanities”. Medicine, after all, is about caring for human beings.
A doctor’s job calls for a wealth of knowledge, and wisdom.
European countries generally spend more on education k-12–and have far more respect for edcucation.
K-12 teachers in other countries are respected in a way that they are not respected here.
So I agree– we’re not doing what we should be doing with regard to k-12 education.
On malpracice: the bill does give money to the states to explore how do address teh malpractice problem.
We know that capping awards does not solve it (see Texas).
I have written extensively on this blog about other solutions that should be explored. No doubt the states will do that.
As for what Pharma etc. got quid pro quod– I don’t think specialits should be looking for a quid pro quo for themselves, they should be looking for a quid pro quo for their patients.
(Meanwhile, the legislation does offer a 5% to 10% increse in parimay care reimburesments, plus increses in Medicaid reimburswemnts for primary care, plus bonuses for doctors who join accountable care organiaitons, establish medical homes, etc. etc. etc.
No question–Medicare will be raising pay for primary care docs.
And the SGR across the board cut for all physicians is dead.
Conservatives like to pretend it is still alive in order to spread fear about heath care refor
Jordan–
I seems to me that you are doing your part to reduce costs and lift the quality of care.
I continue to feel that doctors just need to stand up to “angry patients” who don’t like evidence-based medicine
You’re not a car salesman; you don’t have to curry favor wotj ecistpers
The vast majority of PCPS and specialists have plenty of patients’ lining up for appintments.
(I realize that doctors who are starting a pracice don’t necessarily have enough customers. But I woudl suggest that they need to join large mulitspeicalty accountable care organizations so that they don’t have to worry about recruiting patients.
Concerned FP–
I do remember your comment, and my response.
I didnt’ delete either (and I am the only person with the power to delete anything form this blog.)
But after there are a certain number of porsts on a thread, type-pad (the platofrm for this post), no longer shows them.
I’m sorry. My non-profit foundation doesn’t pay for the more expensive version of Typepad that would give comments a longer life.
To JSmith: I don’t think we disagree as much as you think we do. I think that there are plenty of medical students who will always go where the money is, but there are also plenty who would gladly go into primary care even though the pay is significantly less, IF they didn’t have to worry about their loans and also if we can improve primary care providers’ lifestyles enough that they don’t feel they have to work half-time to tolerate it.
I’m only 1 year out of my residency, so I probably don’t have the perspective someone would have who has been out in practice for years, but I think I have a good idea about how medical students choose their specialties, and the availability of loan repayment is much more powerful than you might think. Again, not for everyone, but for enough people that it could make a big difference. Lots of people go into medicine wanting to be primary care providers and make a calculation that involves student loans, salary, & job satisfaction and decide not to do primary care. But if we could make student loans go away as a worry, and job satisfaction significantly better, I don’t think salary would have to go up as much as everyone thinks.
I decided to go into primary care, am pursuing loan repayment through service, and have far more disposable income than my parents ever did. I have many classmates who made the same choice. Not everyone will make that choice, but I think we could make it easier for people to do what they really want to do by offering more loan repayment and restructuring primary care.
Students also may avoid primary care regardless of the financial situation. Alot of students just want to fix something, maybe they want instant gratification, some want to become an expert on a topic. During your training nobody remembers if they started someone on insulin and 3 months later their HgA1C was improved, but they dang sure remember the thoracotomy they participated in on a Gunshot victim. Watch Grey’s Anatomy specialty care is sexy. You can incentivize primary care all you want it’s hard to make checking a hemoccult or reconciling a medication list sexy. That is a much bigger problem. Those can be motivating enough to make students choose more rigorous residencies that are longer, take more call and work longer hours.
Hi Sharon MD,
I think you make an excellent point. The non-income, negative lifestyle issues associated with primary care are a serious deterrent to medical students choosing the profession. Also, the feeling that being a FP diminishes one’s prospects for advancement in academia is another deterrent. Not one of the 125 US allopathic medical schools has a FP as its dean. Canada boasts several, and last I checked a majority.
As for the income argument, I keep thinking about David Kay Johnston’s book Free Lunch. In it, he discusses all the ways that various corporations or wealthy individuals off load their expenses on the public. They call these costs “externalities.” They don’t officially show up on the company’s books, so the company looks more profitable than it really is because someone else is paying for its costs.
I look at primary care docs and think about the “positive externalities” associated with their practice. These are the “economic/societal goods” that flow as a result of their jobs…. Healthier work force means increased productivity (fewer days missed); less overall use of the healthcare system via preventive medicine means decreased overall healthcare costs to US which leads to increased international competitiveness; etc… Of course, I’m not an economist, but I suspect if these “externalities” were incorporated into the primary care doc’s compensation, the national shortage of primary care docs would disappear quickly.
Maggie,
I thnk we can agree to disagree, but remember that we are not talking about sophomore students doing brain surgery. We are talking about 6 years instead of 8 years until you hit residency, and then you still have several years of supervised training. Post secondary education has become too exorbitantly expensive to waste dollars on extra unneeded years of education. I value my years in undergraduate college, but we may be chasing off some very good doctors with the time and cost just to get to medical school. I also remember my need to concentrate on science courses and avoid subjects in undergraduate studies that might have made me a more well rounded person, but because I wasn’t as good at them and risked damaging my grade point average, I avoided taking these courses for fear of damaging my grade point average and chance of getting into medical school. Is that what we want for an undergraduate experience?
You can cut the cost and beuracracy of medical practice and likely get a better product, or continue the same old. Cutting costs allows us to spend more time doing what we do best, likely result in more income to the docs, and allows us to lower our costs. I figure if patients paid me at time of service without the paperwork needed for the insurance middleman, I could cut my fees by 30% and still take home the same amount of salary.
Regarding your comments about doctors just refusing to do studies that patients demand, you fail to take into account the fear of litigation when you anger patients with your refusal, and how patients often regard failure to perform tests as being incomplete and not thorough. Nothing puts doctors more at risk of litigation than angry patients. Until we have reasonable reforms that protect against such lawsuits, I do not see this will significantly change. As an internist, I do not profit from any tests I order and I have no procedure to sell other than my advice, yet I rarely decline a patients desire to have a test if I feel it will not subject them to undo risk. It is just too risky from a litigation standpoint to do this.
Here are two simple mandatory questions that need to be asked by your primary doctor during every patient visit. If your doctor does NOT ask these – find another doctor.These questions will change US medical practive and save a lot of money
TWO SIMPLE MANDATORY MEDICAL HISTORY QUESTIONS
Proposed by Dr. Rick Lippin, June, 2002
Propose that all health care providers (especially primary care providers) ask adult * patients two simple questions when taking the medical history during every patient visit. Using the JCAHO model for pain (JCAHO’s so called 5th vital sign) patents would report levels from 1 to 10. The questions are simply:
“ How are things at work?”*
“ How are things at home?”
1= “couldn’t be better”
10= “couldn’t be worse” (in crisis stage)
The answers to these questions could then lead to referrals and standardized tests for further diagnostic workup for stress and depression and they would not “burden” the primary care providers with a requirement to do a full exploration of the problems very likely to be elicited
* for students substitute word “school” for “work”
Dr. Rick Lippin
Southampton,Pa
Sharon,
Reasons why people become primary care docs vs. specialists and which specialty they choose are complex. When I was going through this process, financial considerations didn’t play role for me and I don’t think played a major role for most of my classmates. But I am sure you are more familiar with what med students are thinking now.
I went to Med School in 1975 wanting to be a Family Practitioner or Pediatrician. At that time my Med School was committed to turning out primary care docs who would practice in the state. I did a summer rotation in Family Practice during the summer of ’76 with a wonderful older GP. He did everything (surgery, OB, etc.) and I remember staying up at night with him to deliver babies. But working with him convinced me that I wouldn’t be comfortable practicing as he did – too much uncertainty. I was also part of the “Pediatrics Track” for those who were interested in going into Pediatrics and I spent the summer of ‘77 doing research with an excellent Pediatric Endocrinologist, treating diabetes, growth disorders, etc.
But entering the clinical rotations, I soon became disillusioned. Rotating through the VA Hospital and the renal service on Medicine turned me against Internal Medicine. I spend many months working in the Pediatric ER at the U., which basically functioned as a walk in Pediatric Clinic. I liked Peds (although my wife was not happy with all the “creeping crud” I brought home) but after a while, it also developed a certain monotony: earache, rash, vomiting/diarrhea – then repeat. Then on a whim, in my senior year, I took a rotation in Radiology, loved it and never looked back. At that time Radiology was undergoing a renaissance with developments in CT, Ultrasound, Angiography and Invasive Procedures. I was fascinated to be able to look into a body, deduce what was going on and sometimes even treat it. I immediately decided to sign up for Radiology and “the rest is history”.
I say this because some people assume that the reason docs become “specialists” is for the money. That was not true in my case – like you I did not come from a wealthy family and would have been happy (and made more money than my father) with the salary of a Pediatrician and/or Family Practitioner. My observation of my med school classmates was that their decisions also did not seem to be determined primarily by financial considerations. The jocks went into Orthopedics, the aggressive guys (rarely women in those days) went into surgery, those that were interested in the psyche went into psych, etc. Women tended to go into Peds, Psyche, Family Practice, Internal Medicine but not surgery. The best looking guy in our class with the perfect hair cut went into Plastic Surgery. OB/GYN was making the change from a primarily/exclusively male specialty to one in which women are in the majority. In other words, specialty choice seemed to me to be highly correlated with personality, interests, etc. Recently, I went to my 30 year Med School reunion and nothing I heard there made me change my mind.
Of course having gone to a state med school in the 70s, I came out of med school owing less than $10,000 (considering the quality of teaching we received, the number of people in my class and the amount of “scut work” we did in the hospital, I don’t think my education was subsidized – but that’s another story)
The only realistic talk I ever heard about choice of specialty and its financial implications/working conditions was given by the head of OB/GYN at one of our Univ. affiliated hospitals. He basically laid out the working conditions and salaries of all the various fields including primary care and the various specialties. He said: “I am not trying to tell you what specialty to choose, I just want to make you aware of financial and life style issues that they don’t teach you about in Med School so that later on you can’t say: ‘nobody told me’”
I think it is a shame that people would choose a specialty that they don’t like just because of money. I also think it would be a shame if people that truly enjoyed a particular aspect of medicine were forced into primary care – although I believe our country needs more primary care docs and fewer specialists in the future.
Regarding the main point of this thread, I think the “top five” concept is great, yet I agree with the comment that some groups will submit helpful lists, and others probably will not. My specialty society is the result of the now-decades-old merger of two groups. The first was an educationally-oriented society and the other was a political organization. As a result of this merger of academic and economic concerns, the list from my field might be self-serving. It is still worth trying for the reasons given.
On another subject not originally part of this thread, I agree with the physicians who believe four years of college before medical school is an unnecessary luxury. I must admit that the extra two years of electives were extremely enjoyable for me many years ago, and I did indeed take many classes outside my areas of strength, but it is hard to make a case that they made me a better doctor. A humanities professor might not agree, if he fails to consider what each of us reads and learns after our formal education is finished.
One must assume future physicians have already taken the most rigorous curriculum available in their high schools. All the medical school requirements can be taken by such talented students in two years of college (potentially less for those whose high schools offered advanced placement courses). I assume those requirements still include a year of college English. Also keep in mind that the first year and most of the second year of medical school traditionally involve intensive science courses. After that second year, the typical student would be 22 years old, and mature enough to proceed to study clinical medicine. Consider that fully-educated nurses are already in the work force at this age, having begun exposure to patient care several years earlier.
Of course, it is unlikely that decreasing the college requirement to two years would prevent medical schools from accepting, or even preferring, applicants with four or more years of college, but it would give the qualified and motivated younger student the opportunity to avoid amassing two more years of college debt.
And yes, K-12 education needs improvement for the many, but it is currently adequately preparing the few future physicians to make an on-time entry to the track described.
Nice post, thanks for sharing this wonderful and useful information with us.
Green Tea Diet
The reason that I posted my “two simple mandatoty questions” below is that it has been known for decades that up to 80% of visits to primary care doctors are stress related.
But the consensual denial between patients and their doctors continues. And the unnecessary tests are ordered and the unnecessary (and often unsafe) pills are pushed.
Dr. Rick Lippin
Southampton,Pa
Sharon, I was not referring to the decisions and motivations of individual doctors. Of course these vary. I was referring to the aggregate supply of generalists. In that analysis, what are important are the statistical factors that predict specialty choice. This analysis trumps what people say, what they say they believe, and even what they believe that they believe. Remember that people don’t really know why they do the things they do and will often come up with a convenient reason even if it wrong. There is a considerable psychological literature on this.
The cold hard facts are that starting salary predicts residency fill rates. Google Ebell JAMA. If we want enough primary care docs, the only way to get them is more money. Lifestyle factors are much less important –not in individual cases of course, but in the aggregate. Loan repayment, as far as I know, hasn’t been adequately studied. I’d be interested if someone else knows about this.
“If we want enough primary care docs, the only way to get them is more money.” -jsmith
That additional income may be welcome and deserved, but a complementary approach requires a reduction in specialist income through the variety of mechanisms that have been discussed in these blogs and incorporated into reform proposals.
The combined effect should be a reduction in average physician income, which in my view is something the higher paid specialties can afford, and the nation can’t afford to omit from the reform process.
Everyone– Since many of you are discussing the same issue, let me respond to all of you at once. (Later, I’ll add some individual responses.)
First, let me address the argument that med students ultimately pick a specialty based on how much they will make– that money is the primary consideration.
Reserach shows that this is not true of everyone. Students coming from low-income families are much more likely to choose primary care or family practice. And, they are very likely to want to practice in an area like the area where they grew up- a poor rural area or an inner city.
As this recent article from JAMA points out:
“Money is not the only consideration, . . . Medical career choice involves many factors. For example, students who grew up in rural areas and those with a demonstrated interest in caring for underserved groups are more likely than others to practice primary care.
” And students at public medical schools are more likely to choose primary care careers than those at private schools, as are students in rural as opposed to urban schools.”
Why are students from low-income famlies more like to choose famly practice?
Perhaps they don’t feel that they need as much money to live well–and their definition of “living well” may be different.
As we all know, wealth is always relative, and beauty in the eye of the beholder. Someone growing up in a household where her parents have a joint income of $45,000 is likely to feel satisifed with a smaller home, less expensive car, clothing, etc. than something who grew up in a home where the parents have joint income of $200,000.
In the case of the low-income student, their parents (and their parents’ friends)may be less likely to measure their success in terms of how much they make. (Or parents and friends will feel they the young primary care doctor is very successful, even if he is making only $125,000.)
Perhaps those from low-income homes don’t feel as much of a need to compete with others in terms of where they go on vacation, whether they send children to private schools, etc.
Service– “giving back” to their community seems to be important to low-income students (which is why they typically go back to the poor communities where they grew up) and the satisfaction that they get may be more important than money.
Meanwhile, if we want more primary care docs, we’re admitting the wrong kids to medical school. The quotes below are from an article by Dr Robert Bowman on medical school admissions http://www.unmc.edu/Community/ruralmeded/admissions_income_quintile.htm.
“Those most likely to gain admission [to medical schools today] have the highest income levels, and are children of professionals. . .
In 2003, “60% to 65% of students admitted to med school” came from famliies who are among the wealthiest 20% in the nation. And “the percentage of med students coming from these wealthiest homes was rising by 2% a year.”
In 2003 dollars, these were households reporting mean income of $140,309. . “About 1 out of 60 kids in this income group who was medical school age are admitted to medical school, about 1 out of 20 if they were Asian or Indian.
“Basically those that want medical school can get medical school in this income group. The students in this group grew up in high income and professional families and private schools in greatest percentages.”
When Bowman writes “Those who want medical school can get it” he is referring to the fact that the pool of affluent children of professionals who went to private schools competing for the slots is relatively small, making the odds of getting in relatively high.
(It is much harder to get into med school in Canada because med school is subsidized, and students from a much wider demographic apply.)
There are few older or rural-born students in this high-income group.
“This group is likely to include the youngest students, those who are potentially less mature, and are the ones who are more easily influenced by surroundings such as charismatic faculty, medical school environment, peers, . . . ”
They are least likely to choose “family medicine, rural locations, and primary care poverty. ”
By contrast, when you drop down to the second step from the top on a 5 step income ladder, you find that students are coming from homes with “a . mean income of $65,812
18 – 22% of medical students come from this group.” They have a harder time getting in (just 1 out of 209 are admitted.”) When it comes to picking a specialty, you find ” a balanced choice of family medicine, rural, and poverty careers.”
Money just doesn’t seem to be as important.
Drop down to the 3rd step on a 5 step income ladder: $42,930 family income; 9-13% of med students coming from this group; there chances of being admitted are just 1 in 403.
In this group, more and more students are choosing primary care, rural care primary care in very poor areas. Many African Americans in this group.
Move down to the bottom two steps on the income ladder, the number choosing primary care, and”proverty primary care” increases. Here you find more black males, rural males and Mexican-American males.
Then there is this article on who chooses to practice primary care in rural areas:
” Rural born medical . students are more likely to be found in rural practice, primary care, family medicine, and rural underserved locations. .
” Rural interested students were more likely to be older, married, and white. They were more likely to choose rotations away from major medical centers and they did volunteer work at twice the level of other students. About 68% chose family medicine, and 60% were interest in working with socioeconomically deprived populations in practice, the highest of any medical student group. Stability, service orientation, and maturity characterize those most interested in rural practice.”
That last sentence is I think very important: “service orientation and maturity.”
These students are somewhat older –which argues against cutting out those four years of college.
19 year-olds and even 21-year-olds are notoriously self-absorbed.
Four years of college education with a firm grounding in the humanities may begin to open them up to becoming aware of a world beyond themselves— history couses, literature courses, economics courses focusing on developing natoins, philsophy couress that raise questions about ethics, justice etc . .
all can help.
(I taught English lit-undergradutes at Yale for 11 years–including many pre-meds in my classes-so I know this demographic pretty well. During four years of college, those who take advantage of the education change enormously, psychologically, emotionally and intelletually. Their minds open up. They begin to grow up.)
Finally, some months ago I attended a conference at the Mayo clinid focused on how we should change med school education.
There was much discussion of trying to recruit more low-income students (beause they choose primary care and are willing to work in under-served areas.)
And the suggestion was made that we should sliglhtly lower GPA thresholds and test scores required for admission in order to broaden the pool, and draw in the kids most likely to want to choose priamry care and be willing to work where they are needed.
The research shows that low-income kids who go to low-income schools have lower GPA and test scores in college.
But, at the end of med school they are equally good clinical practioners (whether in primary care or in another specialty.)
The feeling is that we’re putting too much emphasis on scores.
Finally, the Senate bill includes much additional funding for scholarsips and loans for low-income kids, so I think we are going to move toward broadening the pool of applicants.
Keith, Fred, Richard, Legacy, Concerned FP, Dr. Rick, Sharon
Keith— What you say about avoiding humanities courses that might bring down your GPA underlines the fact that, in admitting students, we put too much emphasis on GPA and tests scores–too little on maturity, character and the knowledge that can lead to wisdom..
Fred–
Yes, we cannot afford to add to the total amount that we are spending on doctors. We need to cut what we pay for less effective treatments to raise the money to pay primary care docs more.
jsmith- You write: “If we want enough primary care docs, the only way to get them is more money.”
No the evidence shows that one way to do it is to admit more low-income students. (See my long reply to everyone.)
This also means finding bright kids interested in medicine in inner-city and poor rural schools in high school, mentoring them through high school, college and the med school admisssions process.
With much more generous scholarships and loans available, more low-income kids will be going to med school.
Richard–
Certainly, some specialties won’t come up with honest “top five” lists. But some will.
Much depends on the leadership in the specialty society . .
If 1/3 of the specialties took the challenge seriously, this would be enormously helpful.
On college education:
First, I’m afriad I have met quite a few doctors who don’t continue reading adn learning after college, except it their specialty (and some dont’ do that.
What percentage of doctors read history, good novels, serious political writing while practicing medicine?
I enjoy talking to doctors, interviewing them, etc., because on the whole they are bright.
But we have all met insensitive, boorish doctrors– people who seem incapable of imagining what another person (i.e. the patient) is thinking or feeling. As a result, they’re not very good doctors. (Unless they have no patient contact.)
Based on my experience teaching undergraduates, I would say that a great many college sophomores fit the “boorish, insenstiive and self-absorbed” profile. Hence the word “sophmoric.”
But somehow, by the end of senior year, their minds and imaginations have opened.
You can see this in many ways. Poll college sophomores and seniors on a question like
“Do you think we should quarantine people with AIDS on an island?”
or “Do you think George Bush is one of our greatest presidents”
and you’ll find that four years of college makes an enormous difference.
Legacy-
I agree that many students choose a specialty because, like you, they find it intellectually fascinating.
This is one of the best reasons to pick an area of expertise.
I also think that your generation of med students was less money-conscious than med students a decade later. The whole society was more money-driven a decade later.
I too don’t think people should be forced into primary care–or bribed into primary care.
But I do think that broadening the pool of applicants will bring in more students who want to go into primary care. (See my long comment addressed “To Everyone.”
As you say, in medical school, as in life, there are “types”– the guy who is going to be an ortho-pod, the one who will pick plastic surgery . . .
People don’t always conform to “type-casting” but to some degree we do.
And kids coming from poorer families just seem more interested in family care, maybe because, in their own famlies, they became caregivers at a young age, maybe because as children, they saw people in their families not getting the basic care they need.
For whatever reason, they seem more service-oriented. And we need them in the profession.
Dr. Rick– very good questions. And I do think that much of what ails us is stress-related.
Concerned FP–
I agree about externalities.
Antoher way to put it is this: today we pay doctors according to how much it costs them in: time, physical effort, mental effort, years of educatoin needed etc. to perform a procedure.
What we don’t factor in (anywhere in the equation) is how much the patient (Or society) benefits.
So a doctor could spend hours counseling a patient and getting him off tobacco, and be paid far less than a doctor performing one of those procedures that Jenga describes as “sexy.”
Sharon MD-
I think your generation of young doctors are less money-driven than many med students were back in the 1980s. (By the time you went to med school, it was clear that medicine wasn’t a clear path to easy money.)
And I agree about restructuring loans.
Finally , the fact that you compare your disposable income to your parents– and feel lucky– relates to what I was saying in the long comment to “everyone.”
Money is relative.
Maggie,You are correct that demographics predict specialty choice. But notice that I said “enough” primary care docs, not “more” primary care docs. It is estimated we will down down over 100000 of us in the next decade or so. Admitting enough students of the correct demographic 1) is very likely to happen given the realities of the admission process in the US and 2) would probably not close the gap even if it did happen. The best, simplest, most effective solution is more money, which will attract those students, who, for good or for for ill, will likely make up the bulk of med students for the foreseeable future. Unfortunately, it is probably not going to happen to the extent it needs to. Prediction: worsening shortage.
jsmith,
I think the feds do have a plan and that plan is to make a lot more nurse practitioners and physician’s assistants to fill the gap.
Question for you: Do you (or would you consider) use(ing) PAs or NPs in your practice to “extend” your ability to take of patients?
jsmith,
Actually the simplest way to train more primary care residents is to do just that. HHS has the pursestrings for residencies. Medicare currently funds the vast majority of residency slots now. If you want less specialists, simply stop funding and cut say 20% of specialty residency slots, close those and give them to primary care residencies. It closes the gap and is guaranteed to work. If you want fewer specialists, train fewer specialists.
My last post should have read “not very likely…”. Apologies.
Legacy Flyer, Absolutely. I have an NP that I supervise now. She’s great. I don’t know if the feds have a plan for more NPs and PAs (I don’t know that they don’t either), but I think we’re headed that way in any case because of med students’ choices.
jenga, Well, that might work. The problem is political, as I am sure you know.
jsmith, Jenga, Legacy,
jsmith– I think that admitting low-income students is LIKELY (not “unlikely” as you suggest in your correction) to happen at our med schools for a couple of reasons:
1) the Senate bill doubles the amount of money available for studens in terms of scholarships
2) many med schools are realizing that the students they are admitting are not the doctors we need for a new health care system.
Most people agree that medicine has become a “team sport.” We need doctors who know how to collaborate with other docs, nurses, etc.
The bright, very competitive, type A personalities coming from a private schools who have been in teh majority in med schools classes doesn’t work as well in that collaborative situation. They don’t want to be Indians. They want ot be the chief.
Med schools also recognize that we need more doctors who are committed to “service” to the community. Experience shows that low-income students are more likely to embrace this idea.
Not all med schools will be in the vanguard of the change. But many will be.
Finally, in terms of whether “more money” is the best way to build our supply of primary care docs.. .
We don’t need doctors who go into primary care because the money is better than it once was.
We want people going into primary care becuase they Want primary care– long-term relationship with patients,
service to a community, etc.
Family practice requires much work and dedication. You can’t bribe people into doing it.
Jenga– yes, medicare does have control over specialty slots.
And I think they will use it.
They may or may not cut specialty slots (though they could, without harming the system).
But I think Medicare will fight the pressure to increase specialty slots (coming from certain lobbies)–and reduce them at least in some specialties where we have a surplus of docs, and too much overtreatment. .
And I think they will increase the slots for primary care, etc.
Bottom line: you are right. Supply is key. And this can be done.
Legacy–
I agree that nurse practioners and phsycians’ assitants will be key to solving the primary care shortage.
Right now, we have a nursing shortage in large part because nursing school teachers are paid poorly.
This makes it difficult to recruit teachers.
I’m told that there ia long line of qualified candidates trying to get into nursing school (especially today–it’s a stable profession), but not enough space in the schools for these students because not enough teachers.
I know that the House bill hiked pay for nursing school teachers. I’m not sure if that provision is in the Senate bill.
If it’s not, it could be added as they merge the bills. (It’s hard to imagine that there is a great deal of opposition in Congress to the idea of paying nursing school teachers more.)
Maggie,
I’ve been in probably 50 med school interviews and I can tell you probably 49 of those stated they wanted to be rural family practice physicians and they want to help people and their community. Are you suggesting we add their parent’s 1040s to their file and if so why stop there? Should we ask who they voted for in the presidential election and and what party they belong to and only admit Democrats that are pro abortion that voted for Obama? That’s the road you are heading down unless you simply look for the candidate you feel will make the best physician based on interview and objective data. A family’s financial status is irrelevant to how good a physician they will be. Private schools really don’t matter as much as you think they do. They have no bearing in selection. I went to a very small state school and in my group of 10, I beat out 8, 1 from Yale, 1 from Columbia and two from other private schools. And after seeing it from the inside, private schools and certainly income do not matter nor should they.
I’ll say again if you want less specialists, don’t train them. It’s far simpler.
Maggie, I think you mis-read my unclear post. I was trying to state that med schools probably won’t enroll a lot of low-income students. I was not saying that low-income students would not choose primary care.
Why wouldn’t they jsmith?
I’m an idealist I think the best candidate should get the position. I certainly don’t think of someone as boorish, self absorbed or sophmoric based on their political leanings, which I guess happens in the undergraduate world. But it shouldn’t in medicine, and that is the natural progession where this conversation is going. I think most Americans including myself, don’t care what humanities my physician took in college, the last nonmedical book they read is, if they own a Che Guevera Tshirt, if they’ve ever seen CATS or what they think of Mike “the Situation”. . Yes, I like everyone want to see caring and compassion in a Doc, but you know what I want more than anything, the right diagnosis and treatment in the most efficient manner possible. Invoking Occum’s Razor, less specialists, train less. More PCPs, train more.
Jenga–
First, this is not my idea.
It came from a Mayo Clinic conference on how we should reorganize medical educatoin.
We need mroe students who want to be primary care docs in inner cities and in rural areas.
Surveys of what students actually do after med school shows that African Americans are much more likely to become family docs in inner city ghettos.
Kids from poor rural areas are much more likely to practice in poor rural areas.
The majority of kids from famlies in the top quintile have little interest in primary care or in practicing in poor areas.
Meanwhile, each year, the % of students admitted to med school from the top quintile rises, while the % admitted from the lower 4 quintiles drops.
Thus, the AMA recently urged that: “. Admission criteria should focus on recruiting those students who are most likely to care for the neediest patients, despite the obstacles.”
(This issue brief explains that this means admitting more low-income students.)
Low-income students who apply to med school have somewhat lower GPAs and test scores. The Mayo Clinic conference (and others) argue that med schools should lower the bar for admission–perhpas a 3.5 GPA rather than a 3.8 (out of 4).
Reserach shows that after med school the low-income students with lower scores is just as good a clnician.
Unfortunately, too many people interviewing students for med school tend to feel that the candidate who would make a good doctor is someone who reminds them of themselves.
Family income is very relevant. Students from low-income homes are much more interested in “service” — and are willing to practice where they are needed–in poorer areas.
Finally, yes of course verification of family income is needed, just as it is for medical school scholarships and loans based on need.
Funding for those need-based scholarhips has been doubled in the Senate bill.
I completely agree with the Author. In fact I wrote a note on AMA’s unethical behavior on this topic and another one on responsibility of all the stake holders. Both fell on deaf ears.
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Maggie,
I agree on one point and disagree on two points.
I agree, I think GPA is overvalued. It’s too subjective. You are dealing with bias and perceptions of schools and in no way are comparing apples to apples. There can even be bias in the same school due to different teachers. I know personally for me, I never made a 4.0 until I was in medical school. I think you could relax that and not effect graduates.
I disagree about the MCAT. MCAT scores do correlate to the USMLE. The USMLE correlates to the national board exam. The MOST important aspect of a physician’s job is medical decision making. Remember First Do No Harm. We all want less mistakes and relaxing the only metric that has a window into decision making is a mistake. It is the only objective apples to apples comparision we have. Some can better prepare true, but it’s the same test for everyone. Everyone knows that. If you lower the standards for Socioeconomic Class. Do you lower the USMLE when they get there? Do lower their standards for the national board exam when they get there? Which gets to my final disagreement.
At somepoint you have to buck up and do it yourself and stop using your background as a crutch or a stepping stone, a patient’s life doesn’t grade on a curve. Eventually you have to overcome any perceived disadvantages, and privilege can be a distandvantage as well, and make it on your own. It is insulting to those in the low socioeconomic class, myself included, to think you constantly have to make excuses for them or to think they can’t compete with those that are more well off.
You should sit in on an interview. Nobody knows who is interested in primary care. THEY ALL want to be rural family physicians, which gets back to my main point. Just train more PCPs and less specialists if thats what you want to do. These complex algorithms, carrots and sticks, cajoling are weak and unneeded when the direct mechanism is already in place.
You don’t need to verify family income until after someone gets in. Most students get loans. Unless you are saying in addition to lowering standards, adding gold stars to their chart for their financial status we must also pay for most of their school. Again when do you let them stand on their own and stop making excuses.
One thing I left out is “service”. If I have one bias for, it is military service. Medical training is very regimented and people with military experience have proven their commitment and often do extremely well. They have not just have written their “service” on a piece of paper, they’ve lived it.
Jenga-
MCAT scores do not correlate with clinical ability. In fact, the more years that pass after residency, the less correlation there is.
One of the things I like about Mayo is that it puts clinical ability first.
Docs who scored well on their MCATS may be great researchers, but if they are going to choose clinical pracice, I’m more interested in how they are with patients.
Wealthier students who go to private schools are taught to take tests. Much of private education in this country is about preparing to take SATs adn getting into a “top” school.
The fact that lower-income students are not as good at test-taking simply means that they have not been trained to take tests. (And in their world, “how did you do on the test” is not what their peers or their parents focus on.)
Teaching studnets at Yale for 11 years (including 4 years as a grad student) I knew many students who tested well and many who didn’t. When it comes to ability to think critically, imagination, empathy, intuition, etc. etc. test-taking skills just aren’t that important.
Finally, good test-takers tend to be very competitive.
Increasingly medical schools are realizing that very competitive students are not good team-players, and today, medicine is a team sport.
First, people don’t fit into nice categories “team player” or “competitive”. It is not an either or proposition and is a false choice. I would say you want both qualities. Any will tell you he best team players are often the most competitive, because they care how the team does more than other members. They desire to improve. Pushing yourself to get better is a good thing not a negative.
MCAT- We don’t know if MCAT scores correlate with
clinical ability because we really don’t know how to measure clinical ability. Other than opinion, Resident and Intern performance is entirely dependant on an attending’s opinion. There is no metric. The Mayo statement is a tagline every school will say or try and demonstrate the same. We don’t who will have the best clinical ability, heck we’re not even quite sure who the best physicians out in practice are. We have ideas but results can easily vary due to patient demographics, practice arrangements, etc.
And you didn’t answer the question if you admit more people that are “poor test takers”, what are you going to do if they end up being poor test takers on their board examinations? Will they get a pass there as well? Would you want a non board certified physician operating on you and yours? Because the metric we do know, MCAT correlates to USMLE which correlates to Board Exams.
I’ve been teaching med students, interns and residents for about a decade as well. I’ve known all kinds but the handfull I know that were absolutely truly talented, most, not all crushed such tests. The handfull that were truly knuckleheads and I would tend to look elsewhere if sick usually didn’t.
Maggie,
I agree with your assessment of the MCATs and testing in general. Good test-takers are trained to take tests. High scores on tests are a result of excellent training in taking tests and not a reflection on clinical aptitude or clinical decision making. Also, folks who take standardized tests well, tend to take all standardized tests well whether it’s the MCATs, USMLE, Boards, or SATs. I agree there’s too much emphasis on the MCATs and standardized testing for its own sake. I think these tests give administrators a contrived, arbitrary, but “objective looking” score by which to judge a candidate for admission… It also comes with the built in CYA, because if the medical student turns out to be a dud, you can’t blame the administrator because “so and so’s MCATs were off the charts.”
I disagree when it comes to GPA. Unlike the MCATs, GPA is a measure of effort, drive, dedication, and, to a degree, intelligence over an extended period of time. I have found that the folks who have high GPA’s tend to carry these qualities which I think are necessary to becoming a good physician. Note these qualities are necessary, but not sufficient. They still need excellent critical thinking, good communication skills, and compassion. I think taking your literature class at Yale (or one’s like it) should be mandatory for all pre-meds. After your class, I’m certain their critical thinking and communication skills will have bumped up a notch or two.
A few years back, undergraduate admissions directors in California and Texas were moving away from the SAT and instead emphasizing GPA and high school graduation rank for the reasons described above. They had found that GPA was a better indicator of success than the SAT. For all his faults, I think even Larry Summers while president of Harvard made a similar statement.
Concernred FP–
Thanks. Test-taking is a particular skill and if you’re good at taking one test, you’re probably good at taking all tests.
I was always extremely good at taking tests, as is my son. My daughter isn’t. They’re both extremely bright, bright enough to make very good doctors if that was what they wanted to do.
And as a teacher, I saw kids who could ace a test, and those who couldn’t.
On GPAs–I understand what you’re saying about GPA’s showing determination, commitment, persistence, etc. over the long haul.
But pre-meds typically take many math and science courses, and much, if not all of their grade depends on tests . So we’re back to favoring the good test-takers.
Also, as someone else on the thread noted, many pre-meds don’t dare taking courses in the humanities because they don’t have as much practice writing papeprs, know that other students in a really good seminar will be majors, and are afraida “B”will hurt their GPA.
I did have med students in my English seminars, and they tended to be better in class discussion than in the papers.
But they didnt’ get discouraged becaue I didn’t put grades on any of hte papers– I wanted students to just keep improving, competing with themselves.
So instead of giving a grade, I would type up a cover sheet of comments. Often fairly long (you can imagine!)
I kept a carbon of the comments, and at the end of the term, re-read the comments when assigning a grade.
In order to figure out how I felt about hte paper, the students had to read the comments. (Too often, students just look at the grade.)
And at the beginning of the year, I explained that their final grade would be based partly on progress. Throughout the term, I I would look at my comments on their last paper before reading their next paper to see if they were responding to the comments.
As long as the pre-meds did the reading and thought about it (I could tell in class discusssion–I called on people who didn’t have their hand up) I often gave them As instead of Bs just because I wanted to encourage them–and I didn’t want to hurt their chances of getting into med school.
I agree; humanities courses should be required for pre-meds. And rather than focusing so much on the GPA, med school admissions panels should look at the transcript. If the students is getting As in very difficult science and math courses and Bs in what look like serious humanities courses, that should be fine.
The problem with the emphaiss on the GPA is that it makes pre-meds too cautious when picking courses. . (Also if a student is coming from a small college that is not at all well known, it’s hard to know what to make of the GPA. )
At the Mayo Conference, the speaker was suggesting two or three interviews for med school admissions while putting less emphasis on scores.
And let me be clear, he was suggesting including students with a GPA of 3.6 instead of 4 in the pool–still dedicated students and hard workers.
Jenga-
Maybe very competitive people are very good team players in football, but in life that’s not the case.
And while people don’t fit into neat pigeonholes, people at the extremes can be categorized as “very competitive” and “excellent at collaborating.”
We won’t agree on this. Let me just say that very compeitive docotors often don’t
collaborate well with nurses and others.
They tend to become annoyed if a nurse speaks up and says, “Doctor, you forgot number 3 on the checklist.”
And I don’t want someone operating on me because he’s competing with another surgeon to to see who can take on the most difficult cases.
Please just tell me: “You’re not a good candidate for surgery–the risks are too high.