I know there are some real doctors on here. What do they have to say?
I've been wanting to respond to some of the comments on this thread but just haven't had the time. Yesterday, I was on call and worked until 10:30 pm, then paid bills, etc. until 2 am. Today back at work. Now getting ready for a family trip to visit friends and relatives in Switzerland (leaving tomorrow).
What I really want to say will take a while to write. Also, I've been quite afraid it will be taken the wrong way. Please, no one interpret this as bragging or any such thing, because the background is helpful to see where I, and other doctors, are coming from with our opinions.
I'm a radiologist, so this is coming from that perspective, and most of my examples follow. If you don't know what that means, let me give you some background.
I read all the plain x-rays, CT scans, MRI's, ultrasounds, nuclear medicine, barium swallowing studies, barium enema, etc., as well as do CT or ultrasound guided biopsies, abscess/infection drainages, perform angiograms, and other kinds of image guided procedures. Though you don't see me physically taking the pictures, the x-ray technologists running the equipment come to me for questions, because I'm supposed to know how to run the equipment, too, and tell them how I want the pictures taken. The scope of my practice brings me in contact with all the other specialties, from pediatrics to geriatrics. I have to know quite a bit about most specialties as a general radiologist. Radiologists are sometimes referred to as the "doctor's doctor" because they come to the radiologist to discuss patients, while the patients don't have a lot of interaction with me. When you get a scan and go to your doctor or he/she calls you with the results, they are reading a report I sent them. I average about 60 hours of work per week, on call about every 4th night on average. My education involved 4 years of college, then 4 years of medical school. Then 1 year of surgery internship (basically the first year of surgery residency), then 4 years of radiology residency. I also had 1 year of advanced training after that, a fellowship in interventional radiology (like another year of residency). That's 14 years of training after high school before I could go to work. Of course some specialties have a shorter residency, like ER -- 3 years, family practice -- 3 years, and some are longer like some of the surgical subspecialties, cardiothoracic comes to mind at 7-8 years. Some specialties are highly sought after because of either higher pay or perceived or real lifestyle benefits. The highly sought after specialties are therefore very competitive. To get into medical school, you have to be near the top of your college class. To get into certain specialties, you have to be at the top of your med school class. Medical school is very expensive (it was $25-30k/year just for tuition when I was there btwn 1996-2000). In residency, because you are a real doctor now, they pay you, but not a lot. About $35-40k/year. Of course that was 5 years ago, those figures have risen for sure. Residency is like slave labor, 60-80 hours/week depending on the specialty. Then going home to study after work. The gov't has now limited the total amount of time a resident can work contiguously and over the course of a week (to 80). Great news for residents, but sometimes bad for continuity of care for patients.
True, most physicians go into medicine for altruistic reasons, not just money. We want to help people. But you can also see that after spending all that study, with no social life, many broken marriages, etc., it's not unreasonable for MD's to expect to get reimbursed at a fair, decent rate. What a decent rate is is another question!
My dad is a surgeon, and he makes less every year but works just as hard. Now he makes less than when he started working in the late 1970's !!!! That's really how is it across the board. The days of a doctor automatically having an exorbitant mansion are gone. Look at our doctors parking lot at the hospital: mostly average cars, Toyotas, Hondas, P/U trucks, only a few BMW's or Mercedes. One internal medicine doc drives a beat up 3 cyl microcar with duct taped windows! One surgeon rides a little scooter. I mostly walk. Maybe it's just our area. Honestly, I can't complain because I get paid quite well as a radiologist, at the top of the chain so-to-speak. Then again I worked hard both in getting top grades and putting in hours to get here, because it was very competitive. How do you really expect anyone to go through the training, both book studies and hands-on training, to be a physician if there is no reward? Altruism is fine but there has to be incentive. While medicine used to attract the brightest minds, now it is losing them to other fields, like business. And it's not just because of money. Do you have any idea the amount of paper work in a day? Gov't bills to make less paperwork just make more!! Patients used to be grateful and polite. Now we frequently see folks who abuse their body all their life by obesity, tobacco use, alcohol, etc., want it fixed for free because it is their "right", but have plenty of money for the boat, new car, etc. Patients come in self-diagnosed by the internet (arrogant and sure of their diagnosis), telling you what test they want and what specialist they want to see, even though they could be far off on the diagnosis. You tell me how to attract the best students into medicine with an environment like this??? Now you understand why your doctor has an Indian accent! The government provides incentives for foreign medical graduates to take residencies in the USA and then work in underserved areas, with the expectation that they will eventually get a Green Card. And many of these foreign docs are quite good.
Now, we pay a company to do our billing and I don't know for sure exact dollar amounts of what things cost, but I have a general idea from talking with the billing people (good friends). Medicare pays just barely over the break even point for a primary care doc (family practice, internal med, pediatrics, etc.) per office visit to pay the office staff, the electricity, etc. Physicians in all specialties take big hits when we see Medicaid, Medi-Cal, Oregon Health Plan type patients. We have to pay to see them! What about the "no-pays", you may ask? It's no wonder we or the hospital bill the good insurance co's so much. You may think that would make incentive for MD's to see more patients, cramming you into a tighter "time slot" and spending less time with you. It's true to a point. But for the most part, doctors are just overbooked because that's how many patients want to be seen. People want to be seen *now*.
Some of the biggest issues causing spiraling health costs as I see them:
1. Defensive medicine, which needs TORT REFORM !!!!!!! But remember who the politicians are: lawyers. Not going to happen. Casey, your statement about malpractice insurance being only a small cause of the problem is not really true. About 20% of my income goes to malpractice IIRC, and it's much higher for some other specialties, up to 40%. Of course is not just doctors who have malpractice insurance. Hospitals, nursing homes, PT offices, etc. etc. It's not just the malpractice insurance, though, which raise costs. It's the whole pervasive practice of "defensive medicine", so we don't "miss something". That's not good medicine. It's looking for zebras in the forests of the pacific NW. I haven't been out of residency for a long time, but just in the past 3 years I've seen the number of imaging studies skyrocket. While we/I try to hold them back, the ER will say, "it's a rollover MVA (motor vehicle accident), new protocol says we have to get a CT of the head, cervical spine, chest, abdomen, and pelvis, because they may have lost consciousness or may not be accurate in their level of abdominal pain". Etc. Etc. That's a multi-thousand dollar workup for the remote possibility of injury. When I first moved here, our 100+ bed hospital had only 1-2 cross sectional imaging studies per night after 10 pm (i.e. CT scans) on average. Now we have had to resort to sending our scans to US trained radiologists in Europe to get preliminary reports so we can sleep a little. Of course, we pay out of pocket for this luxury, and not everything can be sent. In every specialty, doctors will admit to doing something because they might get sued if they didn't, even though the science is not there to back it up.
2. Too many tests, lab tests or imaging. This dovetails with #1 above. Patients come into offices demanding to have, say, an MRI for their back pain. The family practice doctor knows problem is not something serious, but gives into the patient's request. If he says no, the patient goes "doctor shopping". This is especially noticable with imaging requests from PA's and FNP's (physician assistants and nurse practitioners). They have some training but not enough pathophysiology or anatomy to really understand what is happening. They are great for colds, flus, sore throats, sprains, etc., but you won't find me or may family going to one for anything serious. That's one place where the gov't has it totally backwards: by trying to save money, encouraging more lower level practicioners to do more and shifting patients to them from MD's, they are actually causing waste because these guys order a lot of tests that aren't necessary. Of course, overutilization is happens from PA's and nurses all the way up to high subspecialized MD's. Then, there's the problem of ordering tests without even seeing the patient first: it's now protocol in the ER to be seen by a triage nurse or secretary who asks why you are there. Hand pain = automatic hand X-ray. Leg swelling = ultrasound for possible DVT (clot). Then wait 4 hours until the doc or NP can see you. Boom. See where I'm going with this?
3. It has been estimated that 50% of health care $$ are spent in the last 6 months of a person's life. In other countries, if grandma is spiraling ("down-the-drain") in the ICU, non-recoverable, you pull the plug. Particularly in those with socialized medicine. Here that's termed "playing God." We must keep them alive at all costs, down to the last minute. That's the mentality. There no "Let's celebrate the life well lived, and let them die in peace." Especially in cancer patients, we do absolutely everything possible, whether it is futile chemotherapy or radiation or life support. It's basically our mentality in the USA. As a Christian, this seems unnatural and more "playing God"/interfering with nature than letting someone go. Death is part of life. Of course, we all have our own beliefs and this thread isn't a religious thread.
4. Overutilization of emergency departments. There is a very high percentage of the population who uses the ER as their primary care doc, especially as people lose their health insurance. An ER visit costs at minimum about $700. Compare that to maybe $100 for the same problem when seen in the regular clinic. Who foots the $700 bill?
5. No cost control for pharmaceuticals. Drug co's can charge whatever they want. How many of you try to buy cheaper drugs from Canada?
6. No cost controls for durable medical equipment (i.e. motorized wheelchairs, O2 tanks, etc.). There's a reason why you see so many ads on TV for the motorized wheelchairs. The people selling them buy them from the manufacturers, then sock a huge bill to Medicare, which then pays quite happily.
7. No cost controls for all sorts of other medical equipment. That package of gauze I just opened to help clean your wound cost a few pennies to make, but the manufacturer can charge hundreds of times that, which the hospital or MD's office has to recoup somehow. Now imagine an IV line with bag. Just 2 simple examples.
8. No mandates for insurance company efficiency. Don't get me going on this !!
There's been a lot of talk about how great socialized medicine systems work in other countries, but there's a reason why people with money come to the US for their care. And you have to remember that where it works well, like Switzerland, it is still a combination of private and public payors, the popluation is 7 million instead of 250 million, the the gov't is not bloated beyond reason.
Once, I saw some numbers that the actual overall cost of the health care bill which is attributable to the physicians fees was only a couple percent. Don't know if that's true or not. But I do know that doctors wages have decreased for years while overall health care costs are skyrocketing. Hmmm. Now the gov't wants to take away more from reimbursements and forcing people to get insurance (without insurance reform) thinking it will help. I see doctors leaving medicine in droves in the future, but, hey, one of my partners thinks a single payor system is the panacea. As you see from above, creating a single payor system or making sure everyone is enrolled in a plan won't fix the deficiencies I mentioned.
Lastly, I did take a Hippocratic Oath when graduating medical school. It basically says I have an obligation to treat everyone in need, and to first do no harm.
Marcus
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Marcus A. Bryner, M.D.
Grants Pass, OR
P.S. Why would I put my full name out here if I didn't believe this? Sorry if I rambled too much. It's midnight, I still have to pack, and my little ones will be awake in a few hours..... Arrgh.
