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Doctor Shortage:

N.Y. Times:

Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president.

The officials said they were particularly concerned about shortages of primary care providers who are the main source of health care for most Americans.

One often hears how the U.S. is not graduating enough doctors, and that those who do become physicians feel obliged to go into specialties to pay off their massive student loan debt. I have yet to see in any of these articles one simple reform proposed: abolish the requirement of an undergraduate degree before attending medical school, and turn medical school into a five or six-year post-high school program instead. This would eliminate two or three years of debt, and, perhaps even more important, the opportunity costs of two or three years of college. Right now, an aspiring physician must go to college for four years (and take many classes that have nothing to do with his future career), then medical school for four years, and then typically do a poorly paid internship and then residency for another five years. By the time this aspiring physician goes into practice, he will be at least thirty-one years old, and have eight years of student loan debt.

Surely, one should not be precluded from going to medical school if one has spent four years majoring in political science, or art history, or biology, and taken all the courses currently used to weed out pre-meds. But I don't see any good reason why it should be a requirement, either (and indeed, there are a few six-year medical school programs out there already, and I doubt they produce worse physicians).

Rock On:
Wow. Stop the presses, I agree with David Bernstein on something.
4.27.2009 9:40am
PatHMV (mail) (www):
Simpler would be to have the government and insurance companies (i.e, the taxpayers and the consumers) actually pay higher rates for the primary care physicians who are in such short supply.

Alternatively, reduce the cost of medical education by greater subsidies to medical schools, reducing the tuition amount.
4.27.2009 9:49am
MR:
Long time skeptic, first time supporter. I have long felt that "gateway degrees" are unnecessary for most professional degrees (law included). I suppose the gateway degrees serve a purpose in the law field by preventing an already bloated profession from getting even bigger.
4.27.2009 9:50am
Joeblow1078:
Why would doctors with less student loan debt opt not to specialize? They still would make far less money as primary care providers. They just would get to pocket more of the money.
4.27.2009 9:51am
Strict:
David,

Your plan is basically what they do in India.

And it is similar to the educational plan designed by Fidel Castro.
4.27.2009 9:51am
Prof. S. (mail):
Whoa, whoa, whoa, whoa.... If this goes through, I see the farce of requiring a 4 year degree before going to law school falling as well. Sometimes you need to put up with someone else's senseless protectionist measures in order to preserve your own.
4.27.2009 9:52am
DennisN (mail):
I'm not so sure. There is a value to an undergraduate degree, beyond the strict training value. It is an education; a program that teaches you to learn. That pays off later on.

There is also the weeding factor of filtering out the less capable students and arguably occupying less of the valuable med school resources.

Aren't there are some prerequisites, particularly in the math - biology - chemistry area that must be accomplished prior to entrance into medical school? Those are typically undergrad courses.

The med school program would probably need to be at least six years, if it were a stand alone program.
4.27.2009 9:54am
Gabriel McCall (mail):
Skyrocketing tuition has run in parallel with skyrocketing federal student aid. If you want a degree to cost less, just have the government stop paying for it.

I agree with the proposed solution as well. In general, there are very few jobs for which one is better prepared by an undergraduate degree than by specialized training. Which is not to say that college is pointless- not at all- but rather that a BA should almost never be a prerequisite for either a professional school nor for a job application.

ABA accreditation requirements force law schools to require undergrad degrees. Why? If an autodidact can generate a good score on the LSAT, and perhaps on the GRE or some other test of general knowledge as well, AND convince the school's admission office that he's worth admitting, what is gained by excluding him from the study of law?
4.27.2009 9:57am
DennisN (mail):
@strict:

How well does it work in India? We import a lot of doctors from there. Do they typically need remedial education to practice here?

What does the reference to Uncle Fidel mean? Is that good or bad? Is that guilt by association?
4.27.2009 10:00am
nathan:
As the husband of a medical resident, my suggestion would be to expand residency opportunities. My understanding from talking with the wife and her coworkers is that the residency system in this country is essentially full, with more people looking for residency slots than there are slots. Its even worse when you start looking at the number of foreign medical grads who want to practice here but who can't because they can't get a residency slot.

It will do no good to increase medical school graduates without increasing the number of residency positions available...
4.27.2009 10:00am
Uh_Clem (mail):
Most of the work that primary care physicians do on a day-to-day basis doesn't require the full-blown medical degree with internship etc. etc. Why not create a "medical practitioner" license with less required qualifications to do the basic work?

A typical RN with 10 years of experience could handle most day-to-day issues (with a little extra training, a certificate, and supervision of course.)

I don't need a master mechanic to change my oil. I don't need a constitutional scholar to draw up a simple contract. I don't need the Galloping Gourmet to grill a burger.

Such a program would alleviate the shortage, and lower the cost of care too. Would quality suffer? Maybe a bit, but not as much as some would have you believe.
4.27.2009 10:03am
cboldt (mail):
Why are doctors either leaving or not entering practice in the first place? The proposed solution would generate a one-time velocity boost to increasing the ranks of doctors by cutting off a couple years on the timeline to enter, but what would otherwise entice a person to enter the profession in the first place?
4.27.2009 10:06am
Nick P.:
6 year med programs are certainly possible, but the existing ones in the U.S. (e.g. Penn State's program with Thomas Jefferson Med School) are more intense and more difficult than the standard 4-year undergrad, 4-year med. As such, only the best prepared and most driven students are likely to succeed. I would think that such a program would reduce the number of doctors if it completely replaced the less intense 8-year process, and at best, you are saving two years out of the total 12 or 13, including residency.
4.27.2009 10:09am
DerHahn (mail):
Why not create a "medical practitioner" license with less required qualifications to do the basic work?

Already been done but it certainly could be done more. Quite a bit of basic medical care in rural areas of the West and Midwest is done by people with these kind of qualifications.
4.27.2009 10:10am
David M. Nieporent (www):
Why are doctors either leaving or not entering practice in the first place? The proposed solution would generate a one-time velocity boost to increasing the ranks of doctors by cutting off a couple years on the timeline to enter, but what would otherwise entice a person to enter the profession in the first place?
It's not just that it "cuts off a couple of years," but that it lowers the cost of entry.
4.27.2009 10:10am
PatHMV (mail) (www):
I'm horrified by the apparent disdain for a well-rounded, basic college degree. Perhaps it's due to the increased specialization of many undergraduate degrees, but I think that 4 years of education in the arts, humanities, and basic sciences is very beneficial to a person in life, particularly a person who will be vested with a great deal of power and influence over other people's lives. I don't want a doctor who has all the requisite mechanical skills, but has never devoted a moment's thought to larger questions posed by life and death.
4.27.2009 10:10am
Roguestage:
I'm a bit skeptical of the idea that a 6-year program is sufficient to turn out good doctors. I vaguely recall that when I was in high school, the University of Michigan had such a program (6 years for a BA and MD) that gradually expanded to 7 and then 8 years and then was abolished. This is anecdotal, so perhaps unreliable - but for me, it raises questions: where are the 6-year programs now? Is there any data on their graduates?

Also, I'd respond to the calls for greater subsidization of medical schools so as to encourage them to reduce tuition by saying that we should also institute loan repayment/forgiveness programs for doctors who go into desired specialties or underserved areas, similar to the programs available at many law schools for graduates going into public interest.
4.27.2009 10:12am
Adam J:
Gabriel- "Skyrocketing tuition has run in parallel with skyrocketing federal student aid. If you want a degree to cost less, just have the government stop paying for it. "

Care to explain that one a bit more? Call me crazy but I would think that would have the exact opposite effect.
4.27.2009 10:16am
Wilpert Archibald Gobsmacked (mail):
I think cbolt has hit on the nub of the question. I agree with the post's premise, but why has a medical career become such a pariah? Could it be a too-easy malpractice issue along with the rush to "socialize" medicine - and lower costs [salary's] - has turned many away from something at which they'd otherwise succeed?
4.27.2009 10:18am
Cornellian (mail):
I don't think it's necessary to have an undergrad degree to succeed in medical school (or law school for that matter). Still, it's hard to imagine many 18 years old high school graduates being ready for medical school. I'd be inclined to allow people straight from high school if they can pass an entrance exam (which very few high school grads will be able to do) but also provide some sort of preference for people with undergrad degrees in certain subjects, e.g. chemistry, not journalism.
4.27.2009 10:21am
Uh_Clem (mail):
I think that 4 years of education in the arts, humanities, and basic sciences is very beneficial.

Well, yes. A good undergrad education should develop critical thinking skills - here's some premises, now draw your own conclusions and back them up with a solid argument.

Much of the medical curriculum consists of a large amount of memorization and rote learning. That's by necessity to some degree - the students have a short amount of time to learn a large amount of material. But if we eliminate the undergrad years, when are they going to develop the knack for thinking for themselves?
4.27.2009 10:21am
U.Va. Grad:
(and indeed, there are a few six-year medical school programs out there already, and I doubt they produce worse physicians).

I've sometimes wondered why these haven't caught on. A few friends of mine from high school did the 6.5-year track at NEOUCOM, the Northeast Ohio Universities Colllege of Medicine. 3 years going to school year-round at (I believe) Akron, Kent State, Cleveland State, or Youngstown State, then, provided you meet the GPA requirements, guaranteed acceptance to the medical program at NEOUCOM, where you're done in another 3.5 years. It strikes me as a very efficient way to go about geting a medical degree.
4.27.2009 10:22am
Sk (mail):
"Right now, an aspiring physician must go to college for four years (and take many classes that have nothing to do with his future career), then medical school for four years, and then typically do a poorly paid internship and then residency for another five years. By the time this aspiring physician goes into practice, he will be at least thirty-one years old, and have eight years of student loan debt."

Not correct. 5 year residencies only apply to some specialties (and some specialties are 7 or 8 years). You will be a pediatrician, internal medicine doctor, family physician, and psychiatrist, with a 3 year residency. Thus, for a primary care physician,
18 start college
22 start medical school
26 start residency
29 start career.

One problem with those primary care slots: they don't pay very well. Not just relative to other doctors, but literally. Family physicians can easily be making in the 120K range. (you think that's alot? A journeyman level engineer that works for the federal government-a civil servant-who has 7 fewer years of education-can easily make 90K). I'd say if you want more primary care physicians, 1) pay them more, and 2) reduce their workload/stress load.

Sk
4.27.2009 10:22am
Jon Rowe (mail) (www):
As a libertarian, in principle, I support similar reforms in the law profession as well as the medical profession (in medicine esp. we need to make it easier for non doctors, like nurses to treat patients for simple sicknesses).

However, do we really need more lawyers?
4.27.2009 10:31am
Bill N:
PatHMV is spot on. The essence of Prof. Bernstein's post is that there is not enough value added in a liberal arts education to justify the cost, as opposed to the specialized medical training needed to identify and cure illness. Perhaps that may be true for a bench scientist, but not for the person I want as my primary care physician.

Adam J: Federal funding has expanded the pool of money available to college students, and colleges have (not surprisingly) increased costs to slurp up the extra money. At my own college, when our Dean was asked in a faculty meeting if we were raising tuition this year, he responded that the college wasn't sure; we were waiting to find out how much money would be in any stimulus or budget package from Congress. Increasing subsidies for college students has not resulted in any increase in the percentage of college-age students going to college, it has merely made the cost of a college education greater for those who attend.
4.27.2009 10:32am
Houston Lawyer:
Who are all these people who would be our doctors but for the requirement that they needed an undergraduate degree? My internist stopped taking new patients several years ago. She won't even accept family members of existing patients. Following my last physical, she referred me to both a gastroenterologist and a cardiologist. So we need specialists as well.

Judging from all of the Toronto pictures in the gastro guy's office, I'd venture to guess that he trained in Canada. Care to speculate what brought him to practice in Houston?

Great Britain has managed to make the practice of medicine so annoying that they have a severe doctor shortage. They now have to import physicians from third-world countries.

Promising to make all physicians de facto employees of the federal government is no way to increase the supply of the kind of people you want.
4.27.2009 10:33am
Just checking:
Why does doctor training have to begin after the High School years? Is there something magical about the age of 18? Mainly because High School is a mostly worthless government babysitting program.
4.27.2009 10:33am
Connecticut Lawyer (mail):
The cure to doctor shortages is to pay them more. (You could also try elimating some of the paperwork and regulations, which increase the costs of being a doctor.) This is so obvious I wonder why anyone is asking the question.

IMHO, doctors are woefully underpaid. When you all were out partying on Saturday night (and Thursday night, and Friday night, etc.) in college, where were your premed friends? And the difference in quality between the really good docs and the average doc is vast. But don't worry, once ObamaCare (tm) is enacted, barefoot doctors will take care of you and me, and the top physicians will be reserved for those with political or union connections.
4.27.2009 10:33am
ShelbyC:
Why not just eliminate all requirements and let hospitals figure out how to qualify folks?
4.27.2009 10:33am
xx:
"Could it be a too-easy malpractice issue along with the rush to "socialize" medicine - and lower costs [salary's] - has turned many away from something at which they'd otherwise succeed?"

No. Working at a college, I've observed literally hundreds of pre-meds decide to pursue other careers. None has done so because of future insurance premiums.
4.27.2009 10:36am
DavidBernstein (mail):
I'm horrified by the apparent disdain for a well-rounded, basic college degree. Perhaps it's due to the increased specialization of many undergraduate degrees, but I think that 4 years of education in the arts, humanities, and basic sciences is very beneficial to a person in life, particularly a person who will be vested with a great deal of power and influence over other people's lives. I don't want a doctor who has all the requisite mechanical skills, but has never devoted a moment's thought to larger questions posed by life and death.
I'd be much more inclined to agree with you if today's undergrads actually got a classical liberal education, as opposed to a hodgepodge/mishmash of random courses, often highly politicized. The pre-meds at my alma mater generally took a "gut" course called "Birth and Death" taught in the Sociology department to fulfill their social science requirement. Beyond learning to meditate for the first five minutes of class, and getting a group hug at the end, I don't think they got much out of it.
4.27.2009 10:38am
Horatio (mail):
What about apprenticeships for both medicine and law? Studying under the tutelage of a doctor or attorney. Formal schooling intermixed with day-to-day working experience.

In the mid 70s I worked as a paralegal in NY where it was still possible to "read for the Bar". IIRC, I could work in the law firm under the supervision of a partner, and attend one year of law school prior to taking the bar exam. In the two years working there, I knew more about the the real world practice of law and the workings of the court system - both Federal and State - than any law school graduate. I also knew as much about legal research as they did as a result of working in the firm's library performing tasks assigned by the partners.

I ultimately took another path in life, but that's another story.
4.27.2009 10:38am
xx:
Prof. Bernstein: Won't we reproduce a lot of the same economic waste by having students who would otherwise be "pre-med" at four year colleges attend medical school, drop out, then have to pursue an alternative degree? Right now, if someone gives up on being a doctor at the end of their sophomore year, they're just two years from getting a degree that's usable for other fields.
4.27.2009 10:39am
John Burgess (mail) (www):
I suppose a model could be created that treated medical doctors like auto mechanics, but I'm far more comfortable with an educated doctor, not just a functional mechanic.

It's true that much of undergraduate education today is worthless, but not all of it. Critical thinking skills do not come from equations, for the most part.
4.27.2009 10:46am
Gabriel McCall (mail):
I think that 4 years of education in the arts, humanities, and basic sciences is very beneficial to a person in life.

The question of whether a study of liberal arts is "very beneficial to a person in life" is entirely separate from the question of whether it is necessary to a competent practice of medicine.

I don't want a doctor who has all the requisite mechanical skills, but has never devoted a moment's thought to larger questions posed by life and death.

Should your personal preferences be imposed on the rest of the world as a matter of law, or should people be allowed to make choices you don't agree with?
4.27.2009 10:50am
Kirk:
Uh_Clem,
Why not create a "medical practitioner" license with less required qualifications to do the basic work?
We already have that; it's called the Physician's Assistant (PA.) I suppose their exact capabilities might vary by state, but here in WA I know of a small community hospital somewhere in Eastern WA where the emergency department is actually run by a PA.

Note that the University of Washington's PA program requires a BA or BS for entry; the savings is in the program itself, not in the prereqs.
4.27.2009 10:50am
Halto (mail):
"Why not just eliminate all requirements and let hospitals figure out how to qualify folks?"

That's just crazy talk!! See, this is simply the slippery slope that comes from folks thinking that no official license or training is needed to become an interior designer or sell flowers. What next, no undergrad needed to play in the NBA?
4.27.2009 10:53am
justme:
Here's an idea: Stop opening new law schools and open some new medical schools.


I don't agree with Berstein's idea. But that does raise the question: What, exactly, is an undergrad degree for?
4.27.2009 11:01am
U.Va. Grad:
We already have that; it's called the Physician's Assistant (PA.) I suppose their exact capabilities might vary by state, but here in WA I know of a small community hospital somewhere in Eastern WA where the emergency department is actually run by a PA.

Here in Minnesota, many Target stores have walk-up clinics in them. The clinics are all run by PAs, who can handle around 75-80% of what a traditional primary care doctor does, all for a pretty reasonable price. Expanding the role for PAs and/or NPs strikes me as a good compromise solution.
4.27.2009 11:01am
Adam J:
Bill N- "Increasing subsidies for college students has not resulted in any increase in the percentage of college-age students going to college, it has merely made the cost of a college education greater for those who attend." What's your source for this, because it's wrong. Subsidies have increased the percentage of students going to college (obviously- since it increases demand) &it decreases costs. Colleges captures some of the value of these subsidies thru increased costs, this is true, but its preposterous to claim they get all the value of the subsidies.
4.27.2009 11:01am
Kenvee:
XX

No. Working at a college, I've observed literally hundreds of pre-meds decide to pursue other careers. None has done so because of future insurance premiums.


Well, then, what WAS the reason? What's your suggestion for dealing with it?

I've known many doctors who have gone into alternate careers or at least severely curtailed their practices because of the skyrocketing medmal costs and all the red tape they have to go through every day. I think that reducing some of the mind-numbing bureaucracy would help us keep more of the people we have already, which helps more in the short-run than making school shorter.
4.27.2009 11:04am
xx:
justme:
Here's an idea: Stop opening new law schools and open some new medical schools.

If we open more health food stores than McDonalds, will the obesity epidemic go away?
4.27.2009 11:04am
DennisN (mail):
@ Horatio


What about apprenticeships for both medicine and law? Studying under the tutelage of a doctor or attorney. Formal schooling intermixed with day-to-day working experience.


That's what the Internship and residency are for. It's similar in Engineering. After graduating, you work four years as an Engineer In Training. After four years as an EIT, you can sit the Professional Engineer (PE) Exam.
4.27.2009 11:04am
A.:
The point of the undergrad degree for premeds is not education but quality signaling. Do you really want med schools picking kids based on their SATs and ninth-grade bio grades? It's likely to let lots of dummies into med school (lowering either the quality of doctors or the graduation rates), and to screen out plenty of potentially good doctors who weren't very mature at 15.
4.27.2009 11:06am
xx:
Kenvee: They were bored by the subject, they realized they were following their parents' dream and not theirs, they discovered other majors they didn't know existed (or were interesting), they did awful in bio and organic chem and didn't think they could cut medical school, etc.

There's plenty of reason to decrease medical costs and red tape, but let's not pretend its what the average college student thinks about when deciding what classes to take.
4.27.2009 11:07am
DennisN (mail):
Kenvee:



Working at a college, I've observed literally hundreds of pre-meds decide to pursue other careers. None has done so because of future insurance premiums.


Well, then, what WAS the reason? What's your suggestion for dealing with it?


Is this something that needs to be "dealt with?" or is this simply a natural filtering process. Some people decide, part way through, that they don't like medicine all that much.
4.27.2009 11:09am
LarryA (mail) (www):
Simpler would be to have the government and insurance companies (i.e, the taxpayers and the consumers) actually pay higher rates for the primary care physicians who are in such short supply.

Alternatively, reduce the cost of medical education by greater subsidies to medical schools, reducing the tuition amount.
So instead of eliminating unnecessary costs, you charge them back to the taxpayers and consumers. Thanks a bunch.
Why not create a "medical practitioner" license with less required qualifications to do the basic work?
You mean like a Physicians Assistant?

Most of the GPs I know are limiting practice because they're getting screwed over by Medicare. They aren't optimistic that ObamaCare will fix it.
4.27.2009 11:16am
George Weiss (mail) (www):
DB-

what you propose would make becoming a doctor more attractive. but that would not create more doctors.

to do that you need one thing: more medical school seats.

there are already thousands of people who apply to medical school every year who have taken the required prerequisites but do not get in-simply becuase they do not have a high enough MCAT or GPA. This in turn is becuase there are not enough seats for all the qualified pre meds out there.

we need new med schools or new seats in current schools. but the AMA acts protectionist over the profession because it sympathizes with the student loan debt of graduates-and does not want doctor salaries to decrease or create too many doctors for available residences.

antoher problem is that we dont really allow the forign doctors who come to thiss country to get resideces. this prevents us from using immigration to make up the shortage.

An MD is already the most prestigious degree in the country and more, qualified, people want to be doctors than we can train. not a problem of incentives-its a problem of protectionism.

of course-we as lawyers aren't really used to this-what with lawyers being a dime a dozen and the aba accrediting everyone anyway. but the AMA does what we would want the AMA to do.
4.27.2009 11:33am
James Gibson (mail):
The physician shortage is matched by our shortage of engineers and computer programmers. These careers also are saddled with several semesters of liberal arts classes that add no value to the person's skills or career, but do add to the cost of their degree and the time it takes to finish college. When I entered college in 1980 a four year degree had become a six because of the liberal arts mandate. By 1990 it had become 8 years with all the added costs the student will have to repay. Adding further to this issue, the grades in these liberal arts courses can hold the student back from entering graduate school.

One more thing: the EIT is a state exam which you can take or not. Once you take and pass the exam you have that certification of EIT. After that you can take the PE exam (if you have already completed four years of engineering employment) and you are sponsored by another engineer with professional standing. In short the EIT doesn't come with the BS degree.
4.27.2009 11:33am
Ben P:

Surely, one should not be precluded from going to medical school if one has spent four years majoring in political science, or art history, or biology, and taken all the courses currently used to weed out pre-meds. But I don't see any good reason why it should be a requirement, either (and indeed, there are a few six-year medical school programs out there already, and I doubt they produce worse physicians).



By all means, if someone can figure out how to pass the MCAT an get accepted to medical school without having taken Organic Chemistry and Molecular Biology let them try.

The college I went to was a small liberal arts college with a disproportionate degree of pre-med students (and a remainder that is heavily pre-law or pre graduate) Both my sister and my brother in law are currently in medical school.

With your post clarified by the remark about the "life and death" sociology course, I think this is driven by a misconception about why pre-med students do what they do.

The reason most of those pre-med students take "life and death" (or in my undergrad case it was typically Western Civ) is very similar to the reason my sister decided to take her language requirements at a local community college during the summer and transfer the credits.

Grades.

The courses that "weed out" pre-med students aren't doing so artificially, they're doing so because those courses are difficult. But the weeding out also occurs because of realistic expectations about med-school.

Med School is quite a bit more difficult to get into than law school. Having a C or two or even a string of B's in many cases can sink a student's chances of getting into just about any med school in this country.

Pre-Med students study their asses off in those core courses because they need those A's and B+'s to be sure of getting accepted.

Then they take easy courses for their "other requirements" because they don't want to risk a bad grade that will hurt their GPA.

If you want to compare it to law schools, there's essentially no analogue to "third tier" law schools in the medical school community.

If you want to be a famous research doctor you might still shoot for Harvard or Stanford or Johns Hopkins or Washington U in St. Louis, but below that the acceptance criteria for nearly the rest of the field are extremely close. Moreover, nearly all of the public ones give admissions preference to In-State students, so if you don't get accepted to your local school, your chances of getting accepted to another school elsewhere are basically nil.

The few exceptions to this rule are medical schools outside of this country. If your doctor has a medical degree from a medical school in the Carribean, it's probably because he didn't have the grades to be accepted to a US medical school.

I have no objection to the idea of combined 6 or 7 year programs for medical school, but it we have a shortage of doctors in the country the solution isn't to remove undergrad degrees from the equation, it's to allow more medical schools.
4.27.2009 11:35am
Alan P (mail):

to do that you need one thing: more medical school seats.

there are already thousands of people who apply to medical school every year who have taken the required prerequisites but do not get in-simply becuase they do not have a high enough MCAT or GPA. This in turn is becuase there are not enough seats for all the qualified pre meds out there.

we need new med schools or new seats in current schools. but the AMA acts protectionist over the profession because it sympathizes with the student loan debt of graduates-and does not want doctor salaries to decrease or create too many doctors for available residences.



Absolutely right!!!
4.27.2009 11:37am
Floridan:
". . . why has a medical career become such a pariah?"

One would think that if this were the case, medical schools would be a lot easier to get into.

I find it interesting that when some other overpaid occupation, such as autoworkers, bitch about their working conditions, they are whiners. When physicians do it, it is an indication of systemic problems.

The fact is, physicians are doing quite well, financially. For all the talk of being underpaid by Medicare, etc., medical professionals (physician, dentists, etc.) occupied 13 of the 15 highest-paying occupations in the U.S.

There are plenty of problems with the U.S. health-care system, but I would worry more about the patients than the doctors.
4.27.2009 11:42am
Hannibal Lector:
The armed forces have an excellent medical system based on a series of filters. Anyone seeking medical care starts with a corpsman. The corpsman refers cases beyond his competency to a higher filter and so on. This requires several levels of expertise. The armed forces provide in-house training to man these levels. There are even programs that allow exceptionally skilled and dedicated corpsmen to obtain a medical degree.

The current system ofd medical education in this country is insane. We typically subject would-be doctors to about six years of intensely pressured class-room learning that actually reduces their ability to deal with people and seems almost designed to select out persons with a potential for clinical empathy.

Much better would be a kind of apprentice system where would-be doctors start their training as nurses or physicians assistants. Those who prove good at this could then move on to more advanced medical training with a good deal of clinical experience already under their belts.
4.27.2009 11:43am
Ben P:

When I entered college in 1980 a four year degree had become a six because of the liberal arts mandate. By 1990 it had become 8 years with all the added costs the student will have to repay. Adding further to this issue, the grades in these liberal arts courses can hold the student back from entering graduate school.


What?

Most people still finish their undergraduate degrees in four years, 12-15 hours a semester really is not that difficult. If someone spends 8 years in undergraduate they either changed there course of study about 15 times or were too lazy to carry a full load of courses.

and I'm sympathetic to the grade concerns per what I wrote about medical schools above, but (1) I've seen few graduate programs that are stricter about grades than medical school, on the contrary, most hard science graduate degree programs are starved for qualified students these days, (2) if you're a physics or engineering major, I think a B in English Lit would probably be understood by most admissions committees, I've certainly not seen many history graduate programs or law schools sneer at students because their worst grade in college was a C in the required math course,(3) if you can't pull off a B in a 101 level English or History course, something's wrong.
4.27.2009 11:49am
American Psikhushka (mail):
Time for a topical link to a Mises Institute article:

"Since AMA's creation of the Council a century ago, the U.S. population (75 million in 1900, 288 million in 2002) has increased in size by 284%, yet the number of medical schools has declined by 26% to 123."

The rest of the article is worth reading too.
4.27.2009 11:56am
Duffy Pratt (mail):
Why not just entirely eliminate the need for an undergraduate degree. There are basic science requirements for med school, but a student's ability in these areas is pretty easy to test. Thus, no six year program would be needed.

Under this model, I suppose a bunch of fast track schools would spring up to prepare students for the even more grueling entrance exams to med school. This would have two beneficial aspects: the universities could stop offering the stupid gut/baby courses for pre-meds, since this would be available elsewhere: no more stupid watered-down physics for doctors. And the med schools would not have to start making evaluations of candidates based solely on high school performance. They could still hold to something like their existing baseline for admission.
4.27.2009 11:57am
einhverfr (mail) (www):
I think Bernstien misses the point. We expect our physicians to be doctors both in the sense of medical doctors and also in the sense of folks with broad educations and good critical reasoning skills.

What Bernstein forgets is that the primary care physician in rural America is different from a primary care physician in, say, Boston. While it is conceivable that such a physician in Boston could do ok without being a doctor in the sense of having a broad education and well-tested critical reasoning skills, in rural Montana, the primary care physician typically IS the appropriate specialist.

Do we want doctors to be health technicians or doctors? If we want them to be doctors, we need to require an undergrad degree. If we want them to be health technicians, we need not do so.

I would be in favor of extending the public service scholarship program so that doctor shortages could be addressed by reducing the student loan burdens of those doctors who are willing to address those shortages. That seems to me to be the simplest way forward and one which would have the fewest unintended consequences.
4.27.2009 11:58am
Tony Tutins (mail):
It's certainly possible. Doctors were pushed through med school during WW II: My dermatologist graduated from U Chicago in 42 and got his MD there in 44.

Regarding law school: If I'm not mistaken, ABA law schools admitted people with two years of undergrad until the 50's.
4.27.2009 12:02pm
Tony Tutins (mail):

those who do become physicians feel obliged to go into specialties to pay off their massive student loan debt.

Kind of counterproductive because the more specialized the MD, the more years as a low-paid resident.
4.27.2009 12:03pm
einhverfr (mail) (www):
BTW, my eldest son was born in Jakarta, Indonesia. He had neonatal jaundice and was put under the lights. I remember I had a better grounding of the process, what was happening, and the physics involved than the physician who was responsible for my son's care. That was not a comfortable place to be....
4.27.2009 12:04pm
MCM (mail):
The cure to doctor shortages is to pay them more. (You could also try elimating some of the paperwork and regulations, which increase the costs of being a doctor.) This is so obvious I wonder why anyone is asking the question.


So we're supposed to be simultaneously 1) raise doctor pay and 2) get more doctors. In a health care system that's already breaking under the costs. No thanks.

The real "obvious" solution is to weaken the doctor's guild (the AMA) so that more people can become doctors. More doctors = lower prices from doctors.

In my opinion, cutting out the 4-year degree wouldn't do much because few American 18-year-olds are ready to devote themselves to a career right out of high school. If you can be a doctor by going to to college then medical school, or by going to straight to extended medical school, every 18-year-old is going to pick college anyway. It doesn't limit their options much. An additional 2-3 years of debt amortized across their career isn't going to seem like much of a burden to them at age 18, either. (Even if it really is a burden).

It's the right idea but I don't think it would do much.
4.27.2009 12:04pm
Ken Arromdee:
The physician shortage is matched by our shortage of engineers and computer programmers.

For computer programmers the standard response is "There is not a shortage of computer programmers. There is a shortage of computer programmers willing to work for the amount you want to pay them."
4.27.2009 12:05pm
Ben P:

Regarding law school: If I'm not mistaken, ABA law schools admitted people with two years of undergrad until the 50's.



Interesting, I actually ran across this a few days ago but hadn't looked into it yet. I was interviewing someone for a legal history project here and he mentioned that he graduated from HS in 1937, attended 2 years of undergrad and then three years of law school, finishing Law school in the spring of 1932.

Because he joined up and was commissioned immediately after graduation I assumed it was something to do with the war, but if that was actually standard at the time it's kind of interesting.
4.27.2009 12:06pm
Tony Tutins (mail):

The physician shortage is matched by our shortage of engineers and computer programmers.

Engineers' kids I knew became surgeons and i-bankers. If you're bright and like to work hard, why settle for engineer's salaries?
4.27.2009 12:07pm
Kenvee:
DennisN

Is this something that needs to be "dealt with?" or is this simply a natural filtering process. Some people decide, part way through, that they don't like medicine all that much.


Well, given that the purpose of the post is how to increase the number of doctors, then I would say addressing why people are dropping out of premed is a good thing. If the reason is just that they've decide they don't want to be doctors, then that's fine. If it's because they've discovered they can't afford it or there are other obstacles in place, then yes, that's something I'd think needs "dealing with" if we want more doctors.
4.27.2009 12:07pm
Ben P:
Above that should be 1942, not 1932.
4.27.2009 12:07pm
DCP:

I would think the market is going to self adjust on this to a large extent. Let's face it, being a competent doctor is really something that is only available to the top 1-3% of minds out there. It's just a matter of enticing them into the medical profession and making the necessary adjustments from there.

In today's professional climate, top students are going to be drawn more to the medical profession, simply because the top tier alternatives don't offer anywhere near the same job and pay security, which wasn't necessarily the case ten or twenty-five years ago. Would you want to go into law, finance or engineering right now?

I personally know: (1) a furloughed airline pilot who now works in landscaping, (2) a contractor who managed large construction projects who now delivers packages for UPS and (3) several Wall St guys who are now sitting at home watching TV and babysitting their kids. All of them are extremely bright and hardworking and devoted a lot of time and resources to get to where they were. Think any doctors are going to have tales like this in the next 30 years? Not a chance.
4.27.2009 12:09pm
Slocum (mail):
I'm horrified by the apparent disdain for a well-rounded, basic college degree.

I have gotten to the point where my disdain for a well-rounded basic college degree is pretty complete. I do agree that people absolutely should read literature, study history, learn basic science -- just those the kinds of things that a basic liberal arts degree provides. But nobody -- absolutely nobody -- should have to pay tens of thousands of dollars and spend years of their lives having these things spoon-fed to them (not when it all can be learned much more quickly and efficiently and at a tiny fraction of the cost by anybody with any interest and motivation). Learning by lecture is archaic, exorbitantly expensive nonsense. I wonder what fraction of students sitting in 300 person lectures realize what an shameful ripoff such courses are?
4.27.2009 12:10pm
Tony Tutins (mail):

addressing why people are dropping out of premed is a good thing

Premed is a filtration process. Many people get filtered out during organic chemistry in their second year, giving them plenty of time to change their majors.

There are late entrants, too. A couple of my mechanical engineering classmates eventually went to medical school: one after ten years, the other after twenty. Some colleges offer an undergraduaate course pack tailored to these career changers.
4.27.2009 12:13pm
Losantiville:
How about legalize starting a medical school just because you feel like it. That would certainly increase the number of slots and wouldn't cost (the government) anything.
4.27.2009 12:21pm
DavidBernstein (mail):
Yes, it's true that w/t more medical school seats, the number of docs would not increase. But the number of docs without crushing debt would increase, which, on the margin, would make some more willing to become PCPs.
4.27.2009 12:24pm
DavidBernstein (mail):
And yes, requiring four years of college before law school is at least as counter-productive. When I was bored at a conference once, I wrote out a syllabus for a five-year joint B.A.-J.D. degree that would result in better-educated lawyers than we currently get.
4.27.2009 12:25pm
MCM (mail):
How about legalize starting a medical school just because you feel like it. That would certainly increase the number of slots and wouldn't cost (the government) anything.


The AMA and their associated cronies wouldn't license/approve/whatever they call it all these extra schools. They have a stranglehold on the supply of doctors. It's little different from a medieval guild.
4.27.2009 12:28pm
Oren:

Right now, an aspiring physician must go to college for four years (and take many classes that have nothing to do with his future career)

Heaven forfend our students should have some vague sort of general knowledge outside their chosen specialty. I, for one, am quite glad by undergraduate education exposed me to a wide array of knowledge not directly related to what I do.
4.27.2009 12:36pm
Oren:

How about legalize starting a medical school just because you feel like it. That would certainly increase the number of slots and wouldn't cost (the government) anything.

Sure thing. Just send $100 in cash to my address and I'll give you a medical degree. High-value specialties (radiology, plastic surgery) are an extra $50. Please allow 6-8 weeks for the delivery of your diploma.
4.27.2009 12:37pm
nutbump (mail):
Finally someone raise that very important issue.
The Government make health care very expensive, by limiting number of doctors.
http://www.cogme.gov/rpt11.htm
4.27.2009 12:38pm
Ben P:

Yes, it's true that w/t more medical school seats, the number of docs would not increase. But the number of docs without crushing debt would increase, which, on the margin, would make some more willing to become PCPs.


I assume you meant decrease, but honestly my first reaction to this is to respond, oh those poor people, condemned to a practice that will only pay them $150,000- $180,000 a year.

I fully understand the student loan problem, but lawyers typically have almost as much student loan debt and the earning power of a primary care physician is more than that of lawyers in any but the biggest of markets, and medical specialists even in smaller markets earn as much or more than those at the very pinnacle of the legal profession.

But that's not to say that's not a common problem. I know plenty of people that racked up student loan debt only to belatedly realize that those $150k + starting salaries are much rarer than law school publications would imply even at well ranked schools outside of the top 5.
4.27.2009 12:39pm
Ben P:
I should add, in retrospect, this is starting to feel like a marginal revolution topic. "There's Markets in everything."

One might say "Oh you should go be a doctor" doctors make lots of money, but the reason they make a lot of money is because in proportion of the services needed there really aren't many of them out there.
4.27.2009 12:43pm
theobromophile (www):
If I'm not mistaken, you only need a year's worth of science courses in order to go to medical school: general chem, organic chem, physics, and biology (two semesters each). Students would have at least a year to take courses in other fields, and, if you have students going over the summers, even more time. Universities could also require that their students take a certain number of credits in the humanities ans social sciences, so as to help produce more well-rounded doctors.

No. Working at a college, I've observed literally hundreds of pre-meds decide to pursue other careers. None has done so because of future insurance premiums.

First of all, unless you've talked to each of those students in-depth, you wouldn't know what motivated them. Second, as someone who had considered medicine from the time she was about 13, right up until senior year of college, I can tell you that one of the driving forces was the state of medical malpractise and government-subsidised medical care. My personality is far better suited to being a physician than to being a lawyer, and I certainly have the scientific acumen for it, but, as Barack Obama talks about socialising medicine, I'm so happy that I'm not a med student.

Doctors are actively discouraging people from going into medicine. They say that had it been like this when they started practising, they would never have gone. The advice that doctors give to their children considering the medical field is to think long and hard about it, because their quality of life will be a lot worse than it would have been decades ago.

Just saying.
4.27.2009 12:44pm
rick.felt:
Well, given that the purpose of the post is how to increase the number of doctors, then I would say addressing why people are dropping out of premed is a good thing.

Even with high attrition rates among those who express an interest in medical school early in college, there are still more qualified medical school applicants than their are slots in medical schools. Medical schools have no trouble filling all slots with qualified applicants. Until we get to the point that medical schools can't fill their classes with qualified applicants, we don't have to worry about why students drop out of pre-med.

I'm not saying that it's unimportant to evaluate the pre-med process generally. For example, we might want to know if the process tends to weed out certain students who might make excellent physicians but who don't excel at memorizing reaction mechanisms. That might be a worthwhile inquiry. But there's no real need to investigate why we don't have more medical school applicants.
4.27.2009 12:45pm
theobromophile (www):
And yes, requiring four years of college before law school is at least as counter-productive. When I was bored at a conference once, I wrote out a syllabus for a five-year joint B.A.-J.D. degree that would result in better-educated lawyers than we currently get.

Oddly, I think the opposite: that we could get better lawyers if we required them to have been working for several years before matriculation into law school. Attorneys would benefit from having knowledge of their area of law - knowledge that comes from actually having worked in it before counseling the people in it.

Maybe you can write out a will, help someone get divorced, or the like without having spent a day outside the legal profession, but that's probably not true of people working in highly specialised fields.
4.27.2009 12:49pm
visiting texas lawyer (mail):
Why not create a "medical practitioner" license with less required qualifications to do the basic work?


Bottom line is that there are a number of advance practice nursing degrees. The AMA has been actively trying to destroy or consume them all so that the revenue stream flows to doctors.

Note that a specialist surgeon in England who works a good amount of overtime makes 100k Euros a year. GPs in Europe make 50k to 60k Euros a year. There is no shortage of people who want to become doctors there.

Open up alternatives, break the AMA's hold on the money stream and you will have a plethora of 6 year degree health industry practicioners.

The bottom line is to break the hold on "doctor supervision" that is basically a method for diverting revenue streams (or why CRNAs are supervised from the next building over in many instances).
4.27.2009 12:50pm
Connecticut Lawyer (mail):
MCM,

So few people are qualified to be doctors that you could double the number of medical schools and unless you increased medical compensation to attract the best and the brightest all you would end up doing is adding a bunch of underqualified docs to the system. There are too many of those around today, why make a bad situation worse? I don't know about you, but I want my doctors to be really, really, scary smart people with just the right blend between compassion and distance and a maniacal work ethic. With ObamaCare (tm), they're all going to be turned into the equivalent of DMV employees.
4.27.2009 12:51pm
Tony Tutins (mail):

My personality is far better suited to being a physician than to being a lawyer, and I certainly have the scientific acumen for it,

It's not too late. My classmate who entered med school, 20 years out, is far happier as a pediatrician than she ever was as an engineer.

Barack Obama talks about socialising medicine

Does he really?
4.27.2009 12:52pm
visiting texas lawyer (mail):

I assume you meant decrease, but honestly my first reaction to this is to respond, oh those poor people, condemned to a practice that will only pay them $150,000- $180,000 a year.

I fully understand the student loan problem, but lawyers typically have almost as much student loan debt and the earning power of a primary care physician is more than that of lawyers in any but the biggest of markets, and medical specialists even in smaller markets earn as much or more than those at the very pinnacle of the legal profession.

But that's not to say that's not a common problem. I know plenty of people that racked up student loan debt only to belatedly realize that those $150k + starting salaries are much rarer than law school publications would imply even at well ranked schools outside of the top 5.


What is interesting is that in smaller markets, doctors can make more. Want to be an anesthesiologist in Abilene, Texas? $600,000.00 a year, profit sharing and six weeks of vacation to start. $350,000.00 if you are fresh from school.

You can read more at either gasworks or gaswork (one is a hiring site for anesthesiologists, the other a not-work-safe porn site. I'm not about to visit to find out which right now.

They don't care which school you went to or where in your class you graduated.

Tell me that the law firms are willing to pay that same amount for a J.D. at the bottom of the class from a fourth tier school -- or plan to give them six weeks of vacation a year.

On the other hand, the orthopods who work at Baylor Medical complain how their quality of life just isn't as good as it used to be. They only make two million a year out of residency and they only get two days off a week and only a month or so vacation a year. It just isn't enough.
4.27.2009 12:57pm
Doctor Who?:
Skipping college is a bad idea. I went to med school with people who were in 6 or 7 year combined programs, and they were an unhappy and unproductive lot. You need to mature a bit as a person (and dare I say live a little before you go to medical school)

As far as primary care goes, that was a lie they told us when I was in school (late 90's) Turns out that the specialists have been earning more (with less hassle) than the poor GP's they wanted us to become. Make med school free or half price if you promise to enter a family practice residency and work as one for at least 5 years after training completes. They give "free" medical school if you get into an M.D./Ph.D. program, so you could do this as well if you really wanted more practicing primary care.

No offense to all the advanced practice nurse/anesthetist/whatevers out there, but a couple extra classes isn't going to make you into a physician.
4.27.2009 1:00pm
ShelbyC:

Oddly, I think the opposite: that we could get better lawyers if we required them to have been working for several years before matriculation into law school. Attorneys would benefit from having knowledge of their area of law - knowledge that comes from actually having worked in it before counseling the people in it.


We would get better lawyers if we picked the best two lawyers and barred everybody else from practicing law. But the objective isn't to get better lawyers, it's to have the most cost effective legal expertise available, based on demand. And is the most effective way to do that to have a bunch of bureaucrats opining on what they think the qualifications for being a lawyer ought to be?
4.27.2009 1:03pm
ohwilleke:
The less education solution makes less sense for medicine than it does for law.

In medicine, there are hosts of professionals who are permitted to do work that would otherwise be the practice of medicine, with reduced education. There are LPNs, RNs, nurse practitioners, EMTs, physicians' assistants, medical technologists, phlemobotonists, PhD medicial researchers, pharmacists, dentists, optomitrists, physical therapists, midwives, and more (law, in contrast, has fewer parallel professional options).

Also, since the U.S. has the highest paid doctors in the world, importing doctors from abroad is less of a problem (law, in contrast, is rooted in local legal culture not scientific universals of the human body). Similarly, while primary care doctors make less than specialists, the number of doctors paid very low salaries is much lower than the lowest paid rung of lawyers (e.g. public defenders and prosecutors and fledgling solo practitioners).

And, given the amount of post-secondary training involved in medicine (four years college, two years primarily classroom oriented medical school, two years primarily clinical oriented medical school, four years residency, and often time spent in specialty oriented internships in addition for a couple of years), a couple of years less wouldn't make as much of a difference here as it would elsewhere. The additional time that a full four year college degree requirement allows for weeding out prospective doctors may be worth more than those lost due to additional education as undergraduates, and those extra years of liberal education may have value in a profession that involves relating to other people generally in ways that no medical education can teach (law, in contrast, is a three year program following a degree, so there is more room to impact education).

Rather than rethinking what education doctors need, we should rethink what qualifications are really necessary to provide care. Independent non-MD professionals may more often be enough. We should also think about rewarding MDs less handsomely. One reason we have a shortage of MDs is that so many are retiring early since they are comfortable with what they have earned. More hungry MDs might work normal length careers more often.
4.27.2009 1:10pm
ShelbyC:

We should also think about rewarding MDs less handsomely. One reason we have a shortage of MDs is that so many are retiring early since they are comfortable with what they have earned. More hungry MDs might work normal length careers more often.


Wow!! a whole brand-new school of economics!! :-).
4.27.2009 1:13pm
NickM (mail) (www):

So few people are qualified to be doctors that you could double the number of medical schools and unless you increased medical compensation to attract the best and the brightest all you would end up doing is adding a bunch of underqualified docs to the system.


And if you attracted more of the best and brightest into becoming doctors, that would come at the expense of other important jobs that attract the same sort of people. Start with everything that's normally now done by Ph.Ds in biology or chemistry.

Nick
4.27.2009 1:15pm
George Weiss (mail) (www):
interesting-

it seems that while for many years the AMA and the AAMC (and their associated committee which controls accreditation and class size the LCME) controlled the number of medical school slots creating a shortage....see here: (number of medical graduates about the same over decades despite growth of population as a whole)

it appears lately they have changed their tune and begun responding to the shortage by encouraging growth.

so maybe the problem is going to get better.
4.27.2009 1:18pm
Tony Tutins (mail):

Doctors are actively discouraging people from going into medicine. They say that had it been like this when they started practising, they would never have gone.

Equally true of just about every profession.
4.27.2009 1:19pm
ohwilleke:
I also agree with those that more medical schools are needed. We have licensing exams and selective residencies to control who can enter the profession and who can enter specific specialties. This breaks the link between more medical schools and unqualified doctors. A few dozen more medical schools might not have as high licensing exam pass rates, but many graduates would do as well as those from existing schools.

It is highly unlikely that everyone who applies to medical school, and who is qualified to complete medical school, pass licensing requirements and become a PCP is being admitted to medical school now. If admissions standards to medical school were dropped to 1959 levels, we could dramatically expand the profession while getting people no less qualified than those who recently left the professional after full successful careers.

While there are lots of complaints that too many lawyers is wasteful, there is less of a widespread sense that more doctors would do harm.
4.27.2009 1:25pm
visiting texas lawyer (mail):

No offense to all the advanced practice nurse/anesthetist


But quite frankly, the anestetist is probably better at running a code, more likely to pay attention to the patient's vital signs, and has much harder boards (no one gives them the boards to take in practice, word for word, each year).

It is why the MDs have had such a hard time suppressing them.

Consider, the anesthetist's believed young children could feel pain, the MDs insisted that they couldn't and blocked pain management from treatment. The statistical analysis shows that led to thousands of deaths. You can run the numbers in a variety of ways.

But, no offense, of course. The MDs start off with a great deal less experience, less demanding classes, and a smaller knowledge base. They get better only by intentionally limiting the competition.

I don't know about NPs, it has been a while since I had to litigate a case involving them. But the facts are why CRNAs are "supervised" by MDs in buildings a mile or more away, while those people drink coffee and make stock trades. Of course an MD who "supervises" enough CRNAs makes five to six million dollars a year.
4.27.2009 1:26pm
rick.felt:
So few people are qualified to be doctors that you could double the number of medical schools and unless you increased medical compensation to attract the best and the brightest all you would end up doing is adding a bunch of underqualified docs to the system.

Unqualified? Depends what the task is. Opening more medical schools might not give us any more qualified brain surgeons, but there are oodles of people qualified to write prescriptions for pimple creams and give routine checkups.
4.27.2009 1:26pm
visiting texas lawyer (mail):
Everything said, we are likely to get Wal-Mart medicine in the end, which is what is starting to happen in those states that have allowed Wal-Marts to open primary care outlets inside the stores.

Then we move all the doctors into becoming specialists. It is a better use of MDs to make them into specialist surgeons and other treatment providers. Sure, they will make more money, but the flip side is that we will have more health care providers: more primary care providers where they are needed (for routine treatment of those who can not pay as much) and more specialists for when we need serious care.

What to do about all the non-compliant diabetics though? That is a completely different question, but more important to long term cost containment.
4.27.2009 1:30pm
MadHatChemist:
I've tought many undergrads, who were about to get their degree from a decent college, who didn't understand basic concepts, and would laugh it off saying that college is just about having fun and "finding yourself" -- and then say they want to be doctor's just because it is prestigious or pays alot.

Sadly, it seams that colleges seem more and more likely to just automatically pass people, in large part via dumbing down the curriculum, so I don't know how much of an effective filter college is for weeding out the people who can't hack it, but seeing what gets through, I'll take whatever I can get.
4.27.2009 1:34pm
DennisN (mail):
Kenvee:
DennisN


Is this something that needs to be "dealt with?" or is this simply a natural filtering process. Some people decide, part way through, that they don't like medicine all that much.


Well, given that the purpose of the post is how to increase the number of doctors, then I would say addressing why people are dropping out of premed is a good thing. If the reason is just that they've decide they don't want to be doctors, then that's fine. If it's because they've discovered they can't afford it or there are other obstacles in place, then yes, that's something I'd think needs "dealing with" if we want more doctors.
[Emphasis Added- DN]

That, I agree with.
4.27.2009 1:35pm
Dan Weber (www):

Do we want doctors to be health technicians or doctors?

I think we want some of both.
I, for one, am quite glad by undergraduate education exposed me to a wide array of knowledge not directly related to what I do.

You did it and you are glad you did.But shouldn't we leave this choice open to others?
but I want my doctors to be really, really, scary smart people with just the right blend between compassion and distance and a maniacal work ethic.

Are you prepared to pay for that? You don't need to see a brain surgeon for the flu.
4.27.2009 1:43pm
rick.felt:
I want my doctors to be really, really, scary smart people with just the right blend between compassion and distance and a maniacal work ethic.

Does "maniacal work ethic" translate into "works when he should be sleeping"? Does it translate into "tries to cram as many patients into the day as possible, so she only sees you for ninety seconds?"

The practice of medicine in the U.S. has its problems, but I don't believe that an insufficient proportion of physicians who are Type-A's is one of them.
4.27.2009 1:53pm
Bruce Hayden (mail):
So we're supposed to be simultaneously 1) raise doctor pay and 2) get more doctors. In a health care system that's already breaking under the costs. No thanks.

The real "obvious" solution is to weaken the doctor's guild (the AMA) so that more people can become doctors. More doctors = lower prices from doctors.
I agree with this to some extent. I haven't been following this recently, but from several years ago, the AMA was setting quotas on med school slots AND not allowing new ones to open (contrast this with law schools - likely since attorneys know about anti-trust laws). And ditto with residencies. They are scant apparently because much of their cost is paid for by our government.

But then, even if medical schools could pump out more doctors, why would anyone want to be a general practitioner? Median income there is less than top law school grads make (or made before the current recession) right out of law school, without the opportunity to really make that much more.

Something to keep in mind. Last week, my seatmate on a flight was the CFO for a hospital. I asked him about reimbursement rates, and he indicated that right now MediCal (or whatever it is named) was reimbursing at 10% of costs, and Medicare at 25% of costs, with everyone else cross-subsidizing those patients. The problem when it comes to physicians is that the brunt of governments' attempts to keep their own costs down by underpaying for services falls primarily on the primary care providers. This is probably also true for insurance companies. Paperwork is increasing, while reimbursements are being crammed down. The result is that there are now a lot of better fields to go into if you want to make a comfortable living.
4.27.2009 1:56pm
theobromophile (www):
Shelby: what's with the hostility? It seems to be your MO around here....

That aside, you start off with an assertion with no basis in fact, then move to snark to support it. No, our goal is not always to get the most cost-effective (i.e. cheap) legal services available. There are many situations in which scrimping a bit on the cost of representation is penny-wise and pound-foolish, to use the cliche. The goal isn't cheap or cost-effective: it is to give people the best representation that they can afford.

By the way, I never said anything about bureaucrats. Perhaps you could look at Northwestern's law school, which almost requires its students to have post-college work experience, as a model of how a law school has selected for talented, skilled people who are making a transition into law.
4.27.2009 1:56pm
Adam MD MPH:
I can speak from personal experience to some of the issues raised by the shortage of primary-care physicians as I spent about a decade as a family medicine doc in Maryland, as well as having worked in VA hospitals.

I graduated med school in 79 and began a residency at GW. After being insulted and humiliated repeatedly by my attending, I left for another residency at a small hospital in Virginia. What few people have failed to mention in the costs of becoming a doctor are the non-financial burdens of being a resident: 80-100 hours of work each week (which often means sleeping in an empty room at the hospital between shifts), being on-call even when you're not at work (a problem that afflicts docs in clinical practice as well), and the massive amount of paperwork that has to be done to satisfy health insurance companies.

In fact, in Maryland right now, there is a large shortage of primary care doctors because of how stingy the health insurance companies can afford to be. Part of the reason why I left Kaiser Permanente, which was my last clinical job, is because of the arbitrary cost-saving measures that they used. There is nothing more aggravating about trying to treat people than being told you have 15 minutes to do the entire exam and then being second-guessed by management about whether the treatment was the most cost-effective. And after those workplace frustrations are resolved, the looming threat of malpractice cases, even when frivolous, means even greater taxation of my time and energy.

What's more, and many residents learn this during their servitude, most hospitals load up on unnecessarily expensive equipment or facilities in order to advertise how cutting-edge their quality of care is. This produces patients who show up to a hospital looking for the minimally-invasive treatments with lasers and GPS for the body and all manner of other useless treatments that could be done cheaper and better by traditional methods. But the Sharper Image approach to medicine produces more revenue for hospitals, cost-cutting be damned.

There is no other profession in America that has more money aligned against it than primary care physicians. If the insurance companies, medical schools, hospitals, and malpractice attorneys don't take that desire to help people and smash it into a fine pulp of stress and anger, then the overbearing parents who demand treatments for their children, the patients who self-diagnose from WebMD and some BS they saw on the Discovery Channel, and being awakened at 2 AM once a week because a hospital had to admit one of your patients, all of that will drive you absolutely insane.

Welcome to the state of American medicine.
4.27.2009 1:57pm
Alan K. Henderson (mail) (www):
The fact is, physicians are doing quite well, financially. For all the talk of being underpaid by Medicare, etc., medical professionals (physician, dentists, etc.) occupied 13 of the 15 highest-paying occupations in the U.S.
I'd like to see that list adjust for licensing, insurance, and any other annual fixed costs (such as union dues, in the case of pilots) required for engaging in that profession. The linked article shows us the gross, not the net.

I'd also like to see a salary contrast between docs who do and who don't accept Medicare patients.
4.27.2009 1:58pm
Ben P:

I've tought many undergrads, who were about to get their degree from a decent college, who didn't understand basic concepts, and would laugh it off saying that college is just about having fun and "finding yourself" -- and then say they want to be doctor's just because it is prestigious or pays alot.

Sadly, it seams that colleges seem more and more likely to just automatically pass people, in large part via dumbing down the curriculum, so I don't know how much of an effective filter college is for weeding out the people who can't hack it, but seeing what gets through, I'll take whatever I can get.


Perhaps, but I'm pretty sure you didn't know the pre-meds I knew.

We certainly had a work-hard party-hard ethic, but I have a hard time taking accusations of classes being dumbed down too seriously when so many of my friends were pulling all nighters cramming for that all important A on the Molecular biochemistry or Microbiology final.
4.27.2009 2:06pm
MartyA:
The good news is that President Obama has a great plan. The plan is pricey and must be implemented very quickly so no lengthy debate is appropriate.
Obama will simply retrain the terminated GM Pontiac UAW workers and certify them as qualified to provide medical services for middle class Americans. It will help lazy UAW members and hasten the destruction of the middle class in America.
4.27.2009 2:07pm
Paavo Ojala (mail):
I'm in a 6-year post highschool medical school here in Finland. It works. No one needs college. You can learn the trivia in High School and in your free time.
4.27.2009 2:12pm
NowMDJD (mail):
FWIW, I have been impressed by the lack of maturity of 6-year MD's from US schools whom I've taught in my resiodency programs. They rarely hit the ground running. I don't know whether four years of going to college with non-premeds enhances maturity of would-be doctors or if the 6-year programs select for less mature kids. Possibly it's just that the beginning residents are 2 years older.

In any event, I stopped taking the 6-year graduates because they were less conscientious and didn't do as well with patients. they were higher-maintenance than the residents who wenbt through college and 4 years of med school.
4.27.2009 2:22pm
nutbump (mail):
(link)Adam MD MPH:

I graduated med school in 79 and began a residency at GW. After being insulted and humiliated repeatedly by my attending, I left for another residency at a small hospital in Virginia. What few people have failed to mention in the costs of becoming a doctor are the non-financial burdens of being a resident: 80-100 hours of work each week (which often means sleeping in an empty room at the hospital between shifts), being on-call even when you're not at work (a problem that afflicts docs in clinical practice as well), and the massive amount of paperwork that has to be done to satisfy health insurance companies
....

Sounds like human right violations.
Are not the doctors themselves have created that mess.
Why in the world we need health care like this. Does the ability not to sleep for 40 hours add any additional mental capacities to the doctor. I do not think so.

The whole things about health care is a giant fraud.
4.27.2009 2:24pm
ShelbyC:
theobromophile:

Shelby: what's with the hostility? It seems to be your MO around here....

That aside, you start off with an assertion with no basis in fact, then move to snark to support it. No, our goal is not always to get the most cost-effective (i.e. cheap) legal services available. There are many situations in which scrimping a bit on the cost of representation is penny-wise and pound-foolish, to use the cliche. The goal isn't cheap or cost-effective: it is to give people the best representation that they can afford.


Funny, the only hostility I see is in your comment. The point I made about your original post, the one I blockquoted, was that you (and many other commenters) are addressing one side if the equation. You're saying we would have better lawyers if we required them to work longer, which is true. We probably also have better lawyers and doctors because we require them to have an undergraduate degree. However these requirements decrease the supply of lawyers and doctors, which increases the cost. I can't find where you address how the decreased supply of lawyers is justified?

And no, cheap is not the same as cost-effective. It's the value of the representation over the cost.

And can you please point out where I make an unsupported assertion followed by snark to support it? The only unsupported assertion I can find is that one you just made.
4.27.2009 2:24pm
einhverfr (mail) (www):
Dan Weber:

Are you prepared to pay for that? You don't need to see a brain surgeon for the flu.


Once again, there is a tremendous difference between medicine in the cities and medicine in rural areas where I live. Keep in mind here that most surgeries including emergency surgeries are done by General Practitioners-- the folks you go see for the flu. These guys do a fair bit of EVERYTHING (including sometimes psychiatry).

My suggestion is you go see a nurse practitioner for your flu, and let the physicians continue to be doctors.
4.27.2009 2:46pm
einhverfr (mail) (www):
I think a much better solution if one wants to increase the market for health technicians is to encourage nurse practitioners etc. to open practices in health clinics.

Once again, undereducated doctors would mean a massive decline in standard of care here in rural America. After all, if I need an appendectomy, it is a general practitioner who would do that here. The GP is also the guy who delivers babies, does ER work, and may even do some psychiatry. These folks NEED general education and wide-ranging critical thinking skills because they do so much.

My suggestion is that the better way to go is to keep doctors as doctors (meaning educated people), and shift some primary care responsibilities onto health technicians, such as nurse practitioners. However, reducing doctor requirements would mean the end of rural medicine in this country as we know it.
4.27.2009 2:53pm
Commodore:
Could this principle not work in reverse by applying it to the legal profession? In order to cut the excessive number of lawyers becoming licensed every year, why don't we increase the amount of time lawyers must study, by (for example) increasing law school from three to four years?

(Of course, since many consider their 3L year already to be worthless, this would be very frustrating for law students.)
4.27.2009 2:58pm
Dan Weber (www):
My suggestion is you go see a nurse practitioner for your flu, and let the physicians continue to be doctors.

Oh, I agree, and a nurse diagnosed my ear infection a few weeks ago without needing to bring in an MD. My point was that there seem to be people here who want these super-educated uber-doctors everywhere.

I don't want to get rid of doctors or specialists. But we need more of the less expensive people, like RNs and PAs, who can handle the simpler problems and diagnose for serious ones.
4.27.2009 3:03pm
Mac (mail):

Alternatively, reduce the cost of medical education by greater subsidies to medical schools, reducing the tuition amount.


Pat HMV,

What makes you think they would use the subsidies to reduce tuition cost? Here in AZ. tax money to Universities has skyrocketed and so has the tuition. Now that we are in an economic mess here and the subsidies are getting cut, tuition is skyrocketing again. This, when our State Constitution says that university tuition should be "as nearly free as possible".

Have not had time to read all posts. If I repeat, I apologize.
4.27.2009 3:07pm
einhverfr (mail) (www):
Mac:

A better option is to increase scholarship programs for medical students willing to address specific shortages. This way it goes specifically against the tuition of specific students.
4.27.2009 3:13pm
einhverfr (mail) (www):
Dan Weber:

I don't want to get rid of doctors or specialists. But we need more of the less expensive people, like RNs and PAs, who can handle the simpler problems and diagnose for serious ones.


Agreed there. In my community (total valley has probably around 10000 year-round residents, plus probably 100000 seasonal tourists in the summer) we typically have 2 RN's who do some primary care, 4 PA's who handle ER triage and immediate care (either minor cases or while waiting for the on-call doctor) and some other stuff regarding hospital care, and the rest of the medical staff are all generalist physicians. There are times when the hospital also employs a psychiatrist.

So my concern is the changing criteria for medical school, not the idea that we can't have more health technicians in the medical system. I don't want the education of the actual doctors here to go down. However, there is room for additional folks in the system with less education.
4.27.2009 3:21pm
Ben P:

(Of course, since many consider their 3L year already to be worthless, this would be very frustrating for law students.)



Actually I would say transitioning to a "residency" like system or even a med school type system (2 years class, 2 years clinical training) would be an outstanding development for law schools and the legal profession. (provided of course perhaps that the 3 year salary was not additional)

I think my 3L year was my single most useful year of law school, but I didn't use it to take the few remaining bar courses or "Law and ______" Classes. My school has a strong clinic program and I finished law school and before I even entered practice I had 4 months experience working on Individual Chapter 7 bankruptcy cases, 4 months experience working doing transactional work for non-profits, and 4 months experience working as a prosecutor doing misdemeanors in our local city courts.
4.27.2009 3:29pm
Hannibal Lector:
Paavo Ojala:
I'm in a 6-year post high school medical school here in Finland. It works. No one needs college. You can learn the trivia in High School and in your free time.
The problem in applying this to the US is that the typical gymnasium graduate in Europe has had four more years of science, four more years of mathematics, eight more years of foreign languages, and far more reading in history, geography, and literature than the typical US college graduate. And all at a much higher level of rigor.
4.27.2009 3:45pm
vc_site:
The shortened undergraduate course of study before entering medical school is an old idea that was implemented to make up for a perceived physician shortage -- jump start the system by getting more physicians now. It has been around for 40+ years. Boston University has an example program. Note that over the years, it is has changed from a 6 year medical program into a 7 year program.

An old study showed that the students did fine, although I have always wondered why, if these students were the best and brightest coming out of high school, they didn't they do better. Perhaps the 6 meds burned out, which is the reason for the switch to the 7 year program.

Not getting an undergraduate degree before entering "medical" school is not unprecedented in the United States. This is the system for veterinarians. "Applicants are not required to have a B.S. or B.A., but are urged to consider their overall education and future when planning his/her undergraduate enrollment."

The UK has the MB BS (Bachelor of Medicine and Surgery). It is an "entry level" professional degree that the USA medical establishment essentially treats as the MD. However, the students entering this course of study are probably the equivalent of USA high school student graduating with a years worth of AP credits.

Primary care physicians often treat conditions that physician extenders could treat, however physicians are needed for making the correct diagnosis and dealing with treatment subtleties. These elements require a broad background and depth of training that physician extenders are unlikely to get. With a physician, you are ideally paying for a finely tuned machine who can be awakened from a dead sleep at 3 AM to instantly make the correct life-saving diagnosis and treatment decision, whether in person or over the phone.

The data that I would be interested in seeing is the net earnings per hour for physicians. I would expect that physicians would not be as high on the list as others might expect. And that "high" physician salary is not all that high when one considers the lost opportunity costs involved in the training process.

As for the primary care need, it has been there for years. Back when one could practice medicine independently after a one year rotating internship, most physicians were generalists, but doctors still developed specialties. It is the nature of medicine, law, etc. Now, it takes a minimum of 3 years residency to practice medicine independently in almost every state. (Arkansas was the last hold out that I can recall, but I do not the current requirements in that state.) For many residents, another few years of fellowship specialization is not a that big a deal. They are already in deep debt by the time that they enter fellowship specialization.

The medical establishment is to blame for much of the medical training problems. Many desirable specialties (e.g., cardiology and neurosurgery) have research requirements during training so that the medical school faculty can have highly trained lab technicians. The research often has nothing to do with training physicians for clinical practice. In addition, the USA is a desirable place to live so it is not uncommon for foreign medical graduates to complete more fellowships per capita than USA medical graduates in the hopes that at some point the foreign medical graduate can win the visa "lottery," which feeds into the medical establishment's research, not training, goals.

Of course, one problem is that in the USA we want health care to be a "right" but we expect very bright students to enter medical school then go deep into debt (US News and World Report has 10 of the top 14 USA Research Medical Schools are private with tuition > 40K per year for four years) then finally come out the other end of the grueling process as caring empathetic physicians. And get to deal with insurance nurses trying to deny patient coverage, mail order pharmacies calling monthly to change prescriptions from brand name to generic, etc. Repeatedly miss family obligations while taking care of patients who rarely say thank you. Then get sued for trying to do the right thing. Etc.

BTW, it is really pretty simple how to get more students to enter medical school and then primary care. Make the job more financially attractive. Less debt and more net salary per hour worked.

MD now doing JD.
4.27.2009 3:49pm
Mikeyes (mail):
There was a comprehensive study of pre-med students done by a Tulane sociologist about 15 years ago which is probably still correct. According to the study, about one third of those who start out in pre-med finish and then about half of those survivors get into medical school.

The majority dropped out due to grades or inability to work the high number of hours it took to achieve those grades. But a fair number of students with good grades and aptitude dropped out because they didn't want to face another eight to ten years of a similar grind. Still, there are talented students who go to medical school.

The AMA does not limit the number of medical students. Cost seems to be the great limiting factor. The only new medical schools that will come on line are going to be state sponsored schools. No private university is going to foot the $100M or so bill needed to set up a medical school these days. States have more access to funds and more motivation to develop medical schools but most have already done so. Expanding the slots makes more sense, but there are high costs to that too and each state has to also develop a plan to keep those students in state throughout their careers. Kansas will give you full tuition if you make a bargain with them to stay in a rural area as a primary provider.

The average age of first year medical students is also rising probably due to the salaries mentioned above. My son's class had an average age of 24 his first year including one 48 year old who had been a photographer prior to going to medical school. On the other hand, asking an 18 year old to make a decision that will affect the rest of his or her (schools are usually equally divided by gender) life is not always predictive of success and, as has been pointed out, maturity often becomes a factor later on.

There was a time in the sixties when you could go to medical school after your sophomore year of college and if that medical school was the University of Tennessee you could finish your MD in three years. One of the reasons that the three year program was dropped is that there is a level of magnitude more of information needed to be a medical student these days, much less a fully qualified physician. In the sixties you could go into practice without an internship in six states in the South and with one in the rest of the country. My little town south of Nashville had a physician who had only an internship yet he was doing hip transplants. Of course he had the highest incidence of infections in the state. When the new wave of board certified physicians came into town, he was quietly retired. Every medical student has to have a residency if he or she wants to be fully qualified. (As an aside, virtually every medical student eventually passes a state board via the national board certification process. The same can't be said of lawyers.)

It takes a long time to be a physician and it takes someone who is willing to go through the process of getting good grades, getting good MCAT scores (the average MCAT scores of matriculated students are rising, by the way), and doing all the work needed to learn in medical school.

There is very little difference in medical schools in this country. The main reason is the set of standards that are heeded by the various schools and states. At the beginning of the last century Abraham Flexner, an educator not a physician, wrote a report that ended all of the fly-by-night MD and DO schools in this country. While there have been criticisms of the report, it did allow only those schools with strict academic and clinical standards to survive. (Stanford almost didn't make it, by the way.) If a public policy decision is made to lower these standards, then more people will go to medical school. But that is unlikely to happen.
4.27.2009 3:51pm
MadHatChemist:

We certainly had a work-hard party-hard ethic, but I have a hard time taking accusations of classes being dumbed down too seriously when so many of my friends were pulling all nighters cramming for that all important A on the Molecular biochemistry or Microbiology final.


I remember taking a bioscience class to fill some requirement, and the class just happened to be one that all the pre-meds took. The professor outright said that they catch more people cheating in this class then any other -- so much that mostof the cheaters are probably never caught. Teh ones who were caught had a tendency to be pre-med.

I realize that there are many brilliant and hard working pre-meds, and those that cheat or are morons (hopefully) get weeded out during medical school. But come one, in many schools an A just means getting above average.
4.27.2009 4:02pm
gasman (mail):
David Bernstein,
We have three medical schools in the US that take american kids right out of high-school, and grant both an MD and soft BS degree in 6 years. They've been operating for more than 3 decades.
So what you propose is not novel. And the data is there for the picking; so David, has the lowered cost of entry into doctoring resulted in their flocking to primary care specialties? I doubt it, but since it is David's proposal, the burden of digging up the goods is on him.
4.27.2009 4:29pm
Connecticut Lawyer (mail):
I disagree with all who think that primary care physicians need to be less smart or less skilled than specialists.

What I want, what anybody should want, in a doctor is first and foremost great diagnostic skill. This is more rare than you might think. It's especially important in primary care physicians, who have the chance to diagnose diseases in their early stages when they might be treatable. I don't think that nurse practitioners (who are wonderful, skilled people, but they are not doctors) can be handed the job of figuring out what faint sympton today is heralding a serious problem down the road.

So count me against any plan to shortcut the training of doctors and in favor of any plan that brings the best and brightest into the profession.
4.27.2009 4:34pm
wfjag:
Dear Prof. Bernstein:

As gasman notes, there are some medical schools that have programs where the MD/BS degree is combined. Univ. of Louisville, I believe, is one of those programs.

However, your post (and a number of the comments) remind me of the truism "Those who fail to study history are bound to repeat the mistakes of the past."

The current US medical education program was setup mainly by John A. Wyeth. Wyeth's rather interesting personal history includes having been an underage volunteer for the CSA and serving as a member of John Hunt Morgan's Scout Company during the 1863 Christmas Raid, writing the premier biography of Nathan Bedford Forrest, That Devil Forrest: Life of General Nathan Bedford Forrest, being a noted apologist for "The Lost Cause", and -- becoming a MD before that required the extensive education and training now required, killing a patient due to what he realized was his own malpractice stemming from a lack of the extensive education and training, and having the honesty to admit that was why his patient died. He then set off to obtain that education and training (in England) and then reform US medical education so that other Doctors (meaning MDs) wouldn't kill patients for the reason he had.

Whatever you think about Wyeth and his writings about the Old South and the CSA, his thoughts about the effects of a less than rigorous pre-med and medical education and training address the questions you raise. His criticisms are still valid even over 140 years he wrote them.

About 40 years ago, DOs decided to reform their selection, education and training, so that now there is very little difference between the education and training that a DO receives and a MD receives.

However, if you want someone who attends some short courses and believes that he or she can treat you for whatever, check out the standards for Chiropractors in the state of Missouri. A DC in MO can, after attending a short (as in 1 or 2 day) seminar, perform Neurological Chiropractic, or Pediatric Chiropractic, or Radiological Chiropractic, or any number of other specialties. Whether you are comfortable having a DC be your primary health care provider, or your specialist, is a question you have to answer.

In the UK, homeopaths and homeopathic hospitals are covered by the National Health Services. If you believe that the "memory" of water provides effective medicines, then you can have no objection to this.

So, the answer isn't so much increasing the number of health care providers -- Minnesota recently authorized Naturopaths as "NDs" to provide that type of health care -- as you can find lots of people who represent that they have some sort of health provider specialty that they are ready, willing and able to provide. Rather, the question is what you expect your primary health care provider (and any specialists) to know and be able to do. If you want to go back to the standards under which Wyeth was first licensed to practice medicine, you'll have lots of health care providers. But, if you want people who have undergone a rigorous selection, education and training program so that they have a pretty good chance (although not a perfect one) of not killing their patients due to a lack of knowledge and education, then you'll have to settle for fewer MDs and DOs. This will continue at least till other "doctors" raise their selection, education and training standards.
4.27.2009 5:28pm
einhverfr (mail) (www):
Mikeyes:

There was a comprehensive study of pre-med students done by a Tulane sociologist about 15 years ago which is probably still correct. According to the study, about one third of those who start out in pre-med finish and then about half of those survivors get into medical school.


My father went to medical school after dropping out of his PhD program in Mathematics. He studied for the MCAT exams, etc. made it in, went through on a public service scholarship, and serves rural parts of Washington State.

Pre-med degrees are IMO nearly worthless and there is no evidence that getting that degree makes one more likely to do well in medical school than any other degree. What one is really supposed to get in college is a general education with a strong emphasis in critical thinking skills. I would prefer a doctor who had a geology degree to one that had a pre-med degree in all honesty. Heck, I would probably prefer a physician with a philology degree over a pre-med graduate with an MD.....

However wfjag is absolutely right about the value of history in this issue. I have had family members receive medical care in places where I knew more about the fundamentals of their remedies than the doctors did. I would much prefer to deal with what we have here.
4.27.2009 6:18pm
einhverfr (mail) (www):
Also I treat most illnesses I come down with herbally. Rarely do I go to a doctor, but when I do, I expect them to know more than I do about the illnesses.
4.27.2009 6:21pm
Mikeyes (mail):
einhverfr,

I didn't point to that study as a defense of getting a four year degree, but to show that even with the best intentions, only one sixth of pre-meds (and I assume interested high school graduates going to a good school) have the abilities needed to make it in medical school. College acts in the same way it does for the NFL: it sorts out who will make it and who won't and for the most part, unless you are a serial killer, these candidates make it through and pass all the qualification tests at a rate above 90% and well above similar tests in other professions.

In addition they usually get an education. By the way, there are very few schools that give a "Pre-Med" degree. The most popular degree is usually a science degree, but my son has a degree in Philosophy. The latter degree, from a very good school, was one of the factors that helped him get into medical school. Since he is a white male, he was somewhat handicapped as far as selection went. A philosophy major imparts a better chance at getting in than almost any other undergraduate degree.

Your father also illustrates why maturity is better. An applicant with real life experience and a graduate degree is far better suited for medical school if the statistics about age and education are any indication.
4.27.2009 6:41pm
anotherpsychdoc (mail):
As far as the professional happiness of physicians goes, of course you have to start with the personality types of physicians. I read somewhere, and it seems true, that physicians are comfortable with odds situations like 7:1 or 8:1 whereas business people could be comfortable with 4:3. The physician makes an enormous investment of his talent to get those odds. One finds in hospital practice now 'Doctor's Day;' it used to be only secretaries had 'days.' Why? I think, as a commenter on another post, said, you have, it seems more often than we used to, 'psychotic derelict day' applicable to the same folks. For people who like 7:1 odds this is an unhappy occasion. Naturally, the prospect of axb = c, where "a" equals money to physician for patient contact, b = people seen (said to go up shortly), and "c" equals a dollar number the government would like to see go down doesn't make them excited either. The final problem with being a physician is that it is like being a 19th century cobbler. You can treat people really well but there really is no good way that you can translate your skill into mass production. Maybe the Army can do it but the practice of the brilliant docs I have seen do it has led to poor care.
4.27.2009 7:09pm
DG:
I've gotten some excellent health care from physicians assistants (PAs) working under physician's supervision. One example is my dermatologist, who uses 3 or 4 PAs - I see the doc once in a while or if I have question or concern that stumps the PA. Similarly, I've seen a PA at an orthopedics practice for arm injuries. At one point, he did run something by his physician supervisor, but otherwise treated me himself.

In both of these cases, you have 3 or 4 PAs and a physician in the same office, instead of a bunch of physicians. The medical care is the same, the supervising physicians make more money, I can actually get an appointment - everyone wins.

The AMA really sucks with their dismissal of PAs and NPs - they are very short sighted and don't recognize that a pyramid structure would actually result in more compensation for their members.
4.27.2009 11:00pm
justme:
I find it interesting that when some other overpaid occupation, such as autoworkers, bitch about their working conditions, they are whiners. When physicians do it, it is an indication of systemic problems.

The fact is, physicians are doing quite well, financially. For all the talk of being underpaid by Medicare, etc., medical professionals (physician, dentists, etc.) occupied 13 of the 15 highest-paying occupations in the U.S.


This is so asinine, where do I even begin?

Indeed, doctors do make good money, but let's put some perspective on it. 4 year of college, 4 years of med school, 4-8 years of residency, and 1-3 years of fellowship. Oh, by the way, during med school and residency, you get about 10 days off, work 6 days a week, 16 hours a day.

I defy you to find another profession that puts in that much time.

And as far as Medicaid goes, if you bother to do some research you'll discover that the wages of family physicians has been basically static over the past 20 years (adjusted for inflation of course). And did I mention the $60k malpractice insurance cost?

We do need more med schools. The primary reason we don't have any is the sheer cost - there's tremendous overhead involved in operating a medical school.

But the more pressing issue is the dwindling number of primary care docs = that's something we all should be concerned about.
4.27.2009 11:49pm
orthodoc (mail):
The AMA has absolutely nothing to do with setting enrollment numbers for medical schools, as that's done by the AAMC (Association of American Medical Colleges). Further, the big choke point is at entry into residency - and that's set by the Federal Government, because residency funding is carried out by CMS. In any case, the AMA now represents less than 20% of physicians - I don't belong, and I've never missed it.

Increasing med school enrollment as a solution is quick, attractive, makes a good sound bite - and is completely wrong!

There are any number of reasons for physician shortages:
1. Early retirement
2. MDs can't make enough to pay staff, rent, overhead, etc. and still take home enough to make the whole thing worth it - I can remember as a resident (years ago) hearing from one of my mentors that the taxi driver bringing his patient to his office would make more than he did!
3. A much higher percentage of women as physicians, who work fewer hours than men at all comparable stages of practice, with the possible exception of late in their careers (this is from AAMC demographic data)
4. It's just not particularly fulfilling anymore, so people go John Galt.

I have three kids, and none of them will be physicians if I have anything to do with it....
4.28.2009 10:32am
einhverfr (mail) (www):
Orthodoc:

2. MDs can't make enough to pay staff, rent, overhead, etc. and still take home enough to make the whole thing worth it - I can remember as a resident (years ago) hearing from one of my mentors that the taxi driver bringing his patient to his office would make more than he did!


As an aside, I spent some time in Ecuador and discovered there that bus drivers and taxi drivers made more money than most doctors or lawyers simply because they were well enough organized to be able to effectively extort pay raises (for their monopolies) from the government.

A taxi cab strike could shut down all traffic in the city for 3 days......

This being said, most of the physicians I know (in rural America) seem to have a reasonably comfortable living. Not ostentatious by any means, but fairly comfortable.
4.28.2009 10:53am

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If you have a comment about spelling, typos, or format errors, please e-mail the poster directly rather than posting a comment.

Comment Policy: We reserve the right to edit or delete comments, and in extreme cases to ban commenters, at our discretion. Comments must be relevant and civil (and, especially, free of name-calling). We think of comment threads like dinner parties at our homes. If you make the party unpleasant for us or for others, we'd rather you went elsewhere. We're happy to see a wide range of viewpoints, but we want all of them to be expressed as politely as possible.

We realize that such a comment policy can never be evenly enforced, because we can't possibly monitor every comment equally well. Hundreds of comments are posted every day here, and we don't read them all. Those we read, we read with different degrees of attention, and in different moods. We try to be fair, but we make no promises.

And remember, it's a big Internet. If you think we were mistaken in removing your post (or, in extreme cases, in removing you) -- or if you prefer a more free-for-all approach -- there are surely plenty of ways you can still get your views out.