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It isn't just insurance though. The docs. you mentioned before WWII didn't have access to antibiotics let alone chemotherapies, tPA, useful imaging and a thousand other things. The $5 house call meant the doc. showed up with a bag holding iodine, alcohol, medicinal whiskey, tongue depressors a stethoscope and some bandages.
In other words the problem solving ability of the modern doctor is orders of magnitude greater than his pre-WWII brothers and sisters. With that comes complexity, greatly increased educational requirements etc.
Granted. Inflation is rising price for the same goods or services over time.... In medical care you have more expensive technologies piled on top of inflation. ….When CTs became generally available in the early '80s, we established docs considered it cheating to order one. They haven't added a day to anybody's life. They just allow the surgeon to be more certain of what he'll find when he opens the pt up-- no more "exploratory surgery." …. It's the lawyers who insist that everybody gets one now, and nobody objects because insurance will pay for it.
The real purpose of money is to help determine how goods/services in limited supply will be utilized. We should be asking "Can I afford this? Do I really need it?" When it's not our money, we don't even bother asking.
Granted. Inflation is rising price for the same goods or services over time.... In medical care you have more expensive technologies piled on top of inflation. ….When CTs became generally available in the early '80s, we established docs considered it cheating to order one. They haven't added a day to anybody's life. They just allow the surgeon to be more certain of what he'll find when he opens the pt up-- no more "exploratory surgery." …. It's the lawyers who insist that everybody gets one now, and nobody objects because insurance will pay for it.
The real purpose of money is to help determine how goods/services in limited supply will be utilized. We should be asking "Can I afford this? Do I really need it?" When it's not our money, we don't even bother asking.
Great post.
1. As I've mentioned my son is a neurosurgery resident. One of his best friends is a neurology resident. The two cross paths at work most days. The neuro told my son that most successful lawsuits against neurologists are filed because the neuro did not administer tPA to a stroke victim. Obviously, the effect is that neuros are more likely to prescribe/administer tPA than they probably should.
2. I read somewhere, one if the Wesley pubs I think, that the annual cost of defensive prescriptions, tests and procedures is equal to a sum only a little less than the gross incomes of all doctors combined.
3. I'm an economist and your last point is long accepted holy writ in econ. There is near infinite demand for things that are "free" or that people other than the user are paying for.
Medical costs are "free market" only in this of sense of the supply/demand law: demand goes up when people are covered by insurance. When demand goes up, prices go up. Econ 101.
Agreed, but demand is also a function of supply in the world of medicine.
Going back to McAllen, the insurance industry and coverage was pretty much the same while the number of doctors in McAllen exploded. So it wasn't new insurance that prompted higher medical costs, it was hospitals and doctors advertising their services for all kinds of things from elective cosmetic surgery to cardiac caths.
The population of McAllen wasn't any sicker than before, yet per-capita healthcare costs skyrocketed.
Consider also the case of Manhattan. There are more dermatologists per capita in Manhattan than anywhere else in the United States. Under "normal" economic models that means derms shouldn't get paid very much relative to derms in low supply areas and furthermore dermatology costs per capita should be lower in Manhattan compared to low supply areas However, neither is true. Derms make just as much if not more in Manhattan, even after you adjust for cost of living differences.
My wife demands that one of our kids become a doctor, regardless of their interest. Or I should say she attempts to nurture their interest in this field.
I think this is primarily due to the conventional thinking that doctors are one of the best professions.
Is that conventional thinking still true on the eve of 2020?
Back in the 90s an older relative pushed me to get an MD/PhD which was ridiculous in hindsight. I was a biomedical engineer in graduate school at the time for a master's degree. She very clearly put a high level of prestige on that credential and wanted that for me. I also saw that same attitude in many doctors and medical students of the time. Out west, I witnessed this in the medical schools:
* There was a hierarchy within the medical schools:
- The 1st year < 2nd year < 3rd year < 4th year < resident.
Among residents, there was a hierarchy as well:
- 1st year < 2nd year < 3rd year < chief resident < attending physician
This scene shows a "green" medical student on the 1st day gawked by those higher up the ladder.
In general, the medical students seemed disrespectful of other majors like business, law, engineering, etc. It was a common view that those other professions are not as prestigious. PhD candidates often complained of disrespect in the research setting of the medical school - 2nd class. The "MDs" were on top.
And then within the MDs there was a hierarchy in two separate ways:
1st manner of hierarchy
- prestige of medical school - one professor told me Stanford was much, much higher in prestige than
the University of Arizona for medical school.
- The mindset appeared to be that higher ranking medical schools were more desired like Harvard.
2nd manner of hierarchy
- prestige of chosen residency - specialist versus primary care
- In the 80s and early 90s the heart surgeons were roaring with prestige and money in the era of
fee-for-service. Alec Baldwin's classic persona of a snobby surgeon was very realistic for the time.
Many allied health workers often complain of workplace bullying and doctors with a rude personality - very condescending.
But times have changed. The fee-for-service model was replaced by capitation in many places during the era of healthcare reform recently. The MDs have to deal with medical malpractice suits - the average physician gets sued at least twice in a careeer. The academic research model has shifted away from the MD and more to the clinical translational science. MDs without a master's degree who want to do research are actually encouraged to at least get an MS in translational science. Students who want to do the MD/PhD are often encouraged to focus on the PhD alone - again with translational science. The academic research centers give far more respect to the PhD. This credential is being pushed as a faster, cost-effective, more viable alternative to the classic MD/PhD which is now deemed as "overkill". https://www.tuftsctsi.org/about-us/w...ional-science/
As for the MD model, healthcare reform has pushed the focus to the severe shortage of primary care - they give the biggest bang for the buck in terms of production compared to "high paying" specialties. So, the focus on that shortage has given more importance to allied health care workers who can help like the nurse practitioner (DNP) or physician assistant (PA). Some states give high independence to the DNP. https://www.aei.org/research-product...y-care-crisis/
In summary, the MD has changed. It is no longer a "prestige" profession but has shifted to primary care. If any student wants to go to medical school, there is a priority now on primary care (blatantly or subtly). https://www.medicaleconomics.com/new...and-how-fix-it
So, students should only apply if they truly want to do primary care. Otherwise, it's a waste of money in the system to enter medical school just for the sake of prestige and specialty (EROAD). Tuition has also outpaced inflation so that the "prestigious" private medical schools are now ludicrously expensive with over half a million in debt if interest is taken into account over the life of the loan. https://www.fiercehealthcare.com/pra...es-for-private
As for me, I learned all that above from public health studies. I learned from the MPH that it is best for me to stay in engineering. I work a lot with software testing and development. On the internet, there are many modern physicians discouraging their children from going to medical school.
With that said, there are still many students with a sincere interest in medical school. I would advise the following:
* Go to a community college and get an allied health credential to get patient-interaction experience in a hospital.
* Pay attention to details like health economics, health policy, medical billing, medical coding, Electronic Health Record training (EHR), regulatory compliance, etc.
* Look at hours, time off, culture, etc.
* Look at the lifestyle of residents, physicians, etc. Back in the 80s they had 90+ hours per week as residents. Physicians taking care of HIV patients never really got a day off. In the midst of that, they could be sued for invalid reasons.
* Look at common patient problems, concerns.
Work for a year or two part-time while finishing the bachelor's - ideally in a health related field. But it could be something general like engineering or accounting or even English. The bottom line is the allied health AS degree will give great exposure.
After all the above, the student will know for sure if he or she truly wants medical school. Then they can study for the MCAT. The whole time, the gpa must be near perfection - which can require 15 hours or more per week for those tough science courses. It's not an easy task to get into medical school. Slots are usually less than 10% of the whole applicant pool. If they still want to do it, I commend them. Primary care physicians are badly needed.
As for me, if I knew back in the early 90s what I know now, I would have gotten a PhD in engineering and a JD to work with patent laws for litigation in the upcoming mobile smartphone wars. The patent lawers were the only people who benefitted from that legal battle with all the money they made - lol. And, a JD/PhD is very prestigious in that field of law. They, the JD/PhDs in engineering, are among the few still doing well despite the massive recession for law graduates. https://en.wikipedia.org/wiki/Smartphone_patent_wars
Last edited by grad_student200; 01-01-2020 at 10:49 AM..
My impression is yes, because of the $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$.
And what is more important than$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$?
Well, I always tell youth who are considering medicine as a career - don't do it for the money, because you will need to go through many, many years of training before you can really start to earn. It rewards those who really want to be doctors because you will need persistence and patience to get there.
Easier to be someone who can sell software or broker real estate transactions, for example.
Well, I always tell youth who are considering medicine as a career - don't do it for the money, because you will need to go through many, many years of training before you can really start to earn. It rewards those who really want to be doctors because you will need persistence and patience to get there.
Easier to be someone who can sell software or broker real estate transactions, for example.
Or easier to become a YouTuber like that 8-year-old that made $26 million last year alone from making videos about toys!
Back in the 90s an older relative pushed me to get an MD/PhD which was ridiculous in hindsight. I was a biomedical engineer in graduate school at the time for a master's degree. She very clearly put a high level of prestige on that credential and wanted that for me. I also saw that same attitude in many doctors and medical students of the time. Out west, I witnessed this in the medical schools:
* There was a hierarchy within the medical schools:
- The 1st year < 2nd year < 3rd year < 4th year < resident.
Among residents, there was a hierarchy as well:
- 1st year < 2nd year < 3rd year < chief resident < attending physician
This scene shows a "green" medical student on the 1st day gawked by those higher up the ladder.
In general, the medical students seemed disrespectful of other majors like business, law, engineering, etc. It was a common view that those other professions are not as prestigious. PhD candidates often complained of disrespect in the research setting of the medical school - 2nd class. The "MDs" were on top.
And then within the MDs there was a hierarchy in two separate ways:
1st manner of hierarchy
- prestige of medical school - one professor told me Stanford was much, much higher in prestige than
the University of Arizona for medical school.
- The mindset appeared to be that higher ranking medical schools were more desired like Harvard.
2nd manner of hierarchy
- prestige of chosen residency - specialist versus primary care
- In the 80s and early 90s the heart surgeons were roaring with prestige and money in the era of
fee-for-service. Alec Baldwin's classic persona of a snobby surgeon was very realistic for the time.
Many allied health workers often complain of workplace bullying and doctors with a rude personality - very condescending.
But times have changed. The fee-for-service model was replaced by capitation in many places during the era of healthcare reform recently. The MDs have to deal with medical malpractice suits - the average physician gets sued at least twice in a careeer. The academic research model has shifted away from the MD and more to the clinical translational science. MDs without a master's degree who want to do research are actually encouraged to at least get an MS in translational science. Students who want to do the MD/PhD are often encouraged to focus on the PhD alone - again with translational science. The academic research centers give far more respect to the PhD. This credential is being pushed as a faster, cost-effective, more viable alternative to the classic MD/PhD which is now deemed as "overkill". https://www.tuftsctsi.org/about-us/w...ional-science/
As for the MD model, healthcare reform has pushed the focus to the severe shortage of primary care - they give the biggest bang for the buck in terms of production compared to "high paying" specialties. So, the focus on that shortage has given more importance to allied health care workers who can help like the nurse practitioner (DNP) or physician assistant (PA). Some states give high independence to the DNP. https://www.aei.org/research-product...y-care-crisis/
In summary, the MD has changed. It is no longer a "prestige" profession but has shifted to primary care. If any student wants to go to medical school, there is a priority now on primary care (blatantly or subtly). https://www.medicaleconomics.com/new...and-how-fix-it
So, students should only apply if they truly want to do primary care. Otherwise, it's a waste of money in the system to enter medical school just for the sake of prestige and specialty (EROAD). Tuition has also outpaced inflation so that the "prestigious" private medical schools are now ludicrously expensive with over half a million in debt if interest is taken into account over the life of the loan. https://www.fiercehealthcare.com/pra...es-for-private
As for me, I learned all that above from public health studies. I learned from the MPH that it is best for me to stay in engineering. I work a lot with software testing and development. On the internet, there are many modern physicians discouraging their children from going to medical school.
With that said, there are still many students with a sincere interest in medical school. I would advise the following:
* Go to a community college and get an allied health credential to get patient-interaction experience in a hospital.
* Pay attention to details like health economics, health policy, medical billing, medical coding, Electronic Health Record training (EHR), regulatory compliance, etc.
* Look at hours, time off, culture, etc.
* Look at the lifestyle of residents, physicians, etc. Back in the 80s they had 90+ hours per week as residents. Physicians taking care of HIV patients never really got a day off. In the midst of that, they could be sued for invalid reasons.
* Look at common patient problems, concerns.
Work for a year or two part-time while finishing the bachelor's - ideally in a health related field. But it could be something general like engineering or accounting or even English. The bottom line is the allied health AS degree will give great exposure.
After all the above, the student will know for sure if he or she truly wants medical school. Then they can study for the MCAT. The whole time, the gpa must be near perfection - which can require 15 hours or more per week for those tough science courses. It's not an easy task to get into medical school. Slots are usually less than 10% of the whole applicant pool. If they still want to do it, I commend them. Primary care physicians are badly needed.
As for me, if I knew back in the early 90s what I know now, I would have gotten a PhD in engineering and a JD to work with patent laws for litigation in the upcoming mobile smartphone wars. The patent lawers were the only people who benefitted from that legal battle with all the money they made - lol. And, a JD/PhD is very prestigious in that field of law. They, the JD/PhDs in engineering, are among the few still doing well despite the massive recession for law graduates. https://en.wikipedia.org/wiki/Smartphone_patent_wars
*Sure there are various hierarchies across medical training. The MS-2 looks down on the MS-1, just like the 8th grader looks down on the 7th grader. The medical resident looks down on MS-1-4. That's just real life.
*So far as prestige in medical schooling/training, it's complex. I'd argue that "prestige" per se is a more minimal factor in medical training relative to law or business and significantly so.
Another point along the prestige arc by way of some advice my son received from a college advisor. The gist was - work your butt off, volunteer, do some undergrad research, show some leadership, make A's, crush the MCAT increasing chances for admission into one of the group of medical schools that offer A). excellent academic metrics B). affiliation with a big city hospital C). are big into research. That guy's list of schools was 29 deep with 6 honorable mentions. The logic being in order to really succeed vs. the USMLE Steps 1, 2 and 3, rotation tests etc. one must be exposed to exceptional rigor early in medical school, the big city affiliation will yield lots of patient exposure and research is a differentiator for residency applications.
IMO there are some key weak points in your post above:
A). The notion that MDs have been displaced in medical research is mostly false. There may be proportionally more Ph.Ds and MD+Ph.Ds in medical research now than in say the '80s or '90s but that's it. Anecdotal as it may be my son has been involved in four medical research projects (a first line author twice) - all have been run by MDs (I just looked to be sure). Further, so far as I know no one has suggested that my son get a masters or Ph.D to continue research.
B). Your logic that only those desirous of a primary care career should go into medicine is sorry to say just nonsense. With the exception of a few medical schools most of the "best" couple of dozen do not demonstrate some overwhelming push towards primary care. Further, most of the larger states have one medical body or another which has tallied doctors per specialty along with age information per cohort. I've read several of these - long story short there are and will be regional and per state specialist shortages. Some are red alert situations now. Back to hierarchy........at every excellent medical school, say the 29 above and several more, most years the majority of those in the top half of each class will attempt to specialize. The majority in the bottom will be guided towards primary care via the residency match process.....which is particularly brutal. Back to hierarchy Step 1 scores are a key differentiator. Someone with a 210 has no real shot at derm., plastics, neurosurgery etc. Someone with a 250+ has more options.
I don't have data for last year but the the all time high number of MD grads going into primary care residencies was in 1998 according to The Graham center. There has been no rush to primary care.
C). So far as some docs. being egomaniacs. Many high performers across all professions tend to be egomaniacs.
_______________________
Where I will agree with you is along the notion that medicine generally is some sort of glamorous career = nonsense. During my son's training he's been exposed to active TB at least twice one of those a treatment resistant type, yellow fever, various parasites and more on the infectious disease side. Sick people have coughed in his face, bled, vomited, urinated, defecated and worse on him. He's been lied to, punched, bitten, slapped, threatened and shoved as well. He's also had to tell people that their loved one is never coming home. He's had people beg that he kill them.
A doc. friend of ours told my son years ago, "X you are smart enough to go to medical school which means you are smart enough not go to medical school, if you really love it give it 100%, if you aren't sure don't go."
If it’s not the most coveted, then it should be. In a life full of regret, it is my greatest. If I had kids and they had decent academic ability, I’d tell them the must take a shot at it. They only other worthwhile academic pursuit is computer science/engineering in my opinion simply because of the demand. From my experience, nothing else compares in opportunity or career outcome.
It kills me to read the parents bragging on here about their kids who are doctors or in med school. I wish it could be my parents bragging along with them. Makes me wish a semi truck hits me on the way home from work because the regret is very painful. I know I had the academic ability, but I listened to the wrong people and pursued something less significant.
My kids are in college and they and their friends are a very high achieving group. My son's best friend has wanted to be a doctor since forever and has all A's in pre-med at a respected university. He's sent his applications for med school and no one is calling. He is starting to panic. He couldn't do better in school than he has done, so it just goes to show how competitive it is. Do not push your kids this way unless they are genius kids who have a great back up plan when their brains don't get them far enough.
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