21% Medicare reimbursement cut goes into effect April 1st (salaries, attorney, regime)

[hawkeye2009]

Originally Posted by azriverfan.

First of all, let's have some clarification regarding foreign doctors. I'm an American citizen who attended a U.S. medical school so I have no reason to defend foreign doctors. However, I trained alongside some "foreign trained" doctors and had some attendings that were foreign trained and they were amazing. The truth is a lot of older American doctors are racist. A lot of the older doctors particularly ones in rural and Southern states are racist good ole boys who don't like competition from foreign doctors. Much of it has to do with simple racism. They just don't like the foreign doctors because they have accents, are not Christians and are not like them. Sad but true! And the reason many people prefer foreign doctors is because they have less of that entitled "I'm a doctor" attitude that many American doctors have. They grew up in poor countries and value what they have and recognize it's a privilege to practice medicine in this country. Guys like Hawkeye act like Foreign trained doctors are second rate despite the fact they completed the same training and in some cases more training than them. It's truly sad to see attitudes like that in our profession but unfortunately they exist.

Something else to chew on, some FMG's are European. They didn't train here. They are also Foreign Medical Graduates. But because they are White, Christian and European, these doctors often don't receive the same discrimination from guys like Hawkeye as the ones from India, Pakistan, China, Thailand etc.

The reality is those foreign medical graduates (FMG's) particularly Indian doctors are more skilled than many of their American colleagues. The reason is very simple. They went through training twice. In order to practice in the United States, you are required to do residency here. So even if you completed a residency in your country, you still have to do it here. A lot of FMG's did residency twice; once in their country and a second time here. If you do a residency twice, you are going to be pretty damn good at what you do. Yup, what Hawkeye isn't telling you is there is no such thing as a foreign doctor just hopping off the boat and practicing medicine here. It doesn't work that way. In order to practice in the United States, these foreign doctors have to pass the USMLE Step 1, Step 2 and Step 3 just like U.S. medical students. They then have to complete a residency in the United States. So those "foreign trained doctors" are in fact U.S. trained doctors.

Another difference between the foreign doctors and the U.S. doctors is the foreign doctors must own better test scores to get into residency here. U.S. medical students are given carte blanch when applying for residency. In short, U.S. students can weaker scores and get into residencies whereas a Foreign Medical Graduate will need 90 percent or higher on the boards just to get in.Most foreign doctors have 99's on the USMLE whereas I know U.S. doctors that slouched once they got into medical school and will still get into something like Urology with an 87 on the USMLE.

Lastly, foreign doctors have better clinical skills by far! The reason is they don't have all of the same technology in their respective countries and were not to rely on them like U.S. students. U.S. grads are increasingly spoiled by fancy imaging and tests. Many don't even learn how to do a proper physical exam any longer knowing they will just order imaging. For example, in my experience a second year resident who happens to be of foreign origin can actually listen to heart sounds with more skill than many of my first year cardiology fellows.

The U.S. medical system is the best in the world. The training is the most thorough and organized. However, people seem to have the false impression that these foreign doctors just hop off the plane and practice in hospitals. That's false. ALL FOREIGN DOCTORS are REQUIRED to TRAIN IN THE UNITED STATES to practice. I say this because it's sad when I read ignorant comments about foreign doctors being worse. It's simply not true.

In terms of misconduct, I know plenty of White good ole boy American doctors who have gone to jail for sexually harrassing their patients or using drugs. I served on the Arizona Medical Board and I can say that easily 90% or more of the physicians that were involved with sexual misconduct and drug abuse were American White Doctors! In fact, I don't recall a single foreign doctors being cited for sexual misconduct or drug abuse while I was there. Almost every doctor who was cited for fondling or sexually abusing their patients while under anesthesia were White American doctors. Every single physician we saw who had been reported to be under the influence while on the job were White doctors.

I am afraid that you don't know what you are talking about. I was on the admissions commitee for 2 years at a tip 20 med school and selected residents for six years. I was on faculty at two med schools for six years. How many years have you been in medicine or academics and have you ever been on ANY admissions panel? Easy answer- NO.

1. Residencies CAN take FMGs, however they put them at the bottom of the "pile", therefore FMGs get the worst residency positions. EVERYTHING one learns in medicine is in thier residency. Translation- bad residency- bad doctor.

2. The 'weakest" specialties do not fill with US grads. Therefore FMGs will populate internal medicine and family practice. When was the last time you saw a foriegn Opthomologst, ENT, or Neurosurgeon (harder specialties to get in to)

3. Some specialties (Neurosurgery) DO NOT TAKE FMGs- ONLY US GRADs. That is why the quality of neurosurgery is so high in the US and is courtesy of one man- John Van Gilder- the modern father of Neurosurgery and a direct trainee of Henry Schwartz, who was trained by Cushing.

4. Residency applications (this guy does not know what the hell he is talking about0 do not come with an "admission test". There is no such thing as an admission test for residency. All American grads take the FLEX or National Board of Medical Examiners. The foriegn grads take the FMJIMs, which are less rigorous than the NBME. These are not admission tests to residencies. Residencies are decided by-

a. ranking in med school- top 10% is AOA and usually get the "good residencies". The worst US medical graduate is ranked higher than EVERY foriegn medical applicant. Therefore the FMGs get the residencies that are weaker and that no US grad wants. That is why so many FMGs are "trained" in New Jersey and New York.

b. strength of the medical school- ALL US schools are ranked higher than foriegn medical schools for residency application

c. research- if a FMG comes and works in a lab for a few years, they can improve thier chances of getting a better residency, if they go outside the "match".

5. "Good old white boys" sure US trained docs make mistakes. However, I can tell you that the majority of misconduct and fraud cases I am asked to review involve FMGs. I am not digging these cases up- misconduct occurs and I am asked to investigate. Given that the majority of docs in the US are US trained, I find that this disproportionate incidence of malpractice and fraud to be singularly shocking, but reflects what I observe in our city. Most of the FMGs here are pretty poor.


That being said, I know some exceptional foriegn doctors. There are two Anesthesiologists in our city who are UK trained and are EXCELLENT. I would say the same for Canadian docs. I am aware of one neurosurgeon (US residency) , one cardiac and one trauma surgeon who are excellent. I am not aware of any Indian doc in our city who would come close to the quality of a US doc. Perhaps there are other areas where the US grads went to weaker US schools and residency programs which put them on par with FMGs. That is not the case at all where I live. Not all FMGs are bad, just on the aggregate, this is more likely.

[azriverfan.]

Originally Posted by hawkeye2009

I am afraid that you don't know what you are talking about. I was on the admissions commitee for 2 years at a tip 20 med school and selected residents for six years. I was on faculty at two med schools for six years. How many years have you been in medicine or academics and have you ever been on ANY admissions panel? Easy answer- NO.

What do you consider a top medical school, the University of Iowa?? Not only did I attend a far better medical school (UCSF), I'm also faculty at the new University of Arizona school of medicine in Phoenix. When I was chief, I helped select residents for our program. And I got into medical school in the last 25 years when the admission statistics were far more competitive than when you were applying. I'm also successful enough in my practice that I don't have to consider working for the VA. If you walk in any physician social circle and you tell them you work full time at the VA, the word LOSER immediately comes to mind.

1. Residencies CAN take FMGs, however they put them at the bottom of the "pile", therefore FMGs get the worst residency positions. EVERYTHING one learns in medicine is in thier residency. Translation- bad residency- bad doctor.

They put them at the bottom of the pile when all is equal meaning if you have a US grad with a 99 on the Steps who is AOA compared to a FMG with a 99 and was ranked in the top 10, the US grad will taken every time. However, there are only so many top medical students from top schools that are available so what ends up happening is top FMG's will compete with US grads who are not AOA and don't have great board scores. Guess what, they will take the FMG and that's why you see FMG's at top programs. This is also program dependent so I'm guessing the good ole boys in BFE Iowa are probably pretty biased against FMG's. Furthermore, it also depends on the type of FMG. There is a difference between an FMG who is an American and goes to Ross versus an FMG who got into his own country's respective medical school.

2. The 'weakest" specialties do not fill with US grads. Therefore FMGs will populate internal medicine and family practice. When was the last time you saw a foriegn Opthomologst, ENT, or Neurosurgeon (harder specialties to get in to)

There was a recent FMG grad in the neurosurgery program at St. Joes in Phoenix..yes the same St. Joes program that is considered a top 5 Neurosurgery program in the country. I know an FMG who is graduating from a radiology program in Michigan. Sure, it's not common but there are programs that take FMG's into them. Maybe if you left Iowa, you would recognize that.

Furthermore, internal medicine is competitive depending on the program. A lot of grads want to do cardiology or GI so it's quite assinine to assume that every internal medicine program is weak.

3. Some specialties (Neurosurgery) DO NOT TAKE FMGs- ONLY US GRADs. That is why the quality of neurosurgery is so high in the US and is courtesy of one man- John Van Gilder- the modern father of Neurosurgery and a direct trainee of Henry Schwartz, who was trained by Cushing.

Again, that is a stereotype and not the reality. Yes, the majority of these programs do not take FMG's but each year programs do take FMG's. The FMG at St. Joes was a neurosurgeon in India and had board scores in the 99th percentile. So again, get your facts before making a generalization.

[q4. Residency applications (this guy does not know what the hell he is talking about0 do not come with an "admission test". There is no such thing as an admission test for residency. All American grads take the FLEX or National Board of Medical Examiners. The foriegn grads take the FMJIMs, which are less rigorous than the NBME. These are not admission tests to residencies. Residencies are decided by-

First of all, it's the FMGEM not the FMJIM and that test has been replaced by the United States Medical Licensing Exam steps 1,2 and 3 which is administered by the National Board of Medical Examiners. Foreign Medical Graduates as well U.S. Medical Grads are required to take this exam. Foreign grads no longer take the FMGEM. This shows how out of sync you are with modern medicine. What you are referring to was a practice done nearly 20 years ago. Maybe you have served on a residency selection committee but it's obvious, it hasn't been within the last 20 years considering you didn't even know FMG's are required to take the USMLE.

a. ranking in med school- top 10% is AOA and usually get the "good residencies". The worst US medical graduate is ranked higher than EVERY foriegn medical applicant. Therefore the FMGs get the residencies that are weaker and that no US grad wants. That is why so many FMGs are "trained" in New Jersey and New York.

WRONG! Again, this is program dependent and a lot of programs are favoring foreign grads with higher board scores than the kid in the bottom of his class at a U.S. school. Sure, there are programs that discriminate and won't take any FMG or DO but that has changed a lot in the last 10 years and now programs want the best regardless of where the student went to medical school. I suggest you look at some recent match lists at top programs if you want proof.

"Good old white boys" sure US trained docs make mistakes. However, I can tell you that the majority of misconduct and fraud cases I am asked to review involve FMGs. I am not digging these cases up- misconduct occurs and I am asked to investigate. Given that the majority of docs in the US are US trained, I find that this disproportionate incidence of malpractice and fraud to be singularly shocking, but reflects what I observe in our city. Most of the FMGs here are pretty poor.

First of all, you were doing chart reviews for Medicare. That isn't the same thing as what I did which was work for the Arizona Medical Board and investiage behavioral misconduct.. Your misconduct involves billing issues not behavioral misconduct. So it doesn't help to lie and claim you were investigating sexual misconduct when you were doing chart reviews. If you had sat on a state medical board, you will discover the overwhelming majority of doctors who were cited for sexual misconduct, personal drug abuse, peddling of narcotics, illegal sale and use of performance enhancing drugs like growth hormone were done by White American Doctors.

That being said, I know some exceptional foriegn doctors. There are two Anesthesiologists in our city who are UK trained and are EXCELLENT. I would say the same for Canadian docs. I am aware of one neurosurgeon (US residency) , one cardiac and one trauma surgeon who are excellent. I am not aware of any Indian doc in our city who would come close to the quality of a US doc. Perhaps there are other areas where the US grads went to weaker US schools and residency programs which put them on par with FMGs. That is not the case at all where I live. Not all FMGs are bad, just on the aggregate, this is more likely.

Considering you live in Iowa or West Virginia (I can't remember) it's not a secret why you haven't experienced top Indian doctors as the best ones don't want to live in BFE. If you practiced in a real city, you would see top Indian doctors as the Barrows Neurosurgeon who is on staff there.

[azriverfan.]

Originally Posted by malamute

Who is the racist?

And why shouldn't veterans in the USA be given excellent care? Would you consider yourself too good to treat them? Or there isn't enough money in it for you?

But you aren't joining the VA because you care so much about veterans. You are joining the VA because you want a salaried job because you can't cover your overhead in private practice so spare us the sentimental nonsense.

I'm not being racist. I'm not indicting all Whites. I'm addressing a portion of Whites who hold these racist and bigoted views. Unfortunately physicians are people too and we have racist and bigoted physicians. I've observed this mindset to be fairly prominent among older physicians particularly in your area of the country. I've noticed these physicians are not only bigoted toward foreign doctors but also to female physicians. Many of your generation think women shouldn't be in medicine. It's pretty evident you are racist based on your stereotype of Indian doctors and calling all foreign origin doctors second rate and claiming they should be paid less. That's pretty insulting. They are your colleagues. They passed the same licensing exams, state board and did residency in this country just like any American grad. It's no secret why your area of the country struggles to recruit doctors. After all, why would a bright physician want to live and work alongside old bigoted mysogynists that hate foreigners. It's no secret why residency programs on the coasts are the most competitive and the least competitive ones are in your part of the country because the top medical students simply don't want to go there. After all, who wants to live in a backward part of the country if they can help it.

[florida.bob]

Originally Posted by azriverfan.

What do you consider a top medical school, the University of Iowa?? Not only did I attend a far better medical school (UCSF), I'm also faculty at the new University of Arizona school of medicine in Phoenix. When I was chief, I helped select residents for our program. And I got into medical school in the last 25 years when the admission statistics were far more competitive than when you were applying. I'm also successful enough in my practice that I don't have to consider working for the VA. If you walk in any physician social circle and you tell them you work full time at the VA, the word LOSER immediately comes to mind.

They put them at the bottom of the pile when all is equal meaning if you have a US grad with a 99 on the Steps who is AOA compared to a FMG with a 99 and was ranked in the top 10, the US grad will taken every time. However, there are only so many top medical students from top schools that are available so what ends up happening is top FMG's will compete with US grads who are not AOA and don't have great board scores. Guess what, they will take the FMG and that's why you see FMG's at top programs. This is also program dependent so I'm guessing the good ole boys in BFE Iowa are probably pretty biased against FMG's. Furthermore, it also depends on the type of FMG. There is a difference between an FMG who is an American and goes to Ross versus an FMG who got into his own country's respective medical school.

There was a recent FMG grad in the neurosurgery program at St. Joes in Phoenix..yes the same St. Joes program that is considered a top 5 Neurosurgery program in the country. I know an FMG who is graduating from a radiology program in Michigan. Sure, it's not common but there are programs that take FMG's into them. Maybe if you left Iowa, you would recognize that.

Furthermore, internal medicine is competitive depending on the program. A lot of grads want to do cardiology or GI so it's quite assinine to assume that every internal medicine program is weak.

Again, that is a stereotype and not the reality. Yes, the majority of these programs do not take FMG's but each year programs do take FMG's. The FMG at St. Joes was a neurosurgeon in India and had board scores in the 99th percentile. So again, get your facts before making a generalization.

First of all, it's the FMGEM not the FMJIM and that test has been replaced by the United States Medical Licensing Exam steps 1,2 and 3 which is administered by the National Board of Medical Examiners. Foreign Medical Graduates as well U.S. Medical Grads are required to take this exam. Foreign grads no longer take the FMGEM. This shows how out of sync you are with modern medicine. What you are referring to was a practice done nearly 20 years ago. Maybe you have served on a residency selection committee but it's obvious, it hasn't been within the last 20 years considering you didn't even know FMG's are required to take the USMLE.

WRONG! Again, this is program dependent and a lot of programs are favoring foreign grads with higher board scores than the kid in the bottom of his class at a U.S. school. Sure, there are programs that discriminate and won't take any FMG or DO but that has changed a lot in the last 10 years and now programs want the best regardless of where the student went to medical school. I suggest you look at some recent match lists at top programs if you want proof.


First of all, you were doing chart reviews for Medicare. That isn't the same thing as what I did which was work for the Arizona Medical Board and investiage behavioral misconduct.. Your misconduct involves billing issues not behavioral misconduct. So it doesn't help to lie and claim you were investigating sexual misconduct when you were doing chart reviews. If you had sat on a state medical board, you will discover the overwhelming majority of doctors who were cited for sexual misconduct, personal drug abuse, peddling of narcotics, illegal sale and use of performance enhancing drugs like growth hormone were done by White American Doctors.

Considering you live in Iowa or West Virginia (I can't remember) it's not a secret why you haven't experienced top Indian doctors as the best ones don't want to live in BFE. If you practiced in a real city, you would see top Indian doctors as the Barrows Neurosurgeon who is on staff there.

Other than the above, I assume you have no strong opinions on the character and awareness of the good Hawkeye. I do have to say, that your indictment of VA MDs may be a bit of an over generalization. My experience, as a patient, in the VA system, has allowed me an opportunity to get a little Other than the above, I assume you have no strong opinions on the character and awareness of the good Hawkeye. I do have to say, that your indictment of VA MDs may be a bit of an over generalization. My experience, as a patient, in the VA system, has allowed me an opportunity to get a little perspective on their quality and motivation. I found, in the 6 facilities that I had occasion to personally experience, that all the MDs, as well as support staff and technicians, demonstrated compassion and concern for their patients. They also seemed to be very technically competent, at least as much as a layman, such as I, could determine. Certainly, all the outcomes I experienced were very good. The MDs, I have been in the care of are a fairly wide variety of Domestically and Foreign trained, all equally capable as far as I could tell. Also, a wide variety of ages. Also care services ranging from Primary Care to major Vascular Bypass Surgery. My, non scientific, observation as to the reason these MDs are in the VA system is very basic. I have a feeling that most are there for several reasons. The older ones, perhaps to stay involved and contribute to society, without the hassles and aggravation of a Private Practice. The income no longer, or perhaps never was, a primary influence. The middle aged ones, perhaps more closely resemble those you allude to, again, it could also be that the income is not as much a driving force. The younger ones, what a tremendous learning opportunity the VA presents. pretty much the whole gamut of diseases, physical injury and mental injury, not to mention, no need to build a business, as there is no lack of patient opportunities. So basically, I think there are many good reasons an MD would go into the VA system. As long as income is not the primary motivator, the VA offers great many other motivations.

[hawkeye2009]

Originally Posted by azriverfan.

What do you consider a top medical school, the University of Iowa?? Not only did I attend a far better medical school (UCSF), I'm also faculty at the new University of Arizona school of medicine in Phoenix. When I was chief, I helped select residents for our program. And I got into medical school in the last 25 years when the admission statistics were far more competitive than when you were applying. I'm also successful enough in my practice that I don't have to consider working for the VA. If you walk in any physician social circle and you tell them you work full time at the VA, the word LOSER immediately comes to mind.

They put them at the bottom of the pile when all is equal meaning if you have a US grad with a 99 on the Steps who is AOA compared to a FMG with a 99 and was ranked in the top 10, the US grad will taken every time. However, there are only so many top medical students from top schools that are available so what ends up happening is top FMG's will compete with US grads who are not AOA and don't have great board scores. Guess what, they will take the FMG and that's why you see FMG's at top programs. This is also program dependent so I'm guessing the good ole boys in BFE Iowa are probably pretty biased against FMG's. Furthermore, it also depends on the type of FMG. There is a difference between an FMG who is an American and goes to Ross versus an FMG who got into his own country's respective medical school.

There was a recent FMG grad in the neurosurgery program at St. Joes in Phoenix..yes the same St. Joes program that is considered a top 5 Neurosurgery program in the country. I know an FMG who is graduating from a radiology program in Michigan. Sure, it's not common but there are programs that take FMG's into them. Maybe if you left Iowa, you would recognize that.

Furthermore, internal medicine is competitive depending on the program. A lot of grads want to do cardiology or GI so it's quite assinine to assume that every internal medicine program is weak.

Again, that is a stereotype and not the reality. Yes, the majority of these programs do not take FMG's but each year programs do take FMG's. The FMG at St. Joes was a neurosurgeon in India and had board scores in the 99th percentile. So again, get your facts before making a generalization.

First of all, it's the FMGEM not the FMJIM and that test has been replaced by the United States Medical Licensing Exam steps 1,2 and 3 which is administered by the National Board of Medical Examiners. Foreign Medical Graduates as well U.S. Medical Grads are required to take this exam. Foreign grads no longer take the FMGEM. This shows how out of sync you are with modern medicine. What you are referring to was a practice done nearly 20 years ago. Maybe you have served on a residency selection committee but it's obvious, it hasn't been within the last 20 years considering you didn't even know FMG's are required to take the USMLE.

WRONG! Again, this is program dependent and a lot of programs are favoring foreign grads with higher board scores than the kid in the bottom of his class at a U.S. school. Sure, there are programs that discriminate and won't take any FMG or DO but that has changed a lot in the last 10 years and now programs want the best regardless of where the student went to medical school. I suggest you look at some recent match lists at top programs if you want proof.


First of all, you were doing chart reviews for Medicare. That isn't the same thing as what I did which was work for the Arizona Medical Board and investiage behavioral misconduct.. Your misconduct involves billing issues not behavioral misconduct. So it doesn't help to lie and claim you were investigating sexual misconduct when you were doing chart reviews. If you had sat on a state medical board, you will discover the overwhelming majority of doctors who were cited for sexual misconduct, personal drug abuse, peddling of narcotics, illegal sale and use of performance enhancing drugs like growth hormone were done by White American Doctors.

Considering you live in Iowa or West Virginia (I can't remember) it's not a secret why you haven't experienced top Indian doctors as the best ones don't want to live in BFE. If you practiced in a real city, you would see top Indian doctors as the Barrows Neurosurgeon who is on staff there.

Wowser- a little testy.

1. I am older than you and applied for med school when the admission standards were tougher
2. I turned down Yale, UCSF, Northwestern, and Wash U to attend Iowa at the MDPhD program.
3. I am successful in my practice. I have made an average of $1.2 million per year over the last ten years. If you measure success by money (I do not), I guess I win. Money is not my motivation- it is an artifact of hard work.
4. I like the VA because it is low key. I do not need the money and like the Vets. I can resume my research there, while I cannot in private practice. I had a stage 3 melanoma last year and 6 months of interferon and interluekin (worked through it all). I want to slow down for obvious reasons.
5. I have published over 20 papers in the medical literature
6. Internal medicine is not competetive. Peds, Internal Med and FP are the easiest residencies to get. Many do not even fill. Many of the good internal medicine programs do not fill and must rely upon filling with FMGs.
7. FMGs are here for money. They will tell you so. That is fine, but don't suggest that it is a moral crusade to help Americans.
8. FMGs are not at top programs- FMGs take the slots that US grads don't want. FMGs can improve thier appeal by doing a few years of research- many do.
9. To be a neurosurgeon in the US, you must have attended a US medical school. Van Gilder made sure of that.
10. My residencey was top 3- I was outside the match, as I had done research for three years, and turned down Mass General, Penn, Hopkins, and again, UCSF.
11. There are some Indian docs who went to US medical schools and US training programs who are just fine. They are like the rest of us. There are two (the Anesthesia guys) who are UK trained who are just fine. The rest are very marginal. Talking with my associates around the country, this seems to be the case everywhere. Residency is where you learn EVERYTHING, as you know. If you cannot get into a good residency, chances are that you will be a poor physician.
12. Call me a racist or whatever. I am not. However, if that makes you feel better, that is fine. The best partner I had was a guy born in the Phillipines, but trained at Univ Chicago undergrad, Wash U med school, residency and fellowship. He holds similar views about FMGs. It is not racial- it is quality of training.

[azriverfan.]

Originally Posted by florida.bob

Other than the above, I assume you have no strong opinions on the character and awareness of the good Hawkeye. I do have to say, that your indictment of VA MDs may be a bit of an over generalization. My experience, as a patient, in the VA system, has allowed me an opportunity to get a little Other than the above, I assume you have no strong opinions on the character and awareness of the good Hawkeye. I do have to say, that your indictment of VA MDs may be a bit of an over generalization. My experience, as a patient, in the VA system, has allowed me an opportunity to get a little perspective on their quality and motivation. I found, in the 6 facilities that I had occasion to personally experience, that all the MDs, as well as support staff and technicians, demonstrated compassion and concern for their patients. They also seemed to be very technically competent, at least as much as a layman, such as I, could determine. Certainly, all the outcomes I experienced were very good. The MDs, I have been in the care of are a fairly wide variety of Domestically and Foreign trained, all equally capable as far as I could tell. Also, a wide variety of ages. Also care services ranging from Primary Care to major Vascular Bypass Surgery. My, non scientific, observation as to the reason these MDs are in the VA system is very basic. I have a feeling that most are there for several reasons. The older ones, perhaps to stay involved and contribute to society, without the hassles and aggravation of a Private Practice. The income no longer, or perhaps never was, a primary influence. The middle aged ones, perhaps more closely resemble those you allude to, again, it could also be that the income is not as much a driving force. The younger ones, what a tremendous learning opportunity the VA presents. pretty much the whole gamut of diseases, physical injury and mental injury, not to mention, no need to build a business, as there is no lack of patient opportunities. So basically, I think there are many good reasons an MD would go into the VA system. As long as income is not the primary motivator, the VA offers great many other motivations.

I practiced at the VA and I also love VA patients. You are also generalizing about what it's like to practice in the VA since you assume that lower income is the only drawback to the job. There are other countless factors aside from income that make the VA an unpleasant job. Care is rationed at the VA. And you have to learn how to practice within the VA system. This makes our jobs as physicians much more difficult because we are limited by certain medications. We have to get authorization on treatments that often required quite a bit of fighting on my part to get it authorized. When you do this daily and you have to fight for every little thing, it's a royal pain in the a$$. As a physician, it is extremely frustrating because you want to do everything you can for the soldiers but the facilities and the red tape that comes with treating them is extremely frustrating. Everything is slower in the VA. Labs take longer to get back. Procedures and imaging are never done on time. You have to get countless authorizations to do anything. Case in point, I remember a patient needed a cath but in order to perform any form of interventional procedure, he would have to be transferred to another facility. What is standard practice at a private hospital of doing everything in one procedure required that we perform two separate procedures. Try telling a patient we have to look inside him and then if we find anything wrong, we will have to do that procedure on a separate day later that week. It is well known that working at the VA is generally considered to be undesriable and it has nothing to do with VA patients. The patients were the positive selling point

[azriverfan.]

Originally Posted by hawkeye2009

Wowser- a little testy.

1. I am older than you and applied for med school when the admission standards were tougher

You mean when you competed against far less applicants, didn't have to take the MCAT, and the mean admission statisics were lower. No, it was not more competitive then. You had it easy compared to today's applicants.

2. I turned down Yale, UCSF, Northwestern, and Wash U to attend Iowa at the MDPhD program.

I believe that. Everyone turns down Yale and UCSF to go to Iowa.

3. I am successful in my practice. I have made an average of $1.2 million per year over the last ten years. If you measure success by money (I do not), I guess I win. Money is not my motivation- it is an artifact of hard work.

That's believable. People who earn 1.2 million per year are going to give that up to work for the VA.

4. I like the VA because it is low key. I do not need the money and like the Vets. I can resume my research there, while I cannot in private practice. I had a stage 3 melanoma last year and 6 months of interferon and interluekin (worked through it all). I want to slow down for obvious reasons.

You can do research now. I'm in private practice and spend a good portion of the year doing research and pursuing academic medicine. You can also cut back on your hours now.

5. I have published over 20 papers in the medical literature

That is pretty standard today. Maybe during your time, 20 was a lot. I have more than triple that number since medical school. Most publications are fairly easy to get published like case reports. It also depends on what number author you are. It's easy to become a second or third author as your resident or medical student does all the work and you simply put your name on his paper to help him get it published.

6. Internal medicine is not competetive. Peds, Internal Med and FP are the easiest residencies to get. Many do not even fill. Many of the good internal medicine programs do not fill and must rely upon filling with FMGs.

You are wrong. Many of the internal medicine subspecialties are as lucrative as surgical fields with the advantage of offerring a better lifestyle, and less threat of malpractice. I'm a cardiologist and made more than the 1.2 million you cited in the past. But due to my involvement with research and academics, I make half that. I know GI docs who have also made that amount of money. There has been a huge shift and the best students are electing lifestyle fields whereas as many surgical spots went unfilled. The IM programs without fellowships don't fill but not the best ones. The top IM programs in the nation are competitive. Sure maybe at Iowa they are full of FMG's but not at UCSF.

7. FMGs are here for money. They will tell you so. That is fine, but don't suggest that it is a moral crusade to help Americans.

You went into medicine for money so don't fault an FMG for coming to this country and desiring the same thing you did.

8. FMGs are not at top programs- FMGs take the slots that US grads don't want. FMGs can improve thier appeal by doing a few years of research- many do.

You didn't even know about the USMLE. You didnt know that FMG's are required to take the USMLE so your knowledge of the current system is out of date to say the least. I know more about this than you. So when I tell you that the 5th best Neurosurgery program accepted an FMG, it shows how little you know. Maybe in your day, that wasn't the case but we are talking about 2010 not 1967.

9. To be a neurosurgeon in the US, you must have attended a US medical school. Van Gilder made sure of that.

Sigh..Here are some FMG's practicing neurosurgery in Phoenix. Van Gilder didn't do such a good job. If you want more examples, let me know

http://www.azmd.gov/glsuiteweb/clien...c/Profile.aspx

http://www.azmd.gov/glsuiteweb/clien...c/Profile.aspx

http://www.azmd.gov/glsuiteweb/clien...c/Profile.aspx

10. My residencey was top 3- I was outside the match, as I had done research for three years, and turned down Mass General, Penn, Hopkins, and again, UCSF.

There are no official rankings of neurosurgery programs. However, Iowa is not considered a top 3 let alone a top 20 program. According to U.S. News and World Report, Iowa is 22nd....far cry from top 3. Again, educate yourself before making statements. Look who is #3 on that list!

Best Neurology & Neurosurgery Hospitals - US News and World Report

11. There are some Indian docs who went to US medical schools and US training programs who are just fine. They are like the rest of us. There are two (the Anesthesia guys) who are UK trained who are just fine. The rest are very marginal. Talking with my associates around the country, this seems to be the case everywhere. Residency is where you learn EVERYTHING, as you know. If you cannot get into a good residency, chances are that you will be a poor physician.

That is not true. Most residency programs produce competent and skilled physicians. The more prestigious programs provide research opportunities but it doesn't necessarily mean they provide the best training. Mayo is one of the worst institutions in terms of training but they provide ample research opportunities.

12. Call me a racist or whatever. I am not. However, if that makes you feel better, that is fine. The best partner I had was a guy born in the Phillipines, but trained at Univ Chicago undergrad, Wash U med school, residency and fellowship. He holds similar views about FMGs. It is not racial- it is quality of training.

If you are going to judge doctors by where they did residency, that is at least fair but you didn't say that. You said all FMG's are poorly trained. What about the FMG's who attend top residencies? I mentioned that and you still didn't give them credit. And why didn't you criticize U.S. graduates who attend lower ranked residencies? And I still thinks it's funny that an Iowa trained grad is being elitist about residency programs as if your program is on par with the best programs like Harvard, UCSF etc.

[Boompa]

Originally Posted by azriverfan.

I practiced at the VA and I also love VA patients. You are also generalizing about what it's like to practice in the VA since you assume that lower income is the only drawback to the job. There are other countless factors aside from income that make the VA an unpleasant job. Care is rationed at the VA. And you have to learn how to practice within the VA system. This makes our jobs as physicians much more difficult because we are limited by certain medications. We have to get authorization on treatments that often required quite a bit of fighting on my part to get it authorized. When you do this daily and you have to fight for every little thing, it's a royal pain in the a$$. As a physician, it is extremely frustrating because you want to do everything you can for the soldiers but the facilities and the red tape that comes with treating them is extremely frustrating. Everything is slower in the VA. Labs take longer to get back. Procedures and imaging are never done on time. You have to get countless authorizations to do anything. Case in point, I remember a patient needed a cath but in order to perform any form of interventional procedure, he would have to be transferred to another facility. What is standard practice at a private hospital of doing everything in one procedure required that we perform two separate procedures. Try telling a patient we have to look inside him and then if we find anything wrong, we will have to do that procedure on a separate day later that week. It is well known that working at the VA is generally considered to be undesriable and it has nothing to do with VA patients. The patients were the positive selling point

As a VA patient I still prefer that to being sent for unneccessary tests and Procedures just to run up the Medicare Bill. Don't tell me that isn't 25% of all Medicare Billing

[florida.bob]

Originally Posted by azriverfan.

I practiced at the VA and I also love VA patients. You are also generalizing about what it's like to practice in the VA since you assume that lower income is the only drawback to the job. There are other countless factors aside from income that make the VA an unpleasant job. Care is rationed at the VA. And you have to learn how to practice within the VA system. This makes our jobs as physicians much more difficult because we are limited by certain medications. We have to get authorization on treatments that often required quite a bit of fighting on my part to get it authorized. When you do this daily and you have to fight for every little thing, it's a royal pain in the a$$. As a physician, it is extremely frustrating because you want to do everything you can for the soldiers but the facilities and the red tape that comes with treating them is extremely frustrating. Everything is slower in the VA. Labs take longer to get back. Procedures and imaging are never done on time. You have to get countless authorizations to do anything. Case in point, I remember a patient needed a cath but in order to perform any form of interventional procedure, he would have to be transferred to another facility. What is standard practice at a private hospital of doing everything in one procedure required that we perform two separate procedures. Try telling a patient we have to look inside him and then if we find anything wrong, we will have to do that procedure on a separate day later that week. It is well known that working at the VA is generally considered to be undesriable and it has nothing to do with VA patients. The patients were the positive selling point

Obviously my impressions are limited to the few facilities I have had occasion to experience, also I tend to view the glass half full on things. I know the facilities that I have been in, Hollywood, Miami, Palm Beach, Orlando, Tampa etc, all were extremely busy, yet amazingly efficient and timely. I do not know about the frustrations and the hoops that the physicians have to deal with, to accomplish what they need to have done. Some of the facilities I have been in were Clinics, which do not have all the services available requiring referral to another facility. From, at least this patient's point of view, Florida seems to have generally efficient and effective care. My experience in Miami for example. Had a Cardio Cath that found 2, 100% blocked arteries a 3rd 30% blocked. What to do? I don't know if this is the same procedure used in all VA Hospitals, but in Miami, the Cardio staff meets weekly to review the findings of the previous week evaluations, they obviously don't wait for that in a critical situation, but their meeting is to come to a best approach answer to the condition. I my case, it was their opinion that Heart Bypass surgery might be best. When my Cardiologist next saw me, he explained what they found and recommend. I did not have the typical symptoms of one with so much blockage, the naturally occurring body building bypasses were providing very good blood supply. I feel, because of the nutritional regime I had been on for the previous few years, my body was better able to do that. I wanted to allow my body a chance to do all it could, before resorting to that surgery. He agreed, I guess he had to, as ultimately, the decision is mine. I am not sure that would have been so easily done in a private system. So I appreciate that from the VA. Incidentally, that was about 5 yrs ago, my nutrition regime is apparently still working. I did have to have arterial bypass in my leg last year, I guess because there is less capability of the body to use other vessels as bypass in the leg. The bottom line is, I appreciate the VA and their providers, if they accept less money and have jump thru hoops and fight the bureaucracy to get things done, it makes me appreciate them even more.

[stan4]

Look, I live where practicing medicine is somewhat lucrative, and most surgeons and IM docs I know are not pulling much more than $200k (and some less). Subspecialties may be making more, but I think americans have a very distorted idea of how much physicians make. Probably because all they hear about is some specialized cards or ENT or neurosurg guy pulling in the high six-figures.