Tuesday, February 25, 2014

Why Do They Keep Us So Poor?

$11.25 per hour.  For three to seven years.  Working 60- to 80-hour work weeks.  With a little raise every year to keep up with inflation.  Would you take that job?

That’s the average hourly rate for a physician-in-training in this country.  Surprised?  Disgusted?  Worried about where the rest of the money is going?

That physician-in-training had to put in four years at an undergraduate university earning a bachelor’s degree, followed by four years of a rigorous curriculum at an accredited medical school.  He was swallowed whole for countless nights by the depths of the campus library, studying for organic chemistry exams, medical school admission tests, and preparing his competitive application for medical school.  He had to give up the “yuppy” lifestyle that all of his friends enjoyed after graduating from college and getting their first jobs, just so that he could now be swallowed whole by the medical school library, studying for even tougher anatomy and physiology exams, medical board exams, and once again preparing his competitive application for a residency training program.  And what was it all for?  To get into a residency program where he could continue to climb the endless ladder to become a physician.

Residency is an exciting time for physicians-in-training.  It’s a time for them to finally put to use all of the classroom skills and knowledge they have learned over the years.  It’s also a time to bond with other fellow trainees who are confined within the same trenches.  But it’s no piece of cake.  As recently as the turn of the century, residents would work sometimes 100-120 hours per week on average.  These hours became more strictly regulated by a few of the agencies that oversee medical education, and are currently limited to 80 hours per week.  But the pay hasn’t improved much over this time.  Residents are generally underpaid for the amount and quality of work that they produce.

That’s what I just don’t understand.  Why is there a delay in proper reimbursement for the hard work put in by physicians-in-training?  There are multiple factors and interests involved here, so let’s take a look at some of them.

Residencies were formalized after William Osler created the first residency program for specialty training of Internal Medicine physicians at The Johns Hopkins Hospital in the early 1900’s.  At that time, the residency program he created was one where residents led a restricted and confined life within the walls of the hospital itself (that’s where the term “residency” originated – these physicians resided in the hospital where they were trained).  They were “on call” frequently – sometimes every other night.  There were no pre-specified years required in training; instead, the programs were open-ended, and graduation into the real world of practice was based on your performance and evaluations by those more senior.  A residency that currently would take three years may have taken up to seven or eight years back then.  And pay was minimal beyond room, board, and laundry.  It was expected that you dedicated your life to the study and practice of medicine, and that there was not much outside of this that should detract from such a lifestyle.

Twenty years after President Truman first proposed the concept of health insurance, President Lyndon B. Johnson signed the Social Security Act, establishing both Medicare and Medicaid on July 30, 1965. In 1977, a new department called the Health Care Financing Administration (HCFA) was created to administer the two programs.  The HCFA would later go on to be what is currently known as the Center for Medicare and Medicaid Services, or CMS.  The head of the CMS is a presidential appointee requiring Senate approval.  Currently, Marilyn Tavenner is the acting administrator and chief operating officer. And amongst all of the scrutiny that her organization has come under for increased healthcare costs and sicker patient populations, one of the less talked about roles of the CMS is how they provide the salaries for residents.

Hospitals are paid a yearly “lump-sum” of money from the CMS for each physician-in-training they have on premise.  Current estimates show that they are paid approximately $100,000 per year for each resident, although this information is kept out-of-reach of the public for the most part.  Agencies like the Accreditation Council for Graduate Medical Education (ACGME) ensure that hospitals are able to provide an appropriate training environment for each of the residents, and work with CMS to accredit hospitals as a training-hospital.  Hospitals are then able to use this money at their own discretion, but resident salaries are governed by the National Institute of Health (NIH) and are simply based upon the number of years it has been since the resident has graduated from medical school.  Some hospitals will give an additional stipend to supplement this salary if they are located in regions of the country, like San Francisco, where cost of living is notably higher.  In 2013, an average salary for the first year of residency was approximately $49,000.  If you had already completed five years of training by 2013, you might make approximately $59,000.  This means that a resident who has been training for six years after he graduated from medical school, has celebrated 31 birthdays, and has already begun to pay back the approximately $200,000 in loans is not even breaking $60,000 before taxes from his day job that arguably keeps him busy for at least 50-60 hours per week.

You can imagine that this situation creates a lot of unhappy employees.  In 2002, a class-action lawsuit was filed in Washington against the matching program by which medical students are “matched” into residency programs.  Sherman Marek, a Chicago-based lawyer representing three young physician plaintiffs, challenged the program on antitrust grounds, stating the program is used to keep residents’ wages low and hours long[1].  They were also frustrated that this mandatory “match” program takes away the ability to compare job offers between hospitals – a basic, free market-driven process that exists for other professions like law, consulting, engineering and business.  In April 2004, with help from lobbyists and by attaching her efforts to a pension act, Mona Signer (Director of the National Resident Matching Program) was able to make her program exempt from the accusations through a bill signed into law by President Bush.  She defended that the Match is intended to help students and provides a valuable service.  The case was, thus, dismissed.  To add salt to the wounds and, more importantly, to recuperate the $3.5 million in legal fees it took for her to go to court, Ms. Signer raised the enrollment fees for subsequent Match years[2].

The financial duress that faces the medical field has multiple other facets.  What about the lack of ability for physicians-in-training to make long-term investments in their retirement accounts or other sources?  Any basic wealth management and investment course will teach that compound interest is the most valuable investment tool.  Having to wait until your early 30’s to properly invest your money makes for significant amounts of lost time and money (projected to be in the tens to hundred thousands of dollars over a ten-year period).  Doing it any earlier is almost impossible given the low salaries paired with the high debt from school.

Then there is the moral dilemma of being financially compensated for caring for the sick and the poor.  Is it right to make money off of our patients?  That sort of incentive placed in the wrong hands could lead to an abuse of the “expensive” tests.  On the other hand, adequate money attracts people who work hard.  And wouldn’t you want someone who is going to be fully dedicated to his profession, without having to work a second job or concentrate on a start-up company on the side to make ends meet?  We all have one life to live – staying healthy and having a worthy set of doctors who are willing and able to help you achieve that goal should be priceless, shouldn’t it?

The reality is that none of this has dissuaded students from applying and entering medical school.  Total medical school applications increased 6.1% to more than 48,000 in 2013, according to the Association of American Medical Colleges.  The number of medical students enrolled in medical schools in 2013 also increased by 2.8% to just over 20,000[3].  But something happens to these medical students after they are exposed to the numbers and are kept poor for longer than their friends who went into the business or finance world.  They may have arrived in medical school with dreams of solving the world’s primary care problems, but eventually less of them are entering fields like pediatrics and family medicine which are notoriously underpaid and instead end up choosing specialties like dermatology and ophthalmology which reap high financial reward along with 9-to-5 lifestyles.

If medical schools weren’t so costly, and physicians-in-training saw a competitive salary immediately after completing medical school, one has to wonder if we’d be facing the same primary care physician shortage which is currently being projected given the aging baby boomer population.  But until things change, please take a number and your doctor will see you...eventually.


Doc Veritas



[1] Liptak, Adam.  “Medical Students Sue Over Residency System.”  The New York Times.  May 7, 2002.
[2] Robinson, Sara.  “Antitrust Lawsuit Over Medical Residency System Is Dismissed.”  The New York Times.  Aug 14, 2004.
[3] Lopatto, Elizabeth.  “Medical School Applications, Enrollment Rise to Records.”  Bloomberg News.  Oct 24, 2013.

Monday, February 17, 2014

Treating Friends

“I want to help people.” Every medical school admissions officer has read that line a million times, but not without good reason.  People are attracted to a career in medicine because they get a thrill from performing selfless acts for their fellow man.  They probably got stellar grades in school, but a career in finance or marketing is not exactly what they dreamed about when they were a kid.  They don’t want to make the rich richer; they just want to make other people feel well and happy.

So what happens to these ambitious young men and women after they finish medical school and residency training and finally enter the world of being a doctor?  Aside from the few who jump ship to pursue careers that steer them far away from the nearest patient (see McKinsey’s healthcare division), young doctors pride themselves on their newfound skills that allow them to treat the sick.  Inside the four walls of the hospital, things work out fine and dandy.  Doctors make their rounds in the hospital wards seeing patients in the morning, and then spend the afternoon in their own clinic.  But in the hallways and at the home, there is an all too familiar scene that takes place time and time again.  The custodian stops you on your way to the office to ask about a pain in his foot.  Or your eighty-six year-old neighbor flags you down while you’re walking your dog and shows you a rash in a place you’d rather have her keep covered until you had your morning coffee or at least until there was a curtain to preserve her sanctity (which, notably, she isn’t as concerned about as you are).

The American Medical Association’s (AMA) Code of Ethics recommends that doctors refrain from giving medical advice or treating friends and family unless there is an emergency situation and no one else is around to help.  But even then, these situations come up all the time and sometimes make it tough for a doctor to bottle up those altruisms that made them who they are today.

I was once asked to visit a friend who was feeling ill after returning from a bachelor party in Las Vegas.  It was influenza season, he was twenty-five, and he’d been having muscle pains, fevers, and fatigue.  To add to that, he hadn’t had his “flu” shot yet.  He obviously had the flu – the perfect diagnosis that fit everything about his case.  So I told him to drink plenty of fluids and to get some rest.  Before leaving, I asked him briefly if he had any other medical problems and if there was anything else going on that I should know about.  He looked at his girlfriend who was seated next to him, glanced at my wife who had accompanied me to their house, and then quickly answered “No”.  I left their house with my wife, thinking to myself that I had done a good deed by reassuring my friend that he probably had the simple “flu” and that he’d get better.  I went to bed with a smile on my face that night.

I later found out I was horribly wrong.  A few days later, my friend’s girlfriend called me in a panic, asking me to come over to their house because his condition was worsening.  I stepped into their living room to find his neck impressively swollen.  This time, I opted to talk to him privately.  It turns out that about five years ago he was diagnosed with systemic lupus erythematosus (SLE), a condition where the human body generates antibodies that attack its own self.  The treatment is to give medicines that suppress the immune system so that the damage can be halted.  But because of side effects he developed from the medicines, he decided to stop taking them.  In a twenty-five year-old otherwise healthy patient who complains of fevers, fatigue, and muscle aches during influenza season, a diagnosis of the “flu” is probably not a bad guess.  But in a patient who has untreated SLE, the common “flu” is just one of the things on a longer list of even more dangerous possibilities – possibilities that could have killed him had he not sought appropriate care in a timely fashion.

There’s a reason that the AMA recommends against physicians treating their friends.  Aside from the fact that the usual in-depth history is condensed in casual-speak to a few “yes-no” type questions, there is oftentimes no physical exam to follow.  Many times these conversations are had over the phone or at a social event where a proper physical exam is not even feasible (ahem…okay Mr. Anderson, in order for me to fully assess your complaint, why don’t you put down your martini and go into the kitchen and take your shirt off).  Additionally, friends aren’t always ready to talk about very personal parts of their medical history, like sexually transmitted diseases, illegal substance use, or even classic medical problems (i.e. SLE). A physician trying to create a differential diagnosis for a patient’s symptoms without the full history is like a construction worker trying to build a house without a hammer.

As much as it may be the job of the physician to maintain boundaries for delivering healthcare advice, the onus of responsibility should also be shared with the patient.  Patients should know that unless they are truly forthcoming about their medical history, they should not expect to get the best advice.  They should also realize that most medical diagnoses arise from a thorough history AND physical.  So if a healthcare professional is making therapeutic or diagnostic recommendations without laying their hands or stethoscope on their body, a major element of how doctors think is missing from the equation.

Then there’s the issue of physicians treating family and loved ones.  As any healthcare provider knows, every symptom a patient complains of brings to mind many potential diagnoses, some that are benign and others that are life-threatening.  When treating any patient, physicians are expected to think of the entire spectrum of disease and systematically eliminate those conditions that aren’t so likely, while simultaneously evaluating for those that fit the clinical scenario.  But things are different when a physician attempts to treat a loved one.  It’s only natural to assume that the more life-threatening conditions wouldn’t happen to the ones you love, which makes it tough for physicians to consider certain possibilities.  A cough ends up always being because of a cold and never because of lung cancer; chest pain is always because of heartburn and never because of an impending heart attack.  Medicine should always be practiced in an impartial and unemotional way so as to allow for the most independent and accurate thought.  When emotions cloud clinical judgment, we are performing an injustice.

My friend went to a local emergency room where he underwent a complete history and physical, along with diagnostic testing.  His fevers continued to climb, his white blood cells (the cells that fight infections) were non-existent, his neck continued to swell, and he was very anemic.  This was clearly not just the “flu”.  After performing a biopsy of the enlarged lymph node in his neck, he was diagnosed with a rare syndrome called Kikuchi-Fujimoto disease (a condition where the body’s immune system attacks a lymph node in the neck and can lead to multi-organ failure).  With timely administration of intravenous steroids, he immediately began to get better and a week later was ready to return home.

Every physician probably has a story like this that they will never forget.  After wanting to do our best for every patient that we see, why do we suddenly find it okay to deliver partial care to the ones who are closest to us?  It doesn’t make sense.  Helping friends think through some of their medical problems as a reference seems like a harmless thing to do, but the conversation should stop there before a patient feels like they don’t need to see a real doctor.

Doc Veritas


Wednesday, February 12, 2014

The Changing Face of Medicine


In the early 1900’s, Sir William Osler, master clinician and educator, pulled medical students away from their textbooks and into the living, breathing world of medicine on the wards of his hospital.  He believed that the real learning happened at the bedside with patients serving the role of the textbook.  In the 21st century, it hurts to now see physicians retreating out of the patient’s room and back into an office void of textbooks but filled with glowing computer monitors and electronic charts.


At the Johns Hopkins Hospital, there is still an emphasis on the physical exam and bedside diagnosis.  Medical students are taught how to perform a thorough physical exam by senior faculty, practice their skills on standardized patients, and then are shown interesting findings by residents (doctors-in-training) and attendings (senior physicians leading the medical team) once they arrive on the wards.  But times are changing.  With the government cutting reimbursements to hospitals for the services they offer, there is an emphasis bestowed by hospital administration to streamline the hospital stay and optimize the billing process so that more can be paid for.  This single influence has led to a series of changes in the current face of medicine.


One major change that has become obvious in many hospitals is the physical disappearance of physicians from the hallways of the medical wards.  At one time, patients had binders next to their rooms that housed their medical information, current medications, results of blood tests, and plans for further testing.  When their doctors needed help from a specialist, that specialist would come by to see the patient and jot down their recommendations in that same binder.  The result was a central focus of attention located physically at the patient’s bedside.  Patients would see their physicians stop by often, and subsequently, would be able to ask questions and develop a special relationship with their doctor.  If nothing else, at least they saw their doctors stop by to say “Hello” multiple times in a day which can be therapeutic or, at the least, reassuring that they have not been forgotten.  With the advances made in medical informatics, the bedside binder of information has become obsolete.  Now, every patient has a medical record number and an electronic chart that can be accessed from any computer in the hospital.  No longer does a physician need to come to the patient’s bedside to do such things as check test results, read notes from other specialists, or even order new tests.  This proves to be great for efficiency of the caregiver team.  But the doctor-patient relationship is the casualty here.  Patients often obliviously go to CT scans and have blood drawn without any explanation or reason.  Oftentimes, nurses are the ones left explaining these complex medical decisions to the patients and their families.  Medicines and imaging tests are sometimes ordered on the wrong patient because unique patient identifiers on an electronic chart are often limited to the patient’s name, and doctors are often multi-tasking when ordering such things.  In large teaching hospitals, patients are often seen by so many various members of a medical team that they often leave the hospital unaware of who was the physician in charge of their hospitalization.  They remember their nurses and support staff more than their physicians.

The electronic medical charts at most hospitals were implemented only secondarily for ease of access of medical information.  The primary reason, and the driving force behind how these systems are designed, is to maximize billing.  There is a focus placed on assigning diagnoses to symptoms, as these are the key elements that allow the hospital’s billing department to optimize reimbursement.  Many physicians would say that the written medical record was easier in many ways and facilitated the bedside presence of doctors.  Nowadays, residents and attendings oftentimes discuss patients in front of a computer where laboratory tests, imaging studies, and reports from consultants are readily available at the click of a mouse.  But I’d argue that the most important aspect of the presentation is missing: the patient himself.  

The answer, though, is not so obvious. When medical teams do make the effort to go to the patient’s room, the patient is frequently undergoing an ultrasound or on his way to the MRI department for a three-hour field trip.  With improved coordination of medical care to hasten hospital discharges and make room for the numerous patients awaiting hospital beds, the tradition of “Morning Rounds” where a senior physician accompanies young doctors-in-training to teach key features of the history and physical exam is becoming a disappearing art.  Young doctors find themselves to be less experienced in physical diagnostics and more experienced in ordering tests and facilitating hospital discharges.

Over the past decade, we have seen the growing presence of the “Hospitalist” physician.  Gone are the days of the family doctor leaving his clinic to care for his own patients when they happened to be hospitalized.  With specialization of roles came the advent of the “Hospitalist”, a physician whose only job was to take care of patients hospitalized from the community.  These doctors don’t have clinics to tend to and, thus, can dedicate all hours of their day in coordinating hospital care.  This allows family physicians to remain in the clinic so that they can solve their own struggles of reduced reimbursement rates by increasing their number of patient appointments.  Hospitalists have their own problems though, a major one being a high burnout rate.  Thus, these positions are often filled by doctors just completing their medical training who are attracted by headhunters to the job with promises of loan-forgiveness, excellent compensation, and weekly shift work.  These young doctors are willing to put in the hours for now, but those feelings are sometimes ethereal.  In the process, however, it is these young physicians who sometimes end up leading medical teams at large teaching hospitals.  Young hospitalists find themselves less and less able to pass on any skills at the physical exam and bedside diagnosis, and so these problems find a way to jump to the next generation of physicians.  Modern day apprenticeships are now characterized by teachings on medical informatics, details of laboratory testing and imaging, and proper techniques for billing.  The expectation to complete medical training with confidence in bedside skills as a physician takes a backseat to passing a multiple-choice exam and logging your weekly duty hours.

At a growing number of teaching hospitals around the country, there has been the advent of a procedure service.  In the past, when a patient needed a special procedure such as a central venous catheter, paracentesis, thoracentesis, or lumbar puncture, the team of residents led by the attending physician would coordinate amongst themselves to perform the procedure in a timely manner.  This process allowed the residents on the medical team to gain experience doing such procedures while also allowing for the doctor-patient relationship to be strengthened during the time spent in the procedure. It wasn’t long, though, until hospital administration realized that they were missing out on key opportunities to bill insurance companies simply by not having a board-certified physician present at every procedure.  Their solution was a procedure service.  This is usually a team made up of a board-certified physician, a mid-level (i.e. nurse practitioner or physician assistant), a nurse, and occasionally a few residents in training.  Now, whenever a patient on a medical team needs a procedure, it has been commonplace and frankly easy to simply call the procedure service.  Without too much stress endured by the primary team, the patient undergoes the necessary procedure in an efficient, cost-effective manner.  Additionally, by ensuring that a billing physician is present, the hospital can ensure that it will be properly reimbursed for the procedure.  But there is something that is lost in the process. The medical team has yet again been removed from direct involvement with its own patient.  There is less teaching due to the high volume of procedures that are on the service’s queue, and thus, less apprenticeship.  There is also a diffusion of accountability when it comes to post-procedural complications which can sometimes lead to compromises in patient care.

I don’t think there are going to be easy solutions for these problems.  The majority of these changes are driven by a need to be more profitable in a world of ever-increasing financial stresses, as well as an increasing concern over diagnostic liability.  But one small thing that can be done is for hospital physicians to place just a bit more emphasis on teachings of the physical exam and bedside diagnosis.  Let’s open up a dermatology atlas and figure out what kind of rash our patient has instead of reflexively calling in the dermatology specialists.  Let’s ask our patients to completely undress for a full physical evaluation of every orifice and bodily crease.  Who knows what we may find? This small act will re-establish rapport with our patients while also inspiring the next generation of physicians to keep medicine at the bedside and out of the computer.  The physician’s touch can often be more healing than the reassurance of thousands of dollars of blood tests and imaging studies.  And as these expensive tests begin to garner less and less reimbursements for the hospital, the priceless nature of the physical exam may be a large part of a future solution to healthcare’s financial dilemmas.  If that is indeed the case, I sure hope that the next generation of doctors knows how to even perform one.
Doc Veritas