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HH: Dr., Professor, that’s where clarity enters in. People think this is all about health care, and the comprehensive solution to health care is being proposed. But as you’ve already sort of clarified in the course of this conversation, we’re not fixing Medicare, we’re not fixing the doctor reimbursement problem, so we’re not really fixing health care in America, are we?

JG: But once again, what matters for health care in America is not the physician problem. It’s not the Medicare trust fund. It’s the fact there’s fundamentally, if we don’t control health care costs, in one hundred years, America will be bankrupt. That’s fundamentally what this is about.

HH: I understand that’s your point of view, but if a person’s point of view was that the solution to health care requires a comprehensive solution to the physician availability, to physician incentive to stay in the game, not to leave the game as the Investor’s Business Daily poll showed, to fix Medicare so we have a fiscal sanity going forward, then this bill doesn’t do any of that.

JG: This bill doesn’t do a lot of things. This bill doesn’t deal with the war in Afghanistan. I mean, this bill doesn’t do a lot of things. What you have to ask yourself is, I don’t think we want the perfect to be the enemy of the good here. You have to ask yourself, on net, is this bill a good thing?

Hi Hugh,

I’m an Internal Medicine sub-specialist in Infectious Diseases retired from Academic Medicine, now in medical publishing (at the rip ole age of early 40’s).  I have been listening to your show each evening.  Thank you for focusing exclusively on health care reform.  My upfront disclaimer on what I’ve “done to fix things”: I have contributed to Docs4patientcare, but I have gone above & beyond the call of duty by announcing on my Facebook that you are doing an excellent job with your interviews, and telling everybody to listen to your show.  Yay for me.

You have done well so far in airing the current problems that physicians have with Medicare (& Medicaid) reimbursements. One of your surgeon callers adequately described that an in-house level III consult is worth $70 (of which overhead & taxes take ?), and few physicians can be motivated to get up at 2 a.m. & drive to the hospital, stay for half the night, for roughly $35, no matter how altruistic. 

To play devil’s advocate, I’d like to point out what my liberal non-physician friends say when the cuts in reimbursements are discussed:  “Well, if your income of $185K goes down to $150K, then you’re still making $80K more than I am, so I think you can survive…” (From a strictly philosophical position, there are so many things wrong with this statement that I don’t know where to begin.) But, let’s focus on the pragmatic.  Average Joe doesn’t understand the debt to income ratio incurred by physicians (with debt taking many forms, not only financial). And society has done a great job of stigmatizing physicians as being money-grubbing entrepreneurs who don’t give a damn about patients, such that Average Joe actually feels almost liberated when reimbursements are cut.

I want to point out that current medical students today incur more than $125,000 for 4 years of med school (if they go to a cheap state school). This figure does not include college. The repayment schedule for my debt ($100K, because I graduated in the 1990’s) is $700/month and extends until I’m 65 years old. As a subspecialist physician, I trained for 14 years to do what I do (4 college 4 med school 4 med/peds residency 2 fellowship).  While my friends and neighbors were becoming teachers and loan officers and hair stylists and restaurateurs and claims adjusters, I was going to school learning how to take care of old folks, babies, and AIDS patients. Not only did I incur debt, but concurrently, I deferred income for almost a decade. So, while my friends were buying homes and having babies, again, I was learning to take care of AIDS patients.  

All of this was my choice, and I do not regret that choice. But let me be clear: medical students will not continue to make these sacrifices for peanuts. They will not.  And the Americans who now sit idly by, watching politicians abscond with their health care—all for ideology, will one day wake up to a health care system run by nurse practitioners & physician assistants because they are cheap. And I don’t say that to disparage NPs & PAs. But a Master’s degree does not rival 14 years of training to understand complex disease.  And If you’ve got bacteria growing in your blood or you’re having a heart attack, you don’t want “adequate” care.  You want fantastic care—that only 14 years of training gets you. In no other profession—not teaching, not law enforcement, not journalism—are people expected to make these kinds of sacrifices—financial, familial, emotional, intellectual.  No other profession.  If you want future doctors, you’d better invest in them, because no person is going to go through all this for minimal salary.  They’d be stupid to do that.  And medical students might be a lot of things, but they aren’t stupid.

Thank you for calling attention to these matters,

CM

PS: as one final shocker, I’d like to tell you the salary I had a subspecialty trained Academic ID doc.  As Assist Professor, my salary was $90,000/year, for which I was expected to teach, conduct research, & provide patient care.  I worked 80-100 hrs/week.  My NP who was employed at my HIV clinic, who worked 3 full days/week, was salaried at $80,000.