The economics of medicine: personal reflections
When I was growing up, I viewed being a physician as the zenith of achievement for someone interested in science. That changed when I got to college and became interested in research. I realized I didn’t have the temperament for a physician (OK, maybe a radiologist or a pathologist) and I became a lab rat. I did make a career as a professor in a medical school department and I taught thousands of 1st year medical students, but I really wasn’t interested in medical practice.
When I started my faculty career in 1987, there was a lot of money sloshing around at the medical school. Back then, insurance companies paid a premium for patients seen at academic tertiary care hospitals and clinics. But within a decade, managed care took over and medical schools across the nation were bleeding money. My university sold its hospital to Tenet while the hospital was still profitable. That turned out to be problematic, so eventually they bought it back and sold it to SSM, which was better aligned with the Jesuit Catholic mission of the university.
The basic science curriculum at the medical school has been shortened to make way for more clinical rotations. Meanwhile, for the graduates, the career prospects are evolving. Nurse practitioners and physician assistants are taking over the duties formerly performed by MDs and DOs. AI is more accurate than human radiologists in diagnostic imaging. Private equity is taking over practices and community hospitals and draining resources. Here’s an ophthalmologist in Kansas City:
“Medicine is going to hell. I have been asked to write several editorials but it would be so depressing I would feel bad. My own group, owned by 6 physicians, sold out 2 years ago to private equity (PE). Since then, 5 of us have left. You know the drill: fire local management, install bean counter as head person, golden rule now “MORE REVENUE SO WE CAN SELL OUT AT A PROFIT” down-staffed, told shorter patient contacts/more patients per day, more surgery, more revenue generating tests. Also, by fiat they are shifting all primary eye care to optoms and ophthalmologists do only surgery. This even on patients that have seen an MD and want to see MD not OD for three decades. The partners say no other specialty has had more decline in reimbursement than eye. The younger doctors did not want to buy in as partners and the older doctors had no exit plan. In fact, one of the partners died and they could not raise money to buy her out until sold to PE.
“Scholarship and merit have gone out the windows. The medical students and residents I come in contact with are snowflakes, self-entitled, clueless about intellectual rigor “do it for me” and standards dramatically lowered for some, raised for others in violation of supreme court ruling. You can go on the internet and learn about ‘work arounds” to shape the classes along the lines that are ‘fair’.”
Recently, an MD/PhD who did his PhD in my lab got in touch with me by email. He had initially taken a faculty position at the University of Hawaii medical school. But things changed:
“I am still kind of in academia and made it to associate professor rank but then it was just getting harder as hospitals saw anyone with “MD”s as replaceable billings ($) generating machines and getting rid of all protected time unless you have your own NIH funds (which is hard to do due to very limited support in Hawaii). So I kind of threw in the towel a few years back and started doing private practice (much more flexible schedule), which actually helps to subsidize the limited teach/research I still do pro bono.
“Psychiatry is fun in a way that I have been involved in teaching the psych residents on how to translate individual genetic findings into meaningful clinical decision-making. And geriatric psychiatry addressing dementia behavior is still much a learn as you go field so keeps it interesting. The PhD work I had with you made me think more critically and open minded in embracing newer findings (this is like the most important/enlightening thing I picked up as a grad student), as most MDs are trained to think in a cookie cutter manner, so I always have fun putting my MD students on the spot how their textbook knowledge is ever becoming obsolete.”
What a tragic waste of a physician-scientist.
I guess the medical profession is no longer quite the meal ticket it once was. The only constant in the world is change, and the economics of medicine is driving change in medical practice.
Very interesting. As an elderly customer of medical practitioners I have observed some of the changes enumerated. I am appalled at the lack of knowledge of up-to-date diabetes research (see Dr. Bickman (? sp) (PhD) and others’ cell biology research on the advantages of potentially using insulin level as a more sensitive and more accurate indicator of diabetic condition rather than the currently-used blood glucose level).
@Clifford,
I recall when I was a new assistant professor hearing the MD faculty using the term “evidence-based medicine,” which was new at the time. I asked one of them (sotto voce) “As opposed to what? Fantasy-based medicine?” He replied: “No, as opposed to tradition-based medicine.” The marginalization of basic sciences and critical thinking in the curriculum, together with the impetus to bill more patients rather than maintain currency in the literature, fosters the resistance to new and improved practices.
My experience is that most physicians know only a sliver of what they need to know in order to be competent even within their own sub-sub-specialty. But they sure are confident that they know everything. They see patients that really should be seeing a completely different specialty or sub-specialty and confidently provide incorrect diagnoses and treatments. The schedulers or colleagues within a given department haven’t a clue what the strengths, weaknesses and sub-specialties are of the people even in that one department. (I have seen this in multiple organizations).
@just,
“But they sure are confident that they know everything.”
Among my PhD colleagues, they’re called “MDeities.”
Joel:
As a patient, I spend a lot of time listening to what doctors have to say. I also know what I am there for unless they can give me reasoning why I should consider something else they are proposing for something else. And then support it.
I am old as some would call me. Brain is not dead or overdosed on meds yet. It appears doctoring for some has become a profit center. Hospitals have participated in this charge into profit centers. The more tests, procedures, the more profits.
Then there are groups of doctors who specialize and band together. And then, and then there are the insurance companies and Medicare Advantage who prosper off of their backs and diagnoses. The overhead for commercial enterprise is too high.
Just an observation. I hate BS though. And I will question. I think I blow their time limit. I believe you would have been a good doctor for those who like reality rather than a plethora of unneeded dialogue to convince people they need unneeded tests.