And the Alternative is ... ... ... Lacking?

[GernBlansten]

But Medicare is socialized medicine, the cost of care to the recipients are socialized to all taxpayers. You specifically called out the Federal Government restricting the number of residencies. That may be true only because Medicare funds the residencies and Medicare funding has been cut in the past 10 years. Therefore, one could say that the Federal government is restricting the number of doctors through the residency program. However, the reciprocal to that argument would be that to increase the residency slots, the Federal government would need to enhance funding to Medicare. That would be to increase socialized medicine in the US. That does make sense to me.

 

As for the Dept Of Education applying quotas or limits to medical school enrollment, do you have any backup to that? I just find that a bit hard to swallow that the Dept of Ed interferes with private college enrollment numbers.

[vol_scouter]

It is the similar to the residencies, the Department of Education partially funds medical schools and the schools must do as told or lose the funding. The information is from the Dean of my medical in the mid 1980's.

 

The modus operandi for the federal government is to provide enough funding that it can tell others what to do.

[Beavah]

Yah, hmmmm....

 

I'm sure vol's right about da practical effect.

 

But he's not quite right about the mechanism, eh?

 

Da federal government is only limiting the amount of scholarship support it's providing for residency trainin', eh? That's not at all the same as limiting the number of positions.

 

Believers in da free market would expect that private funders and the students themselves would provide for the rest, eh? But trainin' docs is a big ticket expense, and we don't see private sector entities like insurers jumpin' in the way they should to increase the supply so as to drive down the price.

 

That's a market failure as much as it's a government planning failure. It's again because da private insurers are focused instead on demographic skimming and other short-term profiteering tricks rather than long-term cost containment.

 

Beavah

 

 

[GernBlansten]

Yes Beavah. Vol_scouters claim struck a cord with me. The federal government is to blame for our declining physician population. Not because they do too much, but because they do too little. This is from someone who has demonstrated a very anti-government opinion on this forum. Its dripping with irony.

 

So what's the solution?

Why hasn't the for-profit healthcare infrastructure fixed this problem? Where are the insurance companies on providing training resources for residents? Why aren't they investing in the future of our system?

 

 

[vol_scouter]

There seems to be considerable confusion about medical education. Let me walk every one through a medical education. Here is a typical medical education. There is some variability with some medical schools but this should be a good first approximation

 

!. 4 year undergrad degree with the typical required one year courses in: calculus, general chemistry, organic chemistry, physics, English, and biology. Most take microbiology, anatomy, physiology, and biochemistry among others. You must show community involvement and be well rounded with extra-curricular activities.

 

2. 4 years of medical school - the first 2 years are primarily didactic lectures. The volume of material was far greater than anything in undergraduate or graduate school (physics). At the end of the second year, most schools require passing the first part of the USMLE (when I was in school, it was the NBME) prior to starting the third year. It is a comprehensive exam on the material covered in the first 2 years. The third and fourth years are all clinical. There are several didactic lectures each week with the remainder of the time being on the wards of the hospital. My days would begin at 4-5:00 am each day and ended ~8-10:00 pm unless on call when it would be a ~36 hour period (this has been decreased). The year is divided into rotations that last 2-3 months. The rotations are typically: medicine, surgery, Ob/Gyn, Pediatrics, Psychiatry, Family medicine. The second portion of the USMLE is typically required in order to graduate and is taken in the spring of the 4th year and it is comprehensive for the third and fourth years. During the fourth year, you must decide what kind of a doctor you wish to be and send applications to the programs that you are interested. If they agree to interview you, you travel at your own expense to the cities and are interviewed. Then in Jan. I believe (I might be wrong on this date) in your fourth year, you fill a form for the National Residency Matching Program by ranking the programs that you wish to match from 1-whatever. Most people interview at 20-30 programs or more if they specialty is very competitive. In March, the NRMP comes out and everyone finds out the same day where or if they matched. The program supposedly matches the medical student with the highest program matching them high Those who did not match will talk with their medical school who will start calling to find a position. Medical schools have students and students pay for their education by whatever means possible - scholarships, loans, rich parents, etc. Most schools 'ban' working (it is probably not enforceable).

At graduation, the medical students become Physicians and are no longer considered students.

 

3. After typically graduating in June, the new MD starts their residency. The first year of residency in the past was an internship because the new MD would not be allowed to leave the hospital for a year. That practice is long since gone but the first year is still often called the internship. Residencies are paid positions because the physicians are providing care. Residencies are 3 (Internal medicine, Family practice, ...) to 5 years (General surgery). Residents are now limited to 60 hours per week. This is down considerably from years past and for this reason, the residencies will likely grow longer to get the same amount of experience. At the end of the first year, the MD is usually required to pass the third (and final) portion of the USMLE. In most states, the physician can then get an independent license to practice medicine and surgery (as most licenses read). Few ever stop there but if they do, they are called general practioners. Since GP's have only a single year of training, it is an insult to address an internist or family practioner as a GP. All medicine specialities (cardiology, pulmonary, nephrology, etc.) are 3-5 years after the initial 3 years of internal medicine. Surgical specialities require 3-5 of general surgery first. So many surgeons spend 7-8 years in training. They are caring for patients, putting in long hours and are paid to do so They do not pay tuition. The salaries are paid by Medicare - I think that this is not the appropriate way to fund graduate medical education but it is the way that it is currently done. When I was in training, I worked 80-100 hours per week and when I took my actual hours and divided into my salary, I was making less than the minimum wage. Just remember, residents are physicians who provide a service that they are paid to perform and are nit students. They often have to take exams to proceed to the next year and have to pass exams as well as have attendings continually critique their work. The attendings must approve the advancement of the resident each year. There are a few didcatic lecture each week.

 

4. Whenever the resident completes their training, they will interview for a practice and are typically salaried. They often owe > $125,000 in loans. They have been in undergraduate and medical school for 8 years and then trained for 3 - 8+ years. It is difficult to start families during this time period or in the first few years of practice. They have had to put off many things for years that their colleagues have already purchased. The residents pay is adequate but far from generous.

 

Don't get me wrong, I am not whining, being a physician is an honor. It is an honor to have patients describe intimate details of their lives and be allowed to examine them in an effort to provide comfort and healing. Most physicians earn a comfortable living. However, I had some recent legal work done (not malpractice) and found that his rate was ~3 times my hourly rate (I am employed by the hospital). I do not think the attorney is over paid but that I am underpaid. I take people's lives in my hands everyday that I practice medicine - no one dies if my attorney makes a mistake so that I believe that my hourly rate should be higher. Some have mentioned else where that part of the problem is physicians being over paid. I could have made more money fields other than medicine. That means that there will be fewer going to medical school and a decline in quality (demand was ~5 applicants per space nation-wide in the 70's and ~2:1 now). At some pay, we all could say that the demands of the job are not worth the pay - doctors will quit if the pay gets too low (whatever that is). From what I have read over the years, if physicians and pharmacists were paid exactly 0 (zero) dollars, the savings to medicare would be only 10 %. That is hardly the problem.

 

The VA is a government run medical system and it has significant problems. The democrat plans will not work and will result in massive increases in spending and rationing. There was an AP article this week discussing how health screening actually increases costs rather than decreases the costs. I am practicing medicine only 3 days a month and working full time research so that I am like most of you as a consumer of medical services more than a provider. I left partly because the government makes it more difficult every year to provide high quality care for my patients. The government option will eventually destroy all private coverage and I can only have nightmares as to how difficult it will be to even provide adequate care. Medicine is a complex subject and a very complex system. Obama, Pelosi, and Reid do not have the understanding to correct the problems or if they do, they are refusing to do so.