Practice composition and partisan contributions

Kevin Drum is playing around with Sarah Kliff’s piece on how doctors donate to political parties:

 As high earners, you’d think that doctors would be more likely to contribute money to Republicans than Democrats. But it turns out that isn’t true. A new analysis in JAMA Internal Medicine shows that merely well-off doctors—your allergists, your pediatricians, your pulmonologists—favor Democrats. It’s only when you get into the territory of medical royalty—your surgeons, your urologists, your radiologists—that political contributions start to heavily favor Republicans. Even within one of the best paid professions in the country, there’s a class divide, with the haves favoring Republicans and the have-nots favoring Democrats. That’s fairly remarkable.

I think a sub-component of this split is practice composition.  The basic providers (primary care physicians, pediatrics, cardiology etc) have been under significant pressure in the past fifteen years to move away from the solo or small group practice model towards an employment model.  The NIH has shown this shift:

The percentage of physicians in groups of more than fifty increased from 30.9 percent in 2009 to 35.6 percent in 2011. This shift occurred across all specialty categories, both sexes, and all age groups, although it was more prominent among physicians under age forty than those age sixty or older….

The New York Times in 2010 noted this pattern as well:

As recently as 2005, more than two-thirds of medical practices were physician-owned — a share that had been relatively constant for many years, the Medical Group Management Association says. But within three years, that share dropped below 50 percent, and analysts say the slide has continued…

The move towards Accountable Care Organizations, coordinated care and bundled payments in PPACA has pushed the generalists and PCPS towards more risk bearing and more capital intensity.  The private practices with only a handful of docs usually don’t have the money to upgrade electronic medical records or participate in the risk of patient population management.  So the smaller practices are being bought out by either large hospital based physician groups or banding together to form regional co-ops.  From here, the shift from being owner to employee is rapid, and class interest comes into play.  The high end specialists have not had that degree of pressure yet, so the combination of being very high income, typically older than average and still working as owners may be coming into play here.

65 replies
  1. 1

    My cousin is married to a nephrologist and I have heard him spout libertarian BS but he is socially quite liberal.

  2. 2
    Mnemosyne says:

    When I saw my doctor for my annual exam, she was bitching about Obamacare, but this seems to explain why — she’s a sole practitioner, and the new Obamacare requirements will probably be pretty costly for her. And since she’s in Family Medicine and not a high-paying specialty, she doesn’t really see what Obamacare does for her except give her a major headache trying to comply with the new regulations.

  3. 3
    jl says:

    I agree. A lot of doctors will not achieve the increasingly dysfunctional AMA dream of the independent professional (protected by a powerful special interest lobby with some massive conflict of interest problems). A lot of primary care doctors are treated by the money and medical high brass more or less like nurses clinical and distributional pharmacists, and technicians, and they are starting to think like them. They are wage slaves who need to be careful what they say and do, if you know what I mean.

    And, new docs going into private practice seem more aware of how ruthless the old farts owing a private practice are in working and churning new people and then throwing them away. They realize that the room at the top of the old AMA vision is getting smaller and smaller.

    I roomed with a teamster dude in his twenties for awhile in college. I’ve noticed that most of the students and residents now talk about the AMA fossils like the teamster room mate talked about the high teamster brass: “Look at those rich old crooks!”

  4. 4
    ultraviolet thunder says:

    @Mnemosyne:

    What about all sorts of new patients? People who couldn’t afford care and now can thanks to Obamacare. Seems like a health care practitioner should welcome the business and the improvement in public health.
    But yes, for a single proprietor or small business there’s a burden associated with compliance.

  5. 5
    japa21 says:

    Even many physician owned practices are tied to hospitals through PHOs who handle the insurance contracts, etc. And these PHOs have their own requirements for the physicians to meet, many of which mirror the ACA requirements.

    One of the interesting things that has happened over the past few years is that Medicare has increased reimbursement to the PCP, family medicine and general practitioner groups while lowering it for some of the higher specialty ranks. Since so many insurance carriers have their reimbursement tied to Medicare rates, this has also impacted almost all reimbursements.

    Should be noted that some of the bigger winners on the provider side are the “lower paying” practices, as they are seeing the largest increase in paying patients.

  6. 6
    charluckles says:

    I work in a medical facility and while I don’t have a lot of experience with the radiologists and urologists, a good 90% of the surgeons are the most self-absorbed assholes I have ever met. It’s always fascinated me, because they have clearly had years and years of education and training, but it often seems like they just missed the lessons I learned in elementary school about how to play nice with others.

  7. 7
    gbear says:

    I know my general practice clinic has changed names at least a half-dozen times in the last 10 years. It started out being named after the neighborhood, and each new name has reeked more of market-speak than the previous name, until now it’s called Entira, which is entirely forgettable.

    I still love my doctor and I think he’s spending a lot more than the recommended time allotments with his patients (I usually have to grab a magazine to keep entertained while he’s making sure the previous patient gets all the time they need), but the place might as well be called Universal OnmiCare for all the corporate changes they’ve made over the years.

    And with each corporate update, the phone system gets worse. Entira has the ‘hold’ system from hell.

  8. 8
    Mnemosyne says:

    @ultraviolet thunder:

    She’s already pretty maxed out, patient-wise. Also, insurance companies like Anthem Blue Cross of California are continuing to pay their maybe-we’ll-pay-maybe-we-won’t games so, from her perspective, it’s been a lot of annoyance without a lot of gain. But I did make some headway with my arguments that it was better for everyone to have insurance even if some of us were paying a little more to do it.

  9. 9
    Richard Mayhew says:

    @ultraviolet thunder: Solo primary care physicians are under a lot of pressure. Sure they are seeing more patients who have decent but not amazing coverage, but there is a signifcant deductible risk, plus increased pressure to take on population risk management (ACO) plus lower reimbursement rates (fiscal cliff/sequester deal) for all but Medicaid patients — solo PCP is a tough gig right now economically speaking.

  10. 10
    big ole hound says:

    In NorCal Almost all primary care and other non-surgical types are part of a large network working with a local hospital and are good to work with until they refer you to a high priced specialist who wants your insurance information verified before an appointment can be made. That’s where the GOP backer lives.

  11. 11
    CONGRATULATIONS! says:

    For decades, basic practitioners have been getting Godzilla-stomped by the insurers, getting less and less money for more work. Obamacare, great as it is for patients, doesn’t do shit to help those doctors stop the hit to their bottom line.

    I have the best GP ever, and I’m glad he’s independently wealthy (and yet still a Dem, yay!) because that means his office staff and office stays the same no matter how bad things get.

    I was dismayed to learn he believes Obamacare will eventually fold under cost pressures and we will have to go to single payer, which will not be a pretty, quick, or kind transition. I’d like to argue with him about that, but:

    1. He’s been doing this a long time, and I haven’t. Experience counts.
    2. The private insurance model was obviously going to die long before Obamacare was anything more than a Heritage Foundation proposal. The ACA prolongs but will not stop the death of an institution not fit to live.

    Also, while wishing for ponies, I’d just like to say we need the same program for dental care ASAP. This country has too much money for people to be walking around with their teeth in the condition a lot of them are in.

  12. 12
    rikyrah says:

    are we supposed to feel bad for the docs?

    Just askin’.

  13. 13
    Mudge says:

    In looking at Drum’s plot, the hospital based physicians (who are the high earners) tend to be most Republican.

  14. 14
    Stan says:

    It could have something to do with the sorts of people they come across in their daily life and practice.

  15. 15
    CONGRATULATIONS! says:

    are we supposed to feel bad for the docs?

    Just askin’.

    @rikyrah: By no means. But like any other worker in this country, they don’t have to do what they’re doing. Better to reach some kind of accommodation with them, rather than have a bunch of them flee the profession, and a bunch more not choose to enter it, leaving us shorter on doctors than we already are. I think we all can agree that would be catastrophic.

  16. 16
    BGinCHI says:

    The other reason is ego. The surgeons with the most specialty have a lot of brass (they probably have to in order to cut open someone’s body and work on it). Many of these folks see themselves as Makers.

    Good friend of mine is a pediatric ENT surgeon and he is always talking about the assholes in his profession.

  17. 17
    Hank says:

    My dad is a retired peripheral vascular surgeon. He was trained for this while he was in the Navy and after a couple abortive attempts at private practice, worked at Kaiser until he retired. He didn’t work for kaiser, though, he worked for the medical group that supplies all the doctors for kaiser; essentially a union. He also stayed in the Navy Reserve until he had enough points for a pension.

    If we include Social Security, he’s now living off two government pensions and one union pension and is the most right-wing, gun-fondling, Fox-watching, goes-on-the-NRO-cruises person you’d ever want to avoid.

    So anecdatally, he fits the profile to a tee.

  18. 18
    BGinCHI says:

    Speaking of doctors on the right:

    http://talkingpointsmemo.com/l.....ant-arrest

    Minnehaha!

  19. 19
    FlipYrWhig says:

    @rikyrah: You mean doctors should consider themselves as people with _jobs_, like the rest of us peons, rather than as all-knowing oracles _and_ entrepreneurs? Harrumph harrumph, I say.

  20. 20
    Mary G says:

    My rheumatologist, who practices with her husband, bitched like hell about Obamacare when it first passed. We had many an argument about it. But now that it has actually kicked in, she likes it. She says she had no idea that so many people didn’t have insurance before (!?!!?).

    She gets all kind of love from new patients that she can now sometimes help, but not always, because the deductible on most of the new drugs is horrendous, usually a third having to be paid by the patient. When it’s $7,000 a pop, it’s still like not having insurance, because who has that kind of dough?

  21. 21
    FlipYrWhig says:

    @BGinCHI: Do you think proctologists get offended that people use “asshole” disparagingly?

  22. 22
    FlipYrWhig says:

    @CONGRATULATIONS!: Yeah, soon enough it’ll be so bad that no one will want to be a doctor anymore.

  23. 23
    BGinCHI says:

    @FlipYrWhig: How often at work do they quietly say to themselves, “Wow….nice one.”

  24. 24
    Old Dan and Little Ann says:

    My BIL is a surgeon and my wife and I had the fortune of joining his family and my sister on vacation the last few summers. He is a self-proclaimed LIbertarian that donates to Rand Paul. His son, my 21 year old nephew, was looking for a book to read last summer and my BIL said, “If you only read one book this summer it should be Atlas Shrugged. It changed my life.” I told him that book was a crock of shit and left it at that. We don’t talk politics. Well, he talks. I ignore him.

  25. 25
    drkrick says:

    @charluckles:

    I work in a medical facility and while I don’t have a lot of experience with the radiologists and urologists, a good 90% of the surgeons are the most self-absorbed assholes I have ever met.

    It’s the difference between God and surgeons. God doesn’t think he’s a surgeon.

  26. 26

    @drkrick:
    And it has a lot to do with the kind of people who push for those super high paying medical positions, and the kind who went ‘I want to be a family doctor!’

  27. 27
    pseudonymous in nc says:

    I’ve been to Dem fundraisers where there have been “merely well-off doctors” in attendance, and I may have made a few unacquaintances by saying that they were still overpaid.

    Surgeons, though? Dear me. I think “a-hole” is probably part of the job description, but I also think being forced to work in a public system moderates that to some degree. In the US, they’re allowed to go full hole.

  28. 28
    Soonergrunt says:

    “The basic providers (primary care physicians, pediatrics, cardiology etc) have been under significant pressure in the past fifteen years to move away from the solo or small group practice model towards an employment model.”
    VA has seen this as well. We are up to our eyeballs in GPs and other “non-elites,” but we can’t afford to hire the “elite” specialists like Neurologists, Neurosurgeons, Orthopedic surgeons and so forth.

  29. 29
    Richard Mayhew says:

    @pseudonymous in nc: this is a post I need to write sometime soon as I did the research a while back — there is more than enough demand of very smart people who want to be doctors (2012 entry class had significantly higher MCATS than 2002 entry class etc) so the AMA cartel as well as Grad Med Education restrictions/funding limits are choking off supply of very smart people who could be more than acceptable docs at the same or lower wages.

  30. 30
    jl says:

    @pseudonymous in nc: A lot of primary care doctors are no longer vastly overpaid compared to other high income industrial countries. Specialists and surgeons still are. And compared to other countries, the U.S. is very medical specialist heavy. Way outrageously heavy. So, in terms of physician compensation, that is where most of the excessive compensation goes.

    One factors that RM omitted from the discussion, and I have not seen from other commnters is the ability of independent physicians to refer tests, lab work, specialty inpatient procedures, and rehab to facilities they own, with very few checks on whether the referrals are honest arms length transactions or corrupt self-dealing. I don’t think they can do that with pharmacy, though, except they can channel their patients’ future Rx down certain paths through choice of free samples in the office. The obvious and ample opportunities for conflict of interest, and corrupt practice of such a system should suggest that it be reformed. But not much has been done. Bottom line is that some physicians of weaker character, just might be running little miniature crony capitalist empires.

    And also skimming some take off of other health professionals’ work. I asked around about the rolled up reimbursement mystery of a recent RM post. I;ve been told by clinicians (docs and others) that there are two nexi of power to channel reimbursements. One is authority ot issue medical orders and prescriptions, wihich is under individual state authority. The other is the Medicare reimbursement system which requires a reimbursement number that usually has to belong to an MD, and which is largely adopted by private insurance. Having ability to bill and get reimbursement quickly wins, and that is (say my clinician contacts) why so much billing is rolled up into the MD practice, even if others do the work, even have authority to originate medical orders or prescribe.

  31. 31
    jl says:

    @Richard Mayhew: The AMA specialty establishment is very ingenious at putting up roadblocks to more supply. The last one I heard about was an obscure back door method to restrict the supply for offshore doctors (not just docs trained in other countries, but what are essentially offshore medical schools aimed at training docs for the U.S.). Too many offshore and foreign trained docs were getting residencies, so they established a rule that residency program has to take either 100 percent of its new docs from the U.S. residency matching system from on-shore US schools, or none. Before, programs could take whatever mix they wanted. I can see no reason for this other than cynical and selfish restraint of trade, for money.

    Edit: in case RM comes back, I have a comment above in moderation. probably due to the f A * ^^ a SEE naughty word.

    Edit2: I don’ know if that proposed rule was implemented, but they tried.

  32. 32
    gvg says:

    malpractice insurance is also pushing them toward corperate employees. It’s surprising and high. also time consuming to reapply every year and corperate support helps on that too. Some of them even pay it for their employees.

    Having many fellow doctors on shifts means they can actually sleep through most nights when it’s not their turn and take vacations. As an observer who lives with a doctor (younger sister) the hours they survived in med school and residency get harder and harder on aging bodies. Middle aged with a kid and a large practice of corperation seem the only choice to many. Besides which being good at medicine doesn’t mean you are good at hiring lots of staff, managing building maintenace, keeping up on all kinds of paperwork for employees as well as your self and dealing with insurance companies which is at least as bad for doctors as it is for individuals except its every day multiple companies for the rest of their working life……it’s a kind of hell when you think about it. My sis wanted single payer and did get out the vote for Obama. her main employer is the VA.

  33. 33
    pseudonymous in nc says:

    @Richard Mayhew: I’ve cited Atul Gawande’s piece on McAllen before, but the thing I got from it most was that med students have to think about money from the moment they sign that first tuition loan or make that first tuition payment. That doesn’t happen elsewhere in the developed world, where the goal of medical education is to train doctors to be doctors, not to be entrepreneurs in scrubs.

    The foundation of a coherent healthcare system is a tier of generously-paid general practitioners, but general practice is a mess in the US, because it’s underpaid for the cost of the medical education and it’s considered “non-elite”. This is stupid. But there’s still the cultural problem that middle-class Americans with insurance often want to be treated by The Best Doctor, Hero Doctor, Celebrity Doctor, Superdoc, the Doc With The Golden Scalpel.

    Nye Bevan’s bargain with the specialists and the BMA was to “stuff their mouths with gold” and allow them to retain their private hours in exchange for working in the NHS. I am not opposed to stuffing the mouths of American specialists with gold, but my guess is that at the upper end, they’re already stuffed in every orifice.

  34. 34
    Anonymous At Work says:

    Richard,
    It’s an “empathy gap”. Those practices least likely to be Democratic are also the ones most likely to have systematically “pre-screened” patients for a combination of strong insurance and deep pockets. They are the ones least likely to see medically-necessary care deferred for cost and/or lack of good insurance.

  35. 35
    dr. bloor says:

    @FlipYrWhig: You’re aware that it’s already difficult to get people to go into primary care medicine, right?

  36. 36
    dr. bloor says:

    @Richard Mayhew: Very smart people aren’t going to want to be doctors–at least not the kind we need–when the wages start dropping. We know the industry who puts food on your table would love to see a nation treated by lower wage PA’s and Master’s/Bachelor’s trained widgets, but at least be honest about it.

  37. 37
    rikyrah says:

    @CONGRATULATIONS!:

    By no means. But like any other worker in this country, they don’t have to do what they’re doing. Better to reach some kind of accommodation with them, rather than have a bunch of them flee the profession, and a bunch more not choose to enter it, leaving us shorter on doctors than we already are. I think we all can agree that would be catastrophic.

    I’m having a hard time having any kind of sympathy.

    I honestly believe that we should offer family practice, general practice and pediatricians some sort of deal where if they they work in ‘urban areas’ or ‘poor rural’ areas for 5 years, their med school loans should be wiped out. I think she same for any dentist willing to set up in these areas.

    And, we know which chronic diseases afflict the poor most…I’d put endocrinologists and kidney specialists there too.

    If you’re willing to put that shingle among the least of us, we should help you out with paying off the student loans, which I do know can be astronomical for the middle class and poor student that wants to be a doctor.

    the rest of them?

    no sympathy.

  38. 38
    MikeJ says:

    @dr. bloor:

    Very smart people aren’t going to want to be doctors–at least not the kind we need–when the wages start dropping.

    There are lots of very smart people who teach and they make much, much, much, much, much, much less than doctors.

  39. 39
    Calouste says:

    @CONGRATULATIONS!:

    have a bunch of them flee the profession

    Where are they going to? It’s not like their core skills are transferrable to other professions, except being a medical rep.

  40. 40
    dr. bloor says:

    @rikyrah: Just out of curiosity, do you let your physician know that you think he/she is some greedy old asshole whenever you go in for a checkup?

  41. 41
    FlipYrWhig says:

    @dr. bloor: That’s spectacularly condescending. We seem to get by just fine with non-geniuses in, wait, what was that line of work I was thinking of, let’s see, oh right, all of them.

  42. 42
    FlipYrWhig says:

    @MikeJ: Very few people are very smart. I don’t find that doctors are self-evidently smarter than the run-of-the-mill person I interact with in daily life.

  43. 43
    jl says:

    @dr. bloor:

    I agree to some extent. I don’t think much evidence that primary care doctors aren ow vastly overpaid, or maybe not overpaid at all in the U.S. especially given the demands put on them, and the average size of their loans. I know cost accountants and protocol designers at medical centers have been complaining for at least ten years that dropping primary care and rising allied health and tech compensation have been throwing their financial analysis out of whack. From my moderated comment:

    ” I don’t think there is much evidence that most primary care doctors are vastly overpaid in the U.S. compared to other high income industrial countries. Specialists and surgeons still are. And compared to other countries, the U.S. is very medical specialist heavy. Way outrageously heavy. So, in terms of physician compensation, that is where most of the excessive compensation goes. ”

    Also in moderated comment was observation that what has been missed so far in this thread is the role of independent practice docs in making bank in referrals to practice owned labs, clinics for tests, specialty inpatient and ambulatory and rehab facilities that they own. There may be a lot of corrupt self-dealing in specialty doc incomes, at least in certain parts of the country. All the money for specialists is not just compensation for their professional services.

    Edit: do have to say that I agree with other commenters, though, that pure and super brilliant ‘smarts’ is not only thing needed in a good clinician. In fact, maybe not needed at all, Above average smarts may be good enough. Also need judgment, discipline and attention to detail. On academics, maybe on a level with a Professional Engineer. I deal with both types of students as well and future FUDs, and can see what trouble ;’smarts on its own can do.

  44. 44
    dr. bloor says:

    @FlipYrWhig: My reference to “smart people” was from Richard’s post. Obviously a lot of very smart people do all sorts of things. The issue is one of competition–how do you get people who you trust to cure your kid into primary care/pediatrics instead of the many more lucrative possibilities that are out there for them? Right now, you’re asking them to give up their earning power into their thirties and take on a fuckton of debt for the privilege of an annual salary on par with what a first-year associate makes at a big law firm.

    But fuck this. I’ve been around here long enough to know that all doctors are assholes, but Richard–who makes his money working for the biggest fucking problem in the healthcare system at the moment–is God.

  45. 45
    Alce_y_Ardilla says:

    @dr. bloor:

    Very smart people aren’t going to want to be doctors–at least not the kind we need–when the wages start dropping. We know the industry who puts food on your table would love to see a nation treated by lower wage PA’s and Master’s/Bachelor’s trained widgets, but at least be honest about i

    Medicine hasn’t always attracted the very “smartest” people, but the ones that can put up with the crap of medical school and internship, who are anally compulsive,or have a mission complex
    And as far as mid level providers go, as a mid level myself for 25 years, after a time there is not a dimes worth of difference between the MD, NP or PA at the average office visit. I can diagnose a pinched nerve in the neck as well as anyone. The difference comes in the complex cases, which I am happy to hand over to the doctor.

  46. 46
    jl says:

    Deleted this comment, since it was an edit I thought I did not make in time.

  47. 47
    Alce_y_Ardilla says:

    @rikyrah:

    I honestly believe that we should offer family practice, general practice and pediatricians some sort of deal where if they they work in ‘urban areas’ or ‘poor rural’ areas for 5 years, their med school loans should be wiped out. I think she same for any dentist willing to set up in these areas.

    That has been a policy of HHS for many years

  48. 48
    FlipYrWhig says:

    @dr. bloor:

    Right now, you’re asking them to give up their earning power into their thirties and take on a fuckton of debt

    Oh, the fragile flowers of medicine, how will they survive? Demeaning themselves in this way, with _borrowed_ money?

    Fuck this. Millions of smart people get paid jack squat for doing their jobs, and they don’t whimper like this.

  49. 49
    FlipYrWhig says:

    @Alce_y_Ardilla: If anything, there should be something like the U.S. Medical Corps, and everyone who wants to be a doctor has to be deployed as a primary provider for some number of years before being able to go out on their own or specialize. Like the universal mandatory military service a lot of countries have, only medical in nature.

    ETA I guess that would be a way to rethink the “residency” phase…?

  50. 50
    Alce_y_Ardilla says:

    @jl: What is needed is an examination of what future physicians really need to practice in the next century. The current medical school paradigm was set up over 100 years ago, along the lines of a soul crushing quasi military apprenticeship that was intended to mold doctors into a hierarchical system of attending physician, resident intern medical student, and then everyone else ( nurses,technologists, aides etc….) This system gives almost no credit to professionals who have learned their trade or craft, and have worlds of experience to share. I have met nurses who I would trust over many physicians, and have watched as they sat residents down at a desk and told them what they needed to order to save a patients life

  51. 51
    FlipYrWhig says:

    Also, can I just say, why did anyone decide that “internal medicine” was a useful phrase? As opposed to external medicine?

  52. 52
    Alce_y_Ardilla says:

    @FlipYrWhig: That is an imponderable. Another one, why are surgeons so arrogant and condescending when they are descended from barbers?

  53. 53
    Marci Kiser says:

    Whenever I read studies like this, I always note the overlooked variable: women. Among the Republican “medical royalty” like orthopods and radiologists and neurosurgeons, there are very few women (I’m a female radiologist, and know whereof I speak.) Women have always been a strong progressive contingent, and it was only a few weeks ago when myself and a friend both realized we’d only ever met one female anesthesiologist in our 20 years of practice.

    Not the Rosetta Stone of parsing this data, but worth bringing up.

  54. 54
    Blue in SLC says:

    This discussion about whether PCPs are overpaid is sadly lacking data. Look at what PCPs make annually, but keep in mind that most of them (and especially the younger ones) are working hours that effectively amount to two jobs. You can’t just look at hours worked in clinics/hospitals, but the time at home finishing up notes, checking labs, preparing for tomorrow’s patients, coordinating care, etc. (non of which is compensated). Yes, life is hard for everyone, but more and more work in the medical system is getting dumped onto PCPs, for an ever smaller slice of the pie.

    So, yes, the absolute compensation is higher than for most other workers. But if you index it to hours worked (i.e., halve it if you want to compare their salary to a 40-hour a week job), consider the incredible time investment, recognize the salary stagnation, and you’ll see why Dr. Bloor is right that most of our PCPs are not overcompensated, and to see why PCPs burn out so quickly and ever fewer people want to pursue it rather than specialize once in med school.

  55. 55
    jl says:

    @Marci Kiser: Excellent point. Women tend to go into primary care and public health. Probably several reasons, some good some not good, for that. Until recently, discrimination against women in surgery was ferocious and outrageous. Been a big change in last few years as the first sizable cohort of women surgical residents are becoming prominent.

  56. 56
    pseudonymous in nc says:

    @Alce_y_Ardilla:

    That has been a policy of HHS for many years

    NHSC’s loan forgiveness is pretty restricted and the funds vary from year to year depending upon Congress’s whim; the broader public service ten-year loan forgiveness scheme hasn’t got to the point where people are getting loans written off, and won’t reach that point until 2017.

    A med student or newly-qualified doctor who’s willing to work in high-need areas — and take the career income hit that general practice brings in the US — needs to know that the loan forgiveness is going to happen and won’t get pulled from future budgets. Otherwise, why bother, when a bunch of specialist fields pay sufficiently well right now to clear those loans about as quickly once you’re certified?

    @dr. bloor:

    Very smart people aren’t going to want to be doctors–at least not the kind we need–when the wages start dropping.

    Well, it’s all relative. Specialists in the US are overpaid, and if there are very smart people in the future who make the conscious choice not to become specialists because they won’t be able to own a fleet of Mercedes, then fuck ’em. I don’t want those people in the medical profession.

    I have friends who are doctors in other countries who are paid very well, and wouldn’t want to be paid more if it meant being part of a distorted and fucked-up healthcare system like the one in the US.

  57. 57
    jl says:

    @Alce_y_Ardilla: Older docs are fighting against the cooperative interdisciplinary paradigm. The fact that other countries have shown it results in fewer medical errors and more continuity of care, with better outcomes for the vast majority of cases just infuriates the old guard and sends them into denial. I think that the continued hero doctor approach is one factor, but not only one, that has resulted in US medicine looking sloppier relative to other high income industrial economies.

    Read Atul Gawande’s The Checklist Manifesto for some stories about the resistance and outrageous and irresponsible behavior he ran into simply attempting to get surgeons to try out using checklists before starting surgery. It is a good book and a short read, and has informative stuff about quality control in many fields in addition to medicine.

  58. 58
    jl says:

    @pseudonymous in nc:

    ” I have friends who are doctors in other countries who are paid very well, and wouldn’t want to be paid more if it meant being part of a distorted and fucked-up healthcare system like the one in the US. ”

    Ditto. I also get ‘interesting’ reactions to our interesting health care and medical culture from foreign MD researchers visiting the US.

  59. 59
    The Sailor says:

    @Mnemosyne:

    the new Obamacare requirements will probably be pretty costly for her

    How? Which ones?
    The ICD hasn’t changed, and when it finally does, it’s not the ACA that caused it.

  60. 60
    Alce_y_Ardilla says:

    @The Sailor: There is some cost involved with the EHRs, and some of the meaningful use metrics which can be a royal pain in the patootie, for smaller practices that don’t have dedicated staff to keep up with it. And on another note
    the ICD 10 when it does come out will be a rude shock to those smaller practices. They will have to completely change the way they are coding, and perhaps even have to hire specialist to code for them because he codes will increase up to 60x.

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    Alce_y_Ardilla says:

    @jl: And yet some foreign docs come here with dollar signs in their eyes.

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    BBA says:

    Some more anecdata: my parents are both physicians, though neither has practiced medicine in many years. My dad is a technocratic centrist who loathes bureaucracy and would like to see a national single-payer system as long as the idiots behind Medicare and Medicaid don’t run it. My mom is a total wingnut.

  63. 63

    Pediatrician here. In my experience this is absolutely correct.

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    sempronia says:

    Late to the party, but I think Republican doctors are more common among the high-earners because those specialties are the procedural ones, like surgical subspecialties, interventional cardiology, etc. When it’s your hands working, and the smallest decision may mean a huge difference in outcome for the patient, it’s quite a responsibility, so you want everything done your way, and everyone tries to accommodate you. Because you’re the one getting sued, not the scrub tech, not the bedside nurse, not the resident. If you’re taking all the responsibility for stuff, then stuff should be done your way, and I think that’s reasonable. Unfortunately, being catered to makes some people think they’re gods.

    Surgeons usually work independently (even if they’re in a group) and therefore can be somewhat feral, which is why our political clout has historically kind of sucked. Until ACS-PAC was formed a few years back, we couldn’t get it together enough to act as a bloc.

    The TV in the doctors lounge in Nearby General Hospital is almost always set to Fox, except when the one black surgeon walks by. He changes it to ESPN. A surprising number are gun-nuts, which I think goes with the territory. Also, they hate paying taxes. It’s a very job-creators-ish attitude.

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    Ajaye says:

    Just had this conversation with my pcp. He confirmed for me that it is impossible to practice as a solo pcp. He is part of group practice with about 10 other doctors and has no complaints. They all work long hours, but I have never seen my pcp the slightest bit grumpy. He loves his work and his patients adore him. He exemplifies the way to practice medicine.

    We discussed the recent retirement from private office practice of a locally prominent phsychiatrist who blamed Obamacare for everything and said he would only work for the hospital. Many of my pcp’s patients went to this doctor and were flummoxed. My pcp said the Obamacare thing was a cop out and that the real stressor was simply trying to run a complex business alone without any back up.

    Another point I think needs to be made is that successful pcp practices utilize paraprofessionals appropriately. We can train Physician Assistants and nurse practitioners much more cheaply and they can take on quite a bit of responsibility.

    All I can say is that the two sets of folks I personally know who seem to have very high incomes, over $400k per year are medical specialists and executives. My dh’s cousin is a urologist who had to transition to a group practice decades ago and bitched and moaned about significant loss of income at the time, but never made less than $400k per year.

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