
How Being a Doctor Became the Most Miserable Profession - vwinsyee
http://www.thedailybeast.com/articles/2014/04/14/how-being-a-doctor-became-the-most-miserable-profession.html
======
tdees40
The biggest problem is just the AMA. They limit the number of doctors in
America, so there are just too few. This drives up the salaries for the few
doctors who live the tell the tale (but certainly don't want to go into
primary care, when other more lucrative jobs are on offer), and drives up the
hours for everyone.

Making it easier to become a doctor would improve things immediately
(especially given the recent research that makes it clear that nurse
practitioners do just fine).

~~~
mudil
I am a doctor, an anesthesiologist. I don't like AMA. But to blame AMA is a
complete nonsense. (AMA really is just an insurance and loan agency, just like
AARP.)

The real problem is government regulation of our profession, of the whole
clinical process, and of devices and medications.

Those of you who go up in arms when government sticks its nose in your
internet business, should imagine how it is to deal with the government that
is there all the time for us. For example, how about trying to bill Medicare
for a surgery, when one phrase--one phrase-- is missing from the
documentation, and I don't get a penny for a 4 hour surgery?

~~~
Shinkei
I don't believe you.

I am a physician too and you are repeating a lot of the falsehoods that are
perpetuated among those that don't understand the billing process or aren't
actually physicians.

AMA is an insurance and loan agency? I... I... don't know what to say to this.
How about start by reading this (poorly written, but summary nonetheless):

[http://en.wikipedia.org/wiki/American_Medical_Association](http://en.wikipedia.org/wiki/American_Medical_Association)

and one of their most influential functions:

[http://en.wikipedia.org/wiki/Specialty_Society_Relative_Valu...](http://en.wikipedia.org/wiki/Specialty_Society_Relative_Value_Scale_Update_Committee)

It's true that insurers set up arbitrary requirements (for sentinel effect,
mostly) to try and refuse reimbursement, but often a simple change and
resubmission will result in payment. These are issues that are dealt with in
your contract with the insurer--have you read this contract? If not, then you
can't complain! Even the CMS has a contract with its physicians.. and contrary
to popular belief, they pay pretty well for most anything. It's Medicaid that
is atrocious... especially since it covers children/poor and will often limit
their access to healthcare.

~~~
mudil
Sure it's true. If I do two cases, and my billing times overlap even by one
minute, I am not going to get paid for either one of them by Medicare. If I
place an epidural in Medicaid pt, I get paid something like $36 for the
placement, and I don't get a penny for watching this pt for next 18 hours.

The question is why medicine is becoming the most miserable profession (with
polling data to back it up) while the gov't interference in it is at all
time's high and going higher and higher all the time.

~~~
FireBeyond
"If I place an epidural in Medicaid pt, I get paid something like $36 for the
placement, and I don't get a penny for watching this pt for next 18 hours."

Wuh? I'm not a physician. But I do work for an ambulance service. And my day
job has involved working with insurance reimbursement algorithms for Hospital
and Insurance Administrators.

But "$36 for epidural and not a penny for the next 18 hours?"

You might want to look into that. Medicaid allows a Maximum Fee of
$1.16/minute for an anesthesiologist's time.

"Essentially, hospitals will be reimbursed at $669.90 for the epidural
procedure performed in the hospital setting; whereas, in office setting, after
removing the portion designated for the physician professional fee, office
practice expense will be reimbursed at $30.28 to $34.36 a whopping 2,315% to
2,668% with SGR cut and 1931% to 2312% without SGR cut more in the hospital
setting."

Yes, epidurals are cut - but under what circumstances are you monitoring a
patient bedside for 18 hours in a non-hospital setting?

And for every one of these examples, there's a flip-side:

Wisdom teeth under general anesthesia.

"Hi, I'm Mr X and I'll be your anesthesiologist today. How you doing? Now, to
confirm, no allergies, right? And it says you weigh 180lb? Great, see you in
theater!"

Bill:

"Pre-operative anesthesiologist consultation: $662"

For about 90 seconds. Now, I know the principles of anesthesia, though I'd
never claim my knowledge was within orders of magnitude of that of a
specialist, but I routinely perform RSI for ET intubation, and I know all
about "the charge isn't for the time, it's the knowledge", but nonetheless.

------
SapphireSun
I don't get why overworked personnel aren't regarded as a dire safety issue.
There's a reason the FAA restricted the number of hours commercial pilots are
allowed to fly per week without rest.

[http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot...](http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot-
fatigue-mandatory-rest-new-faa-rules/4304417/)

I met a resident the other day, and they routinely get four hours of sleep or
less and worked for shifts that are insanely long that are basically dictated
by patient demand. Why not just hire more doctors, maybe lower salaries by
increasing supply, and give them a healthier lifestyle? Maybe medical school
prices would go down with additional scale.

~~~
hga
One solid reason is the same reason sleep deprivation is used in basic
training. Most doctors, will, at some point in their life, have to make life
and death decisions when they're operating far from 100% ... or at least that
was true back in the days when they'd take calls at any hour of the day (as
late as the '70s). Less dire, they have office hours they must keep unless
they're really sick, and they certainly won't be at 100% every day.

So this is useful training, albeit at a cost. Although if they make a mistake
that kills a patient during residency and learn they can't deal with the
consequences of that, I suppose the earlier the better. They can of course
move to less life and death specialties.

~~~
adharmad
Not sure why you were downvoted, but this is the exact reason that a couple of
my relatives in medical profession gave when asked why their training involved
24-36 hour shifts routinely with very few sleep breaks.

~~~
SapphireSun
I think it makes sense in training (under supervision), it's just doing it as
an all encompassing lifestyle that I think makes no sense.

------
eldavido
This is completely a story of industry structure and bad incentives, and how
people react to them.

Currently, in the United States, we believe all of the following things: (1)
Human physicians, are the only qualified parties to diagnose, treat, and/or
recommend courses of action related to health (not nurses, physician's
assistants, computer programs, etc.), (2) everyone has a fundamental right to
healthcare, (3) health professionals must undergo expensive, lengthy,
difficult courses of study and training, and (4) we reimburse for procedures,
not pay for outcomes.

Given these incentives, it's not hard to see why doctors are some of the most
overworked, stressed-out, and generally miserable professionals out there.
They're at the nexus of a crushing conflict between keeping people healthy, a
management system that demands more revenue (and remember that
revenue=procedures, because we reimburse for procedures, so the only way to
increase "productivity" is to do more, faster, with fewer breaks and longer
shifts), and a legal regime which mandates DOCTORS perform procedures, and
only after a lengthy course of study.

I believe the way forward is to shift the discussion away from procedures and
more toward outcomes, and give medical professionals more operational and
financial freedom to run their practices using tried-and-true free-market
principles. I believe this outcome is inevitable, but will take a decade or
more to surface, because it requires major shifts in how doctors and insurance
companies think about billing, greater human trust in computers and
recommendation systems, and a collective realization that the current state of
healthcare is untenable.

~~~
idiot900
> greater human trust in computers and recommendation systems

I am an MD and have a degree in CS. Expert systems are not remotely there yet
for this purpose. On no planet would I trust care of my patients to a
computer. Far too many subtleties involved in accurate diagnosis and treatment
that are not encoded in a machine-readable format.

> legal regime which mandates DOCTORS perform procedures, and only after a
> lengthy course of study

Good reasons for this - it actually takes that lengthy course of study to
safely perform many procedures, and, more importantly, to fix things when they
go wrong.

NPs and PAs are helpful but based on the quality of care that I personally
observe they should not function without physician oversight.

There is no escaping that medicine is an extremely complex field, and it is
only getting more so. Not long ago, many of the people who today are restored
to their usual state of health would simply have died. The sicker a patient
is, the more complex and difficult to manage they are. By definition a doctor
is the one who is able to do so.

I am still waiting to meet a patient who comes to the hospital and prefers to
have their care rendered by non-physician providers over physicians, or would
even settle if there were an option.

~~~
HIbachikabuki
It's not that simple. A society cannot afford the triple-A gold standard of
everything for everybody. Not everybody can live in a McMansion and not
everybody can afford to have an MD/CS for their every single health need, no
matter how minor or how routine. Tradeoffs have to be made.

US medicine has been very successful at creating a guild system that's
prevented lower-cost provision of care for decades, all under the concern of
"it'll lower the standards of patient care." End result has been millions of
people who can't afford medical care at all.

One anecdote: for a time I was splitting living in the UK and the US and had
health care experiences in both places. It was fascinating to see the
differences in treating my (very ordinary) health issues. One time I came down
with a mild rash that rebounded a few times before it finally went away. In
the UK, the GP looked at the rash, punctured the pustules with little pokey
thing so they'd drain, and they cleared up in a few days. In the US, the
dermatologist wheeled in a big machine filled with liquid nitrogen and froze
the pustules; they went away in a few days after that too. End result the
same; cost to administer - orders of magnitude different. In the US, it seems
like there's no medical treatment that we can't make more expensive by
requiring more specialists with more years of training, using ever more
expensive machines and medications.

I love modern medicine. My dad's a retired doctor and I almost became an MD
myself. But the system we've created has costs out of control while
simultaneously creating worse societal health outcomes than other countries.

~~~
nathanvanfleet
I like people from the US who want to cut out people poorer from being helped
by an MD because it's "impossible"; when so many other developed countries
seem to manage with it just fine.

~~~
throwwit
I'm still amazed some want to go back to a system that charged them more for
marketing it to themselves than actual care-- boggles the mind.

------
jseliger
Also relevant: I wrote "Why you should become a nurse or physicians assistant
instead of a doctor: the underrated perils of medical school"
([http://jseliger.wordpress.com/2012/10/20/why-you-should-
beco...](http://jseliger.wordpress.com/2012/10/20/why-you-should-become-a-
nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-
medical-school/)) based on watching the experience of my fiancée and her
friends and peers.

EDIT: In the essay I describe why it can become so hard to leave medicine
after one has invested more than a year or two in med school because of
student loans; that may help explain the suicide issue: people who feel
trapped may in turn feel like death is the only way out.

A surprisingly large number of doctors hit residency and realize they don't
want to become doctors. In most professions that's not a tremendous problem,
but in medicine the only way to pay back $100 – $250K in graduate student
loans is by becoming a doctor.

~~~
erikcw
A similar phenomenon is at work with law students. Granted law school is
shorter than an MD program at only 3 years -- but can still result in $150k of
student loan debt.

~~~
karmajunkie
This is true of almost all terminal degrees today. Higher education is such a
corrupt industry, feeding those at the top of the pyramid by making promises
to prospective students they are fully aware are unrealistic.

------
cassowary37
A consideration of the economics would suggest that any doc who trained in the
last two decades isn't in it for the money - the ROI on an MD is far less than
most other advanced degrees. If we wanted to be wealthy, with the grades and
letters required to get into med school in the US, most of us could readily
have chosen other professions. (Heck, some even walk away from startups,
believe it or not). My impression as someone in practice for more than a
decade, who cares for a large number of docs, and has run a large clinic: It's
really not the reimbursement. It's the combination of dealing with payers
determined to deny treatment, massive requirements in terms of documentation
and ongoing accreditation, and - in particular - constant pressure to spend
less time with more patients. Then, we read posts like these which buy into
conspiracy theories about how we're out to poison patients with expensive
medications to line our pockets. The time problem in particular afflicts
primary care docs the most, but even the surgeons complain about it. As far as
ACA and its impact, there's no question it's a hack (and not a good one) -
most economists not on the far right agree single payer would be optimal - but
under the political circumstances, it was probably the best we could get.
Regardless, we'll move to a system where the majority of care isn't delivered
by docs. Then we'll complain about it. But, it will be more cost-effective.

------
tokenadult
A comment here mentioned the absolute number of physicians in the United
States, so I did some Googling and found a convenient website showing the
number of physicians per 10,000 population in different countries. (The
primary source for these data is studies by the World Health Organization, but
the WHO website is not quite as user-friendly.) Note that in some countries
the level of training and clinical experience to become a physician is much
higher than in other countries.

[http://kff.org/global-indicator/physicians/](http://kff.org/global-
indicator/physicians/)

------
rayiner
Suicide rates are about 17.7 per 100,000 for men and 4.5 per 100,000 for
women, and 11.3 overall. There are about 535,000 male physicians in the U.S.,
and 234,000 female physicians, and 66,000 of unreported gender. So the
expected number of suicides would be 113 rather than 300.

~~~
curtis
I don't have a citation handy, but it's my understanding that doctors attempt
suicide at a rate less than the general population but when they do make a
suicide attempt they are more likely to succeed.

------
joshlegs
> In fact, physicians are so bummed out that 9 out of 10 doctors would
> discourage anyone from entering the profession.

OP missed a perfect headline opportunity: "9 out of 10 doctors recommend not
becoming a doctor."

But seriously, we wonder what's wrong with healthcare. I seriously believe
it's because of the lawsuit-happy nature of patients nowadays. Yeah, something
could go wrong during your surgery, or your diagnosis for that matter. But
that's an inherent risk in having something wrong with you that you need
checked out.

~~~
eldavido
Anecdotally, nonpayment is a much bigger problem than lawsuits. I remember
listening to the CEO of Carle, a large Central Illinois healthcare chain,
talking about this, and saying that "we expect to collect 60 cents of every
dollar we bill".

It's a revenue optimization problem -- the goal is to collect the most revenue
overall. Set prices too high and people/insurance goes elsewhere, too low and
you leave money on the table the org could use to cross-subsidize non-payers.

~~~
joshlegs
so what you're saying is no matter how the healthcare system is designed, the
healthy (or maybe just wealthy?) always end up paying for the rest?

~~~
eldavido
In practice, this is exactly what happens. Many hospitals have a mandate not
to deny treatment, so many people come to the hospital (especially to the
emergency room, where care is known to be more expensive than non-emergent
settings) and simply don't pay after the fact.

I don't know how to solve this, or whether it's fair, but it's pretty
universal if you talk to people in healthcare billing.

------
josephschmoe
You'll find this is happening in many industries. Despite that it lowers
productivity and increases costs.

The problem is that management is filled with perverse incentives. It looks
good on the books to have fewer employees - until you realize you have highly
trained specialists spending hours per week working on paperwork or rushing
their actual job and increasing long-term costs.

------
rdmcfee
In Canada our GPs are paid approximately $31 for a regular visit. They pay
their overhead out of this $31 and still typically keep 65-70% of their
billings.

It's amazing that the billing costs in the US are a factor of magnitude
higher.

~~~
adventured
I wonder how salaries for nurses and doctors compare in the US vs Canada. Do
you happen to have any data on that (or know of a good government source for
it in Canada)?

I know that compared to much of first world Europe, our nurses and doctors
often make two to four times as much as their counter parts there. Wonder if
that's true compared to Canada as well.

~~~
PeterisP
If you take away the need to pay back six-figure student loans and tens of
thousands each year for malpractice insurance - then much more of that money
stays in the doctors pocket.

Doctors in Europe live quite well, and don't have as ridiculous workhours as
the numerous USA examples listed, or the suicide problem.

~~~
rdmcfee
Tuition at UBC med is $16,000 per year and many students qualify for up to
$100,000 in bursaries. After 4 years of academics there is a paid residency.
It's not a huge salary (~$50k) but enough to avoid going into debt.

------
DatBear
Funny that the article links to
[http://www.dailymail.co.uk/news/article-2600319/Medicare-
dat...](http://www.dailymail.co.uk/news/article-2600319/Medicare-database-
reveals-paid-doctors.html) which references the top paid doctors by
medicare... I read an article last week saying that this data would be
misinterpreted, as a lot of the "top paid" doctors actually are just like
whole departments using the lead physician's billing code, and they don't
actually get any of that money - and here we are.

------
rdmcfee
There's no evidence that the profession causes doctors to commit suicide. It's
not a stretch to hypothesize that people accepted to medical schools are self
selecting for perfectionism and bipolar disorders.

------
rflrob
"Just processing the insurance forms costs $58 for every patient encounter,
according to Dr. Stephen Schimpff, an internist and former CEO of University
of Maryland Medical Center who is writing a book about the crisis in primary
care."

I'm curious how the arithmetic on that works out. The median pay for medical
assistants is $14.12/hour [1], which means that assuming the assistant is
handling the insurance form, that works out to just over 4 hours per patient
encounter. There might be some fixed costs (filing space, for instance, is not
free), and some costs associated with communicating with the insurance
company, but it's really not obvious to me how any of those can add up to
$58/visit.

[1] [http://www.bls.gov/ooh/healthcare/medical-
assistants.htm](http://www.bls.gov/ooh/healthcare/medical-assistants.htm)

~~~
dunmalg
Cost of employing someone is more than just their hourly rate * hours worked.
For example, at one job where I was paid $26/hr, my time was billed at
$48/hr--- and this was for a government agency internally billing itself, so
there was no profit margin involved, just the cumulative cost of wages,
benefits, and associated overhead.

------
analog31
I'll bet that the half of doctors who want out of the profession, are the ones
who are exploited by the other half. Naturally the profession wants us to see
doctors as selfless workers saving our lives, not as rentiers who are ruining
us.

------
sizzle
did this article "borrow" from the air talk segment this afternoon on the
radio:
[http://www.scpr.org/programs/airtalk/2014/04/15/6508/](http://www.scpr.org/programs/airtalk/2014/04/15/6508/)

------
thefreeman
_And now that Medicare payments will be tied to patient satisfaction—this
problem will get worse._

That just sounds crazy. Can you imagine if your car insurance had to pay less
if you complained about your mechanic? Not to mention that medicare is for the
elderly who tend to have a lot to complain about anyway.

Can I pay my taxes based on my satisfaction with the government?

------
GFK_of_xmaspast
Friendly warning, the article quotes Malcolm Gladwell uncritically.

~~~
aaronem
True, but amazingly enough this is one of the two times per day when
Gladwell's stopped clock happens to coincide with the actual time.

------
al2o3cr
For fun, reread this article with "doctor" universally replaced by "teacher",
and note the similarities. Then note that the doctor is probably taking home
4-5x the cash.

There's also this: [http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-
sh...](http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-shortage-go-
unheeded/)

~~~
Dan_Nguyen
After 1.5x-2x the schooling, 3x-5x the apprenticeship period, and around 6x
the debt.

