Sic transit gloria mundi
Its the start of a brand new school year! Hooray! We’re all that much closer to our fulfilling and meaningful careers as physicians, are we not?
There have been a few changes. For one thing, federal subsidies for student loans were hacked by the “debt compromise” last month- subsidized Stafford loans are no longer available after undergraduate school, and the portion of the transfer fee that is returnable after a certain number of payments (commonly mis-named a “rate reduction”) is now permanently gone. This amounts to between one and two thousand dollars in added costs to the student, per year, beginning when the changes take effect next July. Now, on the scale of medical school loans, which average $100k on graduation, that’s barely more than a rounding error, but there are other, more nebulous changes as well.
For one thing, tuition’s gone up several percent since last year. Universities, like most institutions, depend on large, rolling investment funds for paying pensions, upgrading equipment, and managing donations, and over the past year, many of those endowment funds have tanked. After the S&P structural adjustment plan rating downgrade, an official at my school’s parent university hinted at “mid-session restructuring,” which probably means earlier buy-outs of employees, changes in benefits packages etc, but may spill over into tuition and fees as well.
And then there’s the schooling itself. In order to avoid having to pass on the costs of all the financial rearrangements directly to the students, the school I attend has shifted faculty around to spend more time on clinical work, which is reimbursed by insurers, and less in the classroom. The incoming class is about 15% larger than ours was, which means that overall, fewer professors are teaching more students. Granted, the school is beginning a few hopeful “quality improvement” projects as well, but its hard to escape the notion that more people are paying more money for less of their educators’ time.
“Doctor Shortage Anticipated”
Surprisingly (for those who knew me in person last year) I’m not writing this because I’m angry at the school. Not at all; I do wish they were more honest about the fiscal constraints placed on them, and more open about their individual concerns, but every faculty member I’ve spoken to has basically reflected my concerns- this will be a year (and next year, and the year after) when we all, students and teachers alike, cross our fingers, squinch up our eyes, and jump, promising to do as best we can under the circumstances. We’ll be okay.
I am writing this because I perceive a contradiction between the funding of medicine and the future of medicine. Some context first: the New York Times recently ran an editorial, Addressing the Justice Gap, advocating the sort of modest proposal that drives policy wonks crazy. Too many people are representing themselves in court cases in which they need a lawyer, write the editors, and are getting absolutely trashed by lawyers hired by their opponents. (Criminal defendants can still request a public defender; this editorial deals exclusively with civil suits.) At the same time, one third of law-school graduates are unable to find work as lawyers. Why not, asks the times, create a core of public service lawyers for civil cases?
I’m not really in a position to argue one way or another about that idea, but it highlights something about modern professions- there are multiple ways of calculating demand. It is not uncommon to hear of a looming shortage of primary care doctors, and if one is a medical student, it is not uncommon to be told that our services will be in great demand on graduation. Recent stories (such as this one in the WSJ) stress the effects of health reform, but the idea is older than that.
There is a difference, however, between epidemiologic demand and market demand. Epidemiologically, yes, more Americans are getting older, and more are living with chronic disease (although those two categories are not the same!) and that means more people will need regular medical care. At the same time, more Americans are uninsured and underinsured, which means that they can receive only emergency and public health evaluation and treatment. Lack of adequate insurance tends to be associated with some of the demographics that also suffer disproportionately from chronic health problems as well For those with insurance, and for those institutions (and businesses) that provide insurance, costs are going up as well.
As a result, it isn’t hard to imagine a future in which the need for doctors has increased, but in which so many people (and so many of the sick people) have been effectively pushed out of the market for health care that overall, other than the public health sector, the market demand for doctors stagnates.
Furthermore, much of the current growth in the medical field, both for doctors and for other professionals has been in specialty or even elective care- private centers that provide care that is, well, I dislike hate mail so I’ll just say “not outcome-based means-tested” and wave my hands a bit (seriously, what is a bladder lift?) It is not hard to imagine, in my cash-strapped future, that insurers will become more finicky about reimbursement, and many of these specialty services (some of which are currently burning investment capital, rather than turning a profit) will have to close. That throws another large number of physicians, nurses, pharmacists, administrators, etc. onto the job market as well.
Just because there are people with diabetes, doesn’t mean anyone has the money to hire an endocrinologist. Or, an additional endocrinologist to a given practice. It doesn’t seem that difficult to imagine that by the time I graduate, the New York Times will be complaining about the contradiction between sick Americans and unemployed med school graduates, just like today they complain about unemployed lawyers. Think about it- unemployed lawyers once seemed like a contradiction too!
Public Health
Okay, so there will be fewer upscale hospitals and private practices looking for partners. Surely, the swelling ranks of the sick and underinsured will mean more work for public health clinicians, right? Well, yes and no. In the first place, public health, being public, is definitionally funded by the government, which doesn’t seem too keen on expanding social services right now. Public health funding took a 13.5% cut this year, according to the APHA. (by the way, I don’t understand budget policy very well, so if someone can interpret that document for me, please jump in there!)
Plus, public health has never been the most remunerative specialty in medicine anyway. Estimates of a starting public health salary hover around $90k, vs $160k for pediatrics or $175 for primary care. Tiny, tiny tears, right? That’s still more than 80% of the US population. Then again, go google “primary care shortage” and tell me how many articles cite salaries not matching loans as a reason why med school graduates choose other residencies.
The Part Where I Get Political
Remember up above, where I said that the average med school debt is $100k? If you look at tuition and fees, then multiply by four, you get a much larger number, especially when you add in housing, food, transportation, etc. The dirty secret of medical school (which is not particularly secret) is that people with lower debt are often subsidized by their parents, many of whom are doctors themselves. Students paying their own way, with loans, work-study (yes, you can be a work-study medical student) or part-time jobs, have more than $100k debt. I wish I had statistics on hand, but right now I don’t. Anyone?
And the current tuition/student loan relationship is something of an experiment, as well. Since 1978, progressive changes in student loan law have made it more difficult to discharge student loans, and the penalties for default have expanded. In several states, persons in default on their student loans can have their professional (i.e. medical) licenses revoked. In Montana, default can cost you your driver’s license. In the past, when a valid medical license was virtually a license to print money (and tuition was substantially lower) these sorts of sanctions were uncommon.
But now tuition (and hence debt burden) is skyrocketing, and as I’ve suggested, its entirely likely that today’s graduates may have to take either lower-paying public health jobs after residency, or may not find work at all, we can imagine that more physicians may actually go into default on their loans, and end up unable to practice.
And who’s this going to hurt worst? That’s right, graduates who started their careers without rich parents.
Health, the Disappearing Franchise
I am often annoyed at the power doctors wield in society. Doctors have replaced spiritual and civil leaders as the guardians of what our culture believes it means to be human, or normal, or healthy. What all the foregoing nonsense suggests is that in the future, the gini curve of health care is going to bend further- a greater percentage of care provided will go towards a narrower portion of (upper class) society- and that increasingly the practice of medicine will become difficult for even talented outsiders (poor people) to enter. There is an internet buzzword right now: “plutonomics.” Plutonomics means, if I have this right, that increasingly the US economy depends on goods and services provided by the wealthy to the wealthy, in this country and overseas. We make high-end financial derivatives, value-added luxury exports, and expensive technology, and if these sectors (or health care) stumble, it triggers a public policy response to restore the economy.
On the other hand, the employment or the consumption patterns of the poor are increasingly irrelevant. We have learned, over the last few years, that 10% unemployment doesn’t slow down the core competencies of the FIRE economy (Finance, Insurance, Real Estate) as much as we thought, and if poorer people aren’t consuming, that doesn’t hurt too badly either. I worry that we’ll see a future in which medicine falls into the same trap- a few people from privileged backgrounds, providing an unaffordable service to other people from privileged backgrounds, while the rest of us hope a defrocked outlaw doctor who went afoul of their loan payments moves into the neighborhood.
Just some thoughts on the start of the school year. Good luck everyone!
(PS- this started with a conversation on another blog comment chain that included a debate about whether it was ethical to recommend standard allopathic medical resources to untrained people. I felt that used copies of Harrison’s belong on every family’s bookshelf, the other writer worried that this would encourage practicing without a license. I’ll write more on that later.)
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“I worry that we’ll see a future in which medicine falls into the same trap- a few people from privileged backgrounds, providing an unaffordable service to other people from privileged backgrounds, while the rest of us hope a defrocked outlaw doctor who went afoul of their loan payments moves into the neighborhood.”
Many years ago, I read a short story in one of the major science fiction magazines that described a future more or less like this in which there were radicals who went arounhttp://huntgathermedicine.com/2011/08/25/thoughts-on-returning/#comment-form-guestd deliberately framing doctors for malpractice so that they’d be forced to serve the poor. That was before the changes in student loan law that you describe. If the story were written today, the radicals needn’t bother with falsifying medical histories in order to trick doctors into making horrible misdiagnoses; they could do it all with credit fraud.
Actually, in Texas, a change in malpractice law made it easier for doctors to report each other anonymously for malfeasance. To quote the guy who explained this to me “now you can turn in the competition for funsies!”
Excellent article!
I expect an eventual flood of doctors from Cuba.
I also wonder if we might eventually see businesses that advertise “alternative” medicine but employ trained-but-not licensed doctors.
i’d be interested in whether you see an aperture in the fairly nightmarish present and near future for – i’m struggling for a good term – less monetized? non-cash-payment-based? community-supported? mutual aid based? – doctoring / health work…
what you’re writing about here all sounds to me in part like a big “i dare you” to current medical students to skip out on their loans, join the shit-for-credit majority of us, and start ‘practices’ that are structured more like current/recent needle exchange and other harm reduction projects or the feminist health centers of the 1970s-80s than any current medical industry structures.
who needs doctors from cuba or venezuela when we’ve got unemployed docs from our own communities (some more “our own” than others – yr mileage may vary)?
the problems, or course, start with equipment and materials, from medicines on down. i imagine hacking together a fast MRI set-up is possible, but elaborate. and i don’t expect my chemist friends to be able to fully supply our SSRI-using mutual friends any time soon. but there’s plenty of doctoring that doesn’t need more gear than a community-supported clinic can pull together, plus at least one person with prescribing authority…
Its hard to know. Part of the problem is that insurance structures, both for “health insurance” (i.e. you pay a premium, have some fallback for care) and other health-related insurance policies (carried by medical facilities against equipment problems and malpractice, costs for “good faith” measures like internal audits etc) are heavily monetized, and where public health clinics and other free care exist, there’s usually an enormous back end being picked up by a sponsoring university or health department. Possibly for this reason, several public health departments in medical schools have shifted their focus towards global health- certainly ours has.
I mean, as an example, I agree with you that MRI machines are fundamentally unbuildable (I’m not really sure that the ones in hospitals weren’t teleported in by aliens- seriously, do you know how those things work?) but if you are a doctor, and somebody comes in with some sort of ambiguous complaint, say, you have an obligation to refer them to an MRI. If you try to “work with them” and use either empirical methods or other less restricted/cheaper approaches to diagnosis, you leave yourself open to malpractice or mayhem lawsuits. Most doctors or institutions that hire doctors carry malpractice insurance (which in and of itself makes free or even low cost care difficult!) but I imagine there are specific requirements in the insurance contract that forbid empirical work-arounds even when the evidence is in your favor- so not only are you open to a lawsuit, you could lose coverage that you do carry as well.
Mandatory contracts where the customer/patient promises not to sue are… well, the cell phone companies can get away with them, but I don’t think doctors ever will (or should.) But even then, an independent audit that turns up a case in which less-than-the-maximum care was ordered could get you fined or closed down, even if the patient has no interest in the situation. And then there’s rules like in Texas, where other physicians can force an audit as well.
This isn’t the kind of habitat-for-humanity thing where professionals can spend a weekend working for free for people who need it, unfortunately. Maybe that will change. Public health clinics do exist, even despite these problems, and there are some very good people working at them. More than that?
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I much prefer infromtavie articles like this to that high brow literature.
Fascinating glimpse of how wealth collapse in the West will affect medicine. Thanks. Looks as though there is precious little give in the system and no way to downshift presenting itself. It may be up to concerned medical people to find the way for themselves, since there will be many unconcerned ones who will happily keep the rich-only stuff going as long as possible, in ever smaller gated communities.