• Weep for the radiologists

    The comments to the post are now closed.

    I am sure this will bring me a whole new batch of hate mail, but I can’t ignore the story. I feel like Nina Bernstein wrote it just for me. “Job Prospects Are Dimming for Radiology Trainees“:

    For years, medical students who chose a residency in radiology were said to be on the ROAD to happiness. The acronym highlighted the specialties — radiology, ophthalmology, anesthesiology and dermatology — said to promise the best lifestyle for doctors, including the most money for the least grueling work.

    Not anymore. Radiologists still make twice as much as family doctors, but are high on the list of specialists whose incomes are in steepest decline. Recent radiology graduates with huge medical school debts are having trouble finding work, let alone the $400,000-and-up dream jobs that beckoned as they signed on for five to seven years of relatively low-paid labor as trainees.

    It’s always amazing to me that the stories like this are always written about or by radiologists, or anesthesiologists, or orthopedic surgeons. They often feel like they are owed more money. It’s like… an entitlement.

    You know who else trained for five years? Me. It takes six years to be an neurologist,  an immunologist, a nephrologist, a rheumatologist, or an endocrinologist. Almost none of those specialties expect to have a “$400,000-and-up dream job”.

    “We were somewhat victims of our success,” said Dr. Ellenbogen, in Dallas, whose career spans what radiologists call the golden years, when the cost of diagnostic imaging grew faster than other items in health care.

    Starting in the 1980s, the advent of technology like M.R.I.’s and CT scans, combined with a fee-for-service system, created ballooning demand for imaging and drove the compensation of radiologists to unsustainable heights, he said. “That led to a sense of entitlement in some people’s minds,” he said. “And that led to this development of offshore remote reading of cases.”

    I’m going to give my usual caveat here. I’m not calling for salary caps or anything like that. I know plenty of physicians who work insane hours for arguably low pay. I also know many who come out of training with $200,000 – $300,000 in debt. In order to pay that off, they do often need to make higher than average salaries. They do. It’s also true that physicians are very highly trained. I often joke to my kids that by the time I was done and ready to get a “real” job, I had just finished the 25th grade.

    But, contrary to what many believe, this is still a free market. Someone, somewhere, is going to realize that there are physicians who are overpaid. In this case, it’s some (not all!) radiologists. We also know that we need more primary care docs and fewer specialists – and this is how we get there.

    Before you get too misty, radiologists are still doing pretty well:

    Last year, an annual salary survey of 24,000 physicians by Medscape, an online resource for doctors, found radiologists and orthopedic surgeons still topped the list of specialties, but their mean incomes had dropped by 10 percent between 2010 and 2011, to $315,000 from $350,000.

    Perhaps those salaries are deserved. But they can’t be justified on “length of training”, as many, many less-well-paid specialties train as long or longer. They can’t be justified on debt for the same reason. The best argument would be on quality and outcomes, but that never seems to happen.

    This doesn’t help, either:

    “The times of graduating from medical school and driving a Porsche are done,” said Dr. Dana Lowenthal, a first-year radiology resident and fourth-generation doctor. “It was never easy, but there was light at the end of the tunnel. This is new territory.”

    If your definition of “struggling” is not driving a Porsche, then it’s time to stop expecting the general public to give you any sympathy. I’ve said it before, and I’ll say it again. Is there any other profession that is as tone deaf as we are when it comes to talking about our livelihood? Is there any other profession that feels so free to complain about making too little, when they objectively make so much compared to so many others?

    @aaronecarroll

    P.S. Here’s a piece about St. Barnabas and its ex-CEO Ronald Gade, who was a – wait for it – radiologist that an eagle eyed reader sent me.

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    • I wonder who led the setting of fees for radiologists? How much were they paid before single payer Medicare was created? Is there a connection between the high costs and interference in the market place? Envy doesn’t replace the marketplace. It only causes more and more distortions.

      • That argument might work except for the fact that there are lots of example of single-payer systems where that didn’t happen.

        We have one of the least regulated systems, and the highest costs. Including physician salaries.

        • Aaron you know better than that. Doctor incomes only account for 10% of total healthcare spending, despite the fact that they make more than euro docs or elsewhere.

          So lets say we pay doctors ZERO, Congrats, you just reduced total healthcare spending by 10%. Now how are you going to reduce costs another 40% to get to where the european levels of spending are? You’ve got a lot of work to do to get there since taking docs out of the loop didnt help very much.

          • Nowhere in this did I say that doctors’ salaries were accounting for the majority of health care spending. This is about expressing dismay at the tone deafness of physicians in discussing salaries publicly.

    • Bad apostrophe, bad!
      Sorry, pet peeve.

    • The socialist argument didn’t work in the past and we have seen countries fail. Healthcare is part of a total social service system which due to poor financial planning is causing tremendous problems in the euro nations. Look at Greece, Italy, Spain, Ireland and Cyprus just to mention a few. What is happening in Cyprus with limitations of how much money can be taken out of the country happened in Britain decades ago.

      It is precisely this problem, increasing costs, that are causing other western nations to look elsewhere for solutions to the stresses of their unsustainable healthcare systems. Both Britain and Canada have at various times looked towards the US including the HMO system.

      By the way I think calling so many countries single payer is a misnomer. To my understanding based upon the real meaning of the term “single payer” only two countries qualify. One is Canada and the other, I am not sure, but, it might be Cuba. No other relationship should be made between those two countries based upon this statement.

      • I think Australia and Taiwan could also qualify. As could the UK (although it goes much farther). Even France has a baseline system that could arguable be called single-payer. But I was calling out single payer as the extreme. Pretty much every other country has more regulation than our system does (including price controls). Blaming regulation for our high prices (and physician salaries) is hard to rationalize when that’s true.

        But getting past that, what other “socialist” health care systems have you seen fail? By what metric?

        I’d challenge your assertion that it’s the healthcare systems that are hurting the economies of those nations. The issues of those countries (like Cyprus) are far more complex and unrelated to health care.

        Their systems all cost less in both real dollars and as a percentage of GDP. I’d also challenge your concerns about increasing costs everywhere else when costs are similarly increasing here.

        • Anyone can define a term any way they would like, but I believe that distorts the meaning of a term and makes it more difficult to understand what others are talking about. In Canada there is only one system (in a province). These other countries permit other ‘payer’ methods. I would consider Medicare effectually a ‘single payer’ system for those in the US that are over 65 and that has been a total mess with regard to cost control (and probably a major reason why radiologists ended up being paid so much).

          The Soviet Union went under. We are potentially seeing the failure of others right as we speak. Estonia is an example of a failed socialist system that then turned towards the marketplace and did quite well. I don’t want to enter the realm of geopolitics so I won’t list them all, but look at the mid east especially Egypt and look at Africa.

          There are always complexities as to what is the major cause of economic problems, but look at the nations that are financially doing the best around the world. They will rank freest on the economic index which includes a lot of things making it difficult to evaluate in a short back and forth.

          I’d challenge you in part on how much less other nations spend if that is your desire. It is true we spend a heck of a lot of money. Medicare is a disaster and our social services are ballooning with the number of true unemployed over a period of time growing. This is not good for the people or the economy. We spend more than other countries on entertainment so why not more on healthcare. We have more cars, bigger homes, more bathrooms etc., so why not more healthcare. We have better outcomes though that is often argued. We have less waiting on line and that is an expense as well. In the end it is all a matter of how one counts things. We had two superpowers, socialist vs the marketplace, and now there is just one.

          • We overpay for health care. No reasonable person can dispute that. Look at the Klein piece cited yesterday on this site. Think about the fact that the median worker in America makes about 26k a year and the average family plan in America costs about 20k. Who can afford that? That is why we have 100 million Americans either uninsured or under-insured and that medical bills are one of the main contributing factors in personal bankruptcies. There are three choices: cut the prices the medical industry chargers; cut services available to patients, or a combination of both. Are you prepared to tell a 70 year old that s/he cannot have that chemo therapy because it would not be cost effective (the 70 yr. old has lived long enough and would gain only small benefits relative to a 20 yr. old getting chemo)? Do we cut all medical industry charges by say 33 percent?

            And this doesn’t even address the elephant in the room: (my pet peeve) 5 percent of us costs 50 percent of all medical costs.

            Your comments about the problems in Cyprus et al are not factually based and way off base; see Yves Smith’s site Naked Capitalism for a truer understanding.

            And with all due respect to doctors, as Dean Baker points out, we could reduce doc costs and doc shortages easily by allowing the import of thousands upon thousands of foreign doctors who would be much cheaper; just as we reduced garment costs by shipping our garment industry overseas. But docs (and other protected groups- hear me lawyers?) have WAY more political clout than the garment worker. So we are where we are.

            Something will give.

            • @elboku

              We overpay for a lot of things. Our healthcare premiums are absolutely way too high, but why does that occur? That is what we should be discussing instead of bemoaning how unfair things are. Along with the uninsured we have those that are overinsured and I think that is one of our problems. By over insuring the profits of insurers rise and the premiums climb. Every time insurance premiums go up the number of people insured falls. Thus if one could lower premium costs more people would be insured. However, if one starts to increase the premium on some so that they are paying more than the risk they carry they will refuse to buy insurance. Note the number of uninsured that are young or earn more than $50,000 per year. It is a tremendous portion of the prior 45million uninsured before the crash.

              My discussion regarding Cyprus had to do with the fact that governments can go bankrupt and that many states in the EU are in financial trouble due in part to benefits where healthcare is just one part. We also have a financial crisis that is a major cause, but take note of the real estate bubbles not just in the US, but in Europe as well.

              We could import “cheaper” doctors as you call them, but the physician component is the smallest of the major costs and one could only hope to cut physician salaries to effect at most a few percentage points off total healthcare costs. However, if we imported tremendous amounts of foreign trained doctors be prepared for them to learn our lifestyle, demand more salary and due to massive numbers increase costs. I won’t get into the other reason costs might increase. Studies were done that demonstrated the increase was likely.

            • “And with all due respect to doctors, as Dean Baker points out, we could reduce doc costs and doc shortages easily by allowing the import of thousands upon thousands of foreign doctors who would be much cheaper; ”

              Ummm, wrong. More doctors = HIGHER costs, period. NYC, Boston, LA, Miami have much higher healthcare costs than rural areas DESPITE the fact that they have the largest number of doctors per capita in the world.

              Manhattan is a good example. There are 5 times as many doctors per capita in Manhattan as there is in any city of size 1 million or less. So why arent all these doctors competing against each other and driving down prices? Why does Manhattan have some of the highest healthcare costs in the COUNTRY, EVEN AFTER YOU ADJUST FOR COST OF LIVING?

          • “We had two superpowers, socialist vs the marketplace, and now there is just one.”

            I’m not certain about that. There’s still a lot of socialism in China.

            • Ken Hamer, there might be a lot of communism in China, but that is the communist party. Take a look at China that is not one of the two superpowers that existed. It is using the markets and by doing so has made itself an economic power.

          • “We [the US] have better outcomes though that is often argued.”

            Aaron’s well documented counter-examples are a lot more compelling than your idealogical arm-flailing.

            It seems pretty clear to me that you, along with a few others that troll here, are not interested in the data, facts, truth, or even improvement. Rather it appears you are fixated on a political obsession, and will generate as much noise and smoke as you can in an effort to obscure or otherwise confuse the discussion, as you are unable to provide an actual compelling argument.

            You know, like how Stephan Hawking would have died if he had been subjected to Britain’s NHS. Or how Canada won’t pay for hip replacments for those 62 and older.

            • A little intolerance or should I say a lot and a shabby tone as well. Perhaps I shouldn’t even respond since all you are doing is parroting what others say without even being able to provide details and argument.

              Stephen Hawkings: His nurses are funded by a foundation, not by the NHS. He has ALS where there is no treatment except to prevent and treat things like pneumonia so it is the constant care and perhaps the genetic makeup that have kept him alive so long

              Canada won’t pay for hip fractures over age 62: A straw man argument which is an excuse for laziness. I doubt serious people would make that claim. Hip fractures are done well past 62. There are delays that have been documented and listed at the Fraser Institute.

              Outcomes: Lancet: Concord study”The CONCORD study provides survival estimates for 1·9 million adults (aged 15—99 years) diagnosed with a first, primary, invasive cancer of the breast (women), colon, rectum, or prostate during 1990—94 and followed up to 1999, by use of individual tumour records from 101 population-based cancer registries in 31 countries on five continents. This is, to our knowledge, the first worldwide analysis of cancer survival, with standard quality-control procedures and identical analytic methods for all datasets.”

              The US fared best in this study. You might want to dispute it, but to date I know of no other study that proves Concord’s results to be inaccurate. If the list owner wants the graphs posted I will try and do so. They are interesting and informative.

            • @emily
              The Concord study doesn’t provide reasons to assert that we have the “best” health care, because there are so many factors involved and different ways to view what quality care delivery means. We can only assert we are best in certain categories with respect to certain patients. While we were best overall in cancer survivial, we weren’t best in some specific types, such as colon and rectal cancers for Women (France is best) or for men (Japan tops the list).

              It’s wonderful that the US has the most advanced medical technologies and is a leading innovator, and that at least the economic top 20% of the country has unencumbered access to this care. But there are still too many Americans who don’t share in this technological blessing, and to me uniformity of access at a decent minimum level of care to all Americans matters.

              Even in the Concord study there were indications of fairly wide disparities between subgroups based on their access to care, including how early they were diagnosed and the level of treatment they could afford. Specifically black men and women had significantly lower survival rates. One could argue that this might have biological causes, or it could be an economic circumstances issue, such as diet, but the study results seem to indicate that the timeliness of diagnosis is an important factor here.

              This study didn’t include all states, as I understand from a brief glance at the findings. I wonder whether the results included all incidences of cancer, or only those that were treated. In other words, what we don’t know is what the results would have been if we could have included all cancer deaths, including those undetected and untreated because of lack of access to routine care.

              So we do some things quite well, but we still fall behind in cost per capita for delivering this care, percentage of the population with access to care, average life expectancy, infant mortality, and many other ways of measuring overall quality of care. For those who wish to tout the exceptional qualities of the US, it would be nice if they could tout exceptional overall coverage for the average individual, and exceptional efficiencies on a per capita basis, rather than merely an exceptional level of quality for some and not others, and an exceptionally gluttonous level of spending on a small percentage of the population while so many want.

            • @Jeff Johnson
              I agree with you. No one study or group of studies can conclusively prove much of anything. There are many head to head studies but none as comprehensive as the study in Concord. I agree again that what is best is dependent upon what the word “best” means and though all western nations are facing a sustainability problem I wouldn’t advocate that any of them follow the American example nor do I advocate America blindly follow any of their examples. Different nations require different solutions.

              As far as the specifics of the Concord study that you mention we weren’t the best all the time but we were number one or number two excluding Cuba where I give little credence to their numbers. The other countries if numerically valued varied with the average ~15th place while the US score added up would yield ~1.7th place Australia 3.5th place, France 3.7th place and Canada 4.8th place. The US was consistently #1 or #2. The other front runners varied a bit more and countries like Japan varied a lot.

              I also agree with you that the US is the leading innovator and that some Americans fall through the cracks. It seems we don’t substantially differ in how we view the problem rather we differ in how to solve it. I so happen to be a fan of innovation which might very well be lost in the US at least to the extent it has previously been provided. That will be a loss to people all over the world as well. I also believe that free innovation with the appropriate incentives can lead to lower costs and even better care.

              You discussed the disparities within the US and they most certainly exist, but even with portions of our population having poorer outcomes our average outcomes remain high and that suggests even more superior care being rendered than seen in the numbers. (I so happen to believe that we are overall best in the world, but that is my opinion so you are free to believe whatever you wish. I provide some data to back my contention up so if one wishes to demonstrate another to be best in the world go at it.)

              We finally disagree when you bring up conglomerate numbers for life expectancy, infant mortality etc. because I believe those numbers represent things other than care and the infant mortality numbers as mentioned by another already are somewhat fallacious. I don’t know if WHO will even keep that type of ranking in the future. Another thing we disagree upon is that one portion gets gluttonous care and the other portion doesn’t. If we are talking about the ‘feel good’ part you are likely correct. If we are talking about the outcome portion then the care though weighted to the rich is much better balanced. In any event we see a similar problem in other western nations.

            • @emily
              Recognizing we have problems is important, even if we disagree on the solutions.

              You seem to favor market based approaches, whereby prices will fall to their natural equilibrium levels when no artificial distortions prevent both providers and consumers of care from making their own choices according to ordinary incentives and natural inclinations.

              This is a good approach for the things I need to sustain and enjoy my life at my income, a moderate portion of which is above the median level. Perhaps I can’t afford a Rolex or a Ferrari or an annual luxurious vacation, but I’m comfortable enough, and with market prices being what they are, there are things I can afford which many Americans can not. That is the way of markets, they don’t provide all things to all people, but they find the natural balance between what it costs to produce things and what people can afford to pay for them.

              Talking about prices, what is the fair market price of health? What is the fair market price of life? Are life and health ideally traded according to the same rules as fuel and fertilizer, dog food and laundry detergent? Are health and life more valuable than a Rolex or a Ferrari? Aren’t those who can provide life saving procedures incented to charge what the market will bear for their efforts, and won’t the precious incalculable value of life tend to lift market prices?

              Of course where there is a vacuum the market fills it with niche providers offering lower cost basic treatment. So a naturally tiered system of health services forms, like in the automobile market, some affording luxury, other s mid size, compact, economy, used junkers, or possibly some settling for a bicycle or public transit.

              Is that to be the health care system of the greatest country on earth? If everyone pays for the care they can afford, without the distorting influences of Medicare and Medicaid, do you really believe all of the poor and the elderly, when their income is at its lowest and their health care needs at their greatest, will have the care they need provided at prices they can afford by the marketplace? The marketplace is amoral, and will be indifferent to the misery and suffering of people quietly dying at home, or people in the streets who have sold their homes and spent their life savings fighting cancer. And if charities are capable of filling the holes left by the market, why haven’t they already done so today?

              There are other problems, like the complexity of health care leading to information assymmetry, making it very difficult for consumers to make the most rational choices. Competition in the insurance industry leads to fragmenting of the risk pool, an inefficiency that a single payer system excels at eliminating.

              So even if we had a purely market based system that was a libertarian’s wet dream, where nobody ever paid for anything that didn’t benefit themselves directly, and nobody ever received anything they did not pay for, wouldn’t it be a shame on the nation that 40, 50, or 60 million Americans would be left out in the cold, unable to pay the market price for the care they need? Wouldn’t we need to find some way to compensate for the indifference of the marketplace, as necessity forced us to long ago when we enacted Medicare and Medicaid?

              Maybe, just maybe, health care is an exception that simply does not lend itself to commodification or productization the way gizmos and gadgets and widgets do. Maybe health, like defense, is a special case with overriding moral considerations of life, liberty, and the pursuit of happiness that make it entirely inappropriate, perhaps even cruel and negligent, to turn loose the wild chaos of the efficient market hypothesis and trust that its invisible hand will also be a loving and humane hand capable of protecting the security of the nation’s good health, which is the essential prerequisite to effective productive living.

              What is it about Americans that makes them so different from th Canadians, or the Germans, or the French, or the Norwegians, or the British, that we must have a different system from theirs? Is it cruelty, indifference, or selfishness? What is it about America that prevents us from solving this problem that has already been solved more efficiently and thoroughly by so many other modern advanced economies?

            • @Jeff Johnson
              At present most Americans have enough food to eat, clothing to wear and housing to live with some left over for a large screen TV. The amenities of the poor are great in the US. A lot of our problems occur with people that are incapable of handling their own affairs (mentally ill), drugs, violence and social problems. It is the socio economic factor that we should be putting most of our efforts into and likely we will see marked improvement in the health of our nation.

              That many people fall through the cracks means that some corrections need to be made with regard to health care. However, much of healthcare we provide is somewhat of a luxury. The state should be more concerned with the basics and those that are falling through the cracks rather than the entire system which leads to a trade off of money poorly spent on healthcare that could save many more lives by remidying social economic problems that leads to a healthier and wealthier society.

              Fair market prices are determined by society, not by a bureaucrat. Many would trade a very small risk of life for that Ferrari or Rolex. Many would not. The market permits the individual to make independent choices. Take note a marketplace does not mean that government cannot be somewhat involved.

              At one point in your response you make things seem as if they are all or none. They aren’t. I would propose no such thing that would leave the poor without some safety net, subsidy or whatever is necessary to provide an adequate level of basic care. Americans are not cruel as you might be suggesting. We are a very generous people. Look at the catastrophes throughout the world. The US government frequently provides the most assistance of any nation in the world and then the people supplement that with tremendous generosity. We do not see the same from most of the rest of the world.

      • What does Cyprus have to do with Healthcare? Cyprus is having problems because their banks invested in Greek bonds, particularly “safe” Greek government bonds, which, as we all know, got whacked. And Germany doesn’t want to bail them out because a significant portion of the money in the banks is from Russia, because Cyprus was viewed as a safer place for money than Russia. Some of the Russian money is dirty and everyone finds it easier to believe in Russian kleptocrats than honest businesses which want better banking than they find at home.

        What does any of this have to do with healthcare? I’d argue that health is a service, like good roads, that enables businesses to thrive. We have no private roads, but we do have a great road system that facilitates the exchange of goods. Try getting your goods to market if you live in the middle of Africa or Siberia.

        • @SAO

          For context with regard to Cyprus reread what was written before and since your comment.

          You say: ” We have no private roads”. That is a bit inaccurate. We have private roads in PUD’s and elsewhere where no one but those entitled can ride on. We have toll roads that were built and privately run. Look at a lot of the Turnpikes. The toll paid goes to a private concern who then maintains the road based upon the law and private contracts with all concerned.

      • *** “Both Britain and Canada have at various times looked towards the US including the HMO system.” ***

        Canada has never looked towards the US health care system.

        Individual politicians may have, but generally they find their political career is over before the press conference ends.

        That Canada has not moved towards a US style system in spite of various “lookings” should be an indication of its improbability.

        • @Ken Hammer: Ask Claude Castonguay, “Getting Our Money’s Worth” or many others involved in Canadian healthcare. He was the designer of the Quebec public health system. Other provinces have actually looked into American HMO’s. I did not say Canada was moving towards an American style healthcare system rather they “looked towards the US” The report recommended private sector management of hospitals and medical clinics, more private insurance, etc.

          • Castonguay makes the point perfectly. He was one politician, on a closed committee, and a lonely proponent of limited privatization. When his committee’s report was released the government of the day quickly put as much distance as they could between themselves and the report.

            One politician in one province is *not* Canada. Nor is the small, random assortment of people that advocate for “looking to the US”, particularly as for the most part they each have a vested interest (i.e. profit motive) in greater privatization. They are not looking out for the interests of Canadians in general, as taxpayers or otherwise, but rather for their own pocketbooks.

            ==========================================
            From http://en.wikipedia.org/wiki/Claude_Castonguay :

            “In 2007, the minority Liberal government of Quebec appointed Castonguay to a closed-door committee examining the health-care system’s finances. Castonguay is a long-serving advocate of greater privatization, user fees and private insurance.[1]

            The Castonguay task force released in February 2008 said Quebec residents should pay $25 for every visit to a doctor. The report also called for an increase of up to one percentage point in the Quebec sales tax to help pay for medicare. Castonguay said health care is growing 5.8 per cent a year as a share of the provincial budget, while total government spending increases 3.9 per cent annually.[2]

            Most of the report was publicly dismissed by the government of the day.

            Forty years after being one of the pioneers of socialized medicine, Castonguay’s commission advocates both an increased role for private enterprise in medicine and increased public investment in the socialized system both through taxes and through user fees. Castonguay was quoted as saying “We are proposing to give a greater role to the private sector so that people can exercise freedom of choice.” While concerned about the financial stresses the system places on the government, Castonguay does not advocate dismantling publicly financed health insurance altogether.”
            ==========================================

            And even then, most of his report has no bearing on the rest of Canada. (I don’t think it really has any bearing on Quebec either, but I don’t know enough about their provincial system so say with any authority.)

            But his claim that some level of privatization would bring more “freedom of choice” is patent nonsense in much of the country, and particularly in BC where I live. I already have absolute freedom of choice in my health care — I go to the doctor of my choice, when I need blood or other tests I go to the lab of my choice, when I buy prescription medicine I go to the pharmacy of my choice, and if I need hospital care I go to the hospital of my choice.

            So I’d be grateful if you or anyone else cold explain exactly how privatization or user fees would give me more choices.

            Moreover I doubt most Americans have the same “freedom of choice” that I do, what with “in-network” limitations and the like.

            • @Ken Hamer
              Ask Claude? He was the architect of the Quebec plan and that is why I mentioned him in particular. He called for increased privatization of management, more private insurance, etc. There have been many news articles on this subject from different provinces and once again I will refer to the Fraser Institute on this topic for a simple source. He is not the only one that has suggested looking toward America and other countries. I have seen similar reports from other provinces as well. They are not looking to adopt the American system rather study it and see what they can learn to improve Canada’s system.

              Read the actual report and then look at the Supreme Court decision that was found against the government because the government’s healthcare program wasn’t living up to the law by not providing timely care and was negatively affecting the life, liberty and security of the individual (paraphrased).

              In no way do I encourage Canada to adopt America’s system. The un-sustainability of care in all western nations is each nation’s individual problem and they have to deal with it in a way that meets their individual needs.

    • I should have mentioned that I wouldn’t worry about physician salaries that much. I would worry more about incentives. To rail at the former might satisfy some inward need, but that is counterproductive. The latter is the important issue.

      • I’m not railing at their salaries. I’m railing at the tone-deafness of complaining about them so vocally in public.

        • There are a lot of overpaid people in this country, do you rail about them as well? That really isn’t important. What is important is that type of dialogue is counterproductive to a solution.

          • When they are featured in articles complaining, sure. When they write op-eds bemoaning their “struggles” on multi-six figure incomes, absolutely. But this is also a blog that covers the health care system, so I’m especially likely to cover this.

            I’m also a physician. I’m not a disinterested third party here. Finally, I’m not railing against their salaries. I’m railing against their complaining so tone-deafly about them.

            • Aaron, I can’t disagree that it is unsightly for some doctors to bemoan their struggles in such a way when their benefits are so out of tune with middle-class America. They do not reflect the incomes of the vast majority of physicians nor do they reflect positively on the image of those other hard-working skilled physicians. I just think emphasizing its importance detracts from the discussion and may create an image of physicians in general that is not true.

            • I dont see them complaining about making six figure salaries, I see residents who make 50k a year complaining that the hospital program pulled out the rug from underneath them and that they are not jobless and cant work.

              The residents are right to complain about that — it is obvious that this St Barnabas hospital is a joke with joke management who is screwing over the residents.

              Where did you see attendings in that article complain about how they arent happy making 200k a year?

            • Try Google. You won’t have any trouble finding such pieces.

    • I think that like most professions, doctors probably live in a proverbial bubble regarding their salaries. I’m an engineer, for example, and compared to the vast majority of professions out there, we get paid pretty well. And yet it would be difficult to find an engineer out there who didn’t think they were underpaid (myself included).

      It’s pretty understandable that anyone would want to get out of the burden of debt incurred by medical school as soon as humanly possible. Those numbers are enough to make anyone’s head spin. I always wondered, though, to what extent high medical school costs and high salaries had a cause and effect relationship with one another in this country. i.e. If doctors’ salaries come down, would med schools have to reduce tuition to make sure students still see it as a worthwhile investment? And how would that affect the quality of doctors they produce?

      I just worry about the overall futures of the doctors who were interviewed in the linked article. They sound like the types of people who got into the profession for the combination of regular hours and high pay. Ultimately, that’s not really the best way to choose a career, although they’d hardly be alone in doing so.

    • I can’t say I’m terribly sad for the radiologists – they had a good run. My father-in-law is a recently retired anesthesiologist, though, so I have a bit more sympathy for them. His reflection on 30+ years of practice was “well, at least I can say I never killed anyone.” If that’s a metric for success I’d say that the stress levels alone should earn you a nice big salary.

      That said, I do hope that the move to “accountable care”-type contracts will change health care incentives a bit so there’s less demand for surgery (and anesthesiology) and more business/pay for nephrologists, endocrinologists, and PCPs. It’s really those people that will drive long-term reductions in costs. If only there were similar incentives in place to get people to stop drinking 64 oz of soda with breakfast, exercise a little bit, and for god’s sake go see a PCP before you’re a full blown diabetic and need an anesthesiologist to put you to sleep so they can cut off your foot.

      • I’m not against people earning a lot of money for being extremely talented. I’m against (1) the sense of entitlement that many doctors seem to have (especially when many of them hate entitlement programs in general), (2) their tone-deafness when it comes to talking about their economic “difficulties”, and (3) their need to air their grievances in public. Although I guess (3) is part of (2).

        Should docs earn a good living? Sure. How good is up for debate. If they want to stay as well compensated as they currently are, I suggest them become more savvy about their public discourse.

        • I’m still not sure I understand your anger at the doctors in the article. Again, I see RESIDENTS complaining about being terminated and forced to end their training, not ATTENDINGS who are bitching about being paid 250k. Where are you getting this from?

          • I’ve covered this repeatedly. If you can’t find op-ed pieces with docs complaining, you aren’t looking very hard.

      • How will accountable care (ACO) contracts save money? They have similar incentives to the old HMO so they should have pretty similar results. The difference might be that some of the past court cases settled in favor of patients might now by law already be settled in the favor of the ACO. Patients previously abused by HMO’s might be once again be abused by ACO’s. Many of the doctors made out very well with HMO’s especially early on with big bonus’s and contracts along with sales of their practices for big bucks. That is the problem when the government, health insurers and doctors are on one side and the patient left alone on the other.

        • Make no mistake about it, ACOs are going to cause healthcare costs to skyrocket.

          Whats going to happen when Harvard/Pilgrim Health buys up every doctor practice in Boston? They’re going to have the clout to charge Blue Cross rates that are 100 times higher than previously, and that is going to get to the consumer in terms of higher premiums.

      • I have often joked that the most talented anesthesiologist in the world is someone you’ve likely never heard of. It can be a very thankless job. After all, success is just maintaining the status quo…

    • I am wondering is part of this is not the fact that as nation we have an MRI on every corner and in each and every MacDonalds. Add to that they were added as a way to increase revenue. Use it or loose it ($$$$). And now we are seeing an economic downturn and more and more patients asking questions and saying no to unnecessary testing.

    • Income is not always a function of merit nor the impersonal outcome of market forces. Incomes of medical specialists are heavily influenced by the power of RUC to determine splitting the pie. The RUC acts like every other cartel in the world.
      Radiology income is very vulnerable. Specialists are increasingly moving from being independent to being employees. This decreases their bargaining ability. Radiology deals with images which are transferable to workstations far away even outside the US which obviously impacts the market for radiology skills. Finally, diagnostic radiology deals with pixels which are very suitable for computer processing. I will be amazed if a AI process is not shown to be better than human image reading in a few years. Personally, I believe that AI technologies will replace most radiologists fairly soon; if I were a young med school grad I’d stay away from radiology.
      BTW, a anesthesiologist who never killed a patient deserves applause when we think about what they do to people. I doubt that anyone in my specialty can make the same boast at the end of their career.

      • So much to comment on.

        1) “entitlement”
        Pretty glib term. Someone said that they saw some hypocrisy in physicians feeling entitled while questioning entitlements. BUT I don’t think the word applies here. In the article, I would characterize it not as a sense of entitlement, but as expressing two things: abject fear of what is going to happen to them financially, since the system as it exists now has straddled them with the highest educational debt you can take on and now has taken from them the means to pay it off. And also anger that they probably feel victimized after spending so much money and so many years of 80 hour work weeks to have the system leave them high and dry. So, entitlement is a succinct word and that is probably why it was used here, but there is no succinct way to express what is really going on.
        Also – “entitlements” as given by the govt generally do not come after 9 years of 80 hour work weeks.
        2) oncodoc talks about AI. There are a few of these programs available for Mammography and cardiac nucs, and they are uniformly miserable. The mammo program for example, typically picks anywhere from 3 to 7 suspicious areas per patient. Given the incidence of about 4 cancers per 1000 patients, that means about 5000 positive calls to find 4 cancers. The cardiac nucs programs are no better, massive numbers of false positives. Suffice to say they sound all high tech and get a lot of attention in the press, but for an experienced radiologist, they are next to useless.
        3) Growth of imaging costs due to several factors – 1) older sicker patients who need it (can’t fix that) 2) The large number of imaging centers owned by non-radiologist physicians who self refer and make the profit of the technical fees. It has been shown that when a physician owns his own imaging equipment, he orders up to 7 times (that would be 700%) more scans than a physician who refers to a facility that he doesn’t own. Radiologists never refer to themselves. Other specialists buying their own CT and MR scanners is what drove this. This phenomenon was an unintended consequence of the govt cutting fees paid to physicians for caring for patients to levels that did not allow them to pay their staffs, let alone themselves. A warning – central planning doesn’t work, this is but one example.
        4) The article notes that the administration was doing this as a way to make more money themselves. It says that there was a traditional arrangement with the old radiology group. The traditional arrangement is that the physicians bill for their work (professional fee) and the hospital bills for use of their facilities (technical fee.) There has been a sharp division between the two which means that the radiologists cost nothing to the hospital, and the hospital makes nothing from them. UNLESS the hospital now wants to use its power to essentially steal the professional fee from the radiologists. That is what this sounds like.
        5) I want the physicians who take care of me to be highly paid. I do not want marginal performers cutting me open. I also want them to be on my side. When physicians become employees of the hospital, they do what the hospital says. A recent 60 minutes story detailed the scheme of one hospital company to strong arm their ER physicians to admit a very large number of the patients that they saw, more than 2 times the number they would normally. Most went along, when one didn’t, he was fired. I also am aware that in our area some employed physicians are given performance bonuses for the numbers of studies they do.
        6) This is all a part of the larger picture of the money that patients used to pay directly to their physicians for their care being siphoned off by innumerable business interests that are now making their livings from the work that physicians do. Hospitals are now very big businesses. Our hospital system currently has over 2 billion dollars in CASH. This gets little or no attention in the press. I would be willing to bet that St. Barnabas is not nearly in the financial straits they claim. I want my hospital administrators to be sparse and poorly paid. They add little to my care. Yet they are overrunning our hospital

        • “This is all a part of the larger picture of the money that patients used to pay directly to their physicians for their care being siphoned off by innumerable business interests that are now making their livings from the work that physicians do.”

          Exactly, this is the truth that the academic elites who blame doctors for all the healthcare system’s ills dont understand.

          A study came out in NEJM a few years ago showing that when a doctor’s practice shuts down, on average 22 employees are affected, not just the nurses at the clinic but all the bureaucrats/coders/middle men who make a living by stealing transactions across the middle of the healthcare system.

          • Um, where did you see any academic elites here bashing docs as being the ones to blame for everything? I’ve explicitly written how that’s not the case.

        • @Dr Rolf Rad – via AI and radiology… Sure, the state of the art isn’t very good today, but 5 years ago self driving cars (with a very tough and constantly changing image recognition problem to crack) could barely get out of the parking lot, now Google has logged 500k accident free miles in theirs. I’d be astounded in 15 years if we are still using humans to read imaging except in supervisory roles.

          • @MARK

            Oh – I agree totally that there is potential for exponential improvement. But I have been watching this area for 20 years, and actually did a bit of programming myself. Let me just say that the nuclear cardiac images, as an example, are some very very simple images. Essentially doughnuts. But the software (which as been available since at least 1985, and has hence had a good deal of opportunity to mature) still is no match for a human. Things that are clearly artifacts to a human are diagnosed as abnormal. Similarly, the Mammo programs simply mark everything, it seems. They are not as good as a medical student after 30 minutes of tutorial. They have been out 7-10 years now, with no observable improvement.
            Of course, Google hasn’t applied itself.
            There is something else I didn’t say – I have heard it said that this will never happen because then lawyers would have no one to sue. There must be a human doctor responsible so that someone (human) is accountable. I used to dismiss this as horribly cynical. I don’t dismiss it at all anymore. I think there is real truth there. And that is yet another discussion.

    • I am sympathetic to arguments about structural payment changes being necessary but that said, radiologist pay is a weak example. We did a study for a health care system on what was driving the reimbursement of a few chosen specialties (confidential so not publicly released) and a strict value-based payment system could even lead to higher pay for radiologists unfortunately. There were a few reasons for this:

      1. A lot of the higher pay for radiologists has been due to massively increased productivity (both in terms of number of exams read and difficulty of exams i.e., number of cuts or images examined) on their part. No other part of medicine has utilized technology anywhere as efficiently or kept up with innovation to that extent and on most value-based metrics we came up with their contribution was high.

      2. The dependence of modern clinical care on imaging has significantly increased from a generation ago. Due to the time constraints, significant numbers of physicians (and mid-levels) outsource diagnosis to imaging. The value of this for our client and the impact on time to diagnosis, time to discharge, admission status, etc. was significant.

      3. Per unit prices in radiology have declined over the last 15 years more than most fields in medicine (except for ophtho)

      4. Substitution from other providers is minimal. Unlike with pediatrics or internal medicine (e.g., mid-level NPs, etc), it is almost impossible to find substitutes for a good (or even bad) radiologist. The knowledge is just too specialized (i.e., few physicians can sign off on a CT abdomen report for a trauma case confidently enough to avoid an exploratory laparatomy other than a radiologist)

      Now that said, maybe the absolute level of pay for all specialties is too high (the argument of many) but this would be a very different argument and likely have to examine opportunity costs. As a hospital system executive though, I would not focus savings efforts here (even if I had the market leverage to do so) as opposed to other potential areas.

      • Also, agree with Aaron that length of training is a really bad idea to include as justification for relative payment between specialties (1 or 2 year difference in training does not justify multiples in compensation differences). However, its hard to get worked up about it as the high-scoring students will just switch from radiology to whatever other field now offers higher compensation so raising the salaries of one specialty is not going to structurally change much.

        Training length should play a large role in examining doctor compensation overall though as 10- years of training (and lost income) for a highly intelligent, scientifically literate person along with the risk involved is going to have be compensated pretty highly in a very unequal society like America to attract the right level of talent. Most European countries are less unequal (i.e., across the board lower salaries, fewer folks having high-paying finance or law options at the top end of talent), have fewer lost years of income (i.e., direct to medical school training, significantly higher salaries as “junior doctors”), have less risk (liability limited so less legal risk, state covers cost of school so less financial risk) and overall better work environments (more respect for physicians–admit this is a subjective judgment).

      • V-
        What you say is real. (one of the very few comments I have seen on internet comment boards that match my in the trenches experience)

        About 4 years ago, I looked at my numbers, comparing them to some numbers I had from about 7 years prior to that. The answer- I was working 30% more hours, and producing 80% more clinical work product (in the form of RVUs), and being paid roughly the same. And the trend has gone up from there.
        When I came into radiology, standard practice was to have the ER cases read within 5 or 6 hours of the patient leaving. Our current standard is 15 minutes. Which means that very often, the CT is done, we figure out what is wrong with the patient, and the ER doc has the answer before he ever sees the patient (yes – the CT is ordered by a nurse as they walk through the door). And don’t believe your TV – ER docs simply can’t read CT scans.

      • V, I just thought at least one person should comment positively on a superb explanation that is extremely beneficial to our understanding of the complexities we are dealing with. Thank you.

    • There is an entitlement I would like to see made available to doctors: free medical school, as they do in France.

      After they graduate with a free education, let them be dedicated to, you know, that oath? Remember it radiologists? That’s right, the Hippocratic Oath.

      What if we could staff hospitals and doctors offices nationwide with professionals that have even one quarter of the dedication to service that our troops have? If we paid for free medical school we could flood the field of health professionals with willing dedicated hard working people interested in healing others for $100,000 per year. Which cartel is preventing this from happening?

      • The Hippocratic Oath forbids surgery and abortion, by the way.

        Are you down with that?

        • I suppose if you are a literal stickler for details and a nitpicker of technicalities, you are quite correct.

          A more intelligent reading grasps the meaning that transcendes the technical limitations of the day, and can see the plain intent of placing patients first and not doing harm.

          Clearly what qualifies as doing harm and what qualifies as legitimate benficial treatments has changed over time, while preserving the core of humane intent. So yes, I’m down with that.

      • Also, if flooding the market with doctors would solve the problem, tell me this.

        Why does Manhattan have the highest number of doctors per capita in the world, and ALSO have one of the highest healthcare costs in the world, even after you adjust for cost of living?

        • I don’t know the answer to this question, but I guarantee that the increased number of docters per capita is not what drives up the prices. Even after adjusting for cost of living, there is also higher per capita income, thus greater ability to pay, thus ability to charge higher prices following pure market mechanisms. And comparing cost of living is notoriously difficult, so the adjustment may not account for all real cost differences between New York and Kansas.

          It’s very hard to believe that if you kept all other factors fixed and decreased the number of doctors, that you would see prices fall as a result. The large number of doctors probably keeps prices from being even higher than they are, and those higher prices are driven by other factors.

          According to this article: http://www.usatoday.com/story/money/business/2012/10/20/doctors-shortage-least-most/1644837/

          New York has 277 doctors per 100,000 patients.
          Massachussetts is tops with 314 doctors per 100,00 patients

          According to this site: http://www.globalhealthfacts.org/data/topic/map.aspx?ind=74

          France, which provides free medical school to doctors, has 340 doctors per 100,000 people (34 per 10,000).

          This doesn’t tell us what the mix of specialists to general practitioners is. That could matter as much or more than raw number of doctors.

          It seems there is some evidence that increasing the number of doctors also increases the amount of care being delivered, which should have an upward influence on overall spending, but not necessarily the cost per treatment. The question is, does this mean that unnecessary treatment is being foisted on the public, or that an inadequate number of doctors caused too many people to not receive needed treatment?

          • Read the articles on supplier induced demand on this blog.

            Steve

          • Jeff:

            I have to simply say that you are dealing strictly from a theoretical standpoint, and have no experience or understanding about what is really going on.
            Every study I have ever seen shows that as there are more providers, the costs go up. I understand why this is so. First, the physicians, as I noted previously, have had what should be their primary activity, seeing patients and making decisions, devalued to the point that you cannot be solvent if that is all you do. Many have to have ancillary income streams, like imaging centers, chemo centers, dialysis centers to remain solvent. And, each referral is more money.
            Second, patients LOVE it when you order tests on them. They are not paying, in fact, after years of paying premiums they think you had better order tests on them, they deserve it. And, if you don’t, they think you are a low quality doc, too stupid to know that they need an MR scan because, by god, they are having pain. Also, as was stated to me by an ER doc: “the cheapest malpractice insurance I can buy is a CT scan. I pay nothing, and it clears me”.
            Your statement that more doctors would cut costs misses these points. This is NOT a free market. It is a controlled market where the consumers have already paid and want value for their money.
            As someone else stated, if you could cut physicians fees to $0, then in about a year and a half you would be back to square one, with medical inflation going as it is. So even if you were to cut physician pay by 20% (which would cause a large number of physicians to quit as there are a large number right now deferring retirement), Within a few months the savings would vanish
            The real savings would be in changing ordering habits, which will require a change in tort law. While Obama is in office this won’t happen.

    • This article addresses a lot of issues but lacks focus. Just a few comments.

      1. The residents are idiotic for putting radiology and Porsche in the same sentence. To the New York Times. Do you really expect anyone to feel sorry for you now?

      2. The last thing medicine as a field needs is people within the specialty tearing each other down and calling each other overpaid. In medical school every student makes a conscious decision about what field to go into, and at that time the student must weigh many factors including passion for the field, lifestyle, pay, etc… Often, the most competitive fields are the highest paying. Yes medicine is constantly changing, but you cannot expect your specialty of choice to change for you. Many people are completely happy with their choice of pediatrics despite it being the lowest paying field in medicine, with many PA/NP/CRNA making more money. Many people go into academics and make 1/2 of what they could in private practice. Don’t try to bring other people down because you are not happy with your chosen specialty.

      3. Yet, there are ways to make good money in any field you go into, if you chose to do so. For example, from general surgery you can do a plastics fellowship. From internal medicine you can go into gastroenterology or cardiology. From OB/GYN you can do maternal fetal medicine, urogynecology. From pediatrics, pediatric ICU. In general, medicine rewards people who are willing to delay gratification and put in more years of training before they really get to start their life.

      4. Neurology is a high paying field, if you want it to be. The fellowship options from neurology include sleep medicine, neurophysiology, neurocritical care, and neurointerventional radiology (after stroke). In fact, the average neurology salary has shot up quite a bit over the last few years to over $280,000. I would expect neurologists who have specialized to make significantly more. Also, neurology is typically considered a laid back field and to be honest the pay is not bad at all for what you do.

      5. In medicine, NO ONE’S salary is justified. Medicare reimbursement rates are determined arbitrarily by some suits sitting around a table. In fact, if current trends continue, every specialty’s salary will be cut.

      6. Please stop letting outsiders divide and conquer physicians.

    • “But, contrary to what many believe, this is still a free market. Someone, somewhere, is going to realize that there are physicians who are overpaid. In this case, it’s some (not all!) radiologists. We also know that we need more primary care docs and fewer specialists – and this is how we get there.”

      health care a free market?

      david healy had a better description of the healthcare market today albeit in a different context….

      http://davidhealy.org/not-so-bad-pharma/

      “Whatever frame you opt for, the result is the strangest market on earth in which mega-corporations spouting a rhetoric of market freedom operate in a totalitarian way to control the least free market ever seen.”

    • Congratulations! You and the late Michael Crichton have a commonality. You both love to beat up radiologists. Your ridiculous envy is the same I have heard from ‘cutters’ who are incredulous at the leverage radiologists have and make…for interpreting imagery. If other medical specialties were able to leverage as radiologists, they would have done EXACTLY the same. I present a typical certified, coastal, name brand ‘cutter’s’ POV:

      http://www.youtube.com/watch?v=8g2dkDh4ov4

      P.S. BTW, if the ‘kulak’ radiologists wish to spend on Porsches…so be it. It is a well engineered car.

      • Please. This has nothing to do with radiologists, specifically. I think it’s a tone-deafness that all specialties seem to share. In fact, it’s the first such time I’ve written about this aimed at radiologists.

        Besides, I love my job. That’s why I do it.

      • It’s funny how quickly people leap to the conclusion there is envy involved when people dislike a state of affairs, such as enormous amounts of money earned from the sickness of others while countless millions have no health care and can’t afford it. I guess if that assumption were true, it means that Republicans and conservatives of every stripe are green to the core with envy of President Obama, and when they criticize even his wife for her good efforts, it means they wish they were married to her.

        If radiologists managed to command salaries rivaling corporate CEOs we should really applaud them and cheer at their superb display of business acumen and self-interest. What heros.

        I tell you the people I’m envious of when it comes to health care, and it is not the radiologists. It is the Canadians or the British who live in a country that takes the health of all of its citizens seriously, and which recognizes that the general quality of life, welfare, and prosperity of its citizens is better served by ensuring that no person suffers from disease or pain without receiving needed treatments, and that the misery of people and their loved ones when cancer or other horrible diseases attack is not the joyous opportunity for profit to be made, but rather a natural national emergency that requires concerned and competent response of well trained care providers, just as we see it as the duty for good citizens to respond when any disaster strikes, such as fire, flood, storm, or foreign invasion.

        It isn’t national economic productivity when we figure out how to enrich a subclass of citizens from the majority’s general pain and misery. It is moral failure if that becomes our priority to gleefully celebrate.

    • Fields like neurology, endocrinology, hematology, primary care, etc. are EASY fields to master. You have some of the dumbest residents in those fields (just look at their board scores) and for good reason.

      imo, you should be paid based on a combination of things: the difficulty of your field, the length of training, and your productivity. Neurosurgeons, radiation oncologists, cardiologists, radiologists, urologists, ENT, etc. should all be among the higher paid specialties. Their crafts are difficult to master, they require more years of training (radiology is usually 6 years post grad: 5 + fellowship), and their volume far exceeds the typical PCP.

      Primary care physicians should be among the lowest for the same reasons. Most 4th year med students are fully capable of being a PCP. It’s a skill taught to them throughout med school. I’ll take it even further. After med school, most could do neurology, endocrinology, rheumatology, allergy/immunology, etc with an additional 1-2 years of training. Those fields are not complicated and for the most part, med students have been learning those fields throughout their 2nd, 3rd, and 4th years. However, no one teaches you in med school how to be an ENT surgeon, an orthopedist, a radiation oncologist, a radiologist, a neurosurgeon, etc. Those fields are more complex and merit a higher pay relative to their PCP counterpart.

      • As a pediatrician, I’ll just say you’re ridiculous. Period. You have no idea what you’re talking about.

      • @Matt:
        Actually it is very difficult to determine which are the hardest fields. One could say the Internist and the Pediatrician because both have to know their entire fields and pick up things in a large morass of information. The really good ones have extraordinary talents and what some might call intuition. Additionally they must be able to deal with patients and the stresses that come from the lack of in depth knowledge of each of the specialties with information constantly coming in from all the subspecialty fields.

        General surgeons have a similar problem with regard to being called for one thing and dealing with another. This does not mean that the other specialties don’t have their difficulties as well. They do, but I would say the statement you made means “you’re ridiculous. Period. You have no idea what you’re talking about.”

        • Neurology is something that is easy? Really? I was dumbfounded by that particular statement as a neurologist, especially as I have struggled over the years to get the internal medicine and psychiatry trainees rotating through our service to grasp even basic concepts of localization in neurology and to approach these problems logically. I’ve always felt that individuals in medicine will have temperaments that allow them to do certain work. I thought cardiology was mind-numbingly boring when I was a medical student, and I’m sure many cardiologists would think my field the same. I have a brilliant friend who is a nephrologist, but she is terrified of neurology cases; likewise, I’ve always had issues with the kidney and its functioning. Different strokes, for different folks. But Matt, none of these specialties is easy. Your comments truly are ridiculous…

          • BC and Matt have it wrong about neurology:

            BC: “Neurology is a high paying field, if you want it to be. The fellowship options from neurology include sleep medicine, neurophysiology, neurocritical care, and neurointerventional radiology (after stroke). In fact, the average neurology salary has shot up quite a bit over the last few years to over $280,000. I would expect neurologists who have specialized to make significantly more. Also, neurology is typically considered a laid back field and to be honest the pay is not bad at all for what you do.”

            Matt: Fields like neurology, endocrinology, hematology, primary care, etc. are EASY fields to master. You have some of the dumbest residents in those fields (just look at their board scores) and for good reason.

            I don’t know where BC got the average salary figure for neurology, but it could have been from Medical Economics or the MGMA, both of which grossly overestimate incomes in general, partly because of their selective sampling of physicians and practices. The average salary for neurologists–actually a meaningless figure, since neurologists are hardly homogeneous in terms of subspecialization, hospital or multispecialty clinic or hospital based, region of the country in which they work, etc., is probably more like $180,000.

            And that number is dropping fast, because of two major factors. First, Medicare arbitrarily cut reimbursements for electrophysiologic studies (EMG, nerve conduction studies, and sleep studies by up to 60-70% as of January 1, 2013. These fee cuts will quickly carry over to all the private insurers. Second, neurologists are paid less than so-called primary care specialists for what used to be called consultations, and which are now termed and coded “new patient visits.” They are effectively paid less because neurology consults take about 30-50% more time with each patient (if they are done properly) as compared to most other primary care and specialty fields, and neurologists are required to use the “bullet points” that determine the level of payment, bullet points which have little or no relevance to neurological problems. But you have to be a neurologist, like Chris and myself, to understand that. And neurologists are paid absolutely less than PCPs because neurologists, despite providing primary care to many patients, are not designated as PCPs and are therefore not eligible for the 10% Medicare primary care bonus.

            As for Matt’s contention that neurology and various other medical specialties being “easy to master,” the statement is hardly worthy of rebuttal. Easy to master or not, as Chris says in a post a couple comments above, most non-neurologists know practically nothing about neurology, and resist learning it. According to the AAMC, some 28 out of 131 medical schools in the US don’t even have a required rotation for students in neurology. Neither the internal medicine nor family practice Board Certification entities (ABIM and ABFM) require that primary care residents spend any time in neurology during their training. My experience as a neurologist is the same as Chris’s, which is that there is huge resistance to learning neurology “because it is too difficult.” There is even a literature on the concept of “neurophobia” among medical students.

            As for Matt’s other contention that “some of the dumbest residents” are in the specialties he names, including neurology, perhaps so, at least these days. That is because many of the brightest students are choosing the (now) competitive fields such as radiology (but see the recent NYT article on this), ophthalmology, anesthesiology and dermatology to realize better remuneration and lifestyle. In neurology, 45% of new residents are IMGs (international medical graduates), and it is believed this is because neurology can no longer attract the best US medical school graduates.

            Matt names orthopedic surgery as one of the specialties that is “more complex” than the medical specialties, one that can’t be picked up by the apparent quasi-osmotic method he implies for the other specialties, and therefore deserving of higher remuneration. This statement reflects an unfortunate lack of knowledge and understanding about the complexity and elegance of medicine, and reminds me a little of the naive museum-goer who looks at a piece of abstract art he can’t fathom and says, “my five year old could paint that.” It’s just not worth discussing art with this person.

            In general, I find this thread to be, for the most part, a nice discussion of the huge problems, and lack of good solutions, facing health care delivery in this country. The complexity of it all is mind boggling.

            Personally, I think the only viable solution will be a single-payer and/or nationalized system modeled along the lines of some of the large multispecialty clinics like Mayo, Gunderson, Inter-Mountain, etc., in which quality is the only goal, and in which no one is rewarded for quantity, per se. Such a system is anathema to many conservative ideologues, but in fact it would serve the public much better in every way than what we now have, most physicians would ultimately be happier under it than in the unwieldy and increasingly inefficient system we have lived with for the past 30 years or so, and it would tend to attract people into medicine for more of the right reasons.

          • @Chris
            You are absolutely correct. The person who makes statements that certain specialties are easy is not speaking from any knowledge at all. It was amusing to note (and I want to point out for those here who are not in medicine) that the poster noted that “hematology” was easy. Anyone in medicine knows that there are essentially no hematologists, they are all hematology-oncologists, with a heavy emphasis on the oncology. And, BTW, these people intimidate me with the depth of knowledge that they have to have about the multitude of tumors that they have to deal with and the most recent date on the various treatments.
            So this poster (Matt) as Adam also pointed out is ignorant.
            This illustrates a larger problem: people with no knowledge of medicine are perfectly OK with making broad pronouncements from a place of ignorance. Harmless enough, except that some of these are now in positions to run our health care endeavors. What I see coming from Washington is alarming in its ignorance.
            I once had a conversation with the President of the American College of Radiology. I asked “You have spent a lot of time this year in Washington with legislators and testifying to Congress. What is the one most surprising thing you have learned.” Without skipping a beat he said “It is stunning how little legislators know about the things they write legislation about”
            And I have learned myself that is true.

    • Well this doesn’t endear radiologists to me, and they didn’t start out that well to begin with. As a patient, my frustration has been that apparently many/most radiologists in my area don’t sign on to PPO arrangements — or conversely, are charging so much that the ins cos won’t agree to their rates. I’ve had to have two instances of imagine done in the last five years, and even when done at a clinic/hospital in my network, the radiologist doing the interpretation has not been — I’ve had to pay their full fee. On my plan at least, I have to drive 75 miles, across a state line, to find a covered radiologist. I haven’t found any other specialty for which there’s been any trouble finding local covered providers with my plan. I’ve glanced at some of the other plans my employer offers, and on them too it seems like it is unusually difficult to radiologists on PPO discount plans.

    • We have it completely backwards here. I can get my grandma in to see an orthopedist for a knee replacement in 1 weeks time, but for her to see a competent and caring PCP to adjust her diabetes and blood pressure meds, address her numerous health complaints, and give her appropriate follow up care, she has to wait weeks or months for a rushed appointment with her family doc.

      Much of the problem lies within the cycle of exploitation that characterizes medical education. First from the outrageous tuition and crushing debt and then later the indentured servitude of residency, which drives doctors further into subspecialties and away from working in primary care.

      Expand loan repayment for primary care docs and midlevels working in primary care, especially those going in underserved areas. Many overworked PCP’s can’t afford PA’s or NP’s to help them out as they are fleeing to higher paying specialties as well. Make med school cheaper and more accessible to those who actually want to be doctors, not just bio majors who have been watching Grey’s Anatomy for 4 years. Recruit more students with actual health care experience like nurses and other allied health professionals. Allow some classes like histology, biochem, and embryology to be taken online, which is what many med students essentially do anyway. Spend more time actually teaching practical clinical skills during the 3rd year. Get rid of the useless 4th year – another year of loans and opportunity costs. The whole system has become sclerotic and unresponsive to the actual needs of our population, it’s no wonder people are outraged over radiologists complaining about their reimbursement.

      • @gerard
        All the costs that you are trying to reduce means that some other income is falling that may or may not have significant unintended consequences. It really doesn’t matter for the total amount saved would be relatively small. What has to be attacked in healthcare spending is the %growth and that can be contained in only a few ways.

        • Emily, I’m concerned specifically with the costs incurred by medical students, which entraps them into a dysfunctional system that incentivizes them to pursue lucrative specialties rather than primary care. If this means bankers or other rent-seekers in the medical industry have to take a hit, so be it. It’s quite frankly insane that medical students are graduating with average debt well into the six figures, and I believe a lot of the rot begins here. No other modern healthcare system places such an onerous burden on future doctors and it’s perfectly rational for them to run the other way when they see what PCP’s have to put up with for substantially lower pay. It is hard to argue that our system isn’t lopsided in this regard. Every other system that is successful in containing costs is built upon a solid backbone of accessible primary care.

    • So, let’s put this in perspective. Say the poor radiologist is 300 grand in debt and will “only” make an average of 300 grand a year over their career. Many doctors I have known, and I have many friends and colleagues in the medical industry rent until about 5 or ten years into the career when they can buy a home… In cash! Or, since they tend to come from the ruling class (obviously not every last one of them in this utopian classless meritocracy of ours is from the landed gentry, but a good percentage come from upper middle class backgrounds…) and have mommy and daddy foot the bill for a LOT of their living expenses well into adulthood. I have even known a few who got free rides through medical school curtesy of Mom and Dad Inc. What’s the big deal? I’m a hundred grand in debt from college and my chosen profession (social work) will eventually pay closer to the average annual household income (in the US) somewhere between 40 and 50 grand a year. I am making $15 an hour four years after receiving my master’s degree from Columbia. I would say that the majority in my program were not concerned about the poor pay in the profession because they were also trust funded, but there were a few of us brave souls who just wanted to do something for society and if that meant we’d never vacation in exotic ports of call and we’d need to work as Wal Mart greeters in retirement until we dropped dead in our trailer park, them’s the breaks. The pay sucks but I change lives and help many people on a daily basis so that makes up for the relative poverty. I will also be paying off a 250K mortgage for the next 30 years.Why should ANYONE care about whether or not radiologists make $400K, $300K, $200K, $100K or $50K a year? Want to make money? Go into finance or drug dealing. Find your inner cutthroat greedy sociopath and quit complaining.

      • “Why should ANYONE care about whether or not radiologists make $400K, $300K, $200K, $100K or $50K a year? ”

        Why should you or anyone care? Ever hear of “you get what you pay for?”

        Because until recently, the brightest med students went into radiology, the typical radiology resident was in the top 20% of their med school class. As the compensation of radiologists becomes cut every year, and the rules and regulations get piled on, you will see the quality of radiology applicants decrease. And not just radiology, but physicians across the board have continually lost their autonomy and now answer to administrators. So you might care someday if your less than top notch radiologist misses your Mom’s little 8 mm enhancing breast cancer on MRI. Or if your poorly compensated, bottom of class radiologist, interprets your liver lesion on MRI as a cancer and you’re laying on there for a biopsy when it could have been diagnosed as a focal nodular hyperplasia, a harmless benign lesion. Or say, your poorly trained radiologist recommends a biopsy for your myositis ossificans of your calf, and the biopsy comes back cancer and they amputate your leg, when in fact they shouldn’t have done anything at all. Or say, your radiologist only became a radiologist because he couldn’t get into anything else. He doesn’t see a meniscal tear on your knee MRI, when in fact there’s a big honking bucket handle tear he misinterpreted as an unusually large posterior cruciate ligament. Nothing is done and when you’re only 38, you’re obese and have severe knee osteoarthritis. You see, he didn’t really care all that much because he only got 18 bucks to read your knee MRI and it was time for his state-mandated 15 min. break at the time he was reading your scan. You might care one day when the radiologist is pushing his 18 G trocar towards your abscess which is sitting between your abdominal aorta and your pancreas. Or is it REALLY an abscess…. ? Well, darn, just don’t know. I guess it could be a pancreatic cystadenocarcinoma… or is it only a weird bowel loop? Heck I don’t know, I just barely graduated from med school.

        Most of the time, you actually do get what you pay for.

        So yes, someday you might actually care. You probably won’t, because the vast majority of the public has no idea what goes on in radiology. If things go right, and radiology was the key part of something going right for a patient, the patient, the vast majority of the time, will have no clue that radiology is what saved them. So, no you don’t care now, but someday your Mom or Dad, sister or brother, wife or husband, or your kid might really, really care.

    • Radiologists did much of this to themselves. They were making a lot of money, so they started paying others to take their call, at reduced rates (think Nighthawk) once computer technology made that possible. They didnt seem to think that people would realize you could then do the same for day work. IR should still be safe as you cant hire folks sitting in Israel or India to do that.

      Steve

    • I don’t know where BC got the average salary figure ($280,000) for neurology, but it could have been from Medical Economics or the MGMA, both of which grossly overestimate incomes in general, partly because of their selective sampling of physicians and practices. The average salary for neurologists–actually a meaningless figure, since neurologists are hardly homogeneous in terms of subspecialization, hospital or multispecialty clinic or hospital based, region of the country in which they work, etc., is probably more like $180,000.

      And that number is dropping fast, because of two major factors. First, Medicare arbitrarily cut reimbursements for electrophysiologic studies (EMG, nerve conduction studies, and sleep studies by up to 60-70% as of January 1, 2013. These fee cuts will quickly carry over to all the private insurers. Second, neurologists are paid less than so-called primary care specialists for what used to be called consultations, and which are now termed and coded “new patient visits.” They are effectively paid less because neurology consults take about 30-50% more time with each patient (if they are done properly) as compared to most other primary care and specialty fields, and neurologists are required to use the “bullet points” that determine the level of payment, bullet points which have little or no relevance to neurological problems. And neurologists are paid absolutely less than PCPs because neurologists, despite providing primary care to many patients, are not designated as PCPs and are therefore not eligible for the 10% Medicare primary care bonus.

    • Matt’s contention that neurology and various other medical specialties being “easy to master,” reflects an unfortunate lack of understanding about the complexity and elegance of all these fields. It reminds me of the museum-goer who sees a piece of abstract art and says, “My five year old could paint that.”

      But, as Chris notes, most non-neurologists know practically nothing about neurology, and even resist learning it. According to the AAMC, some 28 out of 131 medical schools in the US don’t even have a required rotation for students in neurology. Neither the internal medicine nor family practice Board Certification entities (ABIM and ABFM) require that primary care residents spend any time in neurology during their training. My experience as a neurologist is the same as Chris’s, which is that there is huge resistance to learning neurology “because it is too difficult.” There is even a literature on the concept of “neurophobia” among medical students.

      As for Matt’s other assertion that “some of the dumbest residents” are in the specialties he names, including neurology, perhaps so, these days. That is because many of the brightest students are choosing the competitive and remunerative fields such as radiology (but see the recent NYT article on this), ophthalmology, anesthesiology and dermatology to realize better remuneration and lifestyle. In neurology, 45% of new residents are IMGs (international medical graduates), and it is believed this is because neurology can no longer attract the best US medical school graduates.

    • “It takes six years to be an neurologist”

      Um, no it does not.

      At least not according to the ACGME.

      “A complete neurology residency requires 48 months of education.”
      ACGME Program Requirements for Graduate Medical Education in Neurology Common Program Requirements are in BOLD
      Effective: July 1, 2010

      This has nothing to do with the changing market for radiologists, but inflating Neurology training requirements by 50% does not advance the discussion.

      The point is how people choose careers in a capitalist country. These people chose a field when it offered high incomes, and they would have done something else had they known those high incomes would not last. They are in the same position as law school students who are discovering that those big associate salaries are harder to come by. No need to cry for them, but they might have chosen different careers had they known what would happen.

      So, yes, they are upset that their investments did not work out as anticipated. I has nothing to do with entitlements. It has everything to do with making huge investments, almost impossible to go back and change careers, and it did not work out. If you wish you made more money, one can simply say “you should have picked a more lucrative career”. If you don’t care about the compensation, then what are you complaining about?

    • Gerard, if you think medical school tuition should be less expensive to prevent the problems you mention then perhaps you should take a look and see why medical school tuition is so high. 2 years are mostly spent in the classroom where the lecture halls can be rather large. 2 years are mostly spent on clinical rotations where frequently the attending physicians are not paid. During the latter 2 years the medical student actually provides a service as well. Me thinks that tuition is not just to pay for educating the doctor paying the bill, but for a whole bunch of other things.

      People go into the subspecialties for many reasons. Incentives matter and your methodology doesn’t adequately deal with the incentives involved.

      By the way despite what you say in your posting all the western healthcare programs have problems with sustainability so their solutions have not yet solved the problem.

    • DBH wrote:

      “‘It takes six years to be an neurologist’
      Um, no it does not.
      At least not according to the ACGME.”

      Literally true, DBH, but completely misleading, at least as things stand in 2013.

      After 48 months, that is, a PGY-1 general medicine year in most cases, and three years of general neurology residency, which includes brief rotations in various sub specialty areas of neurology, one is eligible to take the ABPN Boards, and is considered to be neurologist.

      Problem is, a general neurologist in this imaging-of-everything-before-consulting-the-neurologist environment, a general neurologist has little to offer to most practices, whether in academics, multispecialty clinics, or in a group neurology environment. (Solo neurology practice is becoming extinct.)

      Accordingly, most newly minted neurologists now take another one or two years in fellowship training in epilepsy, neurophysiology, multiple sclerosis, movement disorders, neuromuscular disorders, stroke, neurointensivist practice, neuro-otology, neuro-ophthalmology, neuro-rehabilitation, sleep medicine, or neuropsychiatric disorders, including dementia, and a couple of others. Some go into academic research and earn Ph.Ds.

      All of this adds up to at least five and often six or seven years of training before a neurologist is ready to practice his or her specialty.

      As is all too apparent from this thread, the lay public and even non-neurologist physicians fail to appreciate what it is that neurologists do, or what the field of neurology entails. That is why neurology itself is in so much trouble these days, to the great detriment of the public health.

    • umm just to give an outsider’s perspective…

      1, Doctors make a lotta money. Everyone (except physicians) knows it.

      2, It’s not THE driver behind the ridiculous cost of health care, but it’s one of them.

      3, Until not that long ago, the AMA was simply a guild concerned above all with maintaining income.

      4, Most MDs in this country are highly qualified, had to work hard, still do

      5, I don’t begrudge physicians their money, but I have no patience for their whining. For example, I’m a PhD biomedical researcher. The length and rigor of my training was probably at least that of your average board-certified physician, though I’d be lucky to make 50% of the average physician’s salary. I chose my field, and it has some lovely benefits; I’m not complaining, just think doctors need to get over their sense of entitlement and persecution.

    • Richard wrote:

      It’s not THE driver behind the ridiculous cost of health care, but it’s one of them.

      If there is a single driver behind the ridiculous cost of health care, it is the “payment for quantity of things done” system that has developed over the past 50 years. Innovations like the Obamacare driven accountable care organizations (ACOs) represent an attempt to change the paradigm. ACOs right now are too much like the failed HMOs of the ’90s, and will only work if and when the entire system is overhauled, something which won’t happen soon.

      As for physician remuneration itself, the problem is that it is so uneven, is (again) based on quantity rather than quality, and doesn’t accurately reflect the relative value to society of various specialties and services. After taking into account practice costs, including malpractice insurance (another major factor in health care costs, including the indeterminable costs of defensive medicine), there is no inherent reason why radiologists should be paid more than pediatricians.

      But the problem in this inequity isn’t the unfairness to lower paid specialists, it’s in the maldistribution of physicians and specialties that results from the income disparities.

      Pediatric neurologists, for example, are among the lowest paid of all specialists–they have no remunerative procedures to do, and their patients (parents) often have no money or insurance. There aren’t many medical students choosing pediatric neurology these days. Try to get into see one as a new patient in less than three months.

    • 1 MRI and a neuroradiologist is worth a thousand neurologists

      • Yes, I’ve heard that one, except it’s not even close to being true! Half of neurology is conditions of the peripheral nervous system (neuropathies, neuromuscular transmission issues, and myopathies) where imaging is quite useless.

        Then you have all the CNS conditions where it is quite useless, such as most of the movement disorders, where imaging is of limited utility. It would boggle my mind when serving as a movement disorder fellow at an American academic hospital that all the patients with Parkinson’s disease came with MRI’s of their heads from their PCPs. We only order imaging on such cases here in Canada if we think that it might be something other than PD. I once had a neuroradiologist tell me that my patient had Huntington’s disease because of atrophy of the caudates. The problem was it didn’t fit the clinical picture and the HD gene test was negative (turned out to be choreoacanthocytosis). So, I probably save a bunch of money for the system by not ordering imaging where it is pointless…

        So at the end of the day, I’ll doubt that I’ll be re[placed, especially as non-neurologists are so timid when it comes to treating neurological disease (I doubt my colleagues who are neurorads would ever want to get involved in patient management). And there is a lot we can do, just to explode another myth. Parkinson’s disease is quite treatable with medical and surgical options. The same is true for epilepsies. MS has seen numerous therapies become available over the last two decades. Acute thrombolysis is now the standard of care for acute stroke. Botox for focal dystonia and spasticity. And the list goes on.

        But as a troll, it got me to type up another response!

    • This is from Arnold Relman’s letter to the editor in today’s Times, addressing, and essentially agreeing with, Ezekiel Emmanuel’s recent piece on oncology:

      “We will need a publicly financed single-payer system to support prepaid comprehensive care, and a reformed medical care delivery system based on salaried, nonprofit group practices that integrate services by all specialties and use other professionals such as nurses and physician assistants. That’s a hard sell and will require the strong support of American doctors.

      When will physicians begin to look beyond the silos of their own specialty and think about the needs of the whole dysfunctional health system?”

      Little more need be said.

    • I do not see “salaried” physicians as a viable solution. This does not take into account that, setting aside abilities and quality of work, some docs work much harder than others. This is true even within the same field. If you set the bar so that the 20% percentile worker can clear it, how do you reward the harder working people? Increase their salaries? This is effectively the same as paying them more for doing more work.

      Years of training: Yes, many neurologists do fellowships, as do docs in many other fields. One could compare time to board eligibility in one field to time to eligibility in another. One could compare time including fellowship across fields. But it is silly to include fellowship time for neurology, but ignore it for, say, neurosurgery.

      Neurology is an intellectually challenging field. But it has never been a path to a high income. At least not in the last 40-50 years in the US. So people who enter that specialty know, or should know, that they will make less money than most other specialists. Having made that choice, it seems strange to complain about the compensation.

      I cannot imagine that imaging will replace neurologists. There is so much to be learned by seeing the patient that the diagnostic abilities of good neurologists are amazing, and I agree that few people outside of their field even try to learn the anatomy well enough to evaluate a neurologic patient.

    • For example, see the Health Affairs Datawatch, “Trends in physician income” 11, no.1 (1992):181-193.

      Relevant to this discussion, the authors report physician incomes across a range of specialties, going back to 1982. It is striking that the ranking looks a lot like it would 30 years later. They do not include every field, and at some point ophthalmology fell off the list of top earners.

      For the most part, the compensation of individual physicians reflects the implicit importance they attached to income when they chose their fields. If you graduated in 1982, and money was a major consideration, then you went into orthopedic surgery, not family practice or peds. The same is true today.

      The Times article, careless as it was, concerned people who chose a high income field, only to find it falling in the rankings just as they are looking for work. As the Times has documented, law school grads are seeing the same phenomenon.