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  •  On that last point, I'd disagree (9+ / 0-)

    Free markets and the potential for profit do provide incentives for the best and brightest to enter the field.  If you couldn't make as much money as a doctor (or more) as you could working for Big Pharma, what would you do?

    •  It's a difficult and long path to become a doctor (22+ / 0-)

      It requires years of intense (and expensive) schooling, and the position is one of great responsibility. I am in favor of single-payer, but doctors should be well-compensated.

      •  When I was in Cuba, Doctors moonlighted (9+ / 0-)

        They would work as drivers and operate hotels and restaurants out of their homes for extra income. That's obviously not cool that they have to do that.

      •  or the schooling should be subsidized (23+ / 0-)

        in order to relieve doctors of the pressure to repay med school  loans.

        Also, doctors should be compensated on some other basis than how many procedures or tests they prescribe.

        If they're paid by the test or by the procedure, they're going to act to maximize the number of tests and procedures they perform--and not all of them will always do so in the most ethical way. It's human nature.

        There's a difference between being well-compensated and being super-rich. Should medicine be a profession where doctors are encouraged to become super-wealthy by becoming specialists who concentrate on a very small fraction of the wealthiest patients and perform expensive tests? Is that a system that benefits us?

        The words that people don't want to say are "public health." Public health is not seriously debated in the US. We tend to look at individual patients rather than the multitude, and at care rather than prevention.

        In some cases, as with antibiotic use, the interests of public health are in conflict with the needs of individual patients. Every use of an antibiotic on one patient decreases the value of that antibiotic for other patients--it increases the risk of antibiotic resistant germs.

        So if we are heavily using highly expensive and powerful antibiotics on (mostly white, mostly male, mostly rich) elderly patients to keep them alive for a few months or years, are we thereby dooming (mostly non-white, mostly non-male, mostly poor) younger patients to getting sick from antibiotic-resistant illnesses? What are the tradeoffs?

        This is not an easy debate to have, and for good reason, because it touches on sensitive issues: race, gender, and that touchiest of issues in America, class.

        "In America, the law is king." --Thomas Paine

        by limpidglass on Wed Aug 07, 2013 at 02:04:44 PM PDT

        [ Parent ]

        •  Yes, and using antibiotics on livestock (13+ / 0-)

          does wonders for increasing bacterial resistance to antibiotics (ok, maybe a little off topic, but just saying . . .).

        •  I agree with you. (9+ / 0-)

          The incentives should be based on maximizing good outcomes, not just the number of treatments. I also am a big proponent of finding ways to subsidize medical training. I know the armed forces will pay for med school in exchange for a service commitment. I think it might be worth coming up with programs that help medical students pay for their education costs with service in public clinics that serve low-income communities, or even those who volunteer to serve overseas treating people in poor countries. There are a lot of win-win scenarios we can come up with that promote service to humanity and reduced-cost education.

          •  There are some programs that will subsidize (5+ / 0-)

            medical school if you commit to be a doctor in a rural area for certain number of years. At least they exist in some states.

            •  Good deal.... (1+ / 0-)
              Recommended by:

              I had a family member a few years ago who wanted to be a doctor. I suggested he look into the military, so that he wouldn't be saddled with debt. These are very honorable ways of becoming a doctor and providing service as well. I am in favor.

              •  egads! Ever been treated by a military doctor? (0+ / 0-)

                The main advertisement for the military medical program is the Ferres Doctrine. That means no malpractice from all us little grunt-guinea-pigs you get to stick.

                Good military doctors go to officers and congressmen. The rest-well they go to the rest of us.

                Not fun or fair but there it is. If one can I would say, take the rural internship over the military, until the military can straighten it's shit out.

                Gentlemen, congratulations. You're everything we've come to expect from years of government training (Zed, MIB).

                by GreenMother on Wed Aug 07, 2013 at 04:06:18 PM PDT

                [ Parent ]

                •  Um... (3+ / 0-)
                  Recommended by:
                  VClib, SixSixSix, andalusi

                  a friend of mine went into the Army after graduating from Harvard Medical School. Not all of them suck.

                  Any jackass can kick down a barn, but it takes a good carpenter to build one.--Sam Rayburn

                  by Ice Blue on Wed Aug 07, 2013 at 05:50:06 PM PDT

                  [ Parent ]

                  •  I almost forgot... (2+ / 0-)
                    Recommended by:
                    SixSixSix, andalusi

                    I just saw one, a career Navy vet, who trained in his specialty at Johns Hopkins. He was pretty damn good, too.

                    Any jackass can kick down a barn, but it takes a good carpenter to build one.--Sam Rayburn

                    by Ice Blue on Wed Aug 07, 2013 at 06:00:42 PM PDT

                    [ Parent ]

                  •  Like I said: (0+ / 0-)

                    Good military doctors go to officers and congressmen. The rest-well they go to the rest of us.

                    And who is going to afford to go to either John Hopkins or Yale in my household?

                    And wow--look at that, the ones that don't suck out of reach again.

                    Thanks for making my point perfectly.

                    Must be nice.

                    Being able to see any doctor you want without worrying. What a world that must be like.

                    Gentlemen, congratulations. You're everything we've come to expect from years of government training (Zed, MIB).

                    by GreenMother on Thu Aug 08, 2013 at 05:13:44 AM PDT

                    [ Parent ]

                    •  If you join the military they can put you through (0+ / 0-)

                      med school. Then you have to serve for a period of time.

                      The best doctors are treating the soldiers in the field. There aren't enough officers and congressmen who need the good stateside doctors.

                      That chip on your shoulder must weigh you down a lot.

                      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

                      by samddobermann on Sun Aug 18, 2013 at 05:37:18 AM PDT

                      [ Parent ]

                  •  correct (0+ / 0-)

                    it's a true mixed bag though.

                    Some great, some mediocre, and a fair share of bad.

                •  There are many outstanding physicians (5+ / 0-)

                  and surgeons who serve in the US armed forces.

                  "let's talk about that"

                  by VClib on Wed Aug 07, 2013 at 07:14:17 PM PDT

                  [ Parent ]

                •  A bit of a broad brush (3+ / 0-)
                  Recommended by:
                  wilderness voice, andalusi, joynow

                  I help train military doctors (as part of a combined civilian/military medical residency program).

                  My military residents are a varied bunch, just like the civilians. Some of them are excellent. Top notch. Many stay in careers where they are taking care of the rank-and-file.

                  The docs I know who work at the local base are probably better on average than the docs I know working in community hospitals. The couple of retired military docs who are core faculty in the residency program are docs that I wouldn't hesitate to send a loved one to.

                  My sample size is small. It's possible that my situation might be the unusual one, and yours the more typical.

                  Just thought I might add a bit of a contrary voice.

                  The plural of anecdote is not data.

                  by Skipbidder on Wed Aug 07, 2013 at 07:58:57 PM PDT

                  [ Parent ]

                  •  You know people used to say the same sorts of (0+ / 0-)

                    things when I talked about how bad sexual harassment was in the military. They found out soon enough that I was neither lying nor exaggerating.

                    Gentlemen, congratulations. You're everything we've come to expect from years of government training (Zed, MIB).

                    by GreenMother on Thu Aug 08, 2013 at 05:22:46 AM PDT

                    [ Parent ]

                    •  I believe it (0+ / 0-)

                      I hope this isn't the same sort of case, though.

                      I worked at the VA for a couple of years and saw plenty of patients whose charts said MST on them (for Military Sexual Trauma). And we know that we only learn about a portion of the folks who experienced such things. I was often caring for patients at end of life, and the prevalence of PTSD (or things that looked an awful lot like it) seemed to be a lot higher when I saw MST on the chart.

                      I don't think my post should have been read to suggest that I thought previous poster was lying or exaggerating. I tried to use careful enough language to admit the possibility that my sample size was small and perhaps nonrepresentative.

                      I don't know how generalizeable my experience is. At ONE base, the only one I've ever had experience with (and then mostly indirectly), it looked like the care the rank and file were receiving was better than community civilian patients were receiving. I know it is better than the Medicaid patient were able to get. I think it is better than the VA patients could get. I was better able to care for my patients at the VA than I am now for my Medicaid (or uninsured) patients at the community hospital. The docs I've known from that military base are ones I consider competent, and some of them are really good. (I wouldn't talk politics with some of them, and I think a couple of them can be a little lacking in the compassion department...but I find that fault in civilian doctors too. I think that particular trait is a little bit worse with my military residents, but only a little bit. And there are plenty of exceptions.)

                      The plural of anecdote is not data.

                      by Skipbidder on Thu Aug 08, 2013 at 08:20:28 PM PDT

                      [ Parent ]

                      •  Well I would rather be happy than right (0+ / 0-)

                        However, experience[s] have made me very cautious about military doctors, even those who are now civilian doctors.

                        Someone says they used to be a military doctor, and it makes my sphincter clench immediately. When you find out that many of them don't serve a full residency, after having received substandard care, well--it will make you think twice about going to one.

                        Trust is a delicate thing. And medical personnel occupy a position of trust. When that is abused, it doesn't even reappear when you see a new doctor. And if that trust keeps being abused by different doctors, then the gig is up.

                        Bed Side Manner, Good Research, Patience, and Genuine Communication, with an understanding that I have certain rights over my own body goes a long long way. Without those things, you might as well be playing operation on a real body.

                        Gentlemen, congratulations. You're everything we've come to expect from years of government training (Zed, MIB).

                        by GreenMother on Mon Aug 12, 2013 at 05:48:56 AM PDT

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                •  You paint military doctors with a broad brush. (0+ / 0-)

                  I was a military doctor for 22 years. I know I gave excellent care. I know most of my colleagues gave excellent care too. Then I went to work in the civilian world. I would say there are good and bad doctors in the military and civilian worlds, and leave it at that. It sounds like you had a bad experience with the military medical system, and I am sorry for that. But you cannot generalize and paint all military doctors as being the same, no more than all civilian doctors are the same.

                  "For we, the people, understand that our country cannot succeed when a shrinking few do very well and a growing many barely make it." - President Barack Obama, Second Inaugural Address, January 21, 2013.

                  by surfermom on Sun Aug 11, 2013 at 05:53:31 PM PDT

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          •  There are a lot of repayment (0+ / 0-)

            of loan programs in the ACA for primary care, pediatrics, and also nurses advanced training.

            There have always been programs for loan repay and doctor's training is partially subsidized as is by the federal government.

            I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

            by samddobermann on Sun Aug 18, 2013 at 05:32:59 AM PDT

            [ Parent ]

        •  I'd be in favor of full student loan (0+ / 0-)

          forgiveness for any doctor who worked in underserved areas for a significant amount of time, say 5 years after graduation.

          And interestingly enough, one of my parents-in-law's doctors left private practice to return to college and get his Master's in Public Health; he's now in charge of the Urgent Care department at the local medical foundation. Really nice guy, and a great doctor, but he wanted to do more than just see the same patients every day; he still takes his turn on the rotation at the clinic so we see him occasionally when we have an emergency (like when I banged my head so hard it split open & I needed staples -- long story).

          There's only one rule that I know of, babies -- goddammit, you've got to be kind. -- Kurt Vonnegut

          by Cali Scribe on Wed Aug 07, 2013 at 04:16:17 PM PDT

          [ Parent ]

      •  Everyone should be well compensated. (2+ / 0-)
        Recommended by:
        Pescadero Bill, SixSixSix

        Being a doctor is also a calling. There is no reason that we need to justify sending them over the top of a reasonably good life, and there is no reason that any worker should be denied access to a good life, through a living wage for not having the talent, desire, or mentality to be a doctor--much less a good one.

        Gentlemen, congratulations. You're everything we've come to expect from years of government training (Zed, MIB).

        by GreenMother on Wed Aug 07, 2013 at 04:04:17 PM PDT

        [ Parent ]

      •  Yes, but how well? It's your money (1+ / 0-)
        Recommended by:

        and the US system of high compensation for doctors is why our costs are so high.

        And that is a big part of why insurance costs are so high.

        I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

        by samddobermann on Thu Aug 08, 2013 at 05:25:54 AM PDT

        [ Parent ]

      •  Good doctors are some of the most ethical and (0+ / 0-)

        hard working of any people I know. They work long hours, they have to stay current in their speciality and they are always tied to their cell phones. They may get a few hours on the golf course, but that cell phone is always on and they are technically always on duty, even if they share a practice with other physicians. It is a hard job, if its done right, and most doctors take great pride in their work and should be fairly compensated for it.

    •  Capitalist medicine (22+ / 0-)

      Some people actually like being doctors and like healing the sick, irrespective of how much they're paid. Britain and Canada don't have multi-millionaire doctors, and they don't lack good doctors.

      Free markets don't work in health care. There's no option to not buy the product if you're sick unless you're suicidal. There's no opportunity to comparison shop if your child is bleeding. It isn't like shopping for cars or bananas, both of which people are free to forgo.

      The system we have is akin to having an unregulated, for-profit water utility. Water would be twenty bucks a gallon, and good luck living without it.

      The Bush Family: 0 for 4 in Wisconsin

      by Korkenzieher on Wed Aug 07, 2013 at 01:35:46 PM PDT

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    •  There is logic in your comment, but (21+ / 0-)

      it is not correct.

      I worked at the University of Chicago for ten years, where I knew quite a few foreign MDs.  I remember a conversation with an MD from Germany who was here doing research.  He told me that in Germany, doctors do not make anything comparable to the amount of money that they do in the US.  Regardless of this disparity in income, I have not heard anything about a critical shortage of medical doctors in Germany.  

      Another country that has outstanding health care is Cuba.  People go to Cuba from all over the world for medical procedures, and Cuba certainly does not have free markets.

      Two more points:

      1. Most doctors are disgusted with HMOs, because their ability to make decisions concerning their patients' care is severely limited.

      2. Most doctors do not choose to go into big pharma (where they are handsomely compensated), not due to financial considerations, but because they want to treat patients.

      I suspect that many people become doctors because they want to practice medicine, not to become wealthy.

        •  How many medical innovations (8+ / 0-)

          come from rich, dilettante doctors? Not many.

          The innovations come from the academy where no one gets paid very well. They come from people dedicated to the science, not people dedicated to the money.

          And by the way, most "Billion dollar drugs" also derive from research at the university level NOT from big pharma. It's only AFTER someone else does the hard work that big pharma steps in and reaps all the massive profits.

          •  They often come from people ... (1+ / 0-)
            Recommended by:

            ... who want to become rich.  And that includes the academy.

            •  Right now they are coming from people who are (0+ / 0-)

              often hated by the medical establishment.

              People who use supplements and dietary methods of treatment that are gentler than drugs with fewer side effects.

              I get excited about new cutting edge science in medicine, and then I remember--oh yea, that's only for rich people who can afford it.

              Gentlemen, congratulations. You're everything we've come to expect from years of government training (Zed, MIB).

              by GreenMother on Wed Aug 07, 2013 at 04:10:00 PM PDT

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            •  I'm in academia, in a technical field, (5+ / 0-)

              at an R1 (i.e. research intensive) institution. If I were at all interested in becoming rich, I would most decisively not have chosen this career path. Would I mind if someone threw money at me for some discovery I made? Of course not. Does the prospect of that happening influence what I choose to work on? Not in the slightest.

              And this goes for virtually all my colleagues. In this business, people are mainly motivated by things like curiosity about the world, the ability to be your own boss, accolades from colleagues, and the prospect of being able to contribute to the betterment of humanity. Money, beyond what you need to be comfortable, simply isn't a particularly important motivator.

              "A government that robs Peter to pay Paul can always depend on the support of Paul." - George Bernard Shaw

              by Drobin on Wed Aug 07, 2013 at 05:04:07 PM PDT

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          •  Kind of. (5+ / 0-)

            Big Pharma often pays university medical and chem departments to do research, which not only makes it possible to get research done without having to build labs of your own, but also gives plausible deniability in case of error, and great PR by allowing them to say "we support X!".  And once something is developed there, they step in and find a way to make it profitable, often by hiring the students who did the research.

            It's not a simple thing mapping the money and influence.

            I am not religious, and did NOT say I enjoyed sects.

            by trumpeter on Wed Aug 07, 2013 at 02:20:59 PM PDT

            [ Parent ]

          •  CaptianF - I have licensed drugs compounds (2+ / 0-)
            Recommended by:
            wilderness voice, guyeda

            from some of the top research universities in the US. At the point when these drug candidates are licensed about 10% of the money has been spent that will be needed to bring a drug to market. Add to that the fact that even with the most promising compounds, that are licensed based on data generated in university labs, most of them fail to make it all the way to market due to safety or efficacy issues.

            I know lots of scientists who are involved in drug discovery in university labs, startups and big pharma. They are all hoping that their inventions help people lead longer and healthier lives, but they are also very aware of the potential personal financial rewards of inventing a block buster drug.

            "let's talk about that"

            by VClib on Wed Aug 07, 2013 at 07:09:53 PM PDT

            [ Parent ]

            •  but in some cases it gets handed to them (0+ / 0-)

              parents raised the money and local doc did the vital intial work:

              But it was not until reading Natalie’s birthday wish in 2003 that Ms. Stack and her husband, Geoffrey, a real estate developer, formed the Cystinosis Research Foundation, raising almost $400,000 at an initial cocktail party.

               At about the same time, Dr. Ranjan Dohil, a pediatric gastroenterologist at the University of California, San Diego, who was exploring why Cystagon was so hard to tolerate, stumbled upon something. Testing a child who had a feeding tube, Dr. Dohil accidentally delivered the drug to the child’s small intestine rather than the stomach. He found the drug was absorbed better.

              Then Raptor ran the trials and got it approved.  The old formulation costs 9k/yr.  The Raptor formulation, same compound, which was handed to them, costs 250k/yr, paid for by yours and my insurance premiums for the benefit of their stockholders.
        •  You wouldn't know because of (0+ / 0-)

          the blockade or whatever we call it. Cuba has had to innovate because they can't get a lot of things that come from US or where we can call the shots (some medicines).

          Why don't you google Cuba medical innovation?

          I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

          by samddobermann on Sun Aug 18, 2013 at 05:45:41 AM PDT

          [ Parent ]

      •  And doctors that are only in it for the money (1+ / 0-)
        Recommended by:
        Cassandra Waites

        are not the doctors we should have in the profession.

        This diary is a case in point.

        "We must make our choice. We may have democracy, or we may have wealth concentrated in the hands of a few, but we can't have both." - Louis Brandies

        by Pescadero Bill on Thu Aug 08, 2013 at 07:14:27 AM PDT

        [ Parent ]

    •  'Way back in the early '80s, (1+ / 0-)
      Recommended by:

      the then-president of the Society of Critical Care Medicine made just that choice. He went to Big Pharma. Everybody was shocked back then, but I expect it's become more commonplace in 30 years!

      "Let each unique song be sung and the spell of differentiation be broken" - Winter Rabbit

      by cotterperson on Wed Aug 07, 2013 at 01:40:42 PM PDT

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    •  Disagree. I started out at Cedars Sinai and spent (14+ / 0-)

      more than a dozen years in LA & the Bay area as an RN in critical care. The best and brightest are generally there because they're driven to do what they do. Yes, they're often arrogant as hell and they make sure they're very well paid. But most would do it even if the money was considerably less, it's very attractive being that important to people.

      A lot of the ones who go into it specifically for the money are often the cosmetic surgeons and a lot of oncologists and gerontologists. The plastics guys work with mostly elective surgeries, (people with lots of spare cash to spend), and a fair number of those treating older folks do so because Medicare has historically been easy to scam. And we frankly wouldn't miss the sort of doc that those types tend to be.

      UK's NHS doesn't seem to have as much trouble as we do getting doctors to care for all segments of society. We have many areas in the US which are chronically underserved because docs can't pay off their school debt by working in rural and inner city areas.

      Yes, you get lots of brilliant, talented people aiming for the top of their fields knowing that they will make long tons of money, but there are an awful lot of people who have the impulse to help and heal and the smarts to learn to do it well. As someone who spent a lot of time in the trenches, I think the excessive monetary incentive is almost counter productive to the best health care.

      Information is abundant, wisdom is scarce. ~The Druid.
      ~Ideals aren't goals, they're navigation aids.~

      by FarWestGirl on Wed Aug 07, 2013 at 02:23:29 PM PDT

      [ Parent ]

    •  Free markets and the potential for profit provide (4+ / 0-)

      incentives for the greedy to enter the field.

      The 'best and brightest' enter whatever fields they find interesting and stimulating.  Some of the most intelligent people I know went into fields they knew would earn them pittances, simply because they loved the field.

    •  There's a middle ground (3+ / 0-)

      Not all generous compenstion has to be fee for service, and most doctors operating within it don't commit fraud, let alone completely evil fraud.  FFS can work as price discrimination for more difficult medical cases, but there are clear perverse incentives that need to be regulated away or mitigated.  It's already problematic to the extent it encourages specialization, where we get oversupplies of radiologists in some places and no GPs or internists in others, especially rural areas.  I don't claim to have the answer, but I like the idea of community health centers employing doctors directly or taking another look at the original Kaiser Permanente mutual model.

      Our own profession has moved towards more of a "free" market, and it's not the best and brightest who've made the most money, nor is it necessarily resulting in adequate compensation commensurate to costs of education.  A lot of that has to do with agency costs and auction paradoxes.  I guess I agree there's no straight line between a "profession" and economic gain, but disagree the market would automatically be the thing keeping salaries high.  I'm also not sure I'm worried about diagnosticians' or laboratories' margins.

      Difficult, difficult, lemon difficult.

      by Loge on Wed Aug 07, 2013 at 04:52:02 PM PDT

      [ Parent ]

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