September 23, 2009

Just Say No, Kids

The other day I was sitting around having lunch with the other fellows in my allergy program.  Talk turned to healthcare reform, and from there I had to ask the group: would you tell your kids to go in to medicine?  The nearly universal answer was a quick "no".  The lone exception was a pediatrician.  Which I think is revealing.

In general pediatricians, or pediatric specialists (pediatric cardiology vs. adult cardiology, etc), make significantly less than their adult medicine counterparts.  This is generally attributed to the fact that the complexity of medical problems is less in pediatric patients.  Allergy is an odd bird in that it is the only specialty that can be entered from either pediatrics or medicine, and you see both pediatric and adult patients in your training.  As people discuss reducing doctors' pay and other cost-cutting measures, you might expect that those on the lower end of the medical financial ladder would have the least incentive to want to perpetuate the career in their offspring.  But I think the variable here is that despite lower compensation, pediatricians generally like what they do a whole lot more than medicine doctors.  The money is secondary.  This is not to say that people going in to internal medicine or medicine specialties are in it for the money.  At least not initially.  I think the system makes our lives so messy and focuses on so many things other than the practice of medicine that it makes it about the money.  If you're going to have to put up with fighting through insurance prior authorizations, and lack of funds for the homeless guy you're trying to take care of, and 10,000 forms for every new patient... you're going to start to demand compensation for all the headache.

[As an aside, anyone who thinks that we don't already ration healthcare in the US has clearly never dealt with an insurance company.  We have a multi-level rationing approach.  Level 1) Do you have insurance or medicare/medicaid?  If not, you will likely not be getting basic preventative medicines or procedures because you can't afford them (a month's supply of the basic inhaled steroid we use for most asthmatics would cost you $80-100 a month out of pocket).  Level 2) If you do have insurance, will they go along with what your doctor wants to do?  You have to ask for permission for a great number of procedures and medications, which often are initially rejected to see if you're serious about it, and when you fill out more paperwork will be reviewed by the insurance company to see if they agree with the treatment, having never seen the patient.  In fairness, doctors when given free reign to do what they want may not give the most cost-effective medicine.  Rationing is not inherently evil, society just has to decide on what basis we're going to ration the limited resources we have.]

Pediatricians perhaps have fewer hoops to jump through, and unlike medicine it's easier to get kids on some type of insurance program, but the big difference is that they feel compensated by the act of caring for their patients.  Whether this is part of the culture of pediatrics, or just the nature of people who go into pediatrics I don't know.  But from talking to my colleagues who come through the medicine side of things, and from my dealings with adult patients in fellowship, I have to say that the reward of the job doesn't feel like adequate compensation.  So it comes down to financial compensation.  And increasingly doctors feel like we can't help people anymore, except to guide them through this giant machine that is our patchwork healthcare system as best we can.  It basically boiled down to "I'm not getting paid enough to put up with this".

Me?  While I am a pediatrician, I have to say that I wan't the pediatrician saying I'd encourage my kids to become physicians.  I think that the reality of what it means to be a doctor nowadays is very difficult to convey to people thinking of going in to it.  I heard similar complaints when I was entering medical school, but chalked them up to sour old doctors that weren't able to change with the times.  In retrospect I had no intention of hearing the downsides of a career in doctoring, and perhaps was a bit na├»ve in dismissing the complaints I heard.  If my girls want to be doctors, I would be all in favor of it, but I would do my darndest to make sure they knew what they were getting into.

By and large people felt that healthcare was still interesting and rewarding, but that having that shiny M.D. after your name wasn't likely to be the best way to be a part of the system going forward.  The general consensus was: tell your kids to be nurses, or PAs, or researchers, or policy makers, but momma don't let your babies grow up to be doctors.

September 21, 2009

Why So Contrary?

So after a considerable hiatus I've dusted off the blog.  I've imported most of the old posts here. It seemed a good idea at the time, but maybe I'm just furthering Google's takeover of all digital information in the world.  Who can say?

The last year has been interesting to say the least.  New job, new city, new baby, and along with it all a new year, a new president, and some new outlooks on life.  Living back in Dallas has reminded me of a lot of things I don't particularly like: consumerism, selfishness, insincerity of faith, disdain for honest thought or debate.  That's not to say I'm above those things.  In fact, what I think bugs me about them is that I see them in myself quite readily, either lurking at various depths beneath the surface, or bobbing merrily along on the waves and soaking up the sun.  But being back here has also made me very aware of something else.  I'm not sure I play well with others.  In Connecticut I rolled my eyes at all the liberal elitism and self-righteous political leanings.  Now that we're back in Dallas I can't stomach what seems like conservative greed, lack of concern for others, and self-righteous political leanings.  No matter where we go I think I'll be going against the dominant culture.

It's not helped by the fact that we live in a society where the majority opinion has little incentive to pay any attention whatsoever to the minority opinion.  Chances are that's just who I am; it could be that I just like to stir up trouble.  I probably should have been a lawyer after all.  (But I am rather fond of the fact that my dad speaks to me, and I can't guarantee that would be the case had professional arguer been my career choice.)  So while it normally seems to apply to contrary financial investment strategies, The Contrarian seems an appropriate enough title for this thing.  I'll try to periodically update with what's bouncing around in my head.

September 15, 2009