<p>PSedrish, can you tell me more about opening your own practise and about HMOs. Is working for a hospital the same as working for an HMO. Are there classes in med school about opening your own practise or hiring people?</p>
<p>Few docs work for hospitals per se (with the very notable exceptions of hospital based kinds of practice such as radiology, pathology and anesthesiology), though all docs are associated with hospitals once in practice, as you need a place to admit your pts when they're sick. </p>
<p>However, if a hospital needs more practitioners of your specialty on their staff (eg. there may be a shortage of Infectious Disease specialists in your town, or the only one in town may limit him/herself to another hospital), that hospital may set up a "recruiting pkg" to lure you to the area. These usually feature some start up assistance, staffing & billing help and an income guarantee for a year or two while you get going. </p>
<p>In the alternative, going to work for an HMO or a large group practice is like joining a law firm. You start at the bottom, work like a dog and own nothing until you become a partner. There is certainly no guarantee that you will become one either.</p>
<p>There are few or no courses to prepare you for private practice in most med schools. I suggest using your college electives to learn something about business. </p>
<p>Self employment is still doable and for an independent-minded person, and probably worth doing, though who knows what the economic model of medicine will be in 20 years?</p>
<p>i hear that we might be moving twd single-payer insurance by the end of 2005. i'd like that.</p>
<p>Can you tell us about the more 'academic' types of doctors? Professor so-and-so at Blah Hospital, Chief of Surgery... what is that career track and lifestyle like? My dermatologist is/used to teach at NYU while running his practice.. is that common? Are 'attending physicians' academics or clinicians or what? Since they manage and teach residents, I'm guessing they are more academic. Or does it depend on the type of hospital? Do people tend to take these attending positions at hospitals after residency or go right off into private practice? Thanks 8)</p>
<p>what is single-payer insurance, sar?</p>
<p>First, the single payer thing: The best example is Canada, where there is guaranteed, govt managed health care for everyone. Doctors are paid thru the govt for all the svcs they render. It may be the way we are heading, but believe me nobody knows. It sounds great, but of course there are drawbacks.
From a pt's perspective, svcs aren't available the way they are here. If you need your gallbladder out here, it'll be done tomorrow; in Canada it might be 3 months from now. Likewise, if you need a CT scan here you'll get it this afternoon at whatever facility you select. (My town of roughly 30,000 has at least 4 CT & 4 MRI scanners, plus a PET scanner or two). In Canada, there may be 1 CT scanner per county and the wait may be weeks or months. Americans just may not adapt to this kind of approach, but who knows.
As for the docs, we'd love a generous single payer. Right now, my practice bills hundreds(!) of insurance companies per month, some for just one fragment of the care provided. One pt may require as many as 6 different bills to be produced & printed, mailed, data-entered, tracked, collected, posted, balance-billed, etc.
The result: more than half my staff and most of my equipment comes from the cumbersome billing system in place today. I estimate I could cut visit costs by at least 1/3 if everyone paid cash.
So if the single payer eliminates all that, I think most American docs are open and ready.....but....who decides what we get paid and how do we influence that process and its ongoing adjustments? As it is, govt sponsored insurance plans (egs., Medicaid, Medicare, TriCare) all pay very poorly relative to private payers like Blue Cross. Most practices (mine included) would fold in a month or two if all pts had to be seen at Medicare rates only.
We are, therefore, very apprehensive about this kind of proposal.</p>
<p>Academicians & clinicians: Medical school faculty are almost always academicians with little real clinical interest, though as MDs they have some clinical knowledge and do spend some months on the wards rounding (and teaching) with med students and housestaff. Most of these folks dread those months. I find their bedside manner usually mediocre and their actual clinical skills not much better. This is not so surprising as they chose their working environment based in no small part on their preference for the cloistered life and their intellectual pursuits (bench and/or clinical research and its subsequent publishing opps). Also, their clinical experience quickly falls behind that of their non-academic colleagues just based on the sheer volume of pts seen by the latter relative to the former (example: my closest faculty mentor as a fellow had a private clinic twice a week where she saw 5 pts per afternoon, for a grand total of 10 pts per week; I see, in private practice, over 100 pts every week.)
Let me say here that this is a gross generalization and most of the truly talented and gifted docs I've met have been at med schools.</p>
<p>Now, as to clinicians: They generally practice in the community and are self-sustaining financially. As all docs must affiliate with one or more hospitals so they can admit pts and do procedures, these docs will serve on the medical staff there and rotate responsibilities, such as the title of Chief of Staff. In most places, this is a burden that eveyone tries to avoid but eventually gets saddled with for a year.
If your hospital happens to be affiliated with a med school (though in this case it would not be the med school's primary hospital but one of its outlying affiliates), the med staff often get clinical faculty rank at the med school and do some teaching both at their community hospital and at the med school. Clinical faculty rarely get paid (it's an honorary title but the teaching hours are real enough). I think clinicians generally have better bedside manner than academicians and better clinical skills, but are often behind their academic colleagues in terms of new studies and early treatment trends. This too is of course a generalization.</p>
<p>My approach to this interpretation of the facts has been to refer my "tough cases" back to the med school for an academic opinion, which mixed with my clinical approach might just render the best result. </p>
<p>In any case, both kinds of docs co-exist and are necessary, and both are usually fully competent.</p>
<p>If you graduate from a prestigious med school (i.e. Harvard, Duke, Penn, JHU) will you make more money working for a hospital or privately?</p>
<p>Nope, you'll almost certainly make less as a JHU Professor than as a gastroenterologist working in private practice in a busy suburban community hospital. Maybe 1/2 as much. No kidding. That's one of the reasons the geniuses resent us so much.</p>
<p>PSedrishMD, are you in a hospital or private practice?</p>
<p>I am in private practice mostly affiliated with several community (non-teaching) hospitals, but I serve on the clinical faculty of Tulane and teach mostly 4th year students doing Rheumatology electives.</p>
<p>PSedrish, how do grades in med schools work? How are you placed for your residency? Do they see your board scores?</p>
<p>Dr Sedrish--I've been reading your responses and find them to be very informative. However, I have a question that I'm really confused about.</p>
<p>Are you sayign that doctors who set up a private practice earn more than do doctors who work in large city hospitals?
I don't want to set up a private practice, mostly because of the risk of losing profit and being tied down to one place for the rest of my life. </p>
<p>What are your thoughts on this?</p>
<p>I am only a sophmore in HS but I was wondering whether the name of the school you go to for your Undergrad and/or your graduate(medical School) matter when finding a job as a cardiovascular surgeon? I am debating on whether trying to get into Dukes full 8 year med program or UF's 7 year. I know getting into Duke would be very hard and my grades are not perfect. This year my GPA dropped some from the 4.0 I had last year. I am in challenging courses since I am in IB and I am going to continue IB throughout Junior/Senior years. If any of you surgeons/doctors out there could just help me decide on which path... Duke (Pay more, 1 more year) or University of Florida (Not such good name, maybe less one year, and much less tuition). If I go to UF woudl that decrease my salary? Does it matter at all? Also... after residency... do most surgeons start their own practice or find work at hospitals and whatnot? If you go to practice yourself, then Im thinking that what school you went to flies out of the window right?</p>
<p>Heh.. another question: If I wanted to go to Duke, should I go there for my undergrad too and then apply to its med school from there?
Thanks</p>
<p>Stoned: Grades work a lot like college, especially in the first 2 years. Residency selection is quite a process. Generally known as "the match", it is well covered on its own website: <a href="http://www.nrmp.org/%5B/url%5D">http://www.nrmp.org/</a></p>
<p>antique How and where you practice depends a lot upon your specialty. If you are an ER doc, you'll probably work for a hospital or a group. If you are a cardiovascular surgeon, you're more likely to be in a private practice or working for an HMO.
In any case, docs who work for themselves usually earn more than those who work for someone else; this is a result of basic principles of business (egs. nobody will pay you more than you're worth, you'll work harder if you have more incentive to do so, etc.).</p>
<p>drag If you can get into a combined pgm, it's probably a good idea to take it. If not, go to any undergraduate school you're comfortable with and do as well as possible. A high GPA and good MCATs from a good (not necessarily great) school should be enough to get you into a med school.</p>
<p>The quality of your med school and your med school performance will determine where and in what specialty you get a residency. Once you have your training pgm, high prestige places (eg. harvard) will aid you in getting faculty jobs at other high prestige places, but that's about it.
An Internist who graduated from Texas Tech undergrad & UF for med school and trained at LSU and is in private practice in Oklahoma City will probably out-earn an all Harvard educated Internist practicing in Cambridge.</p>
<p>I was under the impression that they gave out Pass/Fail instead... And I've been to that website and I can't for the life of me find what they require! I know they put your name into a big computer and if you don't get selected you have to scramble, but what are their criteria for selection?</p>
<p>And why will the Texas Tech guy make more than the Harvard guy? Because there aren't enough internists in Oklahoma City?</p>
<p>I believe med. school grades work under some variation of High honors, Honors, Satisfactory, Unsatisfactory or High Pass, Pass, Non-Pass (or Fail, I guess).</p>
<p>But I think this is maybe jumping the gun a bit - focus on your high school grades, then your college grades first. Hopefully good study habits honed in these years will ensure continued success, regardless of how it's measured.</p>
<p>Yeah. I for into the University of Pennsylvania. I just want to know what criteria are looked for in residency admissions.</p>
<p>Stoned: Income for a doc depends upon the number of pts seen per day and what you are paid for each one (not what you charge). No matter where you practice, seeing more than 30 pts a day for an Internist is difficult (one must be thorough with each pt). Honestly, by the end of the day I am too tired sometimes to fully think through a problem set and may wind up temporizing that pt by getting some initial labs and films and then seeing the pt again the next day when I am fresher. (of course this is for a non-urgent problem)
The income derived from these 30 encounters has little to do with what one charges but rather with what insurance companies pay. If I charge $100 for an office visit and Medicare says it's only worth $40, they will send me a pmt for 80% of that and then the pt or their secondary insurance pays me the other 20%, or $8.00.
It is illegal (federal fraud) to try to collect more than the $40 Medicare allowed, unless you formally drop out of the Medicare pgm (very hard to do) for at least a 3 year period. Even then you are only allowed by law to collect 110% of the Medicare allowable.</p>
<p>Now, not all pts have Medicare, some have "better" HMO & PPO plans (like BlueCross). These used to pay nicely, but now most of these plans, knowing you accept Medicare, quickly adjust their reimbursement rates down toward (and in some cases even below!) Medicare rates. </p>
<p>A few pts pay cash (always welcome), but one has to try and cut them a break out of conscience most times, as they are often poor. </p>
<p>The net net is that we are able to collect about 55% of our total charges; the rest go into the trash. These numbers apply essentially the same to the doc in Mass as to the doc in OK. The difference is in overhead. Rents, insurance, utilities and salaries are much lower down south than they are in the northeast or west coast, so out of what is essentially the same revenue, the OK doc takes home more money.
He/she also finds that life there is cheaper (housing, etc.), so with more money taken home in a less expensive environment, of course that doc has more purchasing power from the same labor.</p>