Should aspiring pre-meds read this book? Doctored

Parent Cafe
41

Wouldn’t primary care physicians have some of the most challenging cases, since someone could walk in with anything (or nothing but hypochondria) that the primary care physician needs to figure out (and direct to the appropriate specialist if necessary)? Obviously, they do not seem to be compensated in accordance to their importance in the medical care system relative to some other specialties.

Emergency room physicians may have even more challenging cases, where accurate medical decisions need to be made quickly to keep the patient from dying.

42

Yes, the PCP directs the more complicated cases to the specialists. Read SDN. The medical students there are gunning for high Step 1 scores so they can get into residencies like ortho, derm, rad onc, etc. One wrote recently that a low Step 1 score doomed him to family practice. That’s the mentality. Combined with lower pay, lower status in the medical community, burdensome electronic medical records keeping, it’s no wonder.

43

Assuming that this is true, it makes me feel less “guilty” about asking our child to be loaded with student loan debts for his med school. (Not 6 figures yet fortunately after the very last tuition bill has been paid - not all private med schools are very expensive if you are relatively poor.)

44

http://www.bloomberg.com/news/articles/2013-04-11/medical-school-at-278-000-means-even-bernanke-son-carries-debt

A very good article on the whole issue.

Medical school was affordable in the 1970’s. But tuition and fees are 16 times what they were then.

45

Actually this is not true within the medical community.
Primary care physicians are the gatekeepers, they refer patients to specialists, and the specialists depend on them to get their referrals, hence the primary care physicians are treated with kid gloves.

In the same vein, the cardiologists will direct skin cases to dermatologist. It’s not about the complexities,it’s not what they are trained for.
The PCP is the diagnostician, which requires far more skills in the real world.
They are less well paid because the medical world rewards procedures.

46

@Miamidap, I think you must have missed my several posts about my niece getting 3 full tuition scholarships to medical school. She attended an Ivy undergrad.

47

Are there any statistics showing that those who graduate medical school debt-free being more likely to go into primary care? Not those whose COA is paid in exchange for promising to practice rural medicine or in some equivalent program but those who come from affluence; those whose parents are paying the tuition and don’t expect to be paid back.

48

But a handful of the highly selective colleges offer need-based scholarship. Isn’t it true that Princeton has had a “no loan” FA policy for quite some time?!

I sometimes wonder whether there is a big difference for the out-of-pocket expenses for the students with a great need when they attend these colleges with an extremely good need-based FA policy vs the colleges with a “full ride”, assuming that the former could possibly take advantage of an easier access to a “need-and-unit-loan”-based med school due to the inbred or incest phenomenon. To MiamiDAP: I am referring to your D’s case vs GAmom’s D’s case here. (They could pay less at their need-based med school but they need to get in first. Of course, if we really want to count dollars and cents, the best deal is a “full ride” at a “lesser” college which is willing to “buy” their students and follows it by a “need-and-unit-loan”-based med school or the selective few “almost full tuition” merit based schools. Some may have managed to get it but in general there are not that many such opportunities.)

49

http://macyfoundation.org/docs/macy_pubs/pub_grahamcenterstudy.pdf

Students with no debt were the least likely to go into primary care. Students with debt above $250,000 also less likely to go into primary care. Students with ‘middling’ debt and some scholarship money were the most likely.

Other interesting findings: Married students were more likely to do family practice. Female students least likely to practice in a rural area.

50

If my memory serves me well, it seems UChicago has a higher percentage of their kids going into primary care. The following may be somewhat related:

  1. They have a relatively generous FA for many of their students. So their average debt may be lower.

  2. Their students seem to have a lower STEP-1 average.

  3. The mission of this med school is such that those high stats kids without other soft qualifications may not be that valued (as compared to, say, WUSTL.)

Actually, the “top” med school where the wife of the CEO of Facebook attended seem to share a little bit the same characteristics (albeit it has the notorious “California med school” effect so its standard is high.)

At one time, I mentioned that someone (I forgot the details) went into the primary care. My S’s reply: “He is a true hero!” Not sure whether he will be different after a few years into this “endeavor.” (I heard he is currently not into a competitive specialty, even though I think his step-1 is likely on the high side - likely one of the top 10 or so scorers in his class (in my guess, but I am biased.))

51

It is troubling to read comments made about Obamacare that are completely false when it has resulted in more patients in the system receiving care. But I will avoid falling into a politically based debate.

The economic pressures are real because a lot of physician practices have been purchased by profit seeking management companies. Physicians working for these entities find themselves under pressure to maximize RVU productions sometimes under unsafe conditions. There is still a lot of money in medicine for those who pursue it strictly from an economic perspective. Orthopedic and spine surgeons earning $2 million+ per year, etc are not uncommon. At the same time as their physician employees or counterparts struggle to earn less than average.

I do think that aspiring physicians should learn as much as they can about the medical field including reading the book. Nevertheless, I am not sure how much good it would do when they can’t relate to the issues physicians face. But if there is one advice that I think is universal, spend as little as possible to obtain your education.

52

It’s a helpful for a student aspiring to enter any profession to have an accurate view of that profession, including economic factors. However, I don’t think reading one person’s extremely biased view is especially helpful to that effect. It would be more helpful to focus on what is common, rather than the experiences of one particular person.

I do think that a good portion of aspiring pre-meds are in the field for the wrong reasons. For example, in my freshman year of college I once asked my next door dorm neighbor why she was interested in medicine. Her answer was something like, “You know when parents ask what you want to be… they want you to say doctor.” She seemed interested in pleasing her parents, rather than being truly passionate about medicine. There are also pre-meds who are primarily interested in the field because of societal views of the position in the United States (different from most other countries) or high income expectations. Such students probably have a higher risk of becoming disillusioned physicians than someone who truly enjoys the field and is truly passionate about helping people.

Regarding debt and financial considerations, yes medical students typically have a high debt load and very late start in achieving higher earnings, but by the time they reach middle age, physician’s median net worth has been historically quite high… near 7 figures. I realize debt load was lower in the past, but not enough to negate the higher middle age net worth. Becoming a physician is certainly not a quick and easy way to become wealthy, but it also does not destine one to a lifetime of struggling with debt and other financial difficulties.

53

Have you even read the book? I’m wondering where “extremely biased” came from.

And future doctors might find it interesting that much of the teaching of the practice of medicine is done by “clinical pearls” which are (wait for it) the experiences of one particular person

54

I’ve skimmed through the book and reviews. Many of the reviews from practicing physicians mention different experiences, and physician friends have mentioned different experiences as well. This leads me to believe that it is not a good representation of all physicians, so it would present a biased view for aspiring pre-meds, much more so than focusing on what is common among a larger group instead of experiences of a single person who sounds like he went into medicine for the wrong reasons. Some specific comments about the book are quoted below:

*“I read this book and was profoundly disappointed by it. Dr. Jauhar seems to work in a very small world of status-seeking and business-minded physicians. He does not at all represent the hard-working, dedicated doctors who work in primary care, as I do in pediatrics, and really look after patients with the genuine care and concern that is so needed in modern medicine.”

“As a physician, I was eager to read Dr. Jauhar’s book. As a primary care physician in private practice, I was a bit appalled by what I read. While I do agree with Dr. Jauhar’s musings on the state of medicine, his portrayal of private practice doctors was disheartening and not consistent with my experiences.”

“A layperson who reads this book might assume that most if not all doctors engage in this behavior. As someone in private practice who started his own ophthalmology solo practice last year, I can assure you that this is entirely false; I do not order unnecessary tests, perform unnecessary surgery or refer for the sale of referring. Perhaps I am naive but I find many (but not all) physicians behave the same way as I do.”

"This is a most odious book that surely does not speak for most American physicians. These are the reflections of a man having a breakdown because he hates his job and his profession. "

“What seems clear is that Dr. Jauhar went into Medicine to please his parents, and to try to keep up with his older brother, not because he really wanted to. It seems like he lacks “the calling” and nothing short of accolades and more money will make him happy.”*

55

I recommend reading KevinMD.com. Great blog and blog aggregator.

56

So you haven’t actually read the book. Thanks for owning up to that.

Word choice means a lot, does it not? Before you termed the book “extremely biased” but now we have moved to “not a good representation of all physicians” based on what you’ve read/heard. Regarding that – a quote by Sinclair Lewis comes to mind. “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” Are you truly surprised that your pals object, would you have expected them to say anything different about how medicine (and implicitly them) practice?

Nor are physicians and the press monolithically rejecting the book.

*“Sandeep Jauhar is a compelling storyteller, and Doctored gives us a fantastic tour through the seedy underworld of American medicine.”
—Lisa Sanders, M.D., Assistant Professor, Yale School of Medicine, and author of Every Patient Tells a Story

Doctored takes us behind the façade and allows us to see the seamy underbelly. Jauhar’s gift is to observe and to beautifully tell the stories. In doing so he leads us to a visceral understanding of what has gone wrong. Doctored is a manifesto for reform."
—Abraham Verghese, M.D., author of Cutting for Stone

“Sandeep Jauhar specializes in peeling back the veneer, revealing the discomfiting truths of today’s medical world. He is unafraid to dig deeply and honestly, both within himself and within the medical profession. Doctored raises critical questions that twenty-first-century medicine must answer if it is to meet the needs of its patients as well as of its practitioners.”
—Danielle Ofri, M.D., Ph.D., author of What Doctors Feel: How Emotions Affect the Practice of Medicine

“An extraordinary, brave and even shocking document. Dr. Jauhar’s sharply observed anxieties make him a compelling writer and an astute critic of the wasteful, mercenary, cronyistic and often corrupt practice of medicine today.”
—Florence Williams, The New York Times (Science)

"Jauhar takes a bit of a risk in using his own story to illustrate the many complex problems of early 21st-century American medicine. This beautifully written and unsparing memoir puts a human face on the vast, dysfunctional system in which patients and clinicians alike are now entangled. "
Suzanne Koven, M.D. book review in Boston Globe

“It’s not news, of course, that our medical system has become dysfunctional. But Dr. Jauhar’s personal account shows that brokenness on a human scale, starting with the doctor-patient relationship, which is in tatters. Dr. Jauhar doesn’t offer much in the way of solutions to the system’s ailments, but this thoughtful telling provides a service in itself.”
Susannah Meadows, The New York Times (Books)*

57

I changed my wording to something that I thought you’d be less likely to nitpick. I guess I was wrong.

It’s not a question of whether some persons praise the book. The question is whether the book is a representative experience. Sure there are doctors who enter the field in an effort to please parents, give patients unnecessary surgery, etc. That’s interesting reading, but that does not mean it’s a representative experience of what pre-meds can expect to feel and experience if they enter the field. For example, I enjoyed watching The Social Network and would give high praise to the movie, but I wouldn’t say all aspiring CS majors should watch the movie for a representative experience. It’s often the case that most interesting books and movies involve persons who had unique experiences, rather than the ones who had the best representation of the average.

58

Exactly. At some medical schools, to address that problem, I presume, students considering Primary Care are celebrated and the ones heading to specialties are actually afraid to let their intentions be known because of the discrimination.

59

<<<TatinG wrote:
In D’s medical school class of 150, when asked how many planned on becoming primary care physicians, 6 raised their hands.


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AT what point was this asked? As MS1’s??

I think many enter med school with high hopes of being surgeons and other highly competitive specialties, but then as they see that they’re not “top of class,” or as they do rotations in years 3 and 4, some realize that they are never going to get into those specialties or they discover that they actually like primary care.

60

I’m not aware of any large body of consensus yet on that. There were no comprehensive problems with the “old” system except that the payers were unable to adequately (for their purposes) control the way medicine was practiced. Same with the Patient Privacy laws. The only problem previously was that the powers that be did NOT have the implied right to see your records, but now, when you sign the forms acknowledging your rights, you give that right away.

*"Benefits of EMRs probably increase with larger practices where many physicians may benefit from easier access to the records of a patient who is seeing someone other than his/her regular primary physician. "*Their EMRs are just as bad as everyone else’s. The actual result has been to pasteurize the records so they all look the same.