January 19, 2020

by drplasticpicker

It annoys me to no end when physicians (MDs an DOs) try to profit off other physicians that are lower than them on the training totem pole. Usually these physicians are trying to get out of doing real clinical work, and want to sit there and pontificate at meetings or attend conferences. So @drplasticpicker will now branch out of my environmentalism and talk about the state of student debt and financial health of MDs. Because if MDs are Financially Independent, than they can Save the Earth (FISE) – like drplasticpicker.

It is expensive to train a physician, and this cost is mostly born by tax-payers and society. Most reputable physicians are trained through residency programs that are AGME (Accreditation Counsel on Graduate Medical Education). As Professor Wellman from the University of Tennessee Health Center writes, “Most of a resident’s salary is funded by the United States government. This funding emanated from Congressional hearings which occurred during the formation of Medicare in 1965.” His article published in 2017 on the Huffington Post is very good, and explains the history of residency education funding and he blogs at www.medicalmalpracticeandthelaw.com

The other cost is carried by the student themselves. The private Ivy-League medical school I attended is now $95,055 a year. Looking at their website 4 years of a typical education will cost $396,415. My other choice medical school that I had been admitted to was UCSF, but I wanted to stay with Mr. Plastic Picker (we were dating back then) so stayed in Boston to train instead. It all worked out as we got married, and both work. UCSF School of Medicine is $72,787 for California residents now. Four years at UCSF now will cost $310,737! Geez-Louise. Our daughter says she may want to be a pediatrician. Maybe I’m not so FISE (Financially Independent Save the Earth) as I thought I was. No, we are actually fine and have saved up for the two kids college and graduate schools already. I need to look back at our financial records but when Mr. Plastic Picker (who as you know is an MD too) and I went to medical school it was about $45,000 a year, so in the last 15 years costs have increased over 200%.

It is a big deal to get to the day that as a young physician, you have graduated from your training program and is now are a board eligibe/board certified doctor. You can now work. Yet, there are some senior physicians who have prolonged this “training” period for those who are already trained.

Case in point, the explosion of “chief residents.” Being selected to be chief resident used to be an honor. There was one Chief Resident back 30 years ago for one program, and it was a very competitive process. That position was a stepping stone to an academic appointment or competitive fellowship like hematology-oncology or cardiology. Now the number of chief residents have exploded from one to sometimes three and in very small programs. One local program that I am familiar with, has three of the six residents in their class as “chief residents.” So you have a 50% chance of being a chief resident. Another local program, now there are three “chief residents” out of a larger class of 20 but in that year they do no clinical work and are not allowed to be attendings on the inpatient service – which was typically the carrot that attracted many to this role.

Wake up young susceptible trainees! Why do you think the medical establishment is handing out these previously hallowed positions? Because you are now cheap labour. You are a fully trained board eligible/board certified physician. They are paying you a resident salary to do attending work. When your program is farming you out to that community clinic to be “an attending” and you are seeing 15 patients in a half day, and you are so grateful to see patients but still just receiving your measly 60,000 salary and maybe a small stipend, there is an exchange of funds coming from somewhere. Someone is getting paid, it’s just not you. If an attending makes 200,000 a year, and they are paying you 60,000 – what do you call that? I call that exploitation of our young physicians. There is an opportunity cost to prolonging your trainig. I was a chief resident as well, and it was a very important year for my professional development. But I made this decision with my financial eyes wide open. That’s what happens when your father is an accountant.

Unnecessary fellowships. Fellowships are getting longer and longer. Why is it that adult internal medicine can train a pulmonogist in two years and in pediatrics our pulmonary fellowships are three years? Did you know there are now Pediatric Urgent Care Fellowships? What the heck is an urgent care fellowship?!!! I have joked at many meetings that I’m going to establish a Toddler Fellowship. I’m in charge of our pediatric urgent care and we don’t require a fellowship and I’m not urgent care fellowship trained. In fact these just started popping up a few years ago. I’m actually a general pediatrician who sees sick and healthy kids. Urgent care is just seeing sick kids. You don’t need a fellowship. You need to graduate and get a job and work, and ask questions to older MDs and read and don’t be afraid of learning procedures.

Not to out any specific hospital, but one nationally reknown children’s hospital has on their website. They are “delighted to announce that enrollment has opened for our new Urgent Care Fellowship for the academic year 2020-2021.” During this year when these fellows who are already perfectly eligible to work on their own, will instead be paid probably a third of what they would make actually working real jobs and instead work on

• Caring for patients directly in emergency and urgent care settings
• Supervising other trainees including residents, physician assistants and medical students
• Completing a comprehensive curriculum that includes conferences, didactics, courses, simulation sessions and workshops with a strong focus on academic excellence

Uh, isn’t that called just being a doctor? Oh, and there are 3 faculty that administer that program. I’m sure they sit at plenty of meetings and go to plenty of conferences. I’m a middle manager also, but I truly believe in our organization and we don’t exploit our younger physicians. This is because we aren’t focused on training. We are focused on patient care. I am a physician leader who helps manage 90 outpatient pediatricians and I do so in 6 hours a week. So in this academic urgent care fellowship, there are 3 faculty to manage 2 fellows at that “Urgent Care Fellowship.” Think about that people! Even if its just part of their salary, who is paying for that? The fellow? Tax payers? ACGME? I am not privy to their budget nor funding. Someone is paying.

Okay, @drplasticpicker got that off my chest. I can rant for another post about post-baccalureate programs charging 100K or more to do what I used to do as a premedical advisor. These programs adding another sometimes 50-100K to mounting young physician debt is immoral. I still sometimes will take on students, but I am so busy being drplasticpicker and my middle management HMO job that I just don’t have time anymore. But that reminds me I have 2 college interview reports to finish and one medical school recommendation letter to write. Oh, and guess what? I’m doing it for free! Because that is my moral responsibility as a phyisican that mentors. I was mentored by senior physicians who did not profit off me, and now I am paying forward. Being a physician is not an occupation. It is a calling.

So what began as a post about giving financial advice to medical students and residents became @drplasticpicker ranting about how difficult it is for young physicians. For my young colleagues, I see you. I see how much debt you have. I know life is unfair and a lot of your financial stresses are not of your own creation. I try to help you as much as I can. I see you picking up extra shifts from me and older physicians, just so you can buy some sort of condo and go on some sort of vacation while paying back your student loans. I see your concerns for your children. But I know that we and you are lucky. We work in an organization that is fair and physician led, and everyone gets a vote in our partnership. We have parental leave policies and you have sick days that you can use for your children.

We are a good group. So just remember to ask questions when we are working side-by-side. Don’t be afraid to text your leaders at anytime about clinical questions, these are the texts that we love! We are here to work on budget, work on patient access, work on quality metrics – but we are also here to teach you. We know that it is scary to go out and practice straight out of training, but we believe in you and we don’t want you to have to waste your time nor money on an urgent care fellowship. This is why we hired you. But you have to work, you have to attend our FREE CMEs, you have to use your educational leave for educational purposes. Most importantly you have to ask questions and care about our group and our patients – and that is how you become a doctor without prolonging your training. Dr. Plastic Picker wants you to be FISE – Financially Independent and Save the Earth.