October 26, 2010

Why Do Doctors Accept Gifts, And What Would Happen If They Didn't?

clinton.jpg
fine, I'll just do psych




Is the acceptance of Pharma gifts/honoraria/grants a way of supplementing an income that the medical student expected he would earn, or expected he deserved, in the future-- that didn't materialize?

Apparently not.  A study of medical students found they underestimated their future incomes.


students perception of incomes.png

Pre 1980, med students overestimated the salaries.  After 1980, they underestimated them. Let it sink in, it's pretty easy to retrofit an explanation: after the healthcare overhaul of the 80s (and the lead up to it), post 1980 medical students were trained by doctors who felt "harmed" by the changes.  "Man, it was so much better 5 years ago..." and etc.

The the Clinton years-- both Clintons-- and the prospect of even more severe changes made students even more pessimistic about their salaries.

But think about this.  In order for them to have underestimated, what they thought was going to happen must not have actually happened.  e.g. a 1993 med student made a prediction based on Hillary Clinton's reforms-- which didn't happen.

So a medical student today, making predictions about the future based on the current health care debates, will either be accurate, or will underestimate.


II.

But, as usual, it's more complicated than that.

That graph shows the means of the students' errors.  How variable were the guesses?  Hugely. 10% of the 4th year students overestimated the incomes by 40%.  Did they go on to take Pharma money? 

While most specialties were underestimated, where did students overestimate?  Psychiatry, by 23%!

Worse, 10% of first year students overestimated incomes in surgery, pediatrics, and psychiatry by 60%.  That would be a life plan oops, solved only by...

So while the proposed reforms in internal medicine didn't happen-- or docs were able to compensate for them-- psychiatry did, in fact, dramatically change.  And, not surprisingly (from an economic standpoint) psychiatry found a stop gap.

III.


Along with expectations, there is the reality that doctor salaries (with notable exceptions) have been fairly static since 1969:


physician salaries 1996.png
even as the cost of living, price of homes, college, etc have gone up.  And medical school debt.  

But what's not pictured here is how the atual work of medicine has changed, even if the incomes are the same.  1969 psychiatry was slower, more therapy based than today's 15 minute med checks.  You read medical journals-- and books-- at work.  Now you don't even read your text messages. You can argue the merits of either, but the current system incentivizes doctors to see more patients, faster, for more limited problems.  In 1969 a GP would handle multiple problems; now multiple doctors handle each problem.  I'd predict that the time spent by all 2010 docs collectively is still less than the one guy spent in 1969.

Could a psychiatrist able to make Pharma money just turn his back on $40k extra a year?  It's a cold decision to make when you got one kid in college and another on deck, suddenly public ethics takes a back seat to private ethics: what would you do for your children?  Jean Valjean a bakery?   Sling crack?  Sell it if it was legal?   Rob a crack dealer?   Well, you don't have to yet: just give a lecture about Effexor.


IV.

The part of this that is absent from the healthcare debate is that the people who would most likely complain about the changes in psychiatry are less motivated to do so because their incomes are being supplemented by Pharma.

My point here isn't to engage in an ethical debate, but to bring up the practical one: if you stopped all Pharma money to those that receive most of it-- e.g. academic docs who "also"  get grants to do research, etc-- it's almost certain that they would mobilize to demand higher reimbursement rates, not passively accept lower ones.  The healthcare debate would be turned upside down, from finding ways to "cut costs" to finding ways to "more fairly reimburse doctors."

"Psychiatrists shouldn't do it only for the money!"  Of course, but it's hardly less honorable to not go into psychiatry and go into neurology instead.  Leaving it to be staffed by NPs, which is the immediate problem in family practice.  Of course I know most psychiatrists don't take/aren't offered Pharma money.  But, to repeat, the ones who are likely to be most influential in setting healthcare policy-- academics-- do.  As do the academic departments, who rely heavily on grants to pay for salaries, overhead, and that new Research Centre that just went up.  I'm not blaming them, they may not even realize just how much of their existence is subsidized by Pharma, I'm simply stating a fact.  Stop the Pharma money, and you are quite likely to arouse a sleeping giant.  Harvard's gotta eat.

I am almost tempted to wonder if the rise of Pharma money 1996-2008 wasn't consciously encouraged by policymakers precisely to allow the policymakers the cover to get away with the sort of changes that happened in psychiatry.  Another mercantilist conspiracy theory, I guess.

No doubt people are going to respond that doctors make plenty of money already.  This is not the point.  Each individual doctor is making that determination for themselves, even if they're wrong you won't be able to convince them they're wrong.  And their perception, wrong or right, is going to drive them to make choices like: take Pharma money, go actually work for Pharma, go to another field, go to another job, do/not do only 15 minute med checks, leave Cleveland for San Francisco, etc.

No doubt, doctors universally would be happier with higher reimbursements and no Pharma money. It's not obvious patients would be better served-- psychoanalysis was not Pharma sponsored-- but things would defintely change in some way. 

Time: "The new legislation adds a 10% bonus to primary-care physicians' Medicare reimbursement salaries. But this is nowhere near enough. We need to see a 30% to 50% increase in salaries overall to make any real change in the system," says Dr. Lori Heim, president of the AAFP.
But I'm not sure it's actually possible.

V.

An interesting experiment is to open a forum to solicit practical ideas for reform that takes into account the unintended consequences of the reform, and accounts for them.   To crowd source a crowd's problem. 

It's an experiment because-- hypothesis-- people don't actually care about practical solutions, they are much more interested in their own anger, and will sabotage a potentially useful forum in order to vent it.  They will sabotage the country, just to be able to yell.

If I had to name the specific problem with political debate post 1992, that would be it.  And yes, there's a word for it.




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Comments

I'd like to see those graph... (Below threshold)

October 26, 2010 12:32 PM | Posted by BHE: | Reply

I'd like to see those graphs continue another 8-12 years...

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Alone's got to be kidding i... (Below threshold)

October 26, 2010 12:42 PM | Posted by Jack Coupal: | Reply

Alone's got to be kidding if he thinks today's med students will guess their future income accurately or underestimate it.

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how about we take away doct... (Below threshold)

October 26, 2010 12:49 PM | Posted by randy: | Reply

how about we take away doctors' monopoly powers to subscribe meds? how about we go after their other monopoly powers. there's no way you need 12+ years of education beyond the K-12 to treat sick people.

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Apparently you need over 12... (Below threshold)

October 26, 2010 1:07 PM | Posted, in reply to randy's comment, by AnonyMouse: | Reply

Apparently you need over 12 years for proper grammar, word use, and punctuation.

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"subscribe meds"? I'd say i... (Below threshold)

October 26, 2010 1:14 PM | Posted by Anonymous: | Reply

"subscribe meds"? I'd say it's more than just grammatical ignorance informing that particular comment.

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The other end of this cycle... (Below threshold)

October 26, 2010 1:36 PM | Posted by K2: | Reply

The other end of this cycle is that the more pharma pays physicians, the more they pass the cost on to the patients through drug sales. So the actual cost for diagnostics (to see a doctor) goes down (or is stable); however, the actual price of treatment (drugs) goes up. And, thus the cycle continues.

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Okay, I have an idea: Let'... (Below threshold)

October 26, 2010 3:11 PM | Posted by RC: | Reply

Okay, I have an idea: Let's pay doctors less, but treat them better.

That means don’t burden doctors with the responsibility for paying for malpractice insurance or their medical education. Also, don’t subject them to brutal training programs that deprive them of sleep, food, and water for 36+ hour shifts.

I can see why a doctor needs to be exceptionally brilliant, but he/she does not need the physical stamina of a Navy Seal!

Maybe I’m being myopic, but perhaps such changes would encourage people to enter medicine for the love of it. Those who are more interested in money will have greater success studying business or law (in fact, that’s probably already the case).

Can anybody think of some unintended consequences to this plan?

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In many cases, assessment i... (Below threshold)

October 26, 2010 3:45 PM | Posted by Gary: | Reply

In many cases, assessment is the only value a physician contributes in a manner that a computer program could not. Even assessment can be scaled so that a patient can assess him/herself.

With the exception of delusional disorders, would psychiatric outcomes decrease if care was provided at electronic kiosks? A "self-scan" psychiatrist would perform just as well.

Yes or no questions. Current meds. Medical Hx. And the software determines your pill. Or prints a requisition slip for blood work.

What? You think compassion and understanding takes place during a med check?

The length of medical school required to provide psychiatric care is excessive.

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hypothesis-- peopl... (Below threshold)

October 26, 2010 6:11 PM | Posted by Anonymous: | Reply

hypothesis-- people don't actually care about practical solutions, they are much more interested in their own anger, and will sabotage a potentially useful forum in order to vent it. They will sabotage the country, just to be able to yell.

If I had to name the specific problem with political debate post 1992, that would be it. And yes, there's a word for it.

Is this the word?

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RC, The long shif... (Below threshold)

October 26, 2010 8:07 PM | Posted, in reply to RC's comment, by Jack Coupal: | Reply

RC,

The long shifts are necessary to prepare someone to be able to make correct decisions under lack of sleep and fatigue. Kind of like a soldier, but not as extreme as a Navy Seal. Intentional stress is necessary as part of all physicians' basic training, even though a psychiatrist is not likely to make decisions under such conditions.

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Seeing that graph and readi... (Below threshold)

October 26, 2010 10:02 PM | Posted by Anonymous: | Reply

Seeing that graph and reading today about the Josh Timonen-Richard Dawkins fiasco, wherein a number of IT professionals have commented at RespectfulInsolence, ERV, and Pharyngula, that webmasters routinely make six figures, I am disappoint in this whole psychiatry gig.

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"...but perhaps such change... (Below threshold)

October 27, 2010 3:20 AM | Posted by Anonymous: | Reply

"...but perhaps such changes would encourage people to enter medicine for the love of it."

They're called Nurse Practitioners.

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It's a tough world. There a... (Below threshold)

October 27, 2010 4:35 AM | Posted by David: | Reply

It's a tough world. There are all sorts of people who thought they'd be making more money than they are. Of course, their complaints are dismissed by invoking the "free market" forces mantra rather than consoling them on their "perception of potential loss."

Just as an FYI, I expect to make 20% more this upcoming year because ... I think I should. However, if, doG forbid, I fail to meet these expectations, I'm so there for speaking on subjects I've been given literature on. Really. I'll do it.

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"The healthcare debate w... (Below threshold)

October 27, 2010 5:02 AM | Posted by Dave: | Reply

"The healthcare debate would be turned upside down, from finding ways to "cut costs" to finding ways to "more fairly reimburse doctors."

Doubtful. I'm going to borrow your Wallace Stevens Roman Numeral style in my response.

II. The biggest fiscal challenge this country faces are entitlement costs rising at 3x or more the rate of our GDP.

III. A good chunk of that money goes to physician comp via Medicare and Medicaid.

IV. Medicine is the only profession whose wages aren't lowered by immigration, since the barriers to qualified foreign physicians practicing here are huge (requiring them to re-do their entire residencies here).

V. More likely than finding ways to "more fairly reimburse doctors" would be efforts to lower the barriers to importing qualified foreign physicians, probably by scaling back the requirement for them to redo their residencies here.

VI. Physician comp will probably mirror comp in other professions going forward, with higher inequality. I.e., high pay for the handful of physicians who offer boutique services to the wealthy who can pay cash and more modest pay for the rest who rely largely on insurance and Medicare or Medicaid reimbursements.

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Dave says: "IV. Medicine is... (Below threshold)

October 27, 2010 9:15 AM | Posted by medsvstherapy: | Reply

Dave says: "IV. Medicine is the only profession whose wages aren't lowered by immigration, since the barriers to qualified foreign physicians practicing here are huge (requiring them to re-do their entire residencies here)."

Just wait.

This is plain ol' economics. The docs try to work the Guild model, as well-presented by Milton Friedman, while employers hire employees who are just happy to get the job.

AMA influence and membership is declining.

Look at the VA, and see the future. Foreign-born docs throughout.

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<a href="http://www.nber.or... (Below threshold)

October 27, 2010 11:28 AM | Posted, in reply to medsvstherapy's comment, by student: | Reply

http://www.nber.org/papers/w12497:

"These two facts imply a positive and significant effect of the 1990-2004 immigration on the average wage of U.S.-born workers overall, both in the short run and in the long run. This positive effect results from averaging a positive effect on wages of U.S.-born workers with at least a high school degree and a small negative effect on wages of U.S.-born workers with no high school degree."

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<a href="http://www.creativ... (Below threshold)

October 27, 2010 11:28 AM | Posted, in reply to medsvstherapy's comment, by student: | Reply

http://www.creativeclass.com/rfcgdb/articles/Peri%20and%20Ottavanio,%20Rethinking%20Immigrations%20Effect.pdf:

"These two facts imply a positive and significant effect of the 1990-2004 immigration on the average wage of U.S.-born workers overall, both in the short run and in the long run. This positive effect results from averaging a positive effect on wages of U.S.-born workers with at least a high school degree and a small negative effect on wages of U.S.-born workers with no high school degree."

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Doctors accept gifts becaus... (Below threshold)

October 28, 2010 1:27 AM | Posted by Anonymous: | Reply

Doctors accept gifts because they can. Because they like money, because they like gifts. Because the idea of a doctor who goes into his profession purely for altruistic reasons is clearly bullshit, and most doctors go into the profession because they like money, social power, and having a decent opportunity to accrue more money and power.

You would never ask a question like "why do politicians accept gifts and donations?" because we all know politicians are liars who are not altruistic who only want power and money and are fueled on favors. Yet, you think it is reasonable to ask that question of a doctor. I am still rather young but my experiences with doctors over the past decade of my young adult life have rapidly disabused me of the notion that doctors care about helping people much if at all. When doctors do try to "do a good job" it's only for ego reasons, really.

And, think about it this way... why SHOULD doctors care? They are no different than any other person, or professional. We don't assume CEOs, businessmen, lawyers or politicians are altruistic, so why do we assume doctors must be? Just because they are involved in the care of the sick and unwell? Hardly, hardly. You're describing nurses if any profession at all, contrary to what you might see on the tee vee.

Regarding the tiny violin for doctor's children and their inability to go to college... plzzzz. If you want to see poor, look at my parents. And I'm sure many are more impoverished than them within close living proximity. But you are a DOCTOR so that means you're a demigod which means you are ENTITLED to a huge fancy house(s) and housekeepers and expensive car(s) and vacations, and capital to start independent entrepeneurships because you are a DOCTOR, meaning brilliant and important and you should also be a businessman/investor/landlord too.

Gimmie a fucking break buddie. Even the lowest paid doctors are still making a tremendous mint, nothing at all to cry about.

Perhaps the only thing that needs "reform" is your and your colleagues ego.

I won't judge doctors for being shills for the drug company, because they are human like everyon eelse and prone to greed... (I WILL judge completely blood thirsty monstrous doctors who work for insurance companies and murder people, and doctors who totally cover up major unsafe drugs/therapies just for money). However don't sell this ridiculous song and dance about how doctors HAVE to do it, because they aren't paid enough (LOL), and don't sell me silliness about how doctors are innately above maleficence simply because they're doctors and you know they help people and stuff (lol again).

Medicine is a profession like any other and doctors are not innately better people than businessmen. If you want to stop bullshit, you need to regulate it. Just like businessmen will tend to exploit their employees unless unions and governments stop them, doctors will exploit their knowledge and license privilege to pose as "authorities" in commercials for abilify if you let them, or to bias other doctors and patients toward abilify professionally if you pay them off. If you want to stop this, you need to make rules and regulations preventing this bullshit. I think it is beyond obvious pure free markets end up a quasi feudal system of many slaves and a handful of masters.

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I feel second hand embarras... (Below threshold)

October 28, 2010 2:34 AM | Posted, in reply to randy's comment, by Anonymous: | Reply

I feel second hand embarrassment for this comment.

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RC - thats frigging stupid.... (Below threshold)

October 28, 2010 2:50 AM | Posted, in reply to RC's comment, by Anonymous: | Reply

RC - thats frigging stupid.
Doctors should pay malpractice insurance, and have threat of lawsuits, otherwise incentive to practice properly is eliminated. As I previously said in my first response: DOCTORS ARE NOT ALTRUISTIC. This is a false assumption we are all operating from. Doctors are humans who have proven nothing other than a penchant for power and money which is evident from their choice to become a doctor. Guess what: there are a LOT of ways to help people, people who become doctors are almost invariably significantly narcissistic. Not always, but USUALLY they are. The reason there are SO MANY medical dramas on television is because "doctor" is the most narcissistic profession out there, and it is an appealing fantasy to our mindblowingly narcissistic culture. Think about it: "doctor" means financially powerful, socially successful, very educated, it is assumed by most people they have the knowledge to save lives (thus sorta god-like). Unlike your usually wealthy and powerful professions (ceo/business owner, land lord, merchant, politician, lawyer) doctors alone have this undeserved reputation for being altruistic and "good" morally good and powerful: god. God. This only makes it all that much more of a sploogeworthy fantasy for the narcissistic minded western audience.
I do agree with reducing the costs of education and the hazing that is medical training. It is totally fucking unnecessary and it only fosters the fledgling narcissism and egocentricity of medical students.

I think the real problem here is that few doctors do it because they like it. They like money and power, though. Perhaps some young medical students start out that way but they are broken down by the realities of the world and insurance companies and hospitals. It's just a job, isn't it, at the end of the day. When you actually work in medicine, it becomes beyond evidence that patients are given shitty care, it's really disgusting actually, and the reason is entirely because of companies: hospitals, insurance, all companies, refuse to allow for proper patient care. Even an altruistic energetic young medical professional will want to hang himself after dealing with this. You have to learn to not care that much in order to function in medicine, you have to expect sub par treatment and hospitals are a conveyor belt of half assed treated patients, not all that unlike a slaughter house or a mcdonalds fast food line.

The real problem: our society breeds compassion empathy and any altruistic instinct out of all people, including young doctors.

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The thing computers cannot ... (Below threshold)

October 29, 2010 12:11 AM | Posted, in reply to Gary's comment, by Anonymous: | Reply

The thing computers cannot pick up on that real practitioners can is false statements. If a patient comes to a "kiosk" psychiatrist and states she has not slept in 3 nights and feels extremely depressed, the kiosk psychiatrist might diagnose a severe depressive episode... however a flesh and blood psychiatrist with a long history practicing would know the patient is 1) lying about not sleeping at all 2) might be a dramatic personality exaggerating symptoms (borderline? histrionic?) or a hypochondriac.

The point is, in psychiatry especially, you really need a human with experience to do assessments... only a human psychiatrist knows what real mania looks like (and, unfortunately, not all of them do and are apt to diagnose clear cut anxiety/personality crap as mania). If you answer questions, you can totally end up with a medication cocktail that is entirely inappropriate for you.

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Nothing in this thre... (Below threshold)

October 31, 2010 6:20 PM | Posted by dex: | Reply


Nothing in this thread suggests that Alone's hypothesis is wrong. Quite the opposite, really.

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By "guess correctly or unde... (Below threshold)

October 31, 2010 11:37 PM | Posted, in reply to Jack Coupal's comment, by Anonymous: | Reply

By "guess correctly or underestimate" he means "guess correctly that it's going to be low, or guess that it's going to be low but none of the proposed changes in healthcare happen, so it ends up being the same as it is now."

My money is on the latter. There have been a lot of changes over the past 40 years, and you can see the salary is the same. What's changed is the work itself. I think what will change also is the deviation from the mean. It'll be harder for the top 10% to earn a lot more than the mean.

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<a href="http://www.asics-u... (Below threshold)

November 2, 2010 2:03 AM | Posted by coach handbags: | Reply

asisc shoes

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Maybe he was confused and t... (Below threshold)

November 2, 2010 8:28 AM | Posted by summer dresses: | Reply

Maybe he was confused and thought he was filming an episode of 2 1/2 men.
Come on people..give charlie a break!
Haven't we all had an allergic reaction to medication before?
Sometimes you break out in hives...some times you break furniture in the nude.

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Dear Last Psychiatrist,... (Below threshold)

November 20, 2010 10:09 AM | Posted by Cate Newton: | Reply

Dear Last Psychiatrist,

I love and am an avid reader of The Last Psychiatrist! This post especially interests me and I find it particularly curious that med students underestimate their income.

I wanted to email to let you know about a widget that I just created. There are a lot of people writing about Medical school related news right now so I created a widget that would combine all this great information into one place, http://www.xray-technician-schools.com/medical-student-widget. It would be a useful widget to post on your page so you and your readers can see all of the latest medical student news.

I tried to make it as easy as possible to install the widget. You just copy the code from right below the widget and paste it onto your website. Let me know if you have any issues with the installation or feedback on the widget.

Sincerely,
Cate

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They really underestimated ... (Below threshold)

May 9, 2012 1:17 PM | Posted by amarylis: | Reply

They really underestimated their incomes? This explains why the online health administration degree students are so finely prepared for becoming the utmost future professionals. I stick to my opinion that doctors that don`t accept gifts are the ones truly devoted to their profession. There are countries where you can`t get to the same doctors twice unless you bring him a gift. It seems unfair to me, because not all the patients have the same financial resources, plus they pay for their health insurances. This should be enough, isn`t it?

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I'd love nothing more than ... (Below threshold)

October 10, 2013 7:24 AM | Posted by San Antonio Bankruptcy Attorney Reviews: | Reply

I'd love nothing more than to see the medical system set right, but unfortunately, like the previous attempt at net neutrality, any attempts at fixing the current problems would be subverted by the politicians who collect "campaign contributions" from the slimeballs currently enjoying massive profits from said problems.

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In whatever type of profess... (Below threshold)

April 26, 2014 4:13 AM | Posted by Megan: | Reply

In whatever type of profession you are, I don't see anything wrong with accepting gifts.

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I completely agree with you... (Below threshold)

May 14, 2014 3:51 AM | Posted by Jenna: | Reply

I completely agree with you. This is a great analysis. I really appreciate your thoughts on the subject.

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