Skin in the Game and Other Things

Skin in the Game

I had the privilege to work with one of the specialists in town for the last couple of weeks, a gentleman who still takes call for the Emergency Department but only for one week a month after which we have to ship the emergency cases in his particular area of expertise a hundred miles away to the Big University Medical Center.  His specialty is much needed, vital to our patients, and although there are others with the same qualifications in town, their unwillingness to expose themselves to our patients says a lot about the perverse incentives and obvious disincentives of the goat rodeo known as American medicine.

I followed him in his clinic, assisted him in the operating room, and generally learned a lot and had a good time even though he noted that I have no surgical instincts whatsoever, something that I freely admit.  Because he is at the top of the medical food chain and separated from my typical patient population by several layers of lower-order specialties, his patients were a refreshing change for me.  Almost without exception they were polite, well-spoken, and if not always well-educated at least imbued with the native common sense that at one time was highly prized in our country.  Not only that but they were wonderfully, almost unbelievably, compliant with their follow-up and care plans and the most common thing I heard in two weeks at the clinic was some variation of, “It’s getting better and better. Thanks Doc.”

Either that or, mirabile dictu, “Hey Doc, when can I go back to work?”

The only exception to this were some of his patients for whom he was called into the Emergency Department.  Suffice to say that if you sustain the kind of injury for which his services are necessary while drunk and fleeing from the police or beating your lesbian girlfriend at two in the morning you are probably not a model citizen, insured, or likely to be an ideal patient.  We had one patient like this who on follow-up the next day, surrounded by an irate fleshy phalanx of her extended family,  immediately informed me of her intention to sue the motherfucker who had operated on her.   Naturally my specialist is stuck with this lady as he had laid hands on her and now owned her medical problem until the bitter end; neither will he receive a dime for either the procedure, his time rounding on her in the hospital, or for any of her many follow-up visits over the course of the next several months to a year.

Conversely, when we refer a patient to him for a non-emergency complaint, he will not see this patient for free.  He doesn’t take Medicaid either because the reimbursements are so low that he can’t keep the lights on if he gets swamped with this kind of patient.  The bureaucratic requirements for compliance as well as the restrictions on his ability to practice medicine the way he wants are also particularly onerous and contribute to make Medicaid much more than just a money-losing enterprise; accepting it turns a doctor into a poorly-reimbursed indentured servant.  But he does take charity patients, only asking that they make a commitment to him to show that they both respect his time and abilities and have an interest in their own care.  This commitment is 250 dollars up front to get in the door.

Now, to the shrieking harpies of social justice this sounds incredibly crass.  How dare anyone expect the Great Unwashed, the victims of 230 years of institutional oppression, to cough up some money for a basic human right that should flow as easily as water from the tap?  On the other hand, as I have yet to meet a Medicaid or uninsured patient who couldn’t afford cigarettes, liquor, and many of the other irregular pleasures that it is our legal obligation to subsidize, the fact that a referred patient will stand in the waiting room hurling epithets at the receptionist and threatening to sue because he was asked to pay a little bit for a service without which he will be permanently disabled only shows that his priorities are perhaps a little skewed, the motto of The People having now become “Hundreds for luxuries but not a dime for my doctor.”

All that is being asked is that this fellow put some skin in the game.  Of course, “Skin in the Game” is nothing more than the usual doublethink from the Sun king, Ra-Obama and his pantheon of minor governmental deities.  As our country devolves into nothing more than a crappy nursing home for the care and feeding of the chronically helpless, the only people who are really expected to have skin in the game are those who already have a considerable amount of it in the game already.  You can’t, for example, possibly have more skin in the game than I do.  Not only have I spent four years of residency going into debt providing medical treatment for the Holy Underserved but people like me, suckers that we are, have worked our whole lives to support the entire creaking edifice of entitlement and greed that is the modern mammary state.

Exactly How Stupid Are Medical Students?

Medical student debt and the fear of it is a red herring and just another cynical ploy by The Man to punk you. It is no different than trying to make the excessive work hours and sleep deprivation of residency about Patient Care. In the case of excessive work hours and sleep deprivation the argument is always framed in terms of what is best for patient safety; the mantra being that we have to limit hours only because patients are harmed by tired residents and not because sleep deprivation is, by itself, cruel and unusual punishment and a practice that would lead to arrests if it were discovered in some illegal sweat shop.  The problem with using patient safety as a reason to let residents sleep is obvious however.  All The Man has to do is show that patients are not harmed or that the frequent patient hand-offs required when residents work rational hours are more dangerous and you are now stuck working under conditions that are considered war crimes if forced on prisoners. You have unfortunately allowed someone else to dictate the language and subject of your debate.

Now consider medical student debt. Realistically, most medical students don’t incur that much of it, at least to the extent that it is unmanageable. It is what it is and in my specialty with what I will be making,  it is just a a cost of doing business, a fee I will pay every month for access to a lot more money than I could have made at my previous career. Pace the argument that medical student debt is a looming horror that will impoverish us all, I consolidated the federal portion of my loans at a truly ridiculous interest rate which is so low that it makes no sense doing anything other than paying it off with excruciating slowness, always with the very real possibility that I will be dead of old age before I am done.  Actually, a couple or three years of inflation like we had in the seventies and this portion of my debt will, in relation to real income and purchasing power, disappear as a serious concern.

Would I have accepted a pittance from the government as a salary if they promised to make medical school free? Of course not. The very question is also a tool of The Man and his useful idiots in medical education to frame the debate in their terms. You will agree, strictly from an irrational fear of debt, to have your education paid for and in exchange, the sanctimonious government will dictate your salary, paying you less than you would make even subtracting debt.

And you’ll be stuck because you took the money and now you have nothing to say.

Jeez.  Why don’t you all think things through before opening your cake holes?

I’m Back

I am in the final days of residency training having less than one hundred days to go before I am, after eight long years, finally finished with this great ordeal that has cost me almost everything I have and the completion of which is looking to be one of the great anti-climactic experiences of my life.  On June 30th I will finish my last shift as a resident and three days later I will start a similar shift someplace else but for about ten times what I am making now.


I have learned a lot in the last eight years, some of it I didn’t want to know and the ignorance of which was probably better than the full knowledge I am acquiring of it.  I had no idea, for example, how unconcerned many people are about their own health and with what gusto they ignore common sense, their doctors, the frantic signals from their rapidly collapsing bodies, and any crumb of knowledge they may have gleaned from their ineffectual sojourn through that useless warehouse optimistically known as the public schools.  I am also still amazed at how incredibly sick people can be and at how many different diseases and dysfunctional organ systems can be supported in one patient who nevertheless manages to hang on grimly (or maybe obliviously) year after year while an increasing amount of medical care is sprayed on the burning house (metaphorically speaking).

And I have also learned about the corruption of our system, the unavoidable consequence of the many competing players, most of whose interests are irreconcilable and stem largely from the the titanic sums of somebody else’s money dumped into medical care coupled with the public’s insatiable avarice for it.  That most of the money we spend on medical care is wasted is also becoming clear to me and it is on these and other more entertaining topics I hope to continue writing.

I also want to welcome The Macho Response as an official partner of Panda Bear, MD.  It’s hard to exactly describe this blog.  It’s author, the self-styled Crack Emcee, is not a doctor but he does have a common-sense based grasp of medicine.  He is not a scientist but has the intelligence to know both when smoke is being blown up his ass and to point out the hypocrisy and puritanical tendencies of many in the scientific community.  He is an atheist (where I am most certainly not) but he is intellectually consistent in his principles and has not given up “old-fashioned” religion only to latch onto some nutty cult as is too common in our sad and ridiculous age.

The Crack Emcee is an artist of some note, however, and his blog is a sort of collage, an exploration with links, pictures, and music of the truly ridiculous behavior and ideas of those truly ridiculous individuals in the various elites who style themselves our superiors, our protectors, and our benevolant masters.  Be warned, however, that his blog is not for the spineless products of our apologetic and insipid culture.  You will be offended.  You will shriek in dismay as your icons are defaced and your tin-plated heros are gutted in his arena with their entrails left to cook in the hot sand.

Don’t say I didn’t warn you.

23 thoughts on “Skin in the Game and Other Things

  1. Let me be the first to welcome you back. We need a voice in the bleak darkness of this nanny-dom we are becoming. I have checked your blog every day since you quit about a year ago, reading a bit here and there to keep my spirits high while studying the wonderful intricacies of the human body. Thank you for returning. Thanks for everything. And now, if you will, please proceed with the verbal pounding.

  2. Wow!!! Provacative and purely unapolagetic! I love it (no sarcasm here)! While I have questioned your some of your judgment calls on SDN (riceman04 here…LOL) I must admit the I enjoy reading your blog. Beyond simply being a great writer, I can appreciate the perspective you bring and the emotion you (most likely) elicit from your readers.

    This is just what I needed considering I work for PI’s who would question your moral grounding (or lack thereof) for simply stating the truth about the sense of entitlement that wreaks from those on which we also happen to conduct research (here where I work).

    Great to hear another perspective!!
    Definitely bookmarking!

  3. FYI: Federal student loans. As for July 2006, they are fixed 6.8% … unlike MD class of 2006, current student don’t have as sweet deal. (consolidate at 3% or 2%…sigh. I wish).

  4. Hah, just when I thought it was safe to go back on SDN. I thought the Panda was extinct! Good to have you back, you vitriol-filled fucker. 🙂

    Now, if we could just get you on Twitter…

  5. Finishing residency was anticlimactic: big difference between what it meant to me and what it meant to all the surrounding attendings and nurses. As always, am so impressed by your insight. The difference between you and me at similar stages of our training (or even now for that matter) is laughable. Welcome back, hope you’ll stay.

  6. 1) Glad to have you back

    2) I think you’re missing the point on the med school debt thing. This isn’t a red herring thrown out by ‘the man’, this is a red herring thrown out by ‘the doctors’ (and medical students). And medical students aren’t buying it, what they’re doing is floundering for a different excuse as to why docs deserve to be paid as much as they are. The problem is that they’re unwilling to part with either their dishonest sense of selfsacrifice or their unnecessarily large paychecks.

    You see, when doctors are asked why, exactly, an Ortho needs to make 500K/year other than unappologetic greed, docs generally run and hide behind two excuses: their training and malpractice. The problem is, those are two things that, should socialized healthcare be implemented, the government can absolutely fix. Malpractice is easy, you can’t sue the fed anyway. The cost of training? They can pay your way through med school. Heck they’ll pay you just to go to med school, and then they’ll raise the residency salary to a respectable 80K/year on top of that. And then they’ll still pay you over 100K to be a board certified doctor. Oh, and the hours during residency and practice? They’ll cut those too. The residency might get longer but you won’t mind because you’re being paid like a professional and treated like a human being anyway. So it’s a deal?

    Of course it’s not a deal. The system I’ve just described (minus the good residency hours) is military medicine, which 95% of my classmates selflessly avoided in the name of bigger profit margins. They can do the math, and they know that the despite all their whining that they would untimately have made more working at McDonalds for the rest of their lives, Medicine is actually extremely lucrative in the civilian world and they don’t want to trade that big steaming piles of bills for anything. But neither do they want to drop the veneer of selfless piety that this is somehow a sacrifice, rather than an investment. Which leaves them trapped when the government calls their bluff and forces on them exactly what they’ve been saying they’ve always wanted.

  7. Hey Perrotfish, sanctimonious much?

    I did military medicine. Why don’t you talk about the other downsides of milmed? I didn’t leave for the money, and neither did most of my colleagues… I left to get away from all the !@#a% crazy-makers that military medicine foists on its docs. And it’s not just the specialists. There’s a reason why milmed has a roughly single-digit retention rate across nearly all specialties (except maybe peds).

    It is really your contention that docs are all lazy, dishonest, money-grubbing whores who don’t really sacrifice anything to get where they are, don’t render a valuable service, and don’t really work for a living?

  8. I definitely don’t think that docs are lazy, that they don’t render a valuble service, that they don’t work for a living, or that they’re whores. But, yes, they are money grubbing and, though only in the context of the debate over salaries, occasionally dishonest.

    ‘Money grubbing’ isn’t necessarily a terrible thing, BTW. Lots of professions, especially those that provide valuble, in demand products, are openly money grubbing (or if you want to be less rude about it: profit driven). Microsoft doesn’t make any appologies for the profit margins on their latest processor, and that’s just fine. At the same time, though, Bill Gates generally doesn’t try to pretend that he’s just scraping by or that he’s doing this for the good of humanity. However, at least so far, my experience is that many physicians want it both ways. They want the money and independence that goes along with being a professional providing a very in demand service, while at the same time protecting the brand image of a selfless community healer who is doing this work for so little money that it might as well be considered charity. They shout about how we should have faith in the free market decide what’s best for patient care, and then rend their garments when NPs and PAs (let alone CAM practicioners) want to throw their skills to the mercy of the same free market. They fight tooth an nail to keep the government from the debt they’ve taken on (in exchange for government service) while at the same time claiming in every possible forum that the debt is impossible to pay off.

    Now my point in the origional post was I think that, if we want to defend our standard of living, I think have to first admit that docs have a pretty high standard of living. If the medical profession continues to announce to the world through every possible means that submitting to the medical training process is a financially disasterous decision, then we have very little basis to object when the government comes along and offers us what, by our own claims, would be a ‘better’ deal. What I would like to see in medicine is a little more open honesty about what I think the vast majority of physicans are: hard working professions, performing a valuble and necessary service, who are trying to get compensated the most they possibly can for that service. No better or worse than engineers or chemists. That, or we should live up to our brand image of selflessness and actually accept that being selfless means, almost by definition, getting paid less than everyone else. Until one of those two things happens, I think that our profession will get continually called out on it’s hypocrisy and the government will end up stepping in ‘for the public good’.

  9. Perrotfish,

    You clearly don’t work in my ED, where I basically give away about half of the work I do (Medicaid and self-pay make up about 50% of my patient volume).

    I then get taxed at the usual high rate on what I actually do get paid… so you can understand my annoyance when somebody like yourself pontificates that I’m not giving enough. What specialty are you in again?

    You think physicians are dishonest about what they make? By focusing strictly on the paycheck, you’re being dishonest yourself by neglecting to mention the time value of money. By the time you graduate from med school and the residency of your choice (and start making the “very high standard of living” that you trumpet… but only after you’ve earned your bones in whatever group you join… usually a few more years), you’re around/over 30 years old. You’ve got nothing but debt (with interest), and you’re way behind the compound interest curve. That “high” paycheck is your payback for being in that position, but requires you to practice long enough to get ahead of the comparative hole you inhabit. This isn’t so easy for many specialties. Also, should you decide it isn’t for you, you’re stuck.

    Spare me the “wine and roses” characterization of doctors’ incomes. Make sure you’re telling the whole story.

  10. Again, if you consider all of this true:

    “You’ve got nothing but debt (with interest), and you’re way behind the compound interest curve. That “high” paycheck is your payback for being in that position, but requires you to practice long enough to get ahead of the comparative hole you inhabit. This isn’t so easy for many specialties”

    Why aren’t you, or physicians in general, begging the government to create a deal that would spare them all that agony? Something similar to European nations, or in milimed, where med school is free (with stipend), residency is well paid, you’re a salaried (well paid, though still very middle class) employee as soon as you’re in the door, and your final pay is still well over 100K (though probably peaks at 150)? If your sackcloth and ashes version of medicine is correct, then that seems like a deal that you would WANT. No debt, similar pay and compound interest with your friends in engineering and business (I’m sure you know one guy who made VP 3 months in, but I’m talking about the average), no fighting for partner, and no worrying about who can and can’t pay. It takes care of every concern you have.

    And that, again, was my point in the origional post. This meme that phyician debt and the time cost of money will ruin us all, the one that Panda spent his post calling stupid: it isn’t coming from ‘the man’, it’s coming from us. I’ve heard it over, and over, and over from physicians of all ages, in an attempt to cast themselves as hapless victims rather than prudent investors whose (long, miserable) investment paid off. The government, in suggesting a different system, is doing nothing more sinister than believing their doctors.

    “you can understand my annoyance when somebody like yourself pontificates that I’m not giving enough”

    And, again, I’m not saying you’re not giving enough. I’m saying you’re giving enough for what you’re doing to be considered a form of charity. You’re a highly trained professional doing good work (well, I hope) and you’re being compensated accordingly. I’ve never said that docs are bad people, just that I see them, minus a few Paul Farmer types, as no better or worse than any other hard working technical professional. The only difference I see between a doctor and an engineer is that an engineer wouldn’t be offended by the suggestion that he’s not somehow morally superior to a doctor.

    (I was an engineer. Believe me, no engineer will give away his time for free and the idea that he would be expected to as part of his normal duties would be greeted with incredulity and laughter. There is nothing equivalent in any other profession to a doctor coming into the Emergency Department on his own time to see a patient who is on a hair-trigger to sue anybody and everybody, taking care of the patient for free or so close to free that it’s hardly worth the gas money to come in, and then to accept complete responsibility for the patient until the very last follow-up which may be months or years ahead. There is also nothing equivalent to a freeloader coming into the Emergency Department and demanding treatment for a minor complaint except, perhaps, shoplifting.

    I am perfectly happy with paying my own way through medical school, leveraging a little bit of debt into a lucrative career but Physicians are special and, if we take our responsibilities seriously and act like doctors, we are “morally superior” to other professions, none of which (I reiterate) are routinely asked to provide their services for free or at a low cost determined by someone who is not directly involved in the transaction.

    You make some excellent points, of course, but being a Physician is not like being a lawyer or an engineer or a plumber, at least not if you’re doing it right. -PB)

  11. Perhaps some of us don’t want the government “rescuing us” from our career decision? I did the military because I’m a patriot, not because the scholarship was such a great financial deal (it wasn’t).

    Physicians been on the receiving end of the government so many times that we’re leery of their goodwill, because it’s largely a lie. Only a person who is completely ignorant of the byzantine system the government has devised to pay physicians (or not) for the work we do could front a “free education” followed by a government job in medicine.

    Been there, done that, and no-way-in-fecking-hell I’m doing it again. Sorry… milmed soured me forever on any sort of command-economy, government-run, single-payor salaried health care system.

  12. “Because he is at the top of the medical food chain and separated from my typical patient population by several layers of lower-order specialties, his patients were a refreshing change for me.”

    Haha, that right there is pretty much what I don’t like about EM.

    Also, your income is going to increase by 10? fffffffuuuuuuu, that right there is pretty much what I WOULD like about EM.

  13. “I am perfectly happy with paying my own way”

    Did you really?

    To “give” some of your precious time to charity does not make you morally superior. The two are mutually exlusive. That reeks of socialism. Oh you socialist in doctor clothing! You believe you are so much better than those who don’t have high paying, hugely marketable skills. Just how did you get to where you are today? In comparison to Bill Clinton avoiding the draft where someone had to take his place, you were given an opportunity to get a fulfilling career and make your life better. Whose seat did you occupy in your medical school? How did you get there? Are you feeling morally superior now?

    (Uh, I didn’t avoid the draft, instead volunteering for the Marine Corps where I served as an Infantryman, not to mention that I have worked my whole life in everything from fast food to landscaping to Engineering. I got where I am today by hard work, the ability to think ahead, and the almost nowadays nonexistent ability to defer gratification. I wasn’t “given” the opportunity, I earned the opportunity. It is a sad testament to our idiotic age where hard work and intelligence leading to opportunity is looked at as some kind of “welfare,” no different than a handout to a habitual bum. -PB)

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