Monday, February 15, 2016

One Asshole's Mailbag!

Some great questions coming from Facebook, so why not do a two-fer on posts tonight?

"Hey, question, the fact that the number of doctor's doubled, but the salaries of doctors went up --it's it also because there are more people and baby boomers and getting older, people live longer, etc? I mean, it's still impossible in some areas to find a doctor so demand [is higher than ever]."

Again, it wasn't doctors' salaries but earnings. There's a big difference. A salary is whatever your contract says it is. Doctors (again, speaking traditionally) are self-employed, billing the provincial insurance plan on a FFS basis. The FFS fee schedule, despite claims by some of the more radically-minded doctors of "state monopoly", is a negotiated settlement between the (provincial) medical association and the government. The sky is theoretically the limit on a doctor's earnings, provided they've delivered services to justify the bill.

Doctors' earnings went up because they not only saw more patients, but they found themselves providing more services to the patients they already had--more follow-ups, new conditions to follow long-term, new tests to order and follow-up on, etc. This long predated the "grey tsunami" everybody frets about.

Maldistribution of doctors has been a problem for decades, but there have been broad changes in the past 10-20 years making the problem worse. Part of it is the fading of rural life everywhere, and the uphill task of providing essential services when the youth and lifeblood of an area vanish. This is a bigger problem with schools--close a school, you've automatically turned away young families. The second factor is working spouses, which can limit physician mobility significantly.

The third issue is that practice patterns have changed dramatically. Between parental leave and child care responsibilities, both male and female doctors work far fewer hours than in the past. It's not an exaggeration to say it takes two newly graduated doctors to replace the work of one newly retired one.

Finally, even general practice isn't terribly general anymore. Most family docs don't deliver babies unless it's a passion of theirs, and many don't do house calls. More doctors than ever have some sort of subspecialty interest, or commit significant time to non-insured services (executive physicals, Botox, etc.)

"I'd love if you could write a post about why it's so hard to get into med school. Is the college of doctors wanting to limit people's entry for salary and status? Plenty of people who are not straight A students would be great doctors."

The College has no vested interest in limiting the number of doctors--if anything, more doctors would mean more money and clout for them--so that's one notion that can be filed under myth.

The government has traditionally limited the number of medical school spots with good reason. Even with the increase in tuition across Canada, it is still incredibly expensive to train a doctor. You have dedicated faculty, administrators, and researchers that all need to be paid (clinician teachers get a stipend that barely pays for parking), teaching labs, libraries, IT, etc.

Moreover, the school needs the capacity to train medical students to be competent interns (first year residents). This ties in closely with the number of residency spots a school can offer. There needs to be sufficient and sufficiently varied exposure, and a balance between the service requirements and the education provided. Every med school and residency program is accredited both internally and externally every so often to make sure these demands are met.

As for the insistence on only straight-A (usually science) students getting admitted to med school, you're talking about a culture in the profession dating back over a century. Given that there are something like 30-50 applicants per spot every year, I don't see that changing anytime soon. That being said, it's a fucking absurdity when you consider what the job of a doctor entails...but that I must save for the memoir!

1 comment:

  1. awesome post. Learned tons here. Thank God I'm addicted to research and science - clinical practice is madness.

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