A common fallacy shared by many medical students and pre-meds is that doctors are isolated from business practices such as marketing, management, and finance. A rude awakening is applied to anyone upon graduating residency when he discovers that the laws of economics apply to medicine just as easily as they apply to any other employment field. Many doctors are woefully unprepared for running a hospital or clinic. Many of the private practice physicians I know resort to hiring an office manager to take care of the billing and staffing issues. While we would all love to believe that our medical school and residency program endowed us with certain skills, getting paid by insurance companies for all that knowledge becomes more difficult. Therefore, I propose a business school meant for physicians.
Unfortunately, my suggestion will be slapped down by many of the naysayers within the pre-med and medical school community. A lot of them will say, “If I wanted to go into business, I would’ve gone to business school.” What’s worse is that many physicians have a pretentious, self-righteous attitude that says that they should be shielded away from the profit-seeking motives of businessmen. But I see it differently. I say that anyone who pursues a job paying more than $100,000 a year should have a profit-seeking mindset.
While I don’t suggest that we all go out and get MBAs, I do think that there needs to be some instruction on how to run a business so that physicians can learn to accurately charge for their services. Fourth year medical students would be the best candidates to reap from such a system. I envision a month-long Kaplan-style course where students are taught for 40 hours a week in various business topics. The courses would be condensed, focused on medicine, and would provide real-world instruction for how a doctor should conduct his clinic. And if you think that working for a hospital as either a hospitalist or an emergency physician will shield you from needing to know about business, the only person you’re deceiving is yourself. The physician who knows how to properly bill for his time will be able to generate more revenue for the hospital, thus making him a more valued employee.
For the month-long business course, I envision something similar to the following schedule:
week 1—mornings: economics, afternoons: management
week 2—mornings: accounting, afternoons: marketing
week 3—mornings: finance, afternoons: business law
week 4—medical billing
A video series of these courses could be available online along with a condensed textbook so that practicing physicians and residents could also study this subject. While everything would be taught in one month, there is no need to water down these subjects. Consider an undergraduate management course. Usually, a semester-long class is taught in 40 one-hour lectures. When I took management, I was continually frustrated by how slow the material was being taught. Certainly physicians can cram all of that information and more into 20 hours. Further, by making all of the subjects centered on medicine, doctors would be more likely to enjoy pursuing these classes. Just imagine learning how to balance books, create advertisements for your practice, resolve conflicts amongst your employees, how to pick better assistants, and the laws regarding incorporation of a company.
With this knowledge, physicians would have a more employable skill set. I would imagine that anyone who sets up such an online course would have no shortage of doctors willing to pay to learn those skills.
Shortly after starting this blog I came up with 1-800-IDEA-MAN. My very first post was about letting fourth year medical students become PA’s once they have passed both Step I and Step II of the US Medical Licensing Exam. I decided to finally take some action on my idea by writing to my state’s representative and senator. Here is the letter that I sent to both of them.
I am writing to you today as a resident of District __ with my concerns about ______ health care. I am currently in my third year of medical school at the University of _____ and have witnessed firsthand the lack of proper resources to provide for the well-being of our citizens.
Solving healthcare woes is not only a priority of mine, but has become a major topic in this election year. While there are many ideas tossed around about how to provide greater access to care—such as malpractice reform and socialized medicine—I want to share a novel solution.
Currently, there exists a group of physician extenders known as physician assistants who work as mid-level providers to offer primary care and emergency services to many people. Physician assistants go through two years of training: one year of clinical course work, and one year of hospital experience. They then take a licensing exam to become certified here in the state of ______ as PA’s. Since they are not allowed to carry their own malpractice insurance, nor are they allowed to write unrestricted prescriptions, PA’s work under the guidance of a physician.
Now let’s consider medical school. To become an M.D., students must go through two years of clinical course work and two years of hospital experience. Before graduating, they must take two parts of the United States Medical Licensing Exam series. Even then, they are not licensed to practice as full physicians here in this state until they have completed one year of residency and passed part three of the series.
I propose that medical students who have completed their third year of training and who have successfully passed both Step I and Step II of the US Medical Licensing Exam should be automatically qualified to practice as physician assistants here in the state of ______. There would be several benefits.
First, they would reduce the burden on current physicians. The American Medical Association names ______ as a crisis state because of its medical malpractice woes. Many doctors have left the state and many more are limiting their practice, resulting in reduced access to health care. By having more physician assistants available, state residents would have greater access to primary care.
Second, medical students would enjoy the benefits of holding a job while in their final year of training. At my own university, many medical students graduate with over $200,000 in debt as a result of high tuition costs. By generating some income, medical students will be able to offset a small part of the financial burden of achieving their dreams to become doctors.
I’m not suggesting that these medical students/physician assistants will replace primary care doctors. They will continue to work under the guidance of current licensed physicians. Given the hiring rate of PA’s, I think it’s such a plan would work smoothly without causing any disruption to the job market.
I would appreciate your feedback on my idea. My proposal is certainly not going to completely fix the problem of healthcare access, but it will alleviate some of the strain without causing a rise in taxes or a reduction in physician autonomy.
Before entering graduate business school, applicants must spend a minimum of two years in the corporate world gaining experience and applying the knowledge earned from the undergraduate career. I’ve been thinking more and more recently that medical schools should take the same approach. For starters, we have too many immature people that enter medical school. For example, in my class, the vast majority of the students were accepted directly out of college and were only 22-years-old. Their lack of leadership and work experience showed from the very first day of classes. However, that ignorance and inexperience is now more apparent during the third year than ever before. Now I’ve come to the realization that medical schools should require several years of postbaccalaureate experience before even considering applicants. My take on it is that the whole dynamic of the medical profession would change simply by requiring work experience as an entry to the field.
In my case, I used to be an engineer before coming to medical school. I can use my engineering mindset as a problem solver to get around many issues that I come across on the wards. I can anticipate problems based on prior incidents and adapt to become more efficient in the future. One of my classmates was an investment banker. His knowledge of finance is astounding, and I would gladly trust him with the school’s budget so that he could deliver to us better health fairs and an outstanding graduation party.
Unfortunately, the vast majority of medical students have no touch with the outside world. For them the half study/half party life of college gets translated into the half study/half party life of medical school, which then leads to disastrous results. In addition to the disenchantment that so many medical students experience, there are a small minority that leave the field altogether before completing the four years. Many students feel as if they are being abused-and rightfully so. This dissatisfaction with the American medical schools is at an all-time high. However, requiring work experience would change several things:
Students would no longer accept inefficiencies. The current method of training involves long class hours, Physicianship Training sessions, and endless rounding on the wards, that only leads to scutwork and a secretary-like lifestyle. A new breed of medical students with real-world experience in hand would never tolerate this bullshit. They would demand that class be run more efficiently. They would realize that courses in ethics and professionalism are unnecessary because either students are ethical and professional before school starts, or they are not ethical and professional, and no amount of lecturing will ever change that. They would not accept scutwork as a method of “training.” They would demand that techs be hired to take the place of holding retractors, calling consults, and fetching old medical records.
This new breed of students would lead to a new breed of residents which in turn, would lead to a new breed of attendings. Those would be the type of attendings I would want working on me.
After having been on the wards for a while now, I’ve seen the importance of having a strong background in the basic sciences before moving on to seeing patients. While many students and physicians alike bemoan learning the mechanisms of action and half-lives of medications, this information is important in creating a useful drug regiment for treating disease.
The traditional med school curriculum uses two years of lectures and classwork to teach the basic sciences, followed by two additional years of clinical experience. The thought is that students need a firm foundation in book knowledge before applying that information to patients. Occasionally, universities get students into the hospital to practice on patients. At my school, we have a course called Physicianship Training that teaches students necessary skills for clinical encounters. The school throws us this bone to keep us interested in continuing the lectures that drag on for those first two years. The only problem is that medical school costs about $30,000 a year for those lectures.
I’ve come to realize that the first two years of med school were largely a combination of wasted time in lecture and physicianship training exercises. I’ve noticed that my school charged $60,000 for students to teach themselves from textbooks for two years. Many of my readers who are already in medical school or are doctors are all too familiar with the self-teaching that occurs. Professors are notoriously bad at teaching about mitochondria and the brachial plexus, leaving the student with the task of clarifying the material later.
Given that the students are already self-teaching, I propose that we eliminate the first two years and leave the basic sciences up to the textbook authors. We’ll make the Shelf and Step exams the determining factor of who gets into medical school. The top 17,000 scores get in, while everyone else has to re-take Step I. Naturally, research experience and rec letters will play a role in admissions, but this method will bring in a steady supply of doctors with a strong basic science background.
Some critics will claim that Step I’s 350 questions do not cover enough information to fully assess a person’s ability to become a doctor. My first response is to point out that Step I is already used as the primary indicator of knowledge from the first years. Second, we can extend the exam to cover two days and double the number of questions if there is any concern that the test is not an adequate measure of science comprehension.
Companies such as Kaplan will emerge with their own medical schools to prepare people for these exams. Critics will claim that test prep groups teach to the test and not to the material. While there is some credibility to this argument, I certainly won’t miss out on all of the surgery lectures I saw where the surgeon shows before and after pictures of his work. Further, I am sure that Kaplan would hire better lecturers, would be more efficient at teaching, and would be cheaper. Similar to a cell phone contract, at $30,000 a year I’m currently locked into my school where the professors have a monopoly on my education. Under my plan, when universities are forced to compete against each other, the quality of lectures would improve drastically. Then, after Step I, future doctors could move onto the wards—and the real two years of medical school.
As I was holding retractors one day this week, an awful fit of hunger hit me. I looked at the OR’s clock and realized that I hadn’t eaten in about 9 hours. I also realized that this operation was going to run another 2-3 hours and I would probably miss lunch again. In order to fight off the hunger, I propose that surgeons wear a camel back under their sterile gowns. Commonly used by long distance runners and hikers, a camel back is a back pack that contains water for the purpose of keeping hydrated on the go. A tube runs from the bag, over the wearer’s shoulder, and directly into his mouth. Whenever the runner wants a sip of water, he simply tilts his head toward the flexible straw, takes a drink, and keeps moving. In a similar fashion, surgeons could benefit from these devices during long procedures.
I could use a camel back to hold a can of soup to deliver it to me whenever I start to get hungry. I’ve got three whipples scheduled next week and I’m already thinking of ways to get fed during the surgeries. If I’m going to get varicose veins and hemorrhoids from standing for so long, at least I should be able to fight off the constant hunger pains.
To make matters worse, the bovie-the devices that melts human flesh and cauterizes wounds-makes everything smell like barbecue. A few of my readers might get turned off by the reference to cannibalism, but I call a smell like I sense it.
Perhaps my greatest frustration with surgery is that so many of the residents and students want to perform operations without ever thinking of the reasons why a particular procedure works, or why certain medications are used before and after major procedures. The chief cracks on internists by saying, “They’re only concerned about mechanisms of action and susceptibility.” What he doesn’t realize is that those mechanisms are extremely important. There’s a reason why diabetic patients take ACE inhibitors and not beta blockers. Unfortunately, our attending seems to follow the same line of thought and puts every patient on Reglan and prophylactic triple antibiotic therapy, meaning that all of those whipple patients now have super infections and are at risk for Parkinson’s disease. He could prevent the former problem from ever occurring if he would just wash his hands and use sterile gloves whenever he digs into a patient’s abdomen to look at the surgical site.
As part of the never ending line of assignments that I have to fulfill, I had to go to the residents’ lecture this week. The topic was on fluid management and reviewed all of the material that I had to learn last year as a 2nd year medical student. I was surprised as how elementary the material was. I was even more surprised during the review section when so many senior residents got questions wrong about basic electrolyte balance. It was like watching retards compete in the math Olympics.
Question: what will a high glucose level due to the patient’s sodium level?
Actual surgeon answer: if a person eats a lot of sugar, he must also eat a lot of salt. Therefore, it would be elevated.
Surgeons shouldn’t strive to be only knife jockeys. Anybody can cut stuff out of a patient. Even the scrub nurses have seen enough operations to know how to remove an appendix without causing too many complications. What makes surgeons unique is the “M.D.” after their names. If nothing else, they should at least know more about fluids and electrolytes than a fresh third year medical student.
One of the more exciting trends of extending medical privilege to mid-level providers is that of granting prescribing rights to psychologists. While this idea is not originally mine, I’ll jump on as a fan and claim that licensed psychologist should be allowed to pursue a two-year post-doctoral certification program to obtain prescription rights. Similar to a PA’s training, this new program will require 1 year of classroom work and a year of clinical rotations, with an emphasis on psychiatric experiences.
Two states already have similar programs where Ph.D.’s can spend time learning pharmacology and can then receive a medical license to work under a psychiatrist. With the national shortage of shrinks, particularly pediatric psychiatrists, I would have thought physicians would be eager to have some help in providing medical therapy to mental health patients. Unfortunately, many doctors are against the idea of allowing psychologists to practice medicine.
Some psychiatrists throw out arguments such as “their training isn’t as extensive as ours” or “they wouldn’t be equipped to handle co-morbid conditions.” These points are certainly valid, but we already grant PA’s the right to practice restricted medicine with only two years of training; why shouldn’t we open the doors to others?
Certainly psychologists would not be equipped to work on a patient’s other medical issues, nor should they care for floridly psychotic patients. However, I see no reason that why a psychologist couldn’t write a prescription for Prozac as part of a therapy program. You don’t need 8 years of training to know that SSRI’s are an effective method of treating depression, and you certainly don’t need all of the years of experience to know the adverse effects that can come with giving a mind-altering medication.
The bad news is that psychologists haven’t been on their best behavior. They point out that most psych prescriptions are written by primary care docs, not psychiatrists. Some of the arguments that the psychology crowd throws out include “most MD’s only have six weeks of psychiatry training. Therefore, they are not qualified to fully work with mental health patients, either.” Don’t think that MD’s have only six weeks of training and then they’re done. After two years of basic science to learn how the body would respond to those medications, physicians have lots of training in internal medicine to learn more about clinical aspects of neuropharmacology. The “six weeks” is a time period thrown around to minimize physician training and to try to make grad school in psychology seem more robust than it really is. I’ve heard similar arguments about the length of the pharmacology courses in medical school. True, my pharm class only lasted for a month, but I can guarantee that I’ve been learning drugs for a lot longer than that.
I would love to see other states follow the model led by Louisiana and New Mexico. With adequate pharmacology training, psychologists can make a valuable impact on medical mental health.
I’m always full of ideas. People ask me all the time for various solutions to their problems. I should get the telephone number 1-800-IDEA-MAN so that people could call me anytime day or night with their questions. A typical conversation might go something like this:
CALLER: Hello, Idea Man? I spilled red wine on the carpet and can’t seem to get the stain out. To make matters worse, my son dropped his candy bar on the rug and walked right though it all. What am I supposed to do?
ME: Calm down, Ma’am. All you need to do is get some club soda and a roll of paper towels and that stain will come right out. Just make sure that the roll is lint-free so that you won’t have soggy red bits of paper towel rolling around on the carpet.
Just like that, another problem is solved.
My idea this week is to allow 4th year medical students to receive licenses as physician assistants. The way I envision it is that people who have taken Step 1 and Step 2 should automatically become PA’s. Medical students who have gotten that far will already have more education and experience than a fresh-out-of-school PA. I say these hard working individuals should be paid for their time.
Think about it: students could moonlight during their easier rotations to make some extra cash. While the sub-internships will be difficult, students will certainly have free time during their history of medicine course. Given the pay scale of an average PA, a medical student should be able to make $1,000 in a weekend. The hospital gets weekend coverage and prn service while the student gets paid. It’s a win-win situation for everyone involved.
Some critics might say that a medical student is only partway through the educational process. While true, I am not suggesting that students practice unobserved. If a PA can be trained in two years to work under the supervision of an attending, certainly someone with 3+ years of training can do the same.