Friendly, neighborhood doctor

Working in a hospital I get a interesting, and largely unique, perspective on how they operate and how the people who work in them think.  One of the more interesting things I have encountered is the phenomenon of the “poor MD”.  I was in my lab when I overheard two physicians, in the hallway, talking about how poor they were!  They were bemoaning the fact that their student loans had exited the grace period and now the payments were coming due.  At the time I just thought it was two guys who were just pissing and moaning and it did not mean anything.  Later, I heard a surgeon saying the same thing.  This time this MD was talking to me so I pressed her on the matter.  She really did believe that the “money was leaving the profession”.  Those who know me know this would not be allowed to stand so I called her out on it.  I have the ability to give someone a look that clearly indicates that I believe they uttering the dumbest thing I have heard in quite a while.  The presence of this look initiated a session of stammering and hedging on her part.  As it turns out the money is good.  As it turns out the work is mind numbingly boring at times.  As she speaks I’m doing some math in my head:  she makes in two months what I make in a year and she makes in a day what the population of 33% of the planet makes in year (that’s over 2 billion people).  What it came down to was that she expected something different.  I thought that maybe she was just having a bad day until I ran into a much better example.  I was talking with a male MD about something and he mentioned how poor he was.  “Again?”, I thought.  MDs seemed to be obsessed with their student loans and they treat them like bogymen (I’ll come back to the student loan issue below).  Same story as the female but with one little twist.  The female MD drove a beat-up Celica, the male drove a shinny, new Porsche.  Unfortunately for both of us, he left before I got a chance to compliment him on his titanium balls (though I have been referring to his car as a “penis-mobile” ever since–it annoys him, makes me laugh).

Freddy Kruger of student loans

So exactly how bad is the student loan situation for MDs?  The usual advice from financial advisers who aren’t named “Suze Orman” is borrow about twice the starting salary of the job you are likely to get with your education.  In my case my total student loan debit will be around $35,000.  My starting salary as tenure-track assistant professor (the starting salaries for industry are usually a bit higher) will be about $40,000-45,000 in Charlotte dollars (2009).  That is a ratio of  0.875-0.77.  I do not complain about my student loan debt except to bemoan the fact that some universities, Ph.D. students have $0 debt from their graduate education (but I have made my bed).  Let us compare.  According to the AMA, the average total student loan debt for a newly graduated MD is $154,607.  The median starting salary of a post resident MD is $143,000.  A less than back breaking ratio of 0.92 (which incidentally is a better debt-to-income ratio than I have).  Also, this means that even if MD salaries were cut in half by the upcoming “health care reforms”, they would still have a manageable level of student loan debt.  They would not be able to live the plush lives they do now but that is not such a bad thing.  But in the end that’s really the issue.  I have yet to encounter an MD who convincingly makes the case that they became a physician for anything other than the money (with a close tie for second being the “cool factor” and lifetime employee regardless of your competence).  In the end, MDs take advantage of an artificially created shortage of physicians to bolster their own salaries and even though the vast majority of physicians are not members of the AMA they still are more than willing to profit off the situation and offer no challenge to the draconian regulations the AMA is allowed to impose in order to start a medical school and I have yet to hear any MD group advocating for the enhanced importation of foreign doctors.  In the end, it is not the student loans which scare physicians and MD wanna-bes, it is the thought that the salary may not be there one day.  They are right to be afraid, their salaries will fall as they have been overcharging for many decades now.  They should count themselves lucky that consumers patients are not asking for a refund.

Socrates said that the job of philosopher (a group of which I am a member) is to prepare for death.  The years spent reading and writing are all a way to hone ourselves so that when death approaches we can meet it head held up.  When Socrates was convicted of corrupting the youth of Greece he did not beg for his life, he did not spew venom at his executioners, instead he ordered that a debt be paid.

In America we fear death. We spend the vast majority of our health care dollars at the end of life, largely for procedures that don’t extend life, ease pain or improve the quality of life.  We have a knee-jerk reaction that says we must “pull out all the stops” to prevent death.  But death is a harsh bookie.  It will not be cheated and it will get all that it desires.  Only once we rid ourselves of the foolish, false notion that death is something to be feared and embrace death as the last act of the lives we choose to live, that true health care reform can be had.  Until then we will always be the nation that spends the most money and gets the worst outcomes.  Because we spend it in an effort to unring the bell.

This would be the third blog I have started in my life and only now have I realized something.  I do not have a voice, not in the writer’s sense of the word.  Writers spend a great deal of time finding and refining their voice.  No one would ever confuse Christopher Hitchens with Thomas Friedman.  They each have a unique voice.  I realized today that the entirety of why I don’t seem to be able to write anything is due to the fact that I do not have a voice.  My writing is nondescript and my ideas lack insight.  If you wonder why this blog sits fallow for weeks on end, now you know.

I really have to stop reading the comments attached to news stories (especially on MSN).

A counter intuitive title given that a recent CNN poll showed that 60% of Americans favor some form of universal, single-payer health care.  Also, given that the current system is not sustainable one would think that it would be folly to argue that major health care reform is not a cake-walk.  Further, one would assume that since I am center-left in my political and economic philosophy that I would be cheering the large percentage of Americans who finally get it.  While that may be true and I do support it, I am smart enough to know that it will not happen anytime in the next twenty years.  Here is why.

Show Me The Money!

Data from the Centers for Medicare & Medicaid Studies shows that in 2000 total expenditures (public and private) on health care was $1.3 trillion and I quite confident in saying that at absolute minimum in 2008 it was at least $1.3 trillion.  That represents about 10% of GDP.  Despite a market that big there are only a few places where cost savings can be had.  These are: fees charged by physicians, fees charged by hospitals (nursing services, food services, techs, labs, etc), fees charged for procedures (outside of physicians’ fees) and drugs.  The other areas of health care have heavy competition so prices are usually close to marginal cost. Devices are largely a streamlined affair.  There are many wheel chair types out there but they compete on features not on price.  Things such as grafting supplies (artificial skin and tissue), surgical devices and clinic devices (think fancy exam tables,  machines–MRI, PET and others–and the other various noise making things in a hospital that have a touch screen on them) also compete on features and not price so there is minimal savings to be had there.  It should be noted here that while the prices of these things are close to the marginal costs they are by no means cheap.  An exam table can easily be thousands of dollars, an “inexpensive” MRI is hundreds of thousands of dollars.  The cost of these items rise because of either legitimate advances in technology or bloat (think the difference between MS Word 5 and Word 2007).  And if a company comes out with an especially popular feature for which they own a patent you can be sure you will be paying a premium for it.  I am intentionally excluding the potential for a French style system where there is one or two locations in the country that have an MRI machine and you have to go a major city if you need an MRI.  There is absolutely no way that would fly in America.  So when one talks about reducing health care costs it really boils down to reducing physician salaries and/or reducing hospital profit (and probably nurse salaries along with it).  In short, everybody in the system will be taking a nice hair cut in the health care world and I can assure they will not be happy about it.  Despite what you might hear from the American Medical Association (AMA), my experience teaching a large collection of premed students is that  most go into medicine because the pay is great and you have virtually guaranteed lifetime employment.  And I can assure you, having taught nurses as well, nurses demand good compensation for dealing with the blowhards that permeate the “upper echelon” of the medical food chain.

Reducing hospital profits may be an easier (just ever so slightly) nut to crack for one simple reason…  a lot of major hospitals are not profitable (I do not mean “non-profit”, I mean they break even, at best) and even the the non-profit hospitals are having a hard time covering their costs.  Grady Memorial in Atlanta faced eminent shutdown due to a combination of extraordinary poor management and the simple fact that Atlanta (like every big city) has more poor and middle-class people, for whom health care is an expense they are increasing not able to meet, than rich people who easily pay their bill.  Removing the profit motive from the hospital industry will only draw howls of protest from administrators at the top whose seven figure salaries will be the first to go.  But that is an easy win for those pushing single-payer health care, what is the counter argument: “We need all those MBAs to run the hospitals. They are the only ones with sufficient management ability!”  For the response, see: well, any major company that was in the finance business in 2007.

Drugs are a different story altogether.  Pharmaceutical companies have taken tiered pricing to a whole new level.  No pharmaceutical company sells its drugs at a loss but some countries represent greater profit margins than others and the margins are never higher than here in the United States.  We can easily pay twice what the profitable rate is in Canada for certain drugs.  This is mainly due to price controls established by the government of Canada because they are the ones footing the bill.  Interestingly enough when the U.S. government is footing the bill we still decide to pay full retail (i.e. bogus made up price established by the drug company, based on what they think they can charge and still be able to look themselves in the mirror in the morning).  The pharmaceutical industry is looking at a dramatic reduction in their profits in U.S. single-payer system and I can assure you they will not leave that money on the table without a fight.

The Sleeper Will Awaken.

Predicting the future is always a dicey business but some outcomes are near certainties.  But first a little history.  When Bill Clinton won the presidency in 1992 one of the first major policy initiatives was to push for a single-payer health care system.  In doing so it birthed into the world what one health care analyst on NPR described as “the dragon”.  I do not care for the metaphor.  Dragons only have one head.  The unholy alliance that rose up against the Clinton administration is far better described by referencing the Lernaean Hydra.  Many heads, all of which with poisonous breath and in fact even the tracks left by the Lernaean Hydra were said to be poisonous.  An ungodly creature composed of many parts but was mostly snake.  Hospital corporations, pharmaceutical corporations, insurance industry and the AMA merged into a similar hydra with not just poisonous breath and a deadly trail in their wake but vast oceans of money with which to deceive the public.  It should be noted that with the possible exception of militant Christian, Jews, Sunnis and Shi’ites, I can think of no other grouping of four that has as much natural hostility towards one another than insurers, drug pushers, hospital suits and MDs.  If you think about a single group formed from the militant elements of Christianity, Jewry, Sunni and Shia Islam then you get a sense of just how breath taking it was to see the hydra that clawed it way out of the muck to challenge the Clinton administration.  One perhaps might have thought that with the death of the Clinton health care reform that this hydra died with the Clinton plan.  Not true.  It simply retreated back into the swamp from which it emerged while four of its heads remained above the surface.  It looks like four distinct creatures and the way they snipe at one another one would think they would have nothing to do with one another.  This view would be naive and a mistake.  They share 1.3 trillion things in common.  The beast is merely asleep and when the time comes it will awaken once more with even more heads than it had last time.  Free-market fundamentalist, Republican ideologues, Reagan Republicans and Ron Paul Libertarians, these heads will arise with the other four.  The poison breath will be even more dangerous (and deceptive).  The tracks they leave will be even more slimy (and sleazy).  They will view this as the end of “center-right” America (all this talk of America being a “center-right” country is nonsense.  America, for the last twenty or so years has been well to the right of center, not just a little right).  They will be right to think this, which will make this an existential struggle for them and thereby justify any tactic.

George Bush said it best: “See, in my line of work you got to keep repeating things over and over and over again for the truth to sink in, to kind of catapult the propaganda.”  Prepare yourself for the return of the “Harry and Louise” ads (though the same actors have been hired by a pro-reform group) except this time Harry will be lying in the street dying because he had to wait to get into the hospital (those famous “wait times” you hear so much about–which are utter nonsense for life threatening conditions), but time ran out.  I cannot clearly imagine what the ads will be like but I am sure they will be in the vein of LBJ’s famous “Daisy Girl” ad.

But Why?

The reason it will be this way is that the situation is still not bad enough.  Americans are still convinced that theirs is the best health care system on the planet (it is not, it is the most expensive).  Americans distrust government.  Americans believe in the fairy tale that hard work is all that is needed to rise out of poverty.  There is no data to support this.  With rare exception, those who are born in poverty will die in poverty.  The same relationship holds true for those born wealthy, they will die wealthy as well.  In the end, combine that the health care situation in this country is not bad enough with the fact that there is still a lot of money to be made (by insurers, hospitals, pharmaceuticals and MDs) and I see Obama’s health care reforms either failing outright or he gets some watered-down, incremental nonsense which is the worst of both worlds (i.e. it is more expensive and less functional).  This will only make it harder to do what needs to be done later and it will raise the bar for how bad it will  have to get before the American people see that it needs to be done and are willing to hold their representatives accountable at the ballot box.  Sad to say, but you have another fifteen to twenty years before real health care reform comes to America.

Dear Mr. DeSantis,

How dare you sir.  Have you no shame at all?  Have you no sense of what has happened the last 30 years?  How dare you paint yourself and the 400 others as victims!  You are not the victims, you are the perpetrators, either by action or negligence.  Where was the outrage when those “handful” as you say, were doing stupid things with other peoples’ lives?  Where was this outrage when, as you admit, you (and those 400) were overpaid all those years?  Did you once stop and think that what you were doing was of no actual value, to you or this country.  It was not us who betrayed you.  It is you who are the traitor!  You betrayed this country for 30 pieces of silver to line your own pocket and I will not spend one moment feeling sorry for you.

 I too work “10, 12, 14 hours a day” but unlike you I am doing something worthwhile.  I am getting a Ph.D. in cancer cell biology.  I do it not because there is some fat paycheck waiting for me.  Not because it feeds my ego.  I do it because my grandmother laying on her death bed begged me for her life.  “Do something,” she said.  “I don’t want to die.  I don’t understand why this is happening.”  My grandfather, a few years later, in a hospice for terminal patients writes me into his will at the last minute.  A former Marine he simply says, “Do something about this.”

This is what you do not understand.  This country does not exist as a large get rich quick scheme for those with the moral bankruptcy to take advantage of it.  It exists for those who wish to work hard for their families and society.  It exists to provide a place where people can find and nurture the better angels of their character.  You sir are an anathema to these things.

Respectfully & Sincerely,

M. Adrian Mattocks.

P.S.  Keep the money.  We need neither your pity nor your charity.

Among the many mechanisms available to a human cell is the ability to compensate for a defective gene.  If a gene becomes mutated so that it no longer functions correctly, other proteins (genes are the blueprints for proteins), in some instance, can pick up the functional slack for the damaged gene.  While this is not always the case and I know of no case where another protein can completely replace the damage gene, it does happen more often than one would think.  The replacement, though, is always less efficient than the original.  And in a great deal of circumstances a mutated gene becomes a death sentence.  More than half of all cancers have a mutated gene called p53 and if you have a mutated p53 you will almost certainly develop cancer.

All economies are composed of two things… supply and demand.  There are people who demand things, smartphones, computers, cars, porn etcetera.  People who supply things, HTC, Dell, Ford, Vivid.  An economy is very much like a eukaryotic cell.  It is very complex, there are overlapping pathways, there are built in redundancies (there are many companies offering smartphones with many of the same features) and the loss of any single entity does not automatically doom the system to failure.  Like everything else, there are exceptions.  Some genes, if lost, will result in catastrophe for the cell (and in some instances the body as a whole).  While de Gaulle’s quip about cemeteries and indispensable people is certainly correct as regards people, it does not apply to proteins or economies.  The consumer is two-thirds of the U.S. economy and without those consumers there is no U.S. economy.  A fact we are all now very much aware.  So what does an economy due when the indispensable one keels over dead?  You look for some economic plasticity.  Just as another gene can sometimes “fill-in” for a damaged gene, the Federal government sometimes has to fill-in for the damaged consumer.  Is it optimal?  No of course not.  In the cell, the substitute gene usually can only keep the cell going long enough so that it can be destroyed in an orderly fashion thereby preventing damage to neighboring cells (a process called apoptosis).  Similarly, the Federal government cannot keep the U.S. economy going indefinitely, but it can keep it going long enough for consumers (and by extension businesses) to regain their footing and start moving forward again.

John Maynard Keynes (1883–1946)

Cell (~3 billion years ago[for prokaryote]-present)