Saturday, April 16, 2011

Physician salaries and loan debt: Is it worth it to go to Medical School?

This post is fueled by a few recent blog posts on which have attracted A LOT of discussion:

Real life example of medical school debt

Why medical education needs to be more affordable

Why does society frown on doctors earning a reasonable living

Think about medical school tuition debt before becoming a doctor

The comments attached to these posts are filled with entries by bright eyed medical students cringing at the debt load they will face, seasoned doctors telling them to get out now, nonphysicians telling us to quit our whining, and a few well reasoned entries.  Below are my thoughts. Please note that initially I am taking the cold "financial" approach to evaluating medical school and not adding the human, job satisfaction element of being a doctor.

Not all debt is created equal
As debt goes student loan debt when used correctly is one of the best kinds of debt to have. Any basic personal finance class will tell you that taking a loan that will increase your earning potential is a good thing. Clearly for the subspeciality surgeon working in private practice who will make 300-400k a year the upfront investment of 150-200k for medical school + the time spent making effectively minimum wage as a resident are worth it for the end result. Also, paying off your student loan debt early is not necessarily a good thing. If you have a student loan with a fixed rate of 4% and you could invest your money for more than that you are better off investing your money and being more liquid and lengthening your payment term. This is why it's absolutely essential to consolidate the loans when the rates are low and once you have consolidated them to invest your extra money rather than pay them off early (same goes for low-interest morgage refi's as well). While psychologically it can seem WORSE to wait it out for 30 years, it's better from a financial standpoint to have more low interested fixed debt and more cash on hand (if invested properly).

Physician salaries do not correlate to length of training
What's often amazing to me is the marked difference between physician salaries even with the same training. For example, if a pediatrician does any one of a number of fellowships (effectively doubling the time they make minimum wage from 3 to 6 years) they will often make the SAME SALARY as a general pediatrician (for example adolescent medicine). Unfortunately, doing this extra training does not net additional income despite bringing you clinical expertise. However, with certain other subspecialities (say ER or NICU or even PICU) you can effectively double your salary by doing the extra 3 years. Now, before I get flack from my intensivist friends, I will say that the training in the 3 specialties I named is way more rigorous than the adolescent medicine fellowship. All 3 of those involve in house overnight duties and frequent encounters with deathly ill children while the adolescent medicine fellowship is more outpatient based. Note that for ANY of these fields the amount of educational debt (4 years of med school) is the same and has NO BEARING on future income.

Quantifying the value of medical education
This blog takes an interesting approach to quantify the value of the medical degree as it compares to other fields. What the author does is divide the total money earned over a life time minus debt by the total hours worked for a few common fields. By his math an internist earns about $34/hr while a teacher earns about $30/hr (taking into account the pension). I think while the math is interesting, the are a few flaws with this argument. He does not account that hopefully the physician will advance over time in salary and outpace inflation (i.e. grow their practice, if in a hospital system get promoted, etc). That being said it does show that the debt and minimum wage earned during residency put a dent on the lifetime income of a physician vs. other fields.

Is primary care "worth it"?
Your average person starting a practice in primary care is making 100-130k a year and probably gives 12k (post tax) out in loans. Looking at this that gives them a post tax income of around 70-90k a year. Is it worth it? I'll let you be the judge. However, for the sake of our healthcare system I hope more find it worth it. You can be a nurse anesthetist for less training and make more money. I think it really depends on your perspective. If you are someone who did a bachelors and a masters in a non medical field at a private institution you may say, I don't understand what all the fuss is about. Why do these doctors feel so entitled?

The overwhelming majority of folks I meet in primary care, esp servicing underserved patients are pretty saintly. They'll put in the extra hour to call a kids grandma to make sure he got the right formula or call a kids school to see how the ADHD meds are really working out. Unfortunately these folks are not that common. I find the same thing for doctors in many pediatric subspecialitites who despite extra training make the same as their generalist colleagues.  As evidenced that fewer than 10% of medical school grads go into primary care fields. Like it or not, especially with the new health care reforms we need A LOT more primary care physicians, especially those willing to work with the indigent.

Many primary care doctors are opting out of traditional practice models and are going cash only or adopting a "concierge" model of practice which allows them to not worry about the normal constraints caused by lousy insurance payments. Some say that this is wrong and limits access to care. Others would say: "My mechanic charges a fixed advertised rate for his time, why shouldn't I?"

What can we do to fix it?
The answer is simple and I think one of necessity given primary care workforce issues.

1. Pay primary care docs more. Unfortunately the current CPT codes (billing codes used by doctors) were derived by subspecialists so primary care codes tend to pay less. I think revamping the coding system to place value on the work of the primary care MD. This is the only way to kill the primary care shortage. With out this you will either a) see more doctors not enter primary care or b) go into concierge practice to circumvent the constraints of insurance companies. One answer is to just pay primary care per time with the patient at a rate that's enough to cover expenses and make a decent salary (i.e. enough so people do not bail on primary care for higher paying specialities). Also, to include in the cost the time away from the patient making phone calls and doing paper work. Finally, we need to have codes that allow for "phone visits" and "evisits". Many folks using a concierge type model (free from what traditional insurance will pay) will make an e-visit with a patient over a webcam when appropriate.

2. Revamp the lending system. Medical school loans are some of the safest bets for the banks. They always get paid back. The interest rates should really be next to nothing (i.e. 2-3%) not the 6% that some of them are at now. Also, going into primary care should be accompanied by complete loan payback from the outset. While there are some NHSC (national health service corps) programs out there with loan repayment they are not always competitive. i.e. a doctor can make more money by not taking the NHSC job and just repaying the loans over time.

Monday, April 4, 2011

Three Weeks with the iPad 2: Working, Doctoring, and Playing

I'll be honest, my initial impressions upon first hearing about the iPad last year were negative. I had been anxiously awaiting its release and expecting something that resembled a stripped down Macbook vs. a souped up iPhone. I will admit one year later that Apple may have been on to something. If we can all recall, the initial idea of a "tablet PC" which took Windows and added a touch interface did not cause the revolution that the iPad has caused. Also, now the other major mobile OS's (Palm, Blackberry, and Android) have tried to supersize their product for a bigger screen. Three weeks ago I got lucky and managed to be number 105 of 110 at Best Buy to get an iPad on its release day. What follows are my initial thoughts...

From a business-y standpoint the iPad makes a suitable replacement for a laptop when you are on the go. There is decent exchange support (although I don't think any device supports exchange like a Blackberry with BES) and using Documents to Go ($16.99) you can do some mild to moderate editing of Office documents. One other nice feature of DtG is the abilty to wirelessly sync with your desktop. i.e. you can sync your My Documents folder (or Documents on OSX) with DtG on your iPad and take it all with you. I've found that the iPad is portable enough to take around to meetings, not as conspicuous as having a laptop open in front of you, but more functional than a smart phone. I'm often in situations where I'll receive an email that warrants a longer response than I'd care to thumb out on my phone, but do not feel like waiting until the end of the day until I'm actually at a computer to sit down and compose my thoughts. Also, viewing a calendar on the iPad gives you a much clearer picture of what your day is like as opposed to your smartphone.

Many would say that taking your desktop with you is passe and the real future is in putting your files in the cloud. Most of the iPad programs support Dropbox (including Documents to Go) which seems to be at this point the frontrunner in cloud storage. (Other sites offer more storage: and even amazon, however none have the easy user interface that Dropbox has). Unfortunately the iPad has no "file manager" but GoodReader ($4.99) is an acceptable alternative since you can use it as a launch point for any other program. It also supports annotation of PDF files. Dropbox gives extra space to both the referrer and the referee so if you are interested in Dropbox, click here so we can both get some extra space. Another app that I have been using is SharePlus Lite (free). It lets you interact with Microsoft Sharepoint websites in the same way the GoodReader does for the cloud. The pro version of the program ($14.99) lets you write to the Sharepoint site, while the free version just allows you to view and edit locally.

I have tried both Penultimate ($1.99) and PaperDesk ($2.99) for note taking. Penultimate has the better writing interface but PaperDesk has more features (combining text, writing, audio, and a todo list). There are several apps out there that sound promising that I have yet to try (uPad, Note Taker HD, Notes Plus). I think the ideal app needs to combine smooth writing abilities with the power to mix handwriting with other media (to go beyond what you can do with paper.) I have still yet to find the "perfect" writing app for use with a stylus.

For my work as a doctor I primarily rely on the Citrix client for iPad (free) to connect to my hospital. We can access our hospitals electronic health record system, labs, xrays, and even view the bedside monitors of the ICU patients. Unfortunately using Citrix on your iPad involves accessing a Windows computer via an iPad interface which is clunky. (Many EHRS have iPad apps to access them, but we are not there yet). While the getting there is clunky the pay off is nice. Looking at xrays and CTs on the iPads screen is nice and the pinch to zoom is much more functional than the built in zoom tools in the xray view. Also, viewing patient monitoring on your lap in real time is pretty cool. Citrix on the iPad beats Citrix on the phone since with the phone you have a clunky interface looking at a Windows desktop through a porthole. A week ago I actually spent the good part of an hour meeting (I was only needed for about 5 minutes of it) providing patient care by looking at labs, putting in orders, reviewing x rays, and checking in their monitoring on my iPad.

One area I have yet to find perfection in is in keeping a journal collection. In my field I read two primary journals Critical Care Medicine and Pediatric Critical Care Medicine. I've found a good workflow with MDConsult (which has pdfs of the above journals available), DownThemAll (Firefox extension that auto downloads all the pdfs to your computer), and Mendeley (which then will automatically catalog the metadata for your pdf collection) to effectively have a paperless bookshelf of my two most read journals. My goal was to have a few years of searchable journals at my fingertips. I've met a FEW snags with this on the iPad. First off Mendeley only lets you sync 500MB for free to your personal space and charges you for more. Second the Mendeley app seems to crash on my iPad (I suspect due to the size of my library). I don't think Mendeley was meant to be used in this fashion but more to keep a small focused list of journals for academic folks. What I need to find is pdf viewer that searches INSIDE PDFs and lets you sync a library of PDF documents with your desktop.

The iPad really shines here. I'm a big fan of RSS feeds and find Feedler (free) to be a great way to thumb through my Google Reader stream pretty quickly. Apps like Flipboard (free) and Pulse (free) change this experience from pointing and clicking on a browser to a truly hands on interactive experience. Also, many web apps like Yelp, TripAdvisor or the IMDB for example have iPad specific versions which are more robust than their smartphone equivalents. As far as games I've found there are 2 kinds of games: 1. Supersized smartphone games: games like Angry Birds and Cut the Rope take a game initially made for a phone and upsizes it for the iPad. These games are fun, but other than making things bigger do not change the gaming experience. There are a whole slew of games that really take advantage of the iPad's UI to make it a more immersive experience. For example, recently I've started playing Drawn (free) which is a Myst like adventure game that lets you interact with paintings and solve puzzles on a quest. Also Contract Killer (free) which puts you behind a sniper scope to take out bad guys and is very reminiscent of the Hitman series of games.

I think there are three things that to me hold the iPad back. One is lack of file management and storage. There's no user accessible file system inherent in the iPad. Apps like Documents to Go and GoodReader provide their own file system that you can access via iTunes, but it's not like you can just drag and drop any file on to your iPad from Windows or OSX w/o going through iTunes and the above programs. One other quirk is that you cannot "attach" a file to an email. You can start in the programs mentioned above and then send the document (which opens mail with the document attached) but you cannot start in the Mail app and decide to attach a document. Also, the iPad has no way to easily add external storage. You can use the Camera Connection Kit ($30) to pull in media (just photo and video), there's AirStash which allows you turn any SD card into a portable NAS (but it's $100 and requires that you disconnect from your network to the AirStash), Sanho Hyperdrive ($100 for a drive casing that holds a 2.5 inch HD, $200 to $400 for 320GB to 1TB of storage) is another option that gives you up to 1TB of storage (but here again only photos and video). My music collection alone is 50+GB so to take this with me would fill my 64gb iPad. However, if a good external storage option existed i'd take all my movies and music.

The second negative is the lack of a customizable dashboard. My phone of choice has been a Droid X and I LOVE widgets and being able to set up my home screen with certain apps on certain screens and widgets. Now, I think Apple with its minimalist approach would not allow a UI cluttered with Widgets but I think this is where the Android folks could shine if they play their cards right.

Finally the camera is just crappy. It gets the job done for using face time, but does not work well for quality pictures and video. I'm not really complaining since I don't find the tablet form factor to be the best for taking pictures or video and I would imagine that most folks who own the iPad also have a smartphone with a decent camera and video capture.

I think at this point in the tablet world there really are no other players . Android's Honeycomb is fresh out of the gate and clearly has what is on paper a more powerful device in the Motorola Xoom (SD card input, HDMI out, 1080p). Unfortunately there are just SO MANY apps for the iPad that I think it will take Android a while to catch up. I suspect they will though, just like Android phones are now running in a dead heat with iPhones. Blackberry and Palm are getting out their devices as well but again Apple has such a large headstart with the iPad, especially in the medical arena. For now I think you cannot go wrong with an iPad.

The other option is to just get a full fledged laptop. If you get the iPad with 64gb +3G you spend about $850. For $150 more you can get a Macbook Air. Or if you are into Windows you can get a netbook for around $300 - $500. I think this choice is really dependent on your needs. i.e. if you want to do the EXACT same things that you would do on your computer on the go then you will fall short with the iPad. For example, you cannot do full fledged Photoshop editing or Aperture with your iPad. However, on the flip side try working with a laptop crunched between two people on the train.

Should I get one?
If you are looking for something smaller and portable that has a unique interface consider getting an iPad since you can do 90% of what a laptop does and has some unique features your laptop doesn't (longer battery life, touchable UI, ability to just click on and start using w/o waiting for the computer to boot up). I'll be honest I'd hardly call an iPad (or any tablet for that matter) a necessity but it definitely has a role to fill.

Which one should I get?
The iPad comes in a total of 18 flavors. There are 3 sizes (16, 32, 64gb) x 3 network options (wifi, AT&T 3G, Verizon 3G) x 2 colors (black and white). Personally I'm partial to the black, I think for movie watching having a black border is a nice touch (imagine if your TV had a white bezel instead of a black one). As far as size I think if you are going to just put on some apps and keep a lot of documents in the cloud then the 16gb is the right size. However, if you want to take A LOT of documents then you may need to think about the 32gb and if you want to take pictures, video or music as well then get the 64gb. As far as networking, rather than having a data plan for just your iPad, I think it makes more sense to have either a MiFi device OR WiFi hotspot on your phone which then allows you connect ANY device to the internet. Only negatives here are that WiFi hotspots KILL your cell phone battery AND it does require the extra step of turning on your MiFi or the cell phone's hotspot before connecting your iPad

Good laptop replacement
Screen great for PDFs
Intuitive UI
Fun to use as a "toy" (games and web)

Lack of a file system
Lack of a customizable UI
Weak camera